1
500
101
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Work Memos [2]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057608" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-013-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/67f001fa17872a2b0f2e2e9c0b7c46bd.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Work Memos [1]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057607" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-012-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/dbac991347ec41ab79b20af8815e97a5.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Why America Needs Health Care Reform]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057606" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-011-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/edf81ad9c6d9343bc6bccac54270e675.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
What’s Going On [2]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057605" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-010-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
What’s Going On [1]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057604" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-009-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/f95f59e8077316d87caee18400571df3.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Universal/Coverage
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057603" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-008-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/a83f52e4a49c9e99fbf59b608c5c68c8.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
States
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057602" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-007-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/fbc610d9552af785d64c03b51b239b86.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Statistics
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057601" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-006-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/fb7d19dab9fc87e26bd8880c5897cd23.pdf
34e9bcaf0a4b09305d4668c7ee2f3278
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Senate Finance/Cooper
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057600" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-005-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/36d8ba3eed775ebb185f39feb0649e7c.pdf
964225c7372273c41ebfdda90021eaa9
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Rump Group
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057599" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-004-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/f321ebdb264a1531e6f08009fc3b3305.pdf
b0c4eb3ad8ffc8d43dc420a715fe295f
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Rowland-Bilirakis
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057598" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-003-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/853ac0a455ae7a6c450ee248f57e7ca6.pdf
a3db6a1ca561f6a012728bd80bea1e09
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Republicans [2]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057597" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-002-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/4757d137226901daf8d554c89283a9c5.pdf
cb4457e77e53a353b1bc8007a5f32b6e
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Republicans [1]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 59
<a href="https://catalog.archives.gov/id/26057596" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-059-001-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/29/2016
-
https://clinton.presidentiallibraries.us/files/original/223e8a9ce906d48063ea943ef29e470d.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Numbers Wish List
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057595" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-020-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/0eef382a0d4ed223c0f84c555e1b3a0f.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Mitchell Bill [2]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057594" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-019-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/8b6d1b58da95b71b1dea2b48a1ef7ad0.pdf
902d144f94b6a2150810e97411aae085
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Mitchell Bill [1]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057593" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-018-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/6b799f74642d3d1034a0eaeeb620b8e7.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Miscellaneous] Q and A’s
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057592" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-017-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/789818f5a8be58009f1065d6c70a0cd7.pdf
840301a5522b1b17a999f4c482cb9e39
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Letters
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057591" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-016-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/14b843f60a8843f0b71253b921831e99.pdf
ebedc541ec64d5b19c445bbc2a177ebc
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
House Bill
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057590" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-015-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/2461b018af95e76e66f87f63e8ba36db.pdf
d7b96aad34a5088f2d0f09482d2b6e82
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Hispanics [2]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057589" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-014-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/ecde336db4db95625ff11673efbf4e39.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Hispanics [1]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057588" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-013-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/166be3d9c39ac05c2e92da6c2143acd7.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Health Reform Legislation: A Comparison of Committee Action – A Product of the Kaiser Health Reform Project]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057587" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-012-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/5a6158b3c059157fec3695fd7ac49c88.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Health Care Reform]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057586" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-011-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/c5d80d4c94aa27ff8b4747c29806f2f9.pdf
88280b7ec4a7f4ff1d0a1c0152d7d84c
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Employee Mandate
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057585" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-010-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/678d8a3fce646adf0668abaf434fb70f.pdf
f74c5c0afaff63b8ee5d07ac2cdf99c1
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Economic Team [4]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057584" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-009-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/548dd2610e4437068cb20653271de410.pdf
22e8d10f2749cd288f5d4436af23bb3b
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Economic Team [3]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057583" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-008-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/28a4f73fac8a0747d8a512018b82b0a3.pdf
646fd27d3154939564339ffa9786d6b0
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Economic Team [2]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057582" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-007-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/94e49e7cfddec894d7eda0d01712561c.pdf
19fc098d0a0850927e0e89a0318468a3
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Economic Team [1]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057581" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-006-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/22be9e13baf7531e223011b8815e1cfc.pdf
ca2c3e98e6fe461653d6b97dd0b96383
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Dole Plan [2]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057580" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-005-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/2d8039c2e58978b62ae22969f0d40099.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Dole Plan [1]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057579" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-004-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/51b235ec77b9128824967ce26ad9f443.pdf
fe810748272a2fa006ac8d8fbc3bd363
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Democratic Policy Committee]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057578" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-003-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/43b5fa7aee74114fef6dd41b41bbefc1.pdf
562ebfaa613da7b22262d0a9ef218a51
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Database [4]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057577" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-002-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/fed33414ab41d7cf1392793ad9bc6312.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Database [3]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="https://catalog.archives.gov/id/26057576" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-058-001-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/53aff9233e68bdd44e3b48968b563e88.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Database [2]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 57
<a href="https://catalog.archives.gov/id/26057575" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-057-026-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/381ca97b55ae1b7017f7279da35087fc.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Database [1]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 57
<a href="https://catalog.archives.gov/id/26057574" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-057-025-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/fcf984a29f0ba890bccd45e8f96c6faf.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Amendments
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 57
<a href="https://catalog.archives.gov/id/26057573" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-057-024-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/096bdea6c6eab5780ec92c78da8422ee.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Alternative Plan Comparisons [2]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 57
<a href="https://catalog.archives.gov/id/26057572" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-057-023-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/5986428b0706b262ff4846f524c59bc0.pdf
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records (Segment 8)
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Arnold Epstein
Meeghan Prunty
Jason Solomon
Date
A point or period of time associated with an event in the lifecycle of the resource
1993-1995
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Description
An account of the resource
This collection consists of records dealing with the attempt of the Clinton Administration to transform the health care system of the United States. The material in Segment 8 focuses on the Staff and Office Files of Arnold Epstein, Charlotte Hayes, Paul Jamieson, Kelcey Kintner, Amanda Merryman, Meeghan Prunty, and Jason Solomon. The records include reports, drafts of speeches, talking points, press releases, vmemoranda, newspaper articles, handwritten notes, statistical charts, publications, and correspondence. The documents highlight the history of health care, the “Health Care Express Tour,” and other proposed health care legislation.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
1,402 folders in 59 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Alternative Plan Comparisons [1]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 8
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 57
<a href="https://catalog.archives.gov/id/26057571" target="_blank" rel="noreferrer">National Archives Catalog Description</a>
<a href="https://clinton.presidentiallibraries.us/items/show/48215">Collection Finding Aid</a>
Source
A related resource from which the described resource is derived
12093764
42-t-12093764-20060885F-Seg8-057-022-2016
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
1/28/2016
-
https://clinton.presidentiallibraries.us/files/original/433ba35e2ed173dc5d47a75f0277ecf4.pdf
493222404302bbc55a2a547d575cfcf0
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1968
FolderlD:
Folder Title:
[Westmoreland Health Care Reform Group] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
9
2
�The Westmoreland
Health Care Reform Group
PLATFORM
March 22,1993
�The Westmoreland
Health Care Reform Group
204 Marshall #3
Houston, Texas 77006
713.522.4766
About
The Westmoreland
Health Care Reform Group
The Westmoreland Health Care Reform Group (WHCRG) was founded by
James R. Machuga and Garrett R. Lynch, M.D., after extensive discussion on issues not
being addressed in the process of reforming our health care system.
The two founders of the WHCRG have an in depth understanding of the health care
system, particularly as related to cancer, the most expensive disease to treat, and the
second most prevalent disease affecting Americans.
Garrett R. Lynch, M.D., is acting chief of hematology/oncology at Baylor College of
Medicine in Houston, Texas, where he is an associate professor of medicine. He has
served as chief of medical oncology at Ben Taub Hospital since 1981. A 1974 graduate of
Baylor College of Medicine, Dr. Lynch trained in oncology at Memorial Sloan Kettering
Cancer Center in New York City, and internal medicine at Boston City Hospital.
James R. Machuga has AIDS and is a recipient of Social Security Disability. He will be
eligible for Medicare in March 1994. Mr. Machuga has ten years of experience in the
administration of cancer programs, both at UC Davis Cancer Center in Sacramento,
California, and M.D. Anderson Cancer Center in Houston, Texas. He is a 1982 graduate
of the University of Houston, Clear Lake City, having received a Master of Science in the
Administration of Health Care Services.
�The Westmoreland
Health Care Reform Group
PLATFORM
March 22, 1993
1. Ensure that all Americans, employed, unemployed, disabled, elderly and indigent are
provided or eligible to purchase a basic universal package of health care services.
2. Fund the basic universal package of health care services with the savings realized
through the implementation of this platform and a tax increase for all Americans.
Requiring employers to provide health coverage places afinancialburden on
businesses, especially small businesses.
3. Eliminate Medicare, Medicaid and state funded high risk insurance pools. These
programs should be combined into the basic universal health care package.
4. Ration the limited health care resources in a realistic manner that acknowledges the
limitations of modem medicine.
Use extending the life of the patient by a minimum of one year as a
determining factor in the rationing of services. 0.5% of the Gross National
Product, or $27.8 billion, is spent on Medicare beneficiaries in their last one year
of life. When considering payments by private insurers, a conservative estimate
of 1% of the GNP is spent on keeping patients alive for less than one year.
(Attachment I)
Physicians routinely offer patients major operations, procedures, chemotherapy
and other expensive outpatient/inpatient therapies when it is knownfromthe
beginning of the therapy that the outcome will be certain death within six months.
When scarce resources must be rationed, such an expenditure cannot be justified,
condoned or paid for with public funds.
�The Westmoreland Health Care Reform Group
Platform, March 22, 1993
Page 2
Examples of procedures/treatments of marginal benefit include:
a. Chemotherapy of non-small cell lung cancer, which results in a median
improvement in survival of 17 weeks
b. Second-line chemotherapy for gastric, esophageal, colon, metastatic
head and neck cancer, small cell lung cancer, brain tumors, renal
cell cancer and melanoma
c. Re-operation for uncontrolled metastatic cancer
d. Autologous bone marrow transplantation /peripheral stem cell harvest
for metastatic breast cancer
e. Intensive care support for patients with incurable cancer
f. Organ transplants, including bone marrow transplant, in patients over 65
years of age
g. Coronary artery bypass surgery in patients over 75 years of age
h. Neonatal intensive care for infants less that 750 grams at birth
i. Cosmetic surgery
There are numerous other examples.
While the above quantifies the economic costs of providing therapies with little hope, the
toll in human pain and suffering is immeasurable. Patients are subjected to cruel, painful,
debilitating and hopeless procedures/therapies that add suffering to the last days of life,
not comfort.
Society must acknowledge that when death is inevitable, we are only extending the dying
process, not adding quality life. Now that rationing is inevitable, our society will be forced
to change its expectations of the health care system.
5. Issue a national health insurance card to all Americans and eligible legal residents.
Removefromservice providers the cost and bureaucracy of proving eligibility.
�The Westmoreland Health Care Reform Group
Platform, March 22, 1993
Page 3
6. Fund outpatient medications in the basic universal package.
Many patients on Medicare are unable to afford the high cost of medications.
Medicare does not pay for outpatient medications that could extend the lives of
people still maintaining a high quality of life. Included in this category are persons
sufferingfromheart disease, including hypertension and hyperlipidemia, arthritis,
cancer, diabetes, ADDS and other chronic diseases.
Medical therapy for a variety of illnesses is much cheaper than the surgical therapy
or the treatment of complications of the untreated disease. The inability of many
Medicare patients to pay for outpatient medications results in non-compliance with
prescribed therapy. Non-compliance may lead to serious consequences,
including costly and lengthy inpatient hospitalizations and death. Surely,
outpatient treatment of hypertension is much cheaper than the cost of dialysis for
renal failure resultingfromuntreated hypertension.
Inappropriate hospital admissions occur on a regular basis to overcome this
outpatient medication deficiency in Medicare. Many cancer patients cannot afford
the cost of outpatient narcotics and have to be hospitalized for pain control where
the cost of these medications are covered by Medicare.
Bring the price of pharmaceuticals under control through government regulation.
7. Fund prevention and screening in the basic universal package.
8. Fund abortions in the basic universal package.
Approve RU-486 as a cost effective and safe way to perform abortions.
9. Fund psychiatric services in the basic universal package.
�The Westmoreland Health Care Reform Group
Platform, March 22, 1993
Page 4
10. Fund clinical trials, even of marginal therapies on a limited basis, through the National
Institutes of Health so that advances in clinical research may continue.
In situations where only marginal therapies exist, treatment should be limited to
clinical trials in already established NIH centers of excellence.
11. Stop providing non-emergent services to illegal aliens.
Our health care system is unable to provide a basic universal package of services
for all Americans. A significant portion of the patient populations in city and
county hospitals are in this country illegally. Such patients should receive
continued care in their country of origin.
A national study should be conducted through the Health Care Financing
Administration to determine the cost to American taxpayers of providing
continued care to illegal aliens. This study should be completed within the next
100 days.
12. Recognize that physicians' fees are not a problem.
By rationing services as discussed in Number 4, physicians' incomes will self adjust
as the number of expensive procedures/therapies performed are reduced in the last
year of life.
Even at $100 for an office visit, the cost of retaining a physician is extremely
inexpensive. Physicians spend eight to twelve years in training. When
assuming the care of a patient, the physician is legally and ethically obligated to be
available or provide coverage 24 hours a day, 365 days a year.
Included in the $100 cost of the office visit are reviewing laboratory and imaging
data, telephone callsfromthe patient, telephone calls to the pharmacy, and
discussing the patient's case with consulting physicians and family members.
Indeed, an awesome service at $100 per visit.
�The Westmoreland Health Care Reform Group
Platform, March 22, 1993
PageS
13. Develop and delineate government guidelines regarding the appropriate and funded
patient work-up based on the patient's symptom(s) or disease (by ICD-9 Code), thereby
reducing costs. (Attachment II)
Flexibility should be kept to a minimum, to ensure an equitable rationing of scarce
resources.
The general public has a heightened awareness of medical terms, though not a
thorough understanding of laboratory tests and diagnostic procedures. Many
patients request tests which are not necessary, based on the patient's symptoms or
condition.
Physicians, fearful of malpractice suits, practice defensive medicine even when not
initiated by patient/family requests.
Defensive medicine is not as simple as ordering an MRI in addition to a CT scan,
or even connecting a dying patient to a ventilator. It can also mean prescribing a
therapy, costing thousands of dollars to the American taxpayer, and extending a
persons inevitable death by 17 painful weeks.
Defensive medicine translates into bad medicine when terminal patients are kept
alive solely to avoid a potential lawsuitfromfamily members who cannot face the
inevitable.
14. Set limits of liability.
15. Change the training of physicians.
Physicians must be trained to recognize the limitations of modem medicine, and be
able to communicate those limitations to the patient and family.
Classical clinical training results in patient work-ups that reflect defensive
medicine, training medical students to over order costly diagnostic procedures.
�The Westmoreland Health Care Reform Group
Platform, March 22, 1993
Page 6
16. Allow individuals the option to buy additional coveragefromprivate insurance
companies at government controlled rates for those items not covered in the basic
universal package. Examples include cosmetic surgery and private hospital rooms.
17. Plan now to meet the medical, economic and social needs of patients in the
year 2000.
It is projected by the year 2000 that cancer will be the leading cause of death, and
Alzheimer's disease will be in the top three leading causes of death.
END
THE WESTMORELAND
HEALTH CARE REFORM GROUP
204 Marshall #3
Houston, Texas 77006
713.522.4766
�Attachment I
Dollars in Billions
1990
$666.2 = Total National Health Expenditures
(12.2% of GNP)
$111.2 = Medicare Medical Payments
(2.037% of GNP)
Source: Statistical Abstract of the United States, 1992
U.S. Department of Commerce
$27.8 = 25% of Medicare spent on the last one year of life
Source: Riley, et al. Inquiry, Fall 1987. "The use and costs of Medicare services by cause
of death." AN 88006389. 88000.
$27.8 = 0.5% of GNP spent on last year of life for Medicare enrollees
Dollars in Billions
1990
$666.2 = Total National Health Expenditures
$27.8 = Medicare dollars spent on the last one year of life for enrollees
4.17% = Percentage of Total National Health Expenditures spent on the last one year of
life of Medicare enrollees
�Attachment II
Recommended government guidelines of appropriate and funded work-up of a symptom
Example: Hematuria (blood in the urine)
A. Initial work-up.
1. History and Physical
2. Urinalysis
3. Urine culture
4. Complete blood count
5. Serum creatinine determination
B. If A is non-diagnostic:
Urine cytology
C. If B is non-diagnostic:
Intravenous pyelogram (I VP)
D. If C is non-diagnostic:
Urological consultation for cystoscopy
E. If D is non-diagnostic.
Nephrology consultation regarding possible kidney biopsy
�
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Health Care Task Force Records
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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Health Care Task Force
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<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
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https://clinton.presidentiallibraries.us/files/original/4b36779d3e552907a9b527d894bac9e1.pdf
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FolderlD:
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[Washington Business Group on Health] [loose]
Stack:
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S
56
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Position:
1
3
�c
n
L MAR
N-n- a n
-
5 ^1993
WASHINGTON
First Class Mail
PHOTOCOPY
PRESERVATION
^
"
�Washington Business Group on Health
n/N.GipiiolSteelti.E.
.
S-te60C fchnjton, St. 20002
u
l
AnneRossier
Policy Analyst
(202) 408-9320
iDC 1202) 408-9333
rH (202) 408-9332
|
1
�Washington Business Group on Health
777 N Caoitoi Srreei N c. Suire 300 W s m t n OC 20002
o n go . . .
'202: 408-9320 ID0 i202. 408-9333 FX 2 2 408-9332
A 0
WASHINGTON BUSINESS GROUP ON HEALTH
MEMBERSHIP SURVEY ON HEALTH SYSTEM REFORM
June, 1992
P bi P lc • Institute o A i g W r a d H at • Institute f r R h blt to a d Disability M n g m n • M na H at Services Po r m f r Y uh
u lc oi y
n gn , ok n e lh
o e o iioi n n
aae et
e t l e lh
r ga o o t
N to a B sn s C aii n F r m o H at • N to a R s uc C ne o W r st H at Po oi n • Pe e to L a es i F r m • Q aiy R s uc C ne
ai n l u i e s o lto ou n e lh
ai n l e o r e e t r n ok ie e lh r m t
o
r v ni n e d r hp ou
u lt e o r e e r r
�This report was prepared by Sara Watson and Richard Smith of
W G . W would like to thank the W G members who reviewed draft
BH
e
BH
versions of the survey: John Burns of Honeywell, Charles Buck of
General Electric, Barbara Butler of Bell Atlantic, William Little
of Ford, and Ken Dude of M y Company Stores.
a
Additional copies of this report may be obtained for $25,
including postage, by contacting Misshay White at W G .
BH
�TABLE OF CONTENTS
Executive Summary
i
Introduction
1
Options for Restructuring the System
2
Employer role
Incremental reform
Employer requirements
State reforms
Specific proposals
Benefits
Tax Treatment of Benefits
7
Changing deductibility and excludability
Design for tax on employee benefits
Inclusion of organized systems of care
Cost Containment
9
Financing
10
Resource Allocation
12
Respondent Characteristics
12
Demographics
Plan characteristics
COBRA considerations
Health care costs
Conclusion
14
�EXECUTIVE SUMMARY
This report represents the results of a survey of 76 members
of the Washington Business Group on Health.
Highlights of the
survey are:
When asked i f employers should continue t o provide health
b e n e f i t s t o t h e i r employees and dependents, the vast majority
of respondents said yes, although a s u b s t a n t i a l number would
change t h e i r minds i f current health care cost trends
continue.
Two-thirds of the respondents do not believe t h a t incremental
reform plans w i l l be s u f f i c i e n t t o f i x the health care system.
Employers continue t o have mixed reactions t o .play-or-pay
plans, w i t h 41% supporting them and 48% opposing them.
Members provided s u b s t a n t i a l support f o r the organized systems
of care concept (defined i n the f u l l r e p o r t ) :
delivering
b e n e f i t s through t h i s system makes play-or-pay requirements
more palatable, and a m a j o r i t y of respondents would support
r e t a i n i n g the current tax treatment of b e n e f i t s only i f they
were delivered through organized systems of care.
Respondents showed some support f o r changing the tax treatment
of b e n e f i t s : 40% would strongly or somewhat support capping
the d e d u c t i b i l i t y of employee benefits as a business expense
and the e x c l u d a b i l i t y of employee b e n e f i t s from income, while
46% would s t r o n g l y or somewhat oppose i t .
A value-added tax was the favored method t o raise a d d i t i o n a l
revenue, followed closely by changing the t a x treatment of
b e n e f i t s and a personal income tax.
When asked what benefits should form part of a standard
package delivered through organized systems of care, at least
half of the respondents would include benefits such as
hospital care, physician care, a variety of disease prevention
and health promotion services, pharmaceuticals, mental health
care, chemical dependency treatment, rehabilitation services,
and s k i l l e d nursing f a c i l i t y care.
Other questions i n the survey explore t o p i c s such as s t a t e l e v e l reforms and support f o r various cost containment proposals.
�Washington Business Group on Health
Membership Survey on Health System Reform
INTRODUCTION
In the spring of 1992, the Washington Business Group on Health
(WBGH) conducted i t s second annual survey of members' views on
health system reform. W G i s a n o n - p r o f i t membership organization
BH
of large employers involved i n p u b l i c - and private-sector e f f o r t s
t o improve the health care system.
The survey was intended t o
e l i c i t companies' opinions on general c h a r a c t e r i s t i c s of the health
care system and of proposals f o r health system reform. I n
a d d i t i o n , companies were asked f o r demographic and other
information about t h e i r own organization. Many companies have not
taken formal p o s i t i o n s on these d e t a i l e d questions, so respondents
were asked t o make t h e i r best estimate as t o what t h e i r company
would want.
The survey was mailed t o 169 members on January 30, 1992, and
by June l, 76 companies had responded. R e f l e c t i n g the composition
of the W G membership, most of the respondents are Fortune 500
BH
employers whose primary business i s not the p r o v i s i o n of h e a l t h r e l a t e d services or equipment.
However, the survey r e s u l t s do
include seven insurance companies, and another s i x large and seven
small (under 4,000 employees) employers whose primary business i s
h e a l t h - r e l a t e d . Appendix A l i s t s the responding companies.
A
summary of the survey r e s u l t s i s presented below.
Because the current debate involves a number of complex
concepts t h a t can be i n t e r p r e t e d i n various ways, the f o l l o w i n g
d e f i n i t i o n s were provided i n the survey i n s t r u c t i o n s :
"Play-or-pay": Employers are required t o e i t h e r pay f o r a s p e c i f i e d
b e n e f i t package (or a c t u a r i a l equivalent) or pay a p a y r o l l tax.
[The l e v e l of the tax was not s p e c i f i e d . ]
"Organized systems of care":
A reformed delivery system
characterized by carefully selected networks of physicians and
hospitals that
e s t a b l i s h p r a c t i c e standards and guidelines t o ensure the
d e l i v e r y only of necessary and appropriate care,
measure outcomes,
ensure t h a t p a t i e n t s receive, coordinated treatment,
p a r t i c i p a t e i n continuous q u a l i t y
d e l i v e r y of care, and
improvement i n the
�compete w i t h other such systems on the basis of q u a l i t y ,
outcomes and cost.
"Small group market reform": A v a r i e t y of changes t o address the
way i n which insurance i s provided t o small businesses, including
restriction
of p r e - e x i s t i n g
condition
exclusions,
premium
r e s t r i c t i o n s , guaranteed issue, e t c .
OPTIONS FOR RESTRUCTURING THE SYSTEM
In t h i s section, companies were asked f o r opinions on both
i n d i v i d u a l elements of reform and the a c c e p t a b i l i t y of complete
proposals.
Employer role
When asked i f employers should continue t o be the major
provider of health care b e n e f i t s t o t h e i r employees and dependents,
91% answered yes f o r employees, and 87% answered yes f o r dependents
(the remainder answered no).
Employers t h a t answered yes t o these questions were then asked
i f they would change t h e i r answer i f health b e n e f i t costs continued
t o r i s e a t least 15% annually f o r the next three years. Almost
one-third (30%) of responding companies answered t h a t they would
change t h e i r answers f o r employees; j u s t over one-third (37%) would
change f o r dependents.
This response i s v i r t u a l l y the same as the one reported on the
1991 survey.
This s i g n i f i e s a s u b s t a n t i a l and continuing
f r u s t r a t i o n w i t h the current system. We speculate t h a t i t also
indicates skepticism t h a t non-employment-based a l t e r n a t i v e s would
achieve b e t t e r cost containment r e s u l t s than an employment-based
system.
Incremental reform
W G members generally do not believe that incremental reforms
BH
are s u f f i c i e n t to f i x the health care system.
When asked to
indicate t h e i r reaction to the statement "An 'incremental' reform
package (involving components such as small market reform, outcomes
research, malpractice reform) i s by i t s e l f sufficient to adequately
f i x our health care system," only 7% strongly agreed, 18% somewhat
agreed, 9% neither agreed nor disagreed, 29% somewhat disagreed and
37% strongly disagreed.
�Response to statement that incremental
reform is sufficient to fix health
care system
Strongly agree
Someuhat agree
Neither
Someuhat disagree
Strongly disagree
0
10
20
30
40
50
However, two-thirds of the respondents s t i l l thought that the
incremental approach should be attempted for an average of 4 years
before larger changes in the health care system are attempted.
Last year's survey asked a similar but not identical question
(in particular, the incremental reform package given was less
comprehensive than the incremental reforms currently proposed) , but
the response was the same — the vast majority did not believe that
incremental reforms alone could adequately f i x the health care
system, but over half f e l t that t h i s approach should be attempted
before larger measures were i n i t i a t e d .
This response reveals a struggle between the recognition that
comprehensive changes are required and deep apprehension about the
changes proposed i n other plans. While W G members do not believe
BH
that incremental reform i s sufficient by i t s e l f , specific nonincremental alternatives have not yet proven their merit to large
employers.
Employer requirements
"Play-or-pay" provisions that would require employers either
to provide benefits or pay into a public plan continue to generate
significant controversy. When asked for their current position on
the play-or-pay approach, 9% strongly"supported i t , 32% somewhat
supported i t , 11% neither supported nor opposed i t , 18% somewhat
opposed i t , and 30% strongly opposed i t .
�Percentage uho support "play-or-pay"
approach to health care reform
Strongly support
Someuhat support
Neither
Someuhat oppose
Strongly oppose
I t i s important to note that the general question did not
include any specifics about how a play-or-pay plan would be
enacted. Based on conversations with W G members, i t i s probable
BH
that their answers would change based on numerous details, such as
the level of the tax, the treatment of part-time employees, etc.
The question indicates a willingness on the part of many employers
to consider t h i s concept; however, their f i n a l position would
depend on the c r i t i c a l details of how the concept would be
implemented.
Employers that did not strongly support play-or-pay were asked
what provisions i n such a proposal would be essential for them to
take such a position.
Out of 10 options provided (including
"other" and. "none"), the most popular ( i n descending order of
selection) were:
- prohibiting public programs from cost-shifting,
- implementing a broad cost management program,
- significant employee cost sharing, and
�- the p r o v i s i o n of b e n e f i t s through organized systems of care.
Most of these provisions have been incorporated i n t o c e r t a i n
play-or-pay plans.
For example, the Jackson Hole Group, an
informal c o l l e c t i o n of senior o f f i c i a l s from insurers, employers,
academia and government, has developed an employer mandate proposal
which includes strong incentives f o r the development of organized
systems of care and cost management.
State reforms
An a l t e r n a t i v e t o federal l e g i s l a t i o n i s allowing or
encouraging states t o enact i n d i v i d u a l reforms. This course has
been promoted by those who foresee long delays i n achieving
n a t i o n a l l e g i s l a t i o n or who f e e l t h a t the states would be good
l a b o r a t o r i e s t o t e s t d i f f e r e n t approaches. However, others oppose
t h i s course because i t could engender a fragmented system, create
a complex a d m i n i s t r a t i v e burden f o r m u l t i - s t a t e employers, and
postpone a n a t i o n a l s o l u t i o n .
I n general, W G members support federal over state-by-state
BH
health system reform e f f o r t s , i n large p a r t because o f t h e
s u b s t a n t i a l burden t h i s approach would place on those w i t h m u l t i s t a t e operations. When asked f o r t h e i r p o s i t i o n on allowing states
t o enact i n d i v i d u a l , comprehensive reforms, 7% strongly supported
i t , 22% somewhat supported i t , 8% neither supported nor opposed i t ,
17% somewhat opposed i t and 46% strongly opposed i t .
Even i f comprehensive, federal health system reform seems
unachieveable, W G members are strongly opposed to removing ERISA
BH
barriers to enactment of play-or-pay plans by individual states:
while 20% strongly or somewhat supported such a measure, 73%
somewhat or strongly oppose i t (8% neither support nor oppose).
Specific proposals
Any comprehensive proposal w i l l need to include a variety of
different elements.
Of course, many W G members may support
BH
certain elements and not others in a package. However, i t i s
important to have an idea of the overall reaction to comprehensive
proposals. Therefore, one question asked respondents to rate the
acceptability of s p e c i f i c proposals to change the health care
system over the long term, using a scale of 1 (totally acceptable)
through 4 (totally unacceptable).
Seven different scenarios
grouped into four different approaches were presented: incremental
approach, play-or-pay approach, individual-based approach (in which
individuals would purchase their own insurance), and national
health insurance approach.
�The findings were generally as expected. While no single
approach was deemed to be completely acceptable by a majority of
respondents, the national health insurance approach was the least
favored (average score of 3.5). The individual-based approaches
(average score of 3.2) were almost as disfavored as national health
insurance. Proposals in the incremental and play-or-pay categories
were ranked closely together but ahead of the other strategies (the
range was 2.4-2.6).
Benefits
Numerous proposals involve the development of a standard
benefit package that insurers or employers would be expected or
required to offer. Another survey question asked employers what
types of benefits should be available to a l l people covered under
a health benefit plan. The question further specified that the
benefits would be delivered through an organized system of care.
(However, no limits on level of benefits or amount of cost-sharing
were specified.) The following table l i s t s each benefit and the
percentage of respondents who agreed i t should be included.
Percentage of respondents who agreed the specified benefit should
be available to a l l people covered under a health benefit plan
100%
96%
90%
90%
84%
83%
76%
68%
66%
57%
42%
36%
17%
Hospital and physician care
Prenatal care
Preventive care
Well baby care
Pharmaceuticals
Mental health care (with 59% indicating i t should cover
both inpatient and outpatient care)
Chemical dependency treatment (with 50% indicating i t
should cover both inpatient and outpatient care)
Rehabilitation services
Skilled nursing f a c i l i t y care
Health promotion a c t i v i t i e s
Dental care
Long-term custodial care
Vision care
The l i s t of benefits supported by at least half the
respondents i s substantially more comprehensive than that offered
in most plans, especially play-or-pay and incremental reform
proposals.
Specifically, most proposals that specify a benefit
package do not include pharmaceuticals, rehabilitation services,
�s k i l l e d nursing f a c i l i t y care or health promotion a c t i v i t i e s (as
d i s t i n c t from preventive a c t i v i t i e s ) .
Most W G members offer a l l of these types of benefits, and i t
BH
may be that their experiences have taught them the value of
providing these types of care. I t i s also true that most small
market packages do not include organized systems of care; providing
care under such a system would, in the view of W G , allow the
BH
system to offer a wider array of treatments based on the patients'
individual needs than could be offered in a fee-for-service
arrangement.
TAX TfifiATMENT OF BENEFIT?
Changing deductibility and excludability
Two questions explored respondents' support for changes in the
tax treatment of employee benefits. F i r s t , they were asked for
their position on eliminating the deductibility of employee
benefits as a business expense and the excludability of employee
benefits from income. Twenty percent would strongly or somewhat
support t h i s change, while 73% would strongly or somewhat oppose i t
(8% would neither support nor oppose). They f e l t more favorably
towards only capping t h i s treatment; 40% would strongly or somewhat
support t h i s change, while 46% would strongly or somewhat oppose i t
(13% would neither support nor oppose).
Percentage uho support eliminating
deductibility of benefits as a business
expense and excludability of benefits
from income
Strongly support 1 4
Someuhat support
Neither
Someuhat oppose
Strongly oppose
10 20 30 40 50 60 70
7
�Percentage uho support capping
deductibility of benefits as a business
expense and excludability of benefits
from income
Strongly support
Someuhat support
Neither
Someuhat oppose
Strongly oppose
Design for tax on omployoo benefits
Respondents were then asked i f a tax on employee benefits were
inevitable which one of the following alternative approaches they
would prefer.
A majority would prefer that "only benefits in
addition to a standard plan are taxed" (58%) rather than "only
benefits over a certain monetary level are taxed" (38%).
Inclusion of organiied systems of care
An important s h i f t occurred i n respondents' views about
capping the tax favored treatment of health benefits when the cap
was t i e d t o delivery system reform. When they were asked i f they
would support requiring that the current tax treatment of benefits
be retained only f o r benefits delivered through organized systems
of care,
two-thirds of the respondents strongly or somewhat
supported t h i s requirement, while one-quarter strongly or somewhat
opposed i t (the remainder neither supported nor opposed).
�Percentage uho support requiring current
tax treatment of benefits retained only
for benefits delivered through organized
systems of care
Strongly support
Someuhat support
Someuhat oppose
0
1
0
20
30
40
50
COST CONTAINMENT
The survey explored respondents' level of support for several
different mechanisms to contain costs. Responses could range from
1 (strongly support) to 5 (strongly oppose). The table on the next
page summarizes their reactions.
The average ranking of just below 3 indicates that on balance
there i s some support for these mechanisms. However, a substantial
number of respondents hold completely divergent views on the
acceptability of each option. This schism i s the result of several
factors. Some employers believe such strong measures are necessary
to contain costs. Others do not believe that such mechanisms are
effective, do not support such an extensive government role, and/or
are apprehensive about furthering the practice of government rate
regulation.
�Position on cost containment mechanisms
Cost containment mechanism
Percentage taking
each p o s i t i o n
Avg. score
Rate-setting system i n
which government and
providers negotiate maximum
rates and payers can
negotiate lower ones
17
30
9
21
21
3.0
Mandated n a t i o n a l budget
15
32
12
24
18
2.9
All-payor r a t e s e t t i n g
system i n which government,
payers and providers
negotiate rates which payers
and providers must accept
18
36
8
22
16
2.8
1
2
3
4
5
=
=
=
=
=
s t r o n g l y support
somewhat support
do not support or oppose
somewhat oppose
strongly oppose
Another question asked for respondents' opinions on allowing
services provided through organized systems of care to be exempt
from an all-payor rate-setting system. Opinions were divided, with
44% strongly or somewhat supporting t h i s exemption, and 34%
strongly or somewhat opposing i t (20% neither supported nor opposed
i t ) . This mixed response may be due to the fact that exempting
organized systems of care i s a recently-developed concept and
respondents simply may not have had an opportunity to consider i t s
merits.
One of the most controversial characteristics of any reform
proposal i s the means used to finance different elements. While
some analysts (and some survey respondents) believe that there i s
10
�enough money i n the e x i s t i n g system t o pay f o r adequate care f o r
everyone, i t i s l i k e l y t h a t a d d i t i o n a l funds would be needed at
some p o i n t . Therefore, the survey asked respondents t o indicate
what mechanisms they would favor t o raise these a d d i t i o n a l funds.
The t a b l e below l i s t s the d i f f e r e n t options and the percentage
of the t o t a l amount t h a t respondents would r a i s e from each option.
The d i v e r s i t y of opinion exhibited i n the survey so f a r i s f u r t h e r
demonstrated by the f a c t t h a t the range of percentages allocated t o
each option was very wide, varying from 0 t o at least 50% i n most
cases and 0 t o 100% i n two cases.
Percentage of funds t o be raised from each source
Average
Range
15%
0 -
of employee b e n e f i t s from income
14%
0 - 100%
Personal income t a x
14%
0 -
70%
Corporate income t a x
12%
0 -
75%
I n c r e a s i n g p a y r o l l t a x f o r employers
12%
0 -
50%
I n c r e a s i n g p a y r o l l t a x f o r employees
11%
0 -
50%
Other (1)
11%
0 - 100%
Value added tax
90%
E l i m i n a t i o n of or cap on tax
d e d u c t i b i l i t y of employee b e n e f i t s
as business expense and e x c l u d a b i l i t y
S i n t a x (2)
9%
0 -
25%
(Total does not add t o 100 due t o rounding.)
(1) "Other" sources of revenue suggested included c u t t i n g defense
spending, r e q u i r i n g higher cost-sharing, imposing a n a t i o n a l sales
tax or other health t a x , and several other methods.
(2) The i n s t r u c t i o n s asked t h a t no more than 10% of the t o t a l be
a l l o c a t e d t o s i n taxes; however, one respondent a l l o c a t e d 25%.
Last year's survey provided a s i i g h t l y d i f f e r e n t l i s t , so
exact comparisons cannot be made. However, t h i s year shows a
reduced emphasis on the value added t a x , an increased emphasis on
11
�changing t h e t a x treatment of employee b e n e f i t s , and s i m i l a r
responses f o r the other options. This acceptance of a change i n
the tax treatment of employee benefits i s a major s h i f t i n employer
opinion and i s obviously highly c o n t r o v e r s i a l .
Nevertheless,
several questions, explored above, confirm t h i s f i n d i n g .
RESOURCE ALLOCATION
Three b r i e f questions explored respondents' views on r a t i o n i n g
health care. The vast m a j o r i t y believe t h a t :
r a t i o n i n g of care e x i s t s under the current health care system
(88% yes, 12% no)
some form of e x p l i c i t r a t i o n i n g w i l l be required i n the future
(84% yes, 13% no, 3% d i d not respond)
e x p l i c i t p r i o r i t i e s should be set on how we a l l o c a t e resources
t o pay f o r health care (79% yes, 18% no, 3% d i d not respond).
These responses are v i r t u a l l y the same as those i n l a s t year's
survey.
RESPONDENT CHARACTERISTICS
Demographics
Respondents provided the f o l l o w i n g information about
companies.
their
Demographics of responding companies
Average
Range
Total
Number of employees
44,516
140 - 225,000
3.3 m i l l i o n
Number of dependents
72,793
150 - 500,000
4.5 m i l l i o n
Number of r e t i r e e s
18,619
0 - 125,000 1.3 m i l l i o n
Percent u n i o n members
25%
0 - 87%
12
NA
�Plan Characteristics
Numerous other surveys explore the exact b e n e f i t plans o f f e r e d
by various size f i r m s , so only selected c h a r a c t e r i s t i c s t h a t have
p a r t i c u l a r import f o r p o l i c y p o s i t i o n s were examined.
Health b e n e f i t plan c h a r a c t e r i s t i c s of responding companies
Yes
Financial incentives t o choose
managed care plans
Insurance f o r dependents
Insurance f o r temporary or seasonal
employees
Waiting periods
Pre-existing c o n d i t i o n exclusions
NO
66%
99%
33%
0%
20%
41%
36%
76%
57%
62%
COBRA considerations
Companies t h a t used w a i t i n g periods or p r e - e x i s t i n g c o n d i t i o n
exclusions were asked i f they would be w i l l i n g t o eliminate t h i s
p r o v i s i o n i f t h e i r o b l i g a t i o n s t o provide insurance t o former
employees under COBRA were eliminated as w e l l .
Out of 37
respondents, 73% said yes, while 27% said no.
Health Care Costs
Several questions explored respondents' health care costs.
These f i g u r e s are very s i m i l a r t o those reported i n l a s t year's
survey; the average h e a l t h care plan cost i s , not s u r p r i s i n g l y ,
somewhat higher than l a s t year's f i g u r e , and the r a t e of increase
and percentage of p a y r o l l are s i m i l a r .
13
�Health care costs of responding companies
Average
Range
Average, annual health plan premium
cost per employee (employer and
employee share f o r employees,
dependents and r e t i r e e s ) i n 1990
$3649
Average r a t e of increase i n company's
health b e n e f i t costs per employee
over past three years
14%
6 - 40%
Percentage increase i n company's
health b e n e f i t costs per
employee from 1989 t o 1990
13%
- 2 - 42%
Percentage of 1990 p a y r o l l
c o n s t i t u t e d by health care b e n e f i t
costs f o r a c t i v e employees
and dependents
10%
3-30%
$1,296 - $10,840
CONCLUSION
The survey c l e a r l y reveals employers' continuing f r u s t r a t i o n
w i t h the current health care system, and i t provides i n d i c a t i o n s
t h a t the range of reform options they are w i l l i n g t o consider i s
expanding. However, i t i s also obvious t h a t large employers, w i t h
t h e i r divergent corporate c u l t u r e s , economic p o s i t i o n s , employee
demographics and market philosophies, hold extremely diverse views
on the best means t o reform the health care system. Employers do
not speak w i t h one voice on f i n a n c i n g options, access requirements,
l e v e l of government i n t e r v e n t i o n , or other elements of reform.
However, the responses t o several questions do provide support
f o r s u b s t a n t i a l change i n the d e l i v e r y system along the l i n e s of
the organized system of care model. Employers value t h i s concept
so h i g h l y t h a t they can support making a v a i l a b l e a comprehensive
package of care administered through t h a t system. D e l i v e r i n g
b e n e f i t s through t h i s system makes play-or-pay requirements more
palatable. A m a j o r i t y of respondents would support r e t a i n i n g the
current tax treatment of b e n e f i t s only i f they were delivered
through organized systems of care. Many of the respondents t o the
survey have implemented pieces of the organized system of care
model w i t h i n t h e i r own companies. Clearly, from the perspective of
14
�those who have t r i e d the current system and found i t wanting, and
i n i t i a t e d a new system and found i t promising, t h i s concept
deserves inclusion i n any legislative proposal for substantial
reform.
15
�Appendix A:
Respondents
American A i r l i n e s , I n c .
American Express Company
Ameritech
Armstrong World I n d u s t r i e s
A t l a n t i c R i c h f i e l d Company
Bank of-America
Bechtel Corporation
B e l l A t l a n t i c , NSS
Bethlehem Steel Corporation
Bristol-Myers Squibb Company
Brown-Forman Corporation
B u l l Information Systems, Inc.
Caterpillar, Inc.
Champion I n t e r n a t i o n a l
Chrysler Corporation
Ciba-Geigy Corporation
CIGNA Corporation
CNA Insurance
Coors Brewing Company
Corning, I n c .
Dayton Hudson Corporation
D i g i t a l Equipment Corporation
Dow Chemical Company
Dow Corning Corporation
E. I . duPont deNemours and
Company
Federal Express Corporation
Ford Motor Company
General E l e c t r i c Company
Goodyear
Tire
and Rubber
Company
Honeywell, I n c .
IBM Corporation
Intergroup
Healthcare
Corporation
James River Corporation
J.C. Penney Company, I n c .
J.P. Morgan
Kaiser Permanente
Managed Health Network
M a r r i o t t Corporation
McDonnell Douglas Corporation
Mediqual Systems, I n c .
Metropolitan L i f e
Insurance
Company
Mobile Technology, I n c .
Monsanto Company
Owens-Corning
Fiberglas
Corporation
Owens-Illinois, I n c .
P a c i f i c Telesis
P h i l i p Morris Companies, Inc.
PHP Healthcare Corporation
Pitney Bowes, I n c .
Polaroid Corporation
PPG Industries, I n c .
Premark I n t e r n a t i o n a l , Inc.
Provident
Life
&
Accident
Insurance Company
Prudential Insurance Company
Public Employees' Retirement
System
Quaker Oats Company
Rockefeller Group, I n c .
Southern C a l i f o r n i a Edison
Southern
New
England
Telecommunications
The Southland Corporation
Southwestern B e l l Corporation
Texaco, I n c .
Three M Company
Time Warner, I n c .
Tokos Medical Corporation
Towers P e r r i n Company
Travelers Insurance Companies
Unocal Corporation
UNUM L i f e Insurance Company
Upjohn Company
USX Corporation
Wang Laboratories, Inc.
Warner Lambert Company
Westinghouse E l e c t r i c
Whitman Corporation
Xerox Corporation
16
�ORGANIZED SYSTEMS
O F CARE
A Vision of a Future Healthcare Delivery System
T
Thit »meU it am^he American healthcare
the uninsured. While this goal u
dxmtd frvm • g*ftr
syitem is nearing a
extremeiy impoctuu, an equally funpftpand by Gtnt
crossroads. Healthcare
damental concern is the type of
Crvmn, vutptmcost increases have perhealthcare delivery system co which
imttffcHef, ami,
sistently exceeded genwe are providing access for all
Karmliilpua, put- eral inflation and may have reached
Amen cam, both the currently unin'unsuppomble levels. At the sane
susad and the insured pofakhooi.
time, millions of Americans lack
WBGH believes that effective
healthcare system reform must seek
Gromp m HmUk healthcare coverage at any point in
to change how healthcare is orga(WBGH). Umpmr time or experience some lapse of
nized and delivered, along with how
ptr nfitcB cb com- coverage over the course of a year.
Many policymakers no loafer quesit isfinanced.Equally important is
mom of WBGH
the need to better undemand what
Q\gmnwmi Spurns tion that healthcare system reform
works in medicine so that only neccfCanCommittm, will occur; rather they differ on the
r
A
essary and appcopnate care is delivered and reimcJMittd by gjuhkm riminj %\ direction of change.
Angd, DiffiOd Cor- The Washington Business Group on Health bursed. Absent such restructuring and inibrmaponutcn; WBGH (WBGH) enviaons a healthcare system by the tkn, propoaed cost control andfinancingsoluBemrdcfDinaon, year 2000 that supports continuous improve- tions build the tremendous cost of inefScient
healthcare delivery into their proposals.
cbmtrtd by John
Bmnu, biD, Homy ing quaBty, neccsMty healthcare avaihbk to all at Hie purpoac of this ankle is to provide a vision
woUiimdWBGH an a£Bardabte sodeeal coat. Achieving this will of a future where healthcare is delivered to all
reqtare immedbee fbndamcntal ctfeiina suppos- Americans through fomprring organized systems
**ff>hmd*bj
PmidtmMmjJam ed hy a partnenfaip of providers, govemmentt of care. These systems would provide quality,
OMi-dfcaiwe cue and would serve as an organizpurdiaaen, and uaenofhealthcare.
•i—*"^ to >**»\*yirM'j itfbcm ing focusfarthe currentlyfragmenteddelivery
thut
pmptrw*
Support of this viaoa will guide WBGH
i prifDaijly onfioaocssgacceat Soc
at
tin WBGH
FumnHmttkCam
DttimySpum,
Mmyia-X, 1992,
IBUiry
PoMcymakfi no longtr que* ilon of promoting tha haalth of syatam members.
don that hMlthoara system rtform will occur: Te aocompOan tMa miaaioa OSCs will incorporate
radMr dMy dlffw on tha timing and direction of tha prtnclptaa of continuoua q a t improvamem.
u My
cMntfc Th* WMitaflton Buainm Qreup on HcaKti Ova wN ba JaMwaiad thrautf) care management
WBGHu *m+jmr- •nvMom • futur* hMtthcara doiivtfy syattm taama. which inta»«ta tha phyatcal paychotogcai.
oaiM an oflpniad tyatMn of earn (OSQ. An 06C and admMatratlva naada of tha membar. Such
Flu km* f**
* m\ >K^POTM nnannngana awnary wfwunn mat taama mitfK ba made up of primary cart phys*usaa a pan*! of preridars salactad on tha baa* of eiana. nuraaa, and mental haalth profesaionais.
pomibylMvrquality and ceat managamant critaria to fumWi AMwutfi tha antira team would ba raiponsibia for
tha OSC mam bar, ona team member would be
C 1992 by Tho
Tha moat Important qrttam attrlbuta of tha OSC aaaignad primary raapontiMity for ovtrMeing and
wil ba tha conwnitmant of all involved to tha mto- planning care with tha mambar.
Gmtp mHmhk
Copyright 1992 by The Catholic Haalth Aaaociatlon
Reproduced from Haalth Prograaa with parmiasion
�involvement in the heiithcate tyttem reform foundation that society uses to organize its thinkdebete.
ing. Today's healthcare delivery system was buih
As a delivery system VHSOO, this artide assumes on ideals of indtviduaiian and a belief that docthat all Amehcans hive tccess to hcakhcare and ton-not indhftduais with sscknesa-wtre primanly
does not address the complex issues of financing nesponaibkforcuring illness. These ideals have
access. Other work underway at WBGH address- led co knowledge and technological improvees this area and will ultimately be integrated into ments in healthcare delivery unmatched in any
an overall WBGH healthcare system reform pro- other nation. However, as several key healthcare
posal that addresses both access and healthcare measurements indicate, our nation has not organized and delivered these teaourecs in a manner
delivery.
that has allowed them to teach their full pocendal. For instance, compeddonfortechnologically
PUUMM SHIFTS
Paradigms giveformto the underlying ideals and superior products has led to distoctions in the
philosophies a society holds. They become the balance between the supply and demand of
P R DG SHIFTS T W R O G NZ D SYSTEMS OF CARE
AAIM
O A D R A IE
F M m n n I TU T M
u E m NI UW
phistication of ail perticipents in the fu- comes meesured by companng similar
ture healthcare delivery system, coupled indicators across plans, including patient
with the speed of information transfer, and practitioner satisfaction. T satisfy
o
wU lead to akared rotaa. Patients wil be tha cost-effective equation that defines
i
expected to make informed choices value, quality outcomes wil be balanced
about their care, work with practitioners with tha coat of providing the care.
to design and follow appropriate treatment plane, end take responsibility for IWTM RlffMUUTY TI TtiQM
preventing iKneaa. ProvidofS wil activety RONMMJTT
usa tha system's information, respect The present healthcare system encourpetient preferencee. end feeilitata agpe individual stakeholders to abdicate
approaches to care that include overall rasponaibilty for their actions or lack of
heeth indicators. Purcheesrs wil devel- action. In tha future, incorporation of
op selective end evaluative critaria to continuous quality improvement techprovide better cere for their members. niquee will strongly encourage providers,
system members, and purchasers to
take responsibility.* All will be expected
PlTM FN SONKO TI IfflM VlUK
The absence of cemparabto queUty infor- to find new and batter ways to improve
metion in the healthcare d M ey system cara and to solve problems. Responsio vr
Uy
haa reei^ted In e competitive focus pri- b k impiee that members, purchasers,
marily on coat. In addition, healthcare and providers are able to articulate
o
facMtioa have eompeted with tech other oapoctaUona. agree on h w to measure
thioufi better end more expenaive tech- them, and agree to be held accountable
nology! inaurets end menegad care conv fbrihereeufts.
pert as have competed by cutting back
beneflti to keep premiuma lower, negot^ FKH M Scms n FMB M Hun
atlng diaeeunted payments with pro- Current healthcare delivery is pnmanly
viders, or excluding the sick through centered around episodic care, with the
Pmm ParamM n km
undenafMng practicee; and lionaumers entry point being either acute or chronic
PUTIOMTlli
Patients currently art aipaetad te ba of heeltheare-whether individuate or Mneas. A future daifcery system focus on
passive panicipents in their traatmanL pmchaeera—heve woe or ne informecion health will reauk in long-term pertnerProviders feel constrained by ertemeNy on which to beee their buying dedeione. ships that place a high priority on praPenidpenta in tha future heekhcare vendni Mneas. as walas treating it. The
developed protocols, uttttwion review,
and maneged care potioea. And. untl delivery system will compete en the future system will also recognize that
heefth is a dynamic state and that all
recently, pureneaaia nave peeawaqr para
i of value-that is. i
IndMdueis ragardlaea of age or physieai
premium incraaiei every year or shifted
with specifications that demonstrate or menal capaMHy haws the capacity to
costs to others.
The increase in knowledge and so- that cara is neceeaary end indudee out-
Individual practitioners currently dettver
care without tha baneflt of standardized
practice information or systematic
knowledge of both tha pracaaa of ongoing care or car* outcomes, particularly if
it involves multiple practitioners and
treatment sitae.
Tha development of new information
systems, tha maturing concept of managamant based on cooperation, and tha
potential integration of all healthcare
partners will allow movement toward a
unified system capable of combining a
variety of heretofore isolated delivery
system elements. Thafinance,administrative, and care delivery functions will
be integrated. Treatment sites and
healthcare practitioners will become
integrated with tha help of systamwida
data that guide practitioners, patients,
and purchasers on appropnata practica
standards or gudainas. outtomea data,
and treatment optiona. And. finally,
future healthcare daMvary ayatama w*
ba intagratad Me their oonanunftiaa.
HEALTH PROGRESS
OCTOBER 1992 a 23
�ORtAMIZtO
SVSTCMS Of CARC
hohhoit produca.
Five key paradigm
dkfts that underlie the
movement toward
organized syitenu of
care reflea changes in
the environment that
extend beyond the
healthcare setting and
represent fundamental
managerial, technological, cultural, and
psychological changes
already occurring in a
variety of settings in
the United Sates (see
Box, p. 23).
improvement because
everything can be
I
... .
improved.
I ntCgrcltlOn Will DC
* Q ^corporates
^
Jtatiitical techniques
that involve under•
i
i
standing the steps in a
S C C i i 111 L l l C d . C L l l 3 i
process and reducing
variation where warranted.
H ^ l l V ^ r v o f Cdrf* t n
^ ^nire OSC wall
^ ^ U V ^ L y KJL V.tUC LKJ
- .
tomers," including
, /^^/-i
«
patients/members,
CaCfl O o C > ITiembCr.
payers, OSC emplov
ees, public overseers,
the community at
large, and investors.
OlMMZD S S t S If Clll
V TM
Assessing the needs and expectarions of these difGiven the changed environment and resultingferentcuseomers through such methods as marparadigm shifts, it is now possible to articulate a keting research, advisory boards, membership on
future healthcare delivery system-an organized OSC governing boards,focusgroups, and other
system of care (OSC). An OSC is an integrated techniques will be important OSC functions,
finwing tad delivery system that uses a panel of Even more dulkngmg will be the need to manproviden selected on the basis of quality sod cost age conflicts that arise because different cusmanagement criteria to furnish members with tomers have different needs and expectations,
comprehensive healthcare services. An OSC The molt successful OSCs will be those that can
incorporates continuous quality improvement best align their delivery systems to meet the
(CQI) mrdianiams and incentives to provide only widest number of realistic customer expectations,
appropriate and necessary care and is accountable Thefocuson CQI difftn dgnificanriyfromthe
to puicbasert, paocnts, and others on the basis of current model of delivering healthcare, which
cost, quality, and outcooea information.
involves designing inspection systems focused
WBGH believes that delivery of healthcare primarily on poor performance. Although the
through OSCs should become the predominant undcriying prindpie of protection against abuse is
mode of future healthcare delivery. The vast important, the appikadon hasresultedin troublemajority of Americana,regardlessof how their some levels of dissatisfaction on the part of
healthcare isfinanced,should receive care healthcare practitioners, significant financial
through OSCs by the year 2000.
resources
devoted to inspecting care, and a conifttm AUriMM The most important system summg public increasingty confused by how it all
atxxibuts of the OSC wil be the cammitxnent of wada.
all involved to the ssun** of promoting the
A focus on customers will also make OSCs difhealth of system members. AO staff will know, fctcntfromcommunity to community as they
uodenand, and be able to articulate the misaan reflea the difiering demographic, ethnic, enviof the •ymm. Ike development of shared valuesronmemal,geographic, cultural, and socioccoand a comnion vision will be a central tenet of the nomsc mix of their communities. In some comOSCcnkae.
munitica, a physical plant may define the OSC; in
Tb accompibh this mission, OSCs win ineor- others the OSC mey knoive a series of contractupome the pdndpks of CQI, whidh have success- ai trlarinnshipe invoWng linked informaoon and
&0f n-w**—"*flooyAmerican manufacturing acoouneabffity. OSCs wiB recognize that healtha d service coaf>aaea.Tbeae include a iew banc CMS is vidmetely delivered at the local level, while
danoeriades:
sal sogpacdng the needfoenedanal standardixa• Hie quality of heskhearedefivery is b a ^ on tka aaoea canmunitks on cettain aspects of the
a cawfai iiiniri Binding of the needs sad capcua- tirilthf iiedelvcty lysctm.
tsooaof "cuatomax."
Embracing the principles of continuous
• The spedficarion and improvement of the improvement wfflreaukin an OSC that is strucprodua or service is coorinuous, measurable, and tured differentlyfromnearly afl cuirent delivery
never ending.
systems. The OSC will be marked by the integra• Everyone in the organization is involved in tion o£
24
• OCTOBER 1992
I
C
r
e
h a v e
n u m e r o u i
c u l
HEALTH PROGRESS
�• Those who deliver care (e.g., clinicians, tncted rpedaity cam (e.g., heart transplant) or
healthcare pnc&ooncn)
disease-specific care (e.g., cardiac care). What will
• Those who owene* the defimy of care (e.g., define the OSC is the level of coat-eflectivc intehospital and healthcare &eAty tdotnuncors)
gration aaosa these sites chat ensures cononuicy
• Those who adnunistxr andfinancethe deliv- of careforthe OSC member.
ery of care (e.g., imurers, managed care compaAnother key OSC attribute will be a culture
rues, purchasen)
that stimulates the intellectual curiosity and conIntegration will also occur on a systemwide tinued learning of all participants. In the same
basis around such management functions as way that leading American companies support
strategic planning, budgeting, human resource research and development, OSCs will view themplanning, and system suppott services. The inte- selves as laboratoriesforgenerating new sdennfgraoon will be symbolized by OSC leaden who ic, clinical, and organizational informaoon. The
will be trained in both delivering and managing emphasis on informaoon collection and use will
healthcare.
assist in this pursuit, as will possible linkages to
Integration will also be seen in the actual deliv- practitioner training insaturions.
ery of care to each OSC member. Care will be Res Hssit* PtrtatrtMM OSCs will provide new
delivered through care management teams, which modelsforpartnerships among all involved in
integrate the physical, psychological, and admin- delivering,financing,and receiving healthcare.
istrative needs of the member. Such teams might The patient will oo longer be the passive possescomprise primary care physicians, nurses, nurse sor of an illness, but, as a member and partner
midwives, nurse practitioners, physician assis- with the OSC, will assumeresponsibilityforhis
tants, mental health professionals, and ad- or her health. In addition, to maintain his or her
ministrative support personnel. Although the health, the member will access the OSC at rimes
entire team would be responsibleforthe OSC other than when he or she is sick.
member, one team member would be assigned
The systems will not consider prevention and
primary responsibility for overseeing and plan- ffhiranon as optional benefits and services, but as
ning care with the member. In addition, allied central to the efficiency of the health plan and to
health personnel and providen who practice a the health of the member. Being informed, both
more holistic model of medicine will be inte- about their own health and about options for
grated into the OSC and be available baaed on cam, is crucialforconmmcn if the delivery of
identified p****"* needs and piefcicucca.
care isrobe provided as a member-provider partIntegration will also be assisted by the dewlop- nership. Informed ronsumen will use the plan
ment of linked information aaoea a system com-more effificmly by?
U
ponenu. Infotmadon on resource use, costs, and • Taking more personalresponsibifityformainoutcomes of care will be linked in ways that allow taining their health
OSC management to truly understand the value • Identifying problems at eariy stages of develof care delivered. The OSC computeriaed inte- opment, thus malting it canerforpnetitionen to
grated medical recocd will provide the ability to
track patients over numerous
time
• Providing practitionen with more useful
while ensuring continued
The computerized integrated medical recoed wil
* Seetangmore targeted medical care
also promote continuity of cam by linking cam
* Asking appropoate questions when in practiprovided in one OSC to that provided b another.
• Aaaisting practi tionen in developing and
Information system design wffl tncnipnmti the
tonKonng an appropriate course of treatmcBt
needs and expectat
• Complying with agrecd-on treatment regiwill include new types of
customer pteftxences and
OSCawiUi
Thc new heakh pannenhip wiD involve a dear
dnuum of care, from
understanding of therightsand trapontihiliries
through delivety sites that i
the OSC and its members. Initial and
noiogkalty compia to the OSC i
will
The types of cue received within the t
be crodal to managing nprmrions and achievcontracted out will vary depending on their ing hoped-for mncomei. The new hralrh part*
proven necessity, availability, and coat-cfiective- uriihip may also involvefinancialor other conse> In some commuoipea, members imply may quences for noncompliance with agreed-to
go to another suiteforfoUow-upcare in a verti- Rspontibilmea.
cally integrated OSC model. In other communiReadily accessible and easily understandable
ties, memben may go to another facilityforcon- educational material will assist members in makHEALTH PROGRESS
OfllVtlT
NITWOtQ
OCTOBER 1992 • 2 5
�ORCAMIZIO fVSTIMS O CARC
W
lag informed choicei about their care. OSC pun. Such programs could be particularly useful
memben will be pitwided with informaoon that in rural and inner-dty areas where lack of knowlwill allow them to actively paracipete in treat- edge, coupled with transportanon and cultural
memdeciaona, to planforappropriate preventive barrien, make it difficult for persons to access
medical pnxedura, and to make appropnaee life- appropriate services. Care must be taken, howevstyle chanps because of a particular illness or forer, not to punish the OSCfornegative outcomes
general well-being. To encourage pnetidonen to resultingfrommemben who choose not to use
spend more time explaining options, traditional the system, or ux it inappropriately.
indicaton of practitioner productivity need to be The development of parmenhips will extend to
alteredfromthe number of patients seen daily to other stakeholder relationships as well. Purchasen
a more qualitative measure of the type of care of healthcare, whether the goverrusent or pnvate
provided and overall outcome of the interven- employers, will devdop long-term relationships
tion. Traditional reimbursement structures may wtth one or afewOSCs. Healthcare praennonen
need to be altered to rewaid this dungs in mea- and other OSC staff will also be involved m longsuring performance.
term relationships with one or a few OSCs.
OSCs will have some degree of responsibility Indeed,financialarrange menu with the OSC on
andfinandalinterest to proactively seek out the part of both purchasers and OSC staff will
memben who have not used their services. For encourage long-term investment in the system,
memben who are not as motivated to use OSC rather than short-term gain.
services or do notfindthem accessible, each MMMUM mt taamtttty TTie ability to collect
organized system will develop an outreach pro- and make available information on performance
C M A I G O G NZ D SYSTEMS O
O P RN R A I E
F
both room beeceuse of an incontinence functronel mobility end for self-cere to
problem. Mrs. L eipraeses concern that monitor her progress. To sssist her m
her current limited mobility w make it meeting her urinery incontinence probM
even more difficult to reach the bath- lem, e bedside commode is ordered, and
room In time. She alio expreeaee e she ie advised to void her bladder every
strong preference for remeining at home two hours to prevent any mishaps. It is
if et ell posaiWa. Her children suggest suggested that, if her condition changes,
TIE O C Scoum
S
Mrs. L 87. fads on her way to the beth- that they am anxious to help, but their she could benefit from one o the OSC
f
room and breaks her hip. She foes into time ie limited. They do cook three or day care or day treatment programs or
the hoapkal that contracts with her OSC. four meals for her eech week and help one of the intermediate care facilities
it is 20 minutes away from her houae. with laundry, cleaning, yard work, and that the pien contracts wkh.
The physician on duty, who worka for
Mrs. L's haalth plan, cheeks her comput- The
: teem, in con- SCOHMS nw TU Cntor SYSTO
erized record before examining her and sultation with the family, deddee that tasats 1 Mrs. L is on Medicaid and is
realizes Mrs. I hes breksn her hip Mrs. L needs more inteneive heme bmufft into Medicare, through the qualibefore. The physician advisee the ortho- health aaaistance. but of an uneklled fied Medica re beneficiary program, but
pedic surgeon of this fact, and the bonce nature, at least after her condition ttaM- has never used any home health serare set eccoidk^|L
Rzae. Untk she is mora moMs. toietk* viceethroutfi the program. In her state a
dreeeing. treneferring, simple meel 2176 Waiver program, which allows
A cere management team ie i
preparation, and homemeking o u el Medlceid to pay for home care on a budoM
bled to diecuea racowaqrplaf
a discussion on preventing fans. Tho be probiemetic. The family chooses to gat-neutrai basis (whan k can be shown
provide about one-quarter of the visits that an equel number of persons who
teem coneistB of the eflHapedto
themaaivee te ovoid the higher eopey receive reknbufsemont for home health
her usual primary cam managw. a i
mem that Mrs. L's ptan raqukas if aha servieee would otherwise have entered a
eel sedei worker trained In heme I
checeee mora than 24 hours weekly of nursing home), will cover her home
cam manegemant. a physieai'
and an occupational there plat. This unskilled home health asalatance. Tha hoatti needs. However, there « a waittaam meets with Mrs_L and her family noma nMm aiae was cnanga oooos^ or ing 1st for this program, so Mrs. L's chil(Mrs. L Uvea alone, but haa two children clothing as needed during his er her dren dadde to try to provide cara themwho Uvo 30 minutes eway). In the course visit The physical and the occupetionel sefvee and wait for her to become eligiof the discussion, it became apparent therapiats are assigned one visk weekly ble. She ie eligible te receive skilled nursthat Mrs. I usualy ruahae to gat to the te teach Mrs. L exardaaa to
ing servieee, so she ie able to use the
The following cat* study illustrates h w
o
an organized system of cere (OSC) manages a patient's needs. It then deacribas
tha hurdles a patient faces in tha current
healthcare delivery system.
2 t • OCTOBER 1992
HEALTH PROGRESS
�to various coasntocndes, wfaik tupeaing the will be its members and potential members.
confidauiaiicy of the individual member, will be a Currently paoenu choose healthcare providen
fundamentalfeatureof the OSC. Inibnnanon and make decisions about treatment options
baaed on little or no comparable informatioo,
will be uied primarily tot
thereby calling into question the degree of real
• Improve the performance of the OSC
• Facilitate OSC memben' decision making choice available. Pracnooner proximity, family or
friends' recommendations, or personal impreswd choice about their care
sions are often used as cnteria in phyucian or
• Ensure accountability of the OSC to external
treatment selection.
patties
Infbtmation to improve OSC performance will The future healthcare delivery system will
mostlyfocusoo internal management inforrea- involve the development of comparable infbmiauon sy sterna. One hallmark of the OSC is the tion co underlie member choice and decision
ability to link clinical and other administrative making. There will be several points around
data. This will allow OSC managers and health- which an individual will make decisions regarding
care personnel to evaluate the necessity and cost- the OSC. Thefirstis deciding which of several
effectiveness of various treatments or proccases. competing OSCs to choose. Of panicular imporAnother hallmark of the integrated data system tance here will be comparable infocmarion acrosa
will be components chat identify problems or OSCs regarding aggregate performance indicaweaknesses within the system (e.g., undenervice, ton. These might include infixmatioo on OSC
demognphics, staff profiles, utilization, quality,
overservice).
A second constituencyforOSC information member writfacrion, and cost to the member.
BfTBUIB
oaiviir
NfTWOtB
CARE WT THE CURRENT SYSTEM
IH
services of a physical end en occupe- maintenence organization (HMO) for 10 determining whet they cen afford to
yeers. through Medicare, and hea ahmys spend. However, they reelize that ths *
tionel therapiet.
After three momha Mrs. L's children been setisfied with the quality and a short-term solution, aa both Mrs. L's
reassess the situetion. It hes become acceaaibiiity of her cere providen. The chHdran will need to deplete small savM
increasingly difficult for them to meet hospital that contracts with her H O ings accounts to pay for these services.
her needs. The physical therapist has sets the broken hip. She is advised by They em hoping that Mrs. L will improve
helped her recover some of her mobility both the occupational and physical ther- enoufi to achieve better mobility on her
after the accident. However, becauaa apcsrthst in addition to their services, own. The issue of incontinence does not
o o o n
her incontinence wee never diegnoeed. she wil require h m m M g aaaistanee come up: Mrs. Lis too worried about burno appropriate counseling or cam plan and a home heath aide and. if har con- dening her children further. She s hopwaa initiated. She generally mekee it to dition worsane. mi£it need to be instkt^ ing thet she wil be better able to control
the bedaide commode but sometimes, tionelized. She is then referred to s herself, end after al she does not lose
particularty in the middle of the night, social worker to discuss her options. Tho control ovofy time.
she wakes up diaoriamed and ende up fkst queetion she ie aaked ia about her Mrs. L tries to hide her incontinence
with wet bedclothes. It is difficult for ineumnce for long term cam needs. Mrs. for several weeks, sttempting to hold her
either of her chMien to come both in the U Miostaa that she does not have any; urine. When she does have an accident,
sha has slways used the HMO. It she does not tef her children or the aide.
morning and at night, so <
beecmes dear that if she decides to get As s result, her condition worsens and
goea a day without
H
her bedding end undarpwnenti. It is tfMtalpthst is rocofiwnondtde slM wil she develope e serious urinary tract
also upeetttng to her far her cMUran ta have to pay fer end orrango k hametf. infection. She ia treeted for that conditake on thia role. Not wanting to ba a although skilled nursing services ere tion and raeeivee advice about how to
burden on her chHdran, sha suggMS swiabta. to be reimbursed by Medicare. manage her condkion by voiding every
that perhapa she needs to ba tattute* Mrs. I consults her children. They two houra st a bedtide commode. But at
siizod. Thia would take tha burden off agree to chip in and anange for nttmai this point it is undsar whether these preher chiidran and w u be reknburaed by home heefth help, supplemented with eautiona or tha present level of home
oM
Medicaid. The children. rocogtMng the their time. Mrs. L's chHdran call tha health help will be sufficient. Mrs L's
strain on their rsmkee and the poaslbM social worker end get the nemaa of three children remain concerned about the
ty that their mother will probe M need or four home heekh services. Mrs. Lsnd long-term feasibility of their arrangey
mom inteneive cere in the future. 0900 her cMdiwi spend stoeof tlnw dscidinf ments. They hepe they do not have to
to have her edmitted.
o
how much home heefth help they need, inedtutioneMze her end also wonder h w
SMMtl2 Mm. I haa been in her heekh choooing the appropriate agency, end they would pay fork if they did.
HEALTH PROGRESS
OCTOBER 1992 a 27
�CftCANIZIO
SVfTIMf
0f
CAMI
To facilitate inriik adjujted out
fanned patient choice M
m
comei, »nd member
on encry into the OSC •
M
^
.
con.
and to ennuc condnJ 0\-i ITieiTlbCrS
Finally, OSCi will
ued compatibility be •
^
»1JO be required to prorween the member and
vide comparable iggrc •
the OSC, comparable - - . ^ . . I J U ^ . ^ 'i->^k
information about W O l l l Q f l d V C i r i i O r "
other external parties
OSC staff and operaresponsible for monitions will be made
_
tonng overall pertbravailable to each mem- m i l H n n s H n i ' l t ' f h ^
mance. Recipients of
ber. For example, in- I " d U U n a D O U C U H C
^
^
formation about the
include public or pnfollowing could be
. .
. .
^
*
vate organizations that
developed about the f l S K S 3110. D C Q C l l t S O l
conduct the foUowing
patient care teams:
functions: accrediting,
demographic profiles
certifying, momtonng,
(e.g., training/creden. . .^ Inr/»o
purchasing, collecting
tialing, research inter- V d l l U U O p r U L C U U T C S .
and reporting data,
ests), member sabsfacresearching, overseeing
tion with the patient
financial
solvency, and
care team, statement
sanctioning. Informaabout team treatment philoaophy, utilizatian, and don would be in the public domain and easily
quality indicaton. Armed with thia comparable accessible by any interested party,
informaoon, the member could then make an
The process of deciding what types of infbrmainfbtmed choice about which patient care team is don will be collected, how it will be collected,
most compatible with his or her needs.
and bow it will be released will include an underOnce choaen by a new OSC member, the care standing of and responsiveness to the needs of all
management team will be ttsponsiblefercootaa- OSC customen, including sensitivity to issues of
ing the member and gathering baseline infonna- member confidentiality. Although the process
don. This process will ensue that each member must be viewed as dynamic, given the continual
has contact with the system before an episode of evolution of clinical and technological knowlillneas occun, allow the member to meet the edge, there also must be basic agreement on the
managen of his or her care, and give team mem- parameten of information for which the OSC will
ben the opportunity to provide advice repiding be held accountable. Once these are clearly articpotential health problems and preventive mea- dated and agreed to, the OSC will have wide larisures. The initial member contact wiB also pro- tude in managing its petfbrmance.
vide baseline meaaurea, which, when g l T " ' .
will allow an assessment of the OSC's perfor- A FMMDIIL C H M I
mance, u wtU as that of the care management Organized systems of care represent a fundamenteam.
tal change in the delivery of healthcare, one
In addkson, OSC memben would have infer- marked by an emphasis on CQI through informamation about Otarrarnr options, inrhxting the don, kmg-mm
and accounabillty.
risks and benefits of various procedures. Thia Although some organizations and healthcare
might indude general information about out- plans incorporate various elements of this vision,
comes, an uadentandtag of the proceas of treat- the tacfanological and clinical state of the art still
manti coat, and a more prrmnaliiiffi aasesament psedudea full i "[""*"'j«^»«
of tha Beatmeat, pcthapsfromother OSC manIn addtrian, the development af OSCs involves
ben who have undergone the treatment The a fundamental change in the relationships
process of supported rirnsion making wS recog- between heakhcare providers, between patients
nixc that each individual's decision is entirely per- and their providers, and between providen and
sonal but can build on the shared experience of peftn. The trsnsirion to OSCs wffl therefore be
othen.
inarhrd by rraflra ever siahnrky, responsibility,
If the OSC member and his or her patient carereaoureeaOocatioo, afonnatioo, and other obstateam decide that specialty cam is necessary, the des. These obstades, however, can be overcome
member will also have comparable information if there is the leadership needed to implement the
about the specialty care provider, inchsdiag infor- vision-leadership that indudes all healthcare
mation oo the volume of procedures performed, srakrhnideis.
•
r
g l t e
c
1
r
r
r
t 0
A r
4
<
2 t • OCTOBER 1992
i n f o r m a t l o n
|t
HEALTH PROGRESS
�Washington Business Group on Health
777 N Capitol Street N E Suite 800
.
.
Washington, D C 20002 (202)408-9320 T D (202) 408-9333 FX (202) 408-9332
.
D
A
POSITION OF
THE WASHINGTON BUSINESS GROUP ON HEALTH
ON
MEDICAL MALPRACTICE LIABILITY REFORM
ISSUED BY
THE BOARD OF DIRECTORS
March 24, 1992
P U P k y • Institurt on Aging, W A ond Heottti • Instimte fur Rehobilrtuiion ond Disobifity Monogtmtnt • Mentol H o i Services P g m for Yourti
u k oe
o
«M
om
i
" Notional B sn s Coalition F r m on Health • National R s uc C ne on Worksite Health Pwnolion • Prewntion Leadership F r m • Quality R s uc C ne
ui es
ou
eo re e t r
ou
eo re e t r
�I.
Introduction
The Washington Business Group on Health (WBGH) is an organization of Fortune 500
employers that has been involved in public- and private-sector efforts to improve health care
delivery andfinancingsince 1974. In recent years, WBGH's Board of Directon and Medical
Malpractice Task Force have devoted considerable attention to the malpractice liability system.
We have concluded that the current system (1) does not effectively deter negligent medical care,
(2) reduces access to needed services while increasing utilization of costly, inappropriate care
that can actually threaten patients' health, and (3) resolves claims in an inefficient and
inequitable manner. As a result, the malpractice liability system is in need of fundamental
reform.
The time for reform is now. Although the cost of malpractice insurance and the number
of claims paid have stabilized or declined in recent years, there is little reason for satisfaction
with the status quo. Claims and premiums remain far higher than they were a decade ago. The
system continues to perform very poorly in the three ways specified above. Finally, there are
early indications that we may be entering a new cycle of increased malpractice costs. Between
1989 and 1990, malpractice insurers' loss ratio increased by about 10%, and during 1990 the
nation's largest malpractice liability insurer detected an increase in the number of claims filed.
Until we make structural changes in the malpractice liability system, it will continue to hold
patients, providers and payers at unjustified risk.
Before proceeding to WBGH's analysis of the current system and agenda for reform, we
note that the current system's few defenders often claim that their resistance to change is based
on malpractice victims' "rights." This argument grossly distorts the issue. First, the system
does a poor job of vindicating therightsat issue. We can and must do better for all parties
concerned. Second, the U.S. Supreme Court and many state supreme courts have upheld a wide
range of malpractice reforms, despite intense legal challenges. Clearly, then, the specific
arrangements now used to resolve malpractice claims are not built upon inviolable rights that
must preclude more effective alternative arrangements. Third, Congress has modified how a
number of different types of civil claims are addressed, when there have been compelling public
policy reasons to do so. This has been the case, for example, in areas such as workers'
compensation, labor law and employment law.
The poor results which patients, providers and payers obtain from the current malpractice
system creates a strong case for solving the system's problems, rather than standing pat on a
false rhetoric of "rights."
H.
The Malpractice Ltabilhv System's Flaws
A.
Failure to Deter Negligent Care
A principal purpose of the medical liability system is to deter negligent care. While the
incidence of negligent care is difficult to measure, it appears that the current liability system
1
�does not effectively reduce medical negligence.
The two major studies of the incidence of medical malpractice cover California hospital
discharges in 1974 and New York hospital discharges in 1984. Both found provider negligence
in about 1 % of cases. While caution must be used when comparing the results of different
studies conducted at different times and places, these two studies provide the best data currently
available. National data indicate that between 1974 and 1984 the frequency of claims made
against physicians rose by about 300%. Malpractice insurance premiums also rose dramatically.
If the malpractice system operates as an effective deterrent, we would expect these increases to
result in a significant decrease in the number of negligently treated patients. Of course, the
reduction did not materialize. Even if the current liability system could be shown to produce
a small reduction in the incidence of negligence, it is important to realize that a well-designed
alternative system would serve as a much more effective deterrent to negligence.
Clearly, inappropriate, unnecessary and poor quality health care -- whether or not
classified as negligent under standards of care that are often poorly defined - is a major problem
which permeates our health care system. However, for a variety of reasons (e.g., arbitrary
results, vague standards of care, the filing of m n non-meritorious claims and long lag times
ay
between the provision of negligent care and resolution of claims) the current malpractice liability
system contributes little to quality improvement and even creates incentives to practice poor
quality medicine. Again, a well-designed alternative would achieve better results.
B.
Rcduwd Access t N e e Services a d P o oi n of Defensive Medicine
o edd
n r m to
1.
Access
The current malpractice liability system has placed high barriers in front of poor w m n
o e
and women living in rural areas when they seek prenatal care. In a country with a shamefully
high infant mortality rate, this result makes little sense - especially since the rate of negligent
obstetrical care is blown to be extremely low.
Malpractice costs also limit access to care by the burden they place on Community Health
Centers, which are sometimes the only source of appropriate care for vulnerable populations
such as poor pregnant women, HIV-infected persons and homeless persons. In 1989,
Community Health Centers' malpractice premiums equalled 1 % of total federal grant funds
0
awarded to help the centers provide care.
2.
Defensive Medicine
The current malpractice system's cost encompasses both direct premium costs (used to
pay claims and overhead) and the cost of defensive medicine. Premium costs for physicians and
hospitals are about $7 billion per year. Notably, the premium cost per physician (roughly
$15,000 per year) is in about ten times as high in the United States as in Canada.
�The cost of defensive medicine (i.e., services rendered to protect the provider against
malpractice liability rather than to benefit the patient) is, of course, more difficult to calculate,
but estimates generally suggest it is in the range of $10 billion to $20 billion per year. In
assessing this estimate, it is important to recognize that our poorly structured health care system
allows overutilization to profit providers, as well as to protect them against litigation. This
points to the need to consider malpractice reform along with comprehensive health system
reform. However, despite the multiple incentives for the delivery of inappropriate defensive
care, there is broad consensus that defensive medicine is a real phenomenon. At a minimum,
eliminating the need for defensive medicine would set the stage for broader efforts to reduce the
large amount of inappropriate and unnecessary care now provided to patients.
The use of electronic fetal monitoring during deliveries provides one important example
of defensive medicine. According to a recent report, a Utah malpractice insurer found that
failure to use fetal monitors was one of the delivery practices implicated in the bulk of successful
malpractice claims. It now requires all of the physicians it insures to use fetal monitors in all
deliveries. Yet two years ago the Institute of Medicine reported that studies of fetal monitoring
"do not support [its] effectiveness in reducing neonatal mortality and morbidity."
Defensive medicine is not only costly - it also harms patients. Extra procedures carry
extra risk. One study has found that Caesarean section rates increase as malpractice premiums
go up. Caesarean sections produce more maternal deaths and illnesses than vaginal deliveries,
as well as unnecessary medical and disability costs, lost wages and unnecessary pain and
suffering. The Institute of Medicine has noted a correlation between fetal monitor use, which
is stimulated by the current malpractice system, and Caesarean section rates.
C.
Inefficiency and Inequity
The malpractice liability system incurs extraordinarily high transaction costs. Studies
estimate that only about 30% of premium payments reach claimants as compensation. The
remainder is spent on administrative costs, including the cost of defending claims, and plaintiffs'
attorney fees. Notably, defense costs have skyrocketed. Between 1980 and 1984 they rose by
400%, a much higherratethan experienced in other types of liability claims.
Much of the system's excessive and wasteful administrative cost is incurred because it
does so poorly at deterring thefilingof non-meritorious claims, and at winnowing out such
claims before they go to trial. About three of everyfiveclaims are closed without any payment
for damages sustained by the claimant, but not without generating administrative costs. Plaintiffs
win between 20% and 40% of cases that reach the trial stage, as compared with over 60% for
other types of liability cases. This record suggests that inappropriate incentives drive the
medical liability system, encouraging and keeping alive non-meritorious claims. The system's
poor screening of claims does not end with the jury's decision. Medical malpractice awards are
more likely than other types of liability awards to be reduced after a verdict
�The system's inequities are as striking as its inefficiencies. The Harvard study of
negligence in New York hospitals found that fewer than 1 out of 16 malpractice victims receives
compensation. In fact, most neverfileclaims (though half the claims that werefiledwere
determined to be without merit). Too much can be m d of this widely citedfinding.The large
ae
majority of malpractice victims sustained only minor harm, while othen who were harmed more
severely incurred only limitedfinancialdamages. It is also likely that some injured persons
recover most of their losses from collateral sources, such as health and disability insurance.
Nonetheless, it is clear that some persons with substantial injuries and damages caused by
negligence do not receive compensation.
The system's inequities and arbitrariness are also demonstrated by:
o
o
awards that are about three times as large as in comparable automobile injury
cases; and
o
m.
wide variations in damage awards among similar cases;
4 0 variation across states in the frequency with which cases are filed.
0%
WBGH's Medical Malpractice Liability Reform Proposal
WBGH's Board of Directors has adopted the following malpractice reform plan, drafted
with the assistance of WBGH's Medical Malpractice Task Force.
A.
C m rhni e Rf r
p pe e sY eom
Malpractice reform must be comprehensive in scope. This means that it must apply to
all potential targets and theories of liability. Reform that is less than comprehensive will shift
liability among parties, but will not correct the system's problems. Creative pleading by
plaintiffs' attorneys and some courts' willingness to develop new theories of liability will redirect
malpractice suits to any theories and potential defendants not covered by reform.
i.
E po e Liability in Mngd Care S ti g
m l yr
a ae
etn s
Historically, employers have not been a target of suits seekingrecoveryfor injuries
caused by medical negligence. However, in recent years a number of court decisions have
extended liability for injuries caused by negligent care to third party payers, based on their role
in managing patient care. There are early indications that some courts may go even further, by
extending corporate negligence and related theories of liability to employers when employees are
negligently injured whilereceivingtreatment through employer-selected managed care plans.
Therefore, any malpractice-related claim brought against an employer under state law (regardless
of the legal theory it is based on) should be subject to the samereformsconcerning awards.
�alternative dispute resolution, attorney contingency fees and statute of limitation which we
propose for claims against health care providers.
a.
Managed Care Organizations and HMOs
Similarly, malpractice-related claims brought against managed care organizations and
HMOs under state law should be subject to our proposed reforms concerning awards, alternative
dispute resolution, attorney contingency fees and statute of limitation.
B.
Federal Action
Fifteen years of state experiments with limited tort reforms has produced some partial
successes, but has not produced comprehensive change. Given (1) the stake of the federal
government, multi-state employers, multi-state managed care entities and multi-state malpractice
insurers in malpractice reform and quality improvement and (2) the relationship of malpractice
reform to comprehensive health system reform, the time for federal action has arrived. States
wishing to adopt reforms which go further than the federal-level reforms we are proposing
should be permitted to do so.
C.
Resolution of Claims T r u h Binding Arbitration
ho g
The current court-based system of malpractice litigation should be replaced by a binding
arbitration system designed to speed-up claims resolution, bring greater expertise and consistency
to fact-finding and decisions and reduce transaction costs. A system which meets these criteria
will compensate more injured persons while discouraging non-meritorious claims, encourage
earlier settlement through greater consistency of decisions, and send a more rapid and clear
definition of the standard of care to providers.
Under our proposed system, arbitration panels operating under the auspices of a state
agency would be established to decide medical liability claims. Decisions would continue to be
fault-based (i.e., the panels would apply the legal standard of care to determine whether an
injury was caused by negligence). A simplified procedure for filing claims would be
implemented to promote easy access to the claims resolution process for all persons with
meritorious claims. The process would provide for expedited examination of claims,
investigation and hearing, and appellate review before an agency panel, and would be mandatory
for all persons seeking redress. All arbitration panels would be required to
o
be varied in composition (i.e. business, medical, consumer and legal
representatives) and include physicians in the same specialty as the physician in
question;
o
conduct an arbitration procedure which includes discovery of evidence, a hearing
and a decision within six months;
�o
provide standardized data and information on medical injuries and their causes to
agencies responsible for monitoring quality of care.
Reform legislation would apply a similar process to malpractice-related claims against
parties that are not health care providers.
1.
Appeal to the Courts
A well-designed arbitration system should replace the inefficient and inequitable courtbased resolution of malpractice claims, not add another costly layer to the present system.
Therefore, while the parties should be permitted to appeal from the final agency decision to the
courts, the appeal should not give the parties an opportunity to "retry" the case. The court
which receives appeals should have discretion in deciding which cases to take, and the appellate
court should apply a high standard of review.
D.
Practice Guidelines
The malpractice liability system should encourage high quality care as a means of
reducing the incidence of malpractice. WBGH supports the use of clinical guideline criteria to
improve quality and address the malpractice liability problem. A guideline-centered approach
attacks the causes (rather than the symptoms) of medical malpractice and recognizes the systemic
nature of the malpractice problem.
Practice guidelines will improve quality, and thus reduce the incidence of malpractice,
by challenging inappropriate treatment protocols. Guidelines based on solid research will
indicate that providers should take some steps that they frequently omit (e.g., assuring that a
certain procedure is indicated by the patient's symptoms), or omit some steps that they often take
(e.g, tests ordered for defensiveratherthan diagnostic purposes). Practice guidelines will also
make it easier to resolve malpractice claims by reducing ambiguity in the standard of care that
applies to health care providers.
Practice guidelines should be used in the following manner to make malpractice
determinations. First, defendants should win dismissal of the case against them if they can
prove that (1) they adhered to a practice guideline certified by the Secretary of Health and
Human Services (HHS), (2) the guideline was the correct guideline to apply and (3) the guideline
covers the act or omission alleged to have caused the injury. Second, plaintiffs should be
allowed to raise failure to meet the appropriate certified guideline as a rebuttable presumption
of negligence. If there is no certified practice guideline for the diagnosis or treatment issue,
liability would be determined only with reference to other applicable law.
Practice guidelines used in malpractice claims should be established as follows:
o
The Secretary of Health and Human Services would certify practice guidelines
which would serve as a standard of care for determining malpractice liability.
�The Secretary would also be responsible for appropriate ongoing review and the
updating of guidelines. Initially the Secretary might certify a number of
acceptable guidelines, but ultimately one national uniform guideline would be
certified as the standard for each particular diagnosis for treatment.
o
Procedural requirements for certification should include establishment of a broadbased advisory panel to advise the Secretary on federally supported guideline
development efforts, as well as certification decisions. It is particularly important
to balance medical specialty society participation in guideline development and
certification with participation by other key parties. Therefore, the panel should
include substantial business and consumer representation.
o
Practice guidelines should be uniform to the greatest extend practicable,
regardless of the source of payment for the patient's care. Reliance on local
standards of practice should not be encouraged, but would be permitted during
a transitional period as the guidelines certified by the Secretary are implemented.
E.
Constraints on Awards
1.
Mandatory Payment to Collateral Sources
The collateral source rule prohibits the introduction of any evidence to a jury that a
patient has been compensated or reimbursed for his injury from any source other than the
defendant, such as health or disability benefits. Therefore, plaintiffs can receive a double
recovery: one from an insurer or employer and one from the defendant.
Double recovery should be eliminated. Collateral sources should be paid for their
expenditures out of the settlement or award. Studies suggest that eliminating double recovery
reduces both thefrequencyof claims and the size of awards by about 15%.
Several states now require that damages awards be reduced by the amount paid by
collateral sources, and many reform proposals endorse this rule. WBGH rejects this approach.
Where negligence is found by a reformed malpractice system (either expressly by
arbitration panels or tacitly by settlement), the negligent provider or system of care rather than
the innocent collateral source should bear the cost of negligence.
2.
,ft
Nffli-Rm niff r*™^"
As suggested above, malpractice awards do not correlate well with the level of injury
sustained by a patient. In addition, non-economic damages (damages for pain and suffering, loss
of consortium and loss of enjoyment of life) substantially exceed damages for monetary losses.
Because non-economic damages are difficult to accurately ascertain and are a principal reason
for arbitrary variation between malpractice awards, they should be capped at a reasonable level.
We recommend that the cap be set at the lower of a state-enacted tort liability cap or $250,000.
�A California law which places the ceiling at $250,000 has been effective at stabilizing premiums
and encouraging settlements.
We emphasize that economic losses resulting from malpractice should remain fully
recoverable.
3.
Periodic Payment of Future Economic Damage Awards
Economic damages in excess of $ 100,000 intended to compensate for future losses (e.g.,
lost income, medical expenses) should be paid on a periodic basis rather than in a lump sum.
Insurers are better able to appropriately finance large awards under a periodic payment system.
4.
Punitive D m gs
a ae
Punitive damages are intended to penalize particularly egregious behavior and deter
similar behavior in the future. They are not based on economic or non-economic damages
suffered by plaintiffs. Because they are a policy tool rather than a means of compensation,
punitive damages should be paid to state agencies that monitor and discipline health providen
instead of to patients.
5.
Eliminate Joint a d Several liability
n
Under the doctrine of joint and several liability, each party is fully liable for the total
amount of the award. The effect when one or more defendants are without resources m y be
a
to require a defendant with a limited role in causing an injury, but with a " e p pocket," to bear
de
a disproportionate share of compensating the plaintiff. This doctrine can disrupt settlement
negotiations and is inherendy unfair when defendants are marginally related to the cause of
action. Therefore, WBGH advocates elimination of the joint and several liability doctrine for
all claims against providen, manufacturers and employen.
F.
Cap on Attorney Contingency Fees
Attorney contingency fees should be capped on a sliding scale related to award size.
Attorney fees should be calculated on the basis of net proceeds to the plaintiff after payment of
litigation expenses.
Contingency fees are often defended as giving attorneys an incentive to screen out nonmeritorious cues. The data presented above on the number of non-meritorious claims filed
indicates that they have not performed this function well in the medical malpractice setting.
Nonetheless, to the extend this function is performed by contingency fees, it would be
strengthened by a modified fee schedule.
Contingency fees are also defended as a mechanism to improve plaintiffs' access to legal
services. This argument can be overstated. One observer cited in a 1987 General Accounting
8
�Office report argues that most lawyers will not accept a malpractice case with an anticipated
recoverable amount under $50,000. Furthermore, the principal that contingency fees improve
access does not necessarily dictate that fees should reach the very high levels found in many
cases.
Overall, a sliding fee schedule, combined with a lower-cost alternative dispute resolution
process, should improve screening of non-meritorious claims while maintaining at least the same
level of access as current fee arrangements. Simultaneously, a sliding fee schedule should
reduce abuse of the contingency fee system and return a higher portion of most awards to injured
plaintiffs in need of compensation.
G.
Statute of Limitation
WBGH recommends adopting a two year statute of limitation that begins at the time the
claimant discovered or should have discovered both the harm and its cause. A statute of repose
should also be enacted which provides for an absolute limit on when a case must be brought.
Such a policy is justified for two reasons: (1) it avoids the possibility that the relevant evidence
will become stale because documents are lost, witnesses become unavailable or their clear
recollection dwindles and (2) excessive delay is disruptive to the insurance underwriting process
because it is harder to accurately reserve and price the insurance product when there is a "long
tail of liability."
This provision should include an exemption for minors under six years of age, such that
the statute of limitation does not begin to run until the child's sixth birthday. Abnormalities
resulting from any injury should be detected by the time a child reaches school age.
H.
Physician Licensing a d Discipline
n
Many state physician licensing and discipline agencies are not performing effectively.
They should be given strong incentives and adequate means to significantly improve their
performance.
In connection with physician licensing and discipline, we note that establishment of the
National Practitioner Data Bank was an important step forward. However, the Data Bank should
be modified so that it can function more effectively. In particular, the public should have access
to reports on providen prepared by the Data Bank. With malpractice determinations made
through a reformed system, we see no justification for withholding information from consumers
about the quality of providen.
I.
Malpractice Reform and Competing Integrated Systems of Care
Poor quality, inappropriate and expensive medical care is not simply the result of
individual negligent providen. It is also the predictable outcome of a fragmented medical care
delivery system that is driven by perverse incentives. While malpractice liability typically
�focuses on negligent individuals, it does little to address the systematic causes of negligent and
other poor quality care.
To improve quality and reduce the incidence of negligent care, health system reform
legislation must go beyond redesigning the malpractice liability system and address the
underlying flaws in the way health care is delivered. This entails creating strong incentives for
the development of competing integrated systems of care. In our working definition of this
concept, integrated systems of care are vertically integrated financing and delivery systems that
use panels of providers selected on the basis of quality and cost-management criteria to furnish
members with comprehensive services. The integrated systems incorporate into their operations
continuous quality improvement mechanisms and incentives to provide only appropriate and
necessary care, and are accountable to purchasers and patients on the basis of cost, quality and
outcomes data. Adopting this proactive strategy will produce far greater benefit than consigning
quality improvement solely to a redesigned malpractice liability system.
In our view, an integrated system of care will usually be in a much better position than
an individual provider to prevent negligent and other poor quality care. Malpractice reform
legislation should recognize this by providing that claims involving providers who are part of
an integrated system of care be filed against the system rather than the individual provider.
This, along with strict experience-rating of malpractice insurance premiums charged to integrated
systems of care, would give the system a strong incentive to improve quality.
10
�Washington Business Group on Health
777 N.Capitol Street NE Suite 800 Washington, DC 20002 (202)408-9320
..
..
100(202)408-9333
FX (202) 408-9332
A
POSITION OF THE
WASHINGTON BUSINESS GROUP ON HEALTH
ON
RESTRUCTURING THE SMALL GROUP HEALTH INSURANCE MARKET
ISSUED BY THE
BOARD OF DIRECTORS
February 20, 1992
Public Policy • Institute on Aging, W r and H o h • Institute for Rehobilitotion and Disability M n g m n • Mentol Health Services Po r m for Y uh
ok
eh
oae et
r go
ot
National B s e s Coalition F r m on Health • Nationa! R s uc C ne on Worksite Health Promotion • Prevention L a es i F r m • Quality R s uc C ne
ui s
n
ou
eo re e t r
e d r hp ou
eo re e t r
�I.
INTRODUCTION AND BACKGROUND
The Washington Business Group on Health (WBGH) is an organization of Fortune 500
employers that has been involved in public and private sector efforts to improve health care
financing and delivery since 1974. When WBGH was founded, our nation's health care system
was merely troubled. Today, it is in crisis. Therefore, WBGH supports comprehensive and
fundamental change in the way health care is financed and delivered.
Over the past few years, much of the health system reform debate has focused on small
employers. This is because small employers are less likely than larger employers to provide
health benefits to their workers, and there are serious concerns about the cost, quality, and
stability of the coverage obtained by those small businesses which do offer health insurance to
their employees.
Underlying health care cost trends are the root cause of many of the small group market's
problems. However, these problems have been exacerbated by the ongoing fragmentation of
large insurance pools that spread risk broadly into smaller pools that concentrate risk.
Consequences of the small group market's fragmentation include:
o
Rejection of "highrisk"groups applying for coverage or very high premiums
charged to such groups;
o
Refusal to renew a group's coverage or renewal only at a massive premium
increase when an individual group member becomes sick;
o
Exclusion of highriskindividuals from group coverage;
o
Broadly drawn preexisting condition exclusions; and
o
Excessive movement of small groups from one insurance plan to another, which
greatly increases administrative costs.
In essence, the market has gone from open enrollment at a community rate to selective
enrollment and reenrollment at rates which approximate a group's own level of risk.
In response to the problems cited above, numerous plans have been proposed to change
the way in which the small group health insurance market operates. This paper states the
position of the WBGH Board of Directors on how the small group market should be changed.
Part n. explains the basis of our interest, as mostly large employen, in how the small group
market operates.
The most commonly recommended approach to addressing the small group market's
problems is to restrict insurers' underwriting and rating practices through a set of rules usually
referred to as "small group market reform." A number of states have adopted such plans, or
�at least some of their dements. Many insurers have gone on record in support of small group
market reform.
Most small group marketreformproposals include the following elements, though there
are important differences in how some of the elements are implemented:
o
A guarantee that any small group applying for coverage and meeting minimum
participation requirements will be accepted by some or all insurers operating in the small
group market. Some plans limit this guarantee to a specified benefits package.
o
Guaranteed renewal of coverage, except for cause (such as nonpayment of premium,
fraud, or failure to meet minimum participation requirements).
o
Limits on premium increases at renewal which selectively target specific groups. For
example, an insurer may be prohibited from increasing a group's premium by more than
the average premium increase charged to groups it shares risk with, plus 1 % .
0
o
Strict limits on preexisting condition exclusions. Usually, the exclusions are limited to
a six or twelve month period and new exclusions can not be applied to continuously
insured persons changing jobs and groups changing insurers.
o
Limits on the amount premiums can vary between groups covered by the same insurer.
o
Acceptance or rejection of an entire group in those situations in which an insurer is
permitted to reject a group (i.e., accepting a group but excluding individual members is
not permitted).
o
Voluntary or mandatory insurance to spread the risk of high cost cases across insurers.
Some proposals would also override state mandated benefit and anti-managed care laws
in the small group market.
Small group marketreformis an incremental financing change. It will not, by itself,
appreciably reduce the number of uninsured persons working for small businesses, significantly
contain health care costs or the average cost of insurance to small businesses, or create
incentives for health care providen to correct the serious flaws in the way health care services
are organized. Equally important, most of the small group marketreformproposals made to
date would not set the stage for subsequent, more comprehensive health system changes.
Finally, most of the proposals probably would not fix even some of the narrow problems they
were designed to correct. In Section m. we briefly critique the small group market reform
1
'For discussion of this point, see W G Staff Working Papers
BH
on Public Policy #1, "Small Group Health Insurance Market Reform,"
November, 1991.
�approach.
WBGH has considered the small group market reform concept with caution, because it
supports fundamental rather than incremental change in our health care system. We are
concerned that adoption of small group market reform legislation would only marginally improve
our health care system, but could delay action on more fundamental changes. However, vyelldesigned changes to the small group market that go beyond most current small group reform
proposals can 1) inhibit further deterioration of small group coverage, 2) address some of the
most immediate problems faced by individuals covered through small employers, and 3) begin
to implement a more comprehensive and fruitful health system reform strategy. Therefore, we
have chosen to enter the debate over the design of a plan to address the small group market's
problem.
We are also issuing this position statement in part because changing the rules in the small
group market appears to be one of the most politically viable steps for the 102nd Congress to
take. The changes should be designed to be as effective as possible, and we believe that our
plan can contribute to this goal. However, by recommending changes in the small group market
we are not committing WBGH to an employment-based strategy for comprehensive health system
reform. This is one option, but we will consider others as we finalize WBGH's position on
comprehensive reform during 1992.
Our small group plan, which freely draws on concepts developed by others, is described
in detail in Section IV. below. In general, it would restructure, not simplyreform,the small
group market. While our proposal for small group market restructuring shares small group
market reforms' restrictions on rating and underwriting practices, it goes well beyond them by
aggregating small groups into large, purchaser-driven purchasing corporations.
(Recent proposals by President Bush, some Democrats, such as Senator Bentsen, and
congressional Republicans, such as Senator Chaffe and Representative Chandler, have begun to
incorporate elements of this strategy.)
The restructured market's large, purchaser-driven corporations will contain administrative
costs and health services costs more effectively than areformedsmall group market. They will
also do more than thereformmodel to reduce 1) the "hassle factor" small employers face when
they offer insurance, and 2) selection effects which cause inefficiency in the small group market.
Finally, these purchasing corporations could become catalysts for much broader health system
changes. Standard reform proposals do not have this potential.
By establishing purchasing corporations covering a large number of individuals and
certain rules to avoid biased risk selection, our proposal eliminates the need for undesirable
reinsurance arrangements. This is another important difference between our proposal and many
small group marketreformplans. Mandatory reinsurance arrangements could significantly
interfere with cost containment incentives and efforts to promote accountability throughout the
health care system. This aspect of our plan is also discussed in Section IV.
�In one respect, our proposal would govern large as well as small groups. We would
apply restrictions on preexisting condition exclusions to all employment-based health benefit
plans. This is discussed in Section IV.
We note that we do not expect small group market restructuring, by itself, to markedly
reduce the number of uninsured workers. While it should do better at expanding coverage than
small group market reform because it will more effectively contain costs and reduce the "hassle
factor" for small employers, it will not drive costs low enough to induce a large number of noninsuring small businesses to begin offering coverage voluntarily. Additional steps will have to
be taken to assure that all Americans have adequate health insurance.
H.
BASIS FOR WBGH INVOLVEMENT IN SMALL GROUP MARKET REFORM
WBGH works closely with many small and mid-sized businesses through its close
affiliation with the National Business Coalition Forum on Health. This gives WBGH a direct
stake in the small group market reform debate. However, WBGH's corporate members are
large, mosdy self-insured employers. While our members are adversely affected by out-ofcontrol health care costs, their health benefit plans are not characterized by some of the other
problems that have become all too common in small groups' plans.
Even though WBGH's corporate members are not buying insurance in the small group
market, they are directly affected by it. First, large corporations participate in the same health
care system as small groups. The manner in which the 35 to 40 million persons insured through
small groups (defined here as businesses with fewer than 100 employees) obtain health services
heavily influences the steps large employers are able to take as they work to manage costs and
improve health care quality.
Second, WBGH's members deal with small businesses as customers, suppliers and
franchisees. Small businesses' ability to perform these roles in a productive, competitive fashion
is directly affected by their health insurance arrangements.
Third, WBGH's members pay more than their fair share of health care costs, partly
because the workings of the small group market prevent some of their employees' spouses and/or
dependents from obtaining coverage through their own jobs at small companies. In addition,
the broad preexisting condition exclusions which are much more common in the small group
market than in large employers' health plans cause uncompensated care paid for by large
employers.
Finally, whatever conclusion is reached in the small group market reform debate may
directly affect the larger health system debate. The rules applied to small employers could
eventually influence the rules applied to all employers.
�m. SMALL GROUP MARKET REFORM'S SHORTCOMINGS
Rating and underwriting restrictions are much needed in the small group market.
However, simply superimposing these restrictions on present small group insurance arrangements
has a number of shortcomings. At best, small group market reform will achieve its narrowlydefined goals (principally, making coverage more available, affordable and adequate for high
risk groups) but will fail to promote more fundamental health system changes. At wont, small
group reform will not attain some of its goals. Small group market reform's shortcomings, in
relation to the small group market restructuring that we advocate, include the following seven
points. We emphasize that we are discussing small group market reform in general terms, since
reform proposals vary markedly.
A.
Lack of Market Power
The extreme fragmentation of buyers' purchasing power is one of the key reasons that
our health care system is so wasteful and costly. The present small group market is the most
extreme manifestation of this situation. Small employen have, for practical purposes, no market
power - a small group's decision to switch carriers has little impact on insurers and providers.
This gives insurers and providers little incentive to respond to small groups' needs. Similarly,
many of the small insurers operating in the small group market have little leverage over
providen.
In contrast, pooling small employen and their employees as we propose would give small
groups substantial leverage over insurers and providen, and carriers participating in the small
group pool would all cover enough lives to gain substantial leverage over providers. This
leverage could be used to obtain favorable financial arrangements, avoid cost-shifting, and insist
that providen meet reasonable performance standards.
B.
r. min nftli«.SvstPin
a
?
Small group market reform can achieve its goals only if small groups' selection of their
sources of coverage is not biased by their level of risk. If there is biased selection, high risk
groups will continue to pay much higher premiums than lowriskgroups. Additionally, carrien
will continue to compete on the basis ofriskselection, rather than the efficiency and quality of
services they deliver.
Small group market reform is vulnerable to biased selection, produced by practices such
as selective and passive marketing. Furthermore, small group reform's rating restrictions would
increase insuren* incentive to engage in risk selection. As Lynn Etheridge, a respected
independent health policy analyst testified before the House Ways and Means Committee,
I must raise the question of how well regulation of experience-related plans will
work in the small group health insurance market.
�Are state insurance regulaton really going to police and enforce standards
for marketing, rating and other business practices applied by all insurance
companies for the nation's myriad gas stations, drug stores, laundries, restaurants,
and other small employers - particularly when there are so m n sophisticated
ay
ways to game the system and so m n insurance companies that have already
ay
shown themselves adept at doing so. The track record of state health insurance
regulation is not inspiring...
And I worry that the difficulties of obtaining industry-wide agreements bodies ill
for a presumption that good citizenship can be counted on to prevent egregious
behavior.
Apparently, some insurers agree that biased risk selection could be a problem under small
group market reform rules, since they support creating a reinsurer to spread the cost of high risk
cases across insurers.
In contrast, an employer-governed pool can more effectively prevent biased selection, by
selecting carriers and plans to participate in the pool, handling most marketing functions, and
establishing and enforcing any other needed rules.
c.
Retaining the Hassk Factor
The administrative burdens of offering health insurance fall especially heavily on small
businesses, since they lack the administrative staff to handle plan-related paperwork. Time spent
on administering health benefits is usually time not spent on more productive tasks.
Administrative burdens may also be relatively greater in small than large businesses, due to
higher employee turnover rates.
Small group marketreformdoes little to reduce the administrative burden on small
employers. In contrast, small group marketing restructuring would eliminate nearly all of the
administrative tasks now performed by employers.
D.
Lack of Professional Benefits A
•!.>i
MR-iu-m']'
Small businesses would continue to lack the advantages of professional administration in
a reformed small group market. Small business managers without substantial experience in
arranging health insurance coverage would continue to negotiate with carrien over the structure
of their insurance plans, in addition to performing the routine administrative functions discussed
above. In contrast, professional administrators working on behalf of a small employer pool
would have the expertise needed to effectively design plans, negotiate with carrien, evaluate
�carrien' performance and convey this information to employees, etc. In addition, professional
administraton would have an opportunity to undertake major cost management and quality
improvement projects. For example, they might seek to establish a uniform claims data base
covering all of the pool's insured lives, for the purpose of profiling providen' practice patterns.
E.
Reinsurance
Most small group market reform plans include some type of reinsurance mechanism,
which would spread the cost of high risk groups across insuren. A reinsurance mechanism is
necessary, in part, because many carrien might have small risk pools unable to bear the risks
associated with open enrollment.
Reinsurance pools have the potential to seriously undermine cost management incentives
in the small group market. If the reinsurance pool coven a large proportion of high risks'
groups costs, carriers incentives to manage their costs will be weakened. Further, if the history
of similar mechanisms in the workers' compensation and automobile insurance contexts is a
guide, a high proportion of small groups could become covered through the pool. Reinsurance
arrangements would also add considerable administrative complexity to the small group market.
Finally, the assessment mechanism used to pay for the pool's losses would force more efficient
carrien to subsidize their less efficient competitors.
In contrast, our proposal dispenses with reinsurance. Carrien participating in the pool
would have largeriskpools better able to bearrisk,the pool would control marketing to reduce
biased selection, and the pool could institute other rules as necessary to avoid biased selection.
As discussed in Section IV., the pool would also be authorized to transfer premium revenue
between carrien to resolve any biased selection problem which does arise. This would retain
carrien' financial incentive to effectively manage high cost cases, since they would remain at
risk for costs in excess of their prospectively adjusted premium revenue.
F.
AtiminfrtratiYf Cmto
Small group market reform may help reduce the administrative costs charged to small
groups as part of their premiums. For example, under some plans underwriting and broker costs
could drop, akng with general administrative costs associated with group movement between
insuren. However, by centralizing many market functions and a variety of administrative tasks
and further reducing die turnover rate, the pooling approach we support would do a better job
at keeping administrative costs down. By standardizing how claims are handled for a large
number of people, a pool may also help to constrain providen' administrative costs.
�G.
Uck of Choke
Small group market reform theoretically gives employen at least some choice of carrier.
It does not give most individual employees a choice of coverage, since few small employen are
in a position to offer more than one plan. As discussed below, a restructured small group
market could offer individual employees a choice of several plans.
IV. WBGH'S SMALL GROUP MARKET RESTRUCTURING PROPOSAL
Federal legislation to restructure the small group market should include the provisions
described below. Because (1) local market conditions vary and (2) it is not possible to predict
all of market restructuring's effects overtimewith a high level of confidence, states should be
given the opportunity to choose between a limitedrangeof restructuring models. In addition,
federal legislation should give state insurance commissionera and small employer purchasing
corporations considerable leeway in how they implement restructuring's details. They should
not be micromanaged from Washington.
Our proposal is tailored to a voluntary employment-based health insurance system. All
of its key characteristics would apply to an employment-based system which included mandated
employer-provided coverage or a play-or-pay requirement. However, some details, such as the
specifics of restrictions on insuren' rating practices, would be modified if an employer mandate
or play-or-pay were adopted.
A. Restructuring Models
We propose that states be given a choice between two restructuring models. Under the
fint model, all health insurance sold to small groups in a state would be sold through a not-forprofit small group purchasing corporation. One purchasing corporation could cover the entire
state or separate purchasing corporations could cover each state region, as determined by the
responsible state agency. Each purchasing corporation would encompass all small groups
offering health benefits, regardless of the group's industrial classification, within its territory.
The purchasing corporation itself would not offer insurance, since allowing it to do so
would compromise its role as an honest broker working for employen. Rather, it would
contract with a limited number of competing carriers to provide coverage to the purchasing
corporation's member businesses and employees. Carrien that are not selected to participate
in the purchasing corporation would not be permitted to provide coverage to small groups.
2
'"Carriers" i s broadly defined to include any health care
financing entity.
8
�Small employen which choose to offer health benefits would enroll in the purchasing
corporation, and their employees would choose their coverage from among the competing plans
offered through the corporation. The purchasing corporation would (1) perform a variety of
administrative functions and (2) set and enforce rating and underwriting rules (within legislative
guidelines) to assure a fair and efficient small group market.
Under the second model, statewide or regional purchasing corporations would be
established. However, employer membership would be voluntary, and carrien that do not
participate in the corporation could offer coverage to small groups. All carrien covering small
groups, whether or not operating within the purchasing corporation, would be subject to the
same strict rating and underwriting rules, including the requirment that they accept all groups
applying for coverage.
3
1.
Groups Covered by Restructuring
Small group market restructuring is designed to resolve problems caused by strict
underwriting criteria, experience-related premiums and high administrative costs, among other
facton. At the present time, exclusionary underwriting practices which make coverage
unavailable to high risk groups and individuals are most frequently applied to groups with fewer
than SO employees. Experience-related premiums can cause problems for much larger groups,
since one or two large claims can dramatically increase premiums in experience-rated groups
with up to several hundred employees. (Although a business with a few hundred employees is
not a small business, for insurance purposes it is a small group.) Groups with as many as a few
hundred employees pay administrative costs of 10% or more.
Taking into account both the problems experienced by businesses of different sizes and
the need to create a broad base to spreadriskand generate market power, we propose that all
groups with fewer than 100 employees be covered by small group market restructuring. States
should be authorized to expand market restructuring rules to groups with up to 250 employees.
All employer groups up to the size selected by the state they are located in which choose
to offer health coverage should be required to obtain their coverage through the restructured
small group market.
'Purchasing corporations and state insurance regulators should
be authorized to promulgate rules, at their option, that would
allow small groups to be covered through large groups with which
they have a business affiliation.
Purchasing corporations and
state insurance regulators should have wide latitude to set rules
which prevent any such arrangements they choose to allow from
defeating small group market restructuring's purposes.
�B.
Underwriting Restrictions
1.
Open Enrollment
All plans offered by carriers to small groups and small group employees should be
offered on an open enrollment (i.e., guaranteed
issue) basis, whether the first or second small group market restructuring model is adopted.
Open enrollment should not be limited to a basic benefits package. Any carrier participating in
the small group market should have the capability to effectively manage any benefit it offers,
even though open enrollment may require it to cover sick people. Open enrollment should be
subject to the following conditions, which are designed to avoid undesirable selection effects and
the high administrative costs caused by excessive movement between insurers.
First, purchasing corporations and carriers should be permitted to impose reasonable
minimum participation requirements on groups applying for coverage, so long as those
requirements are applied in a consistent fashion to all groups of a given size.
Second, purchasing corporations should be permitted to place reasonable limits on how
frequently individuals can change their source of coverage on an open enrollment basis. State
insurance regulators should be authorized to set reasonable limits on the frequency of open
enrollment changes in the portion of the small group market operating outside of the purchasing
group. Similarly, purchasing corporations and state insurance regulators should be authorized
to set reasonable limits on small groups' rights to move between purchasing corporation
coverage and coverage brought from insurers operating outside of the purchasing corporation.
Any limits on movement between sources of coverage should be designed to maintain a balance
between (a) avoidance of risk selection and excessive turnover and (b) the competitive dynamic
between insurers.
Third, the purchasing corporation approach allows each small group employee to choose
among offered plans, rather than placing all of a small group's employees into the same plan.
This could produce biased selection, since healthier employees might disproportionately choose
a lower level of coverage, while sicker employees might disproportionately choose a higher level
of coverage. To avoid this outcome, purchasing corporations should be authorized to define (if
necessary) two or three different benefit levels among the plans they offer and require that all
members of a given small group select their coverage from among plans in the same benefit
level.
Fourth, carriers should not be required to enroll groups outside of their service area.
Legislation should set or authorize state insurance regulators to set service areas that are large
enough to prevent "skimming."
10
�Finally, carrien should not be required to enroll more groups or individuals than they
have the capacity to serve. However, carrien denying enrollment to small groups or small
group employees because they lack the capacity to serve them should berequiredto suspend
enrollment of all size groups until capacity limits have been resolved.
2.
Guaranteed Renewal of Coverage
All small groups and their individual memben should be guaranteed that their coverage
will be renewed, except for cause (such as nonpayment of premium, fraud, or failure to meet
minimum participation requirements).
3.
Limits on Preexisting Condition Exclusions
Preexisting condition exclusions are a necessary feature of our present voluntary
insurance system, since they encourage individuals to obtain coverage before they become sick.
Preexisting condition exclusions which are longer or broader thanrequiredto serve this function
should be prohibited.
Preexisting condition exclusions should be limited by law to six months. Continuously
insured individuals changing jobs and continuously insured groups changing insuren should
receive credit for any part of the six month period they met through their prior coverage. New
preexisting condition exclusions should not be permitted to apply to such groups. The definition
of "continuously insured" should permit a brief break in coverage (e.g., 60 days) and should not
include a waiting period for coverage in a new job.
Preexisting condition exclusions should cover only those conditions which actually
manifested themselves during the past year. Thus, an undiagnosed, symptom-free heart ailment
which fint manifests itself during six month exclusion period would be covered, even though
the condition must have been present for yean.
lth
Theserestrictionsshould apply to all emplovment-ba^ hffil ^efit or insurance plans,
regardless of the size of business offering the plan.
Due to the limits on preexisting condition exclusions, worken moving from one job to
another should not be permitted to use COBRA toretaincoverage through their prior employen,
once they are eligible for benefits through their new employen.
C.
Rattof Restrictions
The extreme premium variation between small groups that characterizes the present small
group market should be eliminated. Eliminating all premium variation between small groups
would cause a large one-time increase in many small groups' premiums, possibly leading some
to drop or reduce coverage. A true community rate would also intensify carrien' efforts to
avoid highriskgroups. Because a communityratemay not be desirable at thistimein many
11
�areas, legislation should permit premiums to vary within specified "corridors.'
While we do notrecommendthe corridors that should be set in legislation, they should
balance the goals ofreducedpremium variation between high and low risk groups, and
maintaining coverage in lower risk groups. It is likely that these goals can be balanced at a
point that would produce much less premium variation than is found in the present small group
market. Purchasing corporations and state insurance regulators should be given flexibility to
adjust the permissible amount of premium variation within the legislated corridors, based on
experience in their local markets over time.
Premiums should be permitted to vary only on the basis of age, family status, geography
and benefits. Experience-related factors, gender and industry should not be used to set
premiums.
Purchasing corporations and state insurance regulators should be authorized to set
uniformrelativeweights for some or all of the premium variables (e.g. the ratio between the
premium charged for 20 year old and SO year old individuals). Each carrier would calculate a
group's premium by multiplying these relative weights by a dollar value of its choice.
Alternatively, purchasing corporations and state insurance regulators could permit each carrier
to calculate its own relative weights for premium variables, so long as they come within the
overall rate corridors.
Premium variation between small groups limited to age, geography and benefits will
prevent largerenewalpremium increases selectively targeted at specific groups. Therefore,
separate restrictions on rate increases at renewal are not necessary.
D.
Purchasing Corporation Governance and Functions
Purchasing corporations should be governed by a Board of Directors consisting of small
group employers and employees. Purchasing corporations should be subject to oversight by state
insurance regulators.
The purchasing corporation would perform a broad range of administrative functions.
Most important, it would select the limited number of carriers that would participate in the
purchasing corporation and hold these carriers accountable for their performance. Accountability
would be enforced by dissemination of comparative performance information to small group
employers and employees, and by decisions atregularintervals about whether and under what
conditions a earner's participation in the purchasing group would be renewed. In determining
the number of orrien which will participate in the purchasing corporation, the corporation must
be sensitive to the need to maintain a competitive market among carriers over time.
Other administrative functions would include:
o
Defining the benefits packages to be offered by carrien
12
�(while we expect that purchasing corporations would seek some standardization
of benefits, a determination about whether they should berequiredto do so
should be left to comprehensive health systemreformlegislation);
o
o
Providing marketing materials prepared by carrien to small groups;
o
1.
Establishing and enforcing detailed rating, enrollment and underwriting rules
within the parameters set by legislation;
Enrollment, billing and premium collection.
Risk-Adjusting Carriers' Pe i m Rvn e
rmu e e u
The purchasing corporation strategy should minimize biased selection problems, due to
the large number of lives that would be covered by participating carrien and the purchasing
corporation's control over benefit design, marketing, enrollment and rating practices.
Nonetheless, it is always possible that biased selection could occur, since the public policy
behind small group market restructuring prevents all of the facton that determine a group's
riskiness from being reflected in its premium cost. It is important that biased selection not be
permitted to reduce quality- and cost-based competition between carrien.
This problem should be resolved by authorizing the purchasing corporation to reallocate
premium revenues between carrien which enroll disproportionately large and disproportionately
small shares of high risk groups and individuals. Adjustments should be made only for
substantial selection effects. They should be prospective rather thanretrospective,i.e., based
on actual claims. This maintains carrien' incentive to rigorously manage high risk cases.
As stated above, we do not support reinsurance mechanisms that allow carrien to pass
responsibility for high risk groups' claims to a pool. This reduces incentives to manage care,
and may create opportunities to game the system. We also oppose assessments on large
businesses to pay for reinsurance pool losses. Large businesses typically cover their own high
risk employees. There is no basis for taxing them to pay for high risk cases beyond their own
employees. Furthermore, providing a reinsurance pool with a revenue stream originating outside
of the small group market would reduce the pool'sfinancialdiscipline.
E.
Preempt State Mandated Benefit and Anti-Managed Care Laws
State mandatrd benefit and anti-managed care laws undermine efforts to make small
group coverage more affordable. These laws should be preempted by legislation which
restructures the small group market.
13
�IV.
Conclusion
Piecemeal purchasing of insurance by small groups with little leverage over insuren or
providers makes little sense, even in the context of rating and underwritingreforms.Our small
group market restructuring strategy goes beyond rating and underwritingreformby giving small
groups the market clout and technical capability to establish fair and more efficient competition
in their health insurance market. The changes which would be promoted by small group market
restructuring are not sufficient by themselves to fix the health system's problems. However,
since these changes would apply to the way tens of millions of Americans receive health
insurance and health care, they could help move the broader health system in therightdirection.
In particular, purchasing corporations could use their market clout and technical expertise
to promote a restructuring of the health care delivery system into competing organized systems
of care. In our working definition of this concept, organized systems of care are vertically
integrated financing and delivery systems that use panels of providen criteria to furnish memben
with comprehensive services. The organized systems incorporate into their operations
continuous quality improvement mechanisms and incentives to provide only appropriate and
necessary care, and are accountable to purchasen and patients on the basis of cost, quality and
outcomes data.
Purchasing corporations which couldrequireparticipating carrien to move toward these
standards would make a far greater contribution to comprehensive health system reform than
rating and underwriting rules alone.
14
�Washington Business Group on Health
/// N Copitol Street NE Suite 800 Washingron, DC 20002 (202) 408-9320 T D (202) 408-9333 FX (202) 408-9332
..
..
D
A
STATEMENT OF
RICHARD I . SMITH
BEFORE THE
HOUSE ECONOMIC MATTERS COMMITTEE
ON
MANAGED COMPETITION
FEBRUARY 3, 1993
Public Policy • Institute on Aging, W r ond Health • Institute for Rehobilitotion and Disability M n g m n • Mental Health Services Po r m tot Y uh
ok
ooe et
r ga
ot
Notional B s e s Coalition F r m on Health • National R s uc C ne o Worksite Health Promotion • Prevention L a es i F r m • Quality R s uc C ne
ui s
n
ou
eo re e t r n
e d r hp ou
eo re e r r
�Good afternoon. I am Richard I . Smith, Public Policy Director of the Washington
Business Group on Health (WBGH). WBGH is an organization of Fortune 500 employers which
has worked to improve health care financing and delivery since 1974.
My statement will address the principles and mechanics of the managed competition
approach to comprehensive health system reform. While WBGH actively supports managed
competition, we continue to work through the numerous critically important and complex details
which will determine the success or failure of health system reform. Therefore, while I will
identify the key issues raised by managed competition and discuss different policy options within
a managed competition framework, unless otherwise indicated my comments should not be
viewed as an endorsement of a particular policy option.
The remainder of my statement briefly outlines the central managed competition
principles and policy choices. These are discussed in the context of the employment-based
version of managed competition. As you know, California Insurance Commissioner John
Garamendi has proposed a version of managed competition which would largely if not entirely
end employment-based health coverage. I would be pleased to respond to any questions you
may have concerning the Garamendi proposal.
MANAGED COMPETITION PRINCIPLES
A. Restructuring Health Care Delivery - There is compelling evidence that some
health care delivery arrangements are far more efficient than others, even in our dysfunctional
health care market. For example, the initial results of the recently released Medical Outcomes
Study show that prepaid multispecialty groups were 30% less likely than fee-for-service
physicians in solo or single specialty group practice to hospitalize patients and used about 25 %
fewer resources for diagnostic testing.
Managed competition is intended to both improve the quality of health care services and
save money by replacing our badly fragmented delivery arrangements with Organized Systems
of Care (OSC). OSCs are vertically integrated health carefinancingand delivery mechanisms
which offer comprehensive care through a network of hospitals and practitioners selected on the
basis of cost and quality criteria. An OSC incorporates continuous quality improvement
mechanisms, incentives to provide appropriate care, and is accountable to purchasers and
patients on the basis of cost and quality outcomes. Unlike current unaccountable, fragmented
delivery arrangements, OSCs are organized to make system-level resource allocation decisions.
B. Restructuring the Health Care Market ~ The more efficient delivery system models
have not displaced the less efficient models, despite spiralling health care cost increases. This
is the result, at least in large part, of the many well-known factors which make the health care
market operate differently than other markets.
�Managed competition seeks to improve quality and achieve savings by restructuring the
market so that, for the first time, both purchasers and consumers direct volume to efficient, high
quality systems of care and away from inefficient, low quality arrangements. The results
achieved by pursuing this strategy will be better than the results achieved by current state-of-theart delivery systems. For the first time, meaningful competition between well-operated delivery
systems will drive the systems to substantially improve their performance.
C. Government and Private Sector Roles - Managed competition envisions strong roles
for both government and the private sector. Government action is needed to put in place the
rules and incentives that will force quality and price competition. The scope of the role
contemplated for government in the health sector is considerably broader than the role
government plays in nearly any other sector of the economy.
Private sector purchasers and consumers, operating within these rules and incentives,
need to push systems to continuously improve their performance and reward the better systems
with increased volume. Nearly all managed competition advocates believe that the private sector
will perform this function more effectively and flexibly than government.
POLICY CHOICES
A. Organized Systems of Care - Some managed competition supporters would certify
as OSCs all entities which meet rating and underwriting standards, offer the standardized
package of services and report uniform cost, quality and outcomes data. Proponents of this
approach seek to avoid an overly detailed definition which would suppress innovation in delivery
system design, and believe that cost and quality data can drive the system in the right direction.
Others would adopt a tighter definition intended to foster system-level integration without
specifying structure. For example, a tighter definition might require OSCs to bear a substantial
portion of their practitioners' malpractice liability and use a single medical record for all patient
encounters. The purposes of adding such requirements to the definition are to jumpstart the
restructuring of the delivery system and hedge against market failures which could disadvantage
entities seeking to become well-integrated OSCs.
B. Scope of Covered Services - Most managed competition advocates support creating
a standardized package covering a comprehensive array of services. Over time, the package
would be refined through the use of medical appropriateness criteria.
Standardization has been proposed as one way to diminish risk selection among OSCs.
If OSCs are able to compete based onriskselection, their incentive to effectively manage health
services quality and utilization will be substantially reduced.
�Comprehensiveness has been proposed (1) since the full scope of services must be
financed if we are to hold OSCs accountable for their results and (2) to assure that cost savings
are based on quality improvement and efficiency , rather than arbitrary limits on coverage. Some
managed competition advocates would largely standardize the package, but allow relatively some
variations between OSCs, in areas such as cost sharing and options packages.
C. Purchasing Corporations Health insurance purchasing corporations (HIPCs) play
a central role in nearly all managed competition proposals. They are intended to achieve several
purposes, including (1) administrative efficiencies (the Congressional Research Service estimates
an average 14% savings for groups with up to 50 employees), (2) aggregation of market power,
(3) facilitating a choice among plans for employees of small businesses, and (4) active
management of competition among OSCs, to avoid risk selection. Different managed
competition supporters place different weights on these four purposes.
The issues surrounding the structure and functions of HIPCs are numerous and complex.
I will focus on just three.
First, nearly all HIPC supporters agree that HIPCs will work well only if there if one
HIPC per territory and it is the exclusive purchasing agent for all small groups offering benefits
in that territory. Multiple or non-exclusive HIPCs are viewed as enhancing the likelihood of risk
selection and adding administrative costs back into the system.
Second, the size of business that should be required to join a HIPC is a matter of
considerable contention. Some would place all but the very largest employers in a HIPC. My
recommendation is to limit HIPCs to the small end of the market, where the problems they were
designed to address are the greatest. (Note that even if this is done, HIPCs will still control a
large share of the market, since workers are concentrated in small businesses). Otherwise,
HIPCs will (1) eliminate the pluralistic purchasing which will promote effective managed
competition, (2) promote cost-shifting, (3) inevitably operate under highly politicized decisionmaking, reducing their ability to act as aggressive purchasers, and (4) create barriers to the entry
of new plans into the market (assuming the active HIPC model, discussed below, is adopted).
Third, some managed competition advocates view HIPCs as selecting the OSCs they will
offer, while others view them as passive administrators offering all certified OSCs operating
within their territory. I recommend the active model, since the ability to move volume is one
the key means of driving the system to perform better. I do not believe that exclusive reliance
on employee choice of plans offered by a passive HIPC is an effective substitute for active
purchasing by a sophisticated purchaser.
D. Tax Treatment of Health Benefits - Many analysts argue that the open-ended tax
subsidy for employer-provided health benefits adds to the health care cost spiral, since it reduces
the actual cost of health benefits to employees by 30% to 40%. Others argue that cost increases
over the past few years have been much larger than the value of the tax preference, yet cost
trends have not slowed.
�Obviously, whether to modify the tax treatment of health benefits will be enormously
contentious issue for public officials, employers and workers that will be decided only partly on
health policy grounds. As the policy discussion proceeds, I believe that it would be useful to
exclude from consideration options which would not give each American the opportunity to
purchase coverage from a high quality, efficient OSC on a fully tax-preferred basis or that would
limit only the deduction.
Several of the leading managed competition proposals recommend an "equal contribution
rule" for employer contributions to employee health benefits. Under this rule, employers would
be required to make an equal dollar contribution to employees' health plans. For most
employers, the amount would probably approximate the tax preferred contribution. The equal
contribution rule is intended to address situations in which employers do not arrange their
premium subsidies to promote enrollment in efficient, high quality plans.
A final tax issue is whether the tax preference, at whatever level, should be limited to
OSCs, or should be available to all health plans.
E. Access - Nearly all managed competition proposals retain the employment-based
system of providing health benefits, though they modify that system and supplement it with
sliding scale subsidies for the purchase of OSC coverage (typically through the HIPC) by
persons without employment-based coverage. The specific financing arrangements vary between
proposals.
F. Other Issues - Most managed competition proposals cover a variety of other issues.
For example, the proposals would require OSCs to report uniform cost and quality data, in order
to permit purchasers and consumers to make well-informed choices between OSCs, and would
comprehensively reform the malpractice liability system. Increasingly, analysts are focusing on
the need to fully integrate public insurance programs into the managed competition framework.
President Clinton has placed the question of the relationship between managed
competition and global budgets at the top of the health system reform agenda. Most managed
competition advocates are skeptical of the advantages of global budgeting. Nonetheless, the
President's interest requires careful analysis in this difficult and complex area.
Mr. Chairman, this concludes my prepared statement. I appreciate the opportunity to
appear before the Committee, and would be pleased to answer any questions you or the
Committee members may have.
�
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Title
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Health Care Task Force Records
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White House Health Care Task Force
Is Part Of
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
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[Washington Business Group on Health] [loose]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
Is Part Of
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Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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3/16/2015
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42-t-12092971-20060885F-Seg3-038-014-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/193f92189f20fc3f2aa4f8a6e39b68a5.pdf
299d813547b1027cc6140be5d970c8d1
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1980
OA/ID Number:
FolderlD:
Folder Title:
[Victorian Health Promotion Foundation Newsletter] [2] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
2
2
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
��
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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William J. Clinton Presidential Library & Museum
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Victorian Health Promotion Foundation Newsletter] [2]
Creator
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
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Reproduction-Reference
Date Created
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3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-013-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/567bdbe063708ab06225feb5028c4fbf.pdf
ebe80b8866ad7a64e6a1f837cb82a948
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1980
FolderlD:
Folder Title:
[Victorian Health Promotion Foundation Newsletter] [I] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
2
2
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�Foundation
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�THE VICTORIAN HEALTH PROMOTION FOUNDATION NEWSLETTER
Vic Health
Foundation
;:
: ' - * V ' . . • : „ ; •'-;>}
DECEMBER 1992 ISSUE NUMBER 13
LETTER
�Vic He; ilt h
Foundation
Victorian Health Promotion Foundation
Health Promotion Through Sponsorships
Executive Summary
Introduction
1.
Sponsorships and VicHealth: Where do they fit?
2.
Sponsorships: Part of the VicHealth Promotion
Framework
3.
Sponsorships and the Health Promotion Framework
4.
VicHealth's Sponsors: Who are they?
5.
Evaluation of Sponsorships: How do we know they
work?
Conclusion
�EXECUTIVE-SUMMARY
The Victorian Health Promotion Foundation (VicHealth) is an independent statutory
body established by the Victorian Parliament in November 1987 within the Tobacco Act
(1987).
This legislation has two main purposes. First, to protect the young from cigarette
advertisements through legislative restriction, such as the banning of cinema and
billboard advertising. Secondly, the establishment of a Foundation (VicHealth) from a
wholesale tax of 5% levied on tobacco products.
VicHealth operates five funding programs: Research, Health Promotion. Tobacco
Replacement, Spons Sponsorship and Ait and Culture Sponsorship.
A central focus of VicHealth's operation is health promotion via the sponsorship of Arts
and Sporting events and programs.
The use of sponsorships for the purpose of promoting health has initiated a substantial
cultural movement for health promotion in the Victorian community. The use of a
broad range of Health Promotion Agencies, as well as Sporting and Arts Organisations,
has assisted this movement and provided a broad base of support for health promotion
in Victoria.
The health promotion outcomes from the sponsorship program, including significant
structural change (i.e. creating healthy environments in which sport and ans events take
place such as smoke free zones and provision of healthy food choices), widespread
increased awareness of health issues and broad community support for health
advancement have once and for all destabilised the influence of tobacco companies and
made significant steps to ensuring the health of future generations of Victorians.
�INTRODUCTION - DEFINING SPONSORSHIP
This document examines VicHealth's involvement in sponsorships, and the impact of
sponsorships in achieving VicHealth's primary goal of disease prevention and health
promotion.
Sponsorships have become an increasingly important component of the marketing mix
of most major corporations. Sponsorships are essentially a relationship between a
corporation and an organisation in which there is an exchange of benefits.
In return for financial investment in the activities of an organisation, the sponsor
receives certain benefits, including enhanced community profile, access to target groups,
product awareness, branding, image building, credibility and transfer of messages.
The basis for VicHealth's Sponsorship Programs as a means of promoting health is
specifically identified as a key objective under Section 17 of the Tobacco Act.
"To increase awareness of the programs for promoting good health in the
community through the sponsorship of sports, the arts and popular
culture."
The Sports and Arts Sponsorship Programs are concerned with VicHealth's primary goal,
the promotion of good health.
Sponsorships provide an opportunity for VicHealth to set the agenda in health promotion
in the community, by providing access to particular target groups, (often hard to reach
groups through traditional health promotion means) opportunities for raising awareness,
involvement in health education, informing key decision makers and in developing
multisectoral community coalitions for health promotion.
Not grant maker but sponsor: a niche market for VicHealth
It is most significant that in the Sports and Arts Sponsorship Programs. VicHealth is not
a grant-making body but a sponsorship body as laid down by the Act.
�A grant to an organisation, unlike a sponsorship, is not intended to achieve any other
outcome except to support the event or program. Grants do not serve to market
messages in the way sponsorships can.
Grant-making is the role of the relevant Government Department, in this case the
Ministry for the Arts and the Department of Sport and Recreation, whose role it is to
develop the arts and sport. VicHealth's role, on the other hand, is the promotion of
health and the prevention of disease in Victoria.
VicHealth, in its role as sponsor, has clearly established for itself a niche which is
overwhelmingly supported by Sports and Aits bodies as well as the general public. The
awareness of health messages raised by VicHealth's sponsorship program has assisted
in the permeation of health promotion into the Victorian culture and will continue to
provide a basis for community support for health reforms.
Breaking the nexus between sport / arts and tobacco
VicHealth has been responsible for breaking the nexus the Tobacco Industry has
deliberately established with sport and the arts without threatening the financial basis for
these organisations in Victoria.
However, this should not be the only corrective measure. The important step in breaking
the nexus is replacing it with positive, health enhancing messages and using social
marketing strategies in sponsorships to achieve health outcomes.
�1.
SPONSORSHIPS AND VICHEALTH: WHERE DO THEY FIT ?
An integrated approach to health promotion
VicHealth has adopted an integrated approach to health promotion. Its initiatives are
based on epidemiological information identified through its Research and Health
Promotion programs, and its Arts and Sports Sponsorship Programs focus sponsorships
on designated health priorities.
Health Promotion - the linchpin in sponsorships
The Health Promotion Program is at the centre of VicHealth's operations and is the
linchpin in the execution of all its funding programs. An integrated funding approach
serves to reinforce common health promotion goals across program areas and facilitate
the sharing of health promotion gains from one program to another.
VicHealth's sponsorship program provides sponsorship funds to sporting and arts bodies.
Through the development of appropriate health messages to link with various arts or
sporting events, sponsorships are an excellent way of promoting health.
Sponsorships are supported which offer value-for-money health promotion opportunities
and which increase the level of participation in sporting activities or arts events,
particularly by those people who are disadvantaged in terms of gender, age, disability,
race, geographic location or non-English speaking background.
The linkage of health agencies to these sponsorships ensures that the quality and means
of communicating health messages is maintained. Appropriate messages arc directed
to relevant, designated target groups and the promotion of health messages through
sponsorships is linked to the health agency's health campaign and education activities.
Health Promotion Priorities
Sponsorships focus on health behaviours shown to be important by the Research and
Health Promotion Programs. This table sets out the kinds of behaviours we arc
encouraging and the need for them:
�RISK FACTOR
DISEASES
HEALTH BEHAVIOURS
High cholesterol
Cardiovascular disease
Healthy diet
Regular physical activity
Obesity
Diabetes
Diet and exercise
High blood pressure
Stroke
Substance abuse
Alcohol-related
Personal development
disorders
Responsible use of substances
Smoking
Lung Cancer
Smoke-free lifestyle
High fat diet
Cancers
Better diet
Environment health
Asthma
Environmental protection
Regular physical activity
hazards
Gender
/ poverty /
Mental illness
Supportive social structures
Arthritis
Provision of exercise opportunities
interfamilial stress
Lack of exercise
The substantial cost, and rising each year, of the medical service and treatment budget
in Victoria points strongly to the need to develop a health promotion movement that
emphasises prevention.
�2.
SPONSORSfflPS: PART OF THE HEALTH PROMOTION FRAMEWORK
Sponsorships sit within an overall framework for health promotion and are not
considered by VicHealth or Health Promotion Agencies in isolation.
This mode of operation is consistent with internationally recognised models of health
promotion which indicate that the best opportunity for success lies in the integration of
the following processes.
1.
Health / Awareness Raising - the process of building awareness, broad social
support and placing health issues on the public agenda.
2.
Health Education - the process of working with individuals or groups promoting
personal change.
3.
Health Advocacy - the process of encouraging decision makers to change policy,
structures and legislation if appropriate.
4.
Community Information and Education - the process of working with
community organisations creating support for change.
Sponsorships usually sit within the initial phase of a health promotion strategy, as
outlined above. In this context, sponsorship is a means of placing a particular health
issue on the local community, state or national agenda.
Whilst health sponsorships primarily address awareness raising, it is recognised they also
deliver opportunities for health education, advocacy and community information and
structural change through the creation of healthy environments.
�3.
SPONSORSHIPS AND HEALTH: THE MATCHING PROCESS
Health promotion agencies as the deliverers of the health messages are central to the
success of the sponsorship program.
Arts and sports sponsorships are selected for their ability to reach specific target groups
and to deliver value-for-money health promotion opportunities. The careful matching
of health sponsorship messages to arts/sports activities facilitates access to the
appropriate health target groups.
In practice the health promotion messages developed by the health agencies are
examined by the Foundation Board to assess their scientific validity and relevance,
according to VicHealth's current health priorities and to finalise the important function
of matching messages to arts and sports sponsorships.
The linking of arts, sports and health promotion organisations in sponsorship
arrangements promotes a synergy with more substantial effects than either organisation
could hope to achieve individually.
Health promotion and disease prevention is the tangible outcome of the sponsorship.
While the Sports or Arts body provides the vehicle for effective sponsorships it is the
co-sponsorship arrangement with appropriate health promotion agencies that enables the
planned health promotion outcomes to be kept clearly in sight.
The integration of sponsorships within the strategic plan of the health promotion agency
ensures that the sponsorship does not become a stand-alone strategy. In the same way
that the corporate sector does not use sponsorships in isolation, but rather integrates
sponsorships within a total marketing mix, so also does VicHealth ensure that both
parties co-operate, utilising the opportunities provided by the sponsorship to promote
the health of the Victorian community.
�4.
VICHEALTH'S SPONSORS: WHO ARE THEY?
VicHealth's health sponsors are a range of community based organisations who conduct
comprehensive health programs in which health promotion is prominent.
Included below is a profile of five of VicHealth's key sponsors and the role of
sponsorships within each of their strategically conducted programs.
The Victorian Smoking and Health Program (QUIT Campaign)
The Victorian Smoking and Health Program (QUIT Campaign), conducted by the AntiCancer Council of Victoria, is the Victorian Health Promotion Foundation's major
funded campaign.
QUITs aim is to reduce both the prevalence of smoking and exposure to the harmful
substance of tobacco. The objectives of the program include preventing young people
taking up the smoking habit and encouraging and assisting current smokers to quit.
QUITs strategies include challenging the view that smoking is a symbol of social and
sexual success, reducing the influences on young people pro-smoking from peers, role
models and advertising and encouraging positive lifestyle behaviours.
The QUIT Campaign targets includes adults, young women, non-English speaking
people, Kooris, young adults and it aims at being effective in regional and professional
networks, worksites and restaurants.
Sponsorships deliver QUIT opportunities for prevention, cessation and smoke-free
public activities. For example:
Health Message
Sponsorship
Target Group
QUIT
Netball
Young Women
Sponsored Program
Victorian Netball Association State League
Netta Netball
Junior Development Program
Regional Program
Regional Talent Coaching Clinics
�QUIT Promotions / Activities
•
•
•
•
•
QUIT association on all netball materials and publications:
Briefing of Coaches on quit smoking for role model purposes of junior clinics:
Signage at identified areas and programs;
Production of health materials;
Use of media.
Outcomes
•
Approximately 22,000 young people directly accessed for message through netball
programs;
•
Creation of smoke-free areas within netball venues and club facilities;
•
extended access for message to general public increased media generated for the
sport reinforcing the positive image of QUIT with fun success, creativity, physical
fitness and health.
Health Message
Sponsorship
Target Group
QUIT
Dans
Blue Collar Men
Sponsored Program
Victorian Darts Council Australian Championships
Pacific Cup
Local Clubs Programs
QUIT Promotions / Activities
•
•
•
•
•
Advertising in darts magazines publication and event programs;
Event signage;
Facilitating the change of rule that no player be permitted to smoke between the
tables and the dart board (playing areas);
Provision of no smoking areas;
Clothing identification.
Outcomes
•
Breaking the image between darts participation and smoking;
•
Creation of healthy role models for extensive junior dans programs:
•
Provision of access into hotels to initiate structural changes.
�Health Message
Sponsorship
Target Group
QUIT
Australian Macedonian
Drama Group
Non-English speaking
People
Other QUIT sponsorships include surfing, football, basketball, snooker and indoor
cricket.
Heart Foundation (Heart Health)
The Heart Foundation aims to decrease the incidence of cardiovascular disease, the
number one cause of morbidity and mortality in Australia. There is strong evidence that
smoking, poor diet and lack of exercise are implicated in the onset of cardiovascular
disease. The Heart Foundation conducts programs aimed at prevention of these factors
including the promotion of smoke free environments, healthy diet and regular exercise.
The Heart Foundation regards it as essential that children develop health enhancing
behaviours. Firstly, primary prevention of cardiovascular disease is important because
eating, exercise and other habitual health behaviours develop during childhood and
adolescence and are difficult oh change one established. Secondly, evidence shows that
most Australian children are adopting health behaviour patterns implicated as causes of
cardiovascular disease. Thirdly, children and adolescents are influential in motivating
positive changes in their parents' health behaviours. Finally, any increase in sustained
healthy behaviour at this level will constitute significant savings in future public health
care costs.
Parents are targeted because of their direct and indirect influence on their children's
health behaviours. Further, parents are at risk of a reduced quality and quantity of life.
Cardiovascular disease accounts for 48% of deaths in Australia. The Heart Foundation
argues that parents can be effectively reached through messages directed at their
children.
Health Message
Sponsorship
Target Group
Heart Health
Golf
Older Men, Women &
Young People
Sponsored Program
Victorian Golf Association, Victorian Ladies Golf Union and Professional Golfers
Association Junior Programs
State Mens and Womens Championships
Regional Events
Beginner Programs
Country Programs
10
�NHF Promotions / Activities
•
•
•
•
•
Liaison with caterers to provide healthy food choices:
Signage at events;
Provision of educational and promotional materials;
Use of media to associate message with golf;
Briefing to coaches
•
Clothing identification on players and officials.
Outcomes
•
•
Smoke-free zones established in over 80% of Golf Clubhouses;
Provision of healthy food choices at all major golf events in Victoria and at golf
clubhouses;
•
Sponsorship reached over 4,000 young people directly through sponsorship.
•
Increased panicipation in the spon by women in country Victoria.
Health Message
Sponsorship
Target Group
Heart Health
Vic Athletic League
Young Women
Heart Health
Ilijeri Theatre Community
Koori
11
�Anti-Cancer Council of Victoria - (SunSmart Campaign)
The Anti-Cancer Council of Victoria's SunSmart program aims to substantially reduce
skin cancer incidence,morbidity and mortality in Victoria. It has a range of strategies
including the advocacy of attitudes and beliefs which predispose to healthy behaviour
choices relevant to cancer, prevention to achieve a reduction in sunlight exposure
through changes in individual's behaviours and changes to their environment; early
detection and manager of skin cancers; policy development and cooperation with other
organisations.
SunSmart targets the general population, as 80% of the population can be classified as
fair skinned. Within this extensive group,high priority target groups are identified such
as children and the carers of children. Specific strategies aimed at parents, teachers,
child care nurses and organisers of holiday, after-school, sporting and recreation
programs are thereby conducted. Outdoor workers are another priority for SunSmart.
Communication strategies for SunSmart include direct one-to-one interactions, print and
electronic information, school and community programs, paid and unpaid media and
promotion through the sponsorship of outdoor activities.
Sponsorships provide opportunities for SunSmart to reach targets such as children and
parents on outdoor holidays, beach-goers and those at risk of exposure.
In addition, opportunities are made available to raise awareness and educate through
both participation at sponsored events and mainstream media exposure. Sponsorships
provided by VicHealth encourage healthy environments and are linked with other
program activities, for example, school programs.
Health Message
Sponsorship
Target Group
SunSmart
Life Saving
Youth
Sponsored Program
Royal Life Saving Society and Surf Life Saving Association Junior Programs
Championships
Affiliated Clubs
SunSmart Activities
•
•
•
•
Briefing to Lifcsavcrs;
Provision of on beach shelters, protective clothing:
Signage on beach and at championships;
Access to junior programs for promotion of SunSmart message.
12
�Outcomes
•
Substantive change on behaviour of lifesavers in becoming role modeis for sun
protection;
•
Substantial presence of message on beach targeting general public;
•
High public awareness of message by general public;
•
Widespread use of sun protection behaviour on Victorian beaches.
Health Message
Sponsorship
Target Group
SunSmart
Tennis
Young Women
Sponsored Program
Victorian Tennis Association Junior School Programs
Victorian Womens Championships
Mid-week Ladies
Regional Events
SunSmart Promotions / Activities
•
•
•
•
•
•
Tennis in Schools Programs
Mid-week Ladies Program
Regional Championships and Country Carnival
Club Competitions
Wheelchair tennis Integration Program
Victorian Womens Open Championships
Outcomes
•
Expo site with promotional giveaways and SunSmart competition at Australian
Open;
•
Coaches guide developed with SunSmart reminders for coaches - who act as role
models during clinics;
•
Certificates developed for all clinic participants with SunSmart reminder on it
(approximately 10,000 children);
•
Teacher information on sun protection left in schools:
13
�•
Signage and banners at Regional Championships, the Country Carnival. Mid-week
Ladies program and Club competitions:
•
SunSmart provides VTA with sunscreen for sale within clubs as a fundraiser:
•
Editorial in VTA newsletter (12.000 circulation).
Health Message
Sponsorship
Target Group
SunSmart
The Push Tour
Young adults
Diabetes Australia - Victoria
(Healthy Diet Try It - Tackle Diabetes)
Diabetes Australia - Victoria aims to re-educate both the general public and health
professionals about the prevention and containment of diabetes, a condition which
affects approximately half a million Australians.
Diabetes Australia - Victoria conducts programs in education for diabetics and their
families in:
•
Self management of the disorder in order to reduce the demand for in-patient care;
•
Education of health professionals:
•
Education of the general public to better understand the disorder and enhance the
quality of life of those who have it; and
•
Health promotion activities including the promotion of healthy lifestyles and
diabetes prevention.
Diabetes Australia - Victoria targets the general population with its education,
prevention and containment programs. In particular, it targets at risk groups such as
those who are overweight, over 540, sedentary in their lifestyle or from Koori or nonEnglish speaking backgrounds.
Sponsorship activities provided by VicHealth enable Diabetes Australia - Victona to
raise awareness and educate about the health behaviours associated with prevention and
containment of the condition.
Education opportunities arc provided through Diabetes Australia - Victoria sponsorships
with the distribution f educational materials and regular presentations from their health
promotion personnel.
Establishing healthy environments is a key factor in these sponsorships and excellent
opportunities are provided by sporting and arts organisations./ Smoke-frce zones and
healthy food choices arc important goals for these sponsorships.
14
�Health Message
Sponsorship
Target Group
Healthy Diet - Try It
Melbourne Theatre
Company
Adults
Healthy Diet - Trv It
Indoor Soccer
Non-English
people
speaking
Sponsored Program
Victorian Indoor Soccer Association Junior Programs
School Championships
State Teams
Victorian Championships
Diabetes Promotions / Activities
•
•
•
•
Briefing to coaches;
Provision of promotional / educational materials;
Signage at events;
Promotional activities in key regional areas;
•
Work in food caterers in providing health food choices at events and programs.
Outcomes
•
Substantial increase in participation in the sport particularly by young women;
•
Widespread awareness of health message within target group;
•
Provision of healthy food choices on an on going basis in indoor soccer stadiums;
•
main playing stadium of indoor soccer smoke free.
Health Message
Sponsorship
Healthy Diet - Trv It
Grevhounds
Target Group
Lower
groups
socio-economic
Alcohol and Drug Foundation
(Booze Less. Be Your Best)
The philosophical framework which informs all the ADF programs is based on a belief
in the principles of personal development and social justice.
15
�The ADF believes in an integrated approach which addresses both social structures and
personal issues of psychological development.
The ADF believes in the uniqueness of individuals, their right to self-determination and
the duty of society (through its social structures) to provide an environment which
maximal personal development can occur for all individuals regardless of gender,
sexuality, race or socio-economic status.
The aims of the Alcohol and Drug Foundation are:
•
To equip individuals with the knowledge and skills to make informed and
responsible choices;
•
To promote attitudes, beliefs and values which are conducive to responsible drug
use;
•
To produce a wide range of specifically targeted prevention programs;
•
To affect appropriate policy development in relevant areas;
•
To facilitate on going research on prevention.
1
Campaign Identify: Be Your Best
'Be Your Best' has been developed as an identity or signature slogan to mark all ADFs
activities. In various graphic and textual forms, it is used as the basis for VicHealth's
campaigns such as the young adult responsible drinking campaign 'Booze Less. Be Your
Best'.
'Be Your Best' is deliberately a very broad slogan that allows the ADF to position its
message about personal development, social justice and harm reduction in a simple
shorthand way. The identify accumulates meaning over time through a strategic
association with all events and products of VicHealth. it is the ADFs aim that 'Be Your
Best' will be instantly recognisable as a message about responsible alcohol and drug use.
Health Message
Sponsorship
Target Group
Booze Less. Be Your Best
Giants
Young Adults
Sponsored Program
North Melbourne Giants Basketball Team
(including Junior Programs)
16
�Alcohol and Drug Foundation Promotions / Activities
•
•
•
•
Use of Giants players for promotional activities and briefing for direct message to
young people via clinics;
Development of innovative promotional and educational activities;
Work with Olympic Park management on structural change innovations:
Provision of signage, clothing and naming rights identification material.
Outcomes
•
High level of awareness and understanding of health message within identified
target groups;
•
Provision of low alcohol use at venues;
•
Use of sponsorship to link target group into overall ADF education programs.
•
Status and credibility provided to the message within the media.the public and the
specific target group.
Health Message
Sponsorship
Target Group
Be Your Best
Rock Eisteddfod
Be Your Best
Junior Sport Campaign
17
- Youth
Children
�International Diabetes Institute
(Be Diabetes Wise - Healthy Food and Exercise)
The International Diabetes Institute aims to further knowledge in the field of medical
scientific and clinical research, education and care of diabetes. The Institute has a strong
commitment to its program of education and awareness of any and all potential diabetes
sufferers, and uses the promotional opportunities offered by VicHealth sponsorships to
communicate specific information about prevention of the disease and lifestyle
management.
While the Institute's broad target group for this information consists of all adults, in
order to reduce their chances of suffering adult-onset diabetes, specific high-risk target
groups with greater susceptibility to the disease include the following population subgroups:
•
Overweight adults, particularly over the age of 50
•
Certain Ethnic groups within the community, particularly Aboriginals, people from
certain Mediterranean, Asian and Pacific countries
•
Expectant mothers
The Institute actively promote a healthy diet through their sponsorships by involving
their team of nurse educators and dieticians in working with caterers to provide healthier
food at sponsored events, as well as distributing specially designed recipes to encourage
the public to improve their own diet. Similarly, regular exercise is encouraged amongst
patrons of sponsored events.
Health Message
Sponsorship
Target Group
Be Diabetes Wise.
Healthy Food and Exercise
Antipodes Festival
Adults Greek Community
Sponsored Program
Antipodes Festival - "Glendi" Street Parade Entertainment Stage
Health Promotion Activities
•
Signage on Lonsdale Street Stage
•
Special healthy Greek food provided at all official functions
18
�Street stall on Lonsdale Street distributing free fruit, vegetables and dips with
information on diabetes and healthy Greek recipes
Briefing and information provided to all food stall operators
Outcomes
•
Healthier food available throughout the Festival
•
High profile awareness of the message amongst the Greek community
•
Adoption of modified recipes (using healthier ingredients) by the Greek community
Health Message
Sponsorship
Target Group
Be Diabetes Wise
Healthy Food and Exercise
Monsalvat Jazz Festival
Adults
Sponsored Program
Monsalvat Jazz Festival
- Sponsorship of one pavillion
International Diabetes Institute Promotions
•
Signage around the grounds of Monsalvat, particularly special sponsored pavillion
•
Official caterers briefed by Institute dieticians on healthy food to be served at
functions and sold to the public
•
Range of promotional material distributed around venue
Outcomes
•
Caterers made every effort to improve the health value of food available, and
intentions to modify future food provided at public events
•
High level of awareness of message amongst the audience
19
�Main Health Messages Currently in Use Through Foundations Sponsorships:
Organisation
Message
Anti-Cancer Council
QUIT
Anti-Cancer Council
SunSmart
Heart Foundation
Heart Health
Alcohol and Drug Foundation
Booze Less. Be Your Best
Diabetes Australia - Victoria
Healthy Diet Try It - Tackle Diabetes
International Diabetes Institute
Be Diabetes Wise - Healthy Food and
Exercise
Food and Nutrition Program
2 Fruit 'n' 5 Veg
Life. Be In It
Participate
Arthritis Foundation
Move it or Lose It
Australian Brain Foundation
(individual messages for sponsorship)
Dental Health Services
Keep Teeth for Life
Child Accident Prevention
Play Safe
20
�5.
EVALUATION OF SPONSORSHIPS: HOW DO WE KNOW THEY WORK
A commitment to good health promotion practice means a commitment to planning and
evaluation of programs. Planning takes in the needs of the target group and how to
meet these needs. Evaluation finds out the effect of the program, who has benefited and
who has not.
Extensive planning exists in the appropriate matching of health sponsors to funded
events so as to ensure the most effective 'marriages' possible. In this matching process
the primary target of the health promotion agency is considered, as is its message and
ability to service the sponsorship.
Additionally, the nature of the funded event is carefully assessed to ensure maximum
exposure for the particular health message and, if possible, the provision of other
avenues for the agency to conduct additional health promotion initiatives.
Underpinning the development of health messages and the agencies' skills in health
promotion is a comprehensive evaluation process. This process operates at several levels
so as to monitor and measure the success of discrete sponsorships, the sponsorship
program and the health promotion program of each agency.
Health agencies are required to submit detailed Health Sponsorship Plans outlining target
groups, objectives, strategies, evaluation and budget before commencing each
sponsorship. At the conclusion of each project an evaluation report that examines the
performance indicators, impact and outcome of the sponsorship is submitted. VicHealth
uses this information to feed into the work of the Health Promotion and Research
Programs and influence further assessment of sponsorships.
This process of Formative Evaluation ensures that Process and Outcome Evaluation is
constantly used to develop health promotion strategies.
Step 1
Project Planning
I
Step 2
Project Implementation
Step 5
Outcome evaluation
is analysed and used
as backing for better
future initiatives
Step 3
Process evaluation monitors
and provides information to
adjust projects
Step 4
Impact evaluation measures
the effect of the initiative
21
�This process of continual feedback, assessment and refinement of health promotion
initiatives ensures that the potential of projects is maximised.
22
�6.
ACHIEVEMENTS TO DATE
Healthy Environments
Significant gains have been made in structural change to the environments in which
sport and art events take place. This supports the view that supportive environments
make healthy choices easy choices. As well, structural change assists in sustaining
individuals initial changes in health behaviour, that individuals make, as well as in
achieving long term health outcomes.
Healthy Environments have been achieved in a number of ways. For example, all
organisations contracted with VicHealth agree to encourage and support the prohibition
of smoking in their offices and environs. This has meant that almost every sport in
Victoria has smoke-free headquarters.
Arts go smoke-free
In other cases health promotion agencies have been pro-active in encouraging other
areas of structural change. In 1989, through the Victoria State Opera sponsorship, the
National Heart Foundation negotiated with the Victorian Arts Centre for a trial period
of being a smoke-free venue. The success and support this initiative enjoyed, assisted
the Arts Centre to become a permanent smoke-free zone. Other sponsorships also
negotiated such arrangements: the Zoo made all restaurant areas smoke-free as a result
of the 'Sounds In the Wild' arts sponsorship, The Exhibition Buildings, Playbox Theatre,
Express Australia, the Fashion Design Corporation and others having seen similar
developments.
Catering Improvements
Improved provision of healthy food choices has also been an outstanding achievement
of VicHealth's sponsorships. Initiated in the 1989 sponsorship with the National Gallery
of Victoria, the National Heart Foundation negotiated a complete change-over to healthy
food in the cafeteria, canteen and restaurant for the period of one exhibition. After the
six week period both turn-over and profit had increased by 10% and so catering
management made many of the health changes permanent.
Likewise, The Victorian Arts Centre through the Victoria State Opera Centre, the Zoo
through the 'Sounds in the Wild' sponsorship, the Exhibition Buildings through the 2nd
Australian Contemporary Art Fair sponsorship, and the Meat Market through the
Antipodean Wheel sponsorship have seen the introduction of healthy food choices in
their food outlets.
23
�Sports go smoke-free
Further examples exist in Sports. 80% of squash centres in Victoria are smoke-free as
part of the Victorian Squash Federation sponsorship by the National Heart Foundation.
Albert Park Sports Complex, one of the state's most popular sporting venues, is now also
smoke-free as a result of Basketball and Badminton sponsorships.
At another level the Glenelg Sports Assembly initiated the Voluntary Code of Ethics on
smoking at junior sports venues by all sporting clubs in the Glenelg region as a result
of the sponsorship of their regional games. The local Community Health Centre acted
as support sponsor. This Code of Ethics concept is now being replicated by other
regional sporting assemblies in Victoria.
Access to sport
The increased access many of the sports programs provide for disadvantaged groups
including people with disabilities, rurally isolated, older adults, lower socio-economic
groups and non-English speaking groups through the sponsorship program is also an
important area of structural change within the sponsorship programs.
Increased participation rates
Recent analysis from the Victorian Sport Database indicate increased levels of sports
participation in the major sporting codes which have received sponsorship funding since
the Foundation's inception in 1987.
Further, recent data from the CSIRO indicates increased levels of exercise in large
segments of the Victorian community over the past five years.
Awareness raising
VicHealth evaluation reports show significant awareness of health messages is being
achieved within the Victorian community.
Quit's sponsorship of the Fitzroy Football Club aims to promote non-smoking as a
healthy lifestyle component with a positive image. Specifically the sponsorship aims to
develop a positive profile for the Quit Campaign by identifying it with popular sport and
to use popular sports people as non-smoking role models for the Quit Campaign.
Recent studies reveal that Quit was the most mentioned sponsor of all the major
sponsors of AFL clubs. In regard to children, the study showed that respondents with
a high level of interest in AFL football had a high level of awareness of the Quit
sponsorship of Fitzroy and were less likely to intend to smoke in future, suggesting that
sport sponsorship by Quit may be discouraging the uptake of smoking among this age
group.
24
�Sponsorship of events also contributes to a greater understanding of health issues. For
example, evaluation of the 1992 Stawell Gift, sponsored by VicHealth for the National
Heart Foundation, indicated that 20,000 people attended the event, and audience reach
via television greatly expanded the number of people reached by the sponsorship. The
Heart Foundation's survey of spectators attending the event showed that 86% recognised
Heart Health as the sponsor of the event and 74% understood that this message meant
good nutrition, regular exercise and being smoke-free. This demonstrates that the event
has provided value-for-money opportunities to promote health messages and that the
promotion has been successful in transmitting these messages.
In Arts a further example is the Arthritis Foundation Victoria's sponsorship of the
Australian Ballet Dance Tour for which 100% of respondents to the evaluation survey
could recall the sponsor.
Similarly, the National Heart Foundation's sponsorship of the 1992 Writers' Festival
which targeted schoolchildren was able to achieve a 93% recall rate for the health
message and comprehension of the message.
25
�CONCLUSION
The process of integrating scientific methods of research with health projects that meet
our community's needs is creating a health promotion cultural movement. The
integration of sponsorships in science and health promotion reinforces and facilitates
effective and well designed health programs. It also, weakens destabilises the influence
of tobacco companies.
It ensures the health of future Victorians for generations to
come.
pi73051p.doc
26
�
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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[Victorian Health Promotion Foundation Newsletter] [1]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
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Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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42-t-12092971-20060885F-Seg3-038-012-2015
12092971
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https://clinton.presidentiallibraries.us/files/original/8844ab77d779d8721443e5f7077a351e.pdf
9d6bc176e10473c70022a36abe1977dd
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2006-0885-F
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Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
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Tarmey
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OA/ID Number:
1975
FolderlD:
Folder Title:
[Summit '93 African American Prescription for Health Summit Policy Paper] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
11
3
�SUMMIT '93
AFRICAN AMERICAN PRESCRIPTION
FOR HEALTH
SUMMIT POLICY PAPER
Washington Vista Hotel
Washington, D.C.
May 2-3,1993
�S U M M I T C O A L I T I O N IDEOLOGY
"Summit 93: African American Prescription For Health" is an unprecedented collaboration of
over fifty health and social service organizations. We have come together in a spirit of
cooperation, putting aside narrow organizational agendas and personal interests.
!AS health and social service professionals, we have been closest to the myriad health problems
plaguing our community. We have all battled the combined obstacles of inadequate resources and
institutional racism. We have developed and continue to develop viable solutions and interventions
addressing these challenges. Our expertise is based on "front-line" experience, service as heallh
care providers, and managers of health care delivery systems. Thus, our recommendations for
reforming the health care system are not academic exercises or theoretical abstractions.
A major outcome of "Summit 93" will be the creation of local coalitions of Summit Partners who
are committed to improve the health status of all African Americans. The fruits of our efforts will
benefit all citizens of the United States.
�TABLE OF CONTENTS
page
Executive Summary
1
Overview
3
Issues and Recommendations
6
Addendum: Additional Recommendations
15
�SUMMIT '93
AFRICAN AMERICAN PRESCRIPTION FOR HEALTH
SUMMIT POLICY PAPER
Executive Summary
In the reform of the National Health Care System, it is essential that the unique health needs and
challenges of the African American community are addressed. The factors which are preventing
the adequate delivery of health care services to this community demand specific and immediate
remedies.
This is a call to individuals and organizations to organize now to ensure that our health needs are
met. We urge health providers and consumers to prepare for full participation in a reformed
National Health Care System, no matter what form it ultimately takes. As self-determining heallh
providers, consumers and advocates, we must be ready to make the individual and collective
decisions that will foster disease prevention, health promotion and equity in health care delivery .
The Summit Planning Coalition has developed specific recommendations for immediate and ongoing reforms, focused on ihe growing health crisis in our community and in the nation.
We seek universal heallh care without exception, but if it is to be a reality, health care insurance
coverage must be extended to those who have been shut out of the health care system, particularly
the underserved, the unemployed and the employed without health insurance. The Coalition
strongly believes that all Americans not covered by employer-based health care insurance should be
covered by a single unified federal health plan that combines Medicare, Medicaid and Stateandated benefits. The Coalition also affirms that heallh insurance coverage should include all
agnostic and therapeutic services, and should be independent ol" year-to-year budget fluctuations.
Furthermore, if universal health care is to become a reality, there must be additional federal support
for the recruitment and retention of health care providers in the African American community.
Many solutions are feasible, such as service-payback loans and more funding for Centers of
Excellence in Minority Health.
Experience has shown health professionals that health promotion and disease prevention provide
the most efficient use of the health care dollar. The Coalition recommends that health budgets
reflect the importance of health promotion and disease prevention by ensuring that 20 percent of all
governmental medical and health expenditures be used for those purposes.
Attention must be given to the inclusion of African American health professionals at each level of
health care decision-making on reform. The Coalition recommends that a National Health
Commission or Board be established, along with Regional Health Councils. These bodies would
develop and implement health policy, while keeping in touch with the needs of the health consumer.
The inclusion of African American health and social service professionals on the Board and the
Councils as decision makers and staff will help ensure that existing obstacles to health care access
for the unserved and underserved are identified and overcome.
Financing full access to a health care system that is responsive to the needs of all Americans
presents an additional set of challenges. The Coalition recommends that they be met by the
elimination of unnecessary bureaucracies; centralized handling of all reimbursement claims; and the
1
�negotiation of the fees associated with the health care system through the National Health Board
and the Regional Health Councils. The Summit planners also favor ton reform; the use of a "sin
tax" on tobacco and alcohol products; a surcharge on goods produced abroad under the North
American Free Trade Agreement (NAFTA); and other suggestions that would generate revenue for
the National Health Care System.
In extending access to a reformed National Health Care System, the integrity of the system must be
monitored to ensure that the health consumer is benefiting from the best possible health care.
Guidelines will be needed for the efficient and equitable operation of that system in the delivery of
health care. The Coalition recommends that quality assurance guidelines be developed by the
National Health Board and that the Councils implement these guidelines through quality assurance
programs.
Creative policies can be established to provide incentives in underserved urban and rural areas.
Small business tax credits and banker incentives for loans to minority-owned and operated health
care practices will reinforce community infrastructures and address unmet health needs. The health
consumers in these areas, many of whom are African American, will also benefit from a national
health system that covers everyone; is comprehensive in scope; and is affordable, accessible and
prevention- and outcome-oriented.
�Overview
e commitment of both the private and public sectors is necessary 10 solve the complex problems
facing our society, not the least of which is the reform of the American health care system. If
health care reform is to be viable, it must extend access to all Americans.
Those of us who serve the nation's African American community are closer than other health
professionals to the problems of those who find the health care delivery system inaccessible. The
combination of the high-risk nature of their ailments and the lack of financial resources and
insurance make it difficult in many cases and impossible in others to benefit from a system that
could offer them the health care they so badly need and deserve.
The ever-increasing cost of health care is staggering and the figures are sobering. In 1991, health
care costs accounted for 12 percent of the gross domestic product (GDP). By 1992, that share had
grown to 14 percent, and the Congressional Budget Office predicts that by the end of the decade,
less than seven short years from now. health care will consume IS percent of GDP.
What is even more alarming is the fact that as the cost of health care continues to escalate, more
Americans have less access to systems that could help them afford health care. Approximately 16
percent of the American public is now without health insurance. The impact on the minority
community is more severe than the figure indicates. While the vast majority of health insurance
coverage is obtained through arrangements with employers and/or labor unions, unemployment in
the minority community is consistently higher than in the general population. Additionally, in
many minority families the head of the household may be employed, but employed in a position
that offers very limited health coverage, if any at all.
ore than 600 health maintenance organizations now exist, serving about 30 percent of the insured
pulation. Growth projections indicate enrollment will reach 90 percent of all insured Americans
the year 2000. There will remain, however, a substantial shortfall in the delivery of health
services if the problem is not immediately addressed. Without impacting the number of uninsured,
there will simply be a shifting of the patient load from the sole practitioners to practitioner groups,
while the proportion of the uninsured remains constant or increases.
There will also remain a shortfall in the delivery of health care services in the African American
community, if the issue of shortages of African American health professionals in primary care and
all other specialties are not addressed. It has become imperative that there be a response to this
issue on a national level, with the government taking increased responsibility to support the
recruitment, training and retention of African American health professionals.
African American health care professionals have been major providers of health care for the
underserved, underrepresented and high-risk patient populations. But that same dedication to
serving those most in need has begun to work to the detriment of the health care professional and
ultimately to the detriment of those he or she serves. For it is by answering the medical
requirements of those in the highest risk catagories, that many African American health
professionals have been excluded from panels of practitioners being organized as provider groups.
For example, those patients who have traditionally been served by African American physicians
consistently discover that their own doctors are not included on the lists of preferred providers
offered by their employers' plans. The cause of this exclusion is, in part, the high-risk nature of
the patient population served by these physicians and the fear of the plan or health maintenance
�organization of total financial collapse. Another factor is the often-complicated treatment required
this population. Beyond these financial considerations is also the very high probability that
cism blocks full access to the nation's health care system for both African American health care
consumers and health care providers.
The results are quite evident. The patient in the employer's plan is not free to choose the physician
who has followed his or her medical history. The physician is forced to terminate a
physician/patient relationship which, by the very definition of longitudinal care, best serves the
patient both in terms of treatment and, most importantly, prevention. In addition, many of the highrisk patients, those most in need, find themselves with even more limited access to affordable
health care. The concept of "community rating" must include a large enough universe and socioeconomic cross section of the population to spread and thus diminish the risks.
In order to ensure a level playing field for providers and consumers alike, these African American
health care professionals must be given the opportunity not only to participate as providers, but
also as contractors empowered to organize their own physician (primary care/specialists) provider
groups.
In keeping with the concept of the efficient delivery of health services through provider groups, the
coalition strongly recommends that African American health care providers and patients have equal
access to existing managed health care plans, including Medicare and Medicaid, through open
enrollment periods. The criteria for exclusion and inclusion of physicians in provider groups
should be designed to ensure the delivery of quality care and. at the same time, maximize equal
access and affirmative action. We also see advocacy, community, church and other groups as
important partners in a health care reform movement that engages consumers as active participants
in health promotion and disease prevention.
ile the concept of cost containment is valid and necessary, it should be structured so it neither
its nor reduces services to the patient population. Cost containment should be approached
positively by focusing on wellness, prevention and the avoidance of unnecessary and expensive
treaimem. Here again, those health care professionals with the expertise in serving high-risk
^ Jpatient populations, the African American health care providers, should become an integral part of
osi
cost containment decisions by serving on councils, boards and commissions addressing the same.
We also urge the inclusion of representatives of community-based organizations in decision
making at all levels, in recognition of their role as advocates for consumers.
9'
Cost containment is necessary in the establishment and operation of a national health policy.
However, if cost containment works to limit or reduce services to certain segments of the
population, the result will be an incomplete and ineffective health care system in which "equal
access" becomes only an empty phrase with no practical substance. Cost containment must be
attained, therefore,. through a positive approach to equity and efficiency. This can best be
accomplished through quality assurance measures that expand the concepts of wellness and
prevention. The area of cost containment should be approached also through medical liability
reform.
This forum is being convened to explore the health care issues having the greatest present and
future impact on the African American community. Under the auspices of the National Medical
Association, the Congressional Black Caucus Foundation and ten other national health care and
advocacy organizations, Summit '93: African American Prescription for Health will also produce
recommendations for gaining full access to the nation's health care system for the African
American community.
�To date, those other organizations adding their perspective to the issues of health care for the
ican American community are:
The National Dental Association
The National Black Nurses' Association
The National Black Caucus of Heallh Workers
The Association of Black Cardiologists
The National Association for the Advancement of Colored People The National Urban League
The Joint Center for Political and Economic Studies
The Black Congress on Health. Law and Economics
The National Association of Black County Officials
The National Pharmaceutical Association
After thorough examination of the problems and challenges confronting African American heallh
care providers and consumers, the Summit planners developed specific recommendations on
effective means of bridging the gap which now exist between African American health care
rofessionals and consumers and access to the health care svstem.
mmil '93: African American Prescription for Health affords an opportunity to expand this initial
to encompass many new Coalition Partners. Organizations attending the Summit will
participate in an even broader consensus, as these recommendations are reviewed, expanded and
refined. Through this process, the African American community expects to have significant impact
on health care reform in the United States, for the benefit of our community and all who are
unserved or underserved.
^ ^ a'artnership
i
�GUIDING PRINCIPLES FOR HEALTH CARE REFORM
Universal coverage for all residents
- Every American is entitled to basic health service coverage.
- Every American is entitled to access to a benefit package of basic health care
services.
- Every American is entitled to the highest quality of health care services, delivered
by culturally-sensitive health care providers.
Affordable heallh services withoutfinancialbarrier*
- Access to the health care system should not be limited by a person's ability tc pay
for services which may be long-term and expensive.
- Access to the health care system shnuld not hp determined by whether a person is
employed, unemployed, or under-employed.
- Access to the health care system should begin with an extensive program of healthl
promotion and disease prevention.
- Access to the health care system is enhanced when patients arc made active
participant?; in the promotion of good health and the prevention of disease.
A nalionai health program that includes a basic benefits pjckjge for all medical
conditions
- A national health care program should provide basic benefits, incurporatiny
diagnostic, therapeutic, and reasonable services for every medically necessary
condition, including dental care, mental health, long-term care, and pharmaceutical
products and services.
- A national health care program should be based on health promotion and disease
prevention.
4
A national health care program that is *u.uuntabl« to the public
- A national health care program should be monitored by all levels of government tc
insure quality, access, and standards for cost.
• A national health rare system should be accountable to the public by involving the]
publu to insure that the system responds tn community needs.
• A national health care system should clearly define the roles and relationships of
public hospitals in the broad health care system.
Consumer and provider empowerment
- Health care consumers and health care providers must be involved in the design of
any reformed health care system.
• Health care consumers and health care providers must be involved in the
implementation of any reformed health care system.
- Health care consumers and heallh tare providers must be involved In the
decision-making and evaluation of a reformed health care system thai prumutes
family-oriented, community-based care.
• Adcptetl by the Planning foalirion for Summii 03: African A.-n«ri«im PrMcript.on for Hcalih/Iniereuliural lltalih Coalinon
-9'd-
MSgU I d D I Q l N HfcH Uldt-SrTO ES. SO d3S
�Assurance of high quality and efficiency as well as availability adaptability, and]
acceptability of the national health care program
- Availability must include full and equal access to and participation in health care
plans for all Americans, with the inclusion of health care providers who arc
nilturally-sensitive.
- Adaptability of the national health care program must focus on the diverse and
serious health care concerns of the nations' underserved population and the
delivery of high quality heallh services to that population.
- Acceptability of the national health care program must be based on meeting the
health care needs of all Americans.
A payment mechanisms to Insure desired health outcomes
- A payment mechanism for heallh t-are services should be efficier.t and provide'
incentives for prevention, primary care, and the continuity of ca;e and sc; • ite lu llij
»
underserved.
. A payment mechanism for health care should place emphasis on health promotion]
and disease preventinn.
-
8
A nation*! heallh care program that supports education and training
- A national health care system should provide incentives for the training of Afikan
American health professionals and other persons committed to serving
underserved populations.
- A national health care system should provide additional incentives to historically
black colleges and universities.
A national health care program that encompasses the principle of affirmative
action
- A national health care program must provide for full and equal access by all health ]
care workers, consumers, and trainees.
- A national health care program must include the establishment of African
American-owned and operated networks that provide health-related services.
10
11
— I
Expansion of consumer education
' - Consumer education must focus on the individual, family, and community
institutions.
- Consumer education must focus on health promotion and disease prevention.
- Consumer education must be responsive to cultural diversity in the American
population.
Reform of malpractice insurance, tort procedures, and anti-trust laws
- The delivery of affordable health care services should not be limited by the high
cost of malpractice insurance.
• The delivery of affordable health care services should be enhanced by the reform of j
legal procedures which produces a system which is responsive both to the needs of
the patient and the health care provider.
Please share this message witfi family fritnds. colleagues, neighbors, church members,
public officials, and othenl
ussy idDicGw "iiyn wdes^a es. so d3S
�
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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[Summit ’93 African American Prescription for Health Summit Policy Paper] [loose]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
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Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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3/16/2015
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42-t-12092971-20060885F-Seg3-038-011-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/464efd3c60b2560b8f3b6188218278cd.pdf
77fe7fc80beb6183bcbbbfb50eeca718
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Text
FOIA Number:
2006-0885-F
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MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1987
OA/ID Number:
FolderlD:
Folder Title:
[The State of Alaska Health Resources and Access Task Force] [loose, letter and booklet]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
4
3
�Alaska State
Legislature
Health Resources & Access Task Force
State Capitol • Juneau, AK 99801-1182
(907) 465-2933• (907) 465-3234 Fax
January 11,
1993
Dear Alaskan,
The Health Resources and Access Task Force, created by the Alaska
State Legislature i n May 1991, was charged with the responsibility
for developing a strategy that would provide health care coverage
for a l l Alaskans and that would contain r i s i n g health care costs.
Between September 1991 and November 1992, the Task Force held
fourteen two-day meetings. They labored d i l i g e n t l y to examine the
health care financing and delivery problems facing Alaskans and to
identify the appropriate strategies for making quality health care
available and affordable to a l l .
In carrying out t h e i r r e s p o n s i b i l i t i e s , the Task Force reviewed the
relevant
health services research and
related s c i e n t i f i c
information, examined the relevant experiences i n other states and
countries that have enacted health care reform measures, held
community meetings/public
hearings, heard presentations from
interest groups, conducted public opinion surveys, and reviewed
written comments from numerous individuals and organizations.
Their work lead them to develop fourteen major findings, a number
of important subfindings, and a comprehensive reform strategy
designed to improve the health of Alaskans by making health care
coverage available and affordable to a l l . Both t h e i r findings and
recommendations are included i n t h e i r f i n a l report which i s
enclosed.
The
Task
Force
will
be
presenting
their
findings
and
recommendations to the Governor and Legislature in Juneau on
January 27 and 28, 1993. A s p e c i f i c schedule and agenda for these
presentations i s not yet available.
For further information
regarding these presentations, please c a l l 465-2933.
(continued, next page)
JttCBVEO JAM 15 m
�Page 2
The Task Force w i l l sunset on February 1, 1993. Their o f f i c e w i l l
close on February 15, 1993.
Thereafter, a l l requests f o r
i n f o r m a t i o n should be made through t h e o f f i c e s o f e i t h e r Senator
Jim Duncan or Senator Johnny E l l i s who served as t h e Task Force's
Co-Chairs:
Senator Jim Duncan
Address:
Phone:
State C a p i t o l
Juneau, Alaska
99801-1182
465-4766 (session/interim)
Senator Johnny E l l i s
Address:
State C a p i t o l
Juneau, Alaska
99801-1182 (session)
3111 C Street
Anchorage, Alaska
Phone:
99503 ( i n t e r i m )
465-3704 (session)
I t has been my pleasure t o serve as the p r o j e c t d i r e c t o r f o r t h e
Task Force. On behalf of the Task Force, I would l i k e t o thank you
f o r your i n t e r e s t i n these important issues.
For other i n f o r m a t i o n (through February 15), please c a l l 465-2933.
Sincerely,
Nancy Cornwell
Project Director
enclosure: f i n a l r e p o r t
�THE STATE OF ALASKA
HEALTH RESOURCES AND ACCESS TASK FORCE
FINAL REPORT
to
the Governor and Legislature
January 1993
Alaska State Legislature
Health Resources and Access Task Force
State Capitol
Juneau, Alaska 99801-1182
�THE STATE OF ALASKA
HEALTH RESOURCES AND ACCESS TASK FORCE
FINAL REPORT
to
the Governor and Legislature
January 1993
Alaska State Legislature
Health Resources and Access Task Force
State Capitol
Juneau, Alaska 99801-1182
�MEMBERS
Legislative Branch
Public Members
Senator Jim Duncan
Co-Chair
Mano Frey
Representing Labor Organizations
Senator-Elect Johnny Ellis
Co-Chair
Roxanna Horschel
Representing Private Employers
Representative Mark Boyer
David Mather, Dr. P.H.
Representing Non-Profit Organizations
Senator Jalmar Kerttula
Representative Mike Navarre
Jerry Near
Representing Health Insurers
Senator Robin Taylor
Patricia O'Gorman
Representing Medically Indigent
Executive Branch
Karen Perdue
Representing Consumers
Commissioner Nancy Bear-Usera
Department of Administration
Commissioner Theodore Mala, MD, MPH
Department of Health & Social Services
Commissioner Glenn Olds
Department of Natural Resources
STAFF
Nancy Cornwell
Project Director
Bonnie Gruening
Administrative Assistant
Sister Dona Taylor
Representing Providers
Rodman Wilson, M.D.
Vice Chair
Representing Providers
CONSULTANT
Lawrence Bartlett, Ph.D.
Director
Health Systems Research, Inc.
�The Health Resources and Access Task Force wishes to acknowledge the
assistance of many people and organizations.
We would like to recognize the 17th Alaska State Legislature for creating the
Task Force and for dedicating the necessary resources for our work. We also offer
our appreciation to Senator Virginia Collins who served as an original member of the
Task Force until she resigned in September 1992 and Senator Arliss Sturgulewski who
attended and participated in many of our meetings.
Several members of the Executive Branch actively participated in the Task
Force meetings, including Deputy Commissioner of Health and Social Services Jay
Livey, Deputy Commissioner of Administration Roberley Waldron, and Director Dave
Walsh and Deputy Director Thelma Snow Walker of the Division of Insurance. In
addition, numerous Executive Branch staff provided important information to the Task
Force, including Kim Busch, Deb Erickson, Gordon Landes, Peter Nakamura, M.D.,
Jack Nielson, Larry Streuber, Chris Ulmann, and Brad Whistler. Both Janet Clarke
and Larry Streuber deserve a special thanks for assisting the Task Force in securing
initial resources for our office and for the services of the Institute of Social and
Economic Research.
Many private organizations including the twenty-nine which made brief
presentations to the Task Force deserve our recognition. Several made considerable
contributions to our process including Steve LeBrun of Aetna Life Insurance Company,
Harlan Knudson and Garrey Peska of the Alaska State Hospital and Nursing Home
Association, and well as many representatives of the American Association of Retired
Persons, the Green Party, and the League of Women Voters who consistently
followed our deliberations and asked questions of us.
Worthy of special acknowledgement are the hundreds of member of the public
who participated in our community meetings and public hearings, submitted written
comments, and completed our surveys. Their stories reminded us of the personal
struggles people face in trying to gain access to health care. We would also like to
thank the Anchorage Daily News for publishing our public opinion survey on their
editorial page. As a result, hundreds of Alaskans responded.
We are grateful to Lawrence Bartlett, Ph.D., Director of Health Systems
Research, Inc. who served as our consultant and provided us with invaluable research
and guidance throughout our process. We would also like to thank Scott Goldsmith,
Ph.D., with the Institute of Social and Economic Research for the reports he prepared
for us.
And finally, a special thanks to Nancy Cornwell, our project director, whose
dedicated assistance with all facets of our work added immensely to our success, and
to Bonnie Gruening, our administrative assistant, who responded to many, many
requests and kept all the information coming.
�TABLE OF CONTENTS
EXECUTIVE SUMMARY
CHAPTER ONE:
CHAPTER TWO:
II
BACKGROUND AND PURPOSE
OF THE TASK FORCE
1
TASK FORCE FINDINGS
3
CHAPTER THREE: GUIDING PRINCIPLES
37
CHAPTER FOUR: TASK FORCE RECOMMENDATIONS
39
A.
OVERVIEW
39
B.
TASK FORCE RECOMMENDATIONS
41
C.
IMPLEMENTATION TIMETABLE
75
REFERENCES
79
LIST OF APPENDICES
83
�EXECUTIVE SUMMARY
The Health Resources and Access Task Force was created in 1991 by the
Alaska State Legislature and charged with the responsibility for developing a strategy
that would provide health care coverage for all Alaskans and that would contain rising
health care costs. Over the past sixteen months, the Task Force has labored
diligently to thoroughly examine the health care financing and delivery problems that
exist in the state and to identify the appropriate strategies for making quality health
care available and affordable to all Alaskans. In carrying out its responsibilities, the
Task Force carefully examined a significant amount of data and research on health
care issues both in and outside of Alaska, held numerous community meetings and
public hearings, conducted surveys of the Alaskan public, and received and reviewed
written comments from numerous individuals and organizations across the state.
The Task Force found the health care financing and delivery systems in Alaska
to be in a state of crisis. Specifically, the Task Force found that:
•
Over the past dozen years, health care costs have grown out of control,
far outstripping the growth in the overall economy. Unless steps are
taken to address this problem, future costs can be expected to continue
to spiral upward.
•
Despite the significant amount of health care dollars spent in Alaska, a
significant portion of the state's population-over 76,000 persons-have
no health care coverage. Not only does this lack of coverage have a
negative impact on the health of these persons, but it also results in
higher health care costs to those of us who do have insurance.
•
There are many problems inherent in our current health care financing
system that result in so many uninsured Alaskans. For example, many
insurers who sell coverage to small businesses will refuse to insure or
charge unaffordable rates to those businesses and individuals who most
need health care protection.
•
Significant problems exist within the state's health care delivery system.
For example, in some areas of the state people lack access to even the
most basic of health services, while in other areas a lack of coordination
among providers results in the unnecessary duplication of services.
•
The State does not have the proper policies in place to assure a strong
and stable public health infrastructure.
•
The manner in which we resolve medical malpractice claims is in need of
improvement.
�As a result of the above problems, the Task Force also found that:
•
The health status of Alaska's population is among the worst in the
nation; and
•
A significant portion of the state's population believes that fundamental
reform is necessary to correct the problems in the state's health care
financing and delivery systems.
The Task Force agrees with the message it received from the Alaska public
calling for a significant overhaul of the state's existing health care financing and
delivery systems. We recommend the implementation of a comprehensive health care
reform strategy designed to improve the health of the Alaskan people by making
health care coverage available and affordable to all. The specific components of this
strategy include:
•
The establishment of a statewide health care expenditure limit to bring
skyrocketing costs under control and make health care affordable once
again;
•
The establishment of a single payer system under which health care
coverage will be available to all Alaskans at no additional increase in
total spending. While a single payer system is being developed and
implemented, the Task Force has also recommended a series of interim
measures designed to provide an immediate increase in access to care
for many uninsured and underinsured Alaskans;
•
A series of measures designed to improve the availability, efficiency and
coordination of health care services throughout the state;
A commitment to provide a strong public health infrastructure; and
•
Improvements in medical malpractice claims resolution.
The Task Force firmly believes that enactment of these recommendations will
improve the availability, affordability and quality of health care provided in Alaska. As
a result, Alaskans will live healthier, happier, and more productive lives.
�BACKGROUND AND PURPOSE OF THE TASK FORCE
During the 1991 legislative session, the Alaska State Legislature passed
Legislative Resolve 45 which created the Health Resources and Access Task Force.
The primary purposes of the Task Force were:
1.
To design a cost-efficient program that allows access to a basic level of
health care services for all state residents;
2.
To continue the work of the Health Care Cost Containment Task Force in
seeking ways to achieve savings in the cost of health care in the state;
and,
3.
To define a strategy for implementing a health care program covering all
Alaskans and a strategy to contain the costs of health care in the state.
(The resolution creating the Task Force includes fourteen specific tasks related to
these primary purposes. See Appendix A for resolution.)
The Health Resources and Access Task Force consists of seventeen members
including three members of the Senate, three members of the House, three members
representing the executive branch, and eight public members representing health care
providers (two members), the medically indigent, employers, health insurers, nonprofit
organizations, consumers, and labor organizations.
The Task Force, created in May 1991, sunsets on February 1, 1993. The Task
Force held fourteen two-day meetings between September 1991 and November 1992.
During these meetings, we developed an understanding of the health care access and
cost problems facing Alaskans by reviewing relevant health services research and
related scientific information. Task Force members also drafted "guiding principles"
which we followed in the development of our recommendations. In addition, we
reviewed the full array of possible approaches for addressing identified problems,
including the relevant experience of other states and countries with health care reform
measures. For many of these approaches, we explored how, if implemented in
Alaska, they would change our current health care system.
As a means of getting public input from Alaskans on their health care problems
and recommendations for reform, the Task Force heard brief presentations from
twenty-nine organizations including advocacy groups, professional service and other
provider organizations, private and public sector employers, and business groups. We
also held community meetings and public hearings in Anchorage, Bethel, Cordova,
Delta Junction, Dillingham, Fairbanks, Glenallen, Haines, Homer, Juneau, Kenai,
1
�Ketchikan, Kodiak, Kotzebue, Nenana, Nome, Palmer, Petersburg, Seward, Skagway,
Soldotna, Sitka, Tok, Unalaska, Valdez, Wasilla, and Wrangell. In addition, 495
Alaskans responded to two separate public opinion surveys distributed by the Task
Force. And finally, many Alaskans provided invaluable written comments to us.
(Written comments from interest groups and individuals, summaries of the community
meetings/public hearings, and the survey results are published in a separate
document.)
One important part of Alaska's health care system which we excluded from our
recommendations was long-term care. During our early meetings, we discussed the
daunting scope of the Task Force's charge. We also noted that the financing
problems for primary, preventive and acute care are significantly different from those
for long-term care. The Task Force felt that our principal charge was to address the
problems of spiraling health care costs and lack of health care coverage for primary,
preventive and acute care services. However, our decision to exclude long-term care
from our recommendations should not be interpreted as our believing that this problem
is insignificant. On the contrary, the Task Force concluded that the long-term care
problems facing Alaskans are so significant, and the effort required to address them
so large, that the State should pursue those issues in an arena dedicated solely to
that subject.
The Task Force published an interim report of our findings in January 1992 and
interim recommendations in March 1992. This report represents our final findings and
recommendations.
Chapter Two of this report presents the Task Force's major findings and subfindings. Chapter Three contains our guiding principles, and Chapter Four describes
both the Task Force's short-range and long-range recommendations for health care
reform in Alaska.
�TASK FORCE FINDINGS
Between September 1991 and November 1992, the Task Force examined the
health care access and cost problems facing Alaskans. Our examination led us to a
number of important findings, which we have summarized in this chapter. We also
highlight and discuss a number of important subfindings within each of these areas.
And finally, throughout the chapter we have included excerpts from the letters and
testimony we received that illustrate in very human and personal terms the problems
that Alaska's health care financing system has created for many of its people.
Finding #1: In the 1980s, health care costs in Alaska grew at a rate far
above other measures ol the state's economy.
(
•
In the twelve-year period from 1979 to 1991, total health care spending in
Alaska more than tripled, rising from $479.7 million fo $1,598 billion.
Details on 1979 expenditures can be found in Malhotra and Wills (1981).
Table 2-1 below identifies the sources of health care spending in Alaska in 1991 by
major payer category. Table 2-2 on the following page provides further detail on the
sources of 1991 spending, while Appendix B to this report describes the data upon
which this estimate was developed.
1991 Health Care Spending in Alaska by Payer Category
AMOUNT
PERCENT
OF TOTAL
$ 549 million
34%
Individuals
377 million
24%
State Government
318 million
20%
Businesses
235 million
15%
Local Governments
118 million
7%
PAYER
Federal Government
Total 1991 Spending
$1,598 billion
100%
�:
Table 2 - 2:>::.-.
E S T I M A T E D 1991 HEALTH S P E N D I N G IN ALASKA
BY S O U R C E O F FUNDS
(In Thousands 61 Dollars)
Detail
Employment- Based:
Individual
Business
Local
State
Federal
Insurance Premiums
$61,164
$121,418
$30,861
$65,379
$39,906
$48,774
$47,929
$9,290
$35,402
Self-Insured Plans
Subtotal/Employment- Based
$92,024
$186,796
$88,681
$57,218
TOTAL
$460,121
28,80%
$35,402
Other Private
Individual Policies and Coverage
$77,547
$29,458
4.85%
through Fraternal Orgs and Auto
Liability Insurance
Workers' Compensation
$48,089
Out-Of-Pocket:
Expenses of Uninsured
$255,602
16.00%
$255,602
Co - pay ments/Deductibles
Non-covered Services
$964
Medicare:
$90,000
$90,964
5.69%
$214,550
Medic aid:
Federal
State
$109,248
$95,326
$4,276
Medicaid Administration
13.43%
$5,700
Other Public
Federal:
$206,153
IHS/AANHS
Veterans' Affairs
$46,476
CHAMPUS payments
$14,647
Military Support
$308,561
19.32%
$41,284
$160,455
State:
Pioneers' Homes
10.04%
$12,436
$662
$19,270
Youth Corrections Health Care
API, Harborview
$7,066
$27,977
Grants to Regional Health Corporations
Selected state health services
$313
$5,026
$21,799
$27,995
Revenue Sharing for Health
Other grants for health
Community Mental Health Grants
$1,230
Fisherman's Fund
$7,672
$29,009
General Relief Medical
Other State Health Spending
$29,713
Local:
1.86%
Local Taxes in Support of Hospitals
Other Local Health Spending
$29,713
(net of state grants)
Total
As a % of total spending
$377,084
$234,885
$118,394
$317,926
$549,223
23.60%
14.70%
7.41%
19.90%
34.38%
$1,597,513
Source: Data originally compiled by ISER, UAA from various sources. Selected entries updated by Health Systems Research, Inc.
�•
Per capita health care spending in Alaska increased nearly two and onehalf fold over the past twelve years, growing from $1,160 in 1979 to $2,783
in 1991.
1
A certain portion of the growth in overall health spending in Alaska is due to an
increase in the size of the state's population. The Task Force found that even after
accounting for population growth, 1991 per capita health care spending in Alaska was
roughly two and one-half times greater than in 1979.
•
In Anchorage, while consumer prices for all goods and services grew 28.9
percent since the early 1980s, medical costs grew 81.5 percent
(Anchorage Daily News 1992), or nearly three times the rate of inflation.
The Task Force found that increases in the prices charged for health care
services contributed significantly to the growth in health care spending. For example,
during the last decade, health care prices in the United States increased at nearly
twice the rate of general inflation. Although comparable data is not available for the
entire state, an analysis of Anchorage consumer prices indicates that medical costs
there increased three times faster than overall inflation.
Finding #2: Alaska's per capita /iea/f/7 c a «
the national average, is expected to continue to grow at a fast
•" 7''-; -^ce-M"'-v
In 1991, Alaska's per capita health care spending was roughly equal to the
national average. However, this comparison does not take into account the fact that
Alaska's population is much younger than the nation as a whole. As discussed below,
after adjusting for these age differences, health care spending per person in Alaska
was found to be much higher than the national average.
Alaska's 1991 age-adjusted per capita health care spending was 27
percent above the national average.
U.S. and Alaska 1991 per capita health care spending was estimated to have
been roughly the same, at $2,872 and $2,783, respectively. However, these figures
According to the Alaska Department of Labor, the state's population in 1979 was 413,700. The
1991 population was projected by the Department to be 574,000, see middle series projections
in Alaska Population Projections, November 1991.
�are not adjusted to reflect differences in the age composition of the populations.
Because Alaska's population is younger than the nation as a whole, and because the
young have lower health care costs than the elderly, the age distribution of Alaska's
population would be expected to result in lower health care costs overall than for the
U.S. When per capita costs are adjusted for age, Alaska's 1991 per capita health
spending is estimated to have been twenty-seven percent higher than the national
average.
2
•
Total health care spending in Alaska under our current system is
projected to more than double over a seven year period, increasing from
slightly below $1.6 billion in 1991 to nearly $3.34 billion in 1998. By the
year 2003, health care spending in the state will be nearly $5.6 billion.
3
While the historical rates of growth in health care spending were of great
concern to the Task Force, they found that projections of future health care spending,
which assume "business as usual," were even more alarming. Statewide health care
spending is expected to more than triple over the next twelve years, reaching nearly
$5.6 billion in the year 2003.
Figure 2-1
Projections of Health Care Expenditures in
Alaska under the Current System, 1991-2003
Billions ol $
6
5 -
3 -
1991
1997
tans
tasu
199«
ina?
199B laaa
2000
2001
20*1?
2003
Source- Health Systems Research. Inc.
2
Bartlett, L, Health Systems Research, Inc. For expenditures by age groups, see CRS 1991.
3
See Chapter Four for a fuller discussion of the Task Force's projections of future health care
spending in Alaska.
�Between 1991 and 2003, per capita health care spending under the current
system in Alaska is expected to increase over two and one-half fold to
$7,341, up from $2,783 in 1991.
Figure 2-2
Estimated Per Capita Health Care Spending in
Alaska 1979, 1991, and 2003
$6,000
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
1979
1991
2003
Source: Maholtra and Wills 1981 and Heallh Systems Resoarch, Inc.
In considering projections of health care spending in Alaska, the Task Force
took special note of the proportion of health care spending that is likely to be
consumed by the elderly. During the 1980s, Alaska's elderly population grew at a
faster rate than the U.S. elderly population, and faster than Alaska's population as a
whole (Appendix C, Section IV). Such population growth, together with the fact that
per capita health care costs for the elderly are three times greater than average (CRS
1991), suggests that the elderly will consume an even greater share of health care
spending in future years. This was of great concern to Task Force members, since
services for the elderly are financed disproportionately by the public sector, principally
through Medicare and Medicaid.
Finding #3: Health care costs are having an increasingly negative effect on
Alaska's employers, including both private businesses and
governments, as well as on workers and their families.
As health care spending has grown, it has absorbed a larger percentage of the
Gross Domestic Product, business profits, payroll, and family incomes.
7
�The U.S. spends a larger share of its Gross Domestic Product on health
care than any other industrialized country (see Figure 2-3). As a result,
U.S. industries find it increasingly difficult to compete in the world's
economy (CRS 1991).
Figure 2-3
Health Care Spending as a Percent
of Gross Domestic Product, Selected Countries, 1989
Percent
14
n.8%
12
10
8
6
4
2
0
Source.
•
United States
Sweden
Canada
France
United Kin'gdonn
Congressional Research Service
Rapidly rising health care costs have had a negative impact on the
profitability of most businesses.
According to the Employee Benefits Research Institute, in 1970, health care
benefits paid for by businesses were equivalent to about 35 percent of after-tax profits
for corporations. By 1980, health benefit payments, as a business expense, were
equal to about 48 percent of after tax profits, and by 1989, they had reached roughly
the same level (103 percent) as after-tax profits (see Figure 2-4).
4
Employee Benefit Research Institute tabulations of data from the U.S. Department of Commerce,
Bureau of Economic Analysis, Survey of Current Business, selected years.
8
�Figure 2-4
Employer Spending on Health Insurance
as a Percentage of Corporate After-Tax Profits
Percent
120
1(13%
100
Source:
Employee Bcnefil Hcsoarch Institute tabulation ol U.S Department ol Commerce data
Rapidly rising health care costs have meant less take-home pay for
Alaska workers.
Health care benefits as a percent of payroll have been the fastest growing
component of labor compensation over the last two decades, limiting employers' ability
to increase real wages. As shown in Figure
2-5 on the following page, in 1970, health
care spending by U.S.
businesses
P R O A S O I S ...
E S N L T RE
represented 3.5 percent of total wages and
salaries. By 1987, business health care
7 am a 31 year old, lifelong Alaskan, who
; i has not .had the luxury of being covered by a.
spending had increased to 7.4 percent of
health care plan via the work place. For
wages and salaries
(GAO 1990).
seven years, I went without any coverage at
a//. Fearingfinancialruin due to escalating
health care costs, I obtained a pwate policy ^
in March 1990. My monthly pramium, with a :•
•
$500 deductible, was $55. Today m
y
• premium is $98. My premium increased four . ;
ftmes in 24 months. For certain, I can expect :
more increases. I would also like to mention
that this policy contains three riders for
; excluded coverage for pre-existing conditions." :
-- Anchorage Resident
�Figure 2-5
Business Health Expenditures as a
Percentage of Wages and Salaries, 1970 - 1987
1970
1975
1980
1985
1987
Source. U.S General Accounting Office
In Alaska, the disparity between growth in health care spending and growth in
wages has been especially great. Between 1984 and 1991, health care spending in
Alaska is estimated to have grown by 125 percent, while total wages and salaries for
workers have increased by only 16 percent (see Figure 2-6 below).
5
Figure 2-6
Growth in Total Health Spending and in Total Payroll
for Non-Agricultural Workers in Alaska, 1984 to 1991
Percent
_ 124.9*
140
120
100
80
60
40
20
0
Health Care Spending
Total Payroll lor
Non Agrlcultiiral Workers
Cultural'
Sources: Heallh Resources A Access Task Force and Alaska Department of Labor
Total yearly payroll (nonagricultural earnings) in Alaska were $6,360,017,668 in 1984 and $7,347,053,592 in 1991, see
Alaska Department of Labor, Employment and Earnings Report: 2nd Quarter 1991 and Alaska Statistical Quarterly; 2nd
Quarter 1985. Total health care spending in Alaska is estimated to have been $710.3 million in 1984 (Noble Lowndes
estimate) and $1,598 billion in 1991 (ISER and Health Systems Research, Inc. estimate).
10
�•
In an attempt to offset rising health care costs, businesses have
increasingly required their employees to pay a greater portion of their
health care premiums and often have increased the levels of copayments
and deductibles in their plans. This trend, along with rising provider
rates, has meant that families are spending a larger percentage of their
income on health care.
During the 1980s, both the percentage of plans requiring premium cost-sharing
and the dollar amounts contributed by employees increased. According to the Bureau
of Labor Statistics, between 1982 and 1988 the proportion of workers required to
contribute to the cost of their coverage increased from 21 to 46 percent for workers
with individual coverage, and from 51 percent to 65 percent for those with family
coverage. In addition, over the same time period the average monthly premium cost
increased from $31 to $72 for workers with individual coverage, and from $171 to
$320 for those with family coverage (Short 1988).
As a result of the trend toward requiring larger contributions from employees, as
well as the overall growth in health care spending, the burden that health care costs
have placed on families has increased. In 1980, average family spending on health
care accounted for 9 percent of family income. By 1991, average family health
spending had increased to 11.7 percent. If these trends continue, out-of-pocket health
care expenditures for an average family can be expected to absorb over 16 percent of
annual income by the year 2000 (Families USA Foundation 1991).
Figure 2-7
Family Health Payments as a
Percent of Average Family Income
16.4%
20
e
E
o
15-
f -0
1980
1991
Average Family Health Payments
Source:
Families USA Foundation
11
2000
�Not surprisingly, rising health care
costs also have been at the core of many
disputes between employers and their
workers. In 1989, nearly two-thirds of fortythree major labor walkouts in the United
States were disputes over health benefits
(New York Times 1991).
PERSONAL STORIES . .
"Out own health care system: has
changed dramatically since I started
working here in 1980: At first my
employer paid all the premiums. Now. ?;
every year, we have to pay more and
more and the, benefits are jess'and.
Eagle River Resident
Finding #4: In spite of significant spending on heanbicmr mariy Alaskan*
lack coverage for even the most basic health care services.
While $1.6 billion (the estimated total health care spending in Alaska in 1991)
seems like it should be sufficient to provide a basic level of care to all Alaskans, the
Task Force observed that:
In the late 1980s, over 76,000 non-elderly Alaskans had no health care
coverage.
An analysis of Alaska-specific data from the 1988 through 1991 Current
Population Surveys revealed that approximately 76,000 non-elderly Alaskans had no
health care coverage. That means that they had no coverage for any service, whether
it be private insurance, Medicaid, Medicare, Indian Health Service coverage, or any
other type of third-party health care coverage.
6
The Current Population Survey is a national survey conducted each year by the U.S. Bureau of
the Census. While the number of persons included in the CPS from states with relatively low
populations (such as Alaska) is small, most states nonetheless rely on CPS data to provide
rough estimates of the number of uninsured because better estimates are expensive and
difficult to generate. One technique used to compensate for the small sample size is to analyze
survey results over a several year period. This approach was used in the analyses conducted
for the Task Force. We would also note that in the Task Force's Interim Report (January 11,
1992), 90,000 Alaskans were reported as being uninsured. This number included a certain
number of Alaska Natives who responded in the survey that they had no health care coverage,
despite the fact that they are eligible to receive care through the AANHS/IHS system. Dr.
Bartlett of Health Systems Research, Inc., in response to the Task Force's request to develop
an estimate using the "assumption that all Alaska Natives have health care coverage through
the Indian Health Service system," removed the Alaska Native respondents from the sample
and reanalyzed the data. This reduced the estimate of the number of uninsured Alaskans from
90,000 to 76,000. For complete results of Dr. Bartlett's analyses, see Appendix D.
12
�Over 21,000, more than one in every four, uninsured Alaskans are under
the age of 18
Figure 2-8 presented below displays the distribution of Alaska's non-elderly
uninsured population by age. Because of the nearly universal coverage provided by
Medicare to the elderly population, our analysis focuses on the characteristics of the
non-elderly uninsured population. As can be seen from this chart, over a quarter (28
percent) of uninsured persons in the state are children, while another 15 percent are
young adults aged 18-24. The remainder of the state's uninsured population are
adults aged 25 - 49 (48 percent) and older adults aged 60 - 64 (9 percent).
Figure 2-8
Distribution of Uninsured Non-Elderly Alaskans, by Age
< 18 YRS
(28%)
50
18
64 YRS
(9%)
TOTAL NUMBER OF UNINSURED = 76.000
Source:
24 YRS
(15%)
25 - 49 YRS
(48%)
Hoaltti Systems Research, Inc. analysis ol 1988-91 CPS
In the late 1980s, many uninsured Alaskans did not have sufficient income
to purchase health care coverage on their own.
A 1989 study by the National Health Care Campaign found that, in most states,
it is only when families earn more than 250 percent of the poverty level that they begin
to accumulate the disposable income required to contribute toward a portion of
7
In the Task Force's Interim Report, we reported that there were 28,000 uninsured children.
When Dr. Bartlett removed Alaska Native respondents from the CPS sample, the estimate of
the number of uninsured children was reduced to 21,000. See Appendix D.
13
�premium costs (Appendix D). When the Task
Force compared this finding to its analysis of
the incomes of uninsured Alaskans, it
. • 'When my daughter; and son-in-law were
discovered that a significant portion of the
-] expecting their first child, my daughter was
state's uninsured population could not afford to
unable to work . • v Our son-in-law was
making just enough to pay for essentials.
purchase coverage on their own.
For
The state welfare system declined their
example, the Task Force realized that even
request for medical coverage claiming our
though the federal and State governments
son-in-law's 'i income was too high, wasn't •
making, more than $6 per hour \ :•; . / was
together spent over $214 million in 1991 in
informed that (a particular) hospital would
Alaska for the Medicaid program, more than
help. .The hospital charged according to
13,500 uninsured Alaskans lived in households
:income. They paid all of the hospital bill."s
in the late 1980s with incomes below the
federal poverty level. An additional 16,000
-• Anchorage Resident
uninsured Alaskans lived in households with
incomes between 100 and 200 percent of
poverty (with incomes between $15,120 and $30 ,240 for a family of four).
8
Of particular concern to the Task Force was the fact that so many thousands of
low income children were without basic health care coverage. We found that of the more
than 21,000 uninsured Alaskan children, about 3,900 lived in households with incomes
below the federal poverty level, while another 4,500 were in families with incomes
between one and two times the poverty level.
Given the financial risks of being uninsured, the Task Force also found it
disturbing that nearly 30,000 uninsured Alaskans were in families with incomes in
excess of 300 percent of poverty. Of these,
roughly 18,000 were employed full-time for
the entire year. The Task Force concluded
PERSONAL STORIES . . .
that, under the current system, there may be
a number of reasons why persons with
7 can't get health., insurance because. • I
.
have been diagnosed recently with MS. I
adequate incomes are without coverage.
was working in a full-time position (for a:
Some may be uninsured because they wish
large employer), I was pregnant at the time
to avoid the expense or consider
I was diagnosed.
Unfortunately, . the
themselves to be "immortal." Others have
employer is here in the state and felt a
need to lay me off, when I was pregnant
significant health care needs and cannot
and recently diagnosed. I have contacted
find an insurer who will offer them a policy
several health insurance companies in the
at an affordable price. The Task Force
private sector and to my disbelief, people
further recognized that as long as some
with tuberculosis, any form of cancer within
the last ten years, diabetes, overweight,
Alaskans remain uninsured and continue to
MS. AIDS, or even having open heart
incur health care expenses which they
surgery cannot obtain: health insurance in
cannot afford, providers will continue to shift
the private sector, even though we are
the costs of caring for the uninsured and
willing to pay the premium, we are unable
to get health insurance.": •
underinsured to employers who provide
health care benefits to their employees.
;
-- Anchorage . Resident
The 1989 federal poverty level for a family of four in Alaska was $15,120.
14
�Figure 2-9
Distribution of Uninsured Non-Elderly Alaskans,
by Poverty Status
5 100% of FPL
(18%)
Over 300% o( FPL
(39%)
101 - 200% o l FPL
(21%)
201 - 300% of FPL
(22%)
TOTAL NUMBER OF UNINSURED = 76.000
Source:
Hoalth Systems Research, Inc analysis ol 1988-Bt CPS
Finding #5: Nearly nine out of ten Alaskans without health care coverage
are "working uninsured" Alaskans and their dependents.
•
Contrary to what many believe, the vast majority of uninsured Alaskans
are workers or dependents of workers.
Analysis of Alaska's uninsured population also revealed that in the late 1980s,
over 68,000 uninsured non-elderly Alaskans, or 89 percent of uninsured Alaskans,
lived in a household where the head of household worked some or all of the year (see
Figure 2-10 on the following page). Only 8,000 uninsured Alaskans lived in
households where the head of household was unemployed for the entire year
(Appendix D).
Nearly half of all uninsured Alaskan workers and their dependents are in
families where the head of household worked in seasonal job. Given the
Task Force's charge to design a program to provide access to health care
for all Alaskans, we concluded that efforts to tie health care coverage to
employment would not readily achieve our goal of "universal access."
15
�Figure 2-10
Distribution of Uninsured Non-Elderly Alaskans,
By Employment Status of Head of Household
Full-Time
Full-Year
(43%)
Full-Tlme
- Part-Year
(34%)
Not Employed
(11%)
Part-Time
Part-Year
(9%)
TOTAL NUMBER OF UNINSURED = 76,000
Source:
Heallh Systems Research, Inc analysis ot 1988-91 CPS
Of the 68,000 uninsured Alaskans who
lived in a household where the head of
household worked some or all of the year,
26,000 were in households in which the family
head had a full-time (but not full-year) seasonal
job, while another 6,800 uninsured Alaskans
were in families in which the head of household
had a part-time seasonal job (Appendix D).
The Task Force felt it likely that, even if
employers were required to provide coverage to
their employees, the seasonally-employed and
uninsured in Alaska would still be without
coverage while they were unemployed. Further,
this group would create considerable "churning"
in the health insurance market as they gained
coverage when they worked and lost it when
they did not. The large number of uninsured
Alaskans who have a link to the state's
significant seasonal economy raised doubts
within the Task Force about relying on
employment-based coverage as a viable
approach for achieving universal coverage.
This issue is discussed in greater detail in
Chapter Four.
16
PERSONAL STORIES . .
"You go to an insurance company,
and as soon as they! find put you are
a diabetic, which is my case, or a
number of other diseases, they slam
the door in your face ;'.; . / ran the
Iditarod a few years ago, I had
diabetes then too. They don't come
much healthier than me, I'd like to
think. And the fact that I can't get any
son of insurance is absolutely
disgusting . . . There is very blatant
discrimination that takes place, on a
regular basis throughout the insurance
industry, and if there is a way that the
government can somehow overcome
that or create a system where the
people can •• take the place of the.::
insurance company, let's do it. . . . /
have had a job for years, it's full-time
(full-year) this year (its usually
seasonal), anyway, it's even with the
federal government,
but it's
considered temporary .::: there is no..
coverage involved.
-- Anchorage Resident
�Finding #6: Hard hit by the problems of our current health} care financing
system are Alaska's small businessesrand their workers.
1
•
Small businesses must purchase coverage in an insurance market which
includes high and unpredictable premium increases and onerous
underwriting practices.
As
insurers.
excluding
coverage
health care spending has increased, so has competition among small group
Today, insurers commonly reduce their exposure against losses by
some groups, some individuals, and some health conditions from the
offered.
The rating approaches used by small group insurers can also result in high and
unpredictable rate increases, particularly when pre-existing condition limitations expire.
As a means of attracting groups, insurers have been known to offer groups low rates
in the first year only to raise them dramatically in subsequent years. Additionally,
insurers charge higher premiums for small groups particularly those with groups with
high health needs, women, and older workers, as well as for certain "higher risk"
industries (Butler et al. 1991).
For comparable benefit packages, small employers (defined as employers
with fewer than twenty-five employees) pay 10 to 40 percent more in health
premiums than large employers
(ICF Incorporated 1987). Because
benefits packages for small
PERSONAL STORIES . . .
employers are more expensive, it is
not surprising that small business
: "An uninsured woman I know can only *
owners overwhelmingly cite the
afford going to a neighborhood health
cost of coverage as the most
clinic where she can pay a sliding fee
important reason for not offering
for only the very basic of services.
health care benefits (Butler et al.
• V When she or her children , need a;:
specialist, because:: she is uninsured, •
1991; Formisano 1988; Hall and
the doctors refuse to see her without
Kuder 1990). In Alaska, nearly half
cash up front. It is humiliating to her
of all of the uninsured adults or
to try to beg for medical care for her
26,000 workers were employed by
famijy and this makes me furious."
small businesses in the late 1980s.
9
• -- Anchorage Resident :
In the Task Force's Interim Report, we reported that there were 28,000 uninsured Alaskans
who worked for small businesses. When Dr. Bartlett removed Alaska Native respondents from
the sample, the estimate of the number of uninsured Alaskans who worked for small
businesses was reduced to 26,000. See Appendix D.
17
�One of the reasons why health premiums are significantly higher for small
groups than for large groups is the administrative costs of insurers. As illustrated in
Table 2-3, one national study reported that the smallest groups may pay as much as
40 percent of their incurred claims toward administrative costs while the largest groups
pay as little as 5.5 percent (CRS 1990).
10
Breakdown of Insurance Company Administrative Expenses
(Percentage of Incurred Claims)
Number of Employees
Profit
& Risk
General*
Commission
Total
1
to
4
23.1
8.5
8.4
40.0
5
to
9
21.0
8.0
6.0
35.0
10
to
19
17.5
7.5
5.0
30.0
20
to
49
14.9
6.8
3.3
25.0
50
to
99
10.0
6.0
2.0
18.0
100
to
499
8.9
5.5
1.6
16.0
500
to
2,499
7.8
3.5
0.1
12.0
2,500
to
9,999
5.9
1.8
0.3
8.0
10,000
or
more
4.3
1.1
0.1
5.5
* Includes claims administration, general administration, interest credit, and premium taxes
Source: Congressional Research Service
In January 1991, the Division of Insurance estimated that there were only
nine insurers that were significantly active in Alaska's small group
market. Alaska's small businesses purchasing coverage therefore not
only face onerous underwriting practices and higher premiums than large
groups, but they do so in a market with relatively limited competition.
11
10
The Health Insurance Association of America also reports administrative expenses. Their data
reflect a similar distribution in the types of administrative expenses, but a smaller range for
employers of different sizes (25 percent of incurred claims for groups with fewer than 25
employees and 6 percent for groups of 2,500 or more employees), see Health Insurance
Association of America, 1991. Statement of HIAA on Health Care Reform and Insurers'
Operating Expenses. Presented Before the Subcommittee on Education and Health, Joint
Economic Committee, U.S. Congress. Washington, D.C. (October 16).
11
Chris Ulmann, Alaska Division of Insurance, January 15, 1992.
18
�Alaska's health insurance market can be divided into two segments, self-insured
plans and conventionally-insured plans. Alaska, like all states, is prohibited by the
federal Employment Retirement Income Security Act (ERISA) from regulating selfinsured plans. Therefore, we know very little about this market. The conventionallyinsured market, made up of both commercial and nonprofit insurers, is dominated by
two large insurers, AETNA Life Insurance Company and Blue Cross of Washington
and Alaska. Together, AETNA and Blue Cross wrote 70 percent of total premiums in
the Alaska private insurance market in 1990. The remaining 30 percent of the
market included over 400 insurers, of which only twenty companies had over one-half
of one percent of the market, and many of whom sold few if any policies. Of these
twenty additional insurers, only nine were significantly active in the small group
market.
12
Finding #7; The lack of adequate health care coverage can have a negative
effect on the health of uninsured and underinsured.
The Task Force discovered that the health of the uninsured often suffers because
they delay seeking care for medical problems.
»
The uninsured report a lower health status than the insured (Freeman et al.
1987) and use fewer services overall than the insured. When the uninsured
do use services, if is more likely fo be late in the course of an illness and
occur in costly institutional settings such as emergency rooms (The Robert
Wood Johnson Foundation 1987;
CRS 1988).
Cost is an obvious factor that deters
the uninsured from receiving care. Indeed,
over a third of uninsured Alaskans reported
that "within the last year, there was a time
that they needed to see a doctor, but could
not because of the cost," compared to only
one in ten insured Alaskans. Not surprisingly,
uninsured Alaskans also report waiting longer
periods than the insured for routine preventive
PERSONAL STORIES . . .
7 am one of many Alaskans who has
no health insurance:; / have a partner
:;•: who is in private business who. cannot
afford ; health insurance. I am
unemployed and have been without
insurance for two years. My two
children are without insurance • also.
We all have medical conditions which
should be treated, but we cannot
afford to go the doctor. Our lives are
challenged often by this fact. A major
or emergency illness would be
catastrophic to us."
:
;:
- Nenana Resident
12
Total health insurance premiums written in 1990 were $297 million, of which AETNA wrote
$127 million and Blue Cross wrote $82 million.
19
�13
checkups with a doctor. The fact that the uninsured often do not receive needed
preventive care increases overall health care costs because when the uninsured do
seek care, they may be sicker and incur greater costs in treating their illness-costs
that could have been avoided with adequate preventive care.
Finding #8: The uninsured and underinsured generate unpaid medical bills
the costs of which are uttimately paid in the form of higher
provider charges by persons with health care coverage.
As health care expenditures have increased, there has been an increase in the
amount of "uncompensated" care that providers must cover, which they do by
increasing their charges to those who have health insurance. Data provided by the
Alaska State Hospital and Nursing Home Association was used to estimate the costs
associated with charity care, bad debt, and Hill-Burton free care. In 1990, ten
hospitals, representing 86 percent of the acute care community hospital beds in
Alaska, provided $16.8 million in charity care, care which resulted in bad debt, and
Hill-Burton free care (Appendix E). To remain financially viable, these facilities had
to "cost-shift," that is, increase their charges to insured patients in order to cover these
unpaid or "uncompensated" expenses.
14
This $16.8 million figure may actually understate the magnitude of cost-shifting
by Alaska's acute care community hospitals. Industry representatives have stated that
reimbursement from public payers such as Medicare and Medicaid do not cover the
cost of delivering services to those clients. If this is the case, then the losses
associated with the delivery of services to Medicare and Medicaid patients must also
be shifted to private payers.
The net result is that to recover
uncompensated care costs and insufficient
payments from public programs, Alaska
hospitals must set their charges to privately
insured patients at levels that are 15 to 20
percent, or more, above the actual cost of
caring for these patients.
Although of no less interest to the Task
Force, we were unable to obtain information
on cost-shifting associated with physician
services.
.: "The cost of health care prohibits
routine health visits, therefore my
::family's health care suffers. I can only
hope that my family will not be
affected by an illness before
comprehensive and affordable health
care can be provided to them."
-- Anchorage Resident :
13
Preliminary results from the 1991 Behavioral Risk Factor Surveillance Survey, Alaska Division
of Public Health, November 1992.
14
The costs associated with this care may have been offset by the $3.7 million in revenues from
state and local governments.
20
�Finding #9: Many Alaskans who currently have health care coverage fear
The Task Force asked Alaskans to express their views about our current health
care system by circulating a survey. Four hundred and sixty-two (462) surveys were
returned to the Task Force. They included 124
from our community meetings/public hearings,
PERSONAL STORIES . ..
243 from the Anchorage Daily News (who put
the survey in their editorial column), 79 from
"My insurance has become too costly
the Anchorage Neighborhood Health Center, 6
and next month I will have to do
without. . . / am endangering my life from the Anchorage Rescue Mission, and 10
daily and the financial future of my from Bean's Cafe. Obviously, the survey
family. No one should have to live in results were not generated using a random
this fear that grows daily."
method, but nonetheless, they did give the
Task Force some indication of the concerns of
- (signed) "Helpless," Anchorage
certain Alaskans about our health care system.
(Complete survey results are published in a
separate document.)
Of those Alaskans who returned our survey the vast majority expressed
significant concern about the adequacy and stability of their health care coverage and
their ability to pay for out-of-pocket medical expenses. Specifically:
85 percent of respondents worry "a great deal" or "quite a lot" that their
out-of-pocket costs for medical bills will increase rapidly over the next
few years.
82 percent worry "a great deal" or "quite a lot" about having to pay very
expensive medical bills which are not covered by health insurance.
75 percent worry "a great deal" or "quite a lot" that the benefits under their
current health care plan will be cut back substantially.
75 percent worry "a great deal" or
"quite a lot" that they will have to pay
a much larger premium for their
current health care plan.
67 percent worry "a great deal" or
"quite a lot" that they will lose health
insurance which they now have.
PERSONAL STORIES
"As my health declined, I wasn't able
to work . , .: The constant hassles
:: concerning medical coverage were
overwhelming. My credit was scarred
as I was unable to continue minimal
payments.."
- Kenai Resident
21
�Finding #10: In spite of the significant amount it spends on health care,
the health status of Alaska's population is among the worst
Although Alaska's age-adjusted per capita health care spending is 27 percent
above the national average, the Task Force found that this higher spending has not
translated into a better health status.
•
A 1992 study by Northwestern National Life Insurance Company (NWNL)
ranked the "general health of Alaska's population" the 46th worst among
the 50 states (Eckstein, T.E., and Associates, Inc. 1992).
Rankings such as those in the NWNL study are used by insurers to establish
premiums. For each state, the population's overall health is measured using
seventeen criteria in five major areas: disease, lifestyle, access to health care,
occupational safety and disability, and mortality. Examples of Alaska's rankings for
specific criteria include:
Selected Health Criteria
Support for Public Health Care
Infectious Disease
Occupational Fatalities
Unemployment
Access to Primary Care
Premature Death
Prevalence of Smoking
Violent Crime
Infant Mortality
Ranking
50
49
48
45
43
40
40
28
25
The American Public Health Association recently published a state-bystate report of the health of each state's population. Alaska ranked higher
in this report than in the NWNL ranking in part because of the indexes
chosen. Even so, Alaska ranked lower than might have been expected,
15
The American Public Health Association (APHA) examined statistics on twenty-five measures of
health for each state. These measures were the basis for the five categories for which APHA
developed composite rankings. There were several measures where Alaska ranked high.
Some of these high rankings reflect Alaska's unique service delivery system, while others
suggest high levels of government spending for health and other services. Alaska ranked
relatively high in the following measures: primary care physicians per capita, adequate prenatal
22
�given the higher than average level of age-adjusted per capita health care
spending (APHA 1992).
APHA tabulated statistics for five health categories and ranked each state. Alaska's
rankings were as follows:
Category
Healthy Behaviors
Healthy Environment
Medical Care Access
Healthy Neighborhoods
Community Health Services
Ranking
44
36
25
23
3
The Task Force also examined additional data on the health of Alaskans at
several meetings. We found that age-adjusted death rates in Alaska for certain
preventable diseases were substantially higher than the national average. Alaskans
have above average death rates for unintentional injuries (primarily occupationrelated), for chronic obstructive pulmonary disease (primarily attributable to smoking),
for chronic liver disease (primarily attributable to alcohol), and for suicide (Alaska
Bureau of Vital Statistics 1992).
Finding #11: A strong public health program based on disease
prevention, health promotion, and public health protection Is
essential to controlling health care costs and to achieving a
po//cy that assures the presence of a strong, fullyfunctioning public health program.
Given the overall poor health of Alaskans described under Finding #10, and the
fact that effective public health programs can improve health status, the Task Force
felt it was particularly important to examine the state's public health system.
care, fluoridated water, average public assistance payment per family, education spending per
capita, childhood poverty rate, government health spending per capita, sanitation and sewerage
spending per capita, and public health workers per capita.
23
�Several public health officials briefed the Task Force on the roles and
responsibilities of public health providers in Alaska. While we were reminded of the
State's responsibility to provide health assessment, health policy development, and to
assure the presence of essential, effective public health services, the Task Force
nonetheless found that:
-
The capability of the Division of Public Health to carry out the State's
public health responsibilities continues to be diminished at a time when
program responsibilities are increasing.
In the last decade, the level of per capita public health spending by the State of
Alaska from the General Fund has remained flat after being adjusted for inflation
($48.99 in 1982 vs. $49.15 in 1992). This has occurred despite the fact that during
this period, the Division of Public Health's program responsibilities have grown
substantially due to new technologies and changing patterns of disease (e.g., AIDS,
drug-resistant tuberculosis, substance abuse) (Appendix F). Unfortunately, the Task
Force fears that State funding for public health programs will be further diminished
unless there is greater recognition of the role they play in protecting and maintaining
the health of the state's population.
Finding #12: The financial access issue aside, basic health care services
transportation problems and problems with the mix,
distribution, arid coqrdinatldn of the state's health care
The Task Force observed that Alaska has access and cost problems because
of the maldistribution of health care resources. Many Alaskans live in areas where
health care services are not available or where there are shortages of health care
personnel. In other areas, there is more capacity in the system than is needed. While
sufficient resources exist in some communities, Alaskans will often go outside of those
communities for care. Finally, even though Alaska Natives have access to health care
through the Alaska Area Native Health Service, their health needs far outstrip available
resources.
Alaskans living in remote and rural areas often find that only the most
basic health care services are available in their communities. Access to
advanced services requires travel, frequently hundreds of mile by air.
Many cannot afford to travel and defer their medical treatment.
24
�Alaskans living in remote and rural areas of the state often travel great
distances at significant cost to obtain health care. The Alaska Native Health Board
reported the unmet need for patient travel was $4.9 million in Fiscal Year 1990. Forty
percent of all their patients who need to travel for medical care defer treatment
because they lack money for airfare (Alaska Native Health Board 1991).
-
Alaska has an inadequate supply and maldistribution of primary care
practitioners.
Alaska is directly affected by the nationwide shortage of primary care
practitioners. Alaska currently has twenty federally designated Health Professional
Shortage Areas and ten designated Medically Underserved Areas. Together, these
areas include nearly a third of the population and cover two-thirds of the state
(ADHSS 1992). In many Alaskan communities, the population base is too small to
support a financially viable physician practice. The State of Alaska, recognizing this
aspect of Alaska's health care system, has liberal practice standards that allow midlevel practitioners, such as nurse practitioners and physician assistants, to practice
with minimal supervision and to write prescriptions (ADHSS 1992). Although many
communities rely on mid-level practitioners for care, Alaskans still encounter serious
difficulties in receiving needed primary care, and additional primary care physicians
are still needed.
The Task Force was advised, on a number of occasions, that:
Difficulties in recruiting and retaining health care professionals in Alaska
contribute to the lack of access to appropriate, cost-effective health care
for Alaskans, particularly in rural areas.
Alaskan providers have the greatest difficulty retaining adequate numbers of
nurses, physical therapists, occupational therapists, and diagnostic technicians. Other
categories of health care professionals which are difficult to find are administrators,
physicians, bio-medical technicians, and workers in the areas of patient billing, medical
records, personnel, social work, and alcohol and mental health counseling (Rural
Alaska Health Education Center 1992).
Further, individual Alaskan health care practitioners, particularly in rural areas,
experience high rates of turnover. In Alaska's many small, isolated communities,
health care professionals do not have a peer support group and must be on-call 24
hours a day, 7 days a week. In addition, the undersupply of health care professionals,
cultural and social barriers, isolation, and limited transportation and communication
systems all contribute to "burnout" among practitioners.
Recruitment has become increasingly difficult as salary expectations have
increased. Salaries, particularly those offered in rural Alaskan communities, have
25
�become less competitive than those offered outside of Alaska over the past decade
(ADHSS 1992).
Efforts to recruit health care practitioners in Alaska are limited by the lack of
data on such items as the characteristics of professionals who are most likely to want
to practice in Alaska (particularly rural Alaska), factors that increase the number of
applicants for positions in these areas, and provider characteristics most important to
employers and consumers (ADHSS 1992).
Recruiters have found an important factor in getting practitioners to locate and
practice in rural areas is their exposure to rural settings during their medical education.
Alaska lacks formalized in-state clinical sites for primary health care students. In
addition, there are only rudimentary free-standing medical residency programs in the
state, and none for family practitioners (ADHSS 1992).
While there are significant shortages of health care professionals:
It is estimated that nearly one quarter of the hospital beds in Alaska's
acute care community hospitals represent excess capacity, yet it costs
Alaska's health care payers as much as $21 million annually to maintain
them.
There has been a lack of direction from the State of Alaska regarding standards
for hospital size. Further, there were some major renovations and new construction of
community hospitals when Alaska's revenues from oil peaked in the early 1980s.
These projects were based on occupancy rates using the rapid rate of population
growth experienced in the state at that time. As population growth rates diminished,
the recession hit in the mid- to late 1980s, and a national trend toward decreasing
utilization of care for patients in "inpatient" settings was realized, it became apparent
that the State had overestimated the need for hospital beds.
16
Also in the mid-1980s, the State significantly reduced its health planning efforts
and has not issued a state health plan since 1984. The Certificate of Need process
continues in Alaska and achieves some savings but without the goals and standards
that a state health plan could provide. Capital grants continue to be provided to some
individual communities for facility construction without a clear policy from the State.
Alaska's acute care community hospitals are on the average much smaller than
U.S. hospitals as a whole. Using the national average as the benchmark, the Institute
of Social and Economic Research (ISER) found that twelve of Alaska's sixteen acute
16
Anchorage projects were more justified, but some projects in smaller communities created
significant excess capacity. Not all the projects which were proposed were built however as
State funding declined in the 1980s.
26
�care community hospitals had excess capacity in 1989. At the U.S. average
occupancy rate, 229 (or 22 percent) of the 1,027 acute care beds in Alaska were
surplus. The total annual cost to Alaskans to pay for surplus beds was estimated to
range from $5.8 to $11.6 million or 2 to 4 percent of the total annual acute care facility
costs. However, applying a more rigorous standard, and what some consider a more
reasonable goal for occupancy, 75 percent, and a fixed cost assumption of 20
percent, the annual cost of excess capacity in Alaska's acute care facilities was found
to be as high as $20.8 million. (The complete analysis is in Appendix C, Section 1.)
17
Compounding this excess capacity problem, the Task Force observed that:
Even as Alaska's small communities continue to maintain fully-licensed
hospitals, many residents leave their communities to go to a larger
hospital for care.
The Task Force found that many of Alaska's small hospitals have very low
occupancy rates. However, because residents of communities with small, underutilized hospitals often go to larger hospitals in other areas to receive care instead of
to their local hospitals, the Task Force felt that these facilities will find it difficult to
substantially reduce their surplus capacity.
18
The Task Force reviewed approaches taken in rural communities in other states
when faced with the possibility of closing under-utilized, financially troubled community
hospitals. Often, these hospitals are converted and licensed as "alternative"
facilities, thus maintaining some type of medical facility presence in the community.
Many different models for converting hospitals to alternative facilities exist, but in
general they involve changing the mix of services, limiting the length of stay, providing
only certain core services, and establishing transfer policies with more advanced
facilities. For example, a "converted" hospital might continue to provide only
emergency services, routine obstetrical care, and outpatient services.
19
The Task Force was concerned to find that instead of moving towards an
"alternative facility" model, many Alaskan hospitals with low occupancy rates are
17
In the 1970s, the occupancy rate for mid-sized hospitals in the U.S. approached 75 percent. In
addition, Alaska's 1984 State Health Plan established occupancy rate goals of 80 percent for
Level IV communities (population between 40,000 and 750,000) and 65 percent for Level III
communities (populations between 1,500 and 60,000).
18
Examples of small Alaskan hospitals with low occupancy rates, based on 1989 figures, include:
Cordova Hospital, with 13 beds and a 15 percent occupancy rate; Petersburg Hospital, 8 beds
and 12 percent occupancy; Wrangell General Hospital, 9 beds and 11 percent occupancy; and
Seward General Hospital, 32 beds and 11 percent occupancy. (See Appendix C, Section 1.)
The Task Force reviewed models from the States of Montana, California, Washington,
Colorado, and Kansas for converting hospitals into alternative inpatient facilities.
27
�moving in the opposite direction. In order to attract patients who may currently be
seeking care at larger hospitals, some small hospitals are seeking to duplicate costly,
high-tech services offered in Alaska's tertiary care centers.
Finally, the Task Force found that the State of Alaska has not created
incentives to encourage the conversion of under-utilized hospitals into alternative
facilities. Indeed, the ability and willingness of Alaskan communities to convert underutilized hospitals to alternative facilities is restricted by State licensure standards,
Medicare's conditions of participation, and Alaska's revenue sharing statute (AS
29.60.120) which greatly favors hospitals of ten beds or more (Appendix G; Agency for
Health Care Policy Research 1991).
Alaska does not presently have excessive amounts of expensive high-tech
medical equipment. However, in recent months, physicians and physician
groups in Alaska's urban areas have shown increasing interest in offering
high-tech services that will duplicate services offered at hospitals in these
areas. Small community hospitals have also shown an increased interest
in acquiring high-tech equipment.
It is widely recognized that the increased use of high-tech medical equipment
and services has improved the quality of health care in the United States. However,
at the same time the proliferation of new technology has been a driving factor behind
escalating health care costs.
In October 1991, the Department of Health and Social Services reported to the
Task Force that the current levels of high-tech medical equipment and services
available in Alaska were not excessive (see Appendix I). However, recent interest by
physicians in providing high-tech services in their offices may change this situation.
In Alaska, a Certificate of Need (CON) is currently required for new medical
services or equipment located in a hospital setting and costing $1 million or more.
Because current CON law does not apply to projects in non-hospital-based settings,
many of the high-tech projects under consideration by private physicians and physician
groups would not require review or approval by the State. Even purchases of such
equipment by small hospitals may avoid the Certificate of Need process if they obtain
used equipment that costs less than $1 million. The excessive proliferation of medical
technology could thus become an additional factor contributing to rising health care
expenditures in Alaska.
A lack of effective coordination between the four principal health care
systems in Alaska, the private sector, the Alaska Area Native Health
Service (AANHS), the State of Alaska, and the military, has contributed to
excess capacity in some rural communities and a lack of access to
28
�facilities and some services for some segments of the population in
others.
In some Alaska communities, services are duplicated at facilities run by
different segments of the health care system because of insufficient coordination of
health care resources. For example, Sitka, with a population of 9,000, has two
general acute care hospitals, one operated by the local government and the other by a
tribal organization under contract to the AANHS. Both hospitals, which offer virtually
identical services, are under-utilized.
Other communities suffer from the opposite problem-facilities whose services
are needed by the community are unable to offer those services to some segments of
the population due to restrictions on who is eligible for treatment. The Task Force has
noted recent progress in this area, however. For example, in the western and
northern regions of the state, four out of the five general acute care facilities are
federally-owned, and have historically been restricted to serving only Alaska Natives.
Contracts to operate three of these hospitals-in Dillingham, Bethel and Kotzebuehave recently been awarded by the AANHS to local organizations that are attempting
to expand services to all residents of these communities.
By nearly all measures, the health status of Alaska Natives is significantly
lower than other Alaskans. The health needs of Alaska Natives far
outstrip the resources available through the Alaska Area Native Health
Service and its tribal contractors. Many villages do not have basic water
and sanitation services which are essential to the control of disease.
As part of the their trust responsibility, the federal government is required to
provide health care to all Alaska Natives. This is accomplished through the Alaska
Area Native Health Service and its tribal contractors. Funding for this system in
Alaska, which serves approximately 90,000 Alaska Natives, has not kept pace in
recent years with the growth of the Alaska Native population and health care spending
trends. Providers in this system have been encouraged to enhance collections from
Medicaid, Medicare, and other third-party payers in an effort to make up for the
shortfall in funding. Yet, as a group, Alaska Natives' health needs are greater than
other Alaskans. Their HIV infection rate is the highest in the state and death rates for
suicide and homicide continue to be three to four times the national average.
Substance abuse problems, including fetal alcohol syndrome/effect and brain damage
associated with inhalant abuse are still on the rise. Alaska Natives have one of the
highest age-adjusted mortality rates from cancer in the U.S. and diabetes is
increasing. Water and sanitation services, which are taken for granted in urban
Alaska, are not available in many Alaska Native villages (see Appendix H).
29
�Finding #13:
The way in which we handle claims of injury arising from
medical care is unsatisfactory to almost everyone. It
compensates only a few of the victims, is slow, costly, and
The Task Force recognized that there is considerable disagreement over how
much our system of resolving claims of medical malpractice contributes to rising health
care expenditures and inappropriate patterns of practice. We also acknowledged that
our current system is not necessarily the best way to resolve such claims. Many of
the Task Force's observations of our system of handling claims are based on national
studies and studies in other states, although there is considerable documented
experience on the subject in Alaska (Weeks 1992).
Every year, patients in Alaska are injured by medical care. Comprehensive
data on the numbers of medical injuries are not available. Two landmark studies, one
in New York and one in California, showed that 3.7 percent and 4.65 percent,
respectively, of large samples of hospitalized patients are injured by medical care.
About one quarter of those patients are injured because of negligent care - 1.0
percent in the New York study and 0.8 percent in California. The majority of adverse
events were minor and transient, but many were serious, and some caused or
contributed to death (Harvard Medical Practice Study 1990; Danzon 1985). It is
reasonable to assume that the age-adjusted rate of injury in Alaska is roughly the
same as in New York and California.
>
Most medical injuries caused by negligence do not result in lawsuits.
The New York study (Harvard Medical Practice Study) found that for every eight
hospitalized patients negligently injured, only one patient filed a medical malpractice
claim. In the California study, at most one in ten patients negligently injured filed a
claim.
-
Many lawsuits alleging medical malpractice are without medical
foundation.
The New York study also found that more than eight of ten medical records of
those who file claims show "no evidence of negligence or even injury".
On several occasions, the Task Force was advised that because the costs
of bringing a case to trial are high, plaintiff attorneys in Alaska generally
are reluctant to take a case unless they expect a settlement or award of at
least $100,000 (Weeks 1992).
30
�A significant part of the high cost of pursuing a medical malpractice lawsuit is
the high cost of engaging expert witnesses. One plaintiff attorney says it is impossible
to bring a medical malpractice case to trial in Alaska for less than $75,000 (Weeks
1992). By the same token, NORCAL, which insures about 240 Alaskan physicians,
reports that the "average cost of defending a case through trial is around $60,000"
(Appendix J).
•
Nationwide, studies have shown that fewer than half of all medical
malpractice claims result in any payment to the claimant.
Studies of closed claims found that payments to the claimant were paid in only
40 - 50 percent of cases (40 percent, Danzon 1985; 41 percent, Appendix J
(NORCAL); 43 percent, GAO 1987b; "no more than half," Harvard Medical Practice
Study 1990).
Less than half of the medical malpractice premium dollar goes to the
patient in settlements and awards.
A 1987 Rand Corporation study found that only 43 percent of every dollar spent
on "higher-stakes" litigation, including medical liability, reaches the injured parties as
compensation. A.M. Best estimated that the "total cost of medical malpractice direct
losses paid" were $2.29 billion or 41 percent of the $5.6 billion paid in malpractice
insurance premiums in 1989. The rest is spent on attorneys' fees for both sides,
litigation expenses, and administrative expenses of insurers (Hensler et al. 1987;
Lembo 1992).
•
Medical malpractice claims take a long time to be resolved.
The 1987 GAO study also reported that the median length of time from injury to
claim was 13 months (range <1 to 229 months), from injury to closing for claims
without any payment was 17 months (range <1 to 132 months), and from injury to
closing for claims closed with payment was 23 months (range <1 to 132 months)
(GAO 1987b).
In a study of only obstetrical malpractice cases, the average time
from event to resolution was 33 months (Bovbjerg, Tancredi, and Gaylin 1991).
On numerous occasions, the Task Force voiced concern about the costs
of and practices associated with defensive medicine. We found that the
estimates of the costs of defensive medicine are inconclusive.
Defensive practices include, in order of frequency as established in a 1983
study: (1) maintaining more detailed records, (2) referring more cases to other
physicians, (3) ordering additional diagnostic tests, (4) spending more time with
31
�patients, (5) not accepting certain types of cases, (6) increasing fees, and (7)
providing additional treatments (Zuckerman 1984).
The American Medical Association (AMA) estimated in 1989 that the cost of the
practice of "defensive medicine" by physicians was nearly $21 billion. Of that, $5.6
billion was spent by physicians for malpractice insurance premiums and $15.1 billion
on defensive medicine practices (AMA 1991). In 1989, $21 billion represented about
18 percent of the total expenditures for physician services. Although the AMA's
estimate appears to be made based on a thoughtful analysis, it is important to note
that the core of the study was a physician survey. In addition, the AMA's estimate
includes only costs associated with physicians' services and not other providers, most
notably, hospitals. Therefore, it understates the total cost of defensive medicine in the
U.S.
Other estimates of the cost of defensive medicine exist but the AMA's estimate
is the most frequently cited. All the estimates are controversial, in part because of the
difficulty in defining defensive medicine. The Office of Technology Assessment, a
bipartisan research agency of the Congress, is currently developing its own estimates.
While the Task Force was concerned about costs associated with defensive
medicine, we were also concerned how these practices can effect the quality of care
provided and the level of trust between the physician and patient. For example, some
tests and treatments can be detrimental to the health of the patient.
While total malpractice insurance premiums represented only 5 percent of
total expenditures for physician services, individual physician premiums
represent a significant cost of practicing medicine in Alaska.
Medical Indemnity Exchange of California reports that the current annual rates
for a $1 million/$3 million (most commonly purchased) professional liability insurance
policy in Alaska are: $79,948 for obstetrics, neurosurgery, orthopedics with spinal
surgery; $42,328 for general surgery, orthopedics without spinal surgery, ENT (ear,
nose, and throat) with more than 5 percent plastic surgery; $26,456 for ENT with less
than 5 percent plastic surgery; $13,524 for ophthalmology; $11,760 for internal
medicine and pediatrics; $10,584 for family practice, no surgery; and, $6,468 for
psychiatry. NORCAL rates for a $1 million/$3 million policy for obstetrics are:
$64,519 for OB/GYN and $37,751 for family practitioners with obstetrics (Appendix K).
The system for resolving claims of injury from medical care generates
considerable uneasiness and disgruntlement among providers (Charles et
al. 1985).
32
�The threat of litigation is perceived by providers to be ever-present. It colors
virtually everything they do with respect to patients. While providers agree that their
undivided attention should be focused upon what is best for their patients, physicians
and other providers continually consider what is safest for themselves. This legal
milieu influences clinical decisions when it should not, warps decisions on where to
practice and whom to see, and shortens careers. For example, 29 percent of
physicians practicing obstetrics stop delivering babies before age 45 and 67 percent
before age 55 (Institute of Medicine 1989). Studies show that over 79 percent of
practitioners of obstetrics report that they have been sued at least once during their
careers (American College of Obstetricians and Gynecologists 1992).
•
Obstetricians in Alaska pay between $65,000 and $80,000 annually and
family practitioners delivering babies between $35,000 and $40,000
annually for professional liability insurance. Nationally, practitioners of
obstetrics and gynecology are sued more frequently than any other
specialty (U.S. DHHS 1987). The average damage award paid by an
obstetrician in 1984 was $178,000, more than double the average paid by
other specialties (Gehshan 1991). Nationally, one million dollar-plus
awards are frequent in birth-injury cases (Nocon et al. 1987). Several
have been awarded in Alaska.
20
No group or specialty class of physicians is inherently more negligent than
another, but some groups, such as obstetricians are sued more often than other
providers (GAO 1987a). Settlements tend to be high and award by juries are typically
high because the consequences of serious injury at birth are usually lifelong.
Physicians who have practiced obstetrics and discontinued indicate professional
liability issues as a primary cause including both the expectation for increased
malpractice premiums and the fear of lawsuits (Rosenblatt and Wright 1987; Nesbitt et
al. 1992).
Under the state's statute of limitations, malpractice cases involving injury
to children can be filed up to two years after the age of 19. This requires
physicians to have "tail" insurance to protect against claims filed many
years after an alleged event. However, virtually all residua from birth or
early-life injury or illness are obvious by the time a child is eight years
old.
21
Rodman Wilson, MD, December 2, 1992.
21
"Virtually all sequelae of birth injuries and illnesses early in life should be apparent by the time
a child is eight years old", statement made by Marianne von Hippel, MD, behavioral
pediatrician, November 6, 1992, Anchorage. "Most major residua of birth injuries and early life
illnesses will be clearly apparent by six to eight years of age", statement made by Ron
Brennan, MD, neurodevelopmental pediatrician, November 10, 1992, Anchorage.
33
�<
<
Alaska law requires interest on civil judgments to be paid at rate of 10.5
percent per year from the date of notification of a lawsuit (AS 9.30.070).
The accrued interest can add substantially to medical malpractice and
other awards.
The Task Force learned that the pre-judgement interest rate of 10.5 percent
currently used in Alaska has not been adjusted since 1980. In contrast, federal courts
use an approach that is more responsive to changing economic conditions, awarding
pre-judgement interest using the yield of the 52-week U.S. Treasury bills (3.75% in
November, 1992) as the rate of interest (Title 28, U.S. Code, 1961).
Pre-judgement interest is designed in part to deter casualty insurance
companies from delaying settlement. However, interest payments can add
significantly to medical malpractice awards. For example, if it takes five years to
reach a verdict and make an award of $500,000 in a case of injury from negligent
medical care, an additional $262,500 is added in accrued interest, making the total
award $762,500. In addition, it is possible that interest rates that are high may
provide an incentive for plaintiffs' attorneys to delay in order to increase potential
awards and thereby their contingency fees.
22
Finding #14: Most Alaskans believe that fundamental changes are heeded
in our health care system in order to make things work
better. They also believe health care reform is an Important
issue that State government should address.
>
Nearly 90 percent of respondents to the Task Force's public opinion
survey indicated that Alaskans want substantial change to our health care
system.
Of those Alaskans who returned the survey, 60 percent responded that "there
were some good things in our health care system, but fundamental changes are
needed to make it work better," while an additional 28 percent indicated "that so much
is wrong with it, that we need to completely rebuild it."
Nearly all respondents indicated that health care reform is one of several
important issues, if not the single most important issue, for State officials.
22
Testimony by Dan Hensley to the Health Resources and Access Task Force, November 13,
1992.
34
�Seventy-six percent of survey respondents indicated "that reform of Alaska's
health care system should be one of several important issues for State officials" while
an additional 21 percent believe that it is "the single most important issue for State
officials."
Respondents overwhelmingly believe that the State government should
play a role in controlling health care costs and ensuring access to basic
health services for all Alaskans.
Ninety-four percent of Alaskans who answered the Task Force's survey
responded that "in the absence of national health care reform, the Alaska State
government should play a more active role in controlling rising health care costs" while
96 percent indicated that "the State government should play a more active role in
ensuring access to basic health services for all Alaskans."
These fourteen findings, together with principles used by the Task Force to
guide their policy decisions, are the basis upon which the Task Force made its
recommendations. The Task Force's guiding principles are described in the next
chapter.
35
�CHAPTER THREE:
GUIDING PRINCIPLES
At our September 1991 meeting, the Health Resources and Access Task Force
developed guiding principles to be followed in the development of public policy. Our
original principles were further refined in September and October 1992. The Task
Force used these principles to evaluate alternative health care reform strategies.
PREAMBLE
The Alaska Constitution provides that the State of Alaska is responsible for the public
health. However, each Alaskan bears individual responsibility to maintain and improve
his or her own physical, mental, and emotional health and to pursue a healthful
lifestyle. This fundamental responsibility lies with the individual--not the family, not
schools, not churches, not employers, not health care providers, and not the
government.
The vision of health care reform for Alaska must go beyond the issues of access,
financing, and cost containment. It must include a health care program that merges
the personal health care delivery system with a population-oriented public health
program based on the principles of health promotion, health protection, and disease
prevention.
Health care costs can best be contained by an educated public, committed to
wellness. The state must take an aggressive role in working with all Alaskans on
health and safety education and the prevention of illness.
ACCESS
All Alaskans should have access to timely and appropriate health care without regard
to personal financial means.
A health care plan should include prevention, primary care, early diagnosis and
treatment, and incentives for healthful lifestyles.
FINANCING
All Alaskans have a responsibility to obtain and pay for health care for themselves and
their dependents. It is the responsibility of society at large to finance care for those
unable to pay.
Responsibility for the financing of care should be equitably distributed among payers.
37
�COST CONTAINMENT
Health care services can be extended to everyone only if overall costs are contained.
Duplicate coverage should be avoided.
Cost sharing requirements may be considered as a way of controlling excessive
utilization but should take into account ability to pay.
Health care should be provided in the most efficient and cost effective manner and
location and may include contractual arrangements for patient management and
utilization controls.
Payments to providers should be reasonable and fair.
Health services based on disease prevention, health promotion, and health protection
must be promoted as a major way to lower costs.
GENERAL
Individuals should have an informed and reasonable choice in selecting health care
providers. However, they may be restricted to certain providers in cases where such
arrangements are more cost-effective.
Systems to maintain and expand access and to control costs should be as simple to
administer as possible.
Design of programs should be sensitive to cultural differences and community needs,
including the special problems in rural areas of access and availability of providers.
A public health system based on the core functions of assessment, policy
development, and assurance of essential public health services must be established
and maintained as the foundation of an effective health program for Alaska.
The Task Force's recommendations, which draw upon these guiding principles, are
presented in Chapter Four.
38
�CHAPTER FOUR:
TASK FORCE RECOMMENDATIONS
A
.
OVERVIEW
This chapter presents the Task Force's recommendations for improving the
financing and delivery of health care in the State of Alaska. In developing these
recommendations, the Task Force recognized the skill and dedication of the hundreds
of health care providers working throughout the state to improve the health status of
its residents. However, the Task Force also has come to realize that these efforts are
hampered by many aspects of the Alaskan health care system itself. In fact, to call
the current method of health care delivery and financing in the state a "system" is
inappropriate. The existing structure could more aptly be described as a "non-system"
that allows health care costs to continue to spiral out of control, that leaves even the
most basic health care coverage unaffordable for a large number of Alaskans, and
that leaves an even greater number of Alaskans worried about the possible financial
consequences of a serious illness in the family.
Given this situation, the Task Force agrees with the view expressed by the vast
majority of Alaskans responding to its health care survey, who believe that
fundamental changes must be made to the current structure of our health care system
(see Finding #13). In our view, minor tinkering with the current structure is not
sufficient to address the current health care crisis in Alaska. This conclusion is based
upon our review of a considerable body of evidence indicating that, although a wide
variety of incremental approaches and piecemeal solutions have been attempted over
the past several decades, none has succeeded in controlling health care costs or
providing access to basic health services to all Alaskans.
The Task Force has thus come to the unavoidable conclusion that "business as
usual" approaches to dealing with the problems of our health care system will no
longer suffice. We therefore propose a comprehensive strategy designed to:
1.
Bring runaway health care costs under control and make health care
affordable for all Alaskans;
2.
Move to a unified health care financing system that will provide financial
access to needed care for all Alaskans and eliminate the concerns and
fears that many Alaskans have with our current health insurance system;
3.
Increase the effectiveness and efficiency of the current health care
delivery system by increasing the availability and coordination of health
services throughout the state;
39
�4.
Improve the health status of Alaskans by ensuring adequate support for
vital public health activities and emphasizing the importance of healthy
• lifestyles and access to preventive care; and
5.
Make improvements in the way in which we resolve medical malpractice
disputes.
The recommendations developed by the Task Force to achieve these objectives
are as bold and as ambitious as the charge given to us by the Alaska State
Legislature. They are based upon a careful assessment of the full array of possible
approaches for addressing identified problems, a review of the relevant health services
research and related scientific information, and the examination of the relevant
experience of other states and countries that have enacted health care reform
measures. We believe that they reflect Alaska's unique environment and the concerns
and values of its residents. At the same time, they are also consistent with many of
the major health care reform proposals being discussed at the national level.
The Task Force strongly believes that our proposed strategy represents the
best way to improve the health of the state's population and to provide access to
affordable, high quality health care to all Alaskans. We recognize, however, that our
recommended solutions may be considered quite controversial. There are several
reasons this may occur. The first is that our strategy includes a number of concepts or
terms that may be unfamiliar to or misunderstood by the Alaskan public. The second
reason is that, because our strategy calls for significant changes in the way in which the
health care system currently operates, there
may be certain individuals or groups who may
feel threatened by these reforms and seek to
The Task Force proposes a
paint an unrealistic picture of their implications.
comprehensive health care reform
For these reasons, the Task Force
recognizes that the enactment of meaningful
health care reform in Alaska may require a
significant public education effort. We have
begun this effort by documenting Alaska's
health care problems in earlier chapters of this
report. In this chapter, we will describe in detail
our recommendations for addressing these
problems. In doing so, we have attempted to
further the public's understanding of this
important issue by describing: the range of
options we considered in many areas; why we
selected certain alternatives; and what the
impacts of our recommendations on health care
costs and coverage are expected to be.
40
strategy that will:
1. Bring runaway health care costs
under control and make health
•: care affordable for all Alaskans.
2. Move to a unified health care
financing system that will provide
financial access to needed care
for all Alaskans., •....
:
3. Improve the health status of
Alaskans by ensuring adequate
support . for vital: public.. health
: [activiti&MmyiiM
4. Make improvements in . the way
we resolve medical malpractice
pidisputestpppd
�B.
TASK FORCE RECOMMENDATIONS
The Task Force's recommendations, which together provide a comprehensive
strategy for improving the health of all Alaskans, can be broken down into the
following major components:
•
Cost Containment Efforts
Health Care Access Improvements
•
Public Health/Service Delivery System Enhancements
•
Medical Malpractice Reform
Our recommendations in each of these areas are presented below.
COST CONTAINMENT RECOMMENDATIONS
Tfce Task Force recommends the establishment of a statewide health care
expenditure limit that would bring increases in health care spending in
Because spiralling health care costs have had a negative economic impact on
Alaskan individuals and businesses and have been an important factor contributing to
the growing number of uninsured persons, the Task Force spent considerable time
reviewing possible approaches to bring health care costs under control. Unfortunately,
none of these approaches was found to be completely effective in controlling costs.
Among the approaches examined were:
1
•
Utilization controls, such as prior authorization, second surgical opinion
programs, etc. In general, these measures do decrease utilization, but
have not brought overall costs under control.
Managed care. More formal managed care systems, such as health
maintenance organizations (HMOs), have not been accepted in Alaska
and are therefore virtually non-existent. In other areas of the country
where HMOs are more prevalent, they have resulted in initial reductions
in health care spending, although over time, their health care spending
grows at essentially the same rate as overall health care costs.
'
For a good review of the experiences associated with different cost containment approaches,
see Congressional Research Service. 1990. Controlling Health Care Costs. Washington, D.C.
(January).
41
�Government price setting. Governmental price regulation, particularly in
the area of hospital rate setting, has been shown in a number of cases
to reduce the growth in health care spending. However, price setting
approaches that focus on controlling the growth in unit prices (e.g.,
charges for physician office visits) may cause providers to increase the
amount of services they provide to offset the effects of the price controls.
a
Market-oriented competitive strategies. These efforts may enable larger
purchasers to reduce their costs by negotiating discounts from providers.
However, unless overall cost levels are reduced, the revenues lost to
providers from these discounts may be recovered by charging higher
prices to smaller purchasers, such as individuals or small business policy
holders. In addition, in many ares of the state where the numbers of
providers are limited, competitive strategies are likely to be ineffective.
Based upon this review of possible cost containment options, the Task Force
concluded that any effective strategy to bring costs under control and make health
care affordable to all Alaskans must include the establishment of an overall limit on
health care spending in Alaska. Such expenditure limits or "global budgets" have
succeeded in keeping increases in health care spending in a number of other
countries, including Canada and West Germany, at levels that are more in line with
growth in other segments of their economies.
Within the United States, a global budgeting approach for hospitals has also
been used with considerable success by the State of Maryland and by the Rochester,
New York community to control the growth in hospital spending without diminishing
either the quality of or access to care. The establishment of statewide health care
expenditure limits covering all services has also been the centerpiece of major health
care reform legislation recently passed in the States of Minnesota and Vermont. At
the national level, the concept of global budgeting, including the establishment of
state-specific expenditure limits, has been a key component of a number of major
health care reform proposals and was an important element of the health care reform
strategy put forth by President-elect Bill Clinton during his campaign.
How Would a Statewide Health Care Expenditure Limit Work?
Under a global budgeting approach, an overall limit would be established for
health care spending within the State of Alaska. This limit would not be set so as to
cut health care spending below current levels, but would rather be designed to reduce
its current rate of growth, which far outstrips the growth in inflation and in other
sectors of the economy (see Finding #1 in Chapter Two). The Task Force believes
that the objective of global budgeting should be to limit annual increases in health care
spending to the overall rate of inflation, as reflected in the growth in the Consumer
Price Index (CPI). We recommend that the limits be phased in over a three-year
period beginning in 1994, with the data collection efforts initially required to establish
the limits to be conducted in 1993. Annual adjustments to the target rate of growth
could be made, as appropriate, to reflect such factors as:
42
�•
Changes in the size and/or demographic characteristics (e.g., age
distribution) of the state's population that may affect the need/demand for
health care in the future;
•
Changes in technology and health care delivery that may increase or
decrease health care costs;
2
•
The identification and reduction of the provision of unnecessary health
care;
•
Desired changes in some segments of the population's (e.g., the
uninsured's) access to adequate health care services;
•
Increases or decreases in the costs associated with medical malpractice
premiums and awards as appropriate;
•
Reductions in administrative costs; and
•
Other such factors as a newly established Alaska Health Care Authority
(AHCA) (to be described later in this chapter) may determine to be
appropriate (e.g., changes in the burden of disease, epidemics,
disasters, etc.).
To the extent possible, the overall statewide health care expenditure target
should be subdivided, with separate subtargets established, at a minimum, for such
major services as hospital care, physician services, etc. The Task Force also believes
that it may be appropriate to establish a separate subtarget for capital expenditures,
and to link the State's Certificate of Need policies to the global budgeting process to
ensure that this target is not exceeded.
Once expenditure targets for different services have been established,
reimbursement rates for health care providers would be set at levels that are expected
to result in expenditures that fall within the limit for each provider type. This does not
necessarily mean that the State would unilaterally set rates for each class of provider.
Instead, the Task Force envisions that after establishing the expenditure targets for
different services, the newly established Alaska Health Care Authority would then work
with designated representatives of the various provider groups (e.g., the state medical
The Task Force recognizes that the introduction of new health technologies has been a
significant contributor to the rapid growth in health care costs. And while some technologies
can improve patient outcomes, we also recognize that in many instances new technologies and
procedures may be utilized inappropriately and may not necessarily have demonstrated a
positive impact on health care outcomes. For these reasons, the Task Force felt that upward
allowances for technology changes should be incorporated into the expenditure limits
judiciously and be limited to technologies whose effectiveness has been clearly demonstrated
through scientific study and for which utilization standards have been developed in a similarly
scientific manner.
43
�association and the state hospital and nursing home association) to identify a mutually
acceptable set of reimbursement rates.
These reimbursement rates can initially be developed entirely by the provider
community and could vary across providers of similar services. From the State's
perspective, these reimbursement structures must meet the following basic
requirements:
1.
Given reasonable assumptions concerning anticipated utilization levels,
reimbursement rates should result in total expenditures which will fall
within the expenditure limit;
2.
Different rates may not be charged to different payers by a provider;
3.
For health care facilities overall, the base for the statewide expenditure
goal will be actual costs in a base year. Actual base year costs will also
be the basis for reimbursement levels for individual facilities;
4.
For hospitals, the unit of payment will be on a DRG-specific per
discharge basis. Price or charge levels will be increased above cost
levels to account for uncompensated care and/or rates from any public
payers (e.g., Medicare) that are not sufficient to cover costs;
3
5.
For physician services, the reimbursement schedules will utilize a
resource-based relative-value scale (RBRVS); and
6.
For other services, the Authority will work with the provider community to
develop the specific reimbursement schedules as appropriate.
Only if (a) a provider group fails to initially propose an equitable reimbursement
structure that can reasonably be expected to result in expenditures that fall within
predetermined targets, and (b) subsequent negotiations between the State and that
provider group fail to reach agreement on such a reimbursement schedule, will the
State as a last resort establish and put into effect its own reimbursement schedule for
their services.
If expenditures exceed the target in a given year without good cause, the
Authority will be able to take appropriate measures to ensure compliance with the
expenditure targets, including reducing the subsequent year's reimbursement levels to
bring spending back within the expenditure limit. For example, if the target annual
rate of growth for total hospital expenditures is 7.5 percent, but overall hospital
spending in a given year increases by 9 percent, the Authority could bring hospital
3
It is the Task Force's expectation that the State of Alaska would request the necessary federal
waivers to ensure that all payers comply with the reimbursement rates established as part of
the global budgeting process.
44
�spending back into line with the budget by allowing an increase of only 6 percent in
the following year.
A key feature of the expenditure limit process will be the establishment of
mechanisms through which detailed information on health care spending will be
furnished to the various provider groups. This information will enable these groups to
analyze spending patterns and assist them in identifying and addressing problems,
such as inappropriate utilization or price increases in their own areas. The Task
Force recommends that the State take the appropriate steps to provide the necessary
anti-trust protections to providers participating in negotiations with the Authority or
working with data from the Authority to address problems that are identified.
4
The State's involvement in data-related activities is discussed further in the next
recommendation.
What are the Anticipated Impacts of Establishinp Statewide Health Care Expenditure
Limits?
It is the Task Force's view that the establishment of these expenditure limits will
be effective in bringing skyrocketing health care costs under control. We believe this
can be achieved without harming health care quality or causing health care to be
"rationed." Rather, we would expect these limits to provide incentives for improving
the efficiency of the state's health care delivery system and reducing the utilization of
inappropriate and unnecessary services. The Task Force believes that the potential
reductions in unnecessary utilization could be significant. For example, national
research has found that a substantial portion of a growing number of expensive hightechnology procedures have been found to be "medically inappropriate."
5
The Task Force further anticipates that the establishment of expenditure limits
would provide incentives for existing health care organizations or groups of health care
providers to form new coordinated health care systems that would offer to provide
comprehensive quality care to patients on a prepaid capitated basis. An incentive for
the establishment of such managed care plans would be to exempt them from any
reduction in their subsequent year's rates if they came in within their budget, even if
fee-for-service providers exceeded their expenditure targets. These managed care
systems would achieve their efficiencies through internal patient care management
rather than through heavy-handed "over the shoulder" government regulation. Where
the population base was sufficient to support several of these coordinated care plans,
4
For an interesting discussion of the use of information feedback to providers, see Lasker, R. et
al. 1992. Realizing the Potential of Practice Pattern Profiling. Inquiry 29 (Fall): 287-297.
5
See, for example, Chassin, M. et al. 1987. Does Inappropriate Use Explain Geographic
Variations in the Use of Health Care Services? Journal of the American Medical Association
258:2533-37.
45
�competition between different managed care plans would provide a further incentive to
holding down costs. These plans would be able to compete on the basis of price,
quality, and patient satisfaction, but not on the basis of selecting only healthy patients
and avoiding those with significant illness.
While the Task Force does not anticipate
that the availability or the quality of health care
services would be diminished by expenditure
limits, as noted earlier, we do anticipate that
the affordability of health care in Alaska would
be substantially improved.
The following
analysis illustrates this point by assessing
anticipated future growth in health care
spending with and without an expenditure limit.
As indicated in Chapter Two (see
Finding #1), health care spending in Alaska is
estimated to have reached nearly $1.6 billion in
1991.
To estimate the cost impact of
establishing spending limits, the Task Force
developed projections of health care spending
in Alaska, both with and without the limits,
through the year 2003. Our projections reflect
anticipated changes in the state's population
and increases in health care spending due to
other factors.
STATEWIDE HEALTH CARE
The establishment: of statewide
health care expenditure limits would:
•
Bring runaway health care
costs under control;
" : Not harm quality of care or
result in health care rationing;
»
•
Provide incentives --for-; Hie
development of coordinated
: health care systems that
provide comprehensive quality
Significantly •••:improve the
affordability of health care in
:
Based upon population projections developed by the Alaska Department of Labor,
the growth in the state's population can be expected to cause aggregate health care
spending to rise by approximately 2.76 percent per year from 1991 through the year
2003. The aging of Alaska's population is expected to result in increases of
approximately 0.4 percent per year during the same period. In addition, we assume that
other factors, such as increases in prices, utilization levels, or intensity of care, would
increase health care spending by another 8 percent per year. The combined effect of
these three factors, when compounded, is an 11.4 percent annual rate of growth in health
care spending. As indicated in Table 4-1, under this scenario health care spending in
Alaska would increase from roughly $1.6 billion in 1991 (column 1) to nearly $5.6 billion
by the year 2003 (see column 13), an increase of over 275 percent. That translates to
approximately $7,340 in health care spending per Alaskan in 2003.
The lower half of Table 4-1 presents projections of health care spending in
Alaska under a system with expenditure limits. Under this scenario, the increases in
health care spending due to population growth and aging remain unchanged.
However, the target rate of growth due to factors other than population changes is
reduced from 8 percent per year to 4 percent, which is assumed to be the average
46
�•• Table 4 - 1 •
A COMPARISON O F P R O J E C T E D HEALTH C A R E EXPENDITURES IN ALASKA
UNDER THE CURRENT SYSTEM AND A SYSTEM WITH EXPENDITURE LIMITS, 1991 - 2003
(In BUIIohs of $)
(1)
1991
(2)
(3)
(4)
(5)
(6)
{7)
(8)
1992
1993
1994
1995
1996
1997
1^8
(9)
(10)
(")
(12)
(13)
(14)
1999
2000
2001
2002
2003
CUMULATIVE
$1,598
$1,598
$1,787
$1,983
$^202
$2,446
$2712
$3,008
$3,339
$3,706
$4,117
$4,559
$5,051
1. Increase Due to Population Growlti
$0,053
$0,043
$0,048
$0,053
$0,057
$0,064
$0,071
$0,080
$0,090
$0,086
$0,096
$0,108
2. Increase Due to Aging of Population
$0,004
$0,006
$0,008
$0,009
$0,009
$0,010
$0,011
$0,013
$0,015
$0,019
$0,022
$0,025
3. Increase Due to Other Factors @ 8.0%
$0.132
$0.147
$0.163
$0.181
$0.201
$0.223
$0.247
$0.275
$0.305
$0.338
$0374
$0415
$1,598
$1,787
$1,983
$2202
$2446
$2,712
$3,008
$3,339
$3,706
$4,117
$4,559
$5,051
$5,599
$1,598
$1,598
$1,787
$1,983
$2175
$2356
$2516
$2687
$2872
$3,070
$3,283
$3,502
$3,736
1. Increase Due to Population Growth
$0,053
$0,043
$0,048
$0,052
$0,055
$0,059
$0,064
$0,069
$0,074
$0,068
$0,074
$0,080
2. Increase Due to Aging of Population
$0,004
$0,006
$0,008
$0,009
$0,008
$0,009
$0,010
$0,011
$0,013
$0,015
$0,017
$0,019
3. Increase Due to Other Factors under Expenditure Limits
$0.132
$0.147
$0.136
$0.119
$0.097
$0.103
$0 110
$0.118
$0-126
$0.135
$0144
$0153
$1,598
$1,787
$1,983
$2,175
$2356
$2516
$2687
$2,872
$3,070
$3,283
$3,502
$3,736
$3,988
$0,000
$0,000
$0,000
($0,027) ($0,090) ($0,196) ($0,321) ($0,467) ($0,636) ($0,833) ($1,057) ($1,315) ($1,611)
ALTERNATIVE A: Current System
Baseline/Prior Year Expenditures
TOTAL: Projected Net Cost/Current System
$42,107
ALTERNATIVE B: System With Expenditure Limits
Baseline/Prior Year Expenditures
TOTAL: Net Cost of System With Expenditure Limits
ADDITIONAL COST (SAVINGS) O F
S Y S T E M WITH EXPENDITURE LIMITS
$35,552
($6,555)
�6
annual economy-wide inflation rate during this period. The information presented in
Table 4-1 assumes that the 8 percent annual increase due to non-population changes
is reduced to the target rate of 4 percent over the course of three years, beginning in
1994 and reaching the 4 percent per year level in 1997. As a result, once the
expenditure limits are fully implemented, annual health care spending is projected to
increase a total of 7.3 percent per year, rather than the 11.4 percent anticipated
without the limits.
Based upon these assumptions, the establishment of expenditure limits would
result in aggregate health care spending of $3,988 billion in the year 2003 (column
13). This translates to a per capita cost of slightly less than $5,000 per Alaskan in the
year 2003, or about a third less than what it would have been without expenditure
limits.
Further, cumulative health care spending
over the period from 1991 through 2003 would
total $42.1 billion without expenditure limits
(column 14), compared to less than $35.6
billion with expenditure limits in place. This
represents cumulative savings of $6.55 billion
statewide over the period in which the
expenditure limits are in place. This represents
cumulative savings of over $8,500 per Alaskan.
This difference in the growth in health care
spending is depicted in Figure 4-1.
HEALTH CARE EXPENDITURE
LIMITS: ANTICIPATED SAVINGS
During the first ten years of operation,
statewide health care expenditure
limits could result in $6.55 billion in
statewide health care savings. That
translates to over $8,500 per Alaskan.
The target growth rate used in this analysis is consistent with that included in the State of
Minnesota's health care reform legislation, which calls for increases in spending to be reduced
to half of what they would otherwise have been. An earlier draft of this report used slightly
higher assumptions for non-population based growth in health care spending in the absence of
expenditure limits and for overall inflation (10% and 5%, respectively). In this analysis the
assumptions concerning projected non-population-based health care spending increases and
overall inflation rates have been reduced to 8% and 4%, respectively, to make them consistent
with those used in federal projections of future health care spending. See Sonnefeld, S. et al.
1991. Projections of National Health Expenditures through the Year 2000. Health Care
Financing Review 13 (Fall). To the extent that non-controlled growth in health care spending
and inflation would exceed our assumptions, the savings resulting from the expenditure limits
would increase.
48
�Figure 4-1
Projected Health Care Expenditures in
Alaska under Alternative Systems, 1991 - 2003
Billions of $
$5.6 Billion
Current System
$3,988 Billion
System With
Expenditure
Limits
1991
1992
1993
1994
1995
1996
1997
1998
1
2000
2001
2002
2003
Source: Health Systems Research, Inc.
The Task Force supports the passage of legislation to establish a single
administrative entity to oversee the State's health care cost containment
and access initiatives.. • •.
The Task Force recommends the establishment of the Alaska Health Care
Authority (AHCA) at the State level, which would have responsibility for overseeing the
development, implementation, and enforcement of the statewide expenditure limits, as
well as other cost containment and access initiatives discussed later in this chapter.
To ensure that it is able to carry out its significant responsibilities as effectively as
possible, the Task Force further recommends that the Authority be structured to:
•
Function as independently as possible;
•
Be staffed by the most qualified individuals available; and
•
Not include representation from provider groups, since the Authority will
be responsible for negotiating with these groups.
49
�The AHCA will be responsible for implementing the expenditure limits, which will
include the conduct of negotiations with provider groups concerning reimbursement
arrangements that will meet expenditure targets. The collection and analyses of
comprehensive data on health care utilization and expenditures are also essential
elements of the proposed global budgeting process. The AHCA must have the
authority and capacity to collect and analyze all health care data necessary for the
development, implementation, and monitoring of the health care expenditure limit
process. As discussed under the prior recommendation, the Authority must also be
able to share data on cost and utilization with the provider community in a timely
manner through some form of feedback mechanism. Sharing information on utilization
and expenditures with provider groups will assist in identifying possible problem areas
and in making adjustments in their activities, as appropriate.
In addition to its responsibilities in the area of global budgeting, the Authority
will also be charged with implementing other initiatives designed to reduce costs by
increasing the efficiency of the current health care financing system. These initiatives
include:
The development of uniform billing and common claims forms which are
to be used by all payers and providers;
The development of uniform utilization review standards and criteria; and
•
The establishment of requirements for the timely payment of claims by all
payers, with the goal of providing payment within fifteen working days of
receipt of an error-free or "clean" claim.
As a complement to the development of uniform utilization review standards by
the proposed Alaska Health Care Authority, the Task Force also recommends the
passage of legislation requiring the registration of utilization review agents operating in
Alaska and the development of regulations by the Department of Commerce and
Economic Development (DCED) to ensure their competency and their use of the
uniform standards developed by the Authority.
Additional responsibilities of the Authority will be discussed in later
recommendations.
WCOMMEflMfld
The Task Force supports expanding the State's authority to review and
approve or disapprove rates filed by health insurers.
In addition to establishing the Alaska Health Care Authority, the Task Force
also supports expanding the authority of the State Director of Insurance to allow him
50
�or her to approve or disapprove rate requests filed by all health insurers, both nonprofit and commercial, that sell group and/or individual health insurance policies in
Alaska. Currently the Director of Insurance does review rate filings submitted by
insurance carriers. However, his ability to deny a rate filing is quite limited, even if it
determined that the rates requested are excessively high in relationship to the benefits
to be paid. This expanded authority will provide the State with the ability to deny rate
requests in such instances and will improve the State's ability to ensure that insurance
premiums charged by all health insurers in Alaska are reasonable.
HEALTH CARE ACCESS RECOMMENDATIONS
The cost containment measures called for in the previous recommendations will
slow the erosion in health care coverage caused by rapidly escalating costs.
However, these efforts alone cannot be expected to remove the health care access
barriers faced by the tens of thousands of Alaskans who lack health care coverage.
To address the very real needs of uninsured Alaskans and to meet our mandate from
the Legislature to design a program that will provide universal coverage to all of the
state's residents, the Task Force believes that a major, fundamental change to our
current health care financing structure is required.
As will be discussed in greater detail later in this section, after a careful
assessment of the Alaskan environment as well as pros and cons associated with
alternative approaches to providing universal coverage, including pay-or-play
proposals and employer mandates, the Task Force has concluded that a single payer
financing system is the most efficient, equitable, and appropriate model for Alaska.
The Task Force is committed to the belief that all Alaskans will benefit from a
single payer system. Nonetheless, as noted earlier, we also recognize that the
benefits of a single payer system may not be immediately evident to the Alaska public
and to policymakers. Programs must be put in place to educate the public concerning
the benefits of moving to such a system and to stimulate an expanded public dialogue
on the issue. However, such a public education process may require time for it to
have an effect.
Unfortunately, during the period in which this public education process and
public debate will take place, the problems that exist within our current financing
system will continue. Uninsured persons will die or be admitted for expensive hospital
care for problems that could have been avoided through access to adequate primary
care. Children without access to preventive care may develop lifelong limitations due
to conditions that could have been treated if detected early. And thousands of
Alaskans will continue to live with the fear that their current insurance may not be
there when they need it.
51
�Given this situation, the Task Force felt that, in spite of its commitment to a
single payer system, it should also put forth recommendations for making incremental
improvements to the existing financing system that have already been adopted in
many other states and that could be enacted immediately by the Alaska State
Legislature. The first four of the Task Force's access-related recommendations
(Recommendations 4 through 7) focus on this short term strategy. Our final
recommendation describes the Task Force's rationale for proposing a single payer
system as the preferred approach for providing universal coverage.
The Task Force Commends Me enactment
establishing
regulatory reform measures in the small group healtfr insurance market
As described in Chapter Two (see Finding #6), a significant proportion of
uninsured Alaskans are either employees in small firms or dependents of these
employees. As was also noted, a number of serious problems in the current small
group health insurance market are likely to make health care coverage unattractive to
many small businesses. These problems include:
•
The refusal by some insurers to provide coverage to certain small
businesses because of the type of work in which they are involved or the
health status of their employees or their dependents;
Premium levels charged by the same insurer that may vary widely across
firms with similar employee characteristics;
•
Premium setting practices that result in many small businesses being
offered very attractive first year rates, but then being hit by double-or
even triple-digit increases in their premium costs in the following years.
These staggering increases cause many businesses not to enter the
market in the first place, to drop their coverage, or to switch to another
carrier;
•
High administrative costs due to medical underwriting activities and the
frequent switching of insurers that is promoted by insurer practices; and
•
The dropping of some small businesses without notice or refusing to
renew their coverage because of their claims experience.
52
�A number of organizations, including the National Association of Insurance
Commissioners (NAIC) have worked to develop a package of regulatory reform
measures that would enable states to address these problems. The NAIC has
developed a Small Employer Health Insurance Availability Model Act that incorporates
many desired reform provisions. These provisions, which would apply to policies sold
to employers with fewer than twenty-five employees, include:
•
Guaranteed Issue and Renewability: All small group insurers must
provide coverage to all eligible firms applying for coverage and may not
terminate such coverage for other than good cause, such as nonpayment of premiums.
•
Whole Group Coverage: Insurance policies sold to small groups must
provide coverage to all eligible employees and their dependents and
cannot exclude certain individuals based upon their health status.
•
Elimination of Multiple Waiting Periods for Pre-existing Conditions:
Waiting periods for individuals with pre-existing conditions are to be
waived if these individuals have previously fulfilled a waiting period and
maintain continuous coverage.
•
Development of Standardized Plans: To allow comparison shopping by
small employers, each small group insurer must offer two standardized
plans, one of which is to be a "bare bones" plan.
•
Premium Rating Restrictions: Premium rate "bands" or restrictions would
be established to limit variation in:
annual premium increases faced by individual small businesses;
and
premium rates charged to different types or classes of small
businesses.
•
Reinsurance Pool: A statewide reinsurance pool should be established
to spread the risk associated with the guaranteed issue requirements in
the small group market.
•
Data and Disclosure: Small group insurers must disclose their premium
rating practices and renewability provisions to small businesses. Insurers
must also maintain their records in proper order and submit an annual
statement certifying that the rates they charge small businesses are
actuarially sound and comply with all the above requirements.
53
�Over half of the states have already enacted small group health insurance
market reforms similar to those included in the NAIC Model Act. The Task Force
believes that enactment of such regulatory reform efforts could reduce many problems
that Alaska's small businesses encounter in attempting to obtain or maintain health
care coverage for their workers. The Task Force therefore recommends that the
Legislature enact the NAIC model statute as part of a short term strategy to improve
access to health care coverage in the state. The Task Force further recommends that
the elimination of multiple waiting periods for pre-existing conditions should also apply
to persons moving from group to non-group coverage.
REQpMMEND$TtONm
H
The Task Force recommends that the State of Alaska require insurers to
move toward community rating in establishing premiums in the small
With respect to the development of premiums to be charged in the small group
insurance market, the Task Force viewed the provisions in the NAIC Model Act calling
for the use of specific rate bands to limit variations in premium rates as a starting
point, rather than the endpoint, for reform in this area. To further reduce the variations
in premiums in this market, the Task Force calls for the phased-in use of quasicommunity rates in the small group marketplace. Specifically, the Task Force
recommends:
•
The use of health status/medical underwriting and gender as factors in
the setting of premium rates should be phased out over a three- to fiveyear period.
At the end of the phase-in period, the only allowed variations in
premiums charged to small businesses in a given geographical region of
the state (to be defined by the State Director of Insurance), would be for
differences in age composition and occupation/industry among small
groups, as well as for differences in the family status of group members
(i.e., single vs. family coverage).
•
Limits should be placed on the maximum variation allowed in a
geographic region due to age and industry differences across small
groups. In reviewing the approaches of several other states that recently
passed legislation calling for the use of some form of community rating,
the Task Force viewed favorably an approach incorporated in a
Massachusetts statute, which specified that no small business could be
54
�charged a premium greater than twice that of the lowest small group
premium within a given geographical area. During the phase-in of this
2:1 rate band requirement, the statute requires that renewal rates not
exceed the trend for the class, plus allowable adjustments, plus 10
percent.
Within this quasi-community rate setting structure, the Task Force
recommends that insurers be allowed to offer discounts for non-smoking
and for participation in wellness programs.
While this shift to community rating will mean lower premiums for some higher
risk groups, the Task Force recognizes that it may also mean, at least initially, higher
premiums for some lower risk groups. However, the Task Force believes that the
enactment of the expenditure limits described in an earlier recommendation will reduce
the magnitude of these premium increases. We also recognize that other aspects of
our recommendations-including prohibiting insurers from cancelling policies because
of changes in health status or use and the gradual elimination of medical underwriting-mean that the higher premiums that may be paid by some groups will provide them
with much more predictable and stable health care coverage than they had in the
past.
It also should be noted that the Task Force's recommendations with respect to
community rating are directed at the small group market, which we defined as
including firms with two to twenty-five employees. At this time, we did not extend our
recommendations concerning community rating to larger firms because of the concern
that this requirement might spur them to drop coverage or to self-insure, thereby
avoiding the State's regulatory requirements completely. However, the Task Force
does recommend that the State Director of Insurance explore the feasibility and
implications of extending these community rating requirements to firms with up to fifty
employees.
7
The Task Force was also interested in extending its recommendations to the
individual, non-group market. However, because of the significant potential for
adverse selection that exists in the individual market, unless otherwise specified, our
recommendations do not extend to that segment of the insurance marketplace.
7
The provisions of the federal Employee Retirement and Income Security Act of 1974 (ERISA)
do not allow state governments to regulate self-funded employee health benefit plans.
55
�The Task Force recommends the establishment of State-sponsored health
':insM^^ii^^
During its deliberations, the Task Force reviewed information indicating that
nationwide as much as 40 percent of premiums charged to very small businesses may
be attributable to administrative costs. While the small group market reform provisions
included in earlier recommendations are expected to reduce the administrative costs
associated with providing coverage to small businesses, the Task Force also
considered it appropriate for the State, through the newly established Health Care
Authority, to establish one or more pooling arrangements through which both
individuals and businesses, small and large, could purchase health care coverage. It
is anticipated that certain additional efficiencies and economies could accrue to the
members of these pool arrangements that would further reduce their premium costs.
In designing these pools, the Task Force noted the importance of considering their
medical underwriting and premium setting practices in relation to those of other
insurers governed by the small market reform proposals to ensure that these Statesponsored pools are not damaged by the adverse selection that would result from
other insurers subtly "dumping" undesirable risks into these pools.
mCOMMENDATtON0:
tation providing tor
The task Force recommends ihe passage of legist
:: puDiiciysuosiQizsa cpy@r39" '
rle
and children who are hoi eiigfl for Medicaid.
Even with the recommendations concerning cost containment, market reform,
and pooling measures in place, the Task Force recognizes that it would be necessary
to provide some level of public subsidy to certain low-income uninsured persons if they
are to be able to afford health care coverage (see Finding #4).
The Task Force determined that the populations to be given highest priority for
receiving subsidized coverage should be low income pregnant women and children in
families with incomes too high to be eligible for Medicaid but too low to be able to
56
�8
purchase private health insurance on their own. Priority was given to these groups
because of the documented improvements in birth outcomes and the cost savings
associated with the receipt of prenatal care by pregnant women and the positive
lifelong benefits associated with providing adequate primary and preventive care to
children. The Task Force also determined that the positive health improvements
resulting from public health care subsidies for these populations could be maximized
by providing coverage of comprehensive services (e.g., prenatal and other preventive
sen/ices, plus other ambulatory and inpatient care) for low income pregnant women
and ambulatory care services for low income children.
Given these priorities, the Task Force recommends that legislation be enacted
to establish a program providing State-subsidized insurance coverage for low-income
children who are not eligible for Medicaid or Indian Health Service coverage and who
are in families with incomes below 300% of the federal poverty level. In order to make
the program more affordable at the outset, coverage would be provided for primary
and preventive and/or ambulatory care services, but not for inpatient care.
Experience in other states has shown similar programs to be more attractive to
families if they were perceived to foster self-sufficiency and were similar to private
insurance in design. Therefore, the Task Force recommends that the program be
given an identity apart from Medicaid, particularly the eligibility system. This would not
preclude the Medicaid agency from administering the program if it proves most costeffective, however serious consideration should be given to having a private insurer
administer the program under contract to the State. The Task Force was heartened
by expressions of interest from two major carriers in Alaska in being involved in such
a program.
While coverage would be substantially subsidized by the State, premium
sharing requirements in the range of $50 - $300 per year per child should be
established on an income-related sliding scale basis. This premium sharing will not
only reduce the required level of State subsidy, but also will give parents of enrolled
children a sense of involvement and participation in contributing to coverage for their
children.
As illustrated in Table 4-2 on the following page, approximately 14,600
uninsured Alaskan children would be eligible for coverage under this program. The
Task Force estimates that roughly 8,200 children would actually enroll in the program,
with nearly 90 percent of these children having no previous health care coverage.
The remaining enrollees are expected to be children with private insurance that
provides inadequate coverage of primary and preventive care. The annual cost of the
program is estimated to be $6.1 million, of which $4.2 million would be financed by
State subsidies. The remaining $1.9 million would be paid by families in the form of
premium contributions.
It should be noted that the Task Force identified high-risk individuals as another high priority
population and in our interim recommendations we endorsed the establishment of a statewide
high-risk insurance pool for this population. Legislation establishing such a pool was enacted
last year by the Alaska State Legislature.
57
�ESTIMATES O F E N R O L L E E S AND C O S T S UNDER
SUBSIDIZED AMBULATORY CARE PROGRAM FOR LOWER INCOME
ALASKAN CHILDREN NOT ELIGIBI F FOR MEDICAID OR 1HS COVERAGE
Income
Number of
Uninsured
Children
Costs (in millions of $)
Number of
Enrollees
State
Family
TOTAL
Under Poverty
3,900
300
$0.2
$0.0
$0.2
100- 200% Poverty
4,500
2,900
$1.8
$0.4
$2.2
2 0 0 - 300% Poverty
6,200
5,000
$2.2
$1.5
$3.7
14,600
8,200
$4.2
$1.9
$6.1
TOTAL
Source: Health Systems Research, Inc.
�With respect to the coverage of low income pregnant women, the Task Force
recognizes that, while federal laws enable the State of Alaska to extend Medicaid
eligibility to pregnant women and infants in families with incomes up to 185% of
poverty, the State currently has elected to provide coverage only to pregnant women
and infants in families with incomes below 133% of poverty. The Task Force
recommends that the State expand its Medicaid coverage for pregnant women and
infants up to 185% of poverty. The FY 1994 cost of this expansion to the State is
estimated to be $3.8 million, which will be matched by an equal amount from the
federal government. For uninsured women with incomes above this income level but
below 300% of poverty, the Task Force recommends the establishment of a publiclysubsidized private insurance program providing comprehensive services.
The Task Force recommends the enactment of legislation establishing a
Single payer health care financing system to provide universal health care
While the previous recommendations can be expected to result in short-term
improvements in the availability and affordability of health care coverage, even with
their enactment, tens of thousands of Alaskans will remain without health care
coverage. After considerable examination of alternative approaches to provide health
care coverage for all Alaskans, the Task Force concluded that the most appropriate
model for achieving such a goal in Alaska is through the establishment of a single
payer financing system. Our rationale for selecting this model is described below.
Why a Single Payer Svstem?
In considering what financing structure would be the most appropriate for
providing universal health care coverage in Alaska, the Task Force carefully
considered a range of different models for achieving this goal. They included three of
the major approaches that have been considered both in other states and at the
national level:
•
Mandated employment-based health care coverage;
•
"Pay or Play" coverage requirements; and
•
A single payer system.
Each of these approaches is described below.
59
�Mandated employment-based health care coverage.
Under this approach, all Alaska employers would be required to provide
health care benefits for at least their full time workers. This requirement
could also be extended to the dependents of these workers, and to part
time workers, with employer premium contributions for this latter group
adjusted on a sliding scale basis depending on the number of hours that
they work.
To implement such a requirement, the State of Alaska would require a
federal waiver of the Employee Retirement and Income Security Act of
1974, known as ERISA. This federal statute precludes states from
regulating employee benefit programs and would preclude Alaska from
requiring the provision of health care benefits. Only one state in the
nation, Hawaii, has received a waiver of ERISA, because its employer
mandate was established prior to ERISA's passage. Under this
approach, a publicly subsidized health insurance plan also would have to
be created to provide coverage for low income individuals and families
not tied to the work force.
"Pay or Play" approaches.
In an attempt to avoid the need for an ERISA waiver, a number of states
have enacted legislation that does not directly require employers to
provide health care benefits for their workers, but instead exempts
employers that provide such coverage from newly established payroll
taxes. The States of Massachusetts and Oregon have enacted these
"Pay or Play" employer requirement, but have delayed their
implementation to 1995. The State of Florida also has enacted
legislation proposing a "pay or play" requirement if employers do not
voluntarily extend coverage to their workers.
Like the employer mandated coverage approach, a pay or play approach
would require the establishment of state-sponsored coverage for persons
not linked to the work force or workers whose employer elected to pay
the payroll tax rather than provide health benefits.
A single payer system.
By a "single payer" system we mean a system under which all Alaska
residents would be provided constant health care coverage through a
unified funding mechanism. This would be in contrast to our current
system under which whether or not a person has coverage is dependent
upon whether his or her employer provides health benefits, whether or
not their income is below a certain level to qualify for Medicaid, whether
they are old enough to qualify for Medicare, or whether they would
qualify for coverage under the Indian Health Service.
60
�A single payer systems does not mean that all health care providers
would end up being government employees or that all health care
facilities would be government owned. Under a single payer system, the
current mix of private and public health care providers could continue to
provide services and Alaskans would still have the ability to select the
provider of their choice.
After a careful consideration of each of these possible approaches, the Task
Force concluded that the most appropriate approach for providing universal coverage
in Alaska is a single payer system. There are several important reasons why a single
payer system is preferred to either an employer mandate or a "pay or play" approach,
both of which are based upon our current system. They are the following:
1.
The current mix of public, employer, and individual financing inevitably
creates coverage gaps for some people, particularly when their
employment status changes.
Linking health care coverage to employment is particularly difficult in
Alaska. Given the seasonal nature of many of its industries, there are
considerable fluctuations in employment during the course of the year.
For example, an analysis of all but the state's very largest firms
conducted by the Alaska Department of Labor found that employment in
the "average" business fluctuated by 24 percent from the lowest
employment month to the highest. In the very seasonal industries, those
fluctuations were even greater. In seafood processing, for example, the
highest monthly employment averaged over 300 percent higher than in
the lowest month. The lumber and wood products, utilities, and
construction industries were also found to have fluctuations of from 66 to
87 percent.
9
2.
Health care financing approaches that require all businesses to provide
health care benefits or that levy additional taxes on those businesses
that do not may threaten the economic viability of many small businesses
in Alaska.
As discussed in Chapter Two, a significant proportion of uninsured
Alaskans are workers employed by small businesses or the dependents
of these workers. While many of the businesses that employ these
uninsured workers might be able to afford to provide coverage for these
workers, particularly in a system in which effective cost containment
measures are in place, the financial status of some of these businesses
might be jeopardized by the burden that either a health benefit mandate
or a "pay or play" requirement would place upon them. The Task Force
believes that a single payer approach offers greater flexibility to identify
g
Rae, B. 1991. Alaska's 13,476 Other Employers. Alaska Economic Trends (August).
61
�funding sources and develop financing arrangements that will be less of
a threat to the state's small businesses.
3.
Multiple payer systems would not necessarily address the problems of
cost shifting that exist in our current system.
Unless there was a requirement that all payers would pay the same
amount to providers for comparable services, multiple payer approaches
to providing universal coverage would not necessarily solve the problem
of cost shifting, which places an inequitable burden on some payers.
Under such a system, larger payers might be able to negotiate significant
discounts in charges from providers, with losses in revenues being made
up through higher charges to other, smaller payers. To the extent that
public programs reduce their reimbursement levels below costs due to
budgetary constraints, this source of cost shifting can also exist. Under
a single payer system, by definition, a single rate would be paid to a
given provider for a given service, so that no one's cost would be
artificially increased.
4.
Systems that are built upon the existing public-private financing
arrangements can be expected to inherit its inefficiencies.
These inefficiencies exist because there are considerable administrative
costs associated with conducting eligibility determinations for public
program coverage, enrolling individuals in employment-based plans, and
re-enrolling them when they change jobs and are lucky enough to obtain
coverage at their second job. Given the seasonal fluctuations in
employment discussed above, these costs are likely to be particularly
high in Alaska.
There also are significant costs associated with having multiple insurers
provide coverage. These administrative costs include not only insurer
overhead, but also the cost to providers of filling out different forms and
responding to varying requests from different insurers. In its study of the
Canadian health care system, the U.S. General Accounting Office
concluded that nationwide there would have been administrative cost
savings of approximately $67 billion in 1991 if the U.S. had adopted a
Canadian-style single payer system-more than enough to cover the
increased cost associated with covering all currently uninsured
Americans. While the magnitude of GAO's estimates of administrative
cost savings have been questioned by some analysts, most conclude
that the administrative savings would nonetheless be significant.
10
11
10
11
General Accounting Office. 1991. Canadian Health Insurance: Lessons for the United States.
Washington, D.C. (June).
See Gauthier, A. et al. 1992. Administrative Costs in the U.S. Health Care System: The
Problem or the Solution? Inquiry 29 (Fall).
62
�What Would be the Impact of a Single Paver System on Health Care Costs in Alaska?
An analysis of the cost of moving to a single payer health care financing system
that provides coverage to all Alaskans is presented in Table 4-3. This analysis
assumes that a single payer system providing universal access is implemented in
1995, one year after the beginning of the phase-in of the expenditure limits. To the
projections of health care expenditures in Alaska under a system with expenditure
limits (see Table 4-1 in Recommendation #1) are added the following:
•
The marginal costs associated with providing health care coverage to
Alaska's currently uninsured population. These costs are based upon
analyses which indicate that per capita health care costs for insured
individuals are approximately 40 percent higher than for persons without
health care coverage.
12
Anticipated administrative savings associated with a single payer system,
which is based on a low-end estimate of 4 percent savings of total
expenditures.
13
As can be seen from Table 4-3, the administrative savings associated with the
single payer system are estimated to exceed the anticipated marginal cost of covering
Alaska's uninsured population. As a result, cumulative expenditures under this alternative
scenario for the period 1991 to 2003 total $34.9 billion (see column 14). This figure is
significantly less than the cumulative cost of $42.1 billion for maintaining the current
system without expenditure limits or universal
access, which is presented as Alternative A in
The savings in administrative costs
Table 4-3. It is also less than the estimated
that result from a single payer system
$35.55 billion in cumulative health care
would be enoughtoprovide coverage
spending under a system under in which there
to all uninsured Alaskans.
are expenditure limits, but neither universal
access nor a single payer system (see Table
4-1, Alternative B, column 14).
How Could a Single Paver Svstem be Financed?
As the analysis presented above illustrates, the difficulty in restructuring our
current health care financing system to one that is more equitable, efficient, and
rational is not that it will cost more money. Rather, the problems are due to the fact
that the public may have certain misconceptions about a single payer system, it may
not be aware of the savings that could accrue from moving to such a system, and the
12
Needleman, J. et al. 1990. The Health Care Financing System and the Uninsured. Submitted to
the Office of Research, Health Care Financing Administration, DHSS (April 4).
13
For a fuller discussion of alternative estimates of administrative cost savings associated with a
single payer system, see Gauthier et al. 1992.
63
�Table 4 - 3
A COMPARISON O F PROJECTED HEALTH C A R E EXPENDITURES IN ALASKA
UNDER THE CURRENT SYSTEM AND A SINGLE PAYER S Y S T E M WITH EXPENDITURE LIMITS, 1991 - 2003
(In Billions of i> / ' ' '•
(10)
(1)
1991
(2)
(3)
(4)
(5)
(6)
(7)
(14)
1994
1995
1996
1997
1998
2000
(11)
2001
(13)
1993
(9)
1999
(12)
1992
2002
2003
CUMULATIVE
$1,598
$1,983
$2202
$2446
$2,712
$3,008
$3,339
$3,706
$4,117
$4,559
$5,051
$0,064
$0,071
$0,080
$0,090
$0,086
$0,096
$0 108
(8)
ALTERNATIVE A: Current System
Baseline/Prior Year Expenditures
$1,598
$1,787
1. Increase Due to Population Growth
$0,053
$0,043
$0,048
$0,053
$0,057
2. Increase Due to Aging of Population
$0,004
$0,006
$0,008
$0,009
$0,009
$0,010
$0.011
$0,013
$0,015
$0 019
$0,022
$0,025
3. Increase Due to Other Factors @
$0,132
$0 147
$0,163
$0,181
$0,201
$0,223
$0,247
$0,275
$0,305
$0,338
$0,374
$0,415
$1,598
$1,787
$1,983
$2202
$2446
$2712
$3,008
$3,339
$3,706
$4,117
$4,559
$5,051
$5,599
$1,598
$1,598
$1,787
$1,983
$2175
$2352
$2505
$2,666
$2,836
$3,016
$3,207
$3,397
$3,598
1. Increase Due to Population Growth
$0,053
$0,043
$0,048
$0,052
$0,054
$0,059
$0,063
$0,068
$0,073
$0,067
$0,072
$0,077
2. Increase Due to Aging of Population
$0 004
$0,006
$0,008
$0,009
$0,008
$0 009
$0,010
$0,011
$0,012
$0,015
$0,016
$0,018
3. Increase Due to Other Factors under Expenditure Limits
$0,132
$0,147
$0,136
$0,119
$0,097
$0,103
$0,110
$0,117
$0,124
$0,132
$0,139
$0,148
($0,027)
($0,090)
($0,201)
($0,333)
($0490)
($0,674)
($0,891)
($1,139)
($1,427)
($1,759)
$0,094
$0,098
$0,102
$0,106
$0,110
$0,114
$0,119
$0,124
$0,128
($0,098)
($0,104)
($0,111)
($0,118)
($0 126)
($0 134)
($0,142)
($0,150)
($0,159)
$2666
$2,836
$3,016
$3,207
$3,397
$3,598
$3,810
$34,928
($0,343)
($0,502)
($0,690)
($0,910)
($1,162)
($1,453)
($1,789)
($7,178)
8.0%
TOTAL: Projected Net Cost/Current System
$42,107
CD
ALTERNATIVE C: Single Payer System w/Expenditure Limits
Baseline/Prior Year Expenditures
Savings Due to Expenditure Limits
4. Additional Costs of Universal Access
5. Administrative Savings of Single Payer System
TOTAL: Net Cost of Single Payer System
ADDITIONAL COST (SAVINGS) OF SINGLE
PAYER S Y S T E M WITH EXPENDITURE LIMITS
$1,598
$1,787
$1,983
$2,175
$2352
$2505
$0,000
$0,000
$0,000
($0,027)
($0,094)
($0,208)
�fact that there would be major shifts in the distribution of responsibility for the financing
of health care.
For example, with respect to this latter issue, the establishment of a nonemployment-based single payer financing system would relieve both private and public
employers-including private businesses, school districts, municipal governments, e t c of the significant costs that most currently incur in providing employee health benefits.
At the same time, however, it would require the identification of new sources of
revenues to replace these expenditures. In addition, under a single payer system,
other sources of health care dollars currently financing care in Alaska, such as
Medicare, federal Medicaid funds, IHS, VA, etc., would continue to come into the state
on a block grant-like basis but would go into a Statewide Universal Access Fund
rather than be used to support individual facilities or finance care for specific program
recipients.
The Task Force realizes that federal waivers will be required to integrate these
federal health care funding streams into a single payer financing system. We also
recognize that bringing these different programs into a single payer system must be
done carefully and sensitively. For example, the Task Force recommends that the
newly created Alaska Health Care Authority negotiate with Alaska Natives and the
federal government to bring the IHS/tribal health care system within the single payer
system. These negotiations will require changes to federal law and must recognize
and address the following issues:
•
Recommendations for change which affect the IHS/tribal health care
delivery system in Alaska must recognize and support the federal trust
responsibility to provide health care to Alaska Natives.
•
Recommendations for universal coverage must provide the same rights
for Alaska Natives as for all other Alaskans and must support at least the
level of care currently available to Alaska Natives.
Recommendations for cost control should capture and, if possible,
enhance the direct federal appropriations currently going to the Alaska
Area Native Health Service.
•
Other issues regarding copayments and deductibles (prohibited by law in
the IHS system), native preference in employment, etc. must be
addressed.
As discussed above, employment-based and individually purchased health care
coverage would be eliminated under a single payer system. Table 4-4 uses the
estimates of 1991 health care spending in Alaska originally presented in Table 2-1 to
estimate the need for new revenue sources to replace these private health insurance
payments.
65
�SOURCES OF HEALTH CARE SPENDING IN ALASKA, 1991
(In Thousands of $)
^mSyMy
:
ESTIMATED 1991
EXPENDITURES
SOURCES
1. Private Businesses
• Insurance premiums
$121,418
• Self-insured payments
$65,379
2. Local Government
• Insurance premiums
$39,906
• Self-insured payments
$48,774
• Local taxes to support
hospitals/local spending
$29,713
3. State Government
• Premium contributions for
state employees
$47,929
• Self-insured payments
: $9,290
• Medicaid
$99,602
$161,106
• Other health programs
4. Federal Government
• Premium contributions for
civilian employees
$35,402
• Medicare
$90,000
• Medicaid
$114,948
• IHS/AANHS
$206,153
• Veterans' Affairs
$46,476
• CHAMPUS and military
$55,931
$313
• Other
5. Workers' Compensation
$48,089
6. Individual
• Premium contributions for
employment-based coverage
• Individual policies and policies through
fraternal orgs and auto liability insurance
• Service-related cost sharing
(copayments, deductibles), excess
o u t - o f - p o c k e t expenses of uninsured
$255,602
TOTAL, ALL EXPENDITURES:
$1,597,513
TOTAL, EXPENDITURES IN SHADED AREAS:
$537,668
Source: Data originally compiled by ISER, UAA from various sources. Selected entries updated by Health Systems Research, Inc.
66
�If a single payer system had been put in place in 1991, the sources of health
care spending that would not have been available are identified in the shaded boxes in
Table 4-4. Expenditures for employment-based and non-group coverage, including
the premium contributions made by businesses and individuals, are estimated to total
$489.6 million. If workers' compensation health care payments were included under
the single payer system, which would eliminate this cost to employers, the total is
$537.7 million.
While the Task Force is not recommending a specific revenue source to replace
these dollars, it recognizes that funds could come from a number of existing sources.
These include:
•
Payroll taxes;
•
Income taxes;
Sales taxes;
•
Excise taxes; and
•
Permanent Fund earnings.
Table 4-5 provides estimates of the amount of 1991 revenues that theoretically
could have been available from a number of these different sources. As can be seen
from this table, certain of these potential revenue sources, such as sales taxes on
specific items or "sin" taxes on cigarettes and alcohol, would not raise revenues
sufficient to replace group and non-group insurance premiums. However, several of
these revenue sources, such as payroll tax, income tax, or Permanent Fund earnings,
either alone or in combination with other revenue sources, could replace current
premium contributions.
It should again be emphasized that these new revenue sources would not
represent additional spending on health care, but would instead replace existing
expenditures being made by Alaskan employers and individuals. For example,
because employers would no longer have to make health care contributions on behalf
of their workers and their dependents, it is expected that these savings would be
passed on to the Alaskan workers in the form of higher wages, which in turn might be
subject to a new payroll or income tax. It is this understanding of the need to
redistribute, rather than increase, spending under a single payer system that must be
communicated to the public if this model of universal access is to be accepted.
67
�POSSIBLE SOURCES OF REVENUES TO REPLACE
GROUP ANO NON-GROUP HEALTH PREMIUMS/BENEFITS
PAYROLL TAX
(Based upon 1991 Non-agricultural
@
@
@
@
@
Payroll of $7,347 billion)
3%
5%
7%
8%
9%
$
$
$
$
$
220
367
514
588
661
million
million
million
million
million
$
$
$
$
66.5
199
332
664
million
million
million
million
INCOME TAX
(Based upon 1990 Federal Taxable Income)
@
@
@
@
1%
3%
5%
10%
SALES TAX
1. General Tax on Retail Items
@ 1%
@ 6%
$ 34
$ 216
million
million
2. Sales Tax on Hotel and Lodging
@ 1%
@ 5%
@ 10%
$ 1.9 million
$ 9.0 million
$ 18.6 million
EXCISE TAXES
1. Cigarette Tax
Increasing tax per pack by 10$ would raise about $4.5 - $5 million
2. Alcoholic Beverage Tax
Equaling tax rate on alcoholic
beverages: $4.28 million
Increasing tax to highest rate in
other states: $8.26 million
PERMANENT FUND EARNINGS (7/1/90 - 6/30/91)
$ 1.03
billion
Estimates for C. based upon: Alaska Department of Revenue, Revenue Potential of a
General Sales Tax, January, 1989. Revenues from a 6% sales tax estimated by ISER,
Fiscal Policy Paper No. 6, April 1991. Estimates for D. based upon: Alaska Department of
Revenue, Revenue Alternatives, January, 1989.
68
�PUBLIC HEALTH/SERVICE DEUVERY
SYSTEM RECOMMENDATIONS
While the recommendations presented to this point address the problems with
the affordability of health care services and problems with health care coverage faced
by many Alaskans, as described in Chapter Two, the Task Force also identified
significant problems with respect to the availability of needed health care services,
particularly in many rural areas in the state, as well as problems associated with the
lack of adequate public health interventions and the fragmentation of the existing
health care delivery system. To address these problems, the Task Force developed
recommendations concerning:
•
The retention and recruitment of health care personnel;
•
The creation of more flexible licensure standards;
The expansion of the scope of the State's Certificate of Need program;
and
•
The strengthening of public health efforts.
The Task Force's recommendations for each of these areas are presented
below.
The Task Force recommends that the State of Alaska develop Initiatives to
attract and retain qualified health care professionals in medically
underserved areas of the state.
To address the need for qualified health care professionals in many
underserved areas of the state, the Task Force recommends the development and
implementation of a multi-faceted strategy designed to ensure an adequate supply of
appropriately trained health care professionals in the state. Within this overall
strategy, the Task Force specifically recommends that:
•
The Alaska State Legislature should create a state student loan
forgiveness program that provides for forgiveness of a specified loan
amount each year for health practitioner service in an area designated as
underserved by the Department of Health and Social Services.
69
�The State of
development
State should
underserved
Alaska and Alaska State Legislature should support the
of an Alaska-based family practice residency program. The
stipulate a condition requiring rotations in rural and
areas.
The State of Alaska and the Alaska State Legislature should support the
development and maintenance of Alaska-based training and rotations for
mid-level practitioners, nurses, and other health professionals. They
should also provide incentives for the development and maintenance of
continuing education particularly targeted to professionals that practice in
underserved areas. Particular attention should be paid to recruiting local
residents, especially Alaska Natives, into health care professions.
The Task Force supports continued efforts by the State and the Rural
Alaska Health Professions Foundation to analyze the specific recruitment
and retention problems experienced in Alaska.
mjECQMMENp/nTp^M
The Task Force supports the development of more flexible facility licensure
In addition to the development of a statewide strategy for recruiting and
retaining qualified health care professionals, the Task Force also believes that
flexibility must be incorporated into the State's current facility licensure standards if
needed health care resources are to be made available throughout the state in the
most appropriate and cost efficient manner. To this end, the Task Force has
developed the following specific recommendations:
•
The State of Alaska, in conjunction with the provider community, should
explore the creation of more flexible facility licensure standards that allow
communities to choose from a broader range of levels and types of care.
Facility licensure that provides the ability of mid-level clinics to expand
their capabilities without becoming hospitals ought to be explored for
rural communities, along with study of ways to give communities options
to change the role of their existing hospitals or co-located systems. The
Task Force wishes to stress that communities need to be given the
responsibility for deciding levels of care and that communities that
currently have plans for capital improvements to their facilities should not
be impacted by this effort. This effort should be undertaken in the near
future.
70
�The State of Alaska should join in national efforts to ensure that public
programs, such as Medicare and Medicaid, acknowledge that, the cost of
delivering care in rural areas is different from the costs in urban areas
and should be compensated accordingly.
The Task Force supports the development of reimbursement systems
which create incentives for increasing the number of primary care
providers as well as the availability of primary care.
Because Alaska lacks a primary care clinic system which can assist in
meeting the primary health care needs of those who are uninsured or
underinsured, the State of Alaska should continue to promote these
models of care in their long-range planning and funding and should help
communities become aware of federal funding opportunities that promote
the availability of primary care.
RECOMMENDATION # 11:
The Task Force recommends the strengthening and expansion of the
The Task Force supports strengthening the State's Certificate of Need process.
To this end, it recommends that the Department of Health and Social Services be
directed to promulgate in regulation standards establishing "need" and the criteria for
determining when a Certificate of Need will be awarded. The Task Force also
recommends that the requirements for Certificate of Need be extended to all health
facilities, including Pioneers' Homes, Veterans Homes, and to expensive medical
equipment to be located in any setting. The Task Force further recommends that
federal facilities voluntarily comply with Certificate of Need requirements and file
impact statements with the Department of Health and Social Services. It is estimated
that it will take the Department approximately a year to develop standards once given
the authority to do so.
:
:REpOiyiMENMJIpN
The Task Force recommends that adequate resources be devoted to
maintaining a strong public health infrastructure fn Alaska.
In seeking to broaden access and improve the financing of health care in
Alaska, the Task Force is aware that these efforts must be considered in a broader
71
�context that reaffirms the primacy of public health as the cornerstone of community
and personal health. Indeed, the twin goals of universal access to health care and
containment of costs cannot be achieved without reshaping health care into a rational
system based on prevention of disease and violence, promotion of healthful personal
habits, and paying for diagnostic and treatment measures only if they are known to be
effective. Indeed, the Task Force recognized the importance of prevention, the
promotion of healthful lifestyles, and population-based public health services by
integrating all of these into our guiding principles (see Chapter Three).
In addition, the Task Force also recognizes that clean air, clean land, clean
water, and clean food are basic to good health. It is the responsibility of government
to assure these basics exist and to engage as well in other core public health
functions, such as the collection and analysis of vital data, the formulation of public
health policy, and assuring the availability of essential health services to address
problems such as infant mortality, drug and alcohol abuse, suicide, and domestic
violence.
Because adequate public health services are paramount to the costeffectiveness and efficiency of a reformed personal health care system, the Task
Force strongly recommends that sufficient resources be devoted to maintaining a
strong public health infrastructure in Alaska.
MEDICAL LIABILITY RECOMMENDATIONS
The Task Force developed several recommendations in an effort to address the
problems identified in Chapter Two with the existing process for handling medical
liability claims. These recommendations are described below.
TTra Task Forx» recommends red^
related injuries from current law to the eighth birthday of the child.
Under the State of Alaska's current statute of limitations, malpractice cases
involving injury to children can be filed up to two years after the age of nineteen.
However, the Task Force has been informed that virtually all residua from birth or
early-life injury or illness are obvious by the time a child is in school, and that subtle
learning defects appearing after roughly age eight are almost always genetic.
Nonetheless, "tail" insurance to protect against claims filed many years after the fact,
72
�including those involving injuries to infants and children, is very expensive. Given
these findings, the Task Force, in an effort to make obstetrical and pediatric care more
available and affordable in Alaska, supports a change in the statute of limitations for
medical malpractice claims, reducing it for birth-related injuries to the eighth birthday
of the child.
' Wedm
the Task Force recommends that the State's existing pre-trial screening
process for medical malpractice suits be replaced with a court ordered
: non-binding arbitration process.
The Task Force believes that because medical malpractice litigation is so
cumbersome, costly, and unpredictable, alternative ways of resolving claims of injury
by medical care that are quicker, fairer, and less disruptive are needed.
Several types of "alternative dispute resolution" (ADR) systems are currently
being proposed or tested across the nation. Some are "no-fault" systems which, like
workers' compensation laws, require only that the cause of injury be proved, not
whether negligent care occurred. Another approach, called "accelerated
compensation events," would pay awards for pre-selected, ordinarily avoidable poor
outcomes without determination of cause or fault.
Another approach, arbitration, is frequently used to settle contractual disputes
but has been used only infrequently in medical malpractice cases. Recently, however,
its application to this area of litigation has received increased attention.
Arbitration can take various forms. Some states, including Alaska, have
statutes allowing providers and patients to enter into binding arbitration agreements.
However, as in the case of Alaska, overly restrictive statutory provisions-such as
those that preclude providers from requiring patients to enter into agreements to
arbitrate as a condition of care, that allow the unilateral revocation by the patient of
the agreement to arbitrate, or that add the cumbersome requirement of having a panel
of three arbitrators-have limited the use of this ADR process Many proponents of
arbitration propose eliminating such obstacles in order to provide broad flexibility to
voluntary binding arbitration. Others suggest that non-binding arbitration be ordered
by the courts every time a lawsuit is filed as a way to get quicker and more consistent
resolution of medical malpractice lawsuits. It is not known whether mandatory nonbinding arbitration will reduce overall costs associated with malpractice claims.
The Task Force recommends that a mandatory, court-ordered non-binding
arbitration process be enacted in Alaska for all medical malpractice cases. The
73
�process would entail the submission of all disputes to a neutral arbitrator with known
skill in malpractice or other personal injury claims. The arbitrator would be selected
from a panel developed by the courts with input from all parties. The arbitrator would
conduct a hearing after each affected party had been provided reasonable opportunity
(discovery) to investigate the claim. Either party would have the right to reject the
arbitrator's decision and proceed to trial.
It is further recommended that the current three-person expert panel review
system be replaced by having a single court-appointed physician or other provider
serve as a neutral expert as an integral part of the proposed non-binding arbitration
process. This expert should be adequately compensated and should have duties and
responsibilities similar to those currently given to the expert advisory panel under
AS 09.55.536, but should also be asked to render an opinion as to liability and to
answer specific questions posed by the arbitrator.
In addition, the following time limits and requirements should be applied to the
arbitration process:
•
Parties to the suit will be allowed not more than 120 days from the date
upon which the defendant files an answer to the complaint for discovery;
•
The arbitration hearing may last no more than three days;
The arbitrator will produce a decision in writing, admissible at trial, within
thirty days;
•
The entire arbitration process must be completed within 300 days from
the date of filing of the lawsuit.
Lastly, the Task Force recommends that this court-ordered process be installed
for an experimental period of five years, and that a study be conducted to assess: (1)
litigant satisfaction with the process; (2) disposition rates to ensure that the process
leads to timely resolution of claims; and (3) costs to litigants.
::!1EC6MMEyC$
The Task Force recommends that the Legislature adjust the level of prejudgement interest charged in medical malpractice cases from 10.5% to the
"pmyailing^intemsty
As its final recommendation in the area of medical malpractice, the Task Force
suggests that the Alaska State Legislature examine the reasonableness of the current
74
�statutory requirement for the payment of pre-judgement interest in malpractice cases
at the set annual rate of 10.5 percent (see Finding #13). The Task Force believes
that a more reasonable approach to determining the pre-judgement interest rate would
be to follow the federal courts in using the prevailing rate of yield of short-term U.S.
Treasury bills.
C.
IMPLEMENTATION TIMETABLE
The Task Force strongly encourages the Alaska State Legislature's prompt
enactment of all of the recommendations presented in this chapter. The timetable for
actual implementation of these recommendations is presented in Table 4-6 on the
following page. As shown on this table, the Task Force also calls for immediate
implementation of nearly all its recommendations following passage of the required
legislation. The only exceptions to this are the following:
•
Several steps will be involved in the implementation of the statewide
health care expenditure limits. First and foremost will be the
establishment of the Alaska Health Care Authority, which will have
responsibility for implementing these limits. Assuming that legislation is
enacted and the Authority established in the first half of 1993, during its
first year of operation the Authority's activities will be focused on
collecting the necessary data to establish the initial expenditure limits and
obtaining the necessary federal waivers to ensure that payments made
under federal programs to Alaska health care providers are consistent
with those established through the Authority's negotiation process.
Following this initial data collection period, the expenditure limits would
be phased in over a three-year period, beginning in 1994 and ending in
1996. The statewide expenditure limits would be in full effect beginning
in 1997.
•
All but one of the Task Force's interim short term recommendations for
improving access should be implemented immediately. For example, as
indicated in Table 4-6, small group market reform would be implemented
in 1993. However, as discussed earlier, the Task Force calls for the use
of community rating in the small group market to be phased in over a
three to five period. The small group market reforms would provide the
basis for moving to the community ratings, with the rating bands
established as part of this reform gradually tightened from 1994 through
1996 until the desired community rates are achieved.
•
Finally, as discussed earlier, the Task Force strongly believes that a
single payer financing system is the most appropriate model for providing
coverage to all Alaskans. We recognize however, that while it is hoped
that a single payer system will be enacted by the Alaska State
Legislature in 1993, the possibility exists that further public education and
75
�: Timetable for Implementation of task Force Recommendations
RECOMMENDATION
TIMEFRAME
1.
Establish Alaska Health Care Authority
Immediate
2.
Establish Statewide Expenditure Limits
•
••
•
•
Collect/analyze data to establish initial limits
Obtain necessary federal waivers
Phase-in expenditure limits
Expenditure limits in full effect
1993
1993
1994 - 1996
1997
3.
Expand State's authority to approve/disapprove insurer rate filings
Immediate
4.
Small market insurance reform
1993
5.
Phase-in community rating in small group market
1994 - 1996
6.
Establish State-sponsored health insurance pooling arrangements
1993
7.
Establish program to cover low-income uninsured children and
pregnant women
1993
8.
Establish a single payer health care financing system
•
Conduct program of public education/dialogue on issue
1993 - 1994
•
Negotiate and obtain necessary federal waivers to
bring all payers into the system
1993 - 1994
•
Implement single payer financing system
1995
9.
Develop initiatives to attract and retain health professions in
underserved areas
1993
10.
Develop more flexible licensure standards
1993
11.
Strengthen/expand Certificate of Need program
1993
12.
Devote adequate resources to maintain a strong public health
infrastmcture
1993 onward
13.
Reduce the statute of limitations for medical malpractice claims for
birth-related injuries
1993
14.
Replace existing pre-trial screening process with court ordered
non-binding arbitration on a demonstration basis
1993 - 1998
15.
Adjust the level of pre-judgement interest charged to the prevailing
interest rate
1993
76
�community-based dialogue will be required to generate the public support necessary
for passage of this legislation. For this reason, the timetable presented in Table 4-6
calls for the conduct of a broad-based public education program designed to increase
community awareness and discussion about the benefits of the single payer system.
During the same time period, the Alaska Health Care Authority should be charged with
the responsibility for developing detailed specifications for the single payer system,
and engaging in discussions and negotiations with the federal government and
representatives of the Alaska Native population to secure their participation in the
system. Legislation should also be enacted authorizing the AHCA to submit requests
for the federal waivers necessary to implement a single payer system. Based upon
this timeframe, implementation of a single payer financing system in the state would
begin in 1995.
14
With respect to the public education efforts directed at increasing Alaskans'
awareness of the benefits of a single payer system, the Task Force recognizes that
our authorization expires on February 1, 1993. Because we believe these public
education efforts may be critically important to the successful establishment of the
single payer system, we are extremely concerned that there be a single entity
assigned responsibility for coordinating these education and outreach efforts and given
sufficient resources to do so. We therefore strongly recommend that the legislation
establishing the Alaska Health Care Authority also charge the Authority with the
responsibility for coordinating efforts to increase the public's understanding and
awareness of the benefits of a single payer system.
The Task Force recognizes that prior to the establishment ot such a program in Alaska,
legislation designed to provide universal coverage for all Americans may be enacted at the
national level. If the approach to achieving universal coverage embodied in the federal statute
is not a single payer model (i.e., it involves an employer mandate or a "pay or play" approach),
given the Alaska environment and the problems associated with linking health care coverage
and employment, the Task Force further urges that the Legislature authorize the Authority to
request the necessary federal waivers to implement a single payer system in lieu of any other
approaches that might be embodied in the federal statue.
77
�Agency for Health Care Policy Research. 1991. Delivering Essential Health Care
Services in Rural Areas: An Analysis of Alternative Models. Rockville, MD: U.S.
Department of Health and Human Services (May) No. 91-0017.
Alaska Bureau of Vital Statistics. 1992. 1988-1989 Annual Report. Juneau (July).
Alaska Department of Health and Social Services. 1992. Practice Sites: State Primary
Care Development Strategies. Juneau: Division of Public Health, proposal to the
Robert Wood Johnson Foundation (October 5).
Alaska Division of Insurance. 1990. 53rd Annual Report: 1990 Calendar Year.
Alaska Department of Labor. 1991. Alaska Population Projections. Juneau
(November).
Alaska Native Health Board. 1991. Access to Care: Crisis for Alaska Natives.
Anchorage (January).
American College of Obstetricians and Gynecologists. 1992. Professional Liability and
Its Effects: Report of a 1992 Survey of ACOG's Membership. Washington, D.C.
American Medical Association. 1991. Advocacy Briefs: The Impact of Professional
Liability on Access to Health Care. Chicago: American Medical Association, Office of
Policy, Communication, and Advocacy Support. The brief references: Reynolds, R.
1990. The Cost of Medical Professional Liability in the 1980s. Chicago: Center for
Health Policy Research, American Medical Association. The 1989 estimate of the cost
of defensive medicine is based on earlier estimate, see: Reynolds, R.A., Rizzo, J.A.,
and Gonzales, M.S. 1987. "The Cost of Medical Professional Liability" Journal of the
American Medical Association 257:2776-2781.
American Public Health Association. 1992. America's Public Health Care Report: A
State-by-State Report on the Health of the Public. Washington, D.C. (November).
Anchorage Daily News. 1992. Anchorage's Cost of Living Up 3.2 Percent. (August 14).
Bovbjerg, R., Tancredi, L., and Gaylin, D. 1991. Obstetrics and Malpractice: Evidence
on the Performance of a Selective No-Fault System. Journal of the American Medical
Association 265:2836-2843.
Butler, P. et. al. 1991. Access and the Uninsured: A Guide for States. Portland,
Maine: National Academy for State Health Policy (March).
79
�Charles, S.C., et. al. 1985. Sued and Nonsued Physicians' Self-Reported Reactions to
Malpractice Litigation. American Journal of Psychiatry 142:437-440.
Chassin, M. et al. 1987. Does Inappropriate Use Explain Geographic Variations in the
Use of Health Care Services? Journal of the American Medical Association 258:253337.
Congressional Research Service. 1990. Controlling Health Care Costs. Washington,
D.C. (January).
Congressional Research Service. 1988. Health Insurance and the Uninsured:
Background Data and Analysis. Washington, D.C. (June 9).
Congressional Research Service. 1991. National Health Expenditures: Trends from
1960-1989. Washington, D.C. (July 29).
Congressional Research Service. 1990. Private Health Insurance:
Reform. Washington, D.C. (September 20).
Options for
Danzon, P. 1985. Medical Malpractice: Theory, Evidence and Public Policy. Harvard
University Press. Also see: Mills, D.H. 1978. Medical Insurance Feasibility Study: A
Technical Summary. Western Journal of Medicine 128:360-365.
Eckstein, T.E., and Associates, Inc. 1992. The Northwestern National Life State Health
Rankings: 1992 Edition. Minneapolis: Northwestern National Life Insurance
Company.
Families USA Foundation. 1991. Health Spending: the Growing Threat to the Family
Budget. Washington, D.C. (December).
Formisano, R. 1988. The Market for Small Employer Health Insurance: An
Examination of Demand in Wisconsin. Prepared for the Wisconsin Department of
Health and Social Services and the Robert Wood Johnson Foundation (August).
Freeman, et. al. 1987. Americans Report on Their Access to Health Care. Health
Affairs 6(1).
Gauthier, A. et al. 1992. Administrative Costs in the U.S. Health Care System: The
Problem or the Solution? Inquiry 29 (Fall).
Gehshan, S. 1991. Medical Liability and Access to Obstetrical Care: Can Alternatives
to the Tort System Work? Washington, D.C: Southern Regional Project on Infant
Mortality.
General Accounting Office. 1991. Canadian Health Insurance: Lessons for the United
States. Washington, D.C. (June).
80
�General Accounting Office. 1990. Health Insurance: Cost Increases Lead to Coverage
Limitations and Cost Shifting. Washington, D.C. (May).
General Accounting Office. 1987. Medical Malpractice: A Framework for Action.
Washington, D.C.
General Accounting Office. 1987. Medical Malpractice: Characteristics of Claim
Closed in 1984. Washington, D.C. (April).
Hall, C, and Kuder, J. 1990. Small Business and Health Care: Results of a Survey.
Washington, D.C: National Federation of Independent Businesses Foundation.
Harvard Medical Practice Study. 1990. Patients, Doctors, and Lawyers: Medical
Injury, Malpractice Litigation, and Patient Compensation in New York. Cambridge:
Harvard University. The study is described in the following articles: Brennen, T. et.
al. 1991. Incidence of Adverse Events and Negligence in Hospitalized Patients:
Results of the Harvard Medical Practice Study I. The New England Journal of
Medicine 324:370-376.; Leape, L.L. et. al. 1991. The Nature of Adverse Events in
Hospitalized Patients: Results of the Harvard Medical Practice Study II. The New
England Journal of Medicine 324:377-384.; and, Localio, A.R. et. al. 1991. Relation
Between Malpractice Claims and Adverse Events Due to Negligence: Results of the
Harvard Medical Practice Study III. The New England Journal of Medicine 325:245251.
Health Insurance Association of America. 1991. Statement of HIAA on Health Care
Reform and Insurers' Operating Expenses. Presented Before the Subcommittee on
Education and Health, Joint Economic Committee, U.S. Congress. Washington, D.C.
(October 16).
Hensler, D.R. et. al. 1987. Trends in Tort Litigation. The Story Behind the Statistics.
Santa Monica, California: The RAND Corporation. No. R-3583ICJ.
ICF Incorporated. 1987. Health Care Coverage and Costs in Small and Large
Businesses. Washington, D.C: Small Business Administration, Office of Advocacy.
(April 15).
Institute of Medicine. 1989. Medical Professional Liability and The Delivery of
Obstetrical Care, Volume II, An Interdisciplinary Review. Washington, D.C: National
Academy Press.
Lasker, R. et al. 1992. Realizing the Potential of Practice Pattern Profiling. Inquiry 29
(Fall): 287-297.
Lembo, R. 1992. Materials presented at Issues in Medical Liability and Health Care
Quality, A Workshop for State Legislators and Senior Health Officials, August 3-5,
1992. Rockville, MD.: Agency for Health Care Policy and Research. A.M. Best
referenced as source for "cost of medical malpractice direct losses paid". Reference
for "cost of medical malpractice insurance premiums" equal to $5.6 billion is:
81
�Reynolds, R. 1990. The Cost of Medical Professional Liability in the 1980s. Chicago:
Center for Health Policy Research, American Medical Association.
Malhotra, S., and Wills, J. 1981. Alaska Comprehensive Health Care Financing Study:
A Survey of Health Care Resources and Financing in Alaska, Interim Report #1.
Seattle: Battelle Human Affairs Research Centers (March).
Needleman, J. et al. 1990. The Health Care Financing System and the Uninsured.
Submitted to the Office of Research, Health Care Financing Administration, DHSS
(April 4).
Nesbitt, T.S., et. al. 1992. Factors Influencing Family Physicians to Continue Providing
Obstetric Care. Western Journal of Medicine. 157:44-47.
New York Times. 1991. (October 27).
Nocon, J.J. and Coolman, D.A. 1987. Perinatal Malpractice: Risks and Prevention.
The Journal of Reproductive Medicine. 32:83-90.
Rae, B. 1991. Alaska's 13,476 Other Employers. Alaska Economic Trends (August).
Rosenblatt, R.A., et. al. 1990. Why do Physicians Stop Practicing Obstetrics? The
Impact of Malpractice Claims. Obstetrics and Gynecology 76:245-250.
Rosenblatt, R.A., Wright, CL. 1987. Rising Malpractice Premiums and Obstetric
Practice Pattems-The Impact on Family Physicians in Washington State. Western
Journal of Medicine 146:246-248.
Rural Alaska Health Education Center. 1992. Alaska Health Manpower Survey: A
Limited Survey of Hospitals, Nursing Homes and Health Care Organizations in Alaska.
Fairbanks: University of Alaska, Fairbanks (March).
Short, P. 1988. Trends in Employee Health Insurance Benefits. Health Affairs 7(3).
Sonnefeld, S. et al. 1991. Projections of National Health Expenditures through the
Year 2000. Health Care Financing Review 13 (Fall).
The Robert Wood Johnson Foundation. 1987. Access to Health Care in the United
States: Results of a 1986 Survey. Princeton.
U.S. Department of Health and Human Services. 1987. Report of the Task Force on
Medical Liability and Malpractice. Washington, D.C. (August):166.
Weeks, M. 1992. State Approaches to Medical Malpractice Juneau: Legislative
Research Agency. Report 91.222.
Zuckerman, S. 1984. Medical Malpractice: Claims, Legal Costs, and the Practice of
Defensive Medicine. Health Affairs 3:128-133.
82
�LIST OF APPENDICES
(Appendices are published in a separate document.)
Appendix A: Legislative Resolve 45, Establishing a Health Resources and Access Task
Force.
Appendix B: Estimated 1991 Health Spending in Alaska by Source of Funds (and sources
for table).
Appendix C: Report to the Health Resources and Access Task Force, January, 1992 by
Oliver Scott Goldsmith, Institute of Social and Economic Research, University of Alaska.
Appendix D: Memo to Members, Alaska Health Resources and Access Task Force,
Regarding Additional Information, from Larry Bartlett, Health Systems Research, Inc.,
February 11, 1992.
Appendix E: Worksheet: Computations of Actual Costs Which Were Shifted to Other
Payers to Cover Charity Care, Bad Debt, and Hill Burton Free Care at Alaska's Acute Care
Community Hospitals, 1990, by Nancy Cornwell, January 26, 1992. Letter to Nancy
Cornwell, from Garrey Peska, Alaska State Hospital and Nursing Home Association,
January 13, 1992. Letter to Senator Jim Duncan and Representative Johnny Ellis, from
Garrey Peska, January 10, 1992.
Appendix F: Public Health in Health Care Reform, Presentation to the Health Resources
and Access Task Force, by Peter Nakamura, MD, Alaska Division of Public Health, August
25, 1992.
Appendix G: Presentation to the Public Health/Service Delivery Subcommittee of the Health
Resources and Access Task Force on Problems Facing Rural, Under-utilized Hospitals and
Alternatives to Closing, by Karen Perdue, September 25, 1992.
Appendix H: Presentation to the Public Health/Service Delivery Subcommittee of the Health
Resources and Access Task Force on the Alaska Area Native Health Service Delivery
System and Resources/Demographics and Health Status of Alaskan Natives/Future Trends,
by David Mather, Dr.P.H., April 25, 1992.
Appendix I: Memo to the Health Resources and Access Task Force, from Bradley J.
Whistler, Planning Section, Alaska Department of Health and Social Services, October 21,
1991.
Appendix J: Letter from J.S. Johnston, NORCAL to Maureen Weeks, Legislative Research
Agency, March 11, 1992.
Appendix K: Current Rates for Professional Liability Insurance in Alaska, Provided by
Loreen Killian, Medical Indemnity Exchange of California, October 1992, and 1992 Rate
Chart, NORCAL Mutual Insurance Company.
83
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
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2006-0885-F
Text
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Paper
Dublin Core
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Title
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[The State of Alaska Health Resources and Access Task Force] [loose, letter and booklet]
Creator
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
Is Part Of
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Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
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42-t-12092971-20060885F-Seg3-038-010-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/76c4c521d1e82ebbc5bffe10d601b755.pdf
16164b9637651586d69a99ca2d9c7662
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tanney
Subseries:
1337
OA/ID Number:
FolderlD:
Folder Title:
[St Ann Letters] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
6
1
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
001. fax
SUBJECT/TITLE
DATE
Form letters from St. Ann's patients to Hillary Clinton and Ira
Magaziner [partial] (24 pages)
11/3/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1337
FOLDER TITLE:
[St. Ann Letters] [loose]
2006-0885-F
wr838
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) of the FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA|
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office [(a)(2) of the PRA|
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�11-03-1993 01:17PM
FROM
St. Ann Day Treatment
TO
12024567739
P.01
OUR LADY OF THE LAKE
REGIONAL MEDICAL CENTER
ST ANN
FAX TRANSMITTAL COVER LETTER
DATE; / ^ / ^ / f f J
PAGES (INCLUDING THIS COVER LETTER)
I F . YOU DO NOT RECEIVE ALL PAGES, PLEASE CALL US BACK AS
SOON AS POSSIBLE.
PLEASE DELIVER THE FOLLOWING PAGES TO:
COMPANY:
DEPARTMENT:
ATTENTION:
INFORMATION W NEED--PLEASE RESPOND A.S.A.P.
E
INFORMATION YOU REQUESTED
THIS FAX IS SENT TO YOU FROM O R LADY OF THE LAKE BY:
U
NAME:
DEPARTMENT:
TELEPHONE
ST ANN ADULT DAY TREATMENT PROGRAM
ft:
FAX NUMBER:
504-765-3006
504-763-9568
REMARKS:
TELEPHONE (504)765-3006 / 2041 SILVERSIDE. / B . R . , L A .
70808
�11-03-1993 01 ••17PM
FROM
St. Pnn Day Treatment
TO
120245S7739
P.02
Ira Magaziner/Mrs. Ointon
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know how important it is tha
partial hospitalization be made available as part of the mental health benefit by all acoooniab
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for th
availabiOty of partial hospitalization services. Instead, partial hospitalization has enabled m n
ay
ofraypatients with serious mental illnesses to function independently in the community
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternativetoinpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
�11-03-1993 01:1BPM
F O St. Ann Day Treatment
RM
TO
12024567739
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 2(
Dear Ira Magaziner/Mrs. Clintcm:
As a provider of partial hospitalization services, I want you to know how important it is that
partial hospitalization be made available as pan of the mental health benefit by all accountabl
health plans. Many of my patients might now be unnecessarily hospitaKzed if it weren't for th
availability of partial hospitalization services. Instead, partial hospftalization has enabled m n
ay
of my patients with serious mental illnesses to function independently in the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternativetoinpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 0i:i8PM
FROM
St. Ann Day Treatment
TO
12024567739
P.04
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 2t
Dear Ira Magaziner/Mrs, Clinton:
As a provider of partial hospitalization services, I want you to know how important it is that
partial hospilalization be made available as part of the medal health benefit by all accountable
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for th
availability of partial hospitalization services. Instead, partial hospitalization has enabled many
of my patients with serious mental illnesses to function independently In the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternativetoinpatient psychiatric care.
I urge you to correct this errar before the final legislation is released to Congress.
Sincerely,
&
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. fax
SUBJECT/TITLE
DATE
Form letters from St. Ann's patients to Hillary Clinton and Ira
Magaziner [partial] (24 pages)
11/3/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tanney
OA/Box Number:
1337
FOLDER TITLE:
[St. Ann Letters] [loose]
2006-0885-F
wr838
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information |(a)(l) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information [(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) of the FOIA]
b(3) Release would violate a Federal statute [(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the FOI A]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�U-03-1993 01:13*,
FROM St. finn Day Treatment
TO
12024557739
P.05
Ira Magaziiier/Mn. Oman
The White Howe
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a patient who is receiving partial hospitalization services, 1 want you to know h w import
o
it is that partial hospitalization be m d available as pan of the mental health benefit by all
ae
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalizatioo services. Instead, partial hospitalization has enabled m to
e
function independently in the comimmlty. It is m undemanding that a drafting error m y leav
y
a
the availability of partial hoqnialization services to the discretion of individual health plans.
I urge you to correct this error before thefinallegislation is released to Congrc&s,
Sincerely,
�11-03-1993 0i:i9PN
F O St. Ann Day Treatment
RM
TO
12024567739
P.06
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Ointon:
As a provider of partial hospitalization services, I want you to know how important it is tha
partial hospilalization be made available as part of the medal health benefit by all accounta
health plans. Many of my patients might now be unnecessarily hospitaKzed if it weren't for t
availability of partial hospitalization services. Instead, partial hospitalization has enabled m n
a
of my patients with serious mental illnesses to function independently In the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I inge you to correct this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 01: 19Pn
FROM
St. Ann Day Treatment
TO
12024567739
P. 07
Ira Magaziner/Mrs. Ointon
The White House
Washington, D.C. 2(•MO
Dear Ira Magaziner/Mrs. Ointon:
As a provider of partial hospitalization services, I want you to know how important it is that
partial hospila&ation be made available as part of the mcctal health benefit by all accountable
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalization services. Instead, partial hospitalization has enabled many
of my patients with serious mental illnesses to function independently In the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternativetoinpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 01:20PM
FROM
St. Ann Day Treatment
Ira Magaziner/Mrs. Ointon
The White House
Washington, D.C. 2Q500
TO
12024567739
P.08
/ y ^ f t 3?
Dear Iia Magaziner/Mrs. Ointon:
As a provider of partial hospitalization services, I want you to know how important it is th
partial hospilalization be made available as part of the medal health benefit by all accounta
health plans. Many of my patients might now be unnecessarily hospitalized if it weren'tfort
availability of partial hospitalization services. Instead, partial hospitalization has enabled m
a
of my patients with serious mental illnesses to function independently In the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Cbngzeas.
Sincerely,
�11-03-1993 0i:20PN
FROM
St. Ann Day Treatment
TO
12024567739
P.09
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 2••in
1
Dear Ira Magaziner/Mrs. Ointon:
As a provider of partial hospitalization services, I want you to know how important it is th
partial hospilalization be made available as part of the mental health benefit by all accounta
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for th
availability of partial hospitalization services. Instead, partial hospitalization has enabled m n
a
of my patients with serious mental illnesses to function independently in the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternativetoinpatient psychiatric care.
I urge youtocorrect this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 01:20PM
FROM
St. Ann Day Treatment
TO
12024567739
P.10
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want youtoknow how important it is
partial hospitalization be made available as part of the mental health benefit by all accoun
health plans. Many of m patients might now be unnecessarily hospitalized if it weren't fo
y
availability of partial hospitalization services. Instead, partial hospitalization has enabled m
a
of m patients with serious mental illnesses to function independently in the community.
y
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternativetoinpatient psychiatric care.
I urge youtocorrect this error before the final legislation is released to Congre
Sincerely, ^SJUU^
tyi^uO,
^
�11-03-1993 01:21PM
FROM
St. Ann Day Treatment
TO
12024567739
P.11
Ira Magaziner/Mrs. Clinton
The White Houae
Washington, D.C. 2(
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know how important it is th
partial hospilalization be made available as part of the medal health benefit by all accountab
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for th
availability of partial hospitalization services. Instead, partial hospitalization has enabled m n
a
of my patients with serious mental illnesses to function independently in the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge youtocorrect this errar before the final legislatiofl is released to Congress.
�11-03-1993 01:21PM
FROM
St. Ann Day Treatment
TO
12024567739
P.12
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. IB A A
21
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want youtoknow how important it is t
partial hospilalization be made available as part of the mental health benefit by all accoun
health plans. Many of m patients might now be unnecessarily hospitalized if it weren't for
y
availability of partial hospitalization services. Instead, partial hospitalization has enabled m n
a
of m patients with serious mental illnesses to function independently in the community.
y
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternativetoinpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
,
T
�11-03-1993 01:22PM
FROM
St. Ann Day Treatment
TO
12024567739
P.13
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know how important it is th
partial hospitalization be made available as part of the mental health benefit by all accounta
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for t
availabiOty of partial hospilalization services. Instead, partial hospitalization has enabled m
a
of my patients with serious mental illnesses to function independently in the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care,
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 01:22PM
FROM
St. Ann Day Treatment
TO
12024567739
P.14
Ira Magaziner/Mrs. Clinton
The White Houae
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know how important it is th
partial hospitalization be made available as part of the medal health benefit by all accounta
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for t
availability of partial hospitalization services. Instead, partial hospitalization has enabled m
a
of my patients with serious mental illnesses to function independently In the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely, fi
�11-03-1993 01:22PM
FROM
St. Ann Day Treatment
TO
12024567739
P.15
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C, 2•wo.
1
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know how important it is th
partial hospitalization be made available as part of the mental health benefit by all accounta
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for t
availability of partial hospitalization services. Instead, partial hoqzitalizatian has enabled m n
a
of my patients with serious mental illnesses to function independently in the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 01:23PM
FROM St. Ann Day Treatment
TO
12024567739
P. 16
Ira Magaziner/Mn. Clmton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. CKntm:
As a patient who isreceivingpartial hospitalization services, I want you to know h w import
o
it is that partial bogntaltzatioa be made available as part of the mental health benefit by al
accountable health plans. I might now be unnecessarily twpitaiL&ed if it weren't for the
availability of partial hospiiaKzatioa services. Instead, partial hospitalization has enabled m t
e
function independently in the community. It is my understanding that a drafting error m y leav
a
the availability of partial hoqritslization services to the discretion of individual health plans.
I urge you to correct this error before thefinallegislation isreleasedto Congress.
Sincerely,
�11-03-1993 01:23PM
FROM St. Ann Day Treatment
TO
12024567739
P. 17
lea Magaziner/Mn. Clmtoa
The White House
Washington, O.C. 20500
Dear Irs Magaziner/Mrs. Clinton:
As a patient who is receiving partial hospitalization services, 1 want you to know h w impor
o
it is that partial ho^ntallzatios be made available as part of the mental health benefit by a
acoountable health plans. I might now be onneoessarily hospitalized if it weren't for the
availability of partial hospitalizatioo services. Instead, partial hospitalization has enabled m lo
e
fraction independently in the conummlty. It is m understandingftata dramng error m y leav
y
a
the availability of partial hospitalization services lo the discretion of individual health plans.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 ai.-aPM
FROM St. Ann Day Treatment
TO
12024567739
P.IB
Ira MagaziDer/Mrs. Qintoa
The White House
Washington, D.C. 20500
Dear Ln Magaziner/Mrs. Ctinton:
As a patient who is lecetving partial hospitalization services, 1 want you to know how importan
it is that partial hospitalization be made available as part of die mental health benefit by all
accountable health plans. I might now be unnecessarily hospitalized if it weren'tforthe
availability of partial hospitalization services. Instead, partial hospitaluation has enabled me to
fiinction independently in the community. U is my understanding that a drafting enor may lea
the availability of partial hoqntalization services to the discretion of individual health plans.
I urge you to correct this error before the final legislation isreleasedto Congress.
Sincerely,
�11-03-1993 01:24PM
FROM St. finn Day Treatment
TO
12024567739
P. 19
In Magaziner/Mn. Clmton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a patient who is receiving partial hospitalization services, I want you to know h w import
o
it is that partial hospitalization be made available as part of die mental health benefit by all
accountable heallh plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitaKzatioo services. Instead, partial hospitalization has enabled m to
e
function independently in the couummity. It is m understanding that a drafting error m y leav
y
a
the availability of partial hoqritalization services to the discretion of individual health plans.
I urge youio correct this error before thefinallegislation is released to Congress.
�U-03-1993 Biraipn
FROfl St. finn Day Treatment
TO
12024567739
P.20
Ira Magaziner/Mn. Cbnton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a patient who is receiving partial hospitalization services, I want you to know h w impor
o
it is that partial hospitaHzatian be made available as part of the mental health benefit by a
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalizatioo services. Instead, partial hospitalizatiOQ has enabled m t
e
function independently in the community. It is m undemanding that a drafting error m y Jea
y
a
the availability of partial hoqritalization services to the discretion of individual health plans.
I urge you to correct this error before the final legislation isreleasedto Congress.
Sincerely,
�11-03-1993 01:25PM
FROM St. Ann Day Treatment
TO
12024567739
P.21
Ita Magaztocx/Mrc. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a patient who is receiving partial hospitalizatioo services, 1 want you to know h w impor
o
it is that partial hospitalization be made available as part of the mental health benefit by a
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalizatioo services. Instead, partial hospitalizatiao has enabled m to
e
function independently in the community. It is my undenSmding that a drafting enor m y lea
a
the availability of partial hospitalization services to the discretion of individual health plans.
I urge youtocorrect this error before the final legislation is released to Congress.
Shicereli
�11-03-1993 0i:25Pn
FROM St. finn Day Treatment
TO
12024567739
P.22
Ixa Magazinet/Mrs. Clmton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Cfinton:
As a patient who is leoehring partial hospitalization services, I want you to know h w import
o
it is that partial ho^ntaltzadon be made available as part of the mental health benefit by al
accountable health plans. I might now be unnecessarily hospitalized if it weren't (or the
availability of partial hospitalization services. Instead, partial hospitalization has enabled m to
e
function independently in the community. It is m understanding that a drafting error m y leav
y
a
the availability of partial hoqatalizztion services 1 the discretion of individual health plans.
0
I urge youtocorrect this error before the final legislation is released to Congress.
Sincere!}
�11-03-1993 01:25PM
FROM St. Ann Day Treatment
TO
12024567739
P.23
ha Magazincr/Mn. Clmton
The White House
Washington, D.C. 20500
Dear Xa Magaziner/Mrs. Clinton:
z
As a patient who is receiving partial hospitalization services, 1 want you to know h w impor
o
it is that partial ho^ntalhation be made available as part of the mental health benefit by al
accountable health plans. I might n w be omecessarily hospitalized if it weren't for the
o
availability of partial hospitalizatioo services. Instead, partial hospitalization has enabled m t
e
function independently in the community. It is my understanding that a drafting error m y lea
a
the availability of partial hospitalization services to the discretion of individual health plans.
I urge youtocorrect this error before the final legislation is releasedtoCongress.
�11-03-1333 81:26PM
FROM St. Ann Day Treatment
TO
12024567733
P.24
Ira Msgazinet/Mi*. Cb'nton
The White House
Washington, D.C. 20500
Dear Ixa Magaziner/Mrs. CUnmn:
As a patient who is receiving partial hospitalization services, 1 want you to know h w import
o
it is that partial hospitalization be made available as part of the mental health benefit by al
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalization services. Instead, partial hospitalization has enabled m to
e
function independently in the comrmmity. It is my understanding that a drafting error m y te
a
the availability of partial hoqntaiizathm services to the discretion of individual health plans.
I urge you to correct this error
Sincerely,
frg^^
Congress.
�11-03-1993 01:26PM
FROM St. Ann Day Treatment
TO
12024567739
P.25
In Magazinet/Mr*. Cimton
The White House
Washington, D.C. 20500
Dear Xn Magaziner/Mrs. Ctintoo:
As a patient who is leoriving partial hospitalization services, I want you to know h w import
o
it Is that partial hospitalization be made available as pan of the mental health benefit by a
accountable health plans. I might now be unnecessarily hospitalized if it weren'tforthe
availability of partial hospitalizatioo services. Instead, partial hospitalization has enabled m t
e
fcnctkrt independently in the community. It is m understanding that a drafting error m y
y
a
the availability of partial hoqritalization servicestothe discretion of individual health plans.
I urge yon to correct this error before the final legislation is nkased to Congress.
Sincerely,
�11-03-1993 01:27PM
FROM St. Ann Day Treatment
TO
120245S7739
P.26
la Magazioef/Mn. Omton
The White House
Washington, DX. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a patient who is receiving partial hospitalizatioo services, 1 want you to know h w import
o
it is that partial hospitaitzation be made avaflabie as part of the mental health benefit by a
accountable health plans. I might now be unnecessarily hospitalized if it weten*tforthe
availability of partial hospitafizatioo services. Instead, partial hospitalization has enabled m to
e
frmctkm independently in the community. It is my understanding that a drafting error m y kav
a
the availability of partial hoqritalization services to the discretion of individual health plans.
I urge you to correct this error before thefinallegislation is released to Congress.
Sic
�11-03-1993 01:27PM
F O St. Ann Day Treatment
RM
T
O
12024567739
P.27
Ira Magazinef/Mn. Clmton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a patient who is receiving partial hospitalization services, I want you to know how important
it is that partial hoapitaltzadon be m d available as part of the mental health benefit by all
ae
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalization services. Instead, partial hospitalization has enabled me to
function independently in the coaununity. It is my understanding that a drafting error may leave
the availability of partial hoqntalization services to the discretion of individual health plans.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 01:27PM
FROM St. finn Day Treatment
TO
12024567739
P.28
In Magaziner/Mra. Clmtoa
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Ointon:
As a patient who is receiving partial hospitalization services, I want you to know h w importa
o
it is that partial hospitalization be made available as part of the mental health benefit by all
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalizatioo services. Instead, partial hospitalizatioo has enabled m to
e
function independently in the coaununity. It is m understanding Oat a drafting error m y leav
y
a
the availability of partial hospitalization services to the discretion of individual health plans.
I »
«n correct this error before the final legislation is released to Congress.
�U-03-1993 0i:2BPn
FROM St. finn Day Treatment
TO
12024567739
P.29
In Magaziner/Mn. Clinton
The White Howe
Washington, D.C. 20500
Dear In Magaziner/Mrs. Chntnn:
As a patient who isrcoezvingpartial hospitalization services, I want you to know b w importan
o
it is that partial hospitalization be made avaitible as pan of the mental health benefit by al
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalisation services. Instead, partial hospitalization has enabled m to
e
fcnctkm independently in the community. It is m undenftanding thai a drafting error m y le
y
a
the availability of partial hoqntalizattan services to the discretion of individual health plans.
I urge you to
Sincerely,
ion isreleasedto Congress.
�11-03-1993 Bl.-SBPM
FROM St. finn Day Treatment
TO
120245S7739
P.30
In Magazlnftr/Mrs. Clmton
The White House
Washington, D.C. 20500
Dear In Magaziner/Mrs. Clinton;
As a patient who isreceivingpartial hospitalization services, I want you to know how important
it is that partial hoqntaltzatian be made available as part of the mental health benefit by all
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalization services. Instead, partial hospitalization has enabled m to
e
function independently in the coaununity. bis m understanding that a drafting error m y leave
y
a
the availability of partial hoqatallzation services to the discretion of individual health plans.
I urge you to correct this error before the final legislation isreleasedto Congress.
Sincerely,
r
...^jrf^fc
1
1
^
j j s m j
�U-03-1993 0i:29Pn
FROM
S t . Ann Day Treatment
TO
12024567739
P.31
ha Magazinet/Mra. Cfinton
The White House
Washington, D.C. 20500
Dear ha Magaziner/Mrs. CJinton:
As a patient who is receiving partial hospitalization services, I want you to know h w importa
o
it is that partial hospitalizatioa be made available as part of the mental health benefit by a
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalization services. Instead, partial hospitalizatioo has enabled m to
e
function independently in the community. It is m understanding that a drafting error m y leav
y
a
the availability of partial ho^ntalizadon services to the discretion of individual health plans.
I urge you to correct this error before the final legislation is released to Congress.
�11-03-1993 01:29PM
FROM St. Ann Day Treatment
TO
12024567739
P.32
la Magazira/Mn. Clmton
The Whhe House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a patient who is receiving partial hospitalization services, 1 want you to know h w impor
o
it is that partial hospitalization be made available as part of the mental health benefit by a
accountable health plans. I might now be unnecessarUy hospitalized if it weren't for the
availability of partial hospitalizatioo services. Instead, partial hospitalization has enabled tne t
function independently in the eommunlty. It is m understanding that a drafting error m y leav
y
a
the availability of partial hoqritatizztion services to the discretion of individual health plans.
I urge youtocorrect this error before the final legislation isreleasedto Congress.
Sincerely,
<-' .-5
7 J>
�11-03-1993 01:29PM
FROM
St. Ann Day Treatment
TO
12024567739
P.33
Ira Magaziner/Mrs. Clmton
The White House
Washington, D.C. 2(
Dear Ira Magaziner/Mrs. Ctlntim:
As a provider of partial hospitalization services, I want you to know how important it is that
partial hospitalization be made available as part of the medal health benefit by all accountabl
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for th
availability of partial hospitalization services. Instead, partial hospitalization has enabled man
of my patients with serious mental illnesses to function independently Intilecommunity.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation isreleasedto Congress.
Sincerely,
�11-03-1993 0 l : 3 0 P n
FROM
S t . Ann Day Treatment
TO
12024567739
P.34
la Magaziner/Mrs. Clmton
The White House
Washington, D.C. 20500
Dear Ixa Magaziner/Mrs. Clinton:
As a patient who is receiving partial hosprtalizatioo services, I want you to know h w importa
o
it is that partial hospitalization be made available as part of the mental health benefit by all
accountable heallh plans. I might now be unnecessarily hospitalized if it weren'tforthe
availability of partial hospitalizatioo services. Instead, partial hospitalization has enabled m to
e
function independently in the community. It is m understanding that a drafting error m y leave
y
a
the availability of partial hoqritatizatiofl services to the discretion of individual health plans.
I urge you to correct this error before thefinallegislation is released to Congress.
SiocereL
�UHM-ISH
01:389,1
FROn
S t . Ann Day T r e a t m e n t
TO
12024567739
P.35
In MagaziDer/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Chntnn:
As a patient who isreceivingpartial hospitalizatioarervices,1 want you to know how importan
it is that partial hospttaltzadon be made available as part of die mental health benefit by all
acoomitable health plans. I might now be unnecessarily hospitalised if it weren'tforthe
availability of partial hospitalizatioo services. Instead, partial hospitalization has enabled m to
e
fcnction independently in the community. It is m undemanding that a drafting error m y le
y
a
the availability of partial hospitalization servicestodie discretion of individual health plans.
I urge yontocorrect this error before the final legislation isreleasedto Congress.
Sincerelv.
r •*?}, '" ' '"•4" * f
tip
�11-03-1993 01:30PM
FROM St. finn Day Treatment
TO
12024567739
P.36
Ln Magaziner/Mn. Cfritoa
The White Howe
Washington, D.C. 20500
Dear Ixa Magaziner/Mrs. Ointon:
As a patient who is receiving partia) hospitalization services, 1 want you to know h w import
o
it is that partial hoqutalization be made available as part of the mental health benefit by all
accountable health plans. I might now be unnecessarily hospitalized if it weren'tforthe
availability of partial hospitaHzatioD services. Instead, partial hospitalizatioo has enabled m to
e
function independently in the coamrasity. It is my understanding that a drafting error m y leav
a
the availability of partial hoqrit&lization services to the discretion of individual health plans.
I urge you to correct this error before thefinallegislation is released to Congress.
Sincerely,
iiailM
�11-03-1993 0 i : 3 1 P n
FROM
S t . Ann Day Treatment
TO
12024567739
P.37
Ira Magazinef/Mr?. Clmtoa
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clin too:
As a patient who is receiving partial hospitalizatioo services, 1 want you to know how import
it is that partial hospitalization be made available as part of the mental health benefit by al
accountable health plans. I might now be unnecessarily hospitalized if it weren'tforthe
availability of partial hospitalizatioo services. Instead, partial hospitalizatioo has enabled m to
e
function independently in the community. It is my understanding that a drafting error m y leav
a
the availability of partial hoqritalization servicestothe discretxu of individual health plans.
I urge you tn correct this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 01:31PM
FROM St. Ann Day Treatment
TO
12024567739
P.38
Magaziner/Mrs. CBiiton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton :
As a patient who is receiving partial hospitalization services, I want you to know h w importa
o
it is that partial hospitalization be made available as part of the mental health benefit by al
accountable health plans. I might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalizatioo services. Instead, partial hospitalizatioo has enabled m to
e
function independently in the coomiunity. It is m undemanding that a drafting error m y leav
y
a
the availability of partial hospitalization services to the discretion of individual health plans.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 01:32PM
FROM
St. Ann Day Treatment
TO
12024567739
P.39
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know how important it is th
partial hospitalization be made available as part of the mental health benefit by all accounta
health plans. Many of my patients might now be unnecessarily hospitaKzed if it weren't for t
availability of partial hospitalization services. Instead, partial hospitalization has enabled m
a
of my patients with serious mental illnesses to function independently In the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric caie.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
i"
�11-03-1993 01:32PM
FROM
St. Ann Day Treatment
TO
12024567739
P.40
Ira Magaziner/Mrs. Ointon
The White House
Washington, D.C. 2{
Dear Ira Magaziner/Mrs. Ointon:
As a provider of partial hospitalization services, I want you to know how important it is th
partial hospitaluation be made available as part of the meotal health benefit by all accounta
health plans. Many of my patients might now be unnecessarily hospitaKzed if it weren't for
availability of partial hospitalization services. Instead, partial hospitalization has enabled m
a
of my patients with serious mental illnesses to function independently In the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternativetoinpatient psychiatric care.
I urge youtocorrect this error before the final legislation is released to Congress.
Sincerely,
�11-03-1993 01:32PM
FROM
St. Ann Day Treatment
TO
12024567739
P.41
Ira Magaziner/Mrs. Clinton
The White House
Wi
Washington, D.C. •2ij .
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know how important it is
partial hospilalization be made available as part of the mental health benefit by all accoun
health plans. Many of m patients might now be unnecessarily hospitalized if it weren't fo
y
availability of partial hospitalization services. Instead, partial hospitalization has enabled m
a
of m patients with serious mental illnesses to function independently in the community.
y
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I uige you to correct this errar before the final legislation is released to Congress.
Sincerely,
�— - r r .
,
H
U
„
S
t
.
finn
^
ment
TO
12024567739
P.42
& ^ flv^t p i i L U ^ - f ^ ^ , 4 ^ k,..
/W*^
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�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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Paper
Dublin Core
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Title
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[St. Ann Letters] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-009-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/d7c659647b8293eabe79135cf3c5a60a.pdf
36c681affe72404cdfb208792b6a95ab
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1970
FolderlD:
Folder Title:
[Social Policy on Aging] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
10
1
�STATEMENT BY
I R I S E . SAUNDERS
HUNTER COLLEGE SCHOOL OF SOCIAL WORK
SOCIAL POLICY IN THE FIELD OF AGING PROGRAM
TO
SELECT COMMITTEE ON AGING'S SUBCOMMITTEE
ON HUMAN SERVICES
U. S. HOUSE OF REPRESENTATIVES
ON
HEALTH CARE REFORM
THE UNIVERSAL HEALTH CARE ACT OF 1991
THE "RUSSO B I L L "
INTRODUCED BY CONGRESSMAN MARTY RUSSO
JUNE 29, 1992
�STATEMENT OF I R I S E . SAUNDERS
Thank
you Mr. Chairman
and members
o f t h e Subcommittee.
a p p r e c i a t e t h e o p p o r t u n i t y t o p r e s e n t my views a t t h i s
thrust
Act
o f 1991 i n t r o d u c e d by Congressman Marty Russo, as o f f e r i n g
the
best
coverage
testimony
i s on t h e U n i v e r s a l
hearing.
The
will
of this
I
and f i n a n c i n g h e a l t h care
eliminate financial
barriers
Health
reform
t o adequate
plan
Care
which
h e a l t h care f o r
our poor and e l d e r l y .
The
predominant i s s u e s I p l a n t o p r e s e n t t o t h e committee c e n t e r
around
whether
comprehensive
the
"Russo
Bill"
and e n t i t l e m e n t - b a s e d
as
universalistic,
a
health
care
reform
model
would work b e s t , serve t h e needs o f t h e e l d e r l y p o p u l a t i o n b e s t ,
and
offer
t h e most
effective
cost
controls.
I will
open my
d i s c u s s i o n w i t h t h e key f e a t u r e s o f t h e "Russo B i l l " :
GENERAL APPROACH: The "Russo B i l l "
funded,
compulsory
insurance
and
program
t o provide
coverage t o a l l l e g a l
entitle
them
would e s t a b l i s h
program
employer
taxes
would
payroll
comprehensive
residents o f the United
t o a wide range o f medical
h e a l t h b e n e f i t s v/ithout c o - i n s u r a n c e ,
The
be funded
taxes,
a federally
States
and i n s t i t u t i o n a l
co-payments o r d e d u c t i b l e s .
through
increases
health
premiums f o r t h e e l d e r l y ,
i n corporate
and i n d i v i d u a l
and removal o f t h e wage cap on wages s u b j e c t t o Medicare
H o s p i t a l Insurance p a y r o l l t a x .
�PEOPLE
COVERED:
coverage
The program
t o a l l legal
Department
of
residents
health
responsibility
i s designed
o f t h e United
and Human
f o r ensuring
t o provide
Services
t h e enrollment
health
States.
would
The
have t h e
of individuals i n
t h e program a u t o m a t i c a l l y a t b i r t h o r a t t h e t i m e o f i m m i g r a t i o n
i n t o t h e U n i t e d S t a t e s , and f o r i s s u i n g n a t i o n a l h e a l t h
insurance
cards t o a l l e n r o l l e e s .
SCOPE OF BENEFITS: B e n e f i t s covered under t h e p l a n would i n c l u d e :
In-patient
health
services;
provided
law;
for
services;
hospice
by h e a l t h
preventive
disabled
eyeglasses
as
hospital
care
health
care;
services;
and o t h e r
services;
and o t h e r
authorized
drugs
medical
home
services
under
home and community
State
services
and b i o l o g i c a l s ;
or health
care
items
o f t h e Department o f H e a l t h and
Coverage f o r i n - p a t i e n t
would be p r o v i d e d
and c o u n s e l i n g
medical
prescription
determined by t h e S e c r e t a r y
Human S e r v i c e s .
facility
professionals
individuals;
(bifocals);
nursing
mental h e a l t h
services
f o r 45 days and f o r o u t - p a t i e n t psychotherapy
f o r 20 v i s i t s per year.
ADMINISTRATION: The program would be a d m i n i s t e r e d
a t t h e Federal
l e v e l t h r o u g h t h e H e a l t h Care F i n a n c i n g A d m i n i s t r a t i o n . An o f f i c e
would
be e s t a b l i s h e d
i n each
State
t o administer
t h e program
f o r t h a t S t a t e , and S t a t e s would have t h e o p t i o n o f a d m i n i s t e r i n g
the program w i t h i n t h e i r j u r i s d i c t i o n under Federal
On
both
t h e Federal
and S t a t e
levels,
guidelines.
administrators
would
have t h e r e s p o n s i b i l i t y f o r p r e p a r i n g annual h e a l t h care budgets,
2
�including
care
capital
facilities.
National
FINANCING:
Federal
and
t o be made
of
by t h e program
Health
incurred
Premiums
that
of a
on t h e
have t h e
and determine t h e
required
Trust
to
Fund
by t h e o p e r a t i o n
finance the
would
be c r e a t e d
o f t h e insurance
payroll tax currently
P a r t A o f Medicare, l o n g - t e r m
this
would
The T r u s t Fund would c o n t a i n a l l t h e monies
from t h e H o s p i t a l Insurance
by
t h e Department
administrators
revenue
A National
pay t h e c o s t s
program.
f o r health
f o r the c r e a t i o n
t o advise
and S t a t e
amounts
expenditures.
to
provides
expenses
f o r p r e p a r i n g annual budgets t o s p e c i f y t h e l e v e l
expenditures
sources
Board
education
o f t h e program.
responsibility
of
The b i l l
Advisory
implementation
and medical
bill
and funds
by t h e e l d e r l y
i s presently
used t o f i n a n c e
c a r e / h e a l t h care premiums imposed
appropriated
would
deducted
collected
from
be payable
from
Medicare
general
revenues.
a t t h e same amount
Part
"B" coverage
($31.80 m o n t h l y ) .
PAYMENTS TO/STANDARDS FOR PROVIDERS: A l l p r o v i d e r s
services
under
this
program
would
enter
into
o f medical
participation
agreements s i m i l a r t o those r e q u i r e d under Medicare, and payments
received through
t h e p l a n f o r covered s e r v i c e s would be accepted
as payment i n f u l l .
would
Payments t o h o s p i t a l s and n u r s i n g
be made on t h e b a s i s
program.
Payments
professionals
would
to
o f annual
physicians
be based
facilities
budgets approved by t h e
and
other
health
care
on a f e e schedule e s t a b l i s h e d by
3
�the
Department, u s i n g a n a t i o n a l r e l a t i v e value s c a l e .
for
hospice
patient
annual
the
c a r e , home and community-based
hospital
budget,
Payments
s e r v i c e s , and o u t -
s e r v i c e s would be based on e i t h e r an approved
capitation,
o r a f e e schedule
e s t a b l i s h e d by
Department.
EFFECTS ON OTHER GOVERNMENT PROGRAMS:
Medicare,
Medicaid, t h e
F e d e r a l Employees H e a l t h B e n e f i t s program, and v e t e r a n s ' h e a l t h
b e n e f i t s programs would a l l be e l i m i n a t e d .
I r e c o g n i z e t h e s i g n i f i c a n c e o f r e c e n t h e a l t h care p o l l
v/hich
indicate
American
health
that
overwhelmingly
care
system
seniors
findings
that the
them. T h e i r
i s failing
feel
fears are
that
they w i l l
and
home h e a l t h care s e r v i c e s t h e y w i l l r e q u i r e when they become
ill;
that
n o t be a b l e t o a f f o r d t h e h e a l t h c a r e , l o n g - t e r m
they w i l l
c o n d i t i o n ; and they
drugs.
be denied
coverage
due t o a p r i o r
medical
w i l l be pay e s c a l a t i n g c o s t s o f p r e s c r i p t i o n
I t i s my o p i n i o n t h a t
t h e f o l l o w i n g cases touch on the
magnitude o f t h e problems f a c i n g t h e e l d e r l y :
Mrs. Y., a 79 year o l d widow w i t h c a r d i a c and h i g h b l o o d p r e s s u r e
problems,
drain
felt
her c o n f i d e n c e i n our n a t i o n ' s h e a l t h care
away as she read a l e t t e r
for
h e r f o r many y e a r s , which
as
a
patient
restrictions.
fear.
because
This
of
from h e r Doctor
stated
that
consistently
system
who had cared
he had t o drop her
increasing
Medicare
senior's loss o f confidence turned t o r e a l
She spent an e n t i r e day c a l l i n g Doctor a f t e r Doctor a s k i n g
4
�if
he
the
could
high
they
that
take
blood
learned
a
she
Mrs.
Doctor.
a
patient
had
not
taking
Y.
her
found
i f he
needed; but
more
a P h y s i c i a n who
but
she
or
complain
would
coverage
any
"punting"
p a t i e n t s by P h y s i c i a n s who
she
Medicare
prescription,
Medicare
and
medication
she
were
got
as
pressure
that
they
Eventually,
that
her
as
only,
Z.,
age
30,
for
herself
and
is s t i l l
dropping
arthritis,
using
funds
special n u t r i t i o n a l
coverage
and
Mrs.
husband
patients.
that
needs.
Z.
suffer
should
be
sure
searching f o r
Medicare
o f t h e agency's
who
as
said
agreed t o make
spends $2,000. a n n u a l l y on
her
soon
they
Medicare
covered
restrictions
and r e d t a p e , a f f e c t e d t h i s s e n i o r ' s access t o medical
Mrs.
prescribe
care.
prescription
from
drugs
diabetes
allocated
t o meet
and
their
They cannot a f f o r d h e a l t h i n s u r a n c e
i s deeply
concerned t h a t
she
will
not
be
a b l e t o c o n t i n u e t o pay e s c a l a t i n g c o s t s o f m e d i c a t i o n s .
I do not wish t o c i t e a l l o f t h e s t a t i s t i c s from r e c e n t r e s e a r c h
data
( e . g . , from
the N a t i o n a l Center f o r H e a l t h
Statistics
and
the U. S. Senate S p e c i a l Committee on A g i n g ) , but i t i s i m p o r t a n t
that
the
I emphasize
over
is
following:
The
facts
show t h a t a g i n g
of
p o p u l a t i o n c r e a t e s g r e a t e r demands by s e n i o r s f o r p h y s i c i a n
services,
the
the
65
hospital
(12%
country's
growing
at
$738.2 b i l l i o n
of
facilities
prescription
drugs.
t h e p o p u l a t i o n ) account f o r over
total
an
and
personal
alarming
dollars
health
rate;
i n 1991,
costs
care
t o p r o j e c t i o n of
5
o n e - t h i r d of
expenditures
increased
People
by
9.6%
$809.
which
from
billion
�dollars
i n 1992.
significant
At
health
the current
reform
rate
measures,
of growth,
costs
without
are projected
to
s k y r o c k e t t o $1.6 t r i l l i o n d o l l a r s by t h e year 2000.
A r e v i e w o f t h e t h r e e main groups o f h e a l t h care r e f o r m p r o p o s a l s
advanced
i n Congress, and a l o o k a t t h e i r
advantages
of
and disadvantages
the elderly,
i n meeting
underscores
my
diverse
approaches,
the health
rationale
care
f o r support
needs
of the
"Russo B i l l " :
0
1
GOVERNMENT SPONSORED (SINGLE-PAYER) e.g. THE "RUSSO B I L L "
will
I
n o t go i n t o
have
included
nationwide
Federal
It
and
Its
t h e "Russo B i l l "
statement.
f o r a health
opinion that
completely
a
single
strengths
seniors,
t o discuss
I t basically
proposes
i n s u r a n c e program w i t h t h e
i t i s a more
substantial
eliminating
the private
mechanisms
o f Medicare
federally
administered
l i e i n immediate
access
preventive,
to
a l l basic
p r i m a r y , acute
Physicians or others.
bills.
system-wide
insurance
industry
and Medicaid
insurance
insurance
coverage
services
and
program.
including
for
a l l
quality
and mandated l o n g - t e r m care w i t h o u t
o u t - o f - p o c k e t expenses, co-payment, c o - i n s u r a n c e
from
which
government as t h e s i n g l e - p a y e r o f most medical
the financing
creating
i n my
eligibility
i s my
reform,
detail
or extra
Data from t h e Congressional
bills
Budget
O f f i c e ' s N a t i o n a l H e a l t h E x p e n d i t u r e Accounts r e p o r t shov/s t h a t
the
"Russo
Bill"
i s the only plan with
6
a potential
f o r cost
�control
as i t e l i m i n a t e s a d m i n i s t r a t i v e
v/aste
inherent i n
the
c u r r e n t m u l t i - p a y e r system.
o
EMPLOYER-BASED
plan
f o r employer
care,
or
whereby
pay
needs
the
plan
elderly
p r e s c r i p t i o n drugs.
PLAY")
proposes
f o r basic
either
t o finance
of this
of
OR
liability
employers
taxes
limitations
("PAY
an
benefits
a multi-payer
and p r e v e n t i v e
provide insurance
f o r employees
alternate
system.
are that
public
coverage
f o r long-term
excludes
care
and
The
critical
out-patient
There a r e co-payments and d e d u c t i b l e s which
t e n d t o d i s c o u r a g e s e n i o r s ' e a r l y use o f h e a l t h s e r v i c e s .
o
PRIVATE
COMPREHENSIVE
affordable
(MARKET-BASED REFORM)
HEALTH
REFORM
insurance
purchase
a
basic
reduction
by major
administrative
through
reforms;
and
strategy
i s seriously
favoring
rather
expands
coverage.
ill
Details
actual
t o address c r i t i c a l
to
cost
by r e d u c i n g
i n government
i s that
this tax
of the tax c r e d i t are
i s on t a x breaks
purchase
o f insurance,
coverage.
b u t does n o t r e q u i r e t h a t
I tfails
waste
t h e focus
insurance
access
insurance
growth
position
c l a s s t o encourage
providing
access,
flawed.
My
b u t i t appears t h a t
t h e middle
than
cutting
to
(certificate)
package;
controlling
PRESIDENT'S
proposes
tax credit
market
(Medicare/Medicaid).
sketchy,
a
insurance
programs
still
PROGRAM
health
costs;
e. g. THE
The
bill
a l l Americans
have
concerns o f c h r o n i c a l l y
o r d i s a b l e d s e n i o r s f o r l o n g term i n s u r a n c e t o cover n u r s i n g
home o r home h e a l t h c a r e , and f o r o u t - p a t i e n t p r e s c r i p t i o n d r u g s .
7
�Issues
o f co-payments, d e d u c t i b l e s ,
major f i n a n c i n g
CONCLUSION:
I restate
sources a r e not
I feel
that
out-of-pocket
addressed.
i t i s o f t h e utmost
importance
and re-emphasize my staunch p o s i t i o n t h a t
restructuring
of the health
care
system
e l d e r l y , c e n t e r s around t h r e e e s s e n t i a l
o
expenses and
which
that
fundamental
impacts
on t h e
goals:
P r o v i d i n g access t o h e a l t h care f o r our e l d e r l y and a l l
Americans
o
Cost
cost
0
containment
controls
Improving
of health
the q u a l i t y
care
inflation
of health
care
by e f f e c t i v e
f o r our e l d e r l y
citizens
1
are
am p a r t i c u l a r l y
concerned t h a t h e a l t h
w o r r i e d about t h e u n l i k e l i h o o d
care program i n 1992,
who
are struggling
very vulnerable.
issues
and
of enacting a national
because I r e c o g n i z e t h a t the f r a i l
with
both
economic
and h e a l t h
they
health
elderly
problems a r e
More o f these s e n i o r s a r e p l a c e d a t r i s k when
o f co-payments d i s c o u r a g e
increase
care e x p e r t s s t a t e
the likelihood
unnecessary and/or e a r l y
early
of
use o f h e a l t h
costly
services
h o s p i t a l i z a t i o n and
institutionalization.
I am,
therefore,
making an appeal f o r t h e "Russo B i l l " , which i s a r a d i c a l change
from o u r c u r r e n t
One
-
system, based on the
Recognition
that
8
following:
insurance
coverage
would be
�expanded
most
under
a
universalistic,
public
insurance plan
v/hich would t r a n s f e r r e s o u r c e s t o h i g h e r r i s k , low income groups,
especially senior c i t i z e n s .
o
Two
-
The e l d e r l y a r e i n d i r e need o f comprehensive
medical/health services, including preventive, primary, h o s p i t a l ,
long-term,
home-health
care,
prescription
d r u g s , eye,
dental,
and mental h e a l t h which a r e a t t h e core o f t h e "Russo B i l l " .
o
Three
under
the
health
or
employment
plan
status,
without
and
regard
no
t o age,
payments
income,
of
deductibles,
of
the
or co-insurance.
Four
mechanism
The mechanism f o r coverage o f a l l c i t i z e n s
comprehensive
co-payments
o
-
of
the
The
fiscal
viability
F e d e r a l government
as
payment
the single-payer;
and
o f a d m i n i s t r a t i v e waste
that
no balance b i l l i n g t o t h e consumer.
o
Five
exists
to
under
point
the
Elimination
current
m u l t i - p a y m e n t system.
o u t t o t h e committee t h a t
financial
crisis
same
financial
that
we
that
will
i n the Federal,
problem,
must a c t now
eliminate
i s one
State
f o r our poor and e l d e r l y .
like
a l l t o o aware of the
and C i t y
o f t h e most
to establish
financial
I am
I would
levels.
important
This
reasons
a n a t i o n a l h e a l t h care plan
barriers
t o adequate h e a l t h
care
�My
paramount concern
of
full-scale
i s t h a t t h e e l d e r l y u r g e n t l y need a program
health
care
reform
to
meet
their
need
for
a f f o r d a b l e , q u a l i t y , comprehensive h e a l t h care s e r v i c e s .
Therefore,
I
wholeheartedly
Congressional
support
package
blends
"Russo
the
p l a n s t h a t have been o f f e r e d .
We
must do
human
rights
that
protects
make u n i v e r s a l
basic
h e a l t h care a r e a l i t y
and
Bill"
of
bill
the
the
best
a
that
of
recommend
as
strongly
the
legislative
alternative
a l l we
health
can
to health
i n 1993
urge
care
t o favor
care,
and
f o r a l l Americans.
I t i s e s t i m a t e d t h a t a d o p t i o n o f t h i s p r o p o s a l c o u l d c u t American
health
care
senior
citizens,
it;
spending
by
deserve
billions
of d o l l a r s !
i t ; the
health
The
care
people,
crisis
our
demands
and our a b i l i t y t o be c o m p e t i t i v e i n the 21st c e n t u r y depends
on i t !
I look forward w i t h great a n t i c i p a t i o n t h a t the Universal Health
Care Act o f 1991
forward
into
in this
- t h e "Russo B i l l "
Congress, and
that
# H. R.
this
1 300 w i l l
bill
will
be
be moved
enacted
legislation.
Again,
I thank t h e committee
views w i t h you. Thank you Mr.
f o r t h e o p p o r t u n i t y t o share
Chairman.
10
these
�APPLICATION FOR ADMISSION TO THE DOCTORAL PROGRAM
THE GRADUATE SCHOOL AND UNIVERSITY CENTER
OF THE CITY UNIVERSITY OF NEW YORK
APPLICANT'S STATEMENT: I R I S E. SAUNDERS
As
an
undergraduate
and
Pre-law
and
I attended
after
were
Department o f
to
Hunter
focused
on
a career
Social
of
to
and
to
assumed
vocational
as
children,
greater
to
C i t y of
the
enhance
my
the
and
frail
as
to
attend
areas
Economics
an
attorney
years.
However,
worker a t
I
field
of
the
the
refocused
services
scholarship
from
the
College
were
the
and
s o c i a l p o l i c y issues
my
field
placement
trainee
and
an a l t e r n a t i v e
services
for alcoholics
f o r t h e homeless. I was
in interacting
management and
grant
for
of
predominant
Social
issues
a f f e c t i n g the e l d e r l y .
at
the
as
with
the
on
managers
Aging
Work,
of
As
(AoA)
rny
health
D i v i s i o n of
key
care
disease)
I undertook
caseworker/counselor
Bellevue
1
able
training.
minority
Administration
School
assignment
director
as
p h y s i c a l h e a l t h (dementia, Alzheimer's
and
administrative
mentally
programs, home care
disabled
AIDS s e r v i c e s ,
Aging
interest
reform, mental,
a
Hunter
the
supervisor
human r e l a t i o n s s k i l l s
r e c i p i e n t of
of
as
York,
rehabilitation
c l i e n t p o p u l a t i o n and w i t h s t a f f i n
the
New
e l d e r l y , and
e l d e r l y and
substance abusers and
in
goal
a social service
responsibilities
institutionalization,
a
majors o f
As my e x p e r i e n c e and knowledge broadened,
employment, t r a i n i n g
As
my
p l a n on the f i e l d o f human s e r v i c e s , i n c l u d i n g s e r v i c e s
f a m i l i e s and
services
my
Services,
p h y s i c a l l y challenged.
I
on
College,
lav; school on a s c h o l a r s h i p f o r
embarking
my c a r e e r
at
and
Alcoholism
�and
of
Substance
Abuse
t h e New York
acutely
aware
Services,
City
Department
o f t h e need
homelessness,
alcoholism
services.
found
I
research,
to
v/ork
i n order
"Honors"
and
I
with
a
and
"Professional
in
extensive
and
r e a d i n g and
the practice s k i l l s
required
very
challenging
population of
I
abusers.
(total
of
Behavior
t h e grade o f
received
Human
the elective
Seminar"
i n t h e areas
Human
i n a l l o f t h e Casework,
sequences
I became
abuse s e r v i c e s and AIDS
had t o do
t o develop
substance
Services,
f o r expertise
f o r t h e Casework
effectively
alcoholics
of Social
and substance
that
especially
sequences,
Human Resources A d m i n i s t r a t i o n
Behavior,
"Substance
Honors
Field
Abuse"
grades,
40
Work
and i n
credits
of
61 c r e d i t s ) .
My
field
placement
experience,
planning
which
and g o a l
long-range
setting
family
placement year,
from
included
histories
dysfunctional
successful
assignment
of
was a very
basically
with
alcohol
and
By
my two p r i m a r y c l i e n t s
i n achieving
a l c o h o l and drugs,
casework
intensive
backgrounds.
their
learning
counseling,
homeless males w i t h
poly-drug
abuse
t h e end o f my
and
field
were m o b i l i z e d and were
short-term
and t h e i r
valuable
long-term
goal
of
abstinence
goals o f s o b r i e t y ,
e d u c a t i o n , employment as w e l l as r e i n t e g r a t i o n i n t o t h e community
for
independent
living.
I followed-up
w i t h these
clients
after
t h e i r s u c c e s s f u l c o m p l e t i o n o f t h e s h e l t e r r e h a b i l i t a t i o n program
and t h e i r achievement o f " a l u m n i " s t a t u s .
�As
rny
administrative project,
After-Care
System
questionnaire,
continuum
designed
of
the
the
was
included
to
service
Agency's
by
which
I
fill
model.
assigned
a
the
proposal
gap
This
Division
of
which
and
and
an
"alumni"
system
has
Alcoholism
develop
e x i s t e d i n the
After-Care
a d m i n i s t r a t i v e approval
Bellevue
to
been
and
received
implemented
Substance
Abuse
S e r v i c e s . I s o l i c i t e d my c l i e n t s ' p a r t i c i p a t i o n i n t h e A f t e r - C a r e
Program and they were r e g i s t e r e d as
Based
on
Shelter
I
my
and
practice
my
work.
to
My
review
of
relapse
by
on
Prevention"
study
existing
in
abuse
my
effective
in
preventing
and
the
Social
My
knowledge
in-depth
serious
Work
analysis
Bellevue
to
agencies.
was
attention
the
implications
and
from
investigate
determined
professional staff
The
research
are
that
and
drug
question
are
abuse
the
and
Technology"
and
need
significant
in
most
efforts
overwhelming
very
of
the s p e c i a l i z e d
research
education
Prevention
3
current
to
for
alcohol
"Relapse
this
Seminar
prevention
strategies
My
Viable
practice
"What
relapse?"
A
analyze
relapse
clinical
e x p l o r a t i o n of
regarding
of
in
to
Men's
course,
Professional
research,
prevention
my
Technology:
my
of
and
investigation
relapse
further
the
undertaken
treatment
and
brought
for
interviews with
treatment
findings
was
treatment
researcher
guided
at
Prevention
current l i t e r a t u r e
substance
which
"Relapse
Relapse
prevention
this
six
topic
research
information
experience
study o f substance abuse i n t h e e l e c t i v e
s e l e c t e d the
Approach
and
"alumni".
for
area,
field
of
treatment.
and
its
�restructuring
from
other
techniques
treatment
r e l a p s e p r e v e n t i o n as
d i s t i n g u i s h e d hov/ i t v/orks
modalities
and
highlighted
differently
relapse
a core problem f o r r e s e a r c h and
and
treatment
i n substance abuse. I am i n t e r e s t e d i n s u b m i t t i n g my p r o f e s s i o n a l
seminar
v/ork f o r p u b l i c a t i o n i n a j o u r n a l , and most i m p o r t a n t l y
i n p u r s u i n g e x t e n s i v e r e s e a r c h i n t h e D o c t o r a l program on
and
relapse prevention w i t h a goal of
relapse
c o n t r i b u t i n g t o the
field
by p r o d u c i n g a major work on r e l a p s e and r e l a p s e p r e v e n t i o n .
Based
on
"Social
School
the
Policy
of
recommendation
in
Social
Congressman M a r t i n
Bill"
on
this
the
Work,
I
my
of
Field
professor
Aging"
at
submitted
Russo (D. 111.)
universal health
paper t o Mrs.
of
care
my
who
the
the
Hunter
course
College
paper/testimony
had
reform.
I recently
heads
submitted
President
C l i n t o n ' s t a s k f o r c e on h e a l t h care r e f o r m , and forwarded
t o my
Congressman Charles
A.
a v o c a t i o n a l and
t o S t a t e Senator,
copies
David
Paterson.
My
B. Rangel and
to
proposed t h e "Russo
Rodham C l i n t o n who
Hillary
for
on
community
volunteer
issues
importance,
including
children,
college
that
development
community
of
I
scholarship
a
have focused
consider
educational
grantsmanship w r i t i n g and
for
activities
to
grants
be
to
grants
of
primarily
paramount
under-privileged
for
minorities,
d i r e c t i n g a major fund r a i s i n g
boys
and
socio-economic a r e a .
awards from t h e U n i t e d Negro
girls
club
in a
disadvantaged
I received volunteer
C o l l e g e Fund and
4
effort
t h e M.
leadership
L>.
Wilson
�Boys
and G i r l s
s e r v i c e by
of
Professional
would
view
Profile";
Council;
f o r community
like
v/ork
o f "Who's
Who i n
Women" p u b l i s h e d by t h e U n i v e r s i t y
and i n t h e 1993 e d i t i o n
o f Marquis
"Who's
Women".
to direct
t o research,
written
and r e c o g n i t i o n
t h e 1987 e d i t i o n
and E x e c u t i v e
Who I n American
I
o f Harlem,
"New York Newsday" i n t h e i r March 27, 1992 e d i t i o n
"Manhattan
Research
Club
which
t h e focus o f my d o c t o r a l
teaching, lecturing
would
make
and
a substantial
study v/ith a
producing
a major
contribution
to
the g e n e r a l knowledge p r i m a r i l y i n t h e f i e l d o f substance abuse.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Social Policy on Aging] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-008-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/ea0d6e2063e5b190a411b4255aa1c1e0.pdf
1821483a4e8bacf33af331fe147ba0e3
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1337
OA/ID Number:
FolderlD:
Folder Title:
[Saint Albans Letter] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
6
1
�11/03/93
14:38
©703
633 4558
ST ALBANS
mML
FACSIMILE COMMUNICATION
j b ^ ^ L ^ f P
I
rSUChlOtriC H O S O i t Q l
1
DATE
"Ai
(In Virginia) 1-800-572-3120
(Outside Virginia) 1 -800-368-3468
FAX No. 703-633-1767
300
-
- 7
739
Please deliver to _
Sent from
IgLj./J
Ext.
Total number of pages sent (including this cover sheet)
^^S3^>
3
FAX NUMBER 703-633-1767
If you do not receive the total number of pages listed above, or if there is a problem with this transmission, please call the person
.sending this message.)
Message or comments
St. Albans Psychiatric Hospital
P.O. Box 3608
Radford, VA 24143
�11/03/93
14:38
©703 633 4558
ST ALBANS
1^1002
Letter from staff:
Ira Magaziner/Mrs. Clinton
The White Home
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
- Ai a pruvider of partial hospitalization services, I want you to know how impoitanl it is that
partial hospitaJization be made available as part of the mental health benefit by all accountable
health planj. Many of m patients might now be unnecessarily hospitalized if it weren't for the
y
availability of partial hospitalization services. Instead, partial hospitalization has enabled many
of my patients with serious mental -illnesses to function independently in the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
p. o . ^ b * .
O^Cg —
�11/03/93
14:39
©703 633 4558
ST ALBANS
Letter from Staff:
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear In Magaziner/Mrs. Clinton:
N
A J a provider of partial hospitalization services, I want you to know how nnportam it is that
partial hospitalization be made available as part of the mental health benefit by all accountable
health plans. Many of my patients might now be unnecessarily hospitalized if it weren't for the
availability of partial hospitalization services. Instead, partial hospitalization has enabled m n
ay
of my patients with serious mental illnesses to function independently in the community.
Further, as a provider, I can attest to the cost-effectiveness of partial hospitaJization as an
alternative to inpatient psychiatric care.
I urge you to correct this error before thefinallegislation is released to Congress.
Sincerely,
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Saint Albans Letter] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-007-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/5bf84a6c0c6aa5e5a75c452f52ba5c7e.pdf
c313c0012b90784de8c98643dd8bdb1b
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1978
FolderlD:
Folder Title:
[Reproductive Health Hazards in the Workplace: Policy Options for California] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
1
3
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Reproductive Health Hazards in the Workplace: Policy Options for California] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-006-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/787a4bc236e10c263703265019589e9b.pdf
2301f58f4233a5a34c42d64d2d9280b0
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1967
FolderlD:
Folder Title:
[Public Policy] [loose]
Stack:
Row:
S
56
Section:
1
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Position:
9
1
�SCHOOL OF PUBLIC POLICY AND MANAGEMENT
THE OHIO STATE UNIVERSITY
CAUSING THE SECOND PKU SPECIMEN TO
BE COLLECTED: AN ASSESSMENT OF AND
RECOMMENDATIONS FOR OHIO'S NEONATAL
SCREENING PROGRAM
BY
LYNN MARIE OGDEN
WINTER, 1993
A POLICY PAPER SUBMITTED I N PARTIAL FULFILLMENT
FOR THE MASTER OF PUBLIC ADMINISTRATION DEGREE
Approved by
DR. SVEN B. LUNDSTEDT
FACULTY ADVISOR
DATE
�TABLE OF CONTENTS
I.
ACKNOWLEDGEMENTS
1
II.
EXECUTIVE SUMMARY
2
III.
PREFACE
5
IV.
INTRODUCTION
Definitons
Symptoms i f U n t r e a t e d
H i s t o r y o f PKU
Screening H i s t o r y
Legal H i s t o r y
THE PROBLEM
Second Specimen R a i t o n a l e
6
6
7
8
8
10
12
12
V.
METHODOLOGIES
14
VI.
FINDINGS
19
Observaional Findings
An A c t u a l Case?
Anecdotal Findings
Interviews
Why MUST My Newborn Be Screened?
Newborn Screening Lab
The A c c o u n t i n g U n i t
20
20
23
23
26
Q u e s t i o n n a i r e Responses
Data Reduction
Table 1 B i r t h i n g Centers' Discharge H a b i t s
F i g u r e 1 Neonatal H e a l t h Care System Dropouts?
Table 2 D o c t o r s ' I n - h o s p i t a l E d u c a t i o n o f New Moms
Table 3 O f f i c e T r a c k i n g System
Table 4 Doctor P r o f i l e
Table 5 E a r l y Discharged Mom P r o f i l e
Table 6 Comments
VII.
19
20
29
29
30
31
34
36
39
42
45
CONCLUSIONS
48
V I I I . RECOMMENDATIONS
49
IX.
FUTURE RESEARCH
55
X.
CITATIONS
57
XI.
BIBLIOGRAPHY
60
XII.
INTERVIEWS
63
�X I I I . APPENDICES
Letter of Authorization
Phenylalanine (PHE) Content o f Some Foods
Autosomal Recessive Inheritance
Newborn Screening Law
Newborn Screening Rules and Regulations
Quesionnaire and Cover L e t t e r
PKU Specimen Card
Why MUST My Newborn Be Screened
A
B
C
D
E
F
G
H
�I . ACKNOWLEDGEMENTS
I would l i k e t o take t h i s o p p o r t u n i t y t o thank:
Sven B. Lundstedt, Ph.D., Faculty Advisor, The Ohio State
U n i v e r s i t y School o f Public Policy and Management
Beth S. Hunker, Ph.D., W r i t i n g Advisor, The Ohio State
U n i v e r s i t y School o f Public Policy and Management
Kathleen Meckstroth, Ph.D., Agency Advisor, Ohio Department
Of Health Laboratory D i r e c t o r
Leonard J. Porter, M.S., Newborn Screening Laboratory
Supervisor
Charles L. L i t t l e , M.S., Newborn Screening Laboratory
Supervisor
f o r t h e i r time, support, a i d , and assistance.
I would e s p e c i a l l y l i k e t o thank Michael W McCreary f o r h i s
.
countless hours a t the t y p e w r i t e r .
�II.
Phenylketonuria
EXECUTIVE SUMMARY
(PKU) i s an i n h e r i t e d m e t a b o l i c d i s o r d e r .
P h e n y l a l a n i n e and t y r o s i n e a r e amino a c i d s . Amino a c i d s a r e
b u i l d i n g blocks o f proteins.
Persons w i t h PKU, p h e n y l k e t o n u r i c s ,
have i n h e r i t e d an i n a b i l i t y t o produce a s p e c i f i c enzyme. I n
g e n e r a l , an enzyme h e l p s t r a n s f o r m a c e r t a i n substance i n t o
a n o t h e r substance.
hydroxylase
Those w i t h PKU l a c k t h e enzyme p h e n y l a l a n i n e
(PH). PH h e l p s change p h e n y l a l a n i n e i n t o t y r o s i n e .
Thus, when a p h e n y l k e t o n u r i c i n g e s t s p h e n y l a l a n i n e , an amino
a c i d found i n such p r o t e i n r i c h foods as m i l k , f i s h , eggs,
cheese, meat, and foods and beverages sweetened w i t h
Nutrasweet,
t h e p h e n y l a l a n i n e i s n o t changed i n t o t y r o s i n e . I n s t e a d
p h e n y l a l a n i n e b u i l d s up i n t h e b l o o d . P h e n y l a l a n i n e
continue t o r i s e unless t h e c o n d i t i o n
levels
i s d e t e c t e d and t r e a t e d .
Treatment i n v o l v e s a l i f e t i m e d i e t t h a t i s e x t r e m e l y low i n
p h e n y l a l a n i n e . U n t r e a t e d p h e n y l k e t o n u r i c s have severe
mental
retardation.
At b i r t h , p h e n y l k e t o n u r i c s e x h i b i t no o b s e r v a b l e symptoms.
When a c h i l d w i t h PKU m a n i f e s t s mental r e t a r d a t i o n , around mid
infancy,
changing
t h e d i e t w i l l not reverse t h e r e t a r d a t i o n . I n
t h e e a r l y 1960's an easy, r a p i d , a c c u r a t e and i n e x p e n s i v e t e s t i n g
method was developed
t h a t allowed f o r t h e d e t e c t i o n o f
p h e n y l a l a n i n e i n t h e b l o o d o f neonates. Ohio f i r s t passed a
newborn s c r e e n i n g law i n 1966.
The law has been changed over t h e
years t o i n c o r p o r a t e t e s t i n g f o r o t h e r i n h e r i t e d m e t a b o l i c
disorders:
homocystinuria, galactosemia,
hypothyroidism,
hemoglobinopathies.
Before i n f a n t s a r e d i s c h a r g e d from t h e h o s p i t a l , t h e PKU
�specimen i s c o l l e c t e d . A l l specimens a r e sent t o t h e Newborn
S c r e e n i n g L a b o r a t o r y i n Columbus f o r t e s t i n g . P u b l i c H e a l t h
C o u n c i l r u l e s s t a t e t h a t i f a c h i l d ' s PKU specimen was c o l l e c t e d
b e f o r e age 48 hours, t h e n t h e baby's a t t e n d i n g
physician shall
cause a second specimen t o be c o l l e c t e d when t h e i n f a n t i s
between 48 hours and 2 weeks o f age.
I d e v i s e d a q u e s t i o n n a i r e and sent t h a t and a cover l e t t e r
t o one-hundred and t w e n t y randomly s e l e c t e d
system a c t o r s were i n t e r v i e w e d
pediatricians.
Other
over t h e t e l e p h o n e . A d e s c r i p t i o n
of what happens i n t h e l a b o r a t o r y
i s included.
F r e q u e n t l y , second
PKU t e s t s a r e c o l l e c t e d a t t h e h o s p i t a l o f b i r t h , a t d o c t o r ' s
offices or c l i n i c s ,
The
o r a t t h e c h i l d ' s home by v i s i t i n g nurses.
f o l l o w i n g c o n c l u s i o n s a r e based on my d a t a . I n Ohio,
t h e r e a r e 165,000 b i r t h s p e r year. Surveys and o b s e r v a t i o n s
i n d i c a t e d t h a t o f those 165,000 between 50,000 and 66,000 i n f a n t s
were d i s c h a r g e d from t h e h o s p i t a l b e f o r e age 48 hours. Between
20,000 and 40,000 babies d i d n o t have a second PKU specimen
c o l l e c t e d . There i s a problem.
There i s a language mismatch between t h e p h y s i c i a n s and
t h e i r p a t i e n t s . There i s vague w o r d i n g i n d e p a r t m e n t a l
literature
especially
"Why Must My Newborn Be Screened?" F i n a l l y , a f u l l y
operational
computerized t r a c k i n g system i s l a c k i n g .
Neonatal s c r e e n i n g f o r PKU i s a subsystem o f t h e h e a l t h
system. P e d i a t r i c i a n s
care
a r e one v i t a l l i n k i n t h e c h a i n . A l l o f us
have a s t a k e i n t h e d e l i v e r y o f h e a l t h care s e r v i c e s .
n e o n a t a l s c r e e n i n g system f u n c t i o n s
optimally,
When t h e
r e p e a t PKU
speci-
mens w i l l be c o l l e c t e d . To t h a t end I propose t h e f o l l o w i n g
�recommendations.
* Develop a physician awareness program t h a t h i g h l i g h t s : the
scope of the problem, and the language/culture gap between
primary health care providers and p a t i e n t s .
* Develop a program t o heighten p u b l i c awareness o f the PKU
t e s t procedure, r a t i o n a l e , and a v a i l a b i l i t y i n the p u b l i c ' s
n a t i v e language(s).
* Develop a more i n t e n s i v e educational program f o r pregnant
women and new mothers i n t h e i r n a t i v e language(s).
* Increase t e s t a v a i l a b i l i t y through c r e a t i v e use o f a l l
resources.
* I n s t i t u t e a system-wide computerized t r a c k i n g system.
* Hospitals should stop sending PKU cards home w i t h mom and
baby a t time o f discharge.
* I n s t a l l computer hardware and software t h a t a l l employees
i n Newborn Screening can use no matter how d i f f e r e n t l y
abled we are.
* Immediately change the wording on page 2 of "Why Must My
Newborn Be Screened?" from " I f your baby goes home from the
h o s p i t a l before 48 hours the t e s t may need t o be done
again." t o read "the t e s t MUST be done again."
�I I I . PREFACE
I am employed by the Ohio Department of Health as the l a b
coordinator i n Newborn Screening. Our u n i t does very important
work. We are mandated by the Ohio l e g i s l a t u r e t o t e s t the blood
of each i n f a n t born i n the state f o r phenylketonuria (PKU). We
employ a c e r t a i n methodology t h a t allows us t o measure the l e v e l
of phenylalanine, an amino acid, i n an i n f a n t ' s blood.
We are the d e t e c t i o n phase. Detection i s the f i r s t step i n
treatment. Untreated PKU causes mental r e t a r d a t i o n .
Frankly, I f i n d my work e x c i t i n g . I l i k e t a l k i n g w i t h people
about what I do. I enjoy being part of the health care system. I
t h i n k we make a d i f f e r e n c e .
Working on t h i s paper gave me a chance t o learn what t e s t i n g
f o r PKU i s about s p e c i f i c a l l y and g l o b a l l y . This paper i s my
opportunity t o heighten your awareness, peak your c u r i o s i t y ,
inform, e n t e r t a i n and educate you so t h a t we may a l l understand.
Understanding i s i n t e g r a l t o making a d i f f e r e n c e .
an opportunity t o a i d understanding.
This paper i s
�IV. INTRODUCTION
Definitions
I n b o l d p r i n t , on t h e back panel o f t h e c o n t a i n e r o f any
food o r beverage sweetened w i t h Nutrasweet, i s t h e f o l l o w i n g :
•PHENYLKETONURICS:CONTAINS PHENYLALANINE ( F e d e r a l R e g i s t e r , 7-26-
74, 7-24-81, 7-8-83). Who a r e p h e n y l k e t o n u r i c s ? Why s h o u l d
o r we be concerned about p h e n y l a l a n i n e ?
they
How do we f i n d
p h e n y l k e t o n u r i c s ? I s t h e r e a n y t h i n g we c o u l d o r s h o u l d do t o h e l p
them? P h e n y l a l a n i n e
and t y r o s i n e a r e amino a c i d s o r b u i l d i n g
b l o c k s o f p r o t e i n s . P h e n y l k e t o n u r i c s a r e people w i t h
phenylketonuria
(PKU). PKU i s an autosomal r e c e s s i v e
inherited
i n b o r n e r r o r o f metabolism due t o a d i s t u r b a n c e i n t h e
p h e n y l a l a n i n e h y d r o x y l a t i n g system. T h i s d i s t u r b a n c e i s due t o a
l a c k o f t h e enzyme p h e n y l a l a n i n e h y d r o x y l a s e
(PH) which p r e v e n t s
t h e normal metabolism o r t r a n s f o r m a t i o n o f p h e n y l a l a n i n e t o
t y r o s i n e , g i v i n g r i s e t o high phenylalanine levels
1989).
(Simpson,
People w i t h PKU e x h i b i t no symptoms a t b i r t h .
P h e n y l k e t o n u r i c s , u n l e s s t r e a t e d , w i l l have mental r e t a r d a t i o n by
mid i n f a n c y (Tiwary, 1987). Treatment c o n s i s t s o f a d i e t low i n
phenylalanine.
Phenylalanine
(PHE) i s one o f o u r e i g h t e s s e n t i a l amino
a c i d s , o r b u i l d i n g b l o c k s t h a t t h e body needs f o r f u r t h e r p r o t e i n
s y n t h e s i s . P r o t e i n s y n t h e s i s i s t h e process t h a t a l l o w s f o r
p r o p e r development and growth o f t h e b r a i n and body (Simpson,
1989). The body does n o t manufacture PHE, t h e r e f o r e t h e amino
a c i d must be i n g e s t e d . Foods such as m i l k , cheese, meat, eggs,
and
f i s h a r e r i c h i n PHE. (Appendix B). Nutrasweet o r aspartame
�sweetened foods and beverages are another source of
PHE.
Aspartame i s a d i p e p t i d e or two amino acids bonded together. PHE
i s one of the amino acids which comprise aspartame (Stegink, 1987)
For a non phenylketonuric i n d i v i d u a l the Recommenced Daily
Allowance (RDA)
of p r o t e i n ( i n c l u d i n g PHE)
a f t e r i n g e s t i n g t h a t amount of p r o t e i n PHE
i s 50 grams. Even
l e v e l s w i l l be main-
t a i n e d , by the a c t i o n of phenylalanine hydroxylase on the PHE,
at
a l e v e l of less than 1 mg/dl. This i s a normal PHE concentration
f o r a non phenylketonuric (Berry, p r i v a t e conversation, 1993).
For a phenylketonuric, the allowed d a i l y intake of PHE i s
3 00-500 mg. A blood PHE
l e v e l between 3 and 8 mg/dl i s normal f o r
a person w i t h PKU.This l e v e l prevents b r a i n damage and keeps the
body from d i g e s t i n g
itself.
Phenylalanine hydroxylase (PH) i s a l i v e r enzyme and i s
responsible f o r converting phenylalanine t o t y r o s i n e (Mabry,
1990). Just as our genes are responsible f o r our eye c o l o r , so
too does the code determine whether or not we have PH i n the
l i v e r (Appendix C). The l i v e r must be biopsied t o "see"
PH.
Without the enzyme, phenylalanine i s not converted t o t y r o s i n e .
PHE concentrations increase r a p i d l y .
Symptoms I f Untreated
I f an i n f a n t ' s PHE
l e v e l i s greater than or equal t o 30
mg/dl f o r extended periods of time, e s s e n t i a l l y untreated
PKU,
then around mid infancy symptoms appear. Usual symptoms, none of
which are present a t b i r t h , are i r r e v e r s i b l e mental r e t a r d a t i o n ,
general i r r i t a b i l i t y , vomiting, an odor described as "mousy" or
"musty", f a i r - s k i n n e d and f a i r haired w i t h blue eyes, an eczema
�t y p e s k i n r a s h , b e h a v i o r problems, and delayed m y e l i n a t i o n o f
nerve f i b e r s
( T i w a r y , 1987). C l e a r l y , a way
d e t e c t t h e one person
symptoms
had t o be found t o
i n t e n thousand (1/10,000) w i t h PKU
before
developed.
H i s t o r y Of
PKU
A s b j o r n F o i l i n g , a Norwegian p e d i a t r i c i a n , was
asked i n
1934
t o i n v e s t i g a t e t h e cause o f severe mental r e t a r d a t i o n i n a
b r o t h e r and s i s t e r . He d i s c o v e r e d PKU.
He observed,
e x p e r i m e n t a t i o n , t h e presence o f a phenylketone
through
i n the children's
u r i n e . Phenylketones were not n o r m a l l y p r e s e n t i n u r i n e .
Phe-
n v l k e t o n e s were found i n t h e u r i n e o f u n t r e a t e d p h e n y l k e t o n u r i c s ,
hence t h e name p h e n y l k e t o n u r i a . I n 1939,
PKU
was
J e r v i s suggested
that
i n h e r i t e d a c c o r d i n g t o t h e laws o f Mendelian i n h e r i t a n c e
(Appendix
C). J e r v i s demonstrated
i n 1953
t h a t t h e g e n e t i c mate-
r i a l coded f o r a d e f e c t i n t h e p h e n y l a l a n i n e h y d r o x y l a t i n g system
i n t h e l i v e r . B i c k e l , a l s o i n 1953,
p a t i e n t s w i t h a low PHE
diet
successfully treated
PKU
(Simpson, 1989).
Screening H i s t o r y
U n t i l t h e e a r l y 1960's, PKU
d e t e c t i n g phenylketones
s c r e e n i n g t e s t s were based on
i n t h e u r i n e . Pheylketones
can o n l y be
d e t e c t e d i n t h e u r i n e when b l o o d p h e n y l a l a n i n e c o n c e n t r a t i o n s are
q u i t e h i g h . U n f o r t u n a t e l y , n o t a l l p h e n y l k e t o n u r i c s were
d e t e c t e d , I n 1961, G u t h r i e , an American m i c r o b i o l o g i s t
p e d i a t r i c i a n , developed
and
a semi q u a n t i t a t i v e assay t h a t a l l o w e d
f o r d e t e c t i o n o f p h e n y l a l a n i n e i n b l o o d (Mabry, 1990). The method
was
r a p i d , a c c u r a t e , easy t o use, and
inexpensive.
�G u t h r i e w r o t e i n 1980 i n Neonatal Screening f o r I n b o r n
Errors
o f Metabolism :"What was needed was a r e l i a b l e b u t
economical t e s t f o r b l o o d p h e n y l a l a n i n e . We were f o r t u n a t e enough
t o develop such a t e s t i n 1961.
National
Association
By c o i n c i d e n c e , t h a t y e a r t h e
f o r Retarded C i t i z e n s used as i t s " p o s t e r
c h i l d " two s i s t e r s w i t h PKU, showing p r e v e n t i o n
o f mental
r e t a r d a t i o n i n t h e younger s i s t e r due t o e a r l y d i e t a r y t r e a t m e n t .
P a r t l y because I had r e c e i v e d a N a t i o n a l
Citizens
(NARC) r e s e a r c h g r a n t ,
Association
f o r Retarded
I w i l l i n g l y cooperated i n t h e
NARC's p u b l i c i t y campaign aimed a t t h e a p p l i c a t i o n o f my t e s t t o
r o u t i n e s c r e e n i n g o f newborn i n f a n t s . The NARC's i n d i v i d u a l s t a t e
u n i t s pressed t h e s t a t e l e g i s l a t u r e s f o r enactment o f laws r e q u i r i n g PKU t e s t i n g o f every i n f a n t . W i t h t h e n o t a b l e e x c e p t i o n
o f Massachusetts ( t h e f i r s t s t a t e t o pass a l a w ) , t h e r e was
opposition
by t h e s t a t e medical s o c i e t i e s t o such laws. However,
t h e s t a t e ARC's were so s u c c e s s f u l t h a t by 1970 n e a r l y
had
40 s t a t e s
laws, and 90% o f i n f a n t s were b e i n g t e s t e d f o r PKU."
�Legal H i s t o r y
S e c t i o n 3701.501 o f t h e Ohio Revised Code (ORG) i s Ohio's
newborn s c r e e n i n g law (Appendix
Health Council
D). The law g i v e s t h e P u b l i c
(PHC) a u t h o r i t y t o w r i t e t h e r u l e s and r e g u l a t i o n s
o f PKU t e s t i n g . By ORG 3701.501, t e s t i n g i s conducted
a t t h e Ohio
Department o f H e a l t h L a b o r a t o r y . C h i l d r e n whose p a r e n t s o b j e c t t o
t h e t e s t i n g on r e l i g i o u s grounds a r e n o t t e s t e d . Ohio's newborns
have been t e s t e d f o r PKU s i n c e 1966.
By Ohio Revised Code (ORG) 3701.33, t h e P u b l i c H e a l t h Counc i l o f Ohio c o n s i s t s o f 7 members a p p o i n t e d by t h e governor. Of
t h o s e , a t l e a s t 3 a r e t o be p h y s i c i a n s l i c e n s e d t o p r a c t i c e medic i n e i n Ohio, a t l e a s t 1 i s t o be a r e g i s t e r e d p h a r m a c i s t , and a t
l e a s t 1 a r e g i s t e r e d nurse. Again by t h e ORG, t h e P u b l i c H e a l t h
C o u n c i l (PHC) i s t o c o n s i d e r any m a t t e r r e l a t i v e t o t h e p r e s e r v a t i o n and improvement o f p u b l i c h e a l t h .
PHC w r i t e s t h e r u l e s and r e g u l a t i o n s f o r t h e Ohio Department
o f H e a l t h . These a r e p u b l i s h e d as p a r t o f t h e Ohio A d m i n i s t r a t i v e
Code (OAC) and have t h e f o r c e o f law. PHC has w r i t t e n r e g u l a t i o n s , OAC 3701-45-01 (Appendix
E), concerning t h e t e s t i n g o f
newborn c h i l d r e n f o r g e n e t i c , e n d o c r i n e , and m e t a b o l i c
The
l a b o r a t o r y f e e schedule
i s OAC 3701-49-01 (Appendix
diseases.
E ) . Rules
and r e g u l a t i o n s a r e changed from t i m e t o t i m e as t h e need a r i s e s .
Ohio's PHC r u l e [3701-45-01 ( D ) ( 1 ) ] s t a t e s f o r
births
which occur i n a h o s p i t a l t h e c h i l d ' s a t t e n d i n g p h y s i c i a n s h a l l
cause t h e b l o o d specimen t o be c o l l e c t e d . . . p r i o r t o d i s c h a r g e
from t h e n u r s e r y . "
[3701-45-01 ( D ) ( 1 ) ( C ) ] s t a t e s : i f t h e c h i l d
i s d i s c h a r g e d b e f o r e age 48 hours, t h e n " t h e c h i l d ' s a t t e n d i n g
10
�physician a t the h o s p i t a l of b i r t h s h a l l make reasonable e f f o r t
t o cause a second specimen t o be c o l l e c t e d . " The second newborn
screening specimen i s c o l l e c t e d when the c h i l d i s a t l e a s t age 48
hours and a t most 2 weeks of age.
11
�THE PROBLEM
I n Ohio, i n 1991, t h e r e were 165,000 b i r t h s
Surveys and o b s e r v a t i o n s i n d i c a t e d
(CORN, 1991).
t h a t o f those 165,000 i n f a n t s ,
between 50,000 and 66,000 babies were d i s c h a r g e d from t h e
hospital
p r i o r t o age 48 hours. Between 20,000 and 40,000 b a b i e s
d i d n o t have a second PKU
specimen
collected.
Second Specimen R a t i o n a l e
I n 1973, t h e i d e a l c o n d i t i o n s and age f o r c o l l e c t i n g t h e
newborn s c r e e n i n g specimens were d e s c r i b e d . A h e a l t h y f u l l
infant started
term
f e e d i n g 24 hours a f t e r b i r t h . The i n f a n t ' s b l o o d
sample was t a k e n 48 hours a f t e r t h e f i r s t m i l k f e e d i n g . Day 5 was
p u r p o r t e d t o be t h e i d e a l age. The p h e n y l a l a n i n e h y d r o x y l a s e
system was c o n s i d e r e d t o be developed and a c t i v e
newborn by t h e f i f t h day o f l i f e
i n t h e normal
(Ambrose, 1973).
There i s a d e s i r e t o screen a t t h e e a r l i e s t moment a f t e r
b i r t h w h i l e d e t e c t i n g every p o s s i b l e case. That d e s i r e needs t o
be balanced w i t h t h e p r a c t i c a l c o n s i d e r a t i o n o f some i n f a n t s
b e i n g d i s c h a r g e d i n 1993 b e f o r e age 24 hours. I n Ohio i n 1985 t h e
average age o f i n f a n t s a t d i s c h a r g e was
1991
(Resource Development, ODH,
Many s c i e n t i f i c
an e l e v a t e d PHE
3.2 days and 2.5 days i n
1992).
s t u d i e s have been conducted t o d e t e r m i n e i f
l e v e l i s d e t e c t a b l e i n young i n f a n t s .
I n 1982, a
l e t t e r w r i t t e n by B e r r y and P o r t e r suggested t h a t e l e v a t e d phenylalanine
l e v e l s c o u l d be d e t e c t e d a c c u r a t e l y a t age 24 hours.
They suggested c o l l e c t i n g a second specimen when t h e baby
between 4 8 hours and 2 weeks o f age
1983, a s t u d y which r e l a t e d
( B e r r y and P o r t e r , 1982). I n
s c r e e n i n g age o f i n f a n t t o t h e
12
was
PKU
�l e v e l a t t h a t age concluded:
"not a l l p a t i e n t s w i t h PKU
will
be
d e t e c t e d by s c r e e n i n g , and t h e phenomenon o f e a r l y n u r s e r y d i s charge must be c o n s i d e r e d i n d e v e l o p i n g a p p r o p r i a t e s c r e e n i n g
s t r a t e g i e s . " ( E d w a r d R.B.
Wu,
McCabe, e t . a l . ,
1983).
i n t h e Annals o f C l i n i c a l and L a b o r a t o r y Science i n
V o l . 2 1 , No.2,
pg. 129 s t a t e d : " I t should be r e a l i z e d t h a t a t b i r t h
the
PHE
c o n c e n t r a t i o n o f PKU
babies does n o t always r i s e above
the
u s u a l c u t o f f c o n c e n t r a t i o n . A second b l o o d specimen s h o u l d
be o b t a i n e d f o r t h e measurement o f p h e n y l a l a n i n e two weeks a f t e r
b i r t h , a f t e r p r o t e i n i n t a k e (such as m i l k f e e d i n g ) , e i t h e r t o
c o n f i r m t h e d i a g n o s i s made by t h e f i r s t specimen o r t o r u l e o u t
transient
hyperphenylalanemia.
11
Harvey Levy e t . a l . i n 1991 drew t h e f o l l o w i n g
r e g a r d i n g t h e PKU
the
conclusions
d e t e c t i o n i n v e r y e a r l y newborn b l o o d : " F i r s t ,
g r e a t m a j o r i t y o f neonates w i t h PKU
w i l l have an e l e v a t e d
l e v e l w i t h i n t h e f i r s t 24 hours o f l i f e . T h i s e l e v a t i o n may
PHE
be
l e s s t h a n 4 mg/dl, however, which i s t h e c u t o f f l e v e l o f t e n used
i n s c r e e n i n g . " They suggested
changing
the cut o f f l e v e l t o 2
mg/dl and c o l l e c t i n g a second specimen.
I n a r e v i e w o f England's s c r e e n i n g program f o r PKU,
e t . a l . concluded
t h a t t h e program achieved:
n e a r l y 100% o f newborns had a PKU
1. h i g h coverage,
t e s t , and 2. was
p i c k i n g o u t t h e samples w i t h h i g h PHE
effective in
l e v e l s . Even though
seen t o be e f f e c t i v e some c h i l d r e n were s t i l l missed
e t . a l . , 1991) .
13
Smith
i t was
(Smith
�METHODOLOGIES
Agency, o r Ohio Department o f H e a l t h L a b o r a t o r y ,
a u t h o r i z a t i o n was needed b e f o r e any data c o u l d be c o l l e c t e d . I
w r o t e a l e t t e r which s t a t e d my name, purpose, and proposed
m e t h o d o l o g i e s . I asked f o r p e r m i s s i o n t o use l a b r e c o r d s t o
d e t e r m i n e t h e scope o f t h e problem. P e r m i s s i o n was g r a n t e d and
work was begun
(Appendix A ) .
Methods employed depended upon t h e source o f t h e i n f o r m a t i o n
and f o r what purpose data was sought. A r t i c l e s on every aspect o f
PKU
i n c l u d i n g : d e f i n i t i o n , i n c i d e n c e , h i s t o r y , normal metabolism
of p h e n y l a l a n i n e , c l i n i c a l symptoms i n p a t i e n t s w i t h u n t r e a t e d
PKU,
n e o n a t a l s c r e e n i n g , d i a g n o s i s , and t r e a t m e n t were a v a i l a b l e
i n t h e l i b r a r y . There was l i t t l e
i n f o r m a t i o n a v a i l a b l e on
compliance r a t e s and t h e c o l l e c t i o n o f t h e second PKU specimen.
F i r s t specimens were u s u a l l y t a k e n a t t h e b i r t h i n g c e n t e r
s h o r t l y b e f o r e t h e i n f a n t was d i s c h a r g e d . Compliance r a t e s were
near 100%. I f a second specimen had t o be c o l l e c t e d because o f an
abnormal f i n d i n g on t h e f i r s t , o r t h e r e was a problem w i t h t h e
specimen i t s e l f , t h e n t h e p a r e n t s had t o be n o t i f i e d . I n some
cases i t was d i f f i c u l t t o c o n t a c t t h e p a r e n t s . Reasons f o r t h e
d i f f i c u l t y i n c l u d e d : p a r e n t s had moved, o r t h e r e was i n s u f f i c i e n t
or
i n a c c u r a t e i n f o r m a t i o n on t h e PKU c a r d (Mabry e t . a l . , 1988).
The t e x t o f Ohio's newborn s c r e e n i n g law was found i n t h e
Ohio Revised Code and t h e P u b l i c H e a l t h Rules i n Ohio
A d m i n i s t r a t i v e Code. A f e l l o w employee sent me t h e r e l e v a n t ORG
and OAC s e c t i o n s . Ohio Revised Code and Ohio A d m i n i s t r a t i v e Code
were a v a i l a b l e i n t h e i r e n t i r e t y i n t h e law l i b r a r y .
14
�In
o r d e r t o d e t e r m i n e t h e scope o f t h e problem noses had t o
be c o u n t e d . Data was n o t s t o r e d on d i s c o r t a p e , b u t on i n d i v i d u al
r e p o r t s l i p s . The whole p o p u l a t i o n c o u l d n o t be s t u d i e d . I
s e l e c t e d two samples. On October 16, 1992, 784 specimen c a r d s
were examined. On November 13, 1992, 448 specimen c a r d s were
examined. I f an i n f a n t was d i s c h a r g e d from t h e h o s p i t a l b e f o r e
age 48 h o u r s , t h e n t h e f o l l o w i n g was r e c o r d e d : b i r t h i n g c e n t e r ' s
name; baby's name, sex, d a t e and t i m e o f b i r t h , d a t e and t i m e o f
sample; mother's l a s t name. Every w o r k i n g day o f t h e 3 weeks
f o l l o w i n g 10-16-92 and 11-13-92, second PKU specimens were exami n e d . I f a second specimen matched a f i r s t , t h e n t h e d a t e and
t i m e o f c o l l e c t i o n o f t h e second specimen were r e c o r d e d n e x t t o
the
i n f o r m a t i o n about t h e f i r s t specimen.
" H e a l t h care system" i m p l i e d v a r i o u s t a s k s p e r f o r m e d by many
people. These people d i d n o t n e c e s s a r i l y work a t t h e l a b , b u t
were p a r t o f t h e system. I wanted t o t a l k w i t h them t o g e t a more
complete p i c t u r e o f what went on behind t h e scenes t o cause a
second specimen t o be c o l l e c t e d .
OAC 3701-45-01(C)
states: " P r i o r t o c o l l e c t i n g t h e blood
specimen f o r t e s t i n g f o r g e n e t i c , e n d o c r i n e , and m e t a b o l i c d i s o r ders under paragraph (B) o f t h i s r u l e , t h e person d e s i g n a t e d i n
the
of
a p p l i c a b l e p r o v i s i o n o f t h i s paragraph s h a l l g i v e t h e p a r e n t
each newborn c h i l d n o t i c e o f t h e proposed t e s t s by p r o v i d i n g
p r i n t e d i n f o r m a t i o n d e s c r i b i n g t h e newborn g e n e t i c . e n d o c r i n e .
and m e t a b o l i c s c r e e n i n g program.
(1)
Each h o s p i t a l o f d e l i v e r y s h a l l p r o v i d e t h e p a r e n t s o f
c h i l d r e n born i n t h e h o s p i t a l w i t h t h e i n f o r m a t i o n . "
The p r i n t e d i n f o r m a t i o n i s "Why Must My Newborn Be
15
�Screened?" and i s p r o v i d e d t o every h o s p i t a l having a l i c e n s e d
m a t e r n i t y u n i t , every h e a l t h commissioner, and p h y s i c i a n s and
nurse mid-wives a t t e n d i n g b i r t h s o u t s i d e h o s p i t a l s . I wanted t o
s t u d y t h e i n f o r m a t i o n . I saw t h e need f o r t h e i n f o r m a t i o n . Moms
can l o o k a t t h e b o o k l e t anytime t h e need a r i s e s and t h e y can t a k e
t h e pamphlet home w i t h them. I wanted t o know how t h e second
specimen i s s u e was
handled.
I see e f f e c t i v e p o l i c y as b e i n g comprised o f two v i t a l l y
i m p o r t a n t aspects: t e a c h i n g and p o l i c i n g . T h i s a f f e c t s a l l t h e
a c t o r s . A l l s t a k e h o l d e r s need t o be t a u g h t and p o l i c e d . We
a l l need t o be on t h e same page. How do we g e t everyone on t h e
same page? What have a l l t h e a c t o r s been t a u g h t t o cause t h e
c o l l e c t i o n o f t h e second specimen? Where does one l o o k when t h e
second specimen has n o t been c o l l e c t e d ? Those q u e s t i o n s guided
me
i n what I asked and o f whom i t was asked.
L a b o r a t o r y personnel
suggested names o f people t o c o n t a c t .
Those i n t e r v i e w e e s mentioned o t h e r s ' names. An Ohio H o s p i t a l
D i r e c t o r y was o b t a i n e d from t h e Ohio H o s p i t a l A s s o c i a t i o n . Names
of each h o s p i t a l ' s d i r e c t o r , CEO, c h i e f a d m i n i s t r a t o r o r v i c e p r e s i d e n t was l i s t e d .
person.
I t was p o s s i b l e t o ask t o speak w i t h t h a t
I s t a t e d my name and reason f o r t h e c a l l t o t h e " g a t e -
keeper", t h e person who answered t h e phone f o r t h e h o s p i t a l ' s
d i r e c t o r , CEO, c h i e f a d m i n i s t r a t o r , o r VP. I was t h e n d i r e c t e d t o
t a l k w i t h someone who knew t h e s p e c i f i c s o f t h e d i s c h a r g e
policy
i n t h e m a t e r n i t y ward.
I work i n t h e v e r y l a b o r a t o r y t h a t i s r e s p o n s i b l e f o r
t e s t i n g t h e specimens f o r PKU. I wanted t o asses o u r r o l e i n
16
�c a u s i n g t h e c o l l e c t i o n o f t h e second specimen. H e a l t h c a r e
p r o f e s s i o n a l s c a l l t h e l a b t o check on t h e s t a t u s o f specimens,
r e s u l t s , r e p o r t s , e t c . The i n f o r m a t i o n we g i v e them d e t e r m i n e s
the a c t i o n they take.
New moms and babies were d i s c h a r g e d e a r l y by h o s p i t a l s . By
PHC r e g u l a t i o n s d o c t o r s were t o cause t h e c o l l e c t i o n o f t h e
second PKU specimens from those i n f a n t s d i s c h a r g e d e a r l y . Doctors
were deemed survey r e c i p i e n t s . F u r t h e r d i s c u s s i o n i n d i c a t e d a
change o f focus was needed. E a r l y d i s c h a r g e moms, whose b a b i e s
had n o t had t h e second PKU t e s t , were t o r e c e i v e a q u e s t i o n n a i r e .
I wanted t o know why t h e y had n o t come back. A l e t t e r was d r a f t ed. Q u e s t i o n s were c o n s t r u c t e d . A p p r o v a l was g r a n t e d . For whateve r reason t h o s e moms had d i s e n f r a n c h i s e d themselves, and t h e i r
b a b i e s , from t h e h e a l t h care system. I decided t h e y were n o t
l i k e l y t o respond t o my survey. I f t h e y d i d n o t respond I c o u l d
n o t w r i t e a paper. The pendulum swung back t o t h e d o c t o r s .
A l i s t o f p e d i a t r i c i a n s l i c e n s e d t o p r a c t i c e i n Ohio was
o b t a i n e d . Names and addresses o f 1800 "baby d o c t o r s " were p r i n t e d
on l a b e l s and sent t o me. U n f o r t u n a t e l y , n o t a l l c o u l d be s u r veyed. One hundred and t w e n t y
l a b e l s ( p e d i a t r i c i a n s ) were r a n -
domly s e l e c t e d .
I w r o t e a cover l e t t e r . I n t h e l e t t e r I t o l d them my name
and reason f o r w r i t i n g . I asked f o r t h e i r h e l p . I gave them a
b r i e f d e s c r i p t i o n o f t h e problem based on my 2 samples. I thanked
them. I c o n s t r u c t e d a q u e s t i o n n a i r e (Appendix F ) . I wanted :
i n f o r m a t i o n from them on t h e scope o f t h e problem, what t h e y were
s a y i n g t o t h e moms t o g e t them back, how much t r a c k i n g d i d t h e
d o c t o r s do i f p a t i e n t s d i d n o t come i n f o r t h e second t e s t . I
17
�wanted i n f o r m a t i o n about t h e d o c t o r s themselves.
What
language(s)
d i d t h e y speak, and where were t h e i r p r a c t i c e s l o c a t e d ? I
wondered how d o c t o r s were s i m i l a r t o and d i f f e r e n t
from
their
p a t i e n t s . I asked t h e d o c t o r s f o r i n f o r m a t i o n about t h e i r
" t y p i c a l " e a r l y d i s c h a r g e moms who had t h e i r babies t e s t e d a g a i n
f o r PKU. I t h o u g h t p o s s i b l y one common t h r e a d o r element would
appear. I asked q u e s t i o n s w i t h t h e idea o f drawing a p r o f i l e o f
t h e mom who had h e r baby r e t e s t e d . I t h o u g h t i f a p r o f i l e emerged
t h e n p o s s i b l y a program c o u l d be developed
Addressee l a b e l s were a f f i x e d
and
t o gain
compliance.
t o business envelopes.
t h e l a b o r a t o r y ' s address c o n s t i t u t e d t h e r e t u r n
My name
address.
Cover l e t t e r s were s i g n e d , q u e s t i o n n a i r e s and s e l f - a d d r e s s e d
stamped envelopes were numbered. Those items were f o l d e d and
p l a c e d i n envelopes and m a i l e d on December 15, 1992. Received t o
date were: 1 empty envelope,
trist,
1 phone c a l l from a c h i l d
1 note from a p e d i a t r i c a l l e r g i s t , 1 uncompleted
w i t h a comment o f " t o o l o n g " , and 45 completed
18
psychiasurvey
questionnaires.
�IV.
FINDINGS
Observational Findings
On October 16, 1992, t h e f i r s t
l i s t o f newborns was
compiled. I t was found t h a t 247 o f 784 newborns, o r 3 1 % were
sampled f o r t h e i r m e t a b o l i c s c r e e n i n g t e s t s b e f o r e age 48 hours.
One hundred o f 247 b a b i e s , o r 40% were n o t redrawn.
On November 13, 1992, t h e second l i s t o f newborns was compiled.
I t was found t h a t 133 o f 448 newborns, o r 30% were sampled
f o r t h e i r m e t a b o l i c s c r e e n i n g t e s t s b e f o r e age 48 hours. F i f t y two o f t h o s e 133,or 39% were n o t r e t e s t e d . I n Kentucky, r e p e a t
s c r e e n i n g f o r any reason i s o n l y achieved 50-70% o f t h e t i m e
(Mabry e t . a l . , 1988). I n these cases 60% complied.
I t was b r o u g h t t o t h e a t t e n t i o n o f t h i s r e s e a r c h e r t h a t t h e
samples were n o t v e r y l a r g e . T h i s data i s n o t a v a i l a b l e on
computer. Keeping r e c o r d s by hand was t h e o n l y c h o i c e . The
samples were r e p r e s e n t a t i v e o f Ohio's n e o n a t a l p o p u l a t i o n . The
number and p e r c e n t were e x t r a p o l a t e d t o t h e newborn p o p u l a t i o n o f
the
s t a t e . T h i s r e s e a r c h e r i s c o g n i z a n t o f t h e l a r g e margin o f
error.
I n 1991, t h e r e were 165,000 l i v e b i r t h s . Sample 1
e x t r a p o l a t e d t o t h e newborn p o p u l a t i o n would mean: 53,000 i n f a n t s
were d i s c h a r g e d e a r l y , and o f those 21,000 o r 40% were n o t
r e t e s t e d . Sample 2 e x t r a p o l a t e d t o t h e newborn p o p u l a t i o n would
mean: 50,000 i n f a n t s were d i s c h a r g e d e a r l y , and o f those 20,000,
or 39% were n o t r e t e s t e d . The upside i s t h a t 60% o f t h e i n f a n t s
d i s c h a r g e d e a r l y were r e t e s t e d .
The c u m u l a t i v e i n c i d e n c e o f PKU i n Ohio i s 1/13,540 ( B e r r y ,
p r i v a t e c o n v e r s a t i o n 1993). I n t h e f i r s t
19
case, t h a t would
�t r a n s l a t e i n t o 21,000 over 13,540 or 1.6
c h i l d r e n c o u l d have
p h e n y l k e t o n u r i a and n o t be t r e a t e d . Case two would be,
e x t r a p o l a t i o n , 20,000 over 13,540 or 1.4
by
children.
A s t u d y i n France y i e l d e d a b e n e f i t t o c o s t r a t i o o f
f o r PKU.
B e n e f i t s i n c l u d e d : a "normal"
6.6/1
i n d i v i d u a l , costs of
i n s t i t u t i o n a l i z a t i o n saved. Costs i n c l u d e d : c o s t s a s s o c i a t e d w i t h
t e s t i n g f o r PKU,
t r e a t m e n t c o s t s (low p h e n y l a l a n i n e
foods
p r o v i d e d by s t a t e ) , medical expenses a s s o c i a t e d w i t h t r e a t e d
(Dhondt e t . a l . ,
PKU
1991).
Again, 20,000 i n f a n t s o r 12% are r e l e a s e d from t h e h o s p i t a l
b e f o r e age 4 8 hours and not resampled f o r PKU.
This provided
me
w i t h some idea o f t h e scope o f t h e problem and I used t h e i n f o r mation i n my cover l e t t e r t o t h e d o c t o r s .
An A c t u a l Case?
A n e o n a t a l s c r e e n i n g specimen (Appendix G) was
our l a b . The
i n f a n t was
c o l l e c t e d . The
PKU
second specimen was
submitted t o
17 hours o f age when t h e specimen
r e s u l t t e s t was
was
normal o r l e s s t h a n 4mg/dl. A
c o l l e c t e d when t h e i n f a n t was
age 13 days.
The p h e n y l a l a n i n e l e v e l was measured a t 20mg/dl. We
are a w a i t i n g
diagnosis.
Anecdotal
Findings
Interviews
M a t e r n a l and C h i l d H e a l t h (MCH)
i s a bureau i n t h e Ohio
Department o f H e a l t h (ODH). MCH's many r e s p o n s i b i l i t i e s i n c l u d e :
f o l l o w i n g up on p o s i t i v e PKU
screens, p r o v i d i n g e d u c a t i o n a l
l i t e r a t u r e t o h o s p i t a l s , and u l t i m a t e l y t o p a r e n t s , on t h e
20
impor-
�t a n c e o f t h e PKU t e s t , and g e t t i n g t h e PKU t e s t k i t p r i n t e d and
over t o ODH a c c o u n t i n g . MCH r e l i e s on t h e i n p u t from t h e l a b ,
h e a l t h c a r e p r o v i d e r s , newborn s c r e e n i n g c o o r d i n a t o r s , l o c a l
h e a l t h departments, and h e a l t h commissioners
regarding a l l o f the
above and t h e a l l o f t h e aforementioned r e l y on MCH. Primary
h e a l t h c a r e p r o v i d e r s need t h e i n f o r m a t i o n t h e l a b and MCH
provide t o g i v e t h e p a t i e n t t h e best care.
Newborn s c r e e n i n g c o o r d i n a t o r s a r e employees o f t h e i r p a r t i c u l a r h o s p i t a l and f u n c t i o n as l i a i s o n s between h o s p i t a l s and
ODH (MCH and t h e l a b ) . They a r e p r i m a r i l y concerned w i t h t r a c k i n g
p a t i e n t s and t e s t r e s u l t s . Specimens need t o be c o l l e c t e d from
i n f a n t s who had abnormal s c r e e n i n g r e s u l t s o r who were d i s c h a r g e d
from t h e h o s p i t a l b e f o r e age 48 hours. T r a c k i n g i s n o t cheap o r
easy. Phone c a l l s a r e p l a c e d , l e t t e r s a r e sent r e g u l a r m a i l and
c e r t i f i e d , and l o c a l h e a l t h department
still
o f f i c i a l s n o t i f i e d and
some babies a r e " l o s t . "
A d m i n i s t r a t i v e r e p r e s e n t a t i v e s o f h o s p i t a l s which r e l e a s e a t
or a f t e r 48 hours f e l t t h e main reasons f o r keeping moms and
babies f o r 48 hours were: c o n s e r v a t i v e p h y s i c i a n s , and moms
needed t h e t i m e t o l e a r n about c a r i n g f o r t h e i r
infants.
U n i v e r s i t y H o s p i t a l i n C i n c i n n a t i (UC) i s an anomaly among o t h e r
l a r g e Ohio c i t i e s ' u n i v e r s i t y h o s p i t a l s . UC d i s c h a r g e s v e r y few
babies b e f o r e 48 hours. OSU d i s c h a r g e s 50% o f new moms and t h e i r
i n f a n t s b e f o r e age 48 hours and U n i v e r s i t y i n C l e v e l a n d d i s charges
30% b e f o r e 48 hours. A t a x passed i n H a m i l t o n County pays
t h e p a r t o f t h e h o s p i t a l s t a y n o t covered by M e d i c a i d t h u s a l l o w i n g i n d i g r n t moms t o s t a y 48 hours.
A d m i n i s t r a t i v e r e p r e s e n t a t i v e s from h o s p i t a l s which do
21
�r e l e a s e b e f o r e age 48 hours s a i d t h a t M e d i c a i d and p r i v a t e l y
i n s u r e d p a t i e n t s a r e r e l e a s e d e a r l y because l o n g e r s t a y s would
n o t be covered.
A h e a l t h insurance
b r o k e r s t a t e d t h a t h o s p i t a l s charge about
$3,000.00 p e r day i n m a t e r n i t y . I n s u r a n c e companies would p r e f e r
moms go home as soon as p o s i b l e and d o c t o r s would p r e f e r t o see
p a t i e n t s s t a y t h e f u l l 48 hours. H o s p i t a l s a r e concerned about
t h e i r bottom l i n e . The t r e n d i s t o d i s c h a r g e
saw
e a r l y and t h e b r o k e r
no reason f o r i t t o change.
The
H e a l t h Maintenance O r g a n i z a t i o n
who spoke w i t h me c o n f i r m e d
h e a l t h insurance
(HMO) r e p r e s e n t a t i v e s
what t h e h o s p i t a l r e p r e s e n t a t i v e s and
1
b r o k e r s a i d . These p a r t i c u l a r HMO's a r e a f f i l i -
a t e d w i t h one h o s p i t a l ( i . e . i f you a r e i n s u r e d by e i t h e r o f
t h e s e HMO's t h e n t h e r e i s o n l y one h o s p i t a l where y o u ' l l d e l i v e r
your baby and t h e maximum s t a y , b a r r i n g c o m p l i c a t i o n s ,
i s 24
h o u r s ) . The PKU t e s t was covered.
A r e p r e s e n t a t i v e o f Midwives Care, I n c . i n C i n c i n n a t i spoke
about t h e i r p r e n a t a l c l a s s e s . She discussed
expectant
t h e PKU t e s t w i t h
parents. I n general, t h e r o l e o f t h e midwife
regarding
c o l l e c t i o n o f t h e PKU specimen i s much t h e same as t h e a t t e n d i n g
p h y s i c i a n . Nurse M i d w i f e
attended
d e l i v e r i e s occur i n t h e
p a t i e n t ' s home o r i n h o s p i t a l s . Most moms a t t e n d e d by midwives a r e
s e l f pay o r p r i v a t e l y i n s u r e d . Very few a r e M e d i c a i d moms.
The
newborn s c r e e n i n g
Disease C o n t r o l
r e p r e s e n t a t i v e from t h e Centers f o r
(CDC) i n A t l a n t a spoke about t h e r o l e o f t h e
f e d e r a l government i n n e o n a t a l
t e s t i n g i n Ohio. T h e i r r o l e i s one
o f a d v i s i n g and m o n i t o r i n g . S t a t e s p a r t i c i p a t e v o l u n t a r i l y i n
22
�CDC's s u r v e i l l a n c e program. The Food and Drug A d m i n i s t r a t i o n
(FDA)
wa r e s p o n s i b l e f o r t h e warning l a b e l on foods and beverages
sweetened w i t h
Nutrasweet.
My i n t e r v i e w s gave me food f o r t h o u g h t , c o n f i r m e d s u s p i c i o n s , and suggested areas f o r f u t u r e s t u d y . The i n f o r m a t i o n I
gleaned was used t o round o u t t h e p i c t u r e o f t h e n e o n a t a l h e a l t h
care system.
I saw how r e s o u r c e f u l and c r e a t i v e people can be i n
s o l v i n g problems. No r e a l hard and f a s t data was generated.
Anecdotal F i n d i n g s
Why Must My Newborn Be Screened?
I read " Why Must My Newborn Be Screened?" s e v e r a l t i m e s
(Appendix H). When I g o t t h e OAC r e g u l a t i o n s I read t h o s e w i t h
i n t e r e s t . Then i t h i t me. On page 2 o f t h e pamphlet a sentence
reads r ^ I f your baby goes home from t h e h o s p i t a l b e f o r e 48 hours
t h e t e s t may need t o be done a g a i n . "
OAC r e g u l a t i o n s say t h e
t e s t must be r e p e a t e d . I n o t i f i e d o t h e r s o f t h i s and i t i s b e i n g
investigated.
Anecdotal F i n d i n g s
Newborn Screening Lab
The Newborn Screening Lab r e c e i v e d specimen cards from 155
h o s p i t a l s t h r o u g h o u t Ohio. Cards were assembled i n t o packs. Each
c a r d was numbered a c c o r d i n g t o t h e pack i n which i t was and where
i n t h a t pack i t was. The date r e c e i v e d was w r i t t e n on each c a r d .
One d i s c , o n e - e i g h t h i n c h i n d i a m e t e r , was punched from each c a r d
f o r each t e s t r u n .
Completed t e s t i n g y i e l d e d r e s u l t s . R e s u l t s were e n t e r e d i n t o
23
�a lab l o g book along w i t h p a t i e n t i n f o r m a t i o n . I f a p a t i e n t ' s
r e s u l t s i n d i c a t e d an abnormally elevated phenylalanine l e v e l then
the lab d i r e c t o r or designee phoned the c h i l d ' s physician about
the r e s u l t .
The c h i l d ' s o r i g i n a l PKU
card was marked "abnormal f o r PKU"
and the a c t u a l reading was w r i t t e n on the card. One page from the
o r i g i n a l card w i t h the PKU r e s u l t i n d i c a t e d was mailed t o each of
the f o l l o w i n g : the h o s p i t a l l i s t e d on the PKU card, the p h y s i c i a n , and Maternal and Child Health (MCH). One page was r e t a i n e d
by the lab f o r t h e i r records.
The lab f i l l e d out the information p a r t of a new card f o r
each baby w i t h an elevated PKU.
The new card was mailed along
w i t h the page from the o r i g i n a l card t o the physician. I f the
c h i l d was r e t e s t e d f o r PKU and the physician used the card the
lab sent, then the second specimen r e s u l t s could be matched w i t h
the o r i g i n a l r e s u l t s . I f the c h i l d was resampled but the specimen
was not on the card sent by the lab second specimen r e s u l t s could
not be e a s i l y matched t o o r i g i n a l r e s u l t s .
Most of the newborns had normal phenylalanine l e v e l s . An
"X"
marked i n the "screening t e s t normal" box i n d i c a t e d the lab
obtained a normal phenylalanine l e v e l on t h a t p a r t i c u l a r baby's
specimen. One copy of each normal r e p o r t was r e t a i n e d by the lab
and the other 3 pages were mailed t o the h o s p i t a l l i s t e d .
The
h o s p i t a l kept a copy f o r t h e i r records and d i s t r i b u t e d the p h y s i cian's copy and the other copy accordingly.
Newborn Screening's f i l e s were found t o c o n s i s t of 165,000
plus copies of PKU
cards r e t a i n e d by the lab. " A l l r e s u l t s
normal" r e p o r t s were arranged i n f i l e drawers by h o s p i t a l l i s t e d
24
�on t h e c a r d . Reports o f abnormal r e s u l t s and abnormal specimens
were k e p t t o g e t h e r i n a l p h a b e t i c a l by l a s t name o r d e r , b u t a p a r t
from "normals".
H e a l t h p r o f e s s i o n a l s c a l l e d r e g u l a r l y t o asses t h e s t a t u s o f
r e s u l t s , specimens, and r e p o r t s . Specimens and r e p o r t s were
l o c a t e d w i t h d i f f i c u l t y . The l a b performed f o u r o t h e r h e r e d i t a r y
m e t a b o l i c t e s t s on each specimen. I f f o r any reason a specimen
needed f u r t h e r t e s t i n g r e s u l t s were d e l a y e d . The logbook was k e p t
by hand.
I n 1987, computerized t r a c k i n g was i n t r o d u c e d i n t h e newborn
s c r e e n i n g l a b . The system was developed by Neometrics and
laboratory o f f i c i a l s .
Neometrics s o l d t e s t i n g k i t s and a d a t a
r e d u c t i o n s o f t w a r e package t o t h e l a b o r a t o r y . The t r a c k i n g system
was c a l l e d Remote Data E n t r y System (RDES). A barcode scanner was
i n s t a l l e d i n t h e l a b o r a t o r y . The p r e p r i n t e d c a r d number was i n
t h e barcode. H o s p i t a l p e r s o n n e l e n t e r e d t h e baby's data and t h e
a s s o c i a t e d p r e p r i n t e d c a r d number i n t o t h e system. Specimen cards
were t h e n m a i l e d t o t h e l a b o r a t o r y .
Card numbers and c o r r e s p o n d i n g i n f a n t data were t r a n s m i t t e d
e l e c t r o n i c a l l y t o t h e . l a b o r a t o r y . A l i s t o f c a r d numbers and baby
i n f o r m a t i o n was p r i n t e d o u t a t t h e l a b . When t h e specimens
a r r i v e d t h e y were assembled and numbered as b e f o r e . Once
numbered, specimen barcodes were scanned. The screen f i l l e d up
w i t h c a r d numbers and c o r r e s p o n d i n g p a t i e n t i n f o r m a t i o n . Data was
checked f o r accuracy. L a b o r a t o r y numbers were e n t e r e d i n t o t h e
system, b u t n o t t r a n s m i t t e d t o t h e h o s p i t a l . L a b o r a t o r i a n s
e n t e r e d completed t e s t r e s u l t s i n t o t h e system. R e s u l t s were
25
�s t o r e d e l e c t r o n i c a l l y b u t never t r a n s m i t t e d e l e c t r o n i c a l l y .
R e s u l t s were p r i n t e d o u t i n a format s i m i l a r t o t h e PKU c a r d .
P r i n t o u t s and pages o f t h e c h i l d ' s PKU c a r d were m a i l e d t o t h e
h o s p i t a l . H o s p i t a l s o n l y e n t e r e d data from a baby's o r i g i n a l
specimen. I f a second PKU specimen was drawn on a c h i l d , RDES was
n o t t o l d . Of t h e 155 h o s p i t a l s i n Ohio which send PKU specimens
t o t h e l a b , o n l y 8 used RDES.
Experience and o b s e r v a t i o n have l e d me t o draw t h e f o l l o w i n g
c o n c l u s i o n . RDES i s a good idea i n t h e o r y . I n p r a c t i c e t h e system
i s n o t f u n c t i o n i n g w e l l enough t o b e n e f i t t h e l a b , MCH,
accounting,
t h e p h y s i c i a n s , h o s p i t a l s , p a r e n t s , o r b a b i e s . The
l a b r e c e i v e s a l l o f Ohio's n e o n a t a l s c r e e n i n g specimens and i s
r e s p o n s i b l e f o r t e s t i n g and r e p o r t i n g . OAC 3701-45-01(B)(2)
s t a t e s t h e l a b s h a l l p r o m p t l y t r a n s m i t t h e r e s u l t s o f each t e s t
performed. The l a b would b e n e f i t g r e a t l y , as w e l l as a l l o t h e r
stakeholders,
from computerized t r a c k i n g . I f a specimen and/or
r e p o r t c o u l d be found r a p i d l y , money and t i m e c o u l d be saved.
Unnecessary specimen c o l l e c t i o n c o u l d be avoided.
A v a s t amount
o f i n f o r m a t i o n comes i n t o t h e l a b . With c o m p u t e r i z a t i o n ,
i n f o r m a t i o n would be a v a i l a b l e f o r f u r t h e r
Anecdotal
that
study.
Findings
The Accounting
Unit
S e c t i o n 3701.23 o f t h e Ohio Revised Code (ORG) p e r m i t t e d t h e
Public Health Council
(PHC) t o e s t a b l i s h reasonable fees f o r
s e r v i c e s performed by t h e Ohio Department o f H e a l t h (ODH)
Laboratory.
I f PHC b e l i e v e d t h a t c h a r g i n g f o r s e r v i c e s would
a d v e r s e l y a f f e c t t h e p u b l i c h e a l t h , t h e n no f e e was s e t .
26
�C o l l e c t e d fees were p l a c e d i n a l a b o r a t o r y fund. Monies d e p o s i t e d
i n t o t h e fund were t o d e f r a y
ODH l a b o p e r a t i n g expenses. I n
1981, t h e f e e f o r t h e PKU c a r d was $5.00. By 1991 t h a t had r i s e n
t o $24.00. Of each $24.00 c o l l e c t e d : $10.25 was d e p o s i t e d t o t h e
g e n e t i c s e r v i c e s f u n d , $3.75 was d e p o s i t e d t o t h e s i c k l e
cell
f u n d , and $10.00 was d e p o s i t e d t o t h e l a b o r a t o r y f u n d . Of t h e
$10.25 d e p o s i t e d t o t h e g e n e t i c s e r v i c e s fund : $3.00 were t o
d e f r a y t h e c o s t o f t h e PKU program c o s t s and $7.25 were t o d e f r a y
t h e c o s t o f o t h e r h e r e d i t a r y m e t a b o l i c disease programs
(ORG,1991).
H o s p i t a l s and p h y s i c i a n s were n o t exempt from t h e f e e s .
Local h e a l t h departments r e c e i v e d t h e cards f r e e o f charge.
P u b l i c h e a l t h nurses o b t a i n e d cards from l o c a l h e a l t h d e p a r t ments. PKU cards were ordered from t h e ODH a c c o u n t i n g u n i t . When
a c c o u n t i n g r e c e i v e d $24.00 f o r each c a r d o r d e r e d , t h e cards were
sent t o t h e a p p r o p r i a t e p l a c e . E a r l y r e l e a s e p a t i e n t s were
charged one PKU t e s t i n g f e e o f $24.00.
I n e f f e c t , i f h o s p i t a l s sent b l a n k PKU cards home w i t h e a r l y
d i s c h a r g e p a t i e n t s , $48.00 was p a i d . Hence, those h o s p i t a l s which
p a i d t w i c e were p e r m i t t e d replacement cards. To o b t a i n t h e i r
c a r d s , h o s p i t a l s were r e q u i r e d t o submit a l i s t t o ODH
a c c o u n t i n g . L i s t e d were: h o s p i t a l name; baby's name, sex, date
and t i m e o f b i r t h , date and t i m e o f d i s c h a r g e ; PKU c a r d number o f
t h e c a r d used and t h e c a r d number o f t h e b l a n k c a r d . Numbers were
checked. I f a c c o u n t i n g personnel
found t h a t t h e i r l i s t matched
t h e h o s p i t a l ' s l i s t t h e n replacement cards were s e n t t o t h e
hospital.
From my o b s e r v a t i o n s and survey responses t h e e a r l y d i s 27
�charge r a t e was between 30% and 40%. That means between 50,000
and 66,000 i n d i v i d u a l babies were discharged e a r l y . The non
compliance r a t e f o r PKU r e t e s t s was found t o be between 40% and
60% or between 20,000 and 40,000 i n f a n t s . I f a l l of these babies
were sent home w i t h a blank PKU card t h a t would t r a n s l a t e i n t o a
p o t e n t i a l ODH loss of $480,000.00 t o $960,000.00. Of the people
who comply, not a l l remember the card.
I conclude t h a t Payment i n Kind (PIK) w i t h replacement cards
i s preferable t o cash payments, but without a t r a c k i n g system ODH
increases the chances t o lose s u b s t a n t i a l amounts of money. An
area o f f u t u r e study would be t o f o l l o w t h e flow of cards and see
how many are l o s t and how much i t costs ODH.
28
�QUESTIONNAIRE RESPONSES
Data Reduction
The questionnaire was designed: t o determine the scope o f
the problem, t o see what health care professionals are doing t o
solve the problem, t o see how successful they have been, t o
obtain some general information about the physicians themselves,
and t o produce a p r o f i l e o f e a r l y discharge moms.
Since most women d e l i v e r t h e i r babies a t b i r t h i n g h o s p i t a l s
and, i n Ohio, 3 0% o f those women and t h e i r i n f a n t s are discharged
before babies reach age 48 hours, then the h o s p i t a l s seemed a
l o g i c a l s t a r t i n g p o i n t . Question 1 (see Appendix E) generated the
names o f h o s p i t a l s , and t h e r e f o r e the t o t a l number, where
respondents are on s t a f f . The second question h i g h l i g h t e d two
pieces o f information: names of h o s p i t a l s , again the number,
which discharge e a r l y and i n d i r e c t l y the names and number o f
h o s p i t a l s which r a r e l y i f ever discharge e a r l y (see Table 1 ) .
29
�B i r t h i n g Centers
Discharge H a b i t s
as o f 12-31-92
Number o f
B i r t h i n g Centers
Which:
Percent o f
B i r t h i n g Centers
Which:
Routinely
Discharge
Infants
Early
50
88%
Do Not
Discharge
Infants
Early
5
9%
*Rarely
Discharge
Infants
Early
2
3%
57
100%
•
•
•
Total
* Respondents q u a l i f i e d t h e i r response
TABLE 1
The t h i r d ,
f o u r t h and f i f t h q u e s t i o n s s p e c i f i c a l l y requested
t h e number o f i n f a n t s i n v a r i o u s c a t e g o r i e s : t o t a l number seen,
of t h e t o t a l , t h e number d i s c h a r g e d e a r l y , and o f those
d i s c h a r g e d e a r l y , t h e number who were t e s t e d a g a i n f o r PKU. For
t h e sake o f keeping t h i n g s as s i m p l e and d i r e c t as p o s s i b l e ,
these t h r e e q u e s t i o n s were n o t asked about each h o s p i t a l , b u t
about each p e d i a t r i c i a n . These q u e s t i o n s , t o g e t h e r w i t h t h e f i r s t
two, g i v e d e t a i l t o t h e o v e r a l l p i c t u r e o f d i s c h a r g e p a t t e r n s .
Venn Diagrams (see f i g u r e 1.) a r e used t o r e p r e s e n t
p o p u l a t i o n s and s u b p o p u l a t i o n s , those who posses o r l a c k a
c e r t a i n c h a r a c t e r i s t i c o f t h e whole group and t h e r e l a t i o n s h i p
between each. The t o t a l p o p u l a t i o n i s r e p r e s e n t e d by t h e l a r g e
r e c t a n g l e . Subgroups a r e r e p r e s e n t e d by c i r c l e s . When two o r more
30
�c i r c l e s or subgroups have something i n common the c i r c l e s are
pushed together t o produce a f o o t b a l l shaped area. The common
area i s u s u a l l y shaded f o r emphasis.
NEONATAL HEALTH CAKE SYSIEH DROPOUTS?
T =
F igure 1.
T =
^ p o p u l a t i o n o f 10,662
nrjona Los
C =
m ? . n e o n a t e s hnoui;
e a r l y diacharge
c
shaded a r u a
b e t u e t m ft a m i
C arc neonates
rt and C c o u l d
KA WO i n connun
shaded a r e a
betwenn A , B , And
C a r e nsonatcs
fl, B . a n c C cou Id
have i n comnan
n e o n a t e s loioun
e a r l y d i s c h a r g e and
knoun r e t o s t e d f a r PKU
:
o
= 1688 n o o i m t e s o f
unknown d i s c h a r g e
those c h i l d r r n r c j e a s c d e a r l y
but n o t r c t s s t e d f o r FKU
Rectangle T represents the population o f 10,862 neonates.
C i r c l e A represents the subpopulation of 4,442 neonates
discharged e a r l y . C i r c l e B i s completely i n c i r c l e A because, of
the 17 4 2 neonates i n B, i t i s known t h a t they were discharged
e a r l y and they were retested f o r PKU. C i r c l e B i s not as large as
31
�c i r c l e A because n o t a l l t h e i n f a n t s i n A were r e t e s t e d
f o r PKU.
C i r c l e B's corona o r t h e area o u t s i d e o f B and i n s i d e A
r e p r e s e n t s those i n d i v i d u a l s who were r e l e a s e d e a r l y b u t n o t
retested
f o r PKU. Corona should c o n t a i n c i r c l e A minus c i r c l e B
number o f i n d i v i d u a l s o r , 4,442 - 1,742 = 2,700 b a b i e s . C i r c l e C
i s dashed because i t c o n t a i n s 1600 i n d i v i d u a l s o f unknown
d i s c h a r g e age. C o v e r l a y s A because some o f t h e 1600 were
p r o b a b l y d i s c h a r g e d e a r l y . I found t h a t i n Ohio, a p p r o x i m a t e l y
30% o f babies were r e l e a s e d from t h e b i r t h i n g
c e n t e r b e f o r e age
48 hours. C i r c l e C o v e r l a y s c i r c l e B because o f those
i n f a n t s r e l e a s e d e a r l y some were r e t e s t e d
information
f o r PKU.
1600
Since
about 1600 babies i s n o t known f o r purposes o f t h i s
s t u d y , t h e n t h e s i z e o f t h e f o o t b a l l , o r number o f i n d i v i d u a l s i n
t h a t area cannot be determined.
The c i r c l e s c o u l d have no i n f a n t s
i n common o r a l l i n f a n t s i n common. There i s no way t o know.
By o b s e r v a t i o n o f two samples (see O b s e r v a t i o n a l
Findings)
30% o f neonates were r e l e a s e d e a r l y and o f t h a t 30%, 40% d i d n o t
have a f o l l o w - u p PKU t e s t . Data gathered by q u e s t i o n n a i r e
i n d i c a t e d t h a t 10,862 i n f a n t s r e c e i v e d a n e o n a t a l checkup i n t h e
birthing
c e n t e r . Of those 10,862, 4,442 o r 4 1 % were r e l e a s e d
p r i o r t o age 48 hours. Of t h e 4,442 i n f a n t s r e l e a s e d e a r l y ,
or 39% were r e t e s t e d
f o r PKU. I t can be concluded
babies o f t h e 4,442, o r 6 1 % were n o t r e t e s t e d - f o r
1,742
t h e n t h a t 2,799
PKU.
1991 t h e r e were 165,000 babies b o r n . By e x t r a p o l a t i o n ,
I n Ohio i n
41% of
165,000 o r 68,000 i n f a n t s were r e l e a s e d e a r l y . F u r t h e r , 6 1 % o f
68,000 o r 41,500 babies were n o t r e t e s t e d
f o r PKU. The
cumulative
i n c i d e n c e o f PKU i n Ohio i s 1/13,300. That c o u l d mean
41,500/13,300 o r 3.1 c h i l d r e n w i t h mental r e t a r d a t i o n . PKU i s
32
�t r e a t a b l e and the associated mental r e t a r d a t i o n preventable.
Questions 6 through 9 (see Appendix E) were designed t o see
what inducements the p e d i a t r i c i a n s o f f e r e d moms so t h a t t h e
second PKU specimen would be c o l l e c t e d . None of the physicians
made house c a l l s t o c o l l e c t the specimens. Public h e a l t h nurses
are going t o some homes t o c o l l e c t follow-up PKU specimens.
Health professionals know t h a t once a p a t i e n t has been
discharged,
t h a t p a t i e n t may, f o r whatever reason, never r e t u r n
f o r follow-up care. An i n f a n t must r e l y on adults f o r everything
and t h a t includes health care. I t seems the optimal time and
place t o educate new moms about PKU and set up the follow-up
v i s i t i s while she's s t i l l i n the h o s p i t a l .
Information gleaned from surveys i s found i n Table 2.
33
�Doctors' I n - h o s p i t a l Education of New Moms
Number o f Percent o f
Doctors
Doctors
Who:
Who:
Discuss PKU Test Procedure and
R a t i o n a l e w i t h Mom
a. y e s
b. no
*c. sometimes
*d. o t h e r (nurse discusses)
e. no data
a.
b.
c.
d.
e.
21
10
5
5
2
T o t a l 43
Set up second appointment
a. w h i l e mom s t i l l i n h o s p i t a l
b. mom c a l l s f o r t h e appointment
a f t e r she g e t s home
*c. done t h r o u g h nurses a t h o s p i t a l
not t h e doctor
*d. t e s t t a k e n somewhere o t h e r t h a n
doctor o f f i c e
e. no data ( q u e s t i o n n o t answered o r
n o t an e a r l y d i s c h a r g e p h y s i c i a n )
49%
23%
12%
12%
5%
T o t a l 100%
a.
19
a.
44%
b.
7
b.
16%
c.
4
c.
9%
d.
5
d.
12%
e.
8
e.
19%
Total 4 3
Discuss w i t h mom how s h e ' l l g e t back
a. y e s
b. no
*c. sometimes
d. no data
a.
b.
c.
d.
e.
a.
b.
c.
d.
19
21
2
1
Total 4 3
T o t a l 100%
a.
b.
c.
d.
44%
49%
5%
2%
T o t a l 100%
* Respondents wrote c l a r i f y i n g remarks on survey
TABLE 2
Doctors who discussed t h e PKU t e s t procedure and r a t i o n a l e
w i t h new moms outnumbered those who d i d not by two t o one. F i f t y
percent o f t h e doctors do discuss. Almost one f o u r t h o f them do
not. Five out o f 4 3 p e d i a t r i c i a n s sometimes discussed procedure
and
r a t i o n a l e and another 5 o f 43 said nurses a t t h e h o s p i t a l
discussed the PKU t e s t w i t h moms.
Nineteen doctors out o f 4 3 took advantage o f t h e f a c t t h a t
34
�mom was t h e r e t o s e t up t h e second appointment. Seven had mom
c a l l t h e o f f i c e a f t e r she g o t home. Again, nurses a t t h e h o s p i t a l
s e t up t h e appointment e i t h e r f o r t h e d o c t o r ' s o f f i c e o r f o r
testing
a t t h e h o s p i t a l l a b . The number who d i s c u s s w i t h mom how
she w i l l g e t back (19) was almost equal t o t h e number who do n o t
d i s c u s s ( 2 1 ) . Sometimes people l i v e f a i r l y f a r from t h e b i r t h i n g
c e n t e r and/or do n o t have a c a r . Even i n t h i s h i g h l y m o b i l e
s o c i e t y , people cannot always g e t where t h e y need t o be when t h e y
need t o be t h e r e . P o s s i b l y d o c t o r s do n o t see p a t i e n t s '
t r a n s p o r t a t i o n problems as something w i t h which t h e y need t o be
concerned.
What do d o c t o r s do t o l o c a t e p a t i e n t s who were n o t back i n
f o r t h e second PKU t e s t ? Sometimes people do n o t make i t easy t o
be l o c a t e d .
D o c t o r s ' o f f i c e p e r s o n n e l and h o s p i t a l s t a f f spend a
g r e a t d e a l o f t i m e and money t r a c k i n g people. PKU k i t s o r
specimen cards need t o be t r a c k e d . H o s p i t a l s o r d o c t o r s pay
$24.00 a p i e c e f o r PKU cards (see A n e c d o t a l F i n d i n g s The
Accounting U n i t ) .
Some h o s p i t a l s send t h e second c a r d home w i t h
mom. Doctors t h e n would need t o have cards on hand f o r moms who
f o r g o t t h e i r c a r d o r d i d n o t g e t one from t h e h o s p i t a l . PKU cards
have numbers stamped on them. No two cards have t h e same number.
Some d o c t o r s r e c o r d t h e c a r d number on t h e c h i l d ' s c h a r t and some
do n o t . Questions 21-24 (see appendix E) y i e l d e d t h e f o l l o w i n g
data about t r a c k i n g .
35
�OFFICE TRACKING SYSTEM
Number o f
Doctors
Whose
System f o r
Tracking
Mom and baby i s :
a. t e l e p h o n e
b. send reminder cards
c. c o n t a c t l o c a l h e a l t h department
d. o t h e r ( p o l i c e )
e. some c o m b i n a t i o n o f above
* f . t e s t n o t taken a t doctor's
o f f i c e o r n o t an e a r l y d i s c h a r g e
doctor
g. No data
a.
b.
c.
d.
e.
f.
3
1
1
4
13
10
a.
b.
c.
d.
e.
f.
8%
2%
2%
8%
29%
22%
g.
13
g.
29%
T o t a l 45
PKU CARDS i s :
a. have cards a t t h e o f f i c e
b. have moms b r i n g c a r d
c. t e s t t a k e n somewhere o t h e r t h a n
d o c t o r ' s o f f i c e o r n o t an e a r l y
discharge physician
*d. yes t o a and b because sometimes
mom f o r g e t s c a r d
8
12
12
a.
b.
c.
18%
27%
27%
d.
13
d.
29%
a.
b.
c.
14
21
10
T o t a l 45
* Respondents c l a r i f i e d response
TABLE 3
36
T o t a l 100%
a.
b.
c.
T o t a l 45
PKU CARD NUMBER i s :
a. r e c o r d e d on baby's c h a r t
b. n o t recorded
c. t e s t done somewhere e l s e o r
d o c t o r n o t an e a r l y d i s c h a r g e
physician
Percent o f
Doctors
Whose
System f o r
Tracking
T o t a l 100%
a.
b.
c.
31%
46%
22%
T o t a l 100%
�New moms are v e r y busy people. The PKU c a r d i s n o t an
o r d i n a r y baby i t e m . Some h o s p i t a l s have moms s i g n f o r t h e c a r d s ,
b u t t h a t does not mean mom w i l l remember. T h i s c o u l d e x p l a i n why
d o c t o r s answered yes t o "cards a r e a t t h e o f f i c e " and "mom b r i n g s
t h e c a r d w i t h her". I t appears t h i s system c o u l d use some work.
At one t i m e t h e r e was no charge f o r t h e cards so cards were n o t
as v a l u a b l e as today.
Almost 50% o f t h e d o c t o r s who responded do n o t r e c o r d t h e
PKU c a r d number on t h e baby's c h a r t . They have access t o t h e
number, why n o t r e c o r d i t ? P o s s i b l y , t h e r e i s no reason t o r e c o r d
it.
On t h e l a b o r a t o r y end t h e r e i s no reason t o r e c o r d i t . The
number i s n o t matched w i t h numbers assigned
a t t h e l a b . Very
l i t t l e data i s s t o r e d i n computer and when someone c a l l s f o r
r e s u l t s t h e c a r d number does l i t t l e o r n o t h i n g t o a i d t h e
search
f o r t h e c a r d . Perhaps t h e d o c t o r s f i n d no r e a l use f o r t h e number
and t h e r e f o r e no reason t o r e c o r d i t . A c c o u n t i n g
uses t h e numbers
t o keep t r a c k o f which h o s p i t a l s r e c e i v e which cards.
Doctors
might c o n s i d e r r e c o r d i n g t h e number f o r a c c o u n t i n g purposes and
f o r in-house r e c o r d s .
F o r t y - n i n e p e r c e n t o f t h e d o c t o r s who responded t r a c k
p a t i e n t s by t e l e p h o n e , reminder
cards, t h r o u g h t h e h e a l t h
department, p o l i c e , and o t h e r agencies.
Some 22% e i t h e r do n o t
d i s c h a r g e e a r l y o r t h e moms go somewhere o t h e r t h a n
their
d o c t o r ' s o f f i c e f o r t h e t e s t . Twenty-nine p e r c e n t d i d n o t
respond. Perhaps t h e y f e l t t h e y had a l r e a d y answered t h e
q u e s t i o n . Some respondents suggested q u e s t i o n s were
redundant.
Table 4 i s a d o c t o r p r o f i l e (see Table 4 ) . Questions were
s t r a i g h t f o r w a r d and t h e few non responses were p r o b a b l y due t o
37
�t h e p e r s o n a l n a t u r e o f t h e q u e s t i o n s . Seventy p e r c e n t o f t h e
d o c t o r s a r e middle-aged, w h i t e , E n g l i s h speaking males.
Seventy-
n i n e p e r c e n t o f t h e d o c t o r s who responded had an o f f i c e i n o r
near a c i t y . Since d o c t o r s responded t o t h i s q u e s t i o n n a i r e t h e y
certainly
know t h i s i n f o r m a t i o n about themselves. I t was expected
t h a t t h e d o c t o r s would be easy t o p r o f i l e . Medicine i s a male
dominated f i e l d . C e r t a i n l y a l l have t h e same l e v e l o f e d u c a t i o n .
A l l t h e d o c t o r s surveyed were p e d i a t r i c i a n s . For a l l t h e s e
d o c t o r s have i n common, t h e r e a r e some d i f f e r e n c e s . A l l t h e
d i f f e r e n c e s were noted. The most n o t a b l e d i f f e r e n c e s were t h e
second languages o f t h e d o c t o r s . Ten d o c t o r s o f 45, o r 22%, spoke
a second language. Two respondents o f 45, o r 4%, s a i d t h a t
Spanish was t h e i r second
language.
38
�DOCTOR PROFILE
Number o f
Doctors
Whose:
a.
b.
c.
Gender i s :
a. female
b. male
c. no d a t a
Percent o f
Doctors
Whose:
a.
b.
c.
8
35
2
Total 4 5
E t h n i c / R a c i a l backgrounds i s :
a. A s i a n I s l a n d e r
b. Black/Non-Hispanic
c. H i s p a n i c
d. White/Non-Hispanic
e. Other (Chinese, A s i a n , I n d i a n )
f . No d a t a
a.
b.
c.
d.
e.
f.
3
1
1
32
3
5
T o t a l 45
Spoken language i s
a. E n g l i s h o n l y
*b. E n g l i s h and o t h e r
c. no d a t a
a.
b.
c.
32
10
3
Total 4 5
Age range i s :
a. 25 - 34
b. 35 - 44
c. 45 - 54
d. 55 - 64
e. 65 - 74
f . No d a t a
a.
b.
c.
d.
e.
f.
6
11
14
10
1
3
Total 4 5
O f f i c e i s Located i n t h e
a. c i t y
b. c o u n t r y
c. suburbs
d. o t h e r (town, t o w n s h i p , v i l l a g e )
e. no d a t a
a.
b.
c.
d.
e.
19
5
16
4
1
Total 4 5
18%
78%
4%
T o t a l 100%
a.
b.
c.
c.
e.
d.
7%
2%
2%
71%
7%
11%
T o t a l 100%
a.
b.
c.
71%
22%
7%
T o t a l 100%
a.
b.
c.
c.
e.
d.
13%
24%
31%
22%
2%
7%
T o t a l 100%
a.
b.
c.
d.
e.
43%
11%
36%
9%
2%
T o t a l 100%
* (Chinese 1, Hungarian 1, Hindu 1, Telugu 1, German 1, Spanish
2, Korean 2, F i l i p i n o 1)
TABLE 4
39
�When t h i s p r o j e c t was f i r s t undertaken i t was expected
that
a " t y p i c a l " e a r l y d i s c h a r g e mom who b r o u g h t h e r baby i n f o r t h e
second PKU t e s t would appear. F u r t h e r t h o u g h t c o u l d n o t c o n j u r e
up a mental image o f a " t y p i c a l mom". Moms come i n a l l s i z e s ,
shapes, c o l o r s , and creeds, Responses bore t h a t o u t .
Q u e s t i o n 3 3 (see Appendix E) asked each p h y s i c i a n about t h e
r a c i a l / e t h n i c background
o f a t y p i c a l e a r l y d i s c h a r g e mom. S i x t y -
f o u r p e r c e n t o f t h e respondents s a i d she was w h i t e / n o n - H i s p a n i c .
T h i r t y - s i x p e r c e n t broke t h e i r responses
i n t o p e r c e n t s by race
( i . e . 50% w h i t e , 30% b l a c k , 20% H i s p a n i c ) o r i n some way
i n d i c a t e d t h e r e i s no such t h i n g as a " t y p i c a l " e a r l y d i s c h a r g e
mom. On every q u e s t i o n about t h e mom where t h e r e was a c h o i c e a
c e r t a i n percentage o f respondents would make t h e c h o i c e and
a n o t h e r percentage would n o t . They c i r c l e d a l l t h a t a p p l i e d .
Who has a say i n how l o n g mom and baby w i l l be h o s p i t a l i z e d ?
O b v i o u s l y d o c t o r s , i n s u r a n c e companies, h o s p i t a l s and moms do.
When t h a t many people have a say t h e r e i s no p o s s i b l e way a
" t y p i c a l " c o u l d emerge. New moms and new babies a r e from a l l
socio-economic
l e v e l s . One would expect t h a t babies who were
r e l e a s e d e a r l y and d i d n o t have a second PKU t e s t would a l s o be
from low, m i d d l e , and upper c l a s s f a m i l i e s . Table 5 i s more o f a
p r o f i l e o f every e a r l y d i s c h a r g e mom r a t h e r t h a n a t y p i c a l
early
d i s c h a r g e mom (see Table 5 ) .
L i t e r a t u r e from t h e Ohio Department o f H e a l t h , i n c l u d i n g t h e
PKU c a r d , was a v a i l a b l e o n l y i n E n g l i s h . Four p e r c e n t o f d o c t o r s
speak Spanish as a second language. Seven p e r c e n t o f t h e
respondents s a i d t h a t Spanish was t h e second language
for a
" t y p i c a l " e a r l y d i s c h a r g e mom. Two p e r c e n t o f t h e respondents
40
�stated t h a t t h e i r " t y p i c a l " e a r l y discharge mom spoke Spanish.
Ohio has a large Spanish speaking population. Some are
t r a n s i e n t s . Many are permanent Ohio residents. Ohio has taken a
proactive stance i n a t t r a c t i n g business and i n d u s t r y , thus
i n d i v i d u a l s , from a l l p o i n t s on the globe. Ohio's i n s t i t u t i o n s of
higher l e a r n i n g a t t r a c t students froamaround the world. Many "Ohioans" s
languages other than English. I t seems t o me t h a t a
language/culture gap between providers and p a t i e n t s e x i s t s and
could, t h e r e f o r e , c o n t r i b u t e t o a low compliance r a t e .
41
�EARLY DISCHARGED M M PROFILE
O
Number of
Early
Discharged
M m Whose:
os
Ethnic/Racial background i s :
a.
a. Uhite/non-Hispanic
b. answered more than one choiceO'.e b.
50% white, 30% black, 20% Hispanic)
28
16
Total 44
Spoken language is
a. English only
*b. English and other
*c. other than English only
d. no data
a.
b.
c.
d.
34
4
4
2
Total 44
Age range i s :
a. 15 - 19
b. 20 - 24
c. 25 - 29
d. 30 - 3A
•e. any age
f. No data
a.
b.
c.
d.
e.
f.
4
11
12
2
5
10
Total 44
Residence is located in the
a. city
b. country
c. suburbs
d. answered more than 1 choice)
e. no data
a.
b.
c.
d.
e.
6
6
7
22
3
Total 44
Level of Education is
a. some high school
b. graduated high school
c. some col lege
•d. a l l levels
e. no data
a.
b.
c.
d.
e.
4
16
9
2
13
Total 44
Method of payment for health care
services i s :
a. private health insurance
b. Medicaid
c. self pay
d. chose more than one response
e. no data
a.
b.
c.
d.
e.
13
8
6
15
2
Total 44
Marital Status i s :
a. never married
b. married
c. living with father
d. living with parents
e. chose more than 1 response
f. no data
a.
b.
c.
d.
e.
f.
4
24
3
2
9
2
Total 44
Percent of
Early
Discharged
M m Whose:
os
a.
b.
64%
36%
Total 100%
a.
b.
c.
d.
77%
9%
9%
5%
Total 100%
a.
b.
c.
c.
e.
d.
9%
25%
27%
5%
11%
23%
Total 100%
a.
b.
c.
d.
e.
14%
14%
16%
50%
7%
Total 100%
a.
b.
e.
f.
e.
9%
36%
20%
5%
30%
Total 100%
a.
b.
c.
d.
e.
30%
18%
14%
34%
5%
Total 100%
a.
b.
c.
d.
e.
f.
9%
55%
7%
5%
20%
5%
Total 100%
•(Spanish 3, Chinese 1) *(Spanish 1) •(respondents clarified
response)
TABLE 5
42
�One
doctor d i d not respond t o a s i n g l e question but wrote
t h a t the survey was too long and he d i d not have the records t o
respond. Another doctor answered every question and sent a two
page l e t t e r d e t a i l i n g the d i f f e r e n c e between having a p r i v a t e
p r a c t i c e and being "on c a l l " t o see a baby who has no physician.
Of the p r i v a t e p r a c t i c e p a t i e n t s ( i n t h i s case 95% white non
welfare)
i t was rare when a second PKU t e s t was not obtained.
Such was not the case f o r the "on c a l l " p a t i e n t s . He went on t o
say t h a t e a r l y discharge was not a medical decision, but an
insurance decision. He concludes t h a t as more i n f a n t s are
discharged e a r l i e r , i t w i l l become more d i f f i c u l t t o obtain
the
second PKU's. He wondered who's r e s p o n s i b i l i t y i t i s t o have the
i n f a n t t e s t e d . I s i t the mother's or the doctor's? His biggest
problem w i t h the t e s t i n g system i s t h a t he has d i f f i c u l t y
getting
reports back from the laboratory. A new r e p o r t i n g system was
suggested and he described how i t would work. He i s awaiting my
response and survey r e s u l t s .
Comments between too long and the 2 page l e t t e r were o f f i v e
general t o p i c s : t r a c k i n g , non compliance, e a r l y discharge moms,
why moms are released e a r l y , and the survey i t s e l f . Trying t o
keep t r a c k of the babies can be d i f f i c u l t . One physician
in
northern Ohio does not have t o do the second PKU t e s t . Everything
i s arranged by the nurses at the h o s p i t a l . Nurses explain
the
t e s t t o the moms. Moms b r i n g t h e i r babies back t o the h o s p i t a l
f o r the second PKU t e s t . At another h o s p i t a l near C i n c i n n a t i ,
again, the nurses do the follow-up. One doctor wrote t h a t even
a f t e r moms received,
PKU,
j u s t p r i o r t o discharge: a l e t t e r
explaining
a PKU card, and an appointment t o come t o the o f f i c e , many
43
�never come and i f t h e y do t h e y have f o r g o t t e n t h e c a r d . A nurse
i n C l e v e l a n d suggested more home h e a l t h nurse v i s i t s t o e a r l y
d i s c h a r g e moms.
I n y e t a n o t h e r n o r t h e r n Ohio town, t h e home
h e a l t h nurses do t h e f o l l o w - u p f o r PKU.
Of two respondents t h a t commented on t h e i s s u e o f
noncompliance one suggested t h a t non compliance s h o u l d c a r r y a
c r i m i n a l p e n a l t y and t h e o t h e r r o u t i n e l y t e l l s h i s p a t i e n t s t h a t
noncompliance
i s a form o f c h i l d n e g l e c t . He f i n d s h i s p a t i e n t s
do comply. A Dayton area p h y s i c i a n u n d e r s t o o d t h a t t h e h o s p i t a l
was t o do t h e second PKU t e s t so he does n o t have a compliance
problem. One d o c t o r w r o t e t h a t noncompliance was n o t a problem i n
h i s suburban p r a c t i c e .
I s t h e r e such a person as a " t y p i c a l " e a r l y d i s c h a r g e mom?
Two d o c t o r s w r o t e t h e r e i s no " t y p i c a l " e a r l y d i s c h a r g e mom. Two
d o c t o r s d e s c r i b e d an " i d e a l " e a r l y d i s c h a r g e mom. The " i d e a l "
e a r l y d i s c h a r g e mom:
-must n o t be a f i r s t - t i m e mom
-must have had c h i l d b i r t h c l a s s e s
-must have had no p r e n a t a l
(documented)
problems
(documented p r e n a t a l v i s i t s )
-must have good s u p p o r t system a t home
-must have common sense
" I d e a l s " a r e few and f a r between.
44
�COMMENTS
Percent
Number
Comments i n comment s e c t i o n and t h e n a t u r e
o f t h o s e was:
a. t r a c k i n g
b. consequences o f non compliance
c. an " i d e a l " e a r l y d i s c h a r g e mom o r no
" t y p i c a l e a r l y d i s c h a r g e mom"
d. why moms a r e sent home e a r l y
e. t h e survey i t s e l f
a.
b.
c.
6
2
3
a.
b.
c.
13%
4%
7%
d.
e.
6
8
d.
e.
13%
18%
Comments made t h r o u g h o u t r a t h e r than i n
comment s e c t i o n and n a t u r e o f was:
a. t r a c k i n g ( p o l i c e , c h i l d r e n ' s s e r v i c e s )
b. j u s t s t a r t e d
c. nurses and h o s p i t a l s arrange f o r and do
follow-up
d. Ask a t 2 week o f age appointment i f baby
was d i s c h a r g e d e a r l y
a.
b.
c.
1
1
1
a.
b.
c.
2%
2%
2%
d.
1
d.
2%
Not e a r l y d i s c h a r g e
comments
Comments o n l y
p h y s i c i a n s so no
(too long),no
2
1
responses
4%
2%
No comments
13
29%
Total
45
100%
TABLE 6
Why a r e moms and t h e i r i n f a n t s b e i n g d i s c h a r g e d
a t anywhere
from 12 t o 48 hours a f t e r d e l i v e r y ? Respondents suggested
insurance
o r t h e l a c k t h e r e o f was r e s p o n s i b l e . Maybe a week's
s t a y was t o o l o n g . I n t h e '60s new moms stayed 4-5 days. Now, i n
1993, i f women s t a y a f u l l 48 hours t h a t i s c o n s i d e r e d
a long
stay.
Every day b r i n g s new t e s t s , procedures, and equipment which
a l l o w f o r i n u t e r o d e t e c t i o n o f c o n d i t i o n s , d e f e c t s , and even
gender. F o r t u n a t e l y , a l l t h i s i s a v a i l a b l e . Nonetheless, g i v i n g
b i r t h i s g i v i n g b i r t h . No procedure can s h o r t e n r e c o v e r y
time.
New moms a r e r e c o v e r i n g a t home r a t h e r t h a n i n t h e h o s p i t a l . Some
45
�p h y s i c i a n s do n o t d i s c h a r g e new moms u n t i l 48 hours a f t e r
d e l i v e r y . Respondents w r o t e t h a t t h e i n s u r a n c e companies and
M e d i c a i d a r e n o t w i l l i n g t o pay f o r 2 day s t a y s . M e d i c a i d moms
were seen by respondents as b e i n g f a r l e s s l i k e l y t o r e t u r n f o r
t h e second PKU t e s t t h a n p r i v a t e l y i n s u r e d moms. One d o c t o r w r o t e
t h a t home h e a l t h nurses a r e sent t o t h e homes o f t h e moms
d i s c h a r g e d e a r l y . A c c o r d i n g t o one respondent 75% o f M e d i c a i d
p a t i e n t s do n o t r e t u r n compared t o 20% o f p r i v a t e l y i n s u r e d
p a t i e n t s . Another comment about i n s u r a n c e coverage was t h a t i f
p a t i e n t s were i n t h e h o s p i t a l f o r 48 hours t h e PKU t e s t was
covered. I f mom and baby were d i s c h a r g e d e a r l y and t h e y had t o
have t h e second t e s t , t h e n t h a t c o u l d c o s t as much as $50.00 and
was n o t covered by i n s u r a n c e .
A d o c t o r from t h e Dayton area w r o t e t h a t t h e M e d i c a i d moms
are "pushed" o u t t h e door a t 24 hours a f t e r d e l i v e r y . Some babies
are n o t ready f o r e a r l y d i s c h a r g e and a r e k e p t a n o t h e r day. The
l a s t comment o f 5 on i n s u r a n c e r e i t e r a t e d t h e o t h e r s when he
w r o t e t h a t M e d i c a i d and most p r i v a t e i n s u r e r s urge
early
discharge.
F i n a l l y , on t h e survey i t s e l f , commentors suggested t h e
f o l l o w i n g : use fewer q u e s t i o n s , ask t h e same q u e s t i o n s about
p r i v a t e l y i n s u r e d p a t i e n t s and Medicaid p a t i e n t s and t h e
responses
would be d i f f e r e n t , were t h e responses
a c c u r a t e enough,
some redundancy, and a r a t i n g o f 1-5 would have been b e t t e r t h a n
yes o r no.
One d o c t o r from t h e Youngstown area who does n o t d i s c h a r g e
e a r l y w r o t e t h a t t h i s q u e s t i o n n a i r e was one o f t h e problems
46
�created by the early discharge p o l i c y . He d i d go on and describe
an " i d e a l " e a r l y discharge mom. Several respondents wished me
luck.
The comments which the doctors wrote were sometimes more
informative than t h e i r responses. Comments were found throughout
and served t o c l a r i f y responses. I was glad t o get them.
47
�VII.
CONCLUSIONS
The f o l l o w i n g c o n c l u s i o n s are based on my responses from
q u e s t i o n n a i r e s and i n t e r v i e w s and o b s e r v a t i o n s . There i s a
problem.
Between 20,000 and 40,000 b a b i e s , per year, i n Ohio, a r e
d i s c h a r g e d e a r l y and do n o t have a second PKU t e s t .
There i s a language mismatch between t h e p h y s i c i a n s and
p a t i e n t s . There i s vague wording i n d e p a r t m e n t a l
e s p e c i a l l y "Why Must My Newborn Be Screened?"
literature
Departmental
pamphlets and p u b l i c a t i o n s are a v a i l a b l e o n l y i n E n g l i s h , t h i s
i n c l u d e s t h e Newborn Screening c a r d . A f u l l y o p e r a t i o n a l
computerized
t r a c k i n g system i s l a c k i n g .
Neonatal s c r e e n i n g f o r PKU i s a subsystem o f t h e h e a l t h care
system. P e d i a t r i c i a n s a r e one v i t a l
l i n k i n t h e c h a i n . A l l o f us
have a s t a k e i n t h e d e l i v e r y o f h e a l t h care s e r v i c e s . When t h e
n e o n a t a l s c r e e n i n g system f u n c t i o n s o p t i m a l l y , r e p e a t PKU
specimens w i l l be c o l l e c t e d . E a r l y d i s c h a r g e i s more t h e r u l e
t h a n t h e e x c e p t i o n . To p r o v i d e newborn s c r e e n i n g t o t h e maximum
p o s s i b l e e x t e n t I am p r o p o s i n g t h e f o l l o w i n g recommendations.
48
�RECOMMENDATIONS
* Develop a p h y s i c i a n awareness program t h a t h i g h l i g h t s : t h e
scope o f t h e problem, and t h e l a n g u a g e / c u l t u r e gap between
system s t a k e h o l d e r s .
* Regional seminars would be h e l d t h a t i n c l u d e d
r e p r e s e n t a t i v e s o f a l l system s t a k e h o l d e r s . W i t h i n c r e a s e d
compliance documented, p h y s i c i a n s would be rewarded f o r a
c e r t a i n p e r c e n t i n c r e a s e ( I would suggest a decrease i n c a r d
fees).
* Develop a program t o h e i g h t e n p u b l i c awareness o f PKU t e s t
procedure, r a t i o n a l e , and a v a i l a b i l i t y i n t h e p u b l i c ' s
n a t i v e language(s).
* Develop a more i n t e n s i v e e d u c a t i o n a l program f o r pregnant
women and new mothers i n t h e i r n a t i v e l a n g u a g e ( s ) .
* I n c r e a s e t e s t a v a i l a b i l i t y t h r o u g h c r e a t i v e use o f a l l
resources.
"For t h e H e a l t h o f I t " a d v e r t i s e m e n t s
would be p l a c e d on t h e
s i d e s o f buses. N o t i c e s posted i n s c h o o l s , d o c t o r s *
offices,
c l i n i c s , p o s t o f f i c e s , banks, churches, g r o c e r y s t o r e s , bus
s t o p s , b i l l b o a r d s , l i b r a r i e s , day care centers•, o t h e r
agencies'
c l i n i c s o r l o c a l o f f i c e s who d e a l w i t h moms and young c h i l d r e n
( i . e . Head S t a r t , WIC, C h i l d r e n s S e r v i c e s ) e t c . Radio and TV
spots would be broadcast
i n s e v e r a l languages d u r i n g prime t i m e
and on Saturday mornings. P r i n t e d ads, n o t i c e s , and i n f o r m a t i o n
would be a v a i l a b l e i n t h e 5 most f r e q u e n t l y spoken languages i n
Ohio. L e a f l e t s would be a v a i l a b l e where pregnant women, new moms,
and babies o b t a i n h e a l t h care.
A l l m a t e r i a l , whether broadcast
o r p r i n t e d , would c o n t a i n
i n f o r m a t i o n about where t h e t e s t would be t a k e n , days and t i m e s
t o go, c o s t i f any, t e l e p h o n e numbers, who and how t o c o n t a c t
someone f o r f u r t h e r i n f o r m a t i o n about t h e t e s t , o r how t o g e t t h e
test
(an 800 number).
49
�Some people l i t e r a l l y do n o t have t h e means o r methods t o
g e t t o t h e t e s t i n g s i t e . Some people do n o t have t e l e p h o n e
s e r v i c e a t t h e i r r e s i d e n c e . Even i f t h e y have means and methods
a v a i l a b l e , t h e y may l i v e many m i l e s from a h o s p i t a l o r d o c t o r ' s
o f f i c e o r c l i n i c . C l i n i c s would need t o be open more o f t e n and
more c o n v e n i e n t hours. I f people cannot g e t i n f o r a t e s t , t h e
t e s t s h o u l d come t o them. Doctors do n o t make house c a l l s , b u t
p u b l i c h e a l t h nurses do.
The a t t e n d i n g p h y s i c i a n and h o s p i t a l p e r s o n n e l would d i s c u s s
w i t h new moms t e s t procedures and r a t i o n a l e and a l l t h e
p a r t i c u l a r s o f where t o go f o r i t .
C r i t e r i o n would be s e t up t o
d e t e r m i n e whether o r n o t mom c o u l d be expected t o r e t u r n and how.
I f t h e r e was any doubt about t h e p r o s p e c t o f mom r e t u r n i n g t h e n
t h e home v i s i t a t i o n nurse would be s e n t t o t h e r e s i d e n c e t o
c o l l e c t t h e PKU specimen. C r i t e r i o n might i n c l u d e : d i d she. have
r o u t i n e p r e n a t a l c a r e , how d i d she g e t t o t h e h o s p i t a l t o d e l i v e r
t h i s baby, does she have h e a l t h i n s u r a n c e , does she work o u t s i d e
home, how o l d i s she, what i s h e r " s u p p o r t " system l i k e , and
c o u l d she demonstrate knowledge o f t h e PKU t e s t procedure and
r a t i o n a l e and s i g n a s t a t e m e n t , i n t h e i r spoken language, t o t h a t
effect.
* I n s t i t u t e a system-wide computerized t r a c k i n g system t o
b e t t e r serve Ohio's newest r e s i d e n t s .
The t e c h n o l o g y i s a v a i l a b l e , u n f o r t u n a t e l y i t i s n o t i n
p l a c e . Many bureaus o f ODH t r a c k t h e same p o p u l a t i o n b u t f o r
d i f f e r e n t reasons. V i t a l S t a t i s t i c s keeps b i r t h
certificates,
Newborn S c r e e n i n g keeps PKU t e s t r e c o r d s and r e s u l t s , and
50
�Preventive Medicine administers Ohio's immunization program.
I n f a n t s are assigned many d i f f e r e n t numbers by the same Ohio
Department o f Health. My proposed t r a c k i n g system would assign
one number t o each i n f a n t and a l l bureaus (the l a b , v i t a l
stats,
accounting, preventive medicine, WIC) w i t h i n the department would
t r a c k by t h a t same number. Tracking would also be possible by
l a s t name o f mom and/or baby.
The neonatal screening form would be redesigned. A l l pages
of the form would have the same p r e p r i n t e d number on them and on
the f i l t e r paper tab. Two new pages would be: a page t o replace
the form f o r r e g i s t e r i n g a l i v e b i r t h i n Ohio, and a form f o r the
parent(s) t o obtain a c e r t i f i e d copy of the b i r t h c e r t i f i c a t e .
PKU cards and any other information d i s t r i b u t e d by the Ohio
Department of Health would be available
i n several languages.
Hence, the lab and v i t a l s t a t i s t i c s would have the same
number. An account or record would be s t a r t e d a t preventive
medicine w i t h the same newborn screening number. Accounting knows
which h o s p i t a l s pay f o r and receive which cards, but unless t h e
h o s p i t a l t o l d accounting or unless accounting examined the lab's
records, accounting never knew which baby had used which card.
With t h i s system they would know. They would also know where
every card, whether paid f o r or not, went.
Any card received would be categorized by lab personnel,
assembled i n t o an appropriate pack, and assigned a lab accession
number. Then specimen status would be entered i n t o the computer.
Any specimen status or r e s u l t would be entered as they became
available.
L i s t s of specimens needing f u r t h e r t e s t i n g would be
generated. Specimens p u l l e d f o r f u r t h e r t e s t i n g would be
51
�renumbered
a p p r o p r i a t e l y and t h a t l i s t e n t e r e d i n t o t h e computer.
Doctors and h o s p i t a l s would r e c e i v e r e s u l t s and updates
e l e c t r o n i c a l l y . Doctors and h o s p i t a l s and o t h e r ODH bureaus
would be a b l e t o query t h e system e l e c t r o n i c a l l y .
I f a PKU t e s t specimen was found t e s t a b l e and baby was
d i s c h a r g e d a t 48 hours o f age o r l a t e r t h e n when r e s u l t s became
a v a i l a b l e , t h e c a r d t o r e g i s t e r t h e b i r t h and t h e c a r d f o r a
c e r t i f i e d copy o f t h e b i r t h c e r t i f i c a t e would be s e n t t o V i t a l
S t a t i s t i c s . When t h e l a b sent t h e cards t o v i t a l s t a t i s t i c s t h e
computer r e c o r d a t t h e l a b f o r t h a t baby would be marked
a c c o r d i n g l y . The l a b would t r a n s m i t an a c t u a l and e l e c t r o n i c
of
list
c a r d numbers s e n t t o v i t a l s t a t i s t i c s . V i t a l s t a t i s t i c s would
e n t e r t h e c a r d number i n t o t h e computer and p r e p a r e b i r h t
c e r t i f i c a t e s and c o p i e s o f b i r t h c e r t i f i c a t e s . V i t a l
Statistics
would t r a n s m i t an a c t u a l and e l e c t r o n i c l i s t t o t h e l a b . That
l i s t would c o n t a i n t h e numbers o f t h e cards V i t a l S t a t i s t i c s had
r e c e i v e d from t h e l a b and whether o r n o t t h e b i r t h had been
r e g i s t e r e d and c o p i e s o f t h e c e r t i f i c a t e s e n t t o p a r e n t s ,
hospital, etc.
What about i n f a n t s whose n e o n a t a l s c r e e n i n g specimens were
drawn b e f o r e age 48 hours? L i s t s would be g e n e r a t e d a t t h e l a b o f
c h i l d r e n who were sampled b e f o r e age 48 hours and who were resamp l e d . L i s t s would proceed as above. When t h e second specimen was
r e c e i v e d a t t h e l a b p r o c e s s i n g would proceed as above.
The l i s t o f t h o s e n o t resampled would be s e n t t o m a t e r n a l
and c h i l d h e a l t h , h o s p i t a l s , d o c t o r s , and l o c a l h e a l t h
departments. Those e n t i t i e s would t h e n be a b l e t o s t a r t
52
looking
�f o r t h e b a b i e s so t h a t n e o n a t a l t e s t i n g c o u l d be completed and
the
b i r t h r e g i s t e r e d . The f i r s t i n c e n t i v e o r n e g a t i v e consequence
f o r a p a r e n t whose baby had n o t been s u f f i c i e n t l y
t e s t e d f o r PKU:
p a r e n t ( s ) would n o t be a b l e t o o b t a i n a c e r t i f i e d copy o f t h e
child's b i r t h certificate.(birth
not registered or registered
w i t h a h o l d on i t ) .
* H o s p i t a l s would s t o p sending newborn s c r e e n i n g cards home
w i t h mom and baby a t t h e t i m e o f d i s c h a r g e .
S i t e l o c a t i o n s and hours and days o f o p e r a t i o n would be
determined
by a l l s t a k e h o l d e r s t o p r o v i d e maximum t e s t
availability.
PKU cards would be a v a i l a b l e a t those
places
( h o s p i t a l s , c l i n i c s , doctor's o f f i c e s , l o c a l h e a l t h departments).
Home v i s i t a t i o n nurses and p u b l i c h e a l t h nurses would b r i n g t h e
cards w i t h them.
* Modify computer hardware and s o f t w a r e t o accommodate any
Newborn Screening l a b employee no m a t t e r how d i f f e r e n t l y
a b l e d we a r e .
People who a r e underemployed u s u a l l y l a c k t h e t o o l s t o
p e r f o r m a t a s k r a t h e r t h a n s k i l l s . A computerized
t r a c k i n g system
i s a t o o l f o r t h e whole h e a l t h care system. U n d e r u t i l i z e d t o o l s
are a h i n d r a n c e t o a l l .
* Immediately change t h e m i s l e a d i n g wording
Newborn Be Screened?"
i n "Why Must My
Page 2 o f t h e pamphlet s t a t e s : " I f your baby goes home from
the
h o s p i t a l b e f o r e 48 hours t h e t e s t may need t o be done a g a i n . "
I t s h o u l d read " . . . t h e t e s t MUST be done a g a i n . "
53
�IX. AREAS OF FUTURE STUDY
One area o f t h e problem o f non compliance i n t h e n e o n a t a l
h e a l t h c a r e system was s t u d i e d . Many areas need t o be examined.
Some o f t h e i n t e r v i e w e e s and my own o b s e r v a t i o n s and c u r i o s i t i e s
l e d me t o i n c l u d e t h e f o l l o w i n g areas o f f u t u r e s t u d y .
* Conduct a s t u d y t o d e t e r m i n e when t e s t i n g s i t e s s h o u l d be
open and where t h e y s h o u l d be. Would fewer s i t e s open more
hours be b e t t e r f o r a l l ? Should more s i t e s be open fewer o r
d i f f e r e n t hours?
* A s t u d y would be conducted which would l o o k i n t o t h e
f o l l o w i n g q u e s t i o n s : What i s t h e maximum amount o f t i m e and
money t o be spent t o g a i n compliance? What i s ODH's t a r g e t e d
compliance r a t e ? What i s ODH's a n t i c i p a t e d compliance r a t e ?
What w i l l be done t o i n c r e a s e compliance r a t e s ?
* An i n v e s t i g a t i o n would be undertaken t o l o o k a t t h e f l o w o f
PKU cards from ODH and l o c a l h e a l t h departments.
* T r e a t e d p h e n y l k e t o n u r i c s have t h e p o t e n t i a l t o pass on t h e
genes f o r PKU. The number o f PKU genes i n t h e p o p u l a t i o n
would t h e n i n c r e a s e . Ways must be found t o p r e v e n t t h e
misuse o r abuse o f i n f o r m a t i o n c o n c e r n i n g c a r r i e r s o f PKU
and t r e a t e d p h e n y l k e t o n u r i c s . No one s h o u l d be d e p r i v e d o f
t h e i r c i v i l r i g h t s because t h e y are c a r r i e r s o f a c o n d i t i o n
o r have a c o n d i t i o n which i s b e i n g t r e a t e d .
* H a m i l t o n County uses t h e monies c o l l e c t e d from a t a x t o
enable i n d i g e n t moms s t a y i n t h e h o s p i t a l f o r a f u l l 48
hours f o l l o w i n g d e l i v e r y . How s u c c e s s f u l has t h e program
been? Could i t go s t a t e w i d e ?
* Look i n t o s t u d i e s t h a t have been conducted around t h e
f o l l o w i n g q u e s t i o n s . What i s t h e r a t e o f r e a d m i s s i o n f o r
moms o r babies who were d i s c h a r g e d p r i o r t o 48 hours? I s
t h a t s i g n i f i c a n t l y h i g h e r t h a n r e a d m i s s i o n r a t e s f o r moms o r
b a b i e s who were d i s c h a r g e d a t o r a f t e r 48 hours?
* Survey t h e moms who were d i s c h a r g e d b e f o r e 48 hours and came
back f o r t h e second PKU t e s t t o f i n d o u t what g o t them back.
* Test t h e e f f i c a c y o f an e d u c a t i o n program about PKU. Two
hundred pregnant women would be i n a c o n t r o l group and two
hundred pregnant women i n a t r e a t m e n t group. The t r e a t m e n t
would be a c e r t a i n program o f e d u c a t i o n about PKU. Make s u r e
each group i s as r e p r e s e n t a t i v e o f t h e p o p u l a t i o n o f a l l
p r e g n a n t women as p o s s i b l e (age, socio-economic, l e v e l o f
e d u c a t i o n , r a c e / e t h n i c background, spoken l a n g u a g e ) . A
p r e t e s t and p o s t t e s t would be a d m i n i s t e r e d t o b o t h groups
54
�t o be as c e r t a i n as p o s s i b l e t h a t knowledge about PKU was a
r e s u l t o f t h e program and n o t m a t u r a t i o n and g r o w t h . D i d
compliance r a t e s i n b o t h groups increase? Were compliance
r a t e s o f t h e t r e a t m e n t group s i g n i f i c a n t l y h i g h e r t h a n
compliance r a t e s o f t h e c o n t r o l group?
* Look i n t o t h e l e g a l and e t h i c a l q u e s t i o n o f t e s t i n g someone's b l o o d w i t h o u t t h e i r consent.
* Devise a study about t h e e f f e c t o f t h e words may and must
on people's b e h a v i o r .
* Look i n t o s i m i l a r i t i e s and d i f f e r e n c e s o f an immunization
program f o r i n f a n t s and t o d d l e r s and t h e n e o n a t a l s c r e e n i n g
program. Would reasons f o r underimmunization have
a p p l i c a t i o n f o r non compliance r a t e s i n Ohio's Newborn
Screening e f f o r t ?
* Look i n t o t h e l e g a l i t y o f a b i r t h n o t b e i n g r e g i s t e r e d
a l l n e o n a t a l s c r e e n i n g i s completed.
until
* Devise a system o f inducements o r consequences t h a t would
b o t h educate and p o l i c e t h e non c o m p l i a n t s . The o b j e c t i s t o
g a i n compliance n o t t o " h u r t " them.
1. B i r t h n o t r e g i s t e r e d o r r e g i s t e r e d w i t h a " h o l d " on
it.
2. B e n e f i t s a t o t h e r agencies n o t a v a i l a b l e .
3. Cost o f i n s u r a n c e c o u l d i n c r e a s e i f c h i l d n o t f u l l y
tested.
4. Charges o f c h i l d n e g l e c t f i l e d .
5. Community s e r v i c e w i t h c h i l d r e n i n s c h o o l s ,
institutions.
* T a l k w i t h o t h e r s t a t e d i r e c t o r s who have laws and problems
s i m i l a r t o Ohio's and see what compliance r a t e s t h e y have
and what's b e i n g done t o improve them i f necessary.
55
�X. WORKS CITED
JOURNAL ARTICLES
1. Ambrose, John A., A n a l y s i s o f t h e "Report on a C o o p e r a t i v e
Study o^f V a r i o u s F l o r o m e t r i c Procedures and t h e GBIA i n t h e
D e t e r m i n a t i o n o f Hyperphenylalanemia"
and t h e s i g n i f i c a n c e o f
t h i s s t u d y i n t h e d e t e c t i o n , d i a g n o s i s , and management o f
P h e n y l k e t o n u r i a (PKU), H e a l t h L a b o r a t o r y Science, Vol.10:180187,1973.
2. B e r r y , Helen K., P o r t e r , Leonard J., Newborn Screening f o r
P h e n y l k e t o n u r i a ( l e t t e r ) , P e d i a t r i c s , Vol.70, No.3:505-506, 1982.
3. Dhondt, J. L. , F a r r i a u x , J.P., S a i l l y , J.C, Lebrun, T. ,
Economic E v a l u a t i o n o f C o s t - B e n e f i t R a t i o o f Neonatal Screening
Procedure f o r P h e n y l k e t o n u r i a and H y p o t h y r o i d i s m , J o u r n a l o f
I n h e r i t e d M e t a b o l i c D i s o r d e r s , V o l . 14:633-639, 1991.
4. F e d e r a l R e g i s t e r , V o l . 39, No.
145:27317-27320,
1974.
5. F e d e r a l R e g i s t e r , V o l . 46, No.
142:38285-38305,
1981.
6. F e d e r a l R e g i s t e r , V o l . 48, No.
132:31377-31382,
1983.
7. Levy, Harvey L., G u t h r i e , Robert, Screening f o r
P h e n y l k e t o n u r i a ( l e t t e r ) , The New England J o u r n a l o f Medicine,
V o l . 304, No.21:1300-1301, 1991.
8. McCabe, Edward R.B., McCabe, L i n d a , Mosher, Gayle A., A l l e n ,
R i c h a r d J., Berman, J u l i a n L., Newborn Screening f o r
P h e n y l k e t o n u r i a : P r e d i c t i v e V a l i d i t y as a F u n c t i o n o f Age,
P e d i a t r i c s , V o l . 72, No.3:390-398, 1983.
9. Mabry, C.Charlton, Reid, M.Carol, Kuhn, Robert J . , A Source
o f E r r o r i n P h e n y l k e t o n u r i a Screening, American J o u r n a l o f
C l i n i c a l Pathology, V o l . 90, No. 3:279-283, 1988.
10. Mabry, C.Charlton, P h e n y l k e t o n u r i a : Contemporary Screening
and D i a g n o s i s , Annals o f C l i n i c a l and L a b o r a t o r y Science, V o l .
20, No. 6:392-397, 1990.
11. Simpson, Doreen, P h e n y l k e t o n u r i a , Midwives C h r o n i c l e and
N u r s i n g Notes, February, 1989, pp. 37-41.
12. Smith, I s a b e l , Cook, B e v e r l y , Beasley, M a r t i n , Review o f
n e o n a t a l s c r e e n i n g programs f o r p h e n y l k e t o n u r i a , B r i t i s h Medical
J o u r n a l , V o l . 303, August 10:333-335, 1991.
13. S t e g n i k , Lewis D., The Aspartame S t o r y : a model f o r t h e
c l i n i c a l t e s t i n g o f a food a d d i t i v e , American J o u r n a l o f C l i n i c a l
N u t r i t i o n , V o l . 46:204-215, 1987.
14. T i w a r y , Chandra M., Neonatal Screening f o r M e t a b o l i c and
Endocrine Diseases, Nurse P r a c t i t i o n e r , V o l . 12, No. 9:28-41,
56
1987
�15. Wu, James T., Screening f o r I n b o r n E r r o r s o f Amino A c i d
Metabolism, Annals o f C l i n i c a l and L a b o r a t o r y Science, V o l . 2 1 ,
No. 2:123-142, 1991.
BOOKS
1. Bowes and Church, FOOD VALUES o f PORTIONS COMMONLY USED,
FIFTHTEENTH EDITION, Pennington, Jean A.T.(ed.), P h i l a d e l p h i a ,
1989, pp. 5 1 , 219, 223.
2. G u t h r i e , R., O r g a n i z a t i o n o f a Regional Newborn Screening
L a b o r a t o r y . I n B i c k e l , H., G u t h r i e , R. and Hummersen, G.(eds.)
NEONATAL SCREENING f o r INBORN ERRORS o f METABOLISM, S p r i n g e r V e r l a g , B e r l i n , H e i d e l b e r g , New York, 1980, pp. 263-264.
3. OHIO ADMINISTRATIVE CODE,
3701-49-01
4.
, 1991, 3701-45-01,
OHIO REVISED CODE, Baldwin ( e d . ) , 1992, 3701.33, 3701.501.
5. S t r i c k b e r g e r , Monroe W , GENETICS, The M a c m i l l a n Company,
.
C o l l i e r - M a c m i l l a n Canada, L t d . , T o r o n t o , O n t a r i o , 1969, pp. 99100, 102, 215.
PAMPHLETS
1. OHIO DEPARTMENT OF HEALTH, D i v i s i o n o f M a t e r n a l and c h i l d
H e a l t h , Why Must My Newborn Be Screened?, p. 2.
2.
Ohio H o s p i t a l A s s o c i a t i o n , OHIO HOSPITAL DIRECTORY
REPORTS
1. The C o u n c i l o f R e g i o n a l Networks f o r Genetic S e r v i c e s (CORN)
OHIO NEWBORN SCREENING DATA COLLECTION FORM : 1991.
2. Ohio Department o f H e a l t h Resource Development, HOSPITAL
SUMMARY REPORTS 1985 - 1991.
57
�X I . BIBLIOGRAPHY
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1. Ambrose, John A., A n a l y s i s o f t h e "Report on a C o o p e r a t i v e
Study o f V a r i o u s F l o r o m e t r i c Procedures and t h e GBIA i n t h e
D e t e r m i n a t i o n o f Hyperphenylalanemia"
and t h e s i g n i f i c a n c e o f
t h i s s t u d y i n t h e d e t e c t i o n , d i a g n o s i s , and management o f
P h e n y l k e t o n u r i a (PKU), H e a l t h L a b o r a t o r y Science, Vol.10:180187,1973.
2. B e r r y , Helen K., Hsieh, Monica H., B o f i n g e r , Mary K.,
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3. B e r r y , Helen K., P o r t e r , Leonard'J., Newborn Screening f o r
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58
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Hannon, W. H a r r y , D e s c r i p t i v e Epidemiology o f Missed Cases o f PKU
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the PKU a n x i e t y syndrome, The J o u r n a l o f t h e American Academy o f
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n e o n a t a l s c r e e n i n g programs f o r p h e n y l k e t o n u r i a , B r i t i s h M e d i c a l
J o u r n a l , V o l . 303, August 10:333-335, 1991.
26. S t e g n i k , Lewis D., The Aspartame S t o r y : a model f o r t h e
c l i n i c a l t e s t i n g o f a food a d d i t i v e , American J o u r n a l o f C l i n i c a l
N u t r i t i o n , V o l . 46:204-215, 1987.
59
�27. T i w a r y , Chandra M., Neonatal Screening f o r M e t a b o l i c and
Endocrine Diseases, Nurse P r a c t i t i o n e r , V o l . 12, No. 9:28-41, 1987
28. Wu, James T., Screening f o r I n b o r n E r r o r s o f Amino A c i d
Metabolism, Annals o f C l i n i c a l and L a b o r a t o r y Science, V o l . 2 1 ,
No. 2:123-142, 1991.
BOOKS
1. Bowes and Church, FOOD VALUES o f PORTIONS COMMONLY USED,
FIFTHTEENTH EDITION, Pennington, Jean A.T.(ed.), P h i l a d e l p h i a ,
1989, pp. 5 1 , 219, 223.
2. G u t h r i e , R., O r g a n i z a t i o n o f a Regional Newborn Screening
L a b o r a t o r y . I n B i c k e l , H., g u t h r i e , R. and Hummersen, G.(eds.)
NEONATAL SCREENING f o r INBORN ERRORS o f METABOLISM, S p r i n g e r V e r l a g , B e r l i n , H e i d e l b e r g , New York, 1980, pp. 263^264.
3. OHIO ADMINISTRATIVE CODE,
3701-49-01
4.
, 1991, 3701-45-01,
OHIO REVISED CODE, Baldwin ( e d . ) , 1992, 3701.33,
3701.501.
5. S t r i c k b e r g e r , Monroe W , GENETICS, The M a c m i l l a n Company,
.
C o l l i e r - M a c m i l l a n Canada, L t d . , T o r o n t o , O n t a r i o , 1969, pp. 99100, 102, 215.
PAMPHLETS
1. OHIO DEPARTMENT OF HEALTH, D i v i s i o n o f M a t e r n a l and c h i l d
H e a l t h , Why Must My Newborn Be Screened?, p. 2.
2.
Ohio H o s p i t a l A s s o c i a t i o n , OHIO HOSPITAL DIRECTORY
3. U.S. Department o f H e a l t h , E d u c a t i o n , and W e l f a r e , NEWBORN
SCREENING f o r GENETIC-METABOLIC DISEASES - PROGRESS, PRINCIPLES,
AND RECOMMENDATIONS, Holtzman, N e i l A., 1977.
4. U.S. Department o f H e a l t h , E d u c a t i o n , and W e l f a r e , RECOMMENDED
GUIDELINES FOR PKU PROGRAMS FOR THE NEWBORN, 1971.
REPORTS
1. The C o u n c i l o f R e g i o n a l Networks f o r G e n e t i c s S e r v i c e s
(CORN), OHIO NEWBORN SCREENING DATA COLLECTION FORM : 1991.
2. Ohio Department o f H e a l t h , Resource Development, HOSPITAL
SUMMARY REPORTS 1985 - 1991.
60
�X I I . INTERVIEWS
1. Baker, Lu. Newborn Screening C o o r d i n a t o r , U n i v e r s i t y H o s p i t a l
o f C l e v e l a n d . Telephone i n t e r v i e w . January 20, 1993. 30 m i n u t e s .
2. B e r r y , Helen K. Researcher and a u t h o r i n t h e f i e l d o f newborn
s c r e e n i n g . Telephone i n t e r v i e w . February 23, 1993. 60 m i n u t e s .
3. Gruen, J a c k i e . Nurse m i d w i f e , M i d - w i f e Care, I n c . , C i n c i n n a t i ,
Ohio. Telephone i n t e r v i e w . January 23, 1993. 30 m i n u t e s .
4. K e l l e r , Joseph. H e a l t h Insurance Broker, Columbus, Ohio.
Telephone i n t e r v i e w . January 28, 1993. 60 m i n u t e s .
5. Peake, W i l l . Accountant, Ohio Department o f H e a l t h . I n t e r v i e w .
December 17, 1992. 30 minutes.
6. W r i g h t , Debra. Genetics Program C o o r d i n a t o r ODH
i n t e r v i e w . January 10, 1993. 30 minutes.
61
MCH.
Telephone
�XIII
APPENDICES
�APPENDIX A
LETTER OF AUTHORIZATION
�October 1992
Dear Mr. Porter,
As you already know, I am i n the Master o f Public
A d m i n i s t r a t i o n Program a t Ohio State U n i v e r s i t y . Over t h i s
quarter and c o n t i n u i n g through w i n t e r , I ' l l be involved i n
w r i t i n g and presenting a p o l i c y paper. Since I work i n the
Newborn Screening Lab, I see an important o p p o r t u n i t y t o combine
the p r a c t i c a l and the t h e o r e t i c a l f o r a l l concerned.
Following are several pages o u t l i n i n g my proposed area o f
study. Also included are methods o f data c o l l e c t i o n and, based on
c e r t a i n assumptions and expected f i n d i n g s , s p e c i f i c
recommendations. Also included what I t h i n k t o be minor stumbling
blocks
I n order t o evaluate and u l t i m a t e l y improve any system a
baseline must f i r s t be established. I am proposing t o study the
mothers who were discharged from the h o s p i t a l before i n f a n t s were
48 hours o f age. Mothers who do not r e t u r n f o r the r e q u i r e d
follow-up PKU t e s t need t o be found and questioned as t o why.
There i s the o p p o r t u n i t y t o see where we stand and t o upgrade the
system. I f a c h i l d i s not tested as required and has PKU then
s o c i e t y pays the p r i c e : r e t a r d a t i o n could have been prevented.
Often times when we t e s t early discharges the PKU i s p o s i t i v e .
Follow-up or second t e s t s taken i n the 4 8 hours - 2 week time
frame are then found t o have normal r e s u l t s . The r e q u i r e d second
t e s t f o r e a r l y discharge i s not matched t o the f i r s t t e s t .
Another t e s t i s then requested because o f abnormal r e s u l t s on the
f i r s t and unbeknownst t o us, a second t e s t i s i n the system. Time
and money could and would have been saved.
I n order f o r the study t o go forward, the e a r l y discharge
mothers who d i d not r e t u r n f o r the r e q u i r e d second t e s t w i l l be
sent a questionaire. I am asking t h a t you allow me t o use the
demographics supplied t o us on the PKU k i t . I am also enclosing a
copy o f sample questions and the cover l e t t e r f o r the survey.
Test r e s u l t s w i l l not be discussed w i t h the mothers.
I r e a l l y do t h i n k t h i s study w i l l b e n e f i t our l a b o r a t o r y ,
Ohio State and myself. I look forward t o the challenge. I f you
have any questions, comments, or concerns contact me. I w i l l
continue t o keep you apprised o f the s t a t u s o f the study.
~
Sincerely.
LYlJlN M. OGDENJ
Permissibly t o
proceed
LEONARD J'/^ORTER
'
DATE
�APPENDIX B
Phenylalanine (PHE)
Content of Some Foods
�Nutrient Content: EGGS, EGG DISHES & EGG SUBSTITUTES
KCAL H , 0
(g)
WT
(g)
FAT PUFA CHOL
A
(g)
(g) (mg) (RE)
PRO CHO
(g)
(g)
SFA DFIB
(g)
(g)
A
(IU)
Vitamins
B-2
B-6
(mg) (mg)
C
(mg)
N1A
(mg)
B-l
(mg)
B-l 2
(meg)
51
FOL
(meg)
Minerals
Na
Ca
Mg
Zn Mn
(mg) (mg) (mg) (mg) (mg)
PANT
(mg)
K
P
(mg) (mg)
Fe
(mg)
Cu
(mg)
)
9. EGGS, EGG DISHES & EGG SUBSTITUTES
9.1. EGGS, C H I C K E N
•
•
: boiled, hard/soft
;
/ large
fried
1 large
'omeiet, plain
1 large egg
poached
1 large
• scrambled w/ milk & fat
: ..
1 large egg ...
white, fresh/frzn
while of 1 large egg
whole, dried, stabilized (glucose reduced)
; T
whole, fresh/frzn
1 large
: yolk, fresh
L. . . yolk of ] large egg
'""'79' " 37.3 " 5.6
50
6.1
0.6
83
33.1
6.4
5.4
46
0.5
95"" " 48.8 7.1
64
6.0
1.4
37.1
79
5.6
50
6.0
0.6
- 95 "' 48.8 " 7.1 '
64
6.0
1.4
16
29.1
0.0
3.4
33
0.4
0.1
" ' 31
2.2
5 * 2.4
0.1
79
37.3 "5.6
50
6.1
0.6
8.3 " 5.6 '
63
17_ .2.8
0.0
0.7 274
1.7 0.0
0.7 246
2.4 0.0
0.7 248
2.8 0.0
0.7 273
1.7 0.0
0.7 ' 248
2.8 0.0
0.0
0
0.0 0.0
0.3 101
0.7 0.0
0.7 274
1.7 0.0
0.7 272
1.7 0.0
78" """"6 " '.14" "" .06
.04
0.0
.66
260
0
.13
.05
83
0.0
.58
.03
286
0 " .16" .06
89
.04
0.0 . .64
311
0
.13
.05
78
.04
0.0
.62
259
0 ' .16 """.06 "
"'89
.04
0.0
.64
311
.09
.00
0
0
0.0
.00
.02
0
.06 ' .02
0
" 31 '
0.0
.02
.53
102
J5
!06
0
78 '
.77
.04
0.0
260
.07
94
0
.05
.04
.65
313
:
.0-°
24
.86
22
.76
22
.82
24
.86
22
.82
5
.08
10
.34
32
.86
26
•5 .
7
9.2. EGGS, O T H E R
•
duck, whole
1 egg
goose, whole
I egg
quail, whole
.. J gg ... turkey, whole
[egg
^
e
..........
__
_
9.6
0.9 619
130 " 49.6
9.0
1.0
2.6 0.0
70
2.4 "
276 "101.4 19.1
144
20.0
1.9
5.2 0.0
14
6.7" 1.0
0.1
76
1.2 0.0
0.3 0.0
9
9.4 " 1.3 737
135
57.3
2.9 0.0
79
10.8. 0.9
930
27
.28
0.1
.18
3.78
:o7
0
.01
0.0
.37
0
.09 . 0.0
.01
0
.11
0
56
•
•
omelette
..
cheddar cheese, frzn. Am Hosp Co
4oz__
mushroom &. cheese, frzn. Am Hosp
;' _ Co— S OZ
mushroom, cheese & onion, frzn. Am
Hosp Co—4 oz
f plain, frzn, Am Hosp Co
Spanish, frzn, Am Hosp Co'
4oz
: western, frzn. Am Hosp Co "
; _ 4 oz
.
•
•
1
" 313"
113
' 152"
85
252
113
199
85
199
113
"207 "
113
•- 15.9
9.8
15.3
8.9
10.3
u
-
1
'27.1
1.3
11.6
1.9
20.2
2.3
17.7
0.9
16.3
2.8
16.7
3.0
328
245
""0
.07
0
,04
334
.16
0.3
.29
.07
0 ' .03
.07
767.
0.1
6
.23
671
.07
0.3
...... " " .24
0.4 ;
611
.09
653
298
'365
quiche
"18.0"""
" "bacon &. onion, Pour-a-Quiche
'230"
123 . .„ .13.0. . 6.0
4.3oz
..._.„;.:.._...
19.6
410
Dorentine, frzn. Am Hosp Co
198
28.1 30.2
7oz
iiaml Po'ur-a-Quiche .:' 230
•'17.0
~ *"""
B ':•>:• 4.3 oz
:'::r:: • ^
_4.0
: J23
531
" 19.9*'""""""
lorraine, frzn. Am Hosp Co
24.8 63.3
198
7 oz
16.0 " "
220
: s p i n a c h & onion, Pour-a-Quiche ..:
23
6.0 . ,
.12.0
:
4.3 oz .. ^
.• '
.J .
• Contains tomatoes, onions, mushrooms, green peppers & celery.
366
240
9
—-
-
235
230
;
b
398 245
128
1.58
138 ' " 5 9 "
101
.90
310 145
160
1.60
222 " 41
100
... !-39
197 " 47"
164
1.60
281" 46 "
164
...U60-
-•
113
2I0'
"12
2.70.
.99
J.:2i.
""00
" i
373
5
9
•
-•
•.
102 ' '45
156 154
6 '
•
20
•33
'78
134
......
9.3. EGG ( C H I C K E N ) DISHES
69
28
6
.72
1.04
65. 90
144
26
5" .64"'
58
.92
80
47"
155
8" .70
85
97
.93
146
28
6
.72
1.04
65
90
155 " 47"
8" .70
85 ..97
.93
4
50
3 .01 .002
4
45
.01 .009
27
11
2
.28
"
26
.41
86
69
28
6 ' .72 .02!
1.04 .033
65
90
" 8' 26
' 3 " .58 '.019
15
86
.024
•""
"••
385
170
652
448
'360
165,
1313
421
365
.210.
...... ... .
--•• •
•-.-- •
.••
.
•
• -•
......
-
..
:• ••<:•..-.•..•.• j : ..
• • :;
Contains onions, mushrooms, ham. red & green peppers & tomatoes.
�CYS
PHE
TYR
VAL
11
7
21
18
53
42
32
25
32
25 .
0
0
0
0
0
0
0
15
6
9
15
6
19
79
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
19
0
60
0
80
0
129
0
105
0
33
0
12
0
64
0
64
0
88
0
48
0
36
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0'
0
0
0
0
0
0
0
0
0
TRY
1. Beverages
1.1. Alcoholic Beverages
1.1.1. Ales, Been & Malt Liquors
beer—12/1 oz (356 g)
.
beer, light—12 fl oz (354 g)
THR
11
11
18
14
18
14
0
0
0
0
0
2
13
13
21
0
0
0
0
0
0
0
0
0
0
ISO
LEU
21 '
18
LYS
MET
25
18
4 "
4
ARC
HIS
18 14
i'.
1.1.2. Cocktails & Cocktail Mixes
bourbon & soda—t Jl oz cocktail
(116 g)
screwdriver (orange jce & vodka)—
7Jloz cocktail (213 g)
\
1.1J. Distilled Spirits
gin, 90 proof— 1.5 fl oz jigger (42 g)
gin/nim/vodka/whiskey, 94 proof—
1.5 floz jigger (42 g)
rum, 80 proof—1.5 fl oz jigger (42 g)
vodka, 80 proof—1.5 fl oz jigger (42 g)
whiskey, 86 proof—1.5 fl oz jigger
(42 g)
1.1.4. Liqueurs
coffee w/ cream, 34 proof—1.5 fl oz
(47 g)
creme de menthe—1.5 fl oz (50 g)
1.2. Carbonated Beverages
cream soda—12 fl oz (371 g)
grape soda—12 fl oz (372 g)
lemon-lime soda—12 fl oz (368 g)
orange soda—12 fl oz (372 g)
pepper type soda—12 fl oz (368 g)
tonic water/quinine water—12 fl oz
(366 g)
If
1 J . Carbonated Beverages, Low Calorie
club soda—12 fl oz (355 g)
diet cherrv coke, Coca-Cola—12 fl oz
(354 g)
diet coke, Coca-Cola—12 fl oz (354 g)
diet Sprite—12 fl oz (354 gj
Fresca—12 fl oz (354 g)
Tab—12 fl oz (354 g)
1.4. Cereal Grain Beverages
powder— 1 t (2.3 g)
prep from powder
w/ water—6 fl oz water & 1 t powder
(180 gj
w/ whole milk—6 fl oz milk &
1 t powder (185 g)
1.5. Coffee
brewed—6 fl oz (177 g)
inst powder—1 rd t (1.8 gj
cappuccino flavor, sugar sweetened—
2rdt(14gj
decaffeinated—; rd t (1.8 gj
french flavor, sugar sweetened—.? rd t
(11.5 gj
mocha flavor, sugar sweetened—
2rdt(11.5gj
b
104
104
96"
98''
16
b
b
2
4
5
9
5
2
3
6
4
6
6
3
2
.4
5
9
5
2
2
5
4
7
7
2
85
278
368
598
481
154
57
296
294
409
224
165
0
1
2
3
4
3
9
9
2
2
0
0
4
4
5
5
4
3
5
5
2
1
4
3
1
1
5
2
6
3
16
8
3
2
1
0
7
3
9
5
5
3
9
5
2
1
5
3
1
6
7
19
4
1
8
10
6
11
2
6
5
14
14
24
17
3
6
18
14
21
18
7
' Amino acids for infant formulas and special dietary formulas are in
the main table.
b
Phenylalanine is from aspartame,
219
�Supplementary Tables: AMINO ACIDS (mg)
TRY
7. Creams & Cream Substitutes
creamers
liquid/fan'—1/2 fl oz (15 g)
Kquid/frzTf—'/iflozflSg)
powdered"—; / (2 g)
half& half cream—; T(15g)
light (coffee/table) cream—1 T (15 g)
medium (25% fat) cream—; T (15 g)
sour cream, cultured—; T(12g)
whipped cream, pressurized—; T (3 g)
whipping cream
heavy, fluid—; T(lSg)
light, fluid—; T(15g)
whipped topping
from mix, prep w/ whole milk—; 7"
(fg)
frzn—; T(4g)
pressurized—; T(4g)
THR
2
1
6
6
5
4
1
7
6
4
20
18
17
15
4
4
5
ISO
LEU
LYS
MET
CYS
8
9
6
27
25
22
20
6
13
15
9
. 43
40
36
32
9
10
12
8
35
32
29
25
8
2
5
3
1
14
15
19
20
30
32
2
1
1
6
2
9
3
2
100
68
58
325
• 217
186
73
113
30
PHE
223
HIS
TYR
VAL
ARC
6
9
5
21
20
18
12
6
4
16
15
13
44
3
12
11
10
5
8
11
7
30
27
25
22
6
3
3
11
10
9
8
2
4
4
3
1
8.
8
5
21
20
18
15
5
24
26
8
8
3
3
15
16
15
16
21
22
11
12
8
9
14
5
4
11
4
3
4
2
1
1
0
0
7
3
2
7
3
2
10
4
3
5
2
2
4
1
1
423
290
250
680
470
405
549
381
327
177
120
104
72
44
38
337
232
199
335
232
199
466
321
276
281
174
150
188
130
112
233
363
98
312
486
131
506
787
212
409.
637
171
129
201
54
48
74
20 .
249
388
104
249
388
104
345
.538
145
187
291
78
140
218
59
97 .
86
94
97
298
264
290
297
380
336
372
378
533
472
565
531
410
363
410
408
196
174
188
195
145
128
133
144
343
303
332
341
253
224
252
251
437
387
426
435
388
344
364
387
147
130
146
146
94
290
372
565
410
188
133
332
252
426
364
146
51
149
204
291
206
130
83
210
134
251
195
76
39
97
41
118
298
151
151
380
160
212
533
237
163
410
189
78
196
71
57
145
50
136
343
121
100
253
120
173
437
170
154
388
193
58
147
67
9.2. Eggs, Other
duck, whole—; egg (70 g)
182
515
419
768
666
403
199
588
429
620
535
224
93. Egg (Chicken) Dishes
souffle, spinach'—; cup (136 g)
166
458
650
994
782
298
143
574
487
719
533
313
10. Entrees & Meals
10.2. Canned Entrees
beans, baked
w/ beef—; cup (266 g)
205
713
742
1357
1202
277
181
875
484
878
1067
484
8. Desserts
8.7. Frozen Desserts
ice cream
french van, soft serve—; cup (173 g)
van, reg (\Q% fat)—; cup (133 g)
van, rich (16% fat)—; cup (148 g)
ice milk
van—; cup (131 g)
van, soft serve—; cup (175 g)
sherbet, orange—; cup (193 g)
2 •
2
• 3
sorbet. Dole
mandarin orange—'/; cup (104 g)
peach—'/i cup (104 g)
pineapple—cup (104 g)
raspberry— '/i cup (104 g)
strawberry—'/J cup (104 gj
9. Eggs, Egg Dishes & Egg Substitutes
9.1. Eggs, Chicken
boiled, hard/soft—; large (50 g]
fried—; large (46 g)
omelet, plain—; large egg (64 g)
poached—; large (50 g)
scrambled w/ milk & fat—; large egg
(64 g)
white, fresh/frzn—while of 1 large egg
(33 g)
whole, dried, stabilized (glucose
reduced)—; T (5 g)
whole, fresh/frzn—; large (50 g)
yolk, fresh—yolk of 1 large egg (17 g)
^ ' Contains hydrogenated veg oil & soy protein; veg oils are usually soybean, cottonseed, safflower, or blends thereof.
Contains lauric acid oils and Na caseinateriauric oils include modified
coconut oil, hydrogenated coconut oil, and/or palm kernel oil.
k
'Contains whole milk, spinach, egg white, cheddar cheese, egg yolk,
butter,flour,salt & pepper.
�APPENDIX C
Autosomal Recessive Inheritance
�APPENDIX C
Mendellian
Inheritance
or
autosomal r e c e s s i v e
inheritance
dominance o r dominant - when 2 genes a r e p r e s e n t f o r t h e same
trait
( i . e . a gene f o r brown eyes and a gene f o r b l u e eyes) and
o n l y one appears ( i n t h i s case i t would be brown) t h e n t h e gene
for
brown i s s a i d t o be dominant.
r e c e s s i v e - t h e o p p o s i t e o f dominance, (see above) t h e gene t h a t
did
n o t appear ( b l u e ) .
autosomal - h a v i n g t o do w i t h non-sex chromosomes
( i . e . eye
c o l o r , h a i r c o l o r , e a r shape, r o l l tongue o r n o t , have n o t h i n g t o
do w i t h whether one i s female o r m a l e ) .
homozygous o r homozygote - an i n d i v i d u a l h a v i n g e i t h e r b o t h
dominant genes o r b o t h r e c e s s i v e genes.
heterozygous o r h e t e r o z y g o t e - an i n d i v i d u a l h a v i n g one dominant
gene and one r e c e s s i v e gene f o r t h e same t r a i t o r t h e e f f e c t o f
t h e r e c e s s i v e gene does n o t appear, o r c a r r i e r o f r e c e s s i v e characteristics .
N = normal gene (dominant over r e c e s s i v e n)
n = abnormal gene
Example A: c r o s s a homozygous normal (NN) w i t h a homozygous
abnormal ( n n ) . T h i s i s p o s s i b l e w i t h genes f o r PKU. Since t h e
c o n d i t i o n i s t r e a t a b l e , people w i t h PKU a r e no l o n g e r c o n f i n e d t o
i n s t i t u t i o n s . Phenylketonurics function "normally" i n society.
�Many are o f reproductive age and w i l l be passing on t h e i r genes.
They would be (nn) i n example A.
(homozygous Normal parent)
Nl
(homozygous
abnormal
parent)
N2
nl
Nlnl
N2nl
n2
Nln2
N2nl
In a l l the examples the "parents" w i l l be across t h e t o p and
down t h e l e f t side. The possible o f f s p r i n g (always 4 p o s s i b i l i t i e s ) w i l l be described by the genes i n the 4 inside boxes
(Remember N i s dominant over recessive n. N means Normal, n means
abnormal. Nn means i f the o f f s p r i n g i n h e r i t s t h a t combination i t
w i l l be a c a r r i e r f o r abnormal (n) while appearing normal (N). I n
example A any and a l l c h i l d r e n w i l l appear normal but be c a r r i e r s
for
abnormal.
Example B. cross 2 heterozygotes and the r e s u l t i n g o f f s p r i n g have
a 25% chance of being homozygous f o r normal (NN), a 50% chance of
being a c a r r i e r f o r abnormal, and a 25% chance of being homozygous f o r abnormal.
Nl
nl
N2
N1N2
nlN2
n2
Nln2
nln2
For a long time i n our society t h i s i s what was happening
�w i t h PKU. E i t h e r people d i d not know they were c a r r i e r s or they
knew and went ahead and had c h i l d r e n anyway.
Example C: cross a homozygous normal i n d i v i d u a l w i t h a c a r r i e r
f o r abnormal and again any c h i l d i s l i k e l y t o i n h e r i t any one of
four p o s s i b i l i t i e s : 50% chance of homozygous normal and 50%
chance of c a r r i e r f o r abnormal.
Nl
N2
N
N1N
N2N
n
Nln
N2n
Example D: cross a homozygous f o r abnormal i n d i v i d u a l
(nn) w i t h a
c a r r i e r f o r abnormal (Nn) and the 4 p o s s i b i l i t i e s f o r an
o f f s p r i n g would be: 50% chance of being a c a r r i e r and 50% chance
of being homozygous abnormal.
n2
nl
N
Nnl
Nn2
n
nnl
nn2
�APPENDIX D
Newborn Screening Law
�er>-.:-,..' "
Department of Health
JJjijS's'• whom stafTprivileges have been granted; in order to recover for a
|i§j$«£ ,,-. breach of this duty, a plaintiff injured by the negligence of a staff
. physician must demonstrate that but for the lack of care in the
•^jj&l^'.ielection of or the retention of the physician, the physician would
Y;C.. "Ot have been granted staff privileges and the plaintiff would not
have been injured.
-.;50OS(3d) 251, 553 NE(2d) 1038 (1990), Albain v Flower Hos£t0:;.-pittl.' Hospitals do not have a nondelegable duty to assure the
•bsence of negligence in the medical care provided by private inde.Jsi'typendent physicians granted staff privileges by the hospital.
•^50OS(3d) 251, 553 NE(2d) 1038 (1990), Albain v Flower Hospital. A hospital may, in narrowly defined situations, under the
doctrine of agency by estoppel, be held liable for the negligent acts
.:.
of a physician to whom it has granted staff privileges; in order to
Ottblish such liability, a plaintiff must show that (1) the hospital
' ^ • V : made representations leading the plaintiff to believe that the negliphysician.was operating as an agent under the hospital's
ayYe«?,?S*uihority, and (2) the plaintiff was thereby induced to rely upon the
^P;;;;^;' ostensible agency relationship.
,;. .>, .-,, ....
^
113 (1989), Bouquett v St. Elizabeth
Corp. A board of trustees of a private hospital has broad discretion
0Jf^v£fi.-in determining who shall be permitted to have staff privileges and
"'^ifefc-cburts should not interfere with the exercise of such discretion
biiless the hospital has acted in an arbitrary, capricious, or unreaIbnable manner constituting an abuse of discretion.
;V 43 OS(3d) 50, 538 NE(2d) 113 (1989), Bouquett v St. Elizabeth
Corp. When hospital bylaws provide for summary suspension of a
physician if such action "must be taken immediately in the best
inlerest of patient care in the hospital," the term "best interest of
; patient care in the hospital" encompasses more than technical skills
.and professional competence of the physician; rather, it includes
the perceived integrity of a physician which becomes suspect following his conviction on felony charges.
.,• 936 F(2d) 870 (6th Cir Ohio 1991), Christopher v Stouder
Memorial Hospital. A private scrub nurse who cannot pursue her
employment opportunities with doctors who might hire her unless
the hospital grants her limited hospital privileges is sufficiently
under the hospital's "control" over her ability to practice that she
may maintain a retaliation action against the hospital under 42
USC 2000e-3.
v
:
5 3 8
N E ( 2 d )
3701.501
(B) The advisory council shall;
(1) Consult with the department of health in matters of
policy affecting a d m i n i s t r a t i o n o f sections 3701.01,
3701.04, 3701.08, 3701.09, and 3701.36 to 3701.45 of the
Revised Code, and in the development o f rules and
standards;
(2) Advise and make recommendations with respect to
rules and standards prior to their adoption by the public
health council.
The advisory council shall meet not less than once each
year and additionally at the call of the chairman or at the
request of any five of its members.
HISTORY: 1990 H 623, efT. 7-24-90
1986 H 428; 1980 H 900; 1972 H 494; 1971 S 343; 131 v
H 417; 1953 H 1; GC 1236-11
UNCODIFIED LAW
1990 H 623, § 4: See Uncodified Law under 3701.33.
FEDERAL F U N D S CONSTRUCTION PROJECTS
,|
3701.36
Hospital advisory council
- (A) The director of health, with the approval of the
governor, shall appoint an advisory council which shall
consist of the director, who shall serve as chairman, the
director of human services, the director of mental health,
the director of mental retardation and developmental disabilities, the superintendent of public instruction, and the
following:
, (1) Two individuals of recognized ability in the field o f
hospital administration;
(2) One individual of recognized ability in the field of
nursing;
, (3) Ten individuals, at least one of whom shall be at least
sixty years of age, with broad civic interests representing
consumers of hospital and medical facilities services,
ani'(4) Two individuals of recognized ability in the field of
medicine or surgery;
(5) One individual of recognized ability in the field of
, rehabilitation;
(6) One individual particularly concerned with education or training of health professions personnel.
Members are subject lo removal at the pleasure of the
director of health, with the approval of the governor. Members of the advisory council shall serve without compensa|£%^fc;vtiTO;but shall be reimbursed for actual expenses incurred in
• the performance of their official duties.
•^/wf.---.^.'.'.
3701.40 Minimum standards for hospitals receiving federal aid; injunctive relief against violator
NOTES ON DECISIONS AND OPINIONS
3 Health L J of Ohio 33 (September/October 1991). Credentialing: Remediation, Not Punishment, Patrick Reymann.
51 Pitt L Rev 463 (Winter 1990). Patrick v. Burger. Has The
Death Knell Sounded For State Action Immunity In Peer Review
Antitrust Suits?, Comment.
936 F(2d) 870 (6th Cir Ohio 1991), Christopher v Stouder
Memorial Hospital. A private scrub nurse who cannot pursue her
employment opportunities with doctors who might hire her unless
the hospital grants her limited hospital privileges is sufficiently
under the hospital's "control" over her ability to practice that she
may maintain a retaliation action against the hospital under 42
USC 2000e-3.
;
GENETIC DISORDERS
3701.501
Tests of newborn infants for certain disorders.
(A) The public health council shall adopt rules in accordance with Chapter 119. of the Revised Code for testing of
newborn children for the presence o f phenylketonuria,
homocystinuria, galactosemia, and hypothyroidism. The
person designated in the rules shall cause a child to be
tested in accordance with the rules. The rules may require
tests for other genetic, endocrine, or metabolic disorders i f
the following conditions are met:
(1) A determination is made by the public health council
that the disorders cause disability i f undiagnosed and
untreated and are treatable.
(2) No additional blood samples or specimens are
required to conduct the test.
All tests required by this section or by rules adopted by
the public health council pursuant to this section shall be
performed by the laboratory authorized by section 3701.22
of the Revised Code except that i f the rules adopted by the
public health council under this section provide that retesting of children with abnormal test results may be per-
I9VI
�Health—Safety—Morals
3701.503
formed by laboratories other than that laboratory, retests
may be performed by any laboratory approved by the director of health for that purpose.
Rules adopted by the public health council under this
section shall prescribe a method for giving notice of the
proposed tests and the results of the tests to the parents of
the child. The rules shall also prescribe a method for giving
notice of the proposed tests and the results of the tests to
either the person who caused the child to be tested, employees designated by the rules of the hospital of birth, or the
health commissioner for the health district where the birth
occurred, whichever is appropriate as determined by the
rules. The rules also shall prescribe laboratory methods and
other procedures for the detection of such genetic, endocrine, and metabolic disorders in newborn children, including procedures for retesting and referral of children with
abnormal test results.
(B) Division (A) of this section does not apply if the
parents of the child object thereto on the grounds that such
test conflicts with their religious tenets and practices.
HISTORY: 1991 H 298, efT. 7-26-91
1988 H 790; 1981 H 694; 1980 H 1056; 131 v S 19
INFANT HEARING-IMPAIRMENT SCREENING
3701.503
Definitions
As used in sections 3701.504 to 3701.507 of the Revised
Code:
(A) "Parent" means either parent, unless the parents are
separated or divorced or their marriage has been dissolved
or annulled, in which case "parent" means the parent who
is the residential parent and legal custodian.
(B) "Guardian" has the same meaning as in section
2111.01 of the Revised Code.
(C) "Custodian" means, except as used in division (A) of
this section, a government agency or an individual, other
than the parent or guardian, with legal or permanent custody of a child as defined in divisions (B)(10) and (12) of
section 2151.011 of the Revised Code.
(D) "Address," in the case of an individual, means the
individual's residence and, in the case of a government
agency, means the office at which the records pertaining to
a particular child arc maintained.
(E) "Risk screening" means the identification of infants
who are at risk of hearing impairment, through the use of a
high-risk questionnaire developed by the department of
health under division (A) of section 3701.504 of the
Revised Code.
(F) "Hearing assessment" means the use of audiological
procedures by or under the supervision of an audiologist
licensed under section 4753.07 of the Revised Code, or by a
neurologist or otolaryngologist, to identify infants who are
at risk of hearing impairment.
HISTORY: 1990 S 3, eff. 4-11-91
1988 S 77
20
INDIGENT ACCIDENT PATIENTSREIMBURSEMENT TO HOSPITALS
3701.66
Payment of claim
If the director of health determines that a claim
presented to him under section 3701.64 of the Revised
Code by a hospital which has complied with sections
3701.61 to 3701.69 of the Revised Code, concerns an indigent patient as evidenced by his findings under section
3701.65 of the Revised Code, the director shall determine
the amount of such claim in accordance with the per diem
cost of such hospital as certified by him under section
3701.62 of the Revised Code, for the period of the patient's
indigency, less any amount paid on the hospital account by
an individual or by funds derived through settlement, and
shall pay such ascertained amount to the claimant from the
funds appropriated for that purpose. However, the director
of health shall not make any payment from such appropriations until all efTorts by the hospital to secure payment from
persons legally responsible for the debts of the indigent
patient, from insurance policies, from hospital insurance
benefits, medical insurance benefits, or medical assistance
under Titles X V M and XIX of the "Social Security Act,"
49 Stat. 620(1935), 42 U.S.C.A. 301, as amended, or from
general assistance or disability assistance under Chapter
5113. or 5115. of the Revised Code have been exhausted.
The director of health shall not make any payment from
such appropriations until the appropriate county department of human services certifies to the director of health
that the indigent patient is not eligible for medical assistance under Chapter 5111., 5113., or 5115. of the Revised
Code.
HISTORY: 1991 H 298, e(T. 7-26-91
1988 H 708; 1985 H 238; 1973 H 544
MISCELLANEOUS PROVISIONS
3701.81 Spreading contagion
NOTES ON DECISIONS AND OPINIONS
45 OS(3d) 314, 544 NE(2d) 265 (1989), Mussivand v David. A
person who knows, or should know, that he or she is infected with a
venereal disease has the duty to abstain from sexual conduct or, at a
minimum, to warn those persons with whom he or she expects to
have sexual relations of his or her condition.
45 OS(3d) 314, 544 NE(2d) 265 (1989), Mussivand v David. A
spouse is a foreseeable sexual partner and a person who has a
venereal disease who fails to inform a married person with whom
he or she is engaging in sexual contact of his or her condition is
liable to the third-party spouse until the initially infected spouse
knows or should have known he or she is infected with a venereal
disease.
3701.83
General operations fund
There is hereby created in the state treasury the general
operations fund. Moneys in the fund shall be used for the
purposes specified in sections 3701.04, 3701.344, 3701.88,
3701.912, 3701.913, 3701.92, 3703.07, 3707.373, 3710.15,
3721.02, 3722.04, 3732.04, 3733.04, 3733.25, 3733.43,
For changes after 12-31-91, please consult Baldwin s Ohio Legislalive Senice. 1992 LAWS OF OHIO. For assistance, see the User's Guide in Vol. I .
0
�mmDepartment of Health
3701.92
Inspection of registered sources of radiation; fees;
health director's powers
Radiation advisory council
Handling sources of radiation—Repealed
Prosecution for violations; injunctions
Exception of radiation for medical purposes
Notice of violation; proceedings; declaration of
emergency
30.3
719
30.4
719
30.5
719
2: 5 0 . 6
719
IT^?-.. 3 0 . 7
719
«>;•-:,.
PROHIBITION AND PENALTIES
Prohibition
Penalties
PRACTICE AND STUDY AIDS
F"
I
Painter & Looker, Ohio Driving Under Ihe Influence Law, Text
11.13(C)
3701.98
3701.99
(F) "Medical facilities" means outpatient facilities, rehabilitation facilities, and facilities for long-term care, including nursing homes, as those terms are defined in the federal
act, and such other facilities for which federal aid may be
authorized under the federal act.
HISTORY: 1971 S 343, efT. 9-24-71
131 v H 417; 129 v 582; 126 v 765; 1953 H 1; GC
1236-8
CROSS REFERENCES
Board of building standards, hospital not a "home", OAC
4101:2-2-01
Nursing and rest homes, defined, 3721.01
Duty to report suspected abuse of adult, 5101.61
LEGAL ENCYCLOPEDIAS AND ALR
CROSS REFERENCES
Department of health, OAC Ch 3701-1 to Ch 3701-81
Governmental function defined to include health department
and board activities, for purposes of ton liability, 2744.01
Abuse or neglect of patients, revocation of license, 2903.33 to
2903.37
State-financed health insurance program defined as third party
payer, 3702.51
Mental health department, licensing of hospitals, third-party
payer defined, 5119.202
'•'<
3701.02
OJur 3d: 55, Hospitals and Related Facilities; Health Care
Providers § 6, 7
Am Jur 2d: 40, Hospitals and Asylums § I
NOTES ON DECISIONS AND OPINIONS
OAG 81-079. If it is physically possible for one person to hold
both positions and if the holding of both positions is not prohibited
by local law, the positions of Brunswick city planning commission
member and board of health member are compatible.
NOTES ON DECISIONS AND OPINIONS
6 Tol L Rev 617 (1975). The State Role in the Regulation of the
Health Delivery System, Pamie S. Snoke and Albert W. Snoke.
PRELIMINARY PROVISIONS
3701.01
Definitions
As used in sections 3701.01, 3701.04, 3701.08, 3701.09,
and 3701.36 to 3701.45, inclusive, of the Revised Code:
(A) "The federal act" means Title V I o f the "Public
Health Service Act," 60 Stat. 1041 (1946), 42 U.S.C. 291,
as amended.
(B) "The surgeon general" means the surgeon general of
the public health service of the United States or such other
officer or employee of the United States responsible for
administration of the federal act.
(C) "Hospital" includes public health centers and general, tuberculosis, mental, chronic disease, and other types
of hospitals, and related facilities, such as laboratories, outpatient departments, nurses' home facilities, extended care
facilities, self-care units and central service facilities operated in connection with hospitals, and also includes education and training facilities for health professions personnel
operated as an integral part of a hospital, but does not
include any hospital furnishing primarily domiciliary care.
(D) "Public health center" means a publicly owned facility for the housing of the public health services of a community and one which makes available equipment to aid physicians in the prevention, diagnosis, and treatment o f
disease.
(E) "Nonprofit hospital", or "nonprofit" as applied to a
facility, means any hospital or facility owned and operated
by one or more nonprofit corporations or associations no
part of the net earnings of which inures, or may lawfully
inure, to the benefit o f any private shareholder or
individual.
3701.02
Composition of department of health
There is hereby created a department o f health. The
department shall consist of a director of health and a public
health council.
HISTORY: 1953 H 1, eff. 10-1-53
GC 1232
CROSS REFERENCES
Number, content, and filing of official reports, 149.01
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Health and Sanitation § 4, 8
Am Jur 2d: 39, Health § 4, 12
NOTES ON DECISIONS AND OPINIONS
106 OS 50, 139 NE 204 (1922), Ex parte Company. GC 1232
(RC 3701.02), GC 1234 (RC 3701.33), GC 1235 (RC 3701.34), and
GC 1236 (RC 3701.35), which create a state department ol health,
a public council, and authorize such public council to make and
amend sanitary regulations of general application throughout the
slate and lo provide lor Ihe certification, publication, and enforcement of such regulations arc lawful and a valid exercise of legislative power; thus, a sanitary code, which authorizes the quarantine,
examination, and dclenlion of persons reasonably suspecled of having a venereal disease for the protection of public heallh, does not
violate O Const Art I §5 or violate GC 13031-17 (former RC
2905.28).
1940 OAG 1921. Kesponsihilily lor public heallh service on and
within stale owned properly rests pmuurily willi the stale deparlmcnl of heallh.
1940 OAG 1921. It is the duly of the stale department of health
to adopt rules and regulations governing the installation of plumbing and sanitary equipment in buildings located on slale owned
property, and lo see that such rules and regulations arc followed.
1940 OAG 1921. Such sanitary regulalions and rules rclaling to
public heallh, sanitalion and quaranline as may be deemed necessary to protect and preserve the public health and prevent the
spread of communicable and olher disease applicable generally
throughout the state, and especially lo and within stale owned
June 1989
�3701.025
Health—Safety—Morals
county's share in providing medical, surgical, and other aid
to medically handicapped children residing in such county.
HISTORY: 1986 H 614, ciT. 9-24-86
1974 H 1138
CROSS REFERENCES
Powers and duties of county children services board, 5153.16
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Health and Sanitation § 24
Am Jur 2d: 39, Health (j 12 et seq.; 56, Municipal Corporations,
Counties and Other Political Subdivisions § 337 ct seq.
3701.025 Medically handicapped children's medical
advisory committee
There is hereby created the medically handicapped children's medical advisory committee consisting of twentyone members to be appointed by the director of health for
terms set in accordance with rules adopted by the public
health council under division (A)(6) of section 3701.021 o f
the Revised Code. The committee shall advise the director
regarding the administration of the program for medically
handicapped children, the suitable quality of medical practice for providers, and the requirements for medical eligibility for the program.
All members of the committee shall be licensed physicians, surgeons, dentists, and other professionals in the
field of medicine, representative o f the various disciplines
involved in the treatment of children with medically handicapping conditions, and representative of the treatment
facilities involved, such as hospitals, private and public
health clinics, and private physicians' offices, and shall be
eligible for the program.
Members of the committee shall receive no compensation, but shall receive their actual and necessary travel
expenses incurred in the performance of their official duties
in accordance with the rules o f the office o f budget and
management.
The director of health may appoint a maternal and child
health consultants' group lo represent the views of service
providers, other interest groups, consumers, and various
geographic areas of the state. The maternal and child health
consultants' group shall advise the department of health on
matters pertaining to maternal and child health and, in
particular, the "Maternal and Child Health Block Grant,"
Title V of the "Social Security Act," 95 Stat. 818, (1981) 42
U.S.C.A. 701, as amended. Members of the group shall
receive no compensation, but shall receive their actual and
necessary travel expenses incurred in the performance o f
their official duties in accordance with the rules o f the
office of budget and management.
DEPARTMENT AND DIRECTOR
OF HEALTH
3701.03
General duties of director of health
The director o f health shall perform such duties as are
incident to his position as chief executive officer. He shall
administer the laws relating to health and sanitation and
the regulations of the department of health. He shall prepare sanitary and public health regulations for consideration by the public health council and shall submit to said
council recommendations for new legislation. The director
shall sit at meetings of the council but shall have no vote.
HISTORY: 1953 H 1, efi". 10-1-53
GC 1233
CROSS REFERENCES
Cooperation with other agencies for delivery of services to
multi-need children, OAC 3701-65-01
Health director, membership in cluster for services to youth,
121.37
Nurse aide training and competency evaluation, rulemaking
powers of health director, 3721.28
Nurse aide training and competency evaluation programs,
approval by director, rulemaking powers of health director, 3721.30
Nurse aide training and competency evaluation, powers of
health director, 3721.31
Nurse aide registry, establishment by health director, 3721.32
Director of health a member of midwest interstate low-level
radioactive waste commission, 3747.02
Swimming pools, public director of health to approve plans and
appoint swimming pool and spa advisory board members. 3749.08
Emergency response commission, membership in, 3750.02
Health department and boards of health to enforce RC Ch 3781
and Ch 3791 as to plumbing, 3781.03
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Health and Sanitation § 5, 19
Am Jur 2d: 39, Health § 9 et seq.; 63, Public Officers and
Employees § 275 to 283
NOf ES ON DECISIONS AND OPINIONS
OAG 88-022. The health director may serve as a clinical associate professor of medicine at Wright state university without compensation from the university where his teaching duties involve the
instruction of medical students who accompany him while he is
treating patients only on weekends at a privately owned outpatient
clinic.
1940 OAG 1921. Director of health, in his administration of the
laws and regulations adopted by the public health council relating
to public health, quarantine and sanitation on state owned property
or elsewhere, may call upon local district boards of health and
officials, officers of slate institutions, police officers, sheriffs, constables or other law enforcement officers in the slate or any county,
city or township, to assist in such administration.
H I S T O R Y : 1986 H 614, eff. 9-24-86
1974 H 1138
CROSS REFERENCES
Physicians, licensing, Ch 4731
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Health and Sanitation § 24
Am Jur 2d: 39, Health § 12 et seq.; 56, Municipal Corporations,
Counties and Other Political Subdivisions § 337 et seq.
3701.04
Powers of director of health
The director o f health shall:
(A) Require such reports and make such inspections and
investigations as he deems necessary;
(B) Provide such methods o f administration, appoint
such personnel, make such reports, and take such other
action as may be necessary to comply with the requirements o f the federal act and the regulations thereunder;
sc
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�Department of Health
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3 l 0 i . OL)
'i
•i
3701.07
C^vt^
(C) Procure by contract the temporary or intermittent
services of experts or consultants or organizations thereof
when such services are to be performed on a part-time or
fee-for-service basis and do not involve the performance of
administrative duties;
(D) Enter into agreements for the utilization of the facilities and services of other departments, agencies, and institutions, public or private;
(E) Accept on behalf of the state and deposit with the
treasurer of state any grant, gift, or contribution made to
assist in meeting the cost of carrying out sections 3701.01,
3701.04, 3701.08, 3701.09, and 3701.36 to 3701.45, inclusive, of the Revised Code, and expend the same for such
purpose;
(F) Make an annual report to the governor on activities
and expenditures including recommendations for such
additional legislation as he considers appropriate to furnish
adequate hospital, clinic, and similar facilities to the people
of this state.
HISTORY: 1953 H 1, eff. 10-1-53
GC 1236-10
3701.06 Right of entry to investigate violations
The director of health and any person authorized by him
may, without fee or hindrance, enter, examine, and survey
all grounds, vehicles, apartments, buildings, and places in
furtherance of any duty laid upon the department of health
or where he has reason to believe there exists a violation of
any health law or of the sanitary code.
HISTORY: 1953 H 1, efT. 10-1-53
GC 1236-3
CROSS REFERENCES
Right to be secure against unreasonable searches and seizures, O
Const Art I §14
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Heallh and Sanitation § 43
Am Jur 2d: 39, Heallh § 32 et seq.; 68, Searches and Seizures §
56, 68
Searches and seizures by health officers without warrant. 13
ALR2d 969
Propriety of state or local government health officer's warrantless search—post-Camara cases. 53 ALR4th 1168
CROSS REFERENCES
Yearly report to be filed by department of health, 149.01
Health department powers, effect of state building standards
laws, 3781.16
Disobeying health department order under RC Ch 3781 or Ch
3791, penalty, 3791.02
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Heallh and Sanitation § 5, 6, 43; 55, Hospitals and
Related Facilities; Health Care Providers § 15
Am Jur 2d: 39, Health § 9 el seq.; 63, Public Officers and
Employees § 261 to 274
Searches and seizures by health officers without warrant. 13
ALR2d 969
3701.041
Atmospheric pollution research—Repealed
HISTORY: 1972 S 397, eff. 10-23-72
127 v257
3701.05 Annual report
The director of health shall keep the public health council, health officials, and the general public fully informed in
a printed annual report in regard to the work of the department of health and on the progress that is being made in
studying the cause and prevention of disease and such kindred subjects as may contribute to the welfare of the people
of the state.
HISTORY: 1985 H 238, efT. 7-1-85
1953 H 1;GC 1236-1
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Health and Sanitation § 5
NOTES ON DECISIONS AND OPINIONS
1944 OAG 6785. GC 154-66 (RC 119.05) does not affect duty
of director of health to furnish without request and free of charge a
public health manual to every health commissioner in the state.
3701.07 Reports to health department; registration of
hospitals and dispensaries; residents' rights advocates
(A) The public health council shall adopt rules in accordance with Chapter 119. of the Revised Code defining and
classifying hospitals and dispensaries and providing for the
reporting of classification information by hospitals and dispensaries. The rules may require each hospital to report
information in the following categories, shall limit the
information to information necessary to classify hospitals
and dispensaries as general or specialty facilities, and shall
not include any confidential patient data or any information concerning the financial condition, income, expenses,
or net worth of the facilities other than that financial information already contained in those portions of Ihe medicare
or medicaid cost report that is necessary for the department
of health to certify the per diem cost under section 3701.62
of the Revised Code:
(1) Information needed to identify and classify the
institution;
(2) Information on facilities and type and volume of
services provided by the institution;
(3) The number of beds listed by category of care
provided;
(4) The number of licensed or certified professional
employees by classification;
(5) Information necessary for calculation of a per diem
rate for reimbursement under section 3701.62 of the
Revised Code.
Every hospital and dispensary, public or private, shall
annually register with and report to the department of
health on forms prescribed in rules adopted under this
division.
(B) Every governmental entity or private nonprofit corporation or association whose employees or representatives
are defined as residents' rights advocates under divisions
(E)( 1) and (2) of section 3721.10 of the Revised Code shall
register with the department of health on forms furnished
by the director of health and shall provide such reasonable
identifying information as he may prescribe.
The department shall compile a list of the governmental
entities, corporations, or associations registering under this
June 1989
�3701.19
Department of Health
€
Regional long-term care ombudsman programs, registration as
residents' rights advocates, 173.18
Resolution authorizing acquisition, operation, or lease of
county hospital, applicability, 339.091
Children's hospital, defined, 3702.51
Adult care facilities, residents' rights advocate defined, 3722.01
Joint legislative committee on medicaid oversight, hospital
defined, 5111.75
Hospital care assurance program, hospital defined, 5112.01
Research and education in alcoholism—
HISTORY: 1989 H 317, eff. 10-10-89
1985 H 201; 128 v 800
3701.143
Blood analysis to determine alcoholic content
PRACTICE AND STUDY AIDS
3701.13
Powers of department; nutrition
The department of health shall have supervision of all
matters relating to the preservation of the life and health of
the people and have supreme authority in matters o f quarantine, which it may declare and enforce, when none exists,
and modify, relax, or abolish, when it has been established.
It may approve means of immunization against poliomyelitis, rubeola, diphtheria, rubella (German measles), pertussis, and tetanus for the purpose of carrying out the provisions of section 3313.671 of the Revised Code. It may make
special or standing orders or rules for preventing the use of
fluoroscopes for nonmedical purposes which emit doses of
radiation likely to be harmful to any person, for preventing
the spread of contagious or infectious diseases, for governing the receipt and conveyance of remains of deceased
persons, and for such other sanitary matters as are best
controlled by a general rule. It may make and enforce
orders in local matters when an emergency exists, or when
the board o f health of a general or city health district has
neglected or refused to act with sufficient promptness or
efficiency, or when such board has not been established as
provided by sections 3709.02, 3709.03, 3709.05, 3709.06,
3709.11, 3709.12, and 3709.14 of the Revised Code. In
such cases the necessary expense incurred shall be paid by
the general health district or city for which the services are
rendered.
The department may make evaluative studies of the
nutritional status of Ohio residents, and of the food and
nutrition-related programs operating within the state. Every
agency of the state, at the request of the department, shall
provide information and otherwise assist in the execution
of such studies.
HISTORY: 1990 H 764, eff. 4-10-91
1980 H 965; 1978 H 234; 1969 S 60, S 300; 128 v 707;
127 v 635; 1953 H 1; GC 1237
3701.132 Department to administer special supplemental food program for women, infants, and children
c
3701.141
Repealed
The department of health is hereby designated as the
state agency to administer the "special supplemental food
program for women, infants, and children" established
under the "Child Nutrition Act o f 1966," 80 Stat. 885, 42
U.S.C. 1786, as amended. The public health council may
adopt rules pursuant to Chapter 119. of the Revised Code
as necessary for administering the program.
In determining eligibility for services provided under
the program, the department may use the application form
established under section 5111.013 o f the Revised Code for
the healthy start program. The department may require
applicants to furnish their social security numbers.
HISTORY: ,1990 H 764, eff. 4-10-91
Painter & Looker, Ohio Driving Under the Influence Law (2d
Ed.), Text 9.01, 9.08, II.14(CKD), 17.07(A)
NOTES ON DECISIONS AND OPINIONS
63 App(3d) 535 (Franklin 1989), Stale v Asman. Where a trial
court's findings are general an appellate court will assume regularity
rather than irregularity in the court's findings even if they are
ambiguous; therefore, where a trial court does not explain what it
means by the phrase "properly tested and calibrated as per O.A.C.
3701-53-02(C)," it will be assumed that the court meant substantia)
compliance rather than strict compliance with the regulation, since
the rule is that the BAC verifier is properly tested and calibrated if
the prosecution proves substantial compliance with the regulations
without prejudice to the defendant.
63 App(3d) 535 (Franklin 1989), State v Asman. A trial court
finding that the testing of a BAC verifier did not substantially
comply with OAC 3701-53-02(C), thereby resulting in prejudice to
the defendant, is not erroneous where despite the regulation
requirement that two persons, each using a hand-held radio, perform the test, the radio frequency interference survey was conducted with only one hand-held radio and although the regulations
further require that the radio frequency interference must be tested
from a perimeter of thirty feet around the BAC verifier, the trooper
walked only to the wall of the room in which the instrument was
located or into the adjoining rooms, a distance which varied along
each axis from seven feet lo twenty-four feet.
63 App(3d) 535 (Franklin 1989), State v Asman. Two hand-held
radios are necessary to properly test a blood alcohol content measuring device despite the argument that the internal radio frequency
interference detector serves the same function as the second handheld radio, since the second radio serves to test whether ihe other
radio is active and generating radio frequency energy at the angle
and direction intended, which the internal detector does noi do,
and the second radio also serves to test the proper operation of the
internal detector itself.
62 App(3d) 189, 574 NE(2d) 1168 (Ottawa 1989), Stale v Farris. Where an automobile driver files a motion to suppress Ihe
results of an intoxilyzer based on his claim that the intoxilyzer used
on him produced results that were not within Ihe range of variance
permissible by law, the trial court properly denies Ihe motion where
the variance indicated on the certificate for Ihe calibration solution
of + .005, rather than + or -.005 is a printing error which cannot be
used by the driver to change the requirements of law.
POISON CONTROL
3701.19
Definitions
As used in this section and in sections 3701.20 and
3701.21 of the Revised Code:
(A) "Poison prevention and treatment center" means an
entity designated as a poison prevention and treatment
center by the director of health under section 3701.20 of the
Revised Code.
(B) " H a r m " means injury, death, or loss to person or
property.
1991
�13
3701.22
Department of Health
amended, on the efTective date of this section, for the purpose of assisting such institutions to operate diagnostic and
research centers for Alzheimer's disease. The director, upon
the recommendations of the Alzheimer's disease task force
created under division (C) of this section, shall adopt rules
pursuant to Chapter 119. of the Revised Code governing
the applications for grants, the review of applications, the
awarding of grants, and the purposes for which a grant
awarded under section 3701.181 of the Revised Code may
be used. A school of medicine, hospital, or institution is
eligible for a grant if it meets the following requirements:
(1) The medical school, hospital, or institution has an
operating geriatric assessment unit.
(2) The medical school, hospital, or institution has the
capability to provide diagnostic services for persons with
symptoms of Alzheimer's disease.
(3) The medical school, hospital, or institution can provide access to treatment and care to a broad segment of the
population.
(4) The medical school, hospital, or institution has a
research and training mission in geriatrics, including undergraduate or graduate medical programs.
(B) A school of medicine or hospital operating a diagnostic and research center for Alzheimer's disease under a
grant awarded under division (A) of this section shall:
(1) Make available diagnostic services to persons with
symptoms of Alzheimer's disease;
(2) Conduct human and animal research directed toward
discovery of the cause of, and a cure for, Alzheimer's disease, and improvement of the quality of care for persons
who have the disease;
(3) Conduct training programs to prepare licensed physicians to diagnose and care for persons with symptoms of
Alzheimer's disease.
(C) The governor shall appoint an eleven-member
Alzheimer's disease task force to assist the director of aging
with the rules for this program and with the awarding of
grants under section 3701.181 of the Revised Code. The
eleven members shall be representative of the various geographic areas of the state. Two of the members shall represent the Alzheimer's disease and related disorders association, inc., five of the members shall be physicians licensed
under Chapter 4731. of the Revised Code to practice
medicine or surgery or osteopathic medicine or surgery,
two of the members shall be Ohio scientists recognized for
their expertise in Alzheimer's research, and two of the
members shall be scientists from outside the state and shall
be recognized for their expertise in Alzheimer's research.
The director of the department of health or his designee
shall serve as an ex officio, nonvoting member of the task
force.
The Ohio state medical association, the Ohio osteopathic association, the Alzheimer's disease and related disorders association, inc., and other appropriate organizations shall make recommendations to the governor for the
appointments to the Alzheimer's disease task force created
under this section. The governor shall appoint four members of this task force to serve for three-year terms, four
members to serve for two-year terms, and three members to
serve for one-year terms.
Each member shall hold office from the date of appointment until the end of the term for which he was appointed.
Any member appointed to fill a vacancy occurring prior to
the expiration of the term for which the predecessor was
appointed shall hold office for the remainder of such term.
Six members shall constitute a quorum for transacting
all business of the task force. The task force shall elect one
of its members as chairman and one of its members as vicechairman. The chairman and vice-chairman shall serve in
such positions for one year.
(D) No grant awarded to a single medical school, hospital, or institution shall exceed twenty-five per cent of the
total moneys appropriated under this section to the department of aging for grants for the fiscal year in which the
grant is awarded.
(E) A school of medicine, hospital, or institution that
receives a grant under division (A) of this section shall
submit lo the department of aging an annual report including data from all research projects undertaken with grant
funds. The medical school, hospital, or institution receiving
the grant shall provide a copy of the report to the Ohio state
medical association, the Ohio osteopathic association, and
the Alzheimer's disease and related disorders association,
inc., for dissemination to their members.
(F) On or before the first day of January, 1988, and on
or before each first day of January thereafter, the director
of aging shall submit to the president of the senate and the
speaker of the house of representatives a report on the
progress of the grant programs established under this section. The report shall include:
(1) A description of the progress made in discovering the
cause of and a cure for Alzheimer's disease, and in improving the quality of care of persons who have Alzheimer's
disease;
(2) The number of diagnostic and research centers established under grants awarded under division (A) of this
section;
(3) The characteristics and number of persons served by
programs established under this section;
(4) The costs of programs established under this section;
and
(5) A general evaluation of the programs established
under this section.
HISTORY:
1986 S 256, eff. 6-7-86
Note: Former 3701.181 repealed by 1974 H 717 efT. 6-19-74;
132 v H 314.
3701.19 to 3701.21 Approval of plans and supervision
of waste disposal; study of streams and lakes—Repealed
HISTORY: 1972 S 397, eff. 10-23-72
1969 H 1; 132 v H 314; 125 v 903; 1953 H 1;GC 1240-1
to 1240-3
Note: 3701.19 and 3701.20 amended and recodified as
6111.45 and 611 1.46, respectively, by 1972 S 397, eff. 10-23-72.
3701.22
Chemical and bacteriological laboratory
The department of health shall maintain a chemical and
bacteriological laboratory for the examination of public
water supplies, and the effluent of sewage purification
works, for the diagnosis of diphtheria, typhoid fever, hydrophobia, glanders, and such other diseases as it deems necessary, and for the examination of food suspected to be the
cause of disease. The department shall examine and report
June 1989
�3701.23
Health—Safety—Morals
15
14
3")0|, 2,2, t*^l
to the director of environmental protection and the public
each year the condition of all public water supplies.
HISTORY: 1972 S 397, elT. 10-23-72
1953 H 1;GC 1241
LEGAL ENCYCLOPEDIAS AND ALR
OJur 2d: 55, Water Supply § 49
OJur 3d: 41, Environmental Protection § 85: 50, Food, Drugs,
Poisons, and Hazardous Substances § 8; 53, Heallh and Sanitation §
31
Am Jur 2d: 39, Health § 22
Liability of water supplier for damages resulting from furnishing impure water. 54 ALR3d 936
NOTES ON DECISIONS AND OPINIONS
1927 OAG 559. The state board of health, having the power to
establish and maintain a laboratory for the diagnosis of contagious
and infectious diseases, has as a necessary incident to such power
the right lo make and enforce reasonable rules and regulations
conducive to the efficient operation of such laboratory.
1927 OAG 559. In the exercise of such power the state board of
health may limit the service of such laboratory to physicians and
surgeons licensed to practice in Ohio, but may refuse to furnish
such service to certain physicians and surgeons because of unethical
practice or acts.
3701.23 Supervision of laboratory
The director of health shall have charge of the Iftboratory
authbnzed by section 3701.22 of the RevisejKTode. The
directoKmay employ an assistant for the Jdtooratory who
shall be a>erson skilled in chemistry and^acteriology, and
receive for his services such competition as the director
may allow. AlN^xpenses of such .-laboratory shall be paid
from appropriatiotvsniade for the department of health.
The public healthN^nincil/in accordance with Chapter
119. of the Revised CocteyShall adopt, and may amend or
rescind, rules establishiijgreasonable fees to be charged for
services that the laboratory petforms. The council need not
prescribe fees to be-charged in any case where the council
believes that the^charging of fees^ould significantly and
adversely affecHhe public health. AINjees collected for services that the laboratory performs shalfbe deposited in the
state treasuty to the credit of the "chemical and bacteriological laboratory fund," which is hereby created for the
purpose of defraying expenses of operating the laboratory.
(A) Asiatic cholera;
(B) Yellow fever;
(C) Diphtheria;
(D) Typhus or typhoid fever;
(E) Any other contagious or infectious diseases that the
public health council specifies.
of
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th
sh
HISTORY: 1980 H 965, efT. 4-9-81
1953 H 1; GC 1243
H
CROSS REFERENCES
Communicable diseases, OAC Ch 3701-3
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Health and Sanitation § 31, 33, 34
Am Jur 2d: 39, Health § 23
3701.25 Occupational diseases; report by physician to
department of health
Every physician attending on or called in to visit a
patient whom he believes to be suffering from poisoning
from lead, phosphorus, arsenic, brass, wood alcohol, mercury, or their compounds, or from anthrax or from compressed air illness and such other occupational diseases and
ailments as the department of health shall require to be
reported, shall within forty-eight hours from the time of
first attending such patient send to the director of health a
report stating:
(A) Name, address, and occupation of patient;
(B) Name, address, and business of employer;
(C) Nature of disease;
(D) Such other information as may be reasonably
required by the department.
The reports required by this section shall be made on, or
in conformity with, the standard schedule blanks provided
for in section 3701.26 of the Revised Code. The mailing of
the report, within the time required, in a stamped envelope
addressed to the office of the director, shall be a compliance
with this section.
Such reports shall not be evidence of the facts therein
stated in any action arising out of the disease therein
reported.
HISTORY: 1953 H 1, eff. 10-1-53
GC 1243-1, 1243-3
Penalty: 3701.99(A)
HISTORY: 1988 H 708, efT. 4-19-88
/1980 H 965; 1953 H 1; GC 1242
CROSS REFERENCES
Fees for laboratory services, procedures for administration of
fees, OAC Ch 3701-49
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53. Health and Sanitation § 31, 33, 34
CROSS REFERENCES
Occupational diseases, compensation, statute of limitations,
referees. 4123.68
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Health and Sanitation § 31, 33, 34
Am Jur 2d: 39, Health § 25
NOTES ON DECISIONS AND OPINIONS
3701.24
Report as to contagious or infectious diseases
Boards of health, health authorities or officials, and physicians in localities in which there are no health authorities
or officials, shall report to the department of health
promptly upon the discovery of the disease, the existence of
any one of the following diseases:
459 FSupp 235 (SD Ohio 1978), General Motors Corp v Director of Natl Institute of Occupational Safety & Health. The national
institute for occupational safety and health may require an
employer to submit to it medical information regarding its employees without identification thereof, but medical records identified by
name may not be required without the specific consent of the
employee involved, and the employee is entitled to a due process
hearing to determine whether his identified records may be
examined without his consent.
a
�Department of Health
poison prevention and treatment center may be entitled
under circumstances not specified by this section.
(H) The director shall annually report to the general
assembly findings and recommendations concerning the
effectiveness, impact, and benefits of the poison prevention
and treatment centers.
HISTORY:
1989 H 320, eff. 10-30-89
Note: Former 3701.20 amended and recodified as 6111.46 by
1972 S 397, eff. 10-23-72; 1969 H I ; 132 v H 314; 125 v 903; 1953
H I ; GC 1240-2.
CROSS REFERENCES
Poison control, prevention, and treatment, OAC Ch 3701-41
3701.21 Poison control network advisory committee
There is hereby created the Ohio poison control network
advisory committee to advise the department of health on
matters pertaining to poison prevention and treatment. The
committee shall consist of the director of health or his designee and fourteen additional members appointed by the
director, including, but not limited to, members of the Ohio
association of poison control centers, directors of poison
prevention and treatment centers, representatives of organizations that manufacture poisonous materials, and representatives of state and federal agencies and of the general
public responsible for poison prevention and treatment.
The director or his designee shall serve as chairman of the
committee.
Terms of office of members of the committee shall be
three years. Each member shall hold office from the date of
his appointment until the end of the term for which he was
appointed. In case of a vacancy occurring on the board, the
director shall fill the vacancy by appointing a member. Any
member appointed to fill a vacancy occurring prior to the
expiration of a term for which his predecessor was
appointed shall hold office for the remainder of the term. A
member shall continue in office subsequent to the expiration date of his term until his successor takes office, or until
a period of sixty days has elapsed, whichever occurs first.
The committee shall hold meetings in a manner and at
times prescribed by rules adopted by the committee. A
majority of the committee constitutes a quorum and no
action shall be taken by the committee unless approved by
at least eight members of the committee.
The director shall provide the committee with the
administrative support necessary for it to perform its duties
and exercise its powers. Committee members shall serve
without compensation but shall be reimbursed for actual
and necessary expenses incurred in the performance of
their duties.
HISTORY:
c
1989 H 320, eff. 10-30-89
Note: Former 3701.21 repealed by 1972 S 397, eff. 10-23-72;
1953 H I ; GC 1240-3.
•
UNCODIFIED LAW
1989 H 320, § 2, eff. 10-30-89, reads: The Director of Health
shall make the initial appointments to the Ohio Poison Control
Network Advisory Committee within ninety days after the efTective
date of this act. For the initial appointments by the Director, five
members shall serve three-year terms, five members shall serve twoyear terms, and five members shall serve one-year terms.
3701.24
CROSS REFERENCES
Poison control, prevention, and treatment, OAC Ch 3701-41
3701.23
Supervision of laboratory; fees
(A) The director of health shall have charge of the laboratory authorized by section 3701.22 of the Revised Code.
The director may employ an assistant for the laboratory
who shall be a person skilled in chemistry and bacteriology,
and receive for his services such compensation as the director may allow. All expenses of such laboratory shall be paid
from appropriations made for the department of health.
(B) (1) The public health council, in accordance with
Chapter 119. of the Revised Code, shall adopt, and may
amend or rescind, rules establishing reasonable fees to be
charged for services that the laboratory performs. The
council need not prescribe fees to be charged in any case
where the council believes that the charging of fees would
significantly and adversely affect the public health. Except
as provided in division (B)(2) of this section, all fees collected for services that the laboratory performs shall be
deposited into the state treasury to the credit of the "laboratory handling fee fund," which is hereby created for the
purpose of defraying expenses of operating the laboratory.
(2) The council, in accordance with division (B)(1) of
this section, shall adopt a rule establishing a fee of twentyfour dollars for tests of newborn children conducted under
section 3701.501 of the Revised Code. Of each such fee
colected [sic] on or after the rule's efTective date, ten dollars
and twenty-five cents shall be deposited into the state treasury to the credit of the genetics services fund, which is
hereby created, and three dollars and seventy-five cents
shall be deposited into the state treasury to the credit of the
sickle cell fund, which is hereby created. Three dollars from
each fee credited to the genetics services fund shall be used
to defray costs of phenylketonuria programs. Seven dollars
and twenty-five cents of each fee credited to the genetics
services fund shall be used to defray the costs of the programs authorized by section 3701.502 of the Revised Code.
Money credited to the sickle cell fund shall be used to
defray costs of programs authorized by section 3701.131 of
the Revised Code.
HISTORY: 1991 H 298. eff. 7-26-91
1988 H 708; 1980 H 965; 1953 H 1; GC 1242
CONTAGIOUS OR INFECTIOUS DISEASES;
AIDS; CANCER
3701.24 Definitions; report as to contagious or infectious diseases or AIDS
(A) As used in this section and sections 3701.241 to
3701.249 of the Revised Code:
(1) "AIDS" means the illness designated as acquired
immunodeficiency syndrome.
(2) "HIV" means the human immunodeficiency virus
identified as the causative agent of AIDS.
(3) "AIDS-related condition" means symptoms of illness related to HIV infection, including AIDS-related complex, that are confirmed by a positive HIV test.
1991
�3701.263
Health—Safety—Morals
nated as a medical research project by the department, does
not subject a physician, dentist, hospital, or person providing diagnostic or treatment services to patients with cancer
to liability in an action for damages or other relief for
furnishing the information.
(H) This section docs not affect the authority of any
person or facility providing diagnostic or treatment services
to patients with cancer to maintain facility-based tumor
registries, in addition to complying with the reporting
requirements of this section.
(I) No person shall fail to make the cancer reports
required by division (D) of this section.
HISTORY:
1991 H 213, eff. 11-11-91
Note: Former 3701.262 amended and recodified as 3701.261
by 1991 H213, eff. 11-11-91; 1985 H 201; 1973 S 282.
Penalty: 3701.99(B)
3701.263
Information concerning malignant disease
(A) Any information, data, and reports with respect to a
case of malignant disease which are furnished to, or procured by, any cancer registry in this state or the department
of health shall be confidential and shall be used only for
statistical, scientific, and medical research for the purpose
of reducing the morbidity or mortality of malignant disease. No physician, dentist, person, or hospital furnishing
such information, data, or report to any such cancer registry or the department of health, with respect to a case of
malignant disease treated or examined by such physician,
dentist, or person, or confined in such hospital, shall by
reason of such furnishing be deemed to have violated any
confidential relationship, or be held liable in damages to
any person, or be held to answer for willful betrayal of a
professional confidence within the meaning and intent of
section 4731.22 of the Revised Code.
(B) The department of health shall prescribe a release of
confidential information form for use under this division.
Information concerning individual cancer patients
obtained by the department of health for the Ohio cancer
incidence surveillance system is for the confidential use of
the department only, except as follows:
(1) The department shal) grant to a person involved in a
medical research project that meets the standards established by the director of health under section 3701.262 of
the Revised Code access to confidential information concerning individual cancer patients if all of the following
conditions are met:
(a) The person conducting the research provides written
information about the purpose of the research project, the
nature of the data to be collected and how the researcher
intends to analyze it, the records the researcher seeks to
review, and the safeguards the researcher will take to protect the identity of patients whose records the researcher
will be reviewing.
(b) In the view of the director of health, the proposed
safeguards are adequate to protect the identity of each
patient whose records will be reviewed.
(c) An agreement is executed between the department
and the researcher that specifies the terms of the
researcher's use of the records and prohibits the publication
or release of the names of individual cancer patients or any
facts tending to lead to the identification of individual cancer patients.
16
(2) Notwithstanding division (B)(1) of this section, a
researcher may, with the approval of the department, use
the names of individual cancer patients when requesting
additional information for research purposes or soliciting a
patient's participation in a research project. If a researcher
requests additional information or a cancer patient's participation in a research project, the researcher shall first
obtain the oral or written consent of the patient's attending
physician. If the consent of the patient's attending physician is obtained, the researcher shall obtain the patient's
written consent by having the patient complete a release of
confidential information form.
(3) The department may release confidential information concerning individual cancer patients to physicians for
diagnostic and treatment purposes if the patient's attending
physician gives oral or written consent to the release of the
information and the patient gives written consent by completing a release of confidential information form.
(4) The department may release confidential information concerning individual cancer patients to the cancer
registry of another state, if the other state has entered into a
reciprocal agreement with the department and the agreement provides that the state will comply with this section
and that information identifying a patient will not be
released to any person without the written consent of the
patient.
(C) Nothing in this section prevents the release to any
person of epidemiological information that does not identify individual cancer patients.
(D) No person shall fail to comply with the confidentiality requirements of this section.
HISTORY:
1991 H 213, eff. 11-11-91
Note: 3701.263 is former 3701.261, amended and recodified
by 1991 H 213, efT. 11-11-91; 131 v H 373; 128 v 920.
Penalty: 3701.99(B)
PUBLIC HEALTH COUNCIL—PRIVATE
WATER SYSTEMS
3701.33 Composition of public health council; terms;
procedure
The public health council shall consist of seven members
to be appointed by the governor. Not less than three of the
members shall be physicians who are licensed to practice
medicine in the state, one of the members shall be a pharmacist who has been granted a certificate to practice pharmacy in the state, and one of the members shall be a registered nurse who is licensed to practice nursing as a
registered nurse in the state. At least one member shall
represent the general public and be at least sixty years of
age. Terms of office shall be for seven years, commencing
on the first day of July and ending on the thirtieth day of
June. Each member shall hold office from the date of his
appointment until the end of the term for which he was
appointed. Any member appointed to fill a vacancy occurring prior to the expiration of the term for which his predecessor was appointed shall hold office for the remainder of
such term. Any member shall continue in office subsequent
to the expiration date of his term until his successor takes
office, or until a period of sixty days has elapsed, whichever
occurs first. The council shall meet four times each year
and may meet at such other times as the business of the
For changes after 12-31-91, please consult Baldwin s Ohio Legislative Service. 1992 LAWS OF OHIO. For assistance, see the User's Guide in Vol. 1.
0
�17
'A
council requires. The time and place for holding regular
meetings shall be fixed in the bylaws of the council. Special
meetings may be called upon the request of any four members of the council or upon request of the director of health,
and may be held at any place considered advisable by the
council or director. Four members of the council shall constitute a quorum for the transaction of business. The council, on or before the first day of July of each year, shall
designate the member who shall act as its chairman for the
ensuing year. The director, upon request o f the council,
shall detail an officer or employee o f the department of
health to act as secretary of the council, and shall detail
such other employees as the council requires. The members
of the council shall be paid the rate established pursuant to
division (J) of section 124.15 of the Revised Code while in
conference and shall be reimbursed their necessary and reasonable traveling and other expenses incurred in the performance of their regular duties.
HISTORY: 1990 H 623, eff. 7-24-90
1988 H 790; 1977 H 1; 1973 S 131; 1969 S 297; 130 v H
184; 1953 H I ; GC 1234
UNCODIFIED LAW
1990 H 623, § 4, eff. 7-24-90, reads:
As used in this section "public member" means any of the
following: public member; representative of the public or the general public; private citizen who is not a government employee;
layman; member of the public; consumer member; member who
represents the public interest; member who is not a director, officer,
salaried employee, agent or substantial shareholder of any insurance company; and member who represents the interests of
consumers.
The Governor shall make any appointments of members at least
sixty years of age, as required by sections 3303.24, 3701.33,
3701.36, 4112.03, 4731.01, 4751.03, 4755.03, and 4757.03 of the
Revised Code, as amended by this act, to the first public members'
terms that expire after the effective date of this act or, if there is no
public member, to the next members' terms that expire after that
date.
CROSS REFERENCES
Public health council defined, OAC 3701-28-01
3701.341 Rules relating to abortions; director of health
to implement
Note: See Master Volume for version of this section in
effect until 5-28-92.
(A) The public health council, pursuant to Chapter 119.
and consistent with section 2317.56 o f the Revised Code,
shall adopt rules relating to abortions and the following
subjects:
(1) Post-abortion procedures to protect the heallh of the
pregnant woman;
(2) Reporting forms;
(3) Pathological reports;
' (4) Humane disposition of the product of human
conception;
(5) Counseling.
(B) The director of health shall implement the rules and
shall apply to the court of common pleas for temporary or
permanent injunctions restraining a violation or threatened
1 1
)f
It
:s
3701.344
Department of Health
violation of the rules. This action is an additional remedy
not dependent on the adequacy o f the remedy at law.
HISTORY: 1991 H 108, eff. 5-28-92
1974 H 989
PRACTICE AND STUDY AIDS
Dill Calloway, Ohio Nursing Law, Text 7.06, 10.05(D)
3701.344 Private water systems; limits on rules of public heallh council
As used in this section and sections 3701.345, 3701.346,
and 3701.347 of the Revised Code:
(A) "Private water system" means any water system for
the provision of water for human consumption, i f such
system has fewer than fifteen service connections and does
not regularly serve an average of at least twenty-five individuals daily at least sixty days out of the year. A private
water system includes any well, spring, cistern, pond, or
hauled water and any equipment for the collection, transportation, filtration, disinfection, treatment, or storage of
such water extending from and including the source of the
water to the point of discharge from any pressure tank or
olher storage vessel; to the point of discharge from the
water pump where no pressure tank or other storage vessel
is present; or, in the case of multiple service connections
serving more than one dwelling, to the point of discharge
from each service connection. A private water system does
not include the water service line extending from the point
of discharge to a structure.
(B) Notwithstanding section 3701.347 of the Revised
Code and subject to division (C) of this section, rules
adopted by the public health council regarding private
water systems shall provide for the following:
(1) Except as otherwise provided in this division, boards
of health o f city or general health districts shall be given the
exclusive power to establish fees in accordance with section
3709.09 o f the Revised Code for administering and enforcing such rules. Such fees shall establish a different rale for
administering and enforcing the rules relative to private
water systems serving single-family dwelling houses and
nonsingle-family dwelling houses. Except for an amount
established by the public health council, pursuant lo division (B)(5) of this section, for each new private water system installation, no portion of any fee for administering
and enforcing such rules shall be returned to the department of health. I f the director of health determines that a
board of health of a city or general heallh district is unable '
to administer and enforce a private water system program
in the district, the director shall administer and enforce
such a program in the district and establish fees for such
administration and enforcement.
(2) Boards of health of city or general health districts
shall be given the exclusive power to determine the number
of inspections necessary for determining the safe drinking
characteristics of a private water system.
(3) Private water systems contractors, as a condition of
doing business in this state, shall annually register with, and
comply with surety bonding requirements of, the department of health. No such contractor shall be permitted to
register i f he fails to comply with all applicable rules
adopted by the public health council and the board of
health of the city or general health district. The annual
registration fee for private water systems contractors shall
ir
1991
�Department of Health
17
violate O Const Art 1 §5 or violate GC 13031-17 (former RC
2905.28).
1940 OAG 2423. One may not serve as a member of the public
health council and at the same time serve as clinic physician in the
venereal disease control program, for the reason that the positions
are incompatible.
1932 OAG 4806. The unqualified term "physician," relating to
the state department of health, must be construed as a licensed
practitioner of medicine and does not include licensed dentists.
3701.34
Powers and duties of public health council
The public health council shall:
(A) Adopt, and may amend or rescind, sanitary rules to
be of general application throughout the state. The sanitary
rules shall be known as the sanitary code.
(B) Take evidence in appeals from the decision of the
director of health in a matter relative to the approval or
disapproval of plans, locations, estimates of cost, or other
matters coming before the director for official action. In the
hearing of such appeals the director may be represented in
person or by the attorney general.
(C) Conduct hearings in cases where the law requires
that the department shall give such hearings and reach decisions on the evidence presented, which shall govern subsequent actions of the director with reference thereto;
(D) Prescribe, by rule, the number and functions of divisions and bureaus and the qualifications of chiefs or divisions and bureaus within the department;
(E) Enact and amend bylaws in relation to its meetings
and the transaction of its business;
(F) Consider any matter relating to the preservation and
improvement of the public health and advise the director
thereon with such recommendations as it considers wise.
The council shall neither have nor exercise executive or
administrative duties.
HISTORY: 1981 H 694, eff. 11 -15-81
1953 H 1; GC 1235
CROSS REFERENCES
Confidentiality of council records, OAC 3701-1-03
Communicable diseases, OAC Ch 3701-3
Maternity hospitals, OAC Ch 3701-7
Industrial hygiene, OAC Ch 3701-19
Location, layout, construction, drainage, sanitation, safety, and
operation of camps, OAC Ch 3701-25
Private water systems, OAC Ch 3701-28
Household sewage disposal systems, OAC Ch 3701-29
Swimming pools, OAC Ch 3701-31
Shoe fitting equipment, prohibitions, OAC 3701-38-38,
3701-38-39
Violation of public health council rules an offense, 3701.352
Health districts, fees to be set by rule of board of health; limit
for inspection of aerobic type household sewerage treatment system, 3709.09
Nursing, nursing-related services, defined by rule adopted by
public health council, 3721.27
Nurse aide orientation programs and performance reviews,
rulemaking powers of public health council, 3721.29
Sanitarians, registration, Ch 4736
LEGAL ENCYCLOPEDIAS AND ALR
OJur 3d: 53, Health and Sanitation § 7 , I I , 19, 20, 25, 30, 42,
47; 55, Hospitals and Related Facilities; Health Care Providers § 16
. Am Jur 2d: 39, Health § 4 et seq.
3701.34
NOTES ON DECISIONS AND OPINIONS
31 OS(2d) 78, 285 NE(2d) 378 (1972), Forest Hills Utility Co v
Gardner. Public heallh council, under RC 3701.34(C) and 611 I.I 7,
is required to conduct hearings in cases where law demands that
council shall give such hearings and reach decisions on evidence
presented, and council is required lo make findings and conclusions
and elucidate in writing such decision and basis therefor.
172 OS 227, 174 NE(2d) 251 (1961), Ohio State Federation of
Licensed Nursing Homes v Public Health Council. Prohibition will
not lie to challenge the validity of the adoption of regulations by the
public heallh council.
106 OS 50, 139 NE 204 (1922), Ex parte Company. Designation
of diseases which require quarantining of persons during Ihe infective stage, adopted by the public health council, is a lawful exercise
of the police power and does not violate any constilulional right nor
is it a delegation of legislative power.
106 OS 50, 139 NE 204(1922), Ex parte Company. Regulations
adopted by the public health council may prescribe quaranline of
certain persons found to have venereal disease in an infective form.
5 Misc 178, 214 NE(2d) 853 (CP, Lake 1965), Security Sewage
Equipment Co v Beebe. In the area of sanitation Ihe state of Ohio
has exercised preemptive authority lo promulgate regulations over
Ihe design and specifications of semi-public sewage treatment
plants by virtue of RC Ch 6112 and Ch 3701.
OAG 75-056. The food establishment regulations of the Ohio
sanitary code (HE-22-01 to HE-22-14), proposed by the director of
agricullure and adopted by the public health council, are invalid,
because there is no statutory authority for the public health council
to promulgate rules governing general sanitation standards for food
processing and manufacturing establishments.
OAG 75-056. Under RC 925.01, 913.41 and 913.42, only the
director of agriculture has authority to prescribe sanitary regulations for food establishments, olher than those regulated under RC
3707.371 to 3707.376 and Ch 3732.
OAG 75-056. RC 3715.69 does not provide the public health
council with authority to prescribe sanitation standards for food
establishments.
OAG 74-014. The sanitary regulations adopted by the public
health council constitute a minimum standard with which the regulations of city health districts and general health districts must
comply, but this does not prevent a city or a general health district
from adopting a more stringent regulation when the condition of
the public health within the jurisdiclion of the board of such district may reasonably be said to require such action.
1962 OAG 3343. A health commissioner of a general health
district is authorized to enforce the sanitary rules and regulations
adopted by the public heallh council and may institute criminal
proceedings for violations of such sanitary rules and regulations.
1952 OAG 1770. The public health council has authority to
adopt reasonable sanitary and health regulations governing the
maintenance and operation of maternity hospitals and homes and
the conditions on which such licenses may be issued.
1951 OAG 691. Any person suffering from pulmonary tuberculosis in such an active stage that tubercle bacilli are being discharged, who neglects or refuses to isolate himself as required by
the sanitary code enacted by the public health council under this
section, can be prosecuted for said violation by a local authority
and if found guilty, penalized in accordance with GC 4414 (RC
3707.48).
1945 OAG 609. Public heallh council of slale department of
health has authority to adopt regulations establishing maximum
allowable concentrations for substances used in industry which are
dangerous to public health.
1940 OAG 2369. Department of heallh may not, by means of
regulations adopted by the public health council, establish and
maintain a system of registration of births and deaths occurring in
this state prior to the effective date of the vital statistics registration
law.
1940 OAG 1921. Such sanitary regulations and rules relating to
public health, sanitation and quaranline as may be deemed neces-
June 1989
�3705.09
46
Health—Safety—Morals
PRACTICE AND STUDY AIDS
Baldwin's Ohio Legislative Service, 1990 Laws of Ohio, H
591—LSC Analysis, p 5-576
CROSS REFERENCES
Child support enforcement agency using social security numbers, 2301.35
Child support bureau using social security numbers, 5101.31
370S.09 Filing of birth certificates; birth certificate of
legitimatized child
.._
(A) A birth certificate for each live birth in this state
shall be filed in the registration district in which it occurs
within ten days after such birth and shall be registered if it
has been completed and filed in accordance with this
section.
(B) When a birth occurs in or en route to an institution,
the person in charge of the institution or his designated
representative shall obtain the personal data, prepare the
certificate, secure the signatures required, and file the certificate within ten days with the local registrar of vital statistics. The physician in attendance shall provide the medical information required by the certificate and certify to the
facts of birth within seventy-two hours after the birth.
(C) When a birth occurs outside an institution, the birth
certificate shall be prepared and filed by one of the following in the indicated order of priority:
(1) The physician in attendance at or immediately after
the birth;
(2) Any other person in attendance at or immediately
after the birth;
(3) The father;
(4) The mother;
(5) The person in charge of the premises where the birth
occurred.
(D) Either of the parents of the child or other informant
shall attest to the accuracy of the personal data entered on
the birth certificate in time to permit the filing of the certificate within the ten days prescribed in this section.
(E) When a birth occurs in a moving conveyance within
the United States and the child is first removed from the
conveyance in this state, the birth shall be registered in this
state and the place where it is first removed shall be considered the place of birth. When a birth occurs on a moving
conveyance while in international waters or air space or in
a foreign country or its air space and the child is first
removed from the conveyance in this state, the birth shall
be registered in this state but the record shall show the
actual place of birth insofar as can be determined.
(F) If the mother of a child was married at the time of
either conception or birth or between conception and birth,
the child shall be registered in the surname designated by
the mother, and the name of the husband shall be entered
on the certificate as the father of the child. The presumption of paternity shall be in accordance with section
3111.03 of the Revised Code.
If the mother was not married at the time of conception
or birth or between conception and birth, the child shall be
registered by the surname of the mother. The name of the
father of such child shall also be inserted on the birth certificate if both the mother and the father sign the birth certificate as informants before the birth record is accepted for
filing by the local registrar and in such a case the child may
be registered by the surname of the father if the mother and
father so designate. If the father is not named on the birth
certificate, no other information about the father shall be
entered on the record.
(G) When a man is presumed or found to be the father
of a child, according to sections 3111.01 to 3111.19 of the
Revised Code, or the father has acknowledged the child as
his child in accordance with section 2105.18 of the Revised
Code, and documentary evidence of such fact is submitted
to the department of health in such form as the director
may require, a new birth record shall be issued by the
department which shall have the same overall appearance
as the record which would have been issued under this
section if a marriage had occurred before the birth of such
child. Where handwriting is required to effect such appearance, the department shall supply it. Upon the issuance of
such new birth record, the original birth record shall cease
to be a public record. Such original record and any documentary evidence supporting the new registration of birth
shall be placed in an envelope which shall be sealed by the
department and shall not be open to inspection or copy
unless so ordered by a court of competent jurisdiction.
The department shall then promptly forward a copy of
the new birth record to the local registrar of vital statistics
of the district in which the birth occurred, and such local
registrar shall file a copy of such new birth record along
with and in the same manner as the other copies of birth
records in such local registrar's possession. All copies of the
original birth record in the possession of the local registrar
or the probate court, as well as any and all index references
to it, shall be destroyed. Such new birth record, as well as
any certified or exact copy of it, when properly authenticated by a duly authorized person shall be prima-facie evidence in all courts and places of the facts stated in it.
(H) When a woman who is a legal resident of this state
has given birth to a child in a foreign country that does not
have a system of registration of vital statistics, a birth
record may be filed in the office of vital statistics on evidence satisfactory to the director of health.
(I) Every birth certificate filed under this section on or
after July I, 1990, shall be accompanied by all social security numbers that have been issued to the parents of the
child, unless the bureau of child support in the department
of human services, acting in accordance with regulations
prescribed under the "Family Support Act of 1988," 102
Stat. 2353, 42 U.S.C.A. 405, as amended, finds good cause
for not requiring that the numbers be furnished with the
certificate. The parents' social security numbers shall not be
recorded on the certificate. The local registrar of vital statistics shall transmit the social security numbers to the state
office of vital statistics in accordance with section 3705.07
of the Revised Code. No social security number obtained
under this division shall be used for any purpose other than
child support enforcement.
HISTORY: 1990 H 591, eff. 4-12-90
1989 H 112, § 4 ; 1988 H 790
PRACTICE AND STUDY AIDS
Baldwin's Ohio Legislative Service, 1990 Laws of Ohio, H
591—LSC Analysis, p 5-576
Merrick-Rippner, Ohio Probate Law (4th Ed.), Text 37.01(A),
37.02(B), 205.07(A), 225.03(D); Forms 205.65, 205.66
3705.10
Delayed birth certificate
Any birth certificate submitted for filing eleven or more
days after the birth occurred constitutes a delayed birth
For changes after 12-31-91, please consult Baldwin's Ohio Legislative Service, 1992 LAWS OF OHIO. For assistance, see the User's Guide in Vol. 1.
•
�47
Vital Statistics
3 , IO)
3705.12
UiKLQ
registration. A delayed birth certificate may be filed in
accordance with rules which shall be adopted by the director of health. The rules shall include, but not be limited to,
all of the following requirements for each delayed birth
certificate filed on or after July 1, 1990:
(A) The certificate shall be accompanied by all social
security numbers that have been issued to the parents of the
child, unless the bureau of child support in the department
of human services, acting in accordance with regulations
prescribed under the "Family Support Act o f 1988," 102
Stat. 2353, 42 U.S.C.A. 405, as amended, finds good cause
for not requiring that the numbers be furnished with the
certificate.
(B) The parents' social security numbers shall not be
recorded on the certificate.
(C) The local registrar of vital statistics shall transmit
the social security numbers to the state office of vital statistics in accordance with section 3705.07 of the Revised
Code.
(D) N o social security number obtained under this section shall be used for any purpose other than child support
enforcement.
HISTORY: 1990 H 591, efT. 4-12-90
1988 H 790
PRACTICE AND STUDY AIDS
Baldwin's Ohio Legislative Service, 1990 Laws of Ohio, H
591—LSC Analysis, p 5-576
3705.12 Registration of adoption; foreign birth record;
status of records as to access
(A)(1) Following the entry of each final decree of adoption granted in this state, after January 1, 1964, the court
entering the decree shall forthwith forward to the department of health a certificate o f adoption that is certified by
the probate judge or by his deputy, that attests to the fact
that the decree has been entered, and that contains the
information that is necessary for the department to prepare
a new birth record for the adopted child, except that i f the
birth of the adopted child occurred in another state, the
court shall forward such a certificate o f adoption to the
department o f health o f the state in which the birth
occurred. Upon receipt of a certificate of adoption of a
person born in the U n i t e d States, unless otherwise
requested by the adoptive parents, the department shall
issue a new birth record using the child's adopted name and
the names of and data concerning the adoptive parents. The
new birth record shall have the same overall appearance as
the record that would have been issued under section
3705.09 of the Revised Code i f the adopted child had been
born to the adoptive parents. Where handwriting is
required to effect that appearance, the department shall
supply the handwriting.
(2) Upon the issuance o f the new birth record, the original birth record and index references shall cease to be a
public record. The department shall place the original birth
record and the certificate of adoption in an envelope and
seal the envelop*. The contents o f the envelope shall not be
open to inspection, be copied, or be available for copying,
except that the department shall copy and provide an
agency with a copy of the original birth record upon the
- presentation by the agency, by mail or in another reasona' ble manner, of a certified copy o f an order issued by a
probate judge under section 3107.41 of the Revised Code,
except that the department may inspect the envelope to
determine the court involved in an adoption and provide
the name of that court to the department of human services
under the circumstances described in division (D)(4) of
section 3107.12 or section 3107.121 or provide the name of
that court to an agency under the circumstances described
in division (B)(2)(b) of section 3107.41 of the Revised
Code, and except that the court that decreed the adoption
may order that the contents be made open for inspection or
available for copying.
(3) The department of health shall promptly forward a
copy of the new birth record to the local registrar of vital
statistics of the district in which the birth occurred. The
local registrar shall file a copy of the new birth record along
with and in the same manner as the other copies of birth
records in his possession. All copies of the original birth
record and all other papers, documents, and index references pertaining to the original birth record in the possession of the local registrar or the probate court shall be
destroyed, except that the probate court shall retain permanently in the file of the adoption proceedings information
that is necessary to enable the court to identify both the
child's original birth record and his new birth record.
(4) On receipt of a certificate of adoption granted in this
state for a person born in a foreign country, the department
of health shall issue a "foreign birth record" unless the
adoptive parents or adopted person over eighteen years of
age requests that such record not be issued. A foreign birth
record shall be the same in all respects as a birth record
issued under division (A)(1) of this section, except that it
shall show the actual country of birth. After registration of
the birth record in the new name of the adopted person, the
department shall place the certificate of adoption in an
envelope and seal the envelope. The contents of the envelope shall not be open to inspection, be copied, or be available for copying, except that the department shall copy and
provide an agency with a copy of the original birth record if
available, upon presentation by the agency by mail or in
another reasonable manner of a certified copy of an order
issued by a probate judge under section 3107.41 of the
Revised Code. The department may inspect the envelope to
determine the court involved in an adoption and provide
the name o f that court to the department of human services
under the circumstances described in division (A)(4) of section 3107.12 or in section 3107.121 of the Revised Code, or
provide the name of that court to an agency under the
circumstances described in division (B)(2)(b) of section
3107.41 o f the Revised Code. The court that decreed the'
adoption may order that the contents of the envelope be
made open for inspection or available for copying.
(5) A new birth record or foreign birth record, and any
certified or exact copy of the new birth record or foreign
birth record, when properly authenticated by a duly authorized person, shall be prima-facie evidence in all courts and
places of the facts stated in the new birth record.
(B) When the adoption of a child whose birth occurred
in this state is decreed by a court in another state and when
the department of health has received, from the court that
decreed the adoption, an official communication containing information similar to that contained in the certificate
of adoption for adoptions decreed in this state, division (A)
of this section shall apply to the child's case just as i f the
adoption had taken place in this state. The department
shall place the original birth record and all papers and doc-
1991
�APPENDIX E
Newborn Screening
Rules and Regulations
�3701-45-01
(A)
T e s t i n g o f newborn c h i l d r e n f o r g e n e t i c ,
and m e t a b o l i c d i s o r d e r s .
As used i n t h i s
endocrine,
rule:
(1)
(2)
" H e a l t h commissioner" means t h e h e a l t h commissioner of
a general or c i t y health d i s t r i c t or the i n d i v i d u a l
w i t h the r e s p o n s i b i l i t i e s o f a h e a l t h commissioner i n a
c i t y health d i s t r i c t .
(3)
(B)
" D i r e c t o r " means t h e d i r e c t o r o f h e a l t h o r h i s or her
designee.
"Bureau o f p u b l i c h e a l t h l a b o r a t o r i e s " means the bureau
c r e a t e d by r u l e 3701-2-085 o f t h e A d m i n i s t r a t i v e Code
w h i c h i s r e s p o n s i b l e f o r o p e r a t i n g the Ohio department
o f h e a l t h l a b o r a t o r i e s e s t a b l i s h e d by s e c t i o n 3701.22
o f t h e Revised Code.
The b u r e a u o f p u b l i c h e a l t h l a b o r a t o r i e s s h a l l p r o v i d e
s c r e e n i n g f o r p h e n y l k e t o n u r i a , h o m o c y s t i n u r i a , galactosemia,
h y p o t h y r o i d i s m , and s i c k l e c e l l and o t h e r h e m o g l o b i n o p a thies.
I n p r o v i d i n g t h i s s c r e e n i n g , t h e bureau s h a l l do a l l
of the f o l l o w i n g :
(1)
(2)
Use s t a n d a r d t e s t i n g methods recommended by the United
S t a t e s c e n t e r s f o r disease c o n t r o l o r the " A s s o c i a t i o n
o f S t a t e and T e r r i t o r i a l P u b l i c H e a l t h L a b o r a t o r y
D i r e c t o r s " which have been approved by t h e d i r e c t o r ;
(3)
Complete each t e s t w i t h i n
eight
w o r k i n g days a f t e r
r e c e i v i n g t h e p r o p e r l y c o l l e c t e d and s u b m i t t e d s p e c i men ;
(4)
P r o m p t l y t r a n s m i t the r e s u l t s o f each t e s t performed t o
the
a p p r o p r i a t e p e r s o n as s p e c i f i e d i n p a r a g r a p h
(E)(1) of
this
r u l e , i n the manner p r e s c r i b e d by the
d i r e c t o r ; and
(5)
(C)
P r o v i d e i n s t r u c t i o n s f o r c o l l e c t i n g , h a n d l i n g , and
t r a n s p o r t i n g specimens w i t h specimen c o l l e c t i o n o u t fits;
Keep r e c o r d s on each newborn c h i l d t e s t e d i n the
r a t o r y f o r n o t l e s s than t w e n t y - o n e y e a r s .
labo-
P r i o r t o c o l l e c t i n g the blood specimen f o r t e s t i n g f o r
g e n e t i c , e n d o c r i n e , and m e t a b o l i c d i s o r d e r s under
paragraph
(B) o f t h i s r u l e , t h e person d e s i g n a t e d i n t h e a p p l i c a b l e
p r o v i s i o n o f t h i s p a r a g r a p h s h a l l g i v e t h e p a r e n t o f each
n e w b o r n c h i l d n o t i c e o f t h e p r o p o s e d t e s t s by p r o v i d i n g
p r i n t e d i n f o r m a t i o n d e s c r i b i n g t h e newborn g e n e t i c , endoc r i n e , and m e t a b o l i c screening program.
�•
3701-45-01
(1)
Each h o s p i t a l o f d e l i v e r y s h a l l p r o v i d e t h e p a r e n t s
c h i l d r e n born i n t h e h o s p i t a l w i t h t h e i n f o r m a t i o n
of
(2)
When a b i r t h o c c u r s o u t s i d e a h o s p i t a l , t h e a t t e n d i n g
physician or nurse-midwife s h a l l provide the parent
. w i t h the i n f o r m a t i o n
(3)
I f t h e r e i s no p h y s i c i a n o r nurse-midwife i n a t t e n d a n c e
a t t h e time o f b i r t h , t h e h e a l t h commissioner o f t h e
h e a l t h d i s t r i c t i n which t h e b i r t h occurred s h a l l cause
the parents t o be p r o v i d e d w i t h t h e i n f o r m a t i o n .
The d i r e c t o r s h a l l p r o v i d e t h e p r i n t e d i n f o r m a t i o n
required
by t h i s paragraph t o every h o s p i t a l having a m a t e r n i t y u n i t
l i c e n s e d under C h a p t e r 3 7 1 1 . o f t h e Revised Code, e v e r y
h e a l t h c o m m i s s i o n e r , and p h y s i c i a n s and n u r s e - m i d w i v e s
attending births outside hospitals.
(D)
The p e r s o n r e s p o n s i b l e f o r c a u s i n g b l o o d specimens t o be
c o l l e c t e d f o r i n i t i a l t e s t i n g under t h i s r u l e s h a l l be as
follows:
(1)
Except as p r o v i d e d i n paragraph ( D ) ( 1 ) ( a ) o f t h i s r u l e ,
f o r b i r t h s which occur i n a h o s p i t a l , t h e c h i l d ' s
a t t e n d i n g p h y s i c i a n s h a l l cause t h e b l o o d specimen t o
be c o l l e c t e d .
The p h y s i c i a n s h a l l cause t h e specimen
t o be c o l l e c t e d from each newborn c h i l d p r i o r t o d i s charge from t h e newborn nursery..
(a)
For a premature o r o t h e r w i s e i l l newborn c h i l d who
remains i n t h e h o s p i t a l , t h e b l o o d specimen s h a l l
be c o l l e c t e d when t h e c h i l d ' s a t t e n d i n g p h y s i c i a n
determines t h a t i t i s medically a p p r o p r i a t e t o
c o l l e c t t h e specimen, b u t no l a t e r t h a n when t h e
c h i l d reaches seven days of age;
(b)
For a premature o r o t h e r w i s e i l l newborn c h i l d who
is t r a n s f e r r e d t o another h o s p i t a l , t h e blood
s p e c i m e n s h a l l be c o l l e c t e d when t h e c h i l d ' s
attending physician i n the receiving
hospital
determines t h a t i t i s m e d i c a l l y a p p r o p r i a t e t o
c o l l e c t t h e specimen, b u t no l a t e r t h a n when t h e
c h i l d reaches seven days o f age;
(c)
For c h i l d r e n d i s c h a r g e d a t l e s s t h a n f o r t y - e i g h t
hours o f age, t h e c h i l d ' s a t t e n d i n g p h y s i c i a n a t
the h o s p i t a l of b i r t h a l s o s h a l l make a r e a s o n a b l e
e f f o r t t o cause a second specimen t o be c o l l e c t e d .
The second specimen s h a l l be c o l l e c t e d a f t e r t h e
c h i l d r e a c h e s f o r t y - e i g h t hours o f a g e , b u t no
�3701-45-01
l a t e r than when the c h i l d reaches fourteen days of
age.
I n such a case, t h e h o s p i t a l s h a l l advise
..the p a r e n t , l e g a l g u a r d i a n , or l e g a l c u s t o d i a n
t h a t t h e c h i l d needs t o be r e t e s t e d t o ensure
v a l i d r e s u l t s and of the importance of the parent,
legal guardian, or l e g a l custodian taking a l l
necessary steps t o have the second t e s t performed.
(2)
For b i r t h s which occur outside a h o s p i t a l , the attendi n g p h y s i c i a n or nurse-midwife s h a l l cause t h e blood
specimen t o be c o l l e c t e d .
The p h y s i c i a n o r nursemidwife s h a l l cause the specimen t o be c o l l e c t e d before
the c h i l d reaches seven days o f age, b u t n o t sooner
than f o r t y - e i g h t hours of age;
(3)
I f there i s no physician or nurse-midwife i n attendance
a t t h e time of b i r t h , t h e h e a l t h commissioner of t h e
health d i s t r i c t i n which the b i r t h occurred s h a l l cause
the blood specimen t o be c o l l e c t e d .
I n such a case,
the l o c a l r e g i s t r a r of v i t a l s t a t i s t i c s , when n o t i f i e d
t h a t a b i r t h has occurred without a physician or nursemidwife i n attendance, s h a l l r e p o r t the occurrence of
the b i r t h t o the h e a l t h commissioner. The h e a l t h comm i s s i o n e r s h a l l cause t h e specimen t o be c o l l e c t e d
w i t h i n seven days a f t e r being n o t i f i e d of the b i r t h of
a c h i l d under t h i s paragraph, but not sooner than when
the c h i l d reaches f o r t y - e i g h t hours of age;
A specimen c o l l e c t e d under t h i s paragraph s h a l l be sent t o
the bureau of p u b l i c h e a l t h l a b o r a t o r i e s f o r t e s t i n g n o t
l a t e r than two working days a f t e r i t i s c o l l e c t e d .
A specimen from a newborn c h i l d who i s r e c e i v i n g a n t i b i o t i c s par e n t e r a l l y or o r a l l y , or a c h i l d who has received a t r a n s f u sion of red blood c e l l s , s h a l l be so labeled.
The person d e s i g n a t e d by t h i s paragraph t o c o l l e c t t h e
i n i t i a l specimen s h a l l c o l l e c t a r e p e a t specimen w i t h i n
seven days a f t e r receiving n o t i c e from the bureau of p u b l i c
h e a l t h laboratories that the f i r s t specimen i s inadequate or
unsatisfactory.
U n s a t i s f a c t o r y specimens i n c l u d e , but are
not l i m i t e d t o , specimens t h a t are r e c e i v e d by t h e bureau
more than ten days a f t e r they are c o l l e c t e d .
I f the person
responsible f o r c o l l e c t i n g the repeat specimen i s unable t o
l o c a t e the newborn c h i l d , he or she s h a l l f o l l o w the procedures specified i n paragraph (E)(2)(d) of t h i s r u l e .
(E)
I f , upon i n i t i a l t e s t i n g of a specimen, the bureau of public
h e a l t h laboratories determines that the r e s u l t i s suspicious
or abnormal t o a c l i n i c a l l y s i g n i f i c a n t degree, the f o l l o w ing procedures s h a l l apply:
�3701-45-01
(1)
The d i r e c t o r s h a l l communicate t h e r e s u l t s
f o l l o w i n g person, as a p p l i c a b l e :
t o the
(a)
(b)
(2)
I f the c h i l d was born i n a h o s p i t a l , the d i r e c t o r
s h a l l communicate t h e r e s u l t s t o t h e c h i l d ' s
p r i m a r y care p h y s i c i a n . I f the d i r e c t o r cannot
i d e n t i f y the primary care p h y s i c i a n , the d i r e c t o r
s h a l l communicate t h e r e s u l t s t o the person who
s u b m i t t e d t h e specimen. I f the d i r e c t o r cannot
i d e n t i f y t h a t person, the d i r e c t o r s h a l l communicate the r e s u l t s t o the chief of the medical s t a f f
of the h o s p i t a l of b i r t h or t o a h o s p i t a l employee
designated by the c h i e f ; or
I f t h e c h i l d was n o t born i n a h o s p i t a l , t h e
d i r e c t o r s h a l l communicate t h e r e s u l t s t o t h e
person designated i n paragraph (D)(2) or (D)(3) of
t h i s r u l e , as applicable, who submitted the specimen .
The person n o t i f i e d of t h e r e s u l t s by t h e d i r e c t o r
under paragraph (E)(1) of t h i s r u l e then s h a l l communicate the r e s u l t s t o the c h i l d ' s parent, l e g a l guardian,
or l e g a l custodian and s h a l l o b t a i n and submit a second
b l o o d specimen f o r t e s t i n g i n accordance w i t h t h e
f o l l o w i n g procedures:
(a)
When the abnormal o r s u s p i c i o u s r e s u l t s a r e f o r
phenylketonuria, homocystinuria, galactosemia, o r
hypothyroidism, the second specimen or. a confirmat o r y t e s t s h a l l be o b t a i n e d as soon as p o s s i b l e
but no l a t e r than ten days a f t e r n o t i f i c a t i o n by
the d i r e c t o r of t h e s u s p i c i o u s or abnormal r e sults .
(b)
When the abnormal o r s u s p i c i o u s r e s u l t s a r e f o r
s i c k l e c e l l or another hemoglobinopathy, a c o n f i r matory t e s t , by a l a b o r a t o r y approved t o conduct
the t e s t by the d i r e c t o r , s h a l l be obtained before
the c h i l d reaches one month of age.
(c)
Specimens obtained under paragraph ( E ) ( 2 ) o f t h i s
r u l e s h a l l be submitted f o r t e s t i n g t o the bureau
of p u b l i c h e a l t h l a b o r a t o r i e s o r t o another labor a t o r y approved t o conduct t h e t e s t i n g by t h e
d i r e c t o r . Specimens s h a l l be submitted w i t h i n two
working days a f t e r they are c o l l e c t e d . The bureau
or other laboratory s h a l l analyze the specimens i n
accordance w i t h a p p r o p r i a t e s t a n d a r d t e s t i n g
methods and s h a l l p a r t i c i p a t e i n a p r o f i c i e n c y
t e s t i n g program acceptable t o the d i r e c t o r . The
bureau or other laboratory s h a l l promptly t r a n s m i t
�3701-45-01
the r e s u l t s of the second t e s t to the person who
submitted the specimen.
In a d d i t i o n , a l a b o r a t o r y
other than the bureau that conducts a t e s t under
t h i s paragraph s h a l l t r a n s m i t the r e s u l t s to the
c h i e f of the bureau.
(d)
(F)
I f , a f t e r ten working days, the person r e s p o n s i b l e
f o r o b t a i n i n g and submitting the second specimen,
or f o r o b t a i n i n g and submitting a r e p e a t specimen
under p a r a g r a p h (D) of t h i s r u l e , i s unable to
l o c a t e a newborn c h i l d with an abnormal or s u s p i cious i n i t i a l t e s t r e s u l t despite making a reasona b l e e f f o r t , he or she s h a l l n o t i f y the h e a l t h
commissioner of the h e a l t h d i s t r i c t i n which the
mother, l e g a l g u a r d i a n , or l e g a l c u s t o d i a n r e sides.
The h e a l t h c o m m i s s i o n e r s h a l l make a
r e a s o n a b l e e f f o r t to l o c a t e the c h i l d and cause a
second o r repeat specimen to be o b t a i n e d .
I f the
h e a l t h commissioner has not been a b l e to l o c a t e
t h e c h i l d w i t h i n t h i r t y days', he o r she s h a l l
n o t i f y t h e c h i e f of the bureau of p u b l i c h e a l t h
laboratories.
The c h i e f then s h a l l r e c o r d t h a t
the c h i l d could not be located and s h a l l c l o s e the
file.
I f the r e s u l t s of the second t e s t , conducted under paragraph
( E ) ( 2 ) of t h i s r u l e , a l s o a r e abnormal or s u s p i c i o u s , the
p e r s o n who s u b m i t t e d the specimen s h a l l do b o t h of the
following:
(1)
Communicate the r e s u l t s to the c h i l d ' s p a r e n t ,
guardian, or l e g a l custodian; and
legal
(2)
R e f e r the c h i l d f o r s p e c i f i c d i a g n o s t i c t e s t i n g , f o l low-up, and management.
A c h i l d with s u s p i c i o u s or
abnormal r e s u l t s on the second t e s t f o r phenylketonur i a , h o m o c y s t i n u r i a , g a l a c t o s e m i a , or h y p o t h y r o i d i s m
s h a l l be r e f e r r e d to a physician who i s approved under
r u l e 3701-43-03 of the Administrative Code as a p r o v i d e r f o r the program for medically handicapped c h i l d r e n .
A c h i l d w i t h s u s p i c i o u s or abnormal r e s u l t s on the
i n i t i a l test for sickle c e l l disease, s i c k l e c e l l
t r a i t , or another c l i n i c a l l y s i g n i f i c a n t hemoglobinopathy s h a l l be r e f e r r e d to an Ohio s i c k l e c e l l c e n t e r , to
a p h y s i c i a n approved as a provider for the program f o r
m e d i c a l l y h a n d i c a p p e d c h i l d r e n , or to a p h y s i c i a n
c e r t i f i e d as a p e d i a t r i c hematologist by the "American
Board of Medical S p e c i a l t i e s " or a c e r t i f y i n g board of
the."American Osteopathic A s s o c i a t i o n . "
�3701-45-01
(G)
The p r o v i s i o n s o f t h i s r u l e r e q u i r i n g t e s t i n g o f newborn
c h i l d r e n do n o t a p p l y i f t h e p a r e n t s of t h e c h i l d o b j e c t
. t h e r e t o on t h e grounds t h a t such t e s t c o n f l i c t s w i t h t h e i r
" r e l i g i o u s t e n e t s and p r a c t i c e s .
E f f e c t i v e Date:
December
2, 1991
Certified:
P e t e r Van Runkle, S e c r e t a r y
P u b l i c Health Council
Date
Promulgated under: Chapter 119.
Rule a u t h o r i z e d by: Section 3701.501
Rule a m p l i f i e s : Section 3701.501
P r i o r e f f e c t i v e date: 5/20/82, 1/2/81, 7/1/66
�me*Ch 370M9
Public Health Council
68
Chapter 3701-49
Fees for Laboratory Services
Promulgated pursuant to RC Ch 119
3701-49-01 Fees for laboratory services
(A) Unless exempted under paragraph (B) or (C) of this
rule, the director of health shall charge a fee for each laboratory specimen or sample submitted according to the schedule
in rule 3701-49-011 of the Administrative Code.
(B) The charging of fees for the following laboratory tests
would significantly and adversely affect the public health and
the fees shall not be charged fon
(1) Laboratory tests authorized by the director of health as
pan of an epidemiological investigation supervised by the
department of health.
(2) Laboratory tests on specimens or samples submitted by
the health commissioner of any city or general health district
as pan of an epidemiological investigation if the director of
health determines that the charging of a fee would significantly
and adversely affect the public health and prior arrangements
are made with the director to make the tests.
(3) Viral isolations and serologies for influenza and vectorbome encephalitis.
(4) Syphilis and gonorrhea specimens generated by any
venereal disease clinic recognized by the director of health.
(5) Specimens from food handlers involved in any food
operation except in a private home, if the food handler is
suspected of being infected with any disease.
(6) Specimens for salmonellosis, shigellosis, amebiasis or
other enteric disease from individuals who are contacts with
individuals suspected of having these diseases. This exemption
shall be limited to one diagnostic specimen and shall not
include repeat tests.
(7) Cultures received from other laboratories in Ohio for
identification, grouping or typing.
(8) Rabies examinations of animals involving possible
human or animal exposure, or having symptoms suspicious of
rabies but excluding rabies examinations of pet rodents or of
rabbits, chipmunks, squinels, mice and rats. .
(9) The following hereditary-metabolic disease-screening
specimens for infants:
(a) Metabolic screening retests which are ordered by the
Ohio depanment of health laboratory when the initial test
results on the infant are suspicious or abnormal or in early
discharges when the specimen is taken less than forty-eight
hours after birth, as specified in rule 3701-45-01 of the Administrative Code.
(b) Metabolic screening tests which are submitted by local
health departments for newborns delivered at home.
(c) Metabolic screening tests which are performed on
infants whose parents are unable to pay for the tests upon
certification to that effect by the hospital or the anending
physician or midwife.
(d) Phenylketonuria monitor specimens for cases identified
by screening and for which follow-up forms have been filed
with the depanment of health laboratory. This exemption shall
apply only to specimens from persons under twenty-one years
of age.
(10) Other tests relative to which the director determines,
on a case-by-case basis, that the charging of a fee would
significantly and adversely affect the public health. In such a
case, the director may exempt the test from the fee for a period
of one hundred twenty days.
(C) Tests on the following laboratory specimens also shall
be exempted from the fees required by this chapter
(1) Tests on specimens or samples submitted by any
employee or unit of the department of health as pan of any
official responsibility of the employee or unit for the depanment when prior arrangements are made with the department
of health laboratory.
(2) Tests which are being charged for under a contract
negotiated between the depanment and any party or are funded
by the depanment through a grant or other financial
arrangement.
(3) Tests performed by the department of health laboratory
which are specifically exempted by any statute or by any rule
of the public health council from a fee charged by the
depanment.
(4) Tests on second or additional specimens which are
required by the department of health laboratory because of the
inability to make or complete the test or because the testing
operation or procedure is unsatisfactory for any reason.
(5) Tests for which funds are included in appropriations to
the department of health to pay the costs of the tests in lieu of
charging laboratory test fees.
(6) Water bacteriologic examination of samples collected
under the responsibility of the depanment of health for
administering the agricultural labor camp program under sections 3733.41 to 3733.48 of the Revised Code.
(7) Tests on any specimen or sample in connection with
any enforcement action already filed or for which filing is
imminent or for any administrative hearing or court proceeding
for the enforcement of any rule of the depanment of health
required by section 3701.56 of the Revised Code or any other
provision of law, if prior arrangements are made with the
director of health to make the tests.
(8) Tests on drinking water samples taken by licensors
from food service operations, manufactured housing parks,
marinas, public swimming pools, recreational vehicle parks,
recreation camps and combined park-camps for purposes of
determining compliance with the requirements for issuance or
renewal of a license under Chapter 3732., 3733. or 3749. of the
Revised Code or the rules adopted under those chapters. Tests
on additional water samples taken by the licensor and required
for licensure purposes also shall be exempt if the immediately
previous sample or samples were found to unsafe.
HISTORY: Eff. 4-7-89 (1988-89 OMR 918)
1985-86 OMR 27; 10-31-83, 10-1-82
Note: Effective 10-1-82. see 3701-49-013 for provisions of former 3701-49-01 (5-20-82).
CROSS REFERENCES
RC 3701.22, Chemical and bacteriological laboratory
i
�3701-49-011
Fees for Laboratory Services
|3701-49-011 Fees for .laboratory services (variable
a) '
- •
^(A) Unless exempted under paragraph (B) or (Q of rule
)l-49-01 of the Administrative Code, the director of health
I charge a fee for each parameter or group of parameters in
:eriological, chemical, or radiological analyses of envinental samples or the toxicological analysis of body fluid
Ijs set forth in this rule.
(1) Potable and non-potable water samples
(a) Inorganic chemicals/miscellaneous
f PARAMETER
[Color
'Turbidity
: Conductivity
pH, lab.
AlkaJinity, T.
AUcalimty. PHTH.
Alkalinity. Stab.
Acidity, T.
Hardness
S
Residue. T.
Residue. T. VOL.
Residue. T. NFL.
Reiidue. V. NFL.
Roidue. T. FLT.
Residue. V. FLT.
Rejidue, SEIT.
Totai Kjeldahl
Nitrogen ammonia
Nitrate-nitrite
Nitrite
Phosphorus, T.
Phosphorus, S.
Reactive phosphorus
Sulfate
Sulfide
Chloride
Fluoride
Cyanide
BOD
COD
TOC
Tannin-lignin
MBAS (special
arrangements only)
COST
S 4.00
10.00
4.00
4.00
8.00
8.00
10.00
8.00
4.00
10.00
14.00
10.00
14.00
14.00
15.00
4.00
14.00
8.00
8.00
8.00
14.00
14.00
8.00
8.00
35.00
8.00
7.50
12.00
20.00
15.00
20.00
30.00
PARAMETER
Oil-grease
Phenols
Silica. DISS.
Arsenic
Mercury
Paint chips
Sand sieve
Selenium
Calcium
Magnesium
Potassium
Sodium
Aluminum
Antimony
Barium
Berylium
Boron
Cadmium
Chromium. T.
Chromium. HEX.
Cobalt
Copper
Iron, T.
Iron, DISS.
Lead
Lithium
Manganese
Molybdenum
Nickel
Silver
Strontium
Tin
Titanium
Vanadium
12.00
Zinc
COST
S 48.00
12.00
10.00
15.00
12.00
12.00
50.00
20.00
4.00
4.00
4.00
4.00
4.00
20.00
4.00
10.00
20.00
3.00
4.00
10.00
10.00
4.00
4.00
4.00
8.00
10.00
„ 4.00
10.00;
4.00'
4.00
4.00
30.00
15.00
20.00
4.00
11
I?-
(b) EPA minimum compliance
requirements for public water systems—
arsenic, barium, cadmium, chromium,
fluoride, lead, mercury, selenium, silver,
sodium and nitrates.
COST
$ 83.00
(c) Organic chemicals
Pesticides/herbicides
Trihalomethanes
Base/neutral scan
Acid scan (with b/n)
Acid scan (without b/n)
Extraction (b/n and acid scan)
Acrolein/acrylonitrile
Purgeable aromatics
COST
$ 84.00
100.00
84.00
84.00
134.00
50.00
50.00
100.00
(d) Radioactivity
COST
$ 12.00
Gross alpha or beta
15.00
Gross alpha and beta
Iodine 131
100.00
Strontium 90
65.00
Tritium
30.00
Computerized multichannel analyzer (CMA)
[72 elements]
; 40.00/hour
Gross alpha and beta (milk, soil,
sediment, vegetation, etc.)
65.00
Gamma scan
30.00
Gamma scan (milk)
30.00
Gamma scan (soil, sediment, vegetation,
etc.)
80.00
Radium 226
75.00
Radium 228
75.00
All of the costs listed above are for drinking water umplei
unless otherwise indicated.
(2) Occupational health
Arsenic
Asbestos (fiber count)
Formaldehyde
Inorganics (ion specific electrode)
Mercury
Metals
Organics (first component)
(each additional component)
Particulates
Silica
GC/MS—identification and quantification
of organic chemicals
COST
$ 30.00
30.00
15.00
25.00
15.00
12.00
30.00
20.00
15.00
15.00
40.00/hour
(3) Special toxicology services
A special preparation fee of thirty dollars shall be assessed
in addition to the regular fee for specimens other than blood,
plasma, serum, or urine.
PANEL
(a) Ethanol
(b) Volatiles
DESCRIPTION
Alcohol in bio-fluids
1,1,1 -tricholoroethane
l-propanol
2-propanol
Acetone
Acetonitrile
Carbon tetrachloride
Chloroform
CLINICAL/
FORENSIC
$
10.00
14.00
14.00
14.00
14.00
14.00
14.00
14.00
1990
�Public Health Council
3701-49-011
. PANEL
(c) Blood bound
(d) Drug screens
DESCRIPTION
Dichloromethane
Ethyl acetate
Isobutanol
Methanol
Methyl acetate
N-butanol
N-hexane
Propionaldehyde
Sec-butanol
Tetrachloroethylene
Toluene
Trichloroethylene
Xylene
CLINICAL/
FORENSIC
14.00
"
14.00
14.00
14.00
14.00
14.00
14.00
14.00
14.00
14.00
14.00
14.00
14.00
Carbon monoxide and
hemoglobin (blood only)
S
(Screens only; no confirmation/quantitadon) Ten
drug classes: i.e.,
benzodiazepines, barbiturates, amphetamines.
methadone, propoxyphene, cocaine and
opiates, cannabinoids.
phencyclidine piperidine
(PCP). and methaqualone
S
25.00
(clinical)
(foreniic)
$
$
45.00
57.00
(e) Drug screen/
confirmation/
quamiution
Combination
Ethanol. drug
screen
(ten toxicology classes), confirmation
and quantitation
(clinical)
(forensic)
Cg) Comprehensive
toxicology
G-l
G-2
Sero group/type salmonella
Sero group/hemophilis
Sero group/meningitis
Sero group/lancefield
FA bordetella
B. pertussis culture
Phage type
Beta hemolytic streptococci
$12.00*
5.00
3.00
10.00
5.00
10.00*
9.00*
9.00*
9.00*
7.00
11.00
7.00*
3.00
10.00
Ten drag cUtier Le_ bmmditrepmes.
bsfbrtBruci. mptetvninci. tstcthtiimt,
propoxyphene, cocaine, opme*. cannkbinotds, phencyclidine piperidine.(PCP).
and methaqualone
(0
(6)(a) General bacteriology unit
Identification/confirmation
Stool-positive
Stool-negative
Food screen
Sera group-salmonella/shigella (and
A-;-v
70
S 55.00
S 67.00
Includes ethanol, ten classes and drugs
not listed*
Screen only
(clinical
S 60.00
only)
Screen/confirmation/
S 145.00
quantitation
•Limited by standards available.
(4) Hereditary/metabolic diseases
Newborn screen
Hemoglobin pattern
SI 0.00
10.00
(5) Clinical chemistry
Lead-EP (erythrocyte proto.)
Lead-quantitative
Glucose
S5.00
12.00
5.00
(b) Virus isolation unit
Rabies examination
Stool culture-virus isolation
• Swab-virus isolation
Vifocult FA virus isolation (herpes)
Biopsy-virus isolation
Spinal fluid-virus isolaiion
Urine-virus isolation
Viral isolate-confimt/idemification
Chlamydia
(c) Special microbiology unit
GC cultures
GC smears
Anaerobes-idenii fcauon
Botulism
Leponuires-cuhures
Legionnaires-FA
Mycoplasma
Ureaplasma
Leptospira
Campylobacter/yersinia
Slool-posiiive
Stool-negative
(d) Mycology/parasitology unit
Smear-parasiiology
Stool-paiasitology
Pinwonn
Mycelial identification-mycology
Yeast identification-mycology
Nocardia
Streptomyces
Sputum-mycology
Blood-mycology
Spinal fluid-mycology
Biopsy-mycology
Skin-mycology
Nails (whole)-mycology
Nails (micronized)-mycology
Hair-mycology
Environmental samples (added to
identification charge)
S15.00
22.00
20.00
13.00
22.00
20.00
20.00
18.00*
10.00
S4.00
3.00
18.00*
30.00
18.00*
12.00
8.00
10.00
10.00
5.00
5.00
3.00
S5.00
5.00
3.00
6.00*
8.00*
8.00*
8.00*
10.00
5.00
5.00
5.00
3.00
5.00
3.00
3.00
25.00/hour
#
�71 :
(fi) Serology unit
Crypioeoccus
Cocddiomycoos
HUto/blaitomycoiiJ
HuiopUsnosu
BUnomycosis
; Asperpllosis
Leponella
Respiraiory banery
Pan-influeiua I . 2. and 3
. Adenovinu
Respiraiory lynotial
M. pneumoniae
Mumps
Rubeola
Van celU
Torch banery
Toxoplasmosis
Animal loxoplasmosis-IHA
RubclU
Cytomegalovirus
Herpes simplex
Rocky mountain ipoued fever
Murine typhus
Lyme disease
Q fever
Coxsackie group
VDRL
FTA
MHA-TP
ChUinydia
Lepia^in
... AmcbMU
" ( 0 Sanitary microbiology
(i) Drinking water
Total coliform
Fecal coliform
Fecal streptococcus
MPN
Standard plate count
Staphylococcus
Beta hemolysis
Speciation (first pick)
Each additional
(ii) Stream water
Total coliform
Fecal coliform
Fecal streptococcus
Additional preparation or special
procedures
Fees for Laboratory Services
S7.00
10.00
10.00
7.00
7.00
7.00
12.00
35.00
15.00
.7.00
7.00
7.00
5.00
5.00
5.00
15.00
5.00
10.00
5.00
5.00
5.00
12.00
1100
12.00
12.00
15.00
3.00
12.00
15.00
7.00
3.00
3.00
$5.00
5.00
5.00
12.00
5.00
7.00
3.00
9.00
3.00
$15.00
15.00
15.00
25.00/hour
370M9-011
(iii) Milk samples
Wisconsin mastitis (+DMSCC)
Standard plate count
Coliform count
Phosphatase
Antibiotic
Detection of inhibitory substance
Finished milk product package
Raw milk product package
(g) Mycobacteriology
Clinical material-mycobacleriology
Smear-mycobacteriology
ID-mycobacteriology
Drug sensitivity (mycobac.)
$5.00
5.00
5.00
5.00
5.00
5.00
10.00
6.50
$15.00
3.00
12.00'
12.00
•exempt for pure cultures
d ) Proficiency testing specimens
Syphilis serology (5 sets)
Non-syphilis serology (1 set)
Chemistry , general (2 sets)
Toxicology/endocrinology (2 sets)
Hemoglobin (2 sets)
Blood group & type (2 sets)
Parasitology (1 set)
Enteric micro (1 set)
General micro (1 set)
Mycology (1 set)
Differential slide (1 set)
Irregular antibody (1 set)
Urinalysis (2 sets)
Gonorrhea cultures (1 set)
$100.00
15.00
50.00
20.00
40.00
40.00
20.00
20.00
20.00
25.00
10.00
10.00
30.00
25.00
(B) In cases when it is necessary or desirable for the depanment of health laboratory to perform a test that falls within one
of the general categories specified in paragraph (A)(1), (A)(2),
(A)(3), (A)(4), (A)(5), (A)(6) or (A)(7) of this rule, but for
which no fee has been established by this rule, the director of
health may establish and charge a reasonable fee for the test. A
fee established under this paragraph shall remain in effect for
no longer than one hundred eighty days or until a fee is
established by rule of the public health council, whichever
occurs first.
HISTORY: Eff. 12-29-89 (1989-90 OMR 542)
1988-89 OMR 918; 1985-86 OMR 28; 10-1-82
CROSS REFERENCES
RC 3701.23, Supervision of laboratory
1990
�APPENDIX F
Questionnaire and Cover L e t t e r
�December 1992
Dear Doctor,
My name i s Lynn Ogden and I work f o r the Ohio Department of
Health. Ohio's Newborn Screening lab t e s t s a l l the newborns i n
the s t a t e f o r PKU. As a p r a c t i c i n g p e d i a t r i c i a n i n Ohio, you know
t h a t any newborn whose blood was drawn f o r PKU before the c h i l d
was 48 hours of age must have a second specimen drawn when the
i n f a n t i s between 48 hours and 2 weeks o l d .
New moms and t h e i r babies are being discharged, i n ever
increasing numbers, before i n f a n t s are 48 hours o l d . Thusly,
h e a l t h care providers have a greater r e s p o n s i b i l i t y f o r
c o l l e c t i n g second PKU specimens. I t would be a tragedy t o have an
i n f a n t w i t h PKU go untested.
I have a dual purpose i n asking f o r your assistance: p r a c t i c a l
and academic. As a masters student i n Public A d m i n i s t r a t i o n a t
The Ohio State U n i v e r s i t y , I am required t o research p o l i c y problems
and propose s o l u t i o n s . Last year i n Ohio, 21,600 i n f a n t s who
were discharged e a r l y d i d not have the mandatory second PKU
t e s t . Your responses t o the survey questions w i l l a i d me i n
developing a possible s o l u t i o n f o r 21,600 babies per year. Thank
you f o r t a k i n g the time t o answer the questions concerning you,
your p a t i e n t s , and your p r a c t i c e .
Please, put no i d e n t i f y i n g i n f o r m a t i o n on your questionaire.
Return your answers t o me i n the self-addressed stamped envelope.
No one but me w i l l see your questionaire. I f you have any
questions regarding the survey, contact me a t the Ohio
Department of Health Newborn Screening Lab a t (614) 421-1078
ext.60. Again, thank you f o r your help.
Sincerely,
Lynn Ogden
M i c r o b i o l o g i s t Coordinator
�SURVEY
S e r i a l Number
(
)
Lynn Ogden
December 1992
1.
A t which b i r t h i n g h o s p i t a l ( s ) a r e you on s t a f f ?
hospital
hospital
hospital
2. Which o f t h e b i r t h i n g h o s p i t a l ( s ) where you a r e on s t a f f
d i s c h a r g e e a r l y (new mom and baby a r e d i s c h a r g e d b e f o r e c h i l d i s
48 hours o l d ) ?
hospital
hospital
hospital
3. L a s t year, f o r how many newborns were you t h e p r i m a r y
provider?
health
number
4. How many o f t h e i n f a n t s , f o r whom you were/are t h e p r i m a r y
h e a l t h care p r o v i d e r , were d i s c h a r g e d e a r l y ?
number
5. How many o f those who were d i s c h a r g e d e a r l y were b r o u g h t back
i n f o r t h e second PKU t e s t ?
number
6. Do you s i t and d i s c u s s t h e PKU t e s t i n g p r o c e d u r e and
r a t i o n a l e w i t h moms? yes [ ] no [ ]
7. Do you and mom s e t up t h e appointment f o r t h e second PKU t e s t
w h i l e mom i s s t i l l i n t h e h o s p i t a l ?
yes [ ] no [ ]
8. Does mom c a l l y o u r c l i n i c o r o f f i c e t o s e t up t h e second PKU
t e s t a f t e r she and baby g e t home? yes [ ] no [ ]
9. Do you d i s c u s s w i t h each new mom how she w i l l g e t h e r baby
back f o r t h e second PKU t e s t ? yes [ ] no [ ]
10. Do you o r someone from y o u r o f f i c e make house c a l l s t o
c o l l e c t t h e second PKU specimen? yes [ ] no [ ]
11. I s y o u r age
a. ) 25-34
b. ) 35-44
c. ) 45-54
between:
yes [ ] no [ ]
yes [ ] no [ ]
yes [ ] no [ ]
12. What gender a r e you?
d o c t o r ' s gender
d.) 55-64
e.) 65-74
f . ) 75+
yes [ ] no [ ]
yes [ ] no [ ]
yes [ ] no [ ]
�SURVEY
S e r i a l Number
(
)
Lynn Ogden
December 1992
13.
What race a r e you?
d o c t o r ' s race
14.
What n a t i o n a l o r i g i n a r e you?
doctor's national o r i g i n
15.
Which l a n g u a g e ( s ) do you speak?
d o c t o r ' s language
d o c t o r ' s language
d o c t o r ' s language
d o c t o r ' s language
16. Do you c o l l e c t second PKU specimens a t c l i n i c ( s ) ?
yes [ ] no [ ]
17. Do you c o l l e c t second PKU specimens a t y o u r o f f i c e ?
yes [ ] no [ ]
Please, answer t h e f o l l o w i n g q u e s t i o n s about y o u r main
c l i n i c or o f f i c e .
18.
How l o n g have you been i n p r a c t i c e a t t h i s l o c a t i o n ?
practice length
19. I s a f e e charged t h e p a t i e n t f o r c o l l e c t i o n o f t h e second
PKU specimen? yes [ ] no [ ]
20. I s t h e f e e f o r t h e second PKU t e s t p a r t o f t h e o f f i c e
charge? yes [ ] no [ ]
21. To g e t mom and baby back f o r
do any o f t h e f o l l o w i n g :
a. ) t e l e p h o n e t h e p a r e n t ( s ) ?
b. ) send n o t i c e ? yes [ ] no
c. ) c o n t a c t t h e l o c a l h e a l t h
yes [ ] no [ ]
d. ) o t h e r ?
t h e second PKU does y o u r o f f i c e
yes [ ] no [ ]
[ ]
department about t h e s i t u a t i o n ?
22. Do you have t h e PKU c a r d s f o r t h e second PKU t e s t t h e r e a t
your c l i n i c o r o f f i c e ? yes [ ] no [ ]
23. Does mom b r i n g t h e PKU c a r d w i t h h e r when she and t h e baby
come i n f o r t h e second PKU t e s t ? yes [ ] no [ ]
�SURVEY
S e r i a l Number
(
)
Lynn Ogden
December 1992
24. Do you l i s t t h e PKU k i t number ( b a r code number) on t h e
baby's c h a r t ? yes [ ] no [ ]
25.
Do you o r d e r PKU cards from ODH accounting? yes [ ] no [ ]
26. D i d you know t h a t PKU cards used f o r second PKU t e s t s on
e a r l y d i s c h a r g e s AND p a i d f o r by you can be r e p l a c e d t h r o u g h ODH
a c c o u n t i n g ? yes [ ] no [ ]
27. A t what age do you t y p i c a l l y see an i n f a n t t o c o l l e c t t h e
second PKU specimen?
age o f i n f a n t
28. I s your MAIN c l i n i c o r o f f i c e i n t h e c i t y , c o u n t r y , o r
suburbs?
c i t y , c o u n t r y , suburbs
29. How f a r , i n m i l e s , i s your main c l i n i c o r o f f i c e from t h e
b i r t h i n g center?
miles
30. I f you drew a c i r c l e and t h e c i r c l e r e p r e s e n t e d t h e s e r v i c e
area o f your main c l i n i c o r o f f i c e and had t h e c e n t e r o f t h e
c i r c l e be t h e main c l i n i c o r o f f i c e , what would t h e RADIUS o f t h e
c i r c l e be?
s e r v i c e area r a d i u s
Please, now answer some q u e s t i o n s about your t y p i c a l mom who
r e t u r n e d t o have t h e second PKU specimen t a k e n on h e r baby. T h i n k
about t h e c h a r a c t e r i s t i c s o f t h e t y p i c a l mom a t your MAIN CLINIC
or OFFICE.
31.
Does your t y p i c a l e a r l y d i s c h a r g e mom
a. ) have h e a l t h insurance? yes [ ] no [ ]
b. ) g e t a s s i s t a n c e from a government program? yes [ ] no [ ]
c. ) pay h e r own way? yes [ ] no [ ]
32.
Does your t y p i c a l e a r l y d i s c h a r g e mom l i v e i n t h e
a. ) c i t y ? yes [ ] no [ ]
b. ) c o u n t r y ? yes [ ] no [ ]
c. ) suburbs? yes [ ] no [ ]
�SURVEY
S e r i a l Number
(
)
Lynn Ogden
December 1992
33.
I s your t y p i c a l e a r l y d i s c h a r g e mom
a. ) American I n d i a n / A l a s k a n a t i v e ? yes [ ] no [ ]
b. ) A s i a n / P a c i f i c I s l a n d e r ? yes [ ] no [ ]
c. ) Black/non-Hispanic? yes [ ] no [ ]
d. ) H i s p a n i c ? yes [ ] no [ ]
e. ) White, non-Hispanic? yes [ ] no [ ]
f . ) Other? yes [ ] no [ ]
34. What language(s) does your t y p i c a l e a r l y d i s c h a r g e mom
speak?
mom's language
mom's language
mom's language
35. I s your t y p i c a l e a r l y d i s c h a r g e mom l i t e r a t e i n t h a t
language? yes [ ] no [ ]
36. What was t h e h i g h e s t grade o r year o f s c h o o l completed by
your t y p i c a l e a r l y d i s c h a r g e mom?
mom's year o f s c h o o l
37.
What age i s your t y p i c a l e a r l y d i s c h a r g e mom?
mom's age
38.
yes
Does your t y p i c a l e a r l y d i s c h a r g e mom work o u t s i d e t h e home?
[ ] no [ ]
39. Does your t y p i c a l e a r l y d i s c h a r g e mom have o t h e r c h i l d r e n a t
home? yes [ ] no [ ]
40. How f a r away from your main c l i n i c o r o f f i c e does your
t y p i c a l e a r l y d i s c h a r g e mom l i v e ?
mom l i v e s from c l i n i c o r o f f i c e
41. How f a r away from t h e b i r t h i n g c e n t e r does your
e a r l y d i s c h a r g e mom l i v e ?
typical
mom l i v e s from b i r t h i n g c e n t e r
42. What mode o f t r a n s p o r t a t i o n does your t y p i c a l e a r l y
d i s c h a r g e mom use t o g e t t o your c l i n i c o r o f f i c e ? (her c a r ,
borrowed c a r , t a x i , p u b l i c t r a n s p o r t a t i o n , walk, o t h e r )
mom's mode o f t r a n s p o r t a t i o n
�SURVEY
S e r i a l Number
(
)
Lynn Ogden
December 1992
43. What i s t h e m a r i t a l status of your t y p i c a l e a r l y discharge
mom? (never married, divorced, widowed, l i v i n g w i t h baby's
f a t h e r , married, other)
mom's m a r i t a l status
44. I f your t y p i c a l e a r l y discharge mom i s never married,
divorced, or widowed, does she l i v e
a. ) w i t h her baby? yes [ ] no [ ]
b. ) w i t h her parent(s) and her baby? yes [ ] no [ ]
c. ) w i t h other r e l a t i v e ( s ) of hers and t h e baby?
yes [ ] no [ ]
d. ) w i t h f r i e n d s and her baby? yes [ ] no [ ]
e. ) w i t h any of the baby's father's r e l a t i v e s ?
yes [ ] no [ ]
45.
Make any comments, c r i t i c i s m s , or suggestions i n t h i s space.
�APPENDIX G
Ohio's PKU Specimen Card
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DO NOT WRITE IN SHADED AREAS - DO NOT WRITE ON OR NEAR BAR CODE
Q
LLl
/
BtRTHDATE:
/
TIME:
BABY'S NAME:
(last, first)
1 1
1 I
*CCd70H19441128*
(USE 24 HOUR TIME ONLY)
I
HOSPITAL PROVIDER NUMBER:
HOSPITAL NAME:
m
MOM'S NAME:
(last. Iirsl. Initial)
In
MOM S ADDRESS
ZD
MOM S CITY:
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o
MOM S RACE.
rm
n
rrm
n
MOM'S AGE:
rr
n
TT
n
n
MOM'S ID.
" I BABY'S ID:
PHYSICIAN NAME
PHYSICIAN ADDRESS
CITY
n
n
n
TT
r.
. ON BACK
SPECIMEN REJECTED FOR REASON:
BIRTH WEIGHT:
PREMATURE:
ANTIBIOTICS:
TRANSFUSION:
SPECIMEN:
SUBMITTER:
PHYSICIAN PROVIDER NO
t9
[_J HEMOGLOBINOPATHIES
SEE FOOTNOTE.
BABY SEX
(USE 24 HOUR TIME ONLY)
O
SCREENING TESTS ABNORMAL
OHIO ZIP:
PHYSICIAN S PHONE:
n m ( nMi v-
n
'rrm
TIME:
•
'.
1
HYPOTHYROIDISM
•
MOM'S COUNTY:
SPECIMEN DATE:
<
n
MOM'S SSN.
MOM'S PHONE:
a:
O
n SCREENING TEST NORMAL FOR
— PKU. HOM. GAL HYPOTHYROIDISM,
HEMOGLOBINOPATHIES
n SCREENING TEST NORMAL FOR:
— PKU, AND HOM ONLY
SCREENING TEST NORMAL '• '
: r~|PKU
PlHOM
| 1 GAL
1
CL
LU
TEST RESULTS:
ODH COPY
•
MALE
•
0 r,
FEMALE
GRAMS
YES
YES
YES
FIRST
|—| NO
NO
NO
SECOND
1i
ICE
ftp ?(
HOSPITAL / BIRTH CENTER
PHYSICIAN
HEALTH DEPAFTTMENT
_ l OTHER: (name below)
I
�APPENDIX H
Why MUST My Newborn Be Screened?
�MUST
NEWB
BE SC
Ohio Department
of Health
Division of Maternal
and Child Health
�, INTRODUCTION
Why does my baby need to be
screened?
ii
Newborn screening finds out if your baby has any
of the following diseases: PKU (Phenylketonuria!),
Hypothyroidism, Galactosemia, Homocystinuria,
Sickle Cell Anemia or other Hemoglobinopathies.
Even if your baby looks healthy he or she may
have one of these diseases. If any of these conditions are not treated, serious problems will arise.
Therefore, the State of Ohio requires that all newboms be tested. The only reason your baby would
not be tested would be for religious reasons. The
result of the blood tests will identify babies who
are in need of more testing and future counseling.
How is the screening
done?
A few drops of blood are taken from your
newborn's heel. This blood is tested for PKU,
Hypothyroidism, Galactosemia, Homocystinuria,
and Sickle Cell Anemia (Hemoglobinopathies).
Your doctor will tell you the results of the test and
if there is anything else you need to do. You may
be contacted with the name of a specialist or clinic
that will help you.
When is the screening done?
•mm$m
m
5g aajfi
3 18 • R
o 3J
> Sc
: (£33
^
All Infants are screened before leaving the hospi- /
tal. If your baby goes home from the hospital
before 48 hours the test xnav/jneed to be done
again. It is important thatTlie test be done withi
the first two weeks of life. If a repeat test is
needed, it can be done at your local health department for little or no charge.
9 11
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Public Policy] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-005-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/e9f993a5229e1d9b0b029c04efafa855.pdf
d33f3e1cab4b8b8f26f0e87f9bb50cae
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1337
OA/ID Number:
FolderlD:
Folder Title:
[Public Health Letter] [loose]
Stack:
Row:
S
56
Section:
Shelf:
6
Position:
�October 25, 1993
Judith A. Sartucci
President
150 Washington Street
Hartford, CT 06106
Dear Ms. Sartucci:
Thank you for your policy suggestion's for the reform of our
nation's health care system. I appreciate hearing your comments
and concerns on public health programs/and services. As you may
know, since late January our office h'as been hard at work on a
health care reform i n i t i a t i v e that we hope w i l l be passed into
law before the end of the 103rd Congress.
Correspondence such as yours has provided us with many
thought provoking and innovative ideas about how to reform our
health care system. Our office has established a process to
incorporate these policy suggestions into the reform plan. I
hope you find that the plan adequately adressses your concerns.
Thank you again for yo^r interest and suggestions.
Regards,
Ira C. Magaziner
Senior Advisor to the President
for Policy Development
ICMtyg
/
�ASSOCIATION OF STATE AND TERRITORI
LOCAL HEALTH LIAISON OFFICIALS
VIA
FAX TRANSMISSION AND MAIL
September 17, 1993
I r a Magaziner
H e a l t h Care Reform A d v i s o r
The White House
1600 P e n n s y l v a n i a Avenue
Washington, DC
FAX # (202) 456-7737
Dear Mr. Magaziner:
T h i s l e t t e r i s sent on b e h a l f o f t h e l o c a l h e a l t h l i a i s o n o f f i c i a l s i n t h e p u b l i c
h e a l t h departments o f s t a t e s a n d ^ t e r r i t o r s i e f i t h r o u g h o u t t h e c o u n t r y .
We u n d e r s t a n d t h ^ t ^ t h e c u r r e n t d r a f t o f t h e ^ C l i n t o n A d m i n i s t r a t i o n ' s H e a l t h Care
Reform package/has a p u b l i c h e a l t h component w i t h a proposed 2% s e t - a s i d e t o
s u p p o r t c o r e p u b l i c h e a l t h f u n c t i o n s ( h e a l t h p r o m o t i p n , disease s u r v e i l l a n c e and
p r e v e n t i o n , dat^a. g a t h e r i n g and d i s s e m i n a t i o n j ^ e t c f T ) . We a l s o understand t h a t
s t r o n g p r e s s u r e has~-t>aen mountinq--ij»-^a^HTnqton t o e l i m i n a t e t h e p u b l i c h e a l t h
p o r t i o n from t h e package o r t o d e l a y i t s p h a s e - i n .
I t i s i n c o m p r e h e n s i b l e t o those o f us i n t h e p u b l i c h e a l t h community t h a t a major
h e a l t h care r e f o r m p r o p o s a l would miss t h e o p p o r t u n i t y t o s u p p o r t core p u b l i c
health-functions—right—f-r-om-the-beginning.^ I t i s essentiaTThat €fiese~prevention
i n i t i a t i v e s r e c e i v e adequate f u n d i n g t h r o u g h t h e proposed s e t - a s i d e o f 2% so t h a t
r e f o r m can t r u l y enhance t h e h e a l t h s t a t u s o f t h e American people and a s s i s t s t a t e
and l o c a l p u b l i c h e a l t h agencies i n p r o d u c i n g m e a n i n g f u l change.
-
We urge you t o do e v e r y t h i n g you can t o advocate f o r i t s i n c l u s i o n i n t h e C l i n t o n
A d m i n i s t r a t i o n p r o p o s a l r i g h t from t h e b e g i n n i n g .
Without support o f t h e
i n f r a s t r u c t u r e o f p u b l i c h e a l t h across t h e n a t i o n , ~in terms o f ""health p r o m o t i o n ,
disease s u r v e i l l a n c e and p r e v e n t i o n , d a t a g a t h e r i n g and d i s s e m i n a t i o n , and
assurance o f q u a l i t y o f v a r i o u s h e a l t h programs, h e a l t h care r e f o r m i s very l i k e l y
t o _ f a i l . ^ A t t h e - v e r y — l e a s t , — t h e d e s i r e d c o s t savings cannot p o s s i b l y be r e a l i z e d .
CPublic_heaIth—programs—and_services~-ARE. t h e base o f t h e pyramid t h a t we c a l l t h e
h e a l t h care system. W i t h o u t t h a t base, d e s i r a b l e and necessary g o a l s f o r t h e
system cannot p o s s i b l y be achieved.
Sincerely,
I d i t h A. S a r t u c c i
President
M a i l i n g Address:
c/o O f f i c e o f L o c a l H e a l t h A d m i n i s t r a t i o n
CT S t a t e Department o f P u b l i c H e a l t h and A d d i c t i o n
150 Washington S t r e e t , H a r t f o r d , CT 06106
Tele. (203) 5 6 6 - 7 8 8 ^ 1 ; ^ ^ 0 3 ) 566-3302
Twttatai H H » OAcUt
Services
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Public Health Letter] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-004-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/c0a8cef808dd6d68ee0d5350ec705ed9.pdf
55c64336b0c29a9c313e36231212c6bd
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1976
OA/ID Number:
FolderlD:
Folder Title:
[Preventative Health Services for Medicare Beneficiaries: Policy and Research Issues] [loose]
Stack:
Row:
Section:
Shelf:
Position:
s
56
2
1
1
�III
�Office of Technology Assessment
Congressional Board of the 101st Congress
EDWARD
M. KENNEDY,
CLARENCE
E. MILLER,
Massachusetts,
Chairman
Ohio, Vice Chairman
Senate
House
ERNEST F. HOLLINGS
South Carolina
MORRIS K. UDALL
Arizona
CLAIBORNE
PELL
Rhode Island
TED
ORRIN
CHARLES
GEORGE E. BROWN,
California
JR.
JOHN D. DINGELL
Michigan
STEVENS
Alaska
G. HATCH
Utah
DON
SUNDQUIST
Tennessee
E. GRASSLEY
Iowa
AMO
HOUGHTON
iVew York
JOHN H. GIBBONS
(Nonvoting)
Advisory Council
DAVID S. POTTER, Chairman
General Motors Corp. (Ret.)
NEIL E. HARL
Iowa State University
WILLIAM J. PERRY
H&Q Technology Partners
CHASE N. PETERSON, Vice Chairman
University of Utah
JAMES C. HUNT
University of Tennessee
SALLY RIDE
California Space Institute
CHARLES A. BOWSHER
General Accounting Office
HENRY
KOFFLER
University of Arizona
JOSEPH E. ROSS
Congressional Research Service
MICHEL T. HALBOUTY
Michel T. Halbouty Energy Co.
JOSHUA
LEDERBERG
Rockefeller University
JOHN F.M. SIMS
Usibelli Coal Mine, Inc.
Director
JOHN H. GIBBONS
The Technology Assessment Board approves the release of this report. The views expressed in this repon are not necessarily
those of the Board, OTA Advisory Council, or individual members thereof.
�CONGRESS OF THE UNITED STATES
OFFICE OF TECHNOLOGY ASSESSMENT
PREVENTIVE HEALTH SERVICES
FOR MEDICARE BENEFICIARIES:
POLICY AND RESEARCH ISSUES
February 1990
SPECIAL REPORT
�Recommended Citation:
U.S. Congress, Office of Technology Assessment, Preventive Health Services for Medicare
Beneficiaries: Policy and Research Issues, OTA-H-416 (Washington, DC: U.S. Government
Printing Office, February 1990).
For sale by the Superintendent of Documents
U.S. Government Printing Office, Washington, DC 20402-9325
(order form can be found in the back of this special report)
�Foreword
Interest in health promotion and disease prevention strategies for elderly people has
grown in the past ten years, in part because of the need to find ways to moderate the rising costs
of health care in this rapidly growing segment of the population. Reflecting this interest, the
House Committee on Ways and Means requested that OTA analyze the effectiveness and costs
of providing selected preventive health services to the elderly under the Medicare program.
The Senate Labor and Human Resources Committee had earlier requested that OTA provide
information on the value of preventive services for the American people. OTA responded with
a study of the effectiveness and costs of four specific preventive services for the elderly:
glaucoma screening; cholesterol screening; cervical cancer screening; and colorectal cancer
screening. Background papers on each of these services are now or will soon be available. As
another part of the assessment, OTA prepared a staff paper on the factors affecting older
people's use of preventive services, with particular emphasis on how insurance coverage could
be expected to alter such patterns of use.
This Special Report analyzes policy and research issues raised in considering Medicare
coverage of preventive services. OTA examines how decisions are currendy made about
coverage of specific preventive services under Medicare and lays out options for altering the
process and criteria governing those decisions. The Special Report also reviews and critiques
ongoing demonstration projects and summarizes the results of OTA studies of the costs and
effectiveness of specific preventive services for the elderly.
JOHN H. GIBBONS
Director
�Advisory Panel—Project on Preventive Health Services Under Medicare
Gordon De Friese, Panel Chair
Health Services Research Center
University of North Carolina, Chapel Hill, NC
Marianne C. Fahs
Depanment of Health Economics
Mt. Sinai Medical Center
New York, NY
John Frank
Department of Preventive Medicine & Biostatistics
University of Toronto
Ontario, Canada
Gary D. Friedman
Epidemiology and Biostatistics Division
Permanente Medical Group, Inc.
Oakland, CA
Lawrence Gottlieb
Clinical Guidelines Program
Harvard Community Health Plan
Brookline Village, MA
Mary Knapp
John Whitman and Associates
Philadelphia, PA
Peter McMenamin
Chevy Chase, MD
Meredith Minkler
Center on Aging
University of California, Berkeley
Berkeley, CA
Marilyn Moon
Public Policy Institute
American Association of Retired Persons
Washington, DC
George Moriey
Department of Obstetrics/Gynecology
University of Michigan Medical Center
Ann Arbor, MI
Gilbert Omenn
Dean, School of Public Health & Community Medicin
University of Washington
Seattle, WA
Risa Lavizzo-Mourey
Geriatrics Program
University of Pennsylvania
Philadelphia, PA
George Pickett
Department of Public Health Policy
School of Public Health
University of Michigan
Ann Arbor, MI
M. Crisdna Leske
Depanment of Preventive Medicine
SUNY at Stony Brook
Stony Brook, NY
Donald Shepard
Department of Health Policy and Management
Harvard School of Public Health
Boston, MA
Donald Logsdon
INSURE Project
New York, NY
Barry Stults
Division of General Internal Medicine
University of Utah Medical Center
Salt Lake City, UT
Mildred B. McCauley
American Association of Retired Persons
Washington, DC
NOTE: Advisory Panel members provide valuable guidance during the preparation of OTA repons. However, the presence of a
individual on the Advisory Panel does not mean that individual agrees with or endorses the conclusions of this particular r
iv
�OTA Project StaffPreventive Health Services for Medicare Beneficiaries:
Policy and Research Issues
Roger C. Herdman, Assistant Director, OTA
Health and Life Sciences Division
Clyde J. Behney, Health Program Manager
Project Staff
Judith L. Wagner, Project Director
Elaine J. Power, Analyst
Michael Gluck, Analyst
Brigitte M. Duffy, Research Analyst
Administrative Staff
Virginia Cwalina, Administrative Assistant
Carol Ann Guntow, P.C. Specialist
Karen T. Davis, Word Processor Specialist
Carolyn Martin, Secretary
�Contents
Page
Chapter 1. Executive Summary
Criteria for Including Preventive Services as Covered Benefits
Locus of Responsibility for Coverage Decisions
Research Priorities ,
Chapter 2. Introduction
Chapter 3. Defining Preventive Services for the Elderly
Chapter 4. The Medicare Program and Preventive Services
Current Status of Medicare Funding for Preventive Services
Strengths and Weaknesses of Medicare as a Source of Funding for Preventive Services
Policy Issues in Developing a Medicare Strategy for Preventive Services
The Unit of Payment: Individual Procedures v. Service Package
Standards of Evidence
Locus of Responsibility for Coverage Decisions
Chapter 5. Evaluating the Evidence of the Cost-Effectiveness of Preventive
Services for the Elderly: Selected Issues
Under What Conditions Is It Appropriate To Generalize About the Effectiveness of a
Service on the Elderly From Evidence of Its Effectiveness
in Nonelderly Populations?
How Should the Effects of Services Provided Together in a Package Be
Attributed to Specific Procedures?
How Should the Costs of a Visit Be Apportioned Among the Individual
Procedures and Interventions Provided in the Visit?
What Allowances in Cost Estimates, if Any, Should Be Made for Inefficiencies
Inherent in the Medical Care System?
How Should Uncertainties Be Treated?
Chapter 6. Research Issues
Appendix A. Acknowledgments
Appendix B. Summary of OTA Studies of Preventive Services for the Elderly
Appendix C. The Medicare Preventive Services Demonstration Projects
Appendix D. Summary of Recommendations for Periodic Health Examinations
in the Elderly
References
1
1
2
2
3
5
9
9
9
10
11
11
13
15
15
15
15
16
16
17
19
20
22
.28
34
Box
Page
A. Health Problems of the Elderly
7
Tables
Page
1. Selected Potential Clinical Preventive Services for the Elderly
C-l. Design of Medicare Preventive Services Demonstration Projects
C-2. Preventive Services Offered in the Medicare Demonstration Projects
D-l. Recommendations for Physician Visits for the Elderly
D-2. Published Recommendations for the Use of Selected Preventive Services
by Older Adults
D-3. Recommendations for Screening for Colorectal Cancer in the Elderly
6
23
24
29
30
33
�Chapter 1
Executive Summary
Medicare is prohibited by law from offering
benefits for preventive services except when they are
specifically added to the scope of covered benefits
through amendments to the Medicare act. So far,
vaccines for pneumococcal pneumonia and Hepatitis B and screening Pap smears are the only
preventive services covered by Medicare. The wisdom of this blanket exclusion with legislated exceptions has been questioned by many experts.
How should decisions be made about Medicare
coverage of preventive services? This question has
two components:
• What criteria should govern the decisionmaking process?
• Where should theresponsibilityfor such decisions lie?
CRITERIA FOR INCLUDING
PREVENTIVE SERVICES AS
COVERED BENEFITS
Because they have traditionally been excluded
from insurance benefit packages, preventive services have been held to a burden of proof of
effectiveness or cost-effectiveness that exceeds that
required for diagnostic and therapeutic procedures.
Third-party payers, including Medicare, generally
accept diagnostic or therapeutic services as "reasonable and necessary" unless obvious abuse is encountered. In contrast, for preventive services to be
included in a benefit package, evidence must exist
that they are at least effective, and sometimes that
their medical benefits are worth their costs. This
standard may seem unduly harsh, and proponents of
preventive services often argue that it is unfair to
hold preventive services to a higher standard than
that required for other medical services. Two powerful arguments favor a tough standard for preventive
services, however. First, like all services, preventive
services involve potential risks as well as potential
benefit. However, unlike diagnostic and therapeutic
services, which arerenderedin response to patient
complaints or symptoms, preventive services are
offered to ostensibly healthy individuals and therefore involve an implied promise that they will
improve the patient's health. Second, the more
appropriate response to the double standard may be
to raise the level of evidence required for diagnostic
-1-
and therapeutic services, not to lower that for
preventive services. That one genie is out of the
bottle is no justification for letting others out, too.
Even accepting that the decision to include
preventive services as an insured benefit requires
explicit evidence, criteria must be selected to govern
the coverage decision and the standards of validity
required of the evidence that does exist. Possible
criteria include:
• effectiveness of the intervention in prolonging
life or improving its quality,
• cost-effectiveness of the intervention in achieving given levels of health effects at the lowest
possible cost, and
• impact of the intervention on net Medicare
outlays.
The notion that a preventive health service should
be effective is widely accepted by health care
providers and policymakers. There is less agreement
about whether the cost of such services should be
considered in either coverage or clinical decisions.
The U.S. Preventive Services Task Force, convened
in 1984 to develop guidelines for preventive services, adopted stringent standards of effectiveness but
explicitlyrejectedcost-effectiveness as a criterion
for their task in judging these services. In fact, no
professional group in the United States making
recommendations on preventive services for the
elderly has explicitly accepted cost-effectiveness as
a criterion for making such judgments.
Using the net impact on Medicare expenditures as
the criterion for coverage is unduly stringent,
because it assumes that if a preventive intervention
costs Medicare money, it is not worth it, regardless
of whatever Jiealth benefits it provides. A highly
effective preventive service could also fail the test of
being cost-saving to Medicare if by prolonging life
it induces additional future Medicare expenditures
for unrelated illnesses.
Even specifying a criterion for decisions leaves a
great deal of potential for differing judgments.
Evidence on the effectiveness of preventive services
is often poor and conflicting. Little effectiveness
research has been conducted in elderly populations,
and the validity of applying findings generated from
studies of other populations to the elderly population
is questionable. The Medicare Preventive Services
�2 • Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations
Demonstration Projects currently underway will not
add much to the information base on the effectiveness or cost-effectiveness of these services, although
they will tell a great deal about how elderly people
respond to financial incentives to use such services.
To collect adequate data on effectiveness of preventive services in the elderly would take many years
and many millions of dollars.
Those responsible for the decision of whether to
make preventive services a Medicare benefit will be
taking risks either way. On the one hand, including
these benefits in the Medicare package could increase Medicare outlays without appreciably reducing older people's mortality, morbidity, or disability. On the other hand, if preventive services
continue to be excluded from Medicare payment,
real opportunities for better health or savings in
health care costs could be lost for years to come.
LOCUS OF RESPONSIBILITY FOR
COVERAGE DECISIONS
Responsibility for expanding Medicare to cover
preventive services currently resides with Congress.
To date, such expansions have been limited to
specific procedures, but Congress could authorize
the Health Care Financing Administration (HCFA)
to offer an "appropriate" package of preventive
services to elderly Medicare beneficiaries. Authorizing legislation could include criteria for assessing
the "appropriateness" of such services. For example. Congress could direct HCFA to consider the
cost-effectiveness of alternative packages in its
implementation of regulations.
Vesting HCFA with the authority to decide about
specific packages of services would probably increase the flexibility of the Medicare program to
respond to new evidence on effectiveness or costeffectiveness as it arises. By removing specific
coverage decisions from the legislative process,
preventive services would not have to compete for
approval directly with other uses of the Federal
health budget. However, if the authority for cover-
age decisions is vested in HCFA, the resulting
package of services offered to the elderly would be
unpredictable. As was noted just above, conclusions
about the health and cost consequences of specific
preventive services depend in poorly understood
ways on the composition of the recommending
groups and the criteria and standards used to judge
the evidence. Even directing HCFA to use costeffectiveness as a criterion for coverage decisions
would leave a great deal of uncertainty about how
the available evidence would be assessed. A process
administered by HCFA, however, might be no more
unpredictable than the current legislative process
and would still be subject to oversight by Congress.
RESEARCH PRIORITIES
The Health Care Financing Administration is
currently supporting six Medicare demonstration
projects that offer preventive health services to
Medicare beneficiaries. Although these projects are
unlikely to provide much additional evidence on
effectiveness, opportunities do exist for obtaining
some effectiveness data at relatively low additional
cost if extended follow-up studies are funded at
selected demonstration sites where participation
rates have been high. Since all but one of these
demonstrations were congressionally mandated, extending their length mightrequirean amendment to
the legislation.
Because effectiveness research is costly, it should
be targeted to services that offer the potential for
large impacts on health status or health care costs of
the elderly. Research to clarify the appropriate
components of and target populations for comprehensive geriatric assessments has been recommended by a National Institute of Health consensus
conference panel (65). Because the costs of institutional care for the disabled elderly are high, these
tertiary preventive health services are a promising
subject for effectiveness and cost-effectiveness research.
�Chapter 2
Introduction
and cholesterol testing. Indirect expansions of benefits have also been proposed. For example, S.358
(99th Cong.) would have raised the Medicare Part B
deductible but would have allowed the cost of
disease screening, immunizations, and anti-hypertension drugs to count towards that deductible.
Another proposal considered for the Medicare Catastrophic Coverage Act of 1988 (Public Law 100360) would have allowed a long list of preventive
services to count against the catastrophic deductible
limit One proposal (S. 357,99th Cong.) would have
lowered the Part B premium for nonsmokers by $1
per month. The House considered a proposal (HR
1402) that would allow beneficiaries to purchase
through Medicare a supplemental insurance option
to cover the cost of an annual preventive health
physician visit.
As the primary source of health insurance for the
Nation's 31 million elderly people. Medicare provides access to a wide range of health services for
diagnosis, therapy, and rehabilitation. Medicare is
prohibited by lawfromoffering benefits for preventive services except for a small number that have
been added to the scope of covered benefits through
amendments to the Medicare Act. When compelling evidence has accumulated about the health
benefits or savings in health care costs achievable
from specific preventive services. Congress has
legislated expansions of the Medicare benefit So
far, vaccines for pneumococcal pneumonia and
hepatitis B and, mostrecently,screening mammography and Pap smears are the only preventive
services covered by Medicare.
1
2
In recent years, the wisdom of this blanket
exclusion of preventive services has been questioned by numerous experts and interested groups
In the absence ofreliableinformation about the
(5,12,13,22,40,90,96). Interest in health promotion
health andfinancialconsequences of such proposals.
and disease prevention for the elderly has grown as
Congress has moved cautiously. Except for covering
the U.S. population has aged. The high cost of
the two vaccines. Pap smears and, for a time,
providing acute and chronic health care has led
mammography, legislation has been limited to
researchers to search for ways to prevent or delay the establishing demonstration projects to study the
need for those services. The obligation of Medicare
effects of offering packages of preventive health
to pay for the consequences of not preventing
services to Medicare beneficiaries (Public Law
episodes of illness or disability, at the same time that 99-272) and a demonstration of the effectiveness of
it does not pay for interventions that might prevent
offering the influenza vaccine as a covered benefit
such episodes, seems to be shortsighted. Sometimes
(Public Law 100-203). As part of its effort to obtain
the investment in preventive services can actually
information on the consequences of expanding
save Medicare program costs. Even when prevenMedicare benefits for preventive services, the House
tion does not save money for Medicare, it may
Committee on Ways and Means asked the Office of
improve the health of Medicare beneficiaries or save
Technology Assessment (OTA) to study the effechealth care costs for other payers enough to justify
tiveness and cost of selected preventive services for
the added costs.
the elderly. OTA selected four screening services for
study: glaucoma screening; cholesterol screening;
Congress has actively considered proposals to
colorectal cancer screening; and cervical cancer
expand Medicare benefits for health promotion or
screening. Separate papers on each of these technolpreventive services. In the past 2 years, numerous
ogies have been or soon will be released. A staff
proposals were made to expand coverage for such
paper has also been prepared on preventive services
services as Pap smears, fecal occult blood testing,
3
4
'Medicare will pay for "reasonable and necessary" medical and other health services offered by certified providers if they are diagnostic, therapeutic,
surgical, consultative, or rehabilitative. Some experts define preventive services broadly to include some therapies and rehabilitation. Medicare's stricture
against payment for preventive services pertains to those services not offered in direct response to patient complaints, symptoms, or clinical signs.
Screening mammography was briefly slated to become a covered benefit, but because it was enacted as pan of the Medicare Catastrophic Coverage
Act of 1988 (Public taw 100-360). the benefit was repealed with the other provisions of that law late in 1989.
For example, a 1979 OTA study of pneumococcal pneumonia vaccine in the elderly concluded that, under certain assumptions, the cost of the vaccine
would be more than made up for by savings to the Medicare program (86,88).
For example, a biannual mammography screening is not likely to save Medicare costs but has the potential to detect early breast cancers and prolong
the life of Medicare beneficiaries (89).
3
4
-3-
�4 • Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations
utilization by the elderly. (See app. B for a brief
summary of each of these papers.)
This Special Report is also part of OTA's study of
preventive services for the elderly. Its purpose is to
examine the strengths and weaknesses of the Medicare program as a vehicle for funding the delivery of
preventive services to the elderly. Chapter 3 contains
a general description of the range of preventive
services that are possibly useful to the elderly. This
section is not intended to evaluate the effectiveness
of such services; rather, it will focus on the major
health problems of the elderly and the kinds of
preventive interventions that have been suggested to
deal with those problems. Chapter 4 describes the
elements of the Medicare program that influence the
receipt of effective and efficient preventive service
by the elderly. Chapter 5 discusses issues that aris
in evaluating the effectiveness and cost-effective
ness of offering preventive services to the elderl
under Medicare. Chapter 6 concludes with a discus
sion of research priorities.
As supplementary material, this report also con
tains: abstracts of OTA studies of the costs an.
effectiveness of preventive services for the elderl
(see app. B); a review and critique of the Medicar
Preventive Services Demonstration Projects man
dated by Congress in 1986 (Public Law 99-509) an.
currently underway (see app. C); and a compendiur
of recommendations by expert groups for preventiv'
services for elderly people (see app. D).
�Chapter 3
Defining Preventive Service for the Elderly
• Secondary preventive services are efforts to
detect a disease or condition before it is
clinically recognizable to avoid or delay its
further progression. Screening procedures, such
as mammography or Pap smears, fall into this
category.
• Tertiary preventive services attempt to reduce
the impact of already existing disease on the
quality of a person's life by maintaining or
improving his or her ability to function. These
would include services such as education for
diabetic patients or rehabilitation for stroke
victims.
Although prevention encompasses a wide variety
of actions by individuals or organizations whose
goal is to improve health, the term "preventive
services" refers here to a narrower set of interventions comprising medical procedures, tests, or visits
with health care providers that are undertaken for the
purpose of promoting health, not for responding to
patient signs, symptoms, or complaints. Preventive
services in this report are interactions between
elderly people and health care providers, not interventions such as education through the mass media,
seat-belt safety laws, etc.
A distinction is also necessary between preventive services and individual preventive behavior. For
example, elderly people who quit smoking are
engaging in an exceedingly effective preventive
behavior (41,49), but the behavior is not a preventive
service. A smoking cessation program or counseling
would constitute a preventive service as defined
here. This distinction is important, because different
kinds of services designed to bring about the same
change in behavior may vary widely in effectiveness
and costs. Medicare would pay for the service, not
for the change in behavior; hence. Medicare's
interest is not only in the effectiveness of the change
in behavior on health outcomes, but also in the
effectiveness and costs of the service whose purpose
is to bring about the change in behavior. In the case
of smoking cessation for example, the effectiveness
of smoking cessation counseling by physicians
appears to vary widely across population groups and
counseling techniques (17,20,524i3,84,100). Advocates of increased Medicare support for preventive
services often fail to distinguish between the effectiveness of behavior change and the effectiveness of
services in citing evidence to support their views
(13).
Health insurers, including Medicare, typically
pay providers for undertaking defined activities, not
for accomplishing goals. Many services whose goal
is tertiary prevention are currently covered under
Medicare as therapeutic or rehabilitative services.
An alternative typology, shown in table 1, identifies
preventive services that are generally excluded from
Medicare coverage and are more in keeping with the
fee-for-service payment system than is the traditional typology. There, selected preventive services
are classified into three major categories: immunization; screening; and education or counseling. Health
insurers typically offer specific services whose
delivery can be audited; a "primary prevention"
benefit unrelated to defined services would be too
amorphous for a health insurance package.
The differences between the two taxonomies
reflect the limitations of health insurance programs
as mechanisms for providing appropriate preventive
services. The goal-based taxonomy recognizes the
importance of integrating prevention into the larger
health care system. By including tertiary preventive
services within the scope of prevention, the taxonomy also makes preventive services relevant for all
people regardless of their health status. This is
particularly important for the elderly (31).
1
Preventive services have been described by two
generalframeworks.The traditional approach, used
by most experts, classifies preventive services according to their ultimate goal (48,55):
The increasing incidence of chronic and disabling
diseases with age and the frequency of multiple
coexisting conditions in the elderly threaten the
ability of many to live independently (see box A). In
1985, about 1 in 20 elderly residents of the United
States were in nursing homes. Among people 85
years and older, however, about 1 in 5 were in
• Primary preventive services are intended to
prevent or delay the onset of disease. Immunizations and counseling on lifestyle changes
are classic examples of primary prevention.
'Note, however, that the impact of smoking cessation on life expectancy is so great that even if counseling brings forth a very small reduction in the
smoking rate, it may be very cost-effective (20).
-5-
�6 • Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations
nursing homes (43). If preventive services can avert
the need for some of that institutional care, the
payoff in terms of both better health and lower health
care costs could be high.
Recent experience with programs of comprehensive geriatric assessment for impaired elderly people
(e.g., the very old, frail, hospitalized, or disabled)
suggests that these services, when undertaken by a
well-trained team of professionals and when coupled
with adequate follow-up services, can measurably
improve the health status of the served group
(16,65,79). The effectiveness of such programs
depend on the target group selected and the scope of
services offered and actually received (14,56,65,71,
79,83,85). Because such services must be tailored to
the individual needs of the patient, which must be
carefully identified, they may also be costly (26,79).
Regardless of whether these services are worth
their costs for some portion of the elderly population, health insurance programs, including Medicare, do not encourage their development, and the
current organization of health care delivery for the
elderly inhibits their use. Because it is difficult to
control the content of a visit, health insurers are
reluctant to pay for comprehensive health assessments and follow-up activities. The delivery of
health care to the elderly is often fragmented: the
patient will often see a different specialist for each
particular chronic condition, and frequently no one
provider is managing the overall case. The high
frequency of inappropriate prescribing and use of
medications in the elderly is, at least in part, a
reflection of thisfragmentationof care (59,95).
Today, such programs are typically affiliated with
medical schools, teaching hospitals, or Depanment
of Veterans Affairs' Medical Centers. In 1985, 114
such units were identified as operating in these
institutions (26).
Table 1—Selected Potential Clinical Preventive
Services for the Elderly
Immunizations:
• Influenza
• Tetanus
• Pneumococcus"
• Hepatitis B"
Screening:
• Cancer screening:
—Breast cancer (clinical examination; mammography)
—Colorectal cancer (occult blood stool; sigmoidoscopy)
—Cervical and uterine cancer (clinical examination; Pap smear*;
endometrial biopsy)
—Prostate cancer (clinical examination; ultrasound)
—Skin cancer (clinical examination)
—Melanoma (clinical examination)
• Blood pressure measurement
• Vision examination
• Glaucoma screening
• Hearing test
• Cholesterol measurement
• Mental status/dementia
• Osteoporosis (standard X-ray; quantitative CT; other radiological techniques)
• Diabetes screening
• Asymptomatic coronary artery disease (exercise stress test)
• Dental health assessment
• Multiple health risks appraisal/assessment
• Functional status assessment
• Depression screening
• Screening for hyperthyroidism or hypothyroidism
• Urine testing
Education and counseling:
• Nutrition
• Weight control
• Smoking cessation
• Home safety/injury prevention
• Stress management
• Appropriate use of medications
• Alcohol use
• Exercise
ABBREVIATION: CT - computed tomography.
oCurrently covered by Medicare.
Currently covered by Medicare tor high risk patients.
Coverage effective July 1, 1990.
SOURCE: Office of Technology Assessment, 1990.
�Chapter 3—Defining Preventive Services for the Elderly .• 7
Box A—Health Problems of the Elderly*
"Progressive decrements in physical, mental and social function may occur with advancing age. Multiple
factors contribute to this decline.. . First, there is a physiologic age-related decline in organ function from the fourth
through the ninth decades, the magnitude of which varies considerably among different persons. While these
physiologic losses do not significantly compromise the overall function of an elderly person, in the event of a
superimposed illness or injury they may result in more profound dysfunction and a longer recuperation time than
in younger persons. Physical and mental inactivity (disuse) may also compromise organ function with advancing
age. Some of the decline in organ function that has been attributed to physiologic aging may instead be due to disuse
and therefore be preventable or reversible with appropriate therapy. The prevalence of chronic physical and mental
illness increases dramatically with age, particularly in persons 75 and older. The rates for chronic illnesses in the
elderly such as arthritis, hypertension, organic heart disease, sensory impairments and urinary incontinence are
about twice the rates in persons younger than 65. Nearly 25% of community-dwelling elderly have symptomatic
mental illness, including 10% with significant depression and 5% with dementia. Potentially serious psychosocial
stresses are common and include undesired retirement, inadequate finances, death of a spouse or the necessity of
moving away from the family home. Many elderly persons will simultaneously sufferfromseveral of these chronic
physical or mental conditions.
' 'The magnitude of the decrements in physical, mental and social function varies tremendously among elderly
persons. The vast majority of the elderly are able to tolerate and adjust to their functional impairments or disabilities
andremainindependent within the community. However, a significant minority have major functional disability.
Nearly 20% of the elderly aged 75 through 84 and 30% aged 85 and older are unable to carry on major activities
such as leaving home, doing housework or cooking, compared with 7% with similar disability who are younger than
65. Nearly 10% to 20% of persons aged 80 and older are unable to carry on even basic activities of daily living
(bathing, dressing, eating, toileting) versus 4% younger than 65. Because of this dependency many of these elderly
persons willrequireplacement in a nursing home unless adequate social support can be obtained from family,
friends, or the community. Whereas only 5% of persons older than 65 years are in nursing homes, 20% older than
85 reside in them; the elderly have a 20% chance of requiring at least temporary nursing home placement at some
time in their life."
•Quoted from B.M. StulU. "Preventive Hetlth Care for \tm Elderly." WuurnJ. Mtd. 141(6):832-844, 1984.
�Chapter 4
The Medicare Program and Preventive Services
Medicare enrollees, based on age, sex, whether or
not the enrollee resides in a nursing home or other
institution, and whether or not the enrollee is
Medicaid eligible. In exchange, the HMOs and
CMPs are required to cover all part A and part B
benefits, and they may also offer additional benefits
such as preventive services. One large HMO reported to OTA that over one-half of its elderly
enrollees had a complete check-up within the
previous year and 71 percent of its elderly female
enrollees had had a Pap smear within the previous 3
years (37). In some Medicare HMOs, particularly
those organized as independent practice associations
(DPAs), the decision regarding provision of specific
services may be made by the individual physician,
not by plan administrators (44). Thus, even within
specific HMOs, some beneficiaries may be offered
such services while others are not.
CURRENT STATUS OF
MEDICARE FUNDING FOR
PREVENTIVE SERVICES
Despite the statutory exclusion of preventive
services from Medicare coverage, today Medicare
pays for some preventive services that are not
explicitly mandated by legislation, although the
frequency and distribution of these reimbursed
services in the elderly population have not been
estimated.
First, a substantial number of procedures, particularly screening tests, may be reimbursed in part or in
full as diagnostic rather than as screening procedures. Whether Medicare reimburses for a visit or
procedure depends on how the visit is characterized
on the Medicare claim. If a visit is initiated by a
patient because of a medical complaint, the physician fee is covered. Similarly, a test is covered if it
is performed because of a symptom or suspected
diagnosis.
When a preventive service is legislated as a new
Medicare covered benefit, beneficiaries enrolled in
Medicare risk-contracting plans are automatically
entitled to it. Thus, a legislative decision to add a
preventive service as a covered benefit not only
provides access to beneficiaries under a fee-forservice payment but also reduces the variation in the
scope of services available to Medicare beneficiaries
enrolled in capitation plans.
Anecdotal examples suggest that some procedures done for screening purposes may be paid for
by Medicare as diagnostic procedures. A recent
review of over 200 medical records of lower GI
endoscopies (sigmoidoscopy and colonoscopy) performed on Medicare patients and reimbursed by
Medicare found that at least 13 percent were
performed for cancer screening purposes, not for
diagnostic reasons (94).
Second, many tertiary preventive services (e.g.,
hypertension control or treatment of hypercholesterolemia) are reimbursable expenses under Medicare,
because they are defined as therapeutic. Visits made
for monitoring, counseling, or prescribing of treatment would be reimbursable by Medicare.
STRENGTHS AND WEAKNESSES
OF MEDICARE AS A SOURCE OF
FUNDING FOR PREVENTIVE
SERVICES
Paying for preventive services through Medicare
is, in many respects, an efficient and simple way to
providefinancialaccess to such services for the
elderly. To the extent that a service can be defined
and assigned a procedure code, it can be incorporated very easily into the existing payment system.
It is also arelativelysimple administrative task to
exempt such services from the deductible and
coinsurance requirements that apply to other Medicare services. For a number of reasons, however,
covering a preventive service as a Medicare benefit
may be insufficient to bring about appropriate
patterns of use.
1
Finally, an unknown percentage of the almost 1
million Medicare beneficiaries currently enrolled in
health maintenance organizations (HMOs) or other
competitive medical plans (CMPs) may receive
additional preventive care. Since 1982, Medicare
has provided capitation payments on a riskcontracting basis to HMOs and CMPs who enroll
Medicare beneficiaries (Public Law 97-248). Such
Medicare plans receive a fixed price per capita for
'All reimbursable Medicare procedures and visits are assigned a unique five-digit code and published as the Health Care Procedural Coding System
(HCPCS), which is an expansion of the American Medical Association's Current Procedural Terminology (19).
-9-
�10 • Preventive Health Services for Medicare Beneficiaries:
Policy Issues and
The decision to use a preventive service may
depend more on the information available to the
consumer or physician, and the attitudes of each,
than on its out-of-pocket cost. OTA's study suggests
that the use of preventive services by the elderly may
depend more on characteristics of the consumer,
physician, and service than on the out-of pocket
costs (37). Although adding a preventive service to
the list of covered Medicare benefits would certainly
not reduce its utilization, it is questionable whether,
in the absence of concerted efforts to educate
physicians and Medicare beneficiaries about the
value of such services and to encourage their use,
overall rates of use would increase substantially
(63,80,101 ). Moreover, to the extent that people
who would benefit most are the least likely to use
such services, as appears to be the case with cervical
cancer screening (61), the real medical benefits
deriving from coverage could be minimal in some
cases.
can be limited to a maximum frequency, such a
every 2 years, but under the existing claims paymer
structure of the Medicare program, it is difficult fc
Medicare carriers to monitor compliance with an
enforce such limitations on use (42). As the technol
ogy of claims payment improves, this problem ma
disappear.
2
Some services are beneficial only to people with
conditions or circumstances that render them particularly "at-risk" for the preventable condition, but it
can be difficult and costly to limit payment for a
preventive service to an at-risk population. For
example, the health benefits of cervical cancer
screening appear to be great for women at or near the
poverty level who have never been previously
screened (61), but it might be impractical to restrict
Medicare coverage of cervical cancer screening to
high-risk women defined in this way. Medicare is
not designed as a means-tested program of benefits.
A Medicare cervical cancer screening benefit may
have to be offered to all women, including those who
stand to gain little from repeated screening. Other
approaches such as direct grant programs, or coverage of such services through Medicaid, might allow
targeting of services to elderly groups most in need,
but these alternatives also have limitations.
3
Some preventive services (particularly screening
tests) are highly effective if offered at infrequent
intervals, but as the frequency of use increases, the
added effectiveness declines. A Medicare benefit
Recommendations
:
Like most "cognitive" medical services, cour
seling and education are inherently difficult t
standardize or audit. Because such services would b
delivered in outpatient or office settings, they coul
not easily be incorporated in quality assuranc
programs focusing on content. Hence, provider
could deliver services of low quality (and lo\
effectiveness) and still receive payment from Medi
care.
Some preventive services, particularly educatio
and counseling, may be most efficiently and effec
lively delivered by nonphysician personnel. Th
Medicare program, however, requires nonphysicia:
services such as those of physical or occupationE
therapists, nurse practitioners, and clinical psychol
ogists to be provided under the supervision of .
physician. This requirement adds to the cost o
providing services that may not require such super
vision. In addition, most physician practices are no
organized to supervise a wide variety of nonphysi
cian personnel, and their Medicare patient loads an
not large enough to justify hiring staff trained ir
multiple disciplines for the purpose of delivering ar
array of preventive services to the elderly (56).
4
POLICY ISSUES IN DEVELOPING
A MEDICARE STRATEGY FOR
PREVENTIVE SERVICES
Despite the problems with Medicare as a mechanism for implementing preventive services for the
elderly, it is nevertheless a potential vehicle for
enhancing access to these services. The curreni
strategy for adding preventive services to Medicare
is ad hoc and procedure specific. It is worth
considering approaches to developing a more com-
^The case of pneumococcal vaccine may be instructive. Despite Medicare coverage of this vaccine in 1982 for all beneficiaries, rates of use did n
increase in ihe United States between 1982 and 1986. In 1985, only about 11 percent of all elderly people were immunized with the pneumococcal vac
(27).
'Direct grants to providers of services to elderly women in poverty would superimpose a separate service delivery system on the existing system
care and might interfere with the continuity of care for these women.
This is largely, but not strictly, true. Since 1988 the services of clinical psychologists can be directly reimbursed i f they are delivered in a Commu
Mental Health Clinic or a Rural Health Ginic as defined by the Public Health Service. Otherwise, clinical psychologists can be separately reimbursed
for services only when the services are delivered under the supervision of a physician.
4
�Chapter 4—The Medicare Program and Preventive Services * 11
plete strategy for incorporating preventive services
into the Medicare benefit package. The formulation
of such a policy requires choices in the following
areas:
The Unit of Payment: Individual Procedures
v. Service Package
Up to now, newly covered preventive procedures
have been added to the list of billable payment
codes, giving physicians the power to bill for these
services as they do for other medical procedures.
Payment is made only for the procedure itself (e.g.,
the cost of administering a vaccine) and not for the
physician's visit in which the procedure is administered. Implicit in this policy is the assumption that
the preventive procedure will be delivered as part of
a visit made for a nonpreventive purpose. This
approach to adding new services is both simple and
consistent with existing Medicare billing systems.
This incremental procedure-specific approach ignores the potential benefits of offering services in a
package that may economize on the total cost of
providing any given set of such services. If a
periodic Pap smear were added to the list of covered
services, for example, the additional cost of a
clinical breast examination or a digital rectal examination during the same visit would be minimal.
Counseling sessions on smoking cessation or appropriate medication use could be easily and inexpensively expanded to include information on nutrition.
The fixed costs associated with patient scheduling
and preparation, medical recordkeeping, and billing
could be spread across a number of specific interventions.
Paying for a package of preventive procedures or
activities in a defined visit schedule provides the
physician or other provider with the opportunity to
integraterelatedservices with one another. It is also
compatible with the introduction of educational
materials and encounter forms for physicians as a
guide for providing such services (60). This very
integration also has disadvantages, however. One is
that the package approach can force the patient into
a rather inflexible mode of service delivery that
could ultimately lower his or her use of such
services. Paying by the procedure allows any physi-
cian to provide a specific preventive service, such as
a vaccination, as part of a visit for another purpose.
About 85 percent of elderly people made at least one
ambulatory health care visit in 1980 (34). Some
elderly people might accept a single quick intervention as part of another visit but might not be willing
to make a special trip to the doctor each year to
receive a more comprehensive package of services.
Two major preventive services demonstration
projects have adopted the package approach to
payment for preventive services. The first, Project
INSURE, was begun in 1980 by a consortium of
public and private sources (60). An age-specific
schedule of preventive visits containing a defined set
of preventive services was specified for the study
population. (See app. D for the package of services
provided under Project INSURE for people 65 years
of age and older.) Participants were eligible for and
encouraged to receive the package of services at no
cost; providers were paid on a fee-for-service basis
for services rendered as part of the package.
A more recent set of federally funded studies
currently underway at six sites is testing the feasibility and effects of offering different defined packages
of preventive care to elderly Medicare beneficiaries
and paying providers for the package of services
delivered during the visit or over a period of time.
These projects should provide information on how
Medicare recipients respond to service offered in
packages. (See app. C for a description of these
Medicare demonstration projects.)
Standards of Evidence
Because they have traditionally been excluded
from insurance benefit packages, preventive services have been held to a burden of proof of
effectiveness or cost-effectiveness that is not typicallyrequiredof diagnostic and therapeutic procedures. For the most part, third-party payers, including Medicare, accept diagnostic or therapeutic
services as "reasonable and necessary" unless
obvious abuse is encountered. In contrast, for
preventive services to be included in a benefit
package, evidence must exist that they are at least
effective, and sometimes that their medical benefits
are worth their costs. This standard may seem
unduly harsh, and proponents of preventive services
5
'The situation is changing. Diagnostic and therapeutic procedures are increasingly scrutinized through utilization review and quality assurance
activities undertaken by insurers or providers such as hospitals or health maintenance organizations. Medicare's process for covering new medical
procedures has also recently been strengthened and revised; proposed regulations issued in January 1989 would change the criterion for coverage from
effectiveness to cost-effectiveness (91).
�12 • Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations
often argue that it is unfair to hold prevention to a
higher standard than that required for other medical
services (48,96). Two powerful arguments favor a
tough standard for preventive services, however.
First, like all services, preventive services involve
potential risks as well as potential benefits. However, unlike diagnostic and therapeutic services,
which are rendered in response to patient complaints
or symptoms, preventive services are offered to
ostensibly healthy individuals and therefore involve
an implied promise that they will improve the
patient's health (74). Second, the more appropriate
response to the double standard may be to raise the
level of evidence required for diagnostic and therapeutic services, not to lower those for preventive
services. That one genie is out of the bottle is no
justification for letting others out, too.
Even accepting that the decision to include
preventive services as an insured benefit requires
explicit evidence, choices exist about the criteria
that will be used to govern the coverage decision and
the standards of validity required of the evidence
that does exist Possible criteria include:
• Effectiveness (impact on health status)—
Evidence would be required that the expected
length or quality of life would be increased for
the person receiving a preventive service. This
criterion also requires the assessment of medical risks associated with the use of the service.
X-ray screening procedures, for example, may
subject the user to a small cancer risk associated with ionizing radiation; these risks would
be weighed against the potential beneficial
effects of the screening procedure on longevity
or quality of life.
• Cost-effectiveness—The health effects of a
preventive service would be arrayed against the
net health care costs of achieving those effects.
Whether the health effects are worth their costs
is a policy judgment. If the health effects can be
reduced to a single dimension (through the use
of a health status index or a quality-adjusted
life-years scale), the ratio of health care costs to
effectiveness can be computed and used as the
basis for judgments about whether the service
is worth its costs. If a preventive service both
improves health (i.e., lengthens life or improves the quality of a person's remaining
years) and reduces health care costs (by averting costly therapy), then it is not only costeffective but also cost-saving to the health care
system, and unequivocally desirable under this
criterion.
• Impact on Medicare outlays—The net effect of
the preventive service on Medicare expenditures would be the basis for a coverage decision. A preventive service would be covered if
it can be expected to reduce net Medicare
outlays by averting expenditures for covered
diagnostic and therapeutic services. If expected
net Medicare outlays are positive, policymakers
would have to decide whether the health
outcomes are worth the net outlay, thus implicitly returning to the cost-effectiveness criterion.
Highly effective preventive services could fail
the test of being cost-saving to Medicare,
because in prolonging life, they could induce
future Medicare expenditures for unrelated
illnesses.
6
• Net economic benefits—This criterion combines all consequences of a preventive strategy
(health effects and health care costs) into
monetary values. The economic value of health
benefits is compared to the cost of the strategy.
If the net economic benefits are positive, then
the service is worth its costs; if negative, it is
not. This benefit-cost framework is attractive in
principle but almost impossible to implement.
Major conceptual, methodological, and social
problems exist in placing dollar values on the
health effects of specific strategies (99).
The notion that a preventive health service should
be effective is widely accepted by health care
providers and policymakers. There is less agreement
about whether the cost of such services should be
considered in either coverage or clinical decisions.
The U.S. Preventive Services Task Force, convened
in 1984 to develop guidelines for preventive services, adopted stringent standards of effectiveness but
explicitly rejected cost-effectiveness as a criterion
for their task in judging these services. (See app. D
for a description of the Task Force and its recommendations for the elderly.) In fact, no professional group
in the United States making recommendations on
preventive services for the elderly has explicitly
'Alternatively, the decision could be based on a preventive service's net impact on total Federal expenditures, including Medicare. Medicaid, and
income transfer programs.
�Chapter 4—The Medicare Program and Preventive Services •IS
accepted cost-effectiveness as a criterion for making
such judgments.
Locus of Responsibility for
Coverage Decisions
Still, expert groups making recommendations
differ widely on specific preventive services. Appendix D contains a summary of such recommendations pertaining to the elderly. Recommendations for
colorectal cancer screening, for example, vary widely.
The U.S. Preventive Services Task Force and the
Canadian Task Force on the Periodic Health Examination have concluded that the evidence does not
support a recommendation for routine screening of
older Americans for colorectal cancer, in contrast,
the Working Guidelines adopted by the National
Cancer Institute include a relatively aggressive
screening schedule.
Responsibility for expanding Medicare to cover
preventive services presently resides with Congress.
To date, such expansions have been limited to
specific procedures, but Congress could authorize
the Health Care Financing Administration (HCFA)
to offer an "appropriate" package of preventive
services to elderly Medicare beneficiaries. Authorizing legislation could include criteria for assessing
the "appropriateness" of such services. For example. Congress could direct HCFA to consider the
cost-effectiveness of alternative packages in its
implementing regulations.
Why do such differences remain even when the
criterion for judging the service—effectiveness—is
the same across recommending groups? The answer
seems to lie in how different groups interpret the
available evidence. At one end of the spectrum is the
requirement that any recommendation be buttressed
by well-designed controlled trials documenting the
effectiveness of an intervention; at the other is the
acceptance of either anecdotes or professional opinions about the effectiveness of a procedure as
sufficient to justify recommending it. For many
(perhaps most) preventive services, unequivocal
evidence about positive or negative health benefits
does not exist; the evidence may be weak or
conflicting. Even when there is general agreement
about the standards of scientific validity, the application of those standards to interpretation of specific
studies may differ. Studies are conducted in different
populations, measure different outcomes, and apply
different protocols and measurement techniques.
Judgments about the importance of one study versus
another are made continually, and methods for
synthesizing the results of many studies are currently unstandardized.
Vesting HCFA with the authority to decide about
specific packages of services would probably increase the flexibility of the Medicare program to
respond to new evidence on effectiveness or costeffectiveness as it arises. By removing specific
coverage decisions from the legislative process,
preventive services would not have to compete for
approval directly with other uses of the Federal
health budget. However, if the authority for coverage decisions is vested in HCFA, the resulting
package of services offered to the elderly would be
unpredictable. As was noted just above, conclusions
about the health and cost consequences of specific
preventive services depend, in poorly understood
ways, on the composition of the recommending
groups and the criteria and standards used to judge
the evidence. Even directing HCFA to use costeffectiveness as a criterion for coverage decisions
would leave a great deal of uncertainty about how
the available evidence would be assessed. A process
administered by HCFA, however, might be no more
unpredictable than the current legislative process
and would still be subject to oversight by Congress.
7
8
7
Evidence that a preventive service is actually cost saving is often used as secondary supporting information to buttress a recommendation made on
effectiveness grounds alone, but, to our knowledge, an effective service has never been denied a recommendation by such a group on the argument that
it is too costly.
'Over the past decade, a new approach, referred to as "meta-analysis of research" has been developed to provide rules for integrating the results
of many studies of the same intervention into an overall finding (36). Even with comparatively standardized methods for pooling the results of individual
studies, however, the criteria governing inclusion or exclusion of specific studies and the comprehensiveness of the search for relevant studies can
influence the outcomes of meta-analysis (35,36). For example, a meta-analysis of a preventive intervention that includes only studies whoseresultsare
published in peer-reviewed journals will ignore many studies in the so-called "phantom literature," and may be biased in favor of finding that the
intervention is successful (36).
�Chapter 5
Evaluating the Evidence on the Cost-Effectiveness of
Preventive Services for the Elderly: Selected Issues
In the past decade, OTA has studied the effectiveness and costs of seven preventive services for the
elderly. The general approaches followed in these
studies are consistent with the principles of economic evaluation of medical procedures laid out in
recent primers on the subject (23,73,99) and will not
be described here. (See app. B for a summary of
these studies.) Common to all cost-effectiveness
analyses are unresolved methodological issues such
as how to come up with an index of effectiveness
that incorporates all important dimensions of health
outcomes, what discount rate to use for costs and
effects expected to occur in the future, how to place
a value on unpaid services provided by volunteers or
family members, and which nonhealth care costs to
include in the cost estimates. Applying the general
principles of economic evaluation to preventive
services for the elderly raises an additional set of
questions that, depending on how they are resolved,
may have a major influence on the final estimates of
effectiveness or cost
1
Issue: Under what conditions is it appropriate to
generalize about the effectiveness of a
service on the elderly from evidence of its
effectiveness in nonelderly populations?
This issue arises frequently because so little
effectiveness research is conducted on elderly populations. For example, neither mammography nor
cervical cancer screening have ever been rigorously
tested for effectiveness in the general population of
elderly women (64a,89). To date no studies of the
impact of cholesterol reduction on heart disease or
death have reponed on elderly patients as a separate
group (32). To generalize from information on the
nonelderly, assumptions are required about the
natural course of the disease in the elderly relative to
the nonelderly and the relative response of the
elderly to preventive interventions or to therapy
initiated in response to screening. Some hold the
view that such extrapolations are always unacceptable, that without evidence directly pertaining to the
elderly, no valid conclusions about the elderly are
possible. This position seems extreme and perhaps
unfair to elderly people if services are withheld
because studies have never been conducted in their
age group (47). But, extrapolating evidence opens up
the possibility for errors of judgment and is one
reason the conclusions of different expert groups can
vary widely.
Issue: How should the effects of services provided
together in a package be attributed to
specific procedures?
Quite often, studies of preventive services examine programs that deliver a number of procedures or
interventions in a combined visit or set of visits.
Unless an evaluation study has a very large number
of subjects and has detailed information on the exact
set of services received by each subject, it is
impossible to distinguish the effects of individual
components. The ongoing HCFA Preventive Services Demonstration projects, for example, which
offer defined service packages to experimental
groups, will not be able to determine which specific
tests or services are responsible for the observed
outcomes. This weakness of the evaluation studies is
important because the composition of the package
can have a major impact on the cost of an intervention and therefore on its estimated costeffectiveness.
Issue: How should the costs of a visit be apportioned among the individual procedures
and interventions provided in the visit?
In estimating the cost-effectiveness of a specific
preventive intervention, the issue invariably arises
whether some or all of the costs of the visit in which
the specific services is delivered should be considered costs of the service itself. Some preventive
procedures are by themselves very inexpensive. In
1986, Medicare paid less than $7 for a total
cholesterol determination, for example. The Medicare reimbursement for a Pap smear was about $10
including a small fee for preparation. Nevertheless,
the physician may charge a visit fee. and Medicare
paid an average $21 in 1986 for a "brief' visit (67).
The estimated screening costs for either of these
procedures would more than triple if the full cost of
a brief visit were included in the estimate. Not to
attribute any visit costs to the procedure implies that
the visit was made for another purpose altogether
'They are: pneumococcal pneumonia vaccination (86,88); influenza vaccination (87); mammography (89); glaucoma screening (70); cholesterol
screening (32); cervical cancer screening (64a); and colorectal cancer screening (in preparation for early 1990 release).
-15-
�16 • Preventive Health Services for Medicare Beneficiaries : Policy Issues and Recommendations
and the delivery of the preventive service is incidental. To fully attribute the costs of the visit to the
preventive intervention implies that the purpose of
the visit was entirely to receive the preventive
service. OTA's study of cholesterol screening costs
assumed that such tests would be conducted as an
incidental part of a visit for other purposes (32);
conversely, the cervical cancer screening analysis
assumed that a proportion of the visit costs were
attributable to the procedure (64a).
Issue: What allowances in cost estimates, if any,
should be made for inefficiencies inherent
in the medical care system?
Preventive services are layered on an existing
delivery system that may not be organized to offer
such services in the least costly way possible. For
example, what are the costs of providing screening
mammograms to elderly women? The answer to that
question presupposes a specific level of capacity
utilization of mammography facilities. Reasonable
geographical access to facilities, particularly in rural
areas, may require some excess capacity. The
estimated cost per examination will be much lower
if full capacity operation is assumed than it would be
if, say, only 50-percent capacity is assumed. Or, if
substantial excess mammography capacity already
exists in the health care system for diagnostic uses
the extra costs of performing screening examinations might be even less than the estimated average
costs of a dedicated screening facility operating ai
full capacity.
Issue: How should uncertainties be treated?
There is no single correct answer to the question
posed above; the most appropriate approach depend.
on the particular preventive service being evaluatec
and the context for the evaluation. In cases where the
most appropriate approach is not obvious, analyst:
can show how changing assumptions will affect tht
findings (commonly referred to as sensitivity analy
sis), but when changing the assumptions leads tc
major changes infindings,sensitivity analysis ma}
be tantamount to refusing to conclude anything
about the magnitude of effectiveness and cost
Although this can be very frustrating to the users oi
such analyses, it is a necessary component of a sounc
analysis. The analysis is informing decisionmaken
that better data are needed to make better decisions.
At the very least, any analysis of preventive service;
for the elderly should explicitly identify the choice?
that are made in the areas enumerated above, so thai
the resulting findings can be held up to careful
scrutiny by interested users of the analysis.
1
�Chapter 6
Research Issues
The paucity of direct evidence on the effectiveness of preventive services for the elderly is strikingly similar across all kinds of services. In response
to congressional mandate, HCFA is currendy supporting six demonstration projects whose goal is to
assess the costs and effectiveness of providing
preventive health services under the Medicare program. These projects are unlikely to provide enough
evidence on effectiveness to improve the state of
knowledge substantially in that regard. Problems of
design, inadequate funding and follow-up periods
that are too short, and basic problems of organizing
services so that the elderly will use them, all suggest
that the evidence arising from these studies is likely
to be limited (see app. C). The demonstration
projects will tell a great deal about how elderly
peoplerespondto thefinancialincentives to use
such services, and how their use affects their
preventive behaviors. At the very least, consideration should be given as soon as possible to funding
extended follow-up periods at selected demonstration sites where participation rates have been high.
By extending these projects, more information
would be captured on the health effects of the
preventive interventions. Since these demonstrations were congressionally mandated, extending
their length mightrequirea technical amendment to
the legislation.
-17-
Because effectiveness research is costly, it should
be targeted to services that offer the potential for
large impacts on health status or health care costs of
the elderly. Research to clarify the appropriate
components of and target populations for comprehensive geriatric assessments has been recommended by an NIH consensus conference panel (65).
Because the costs of institutional care for the
disabled elderly are so high, these tertiary preventive
health services are a promising research subject for
effectiveness and cost-effectiveness research.
Even when direct evidence on effectiveness is
available, the process of translating that evidence
into guidelines for practice has a major impact on
final recommendations. Not only does the composition of deciding groups appear to affect the final
recommendations, but the standards used to interpret
the evidence are critical. There is little consensus
among professional groups that have periodically
addressed issues of specific preventive services as to
the standards of evidence that should guide the
development of recommendations. The extent to
which the net health care costs of preventive
interventions should be considered in Medicare
payment decisions is a question that has not been,
but could be, answered explicitly.
�Appendix A
Acknowledgments
This repon has benefited from the advice and review of many people in addition to the advisory panel. The staff
would like to express its appreciation to the following people for their valuable help and guidance.
William Antos
Robert Kane
Health Care Financing Administration University of Minnesota
Minneapolis, MN
Baltimore, MD
Allison Mayer Oaks
University of California at Los Angeles
Los Angeles, CA
William F. Bridgers
Director, Lister Hill Center
The University of Alabama
in Birmingham
Birmingham, AL
Mary Grace Kovar
National Center for Health Statistics
Hyattsville, MD
Michael Parkinson
USAF School of Aerospace Medicine
Brooks Air Force Base, TX
Lewis H. Kuller
University of Pennsylvania
Pittsburgh, PA
Louise Russell
Rutgers University
New Brunswick, NJ
F. Marc LaForce
The Genesee Hospital
Rochester, NY
Clyde Schechter
Mt Sinai School of Medicine
New York, NY
Mary Cummings
National Center for Health
Services Research
Rockville, MD
Bonnie M. Edington
Health Care Financing Administration Robert S. Lawrence
Baltimore, MD
The Cambridge Hospital
Cambridge, MA
Al Esposito
Office of Research and Demonstrations Benjamin Littenberg
Health Care Financing Administration Veterans Administration
Baltimore, MD
Medical Center
Palo Alto, CA
David Fedson
University of Virginia Health
John Meitl
Science Center
Health Care Financing Administration
Charlottesville, VA
Baltimore, MD
Robert Fried
University of Colorado School
of Medicine
Denver, CO
Sam Merrill
Congressional Research Service
Washington, DC
Angela Michelide
Alan Garber
U.S. Department of Health and
National Bureau of Economic Research
Human Services
Stanford CA
Washington, DC
Michael Gemmell
Association of Schools of
Public Health
Washington, DC
Pearl S. German
Johns Hopkins University
Baltimore, MD
Steven Moore
Food and Drug Administration
Washington, DC
Joseph Morrissey
The University of North Carolina
Chapel Hill, NC
-19-
Stuart O. Schweitzer
University of California, Los Angeles
Los Angeles, CA
Katharine Bauer Sommers
Institute of Medicine
Washington, DC
Stephen J. Williams
San Diego State University
San Diego, CA
T. Franklin Williams
National Institute on Aging
Bethesda, MD
Steven H. Woolf
U.S. Department of Health and
Human Services
Washington, DC
Steffie Woolhandler
Cambridge, MA
�Appendix B
Summary of OTA Studies of Preventive Services for the Elderly
The Office of Technology Assessment has conducted
a number of assessments of preventive services for the
elderly over the past decade. This section summarizes the
main findings of each study.
Breast Cancer
Screening
OTA conducted an analysis of the effectiveness and
costs to Medicare of breast cancer screening for Medicare
beneficiaries in 1987 (89). It was estimated that a
screening program begun in 1987, in which 30 percent of
female Medicare beneficiaries ages 65 to 74 accepted
annual screening, would result in avoidance of about
2,500 advanced-stage breast cancers every year from
1990 to 2020, with a total of 85,041 advanced-stage breast
cancers prevented and 268,000 life-years saved by 2020.
As far as costs to Medicare are concerned, the analysis
showed that breast cancer screening cannot be expected to
save enough money in decreased treatment costs to offset
the costs of screening and workups. There are savings due
to a reduction in initial and terminal treatment costs for
breast cancer, but the cost of screening far exceeds these
savings. The analysis found that a breast cancer screening
program would cost Medicare about $185 million in
1990. The cost to Medicare per life-year saved by 2020
(costs discounted at 5 percent, life-years undiscounted)
would be approximately $13,200.
Pneumococcal Vaccine
OTA analyzed the cost-effectiveness of the pneumococcal vaccine in elderly people (86,88). In 1983, the
estimated net discounted costs per discounted healthy
year of life gained (at 5 percent discount rate) ranged from
negative net costs to $6154, depending on the assumptions adopted regarding the percent of pneumonias that
are pneumoccocal and the duration of immunity conferred
by the vaccine.
overall survival in either elderly men or women (33). The
few studies of the elderly found either that the cholesterol
level does not predict mortality at all or that it is a
statistically significant predictor of lower mortality. There
are no randomized trials of the impact of cholesterol
reduction in the elderly, so the effectiveness of treatment
must be inferred from the studies in middle-aged populations. While cholesterol reduction can reduce CHD
incidence and death in middle-aged men, it has not been
shown to lower overall mortality in this population. It may
be that the studies on which such findings have been based
have had insufficient power or too few years of followup,
but benefits delayed for many years might not be pertinent
to the elderly, who have a high rate of death from other
causes.
The equivocal nature of the evidence on the effectiveness of cholesterol screening and treatment in the elderly
must be considered in light of the potential costs
associated with this preventive intervention. If all people
65 years of age and older were to fully comply with the
National Cholesterol Education Program's (NCEP) Adult
Treatment Panel Guidelines, the annual national health
care expenditures associated with screening and treatment
would range from at least $2.9 billion to $14.2 billion,
depending on the prevalence of certain risk factors and the
mix of drugs prescribed. The costs of screening and
followup alone are a small fraction of that total, about $57
million per year. Drugs and monitoring services constitute the bulk of the annual health cost burden.
Medicare's share of national health expenditures for
cholesterol screening and treatment is likely to be high. If
the entire elderly population were to fully comply with the
NCEP guidelines. Medicare expenditures for testing and
monitoring would range from $1 billion to $5.4 billion per
year.
Cervical Cancer Screening
Influenza Vaccine
OTA evaluated the costs and effectiveness of screening
for cervical cancer among elderly women (64a). Studies
have found that women who have been screened are two
to ten times less likely than others to develop cervical
cancer. The protection associated with prior screening is
found in elderly women as well as younger women.
Elderly women, however, are less likely to be screened
than younger women and have seen less reduction in
mortality rates than other groups. Medicare coverage of
Pap smear screening (which was mandated in the
Omnibus Reconciliation Act of 1989) might induce
increased utilization of this test among elderly women.
Additionally, Pap smear screening in elderly women does
not appear to be very costly for the potential life years
saved from this technology, although it is unlikely to
actually save health care costs.
OTA performed a retrospective analysis of the costeffectiveness of the influenza vaccination among elderly
people in the 1972-78 period (87). The annual vaccination
was found to be cost-saving to the medical care system
when costs were discounted at 5 percent per year. If
medical cart costs for unrelated illnesses occurring in
extended years of life gained from the vaccination are
included, the vaccination would have cost $1,782 per
added healthy year of life.
Cholesterol Screening
In a study of the effectiveness and costs of cholesterol
screening in the elderly, OTA found that the cholesterol
level does not appear to be a significant predictor of
-20-
�Appendix B—Summary of OTA Studies of Preventive Services for the Elderly
OTA estimated that a single screening of women at age
65, when they become eligible for Medicare, would save
14,400 life-years per 1 million women screened (lifeyears and costs discounted at 5 percent) and would cost
the health care system $1,666 per year of life saved. The
incremental cost per year of life saved is least for 5-year
screening ($1,453) and is progressively greater as screeningfrequencyincreases. It amounts to $5,956 per life-year
saved for the incremental effects of a 3-year screening
cycle over a 5-year cycle, and rises to $39,693 per
life-year saved for annual screening.
5
office settings, and all have the potential to be high
inaccurate. Tonometry, for example, produces many fal:
positives and negatives because elevated IOP and OA
are not always related. Although tonometry itself
inexpensive, diagnostic workups of individuals with fal;
positive tests and treatment of many people who wou.
not have developed OAG in any caseresultin substanti
associated costs.
:
Glaucoma Screening
The accuracy of screening tests is not the only soun
of uncertainty. Considerable uncertainty also surroum
the effectiveness of medical treatment in preventir.
visual disability in individuals with high IOP or suspecte
OAG. The published, objective evidence on the effectivi
ness of treatment is highly contradictory. Many individi
als suffer progression of disease despite treatmen
conversely, many untreated persons go for years withoi
suffering loss of vision. Few adequate studies of treatme
have been undertaken, and those available do not she
consistentresults.Studies currently underway may he!
resolve the uncertainty.
OTA examined the existing evidence regarding the
effectiveness and potential costs to Medicare of screening
for open angle glaucoma (OAG) in the elderly (70). Three
methods of screening for OAG exist: tonometry, which
measures intraocular pressure (IOP); ophthalmoscopy,
which identifies abnormalities of the optic disc; and
perimetry, which identifies visual field defects. None of
the methods has been tested for accuracy in everyday
Screening elderly individuals for OAG may we
eventually prove to be a highly beneficial technology. /
present, however, the contradictory evidence on th
effectiveness of treatment, combined with the unknow
accuracy of screening tests, makes widespread screenin
of the elderly a very uncertain, and probably cosd}
endeavor.
The cost-effectiveness ratio for Pap smear screening
depends heavily on the extent to which high-risk, rather
than low-risk, women are screened. Low-risk women
derive some benefitfromscreening, but at very high cost
to the health care system. Screening only high-risk
women, on the other hand, has a very low cost per
life-year saved.
�Appendix C
The Medicare Preventive Services Demonstration Projects
Description of the Projects
Authority and Funding
The Health Care Financing Administration (HCFA) is
cuirendy supporting six projects whose goal is to
demonstrate the costs and effectiveness of providing
preventive health services under the Medicare program.
These projects provide a mix of health status assessments,
immunizations, clinical screening services, and educational services to elderly individuals enrolled in the
experimental arms of the projects.
mandated studies are subject to a collective maximum
funding amount of $5.9 million for their administrative
costs (Public Law 99-509), which covers items such as
researchers' salaries, patient and physician recruitment,
and data collection and analysis.
The costs of the actual preventive health services
provided under the waivers are not reimbursed from the
project research funds and are not subject to any legislated
cap. HCFA estimates that the cost of these services will
be approximately $150 per person per year (24). These
costs are paid out of ordinary part B Medicare funds.
Design
The first of the six ongoing projects, administered by
the University of North Carolina, was funded at HCFA's
own initiative. HCFA solicited applications for preventive services projects in 1983 (48 FR 36660) and awarded
funds to the University of North Carolina and Blue
Cross/Blue Shield of Massachusetts in October 1985. The
North Carolina study began offering services to the first
participants in October 1986, completedrecruitmentof
2,400 participants in June 1988, and is now in its fourth
year of operation. The Massachusetts study was ended
after 18 months due to difficulty recruiting beneficiaries
(64). The design of this study required participants to be
randomized to one of three clinics toreceiveservices, and
many of the individuals asked to participate did not
understand the purpose of the study or were unwilling to
go to a provider other than their usual physician.
All six demonstration projects share certain similarities
in objective and design. In each study, all study participants undergo an extensive health status assessment,
performed by a nonphysician. Individuals in the experimental groups are alsoreferredfor appropriate screening,
immunization, and educational services, with the exact
services they receive varying by project and usually
depending on their individual medical history and risk
status. Control group patients get their usual care.
The remaining five of the six ongoing demonstration
projects have only just begun. Unlike the North Carolina
project, these projects were mandated by law (Public Law
99-272, as amended by Public Law 99-509). Applications for these projects were solicited in May 1987 (52 FR
20148), and funds were awarded in May 1988 (24). Each
project had a 6-month developmental phase prior to
recruitment. In addition, in order to carry out the
demonstration, each project must receive permission to
waive the usual Medicare coverage rules (which do not
permit reimbursement for most preventive services) for
the duration of the study. These waivers are subject to
review by the Office of Management and Budget (OMB),
which did not approve them until April 1989. Thus, these
five projects could not beginrecruitingsubjects until May
1, 1989 (24).
1
Project funding for fiscal year 1989 is approximately
$300,000 per study (range $290,000 to $330,000) (24).
HCFA willrenewfunding on a noncompetitive basis each
year subject to funding availability and to each project's
ability to meet its objectives (52 FR 20148). The five
l
All studies randomize patients to experimental and
control groups, although the groups being compared
differ among studies (see table C-l). (In most cases,
patients in both groups see their usual provider rather than
beingrandomizedto a particular provider.) In addition to
examining the costs and effectiveness of preventive
services, the projects test alternative methods of payment
for these services (e.g., prepayment, fee-for-service) and
involve a variety of different settings and health care
providers in the provision of the services.
The scope of services provided by the demonstration
projects is presented in table C-2. In general:
• The North Carolina project, which served as an
example for the designs of the later projects, offers
a mix of services that are fairly evenly divided
between screening and counseling services. This
project's design emphasizes a comparison of the
effects of the broad components of a prevention
program (screening alone, counseling alone, or both
together) provided by a subject's usual primary care
physician.
• Seattle incorporates the preventive services into the
scope of care provided to the experimental patients
in a health maintenance organization (HMO). This
project offers the most comprehensive prevention
package. It emphasizes immunization, cancer screen-
The law specified that the demonstration projects must be administered by "accredited public or private nonprofit schools of public health or
preventive medicine departments accredited by the Council on Education for Public Health" (Public Law 99-272). Thirty-four programs—twenty-four
schools of public health and ten programs in community hcallh/prevemive medicine—meet these requirements (18). Eleven of them submitted proposals,
and five of those proposals were funded (64).
-22-
�Table C-1—Design of Medicare Preventive Services Demonstration Protects
Raleigh-Durtiam,
Seattle. WA
NC
Directing
University ot North University of
organization
Carolina
Washington
Service provider ? Physicians' offices,
clinics ^ >'
•
Location
o f
5 health assessment sites; 1
5 screening sites;
approximately 11 health
promotion sites in the
community
13
1
%
Elderly patients of
partidpabhg ^ •'
practices«-_-
EWe'rtyHMO
enrollees j ; "
Sample size (total 2.538
2,250"
participants)
Conuol group 958
1.125"
Experimental Screening only (307) Receive services
group(s)
(1.625)
Healthpromotiononly
(317)
Both screening and
promotion (900)
Pittsburgh, PA area
University of Pittsburgh
Rural hospitals, clinics,;^
^ysKdara^olfices ^ j
;
Number of
providing sites
Sample pool .
_ /
San Diego, CA
Los Angeles, CA
Baltimore. MO
San Diego State University University of California Johns Hopkins
University
Many
*
Many
3
Elderly HMO enrollees' -^Elderly patients o r yi'EWeriy Medicare .
Ekterty'Mediraire ' " ^ " ^
^
_V
/L
participating physicians^ t&iefclarles in local area, benefictanes in local area
r
2,400"
1,800"
4.400"
1,200"
Receive services (1,200)
900"
2.200"
1.500"
Receive services (900) Receive services at usual Receive preventive
source of care (2,200) servicesfromctinic(2,000)
Receive services from
private physician (2,000)
4.500"
"Anticipated sample size as of November 1989 (recruitment still ongoing).
SOURCE: Office of Technology Assessment, 1990 (Information from project proposals and personal communication with project and HCFA personnel. See references.)
a
5'
a
re
<>
5
Ki
�24 • Preventive Health Services for Medicare Beneficiaries : Policy Issues and Recommendations
Table C-2—Preventive Services Offered in the Medicare Demonstration Projects
Service
ImmunUatlans?
Influenza
DiphtheriaAetanus
General clinical screening:
Risk assessment review
Height/weight
Blood pressure
Dental exam
Vision screen
Heariscreen
Other history/physical at
physician's discretion
Laboratory teats:
Hematocrit
Cholesterol (fingerstick)
Blood sugar (fingerstick)
Urinalysis
Mean cell volume
Creatinine
Thyroid (TSH)
Cancer screening:
Physical breast exam
Fecal occult blood
Digital rectal exam
Pap smear
Pelvic exam
Mammography
Counseling services:
RaJeigh-Durtiam,
NC
Seattle,
WA
San Oiego,
CA
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Baltimore,
MD
Pittsburgh,
PA
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Los Angeles.
CA
b
6
x
x
x
x
x
x
x
x
x
x
x
b
x
x
x
x
x
x
x
x
x
x
b
Diet/nutrition
x
x
x
x
x
Stress reduction
Exercise
Sleep regulation
Injury prevention
Drug/alcohol abuse prevention
Mental disorder prevention
Self-care/medication use
Smoking reduction/cessation
Life planning
Breast self-exam
Health care utilization
Disease-specific education
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
a
b
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
AII demonstration projects include an assessment of immunization history and administration of or referral for pneumococcal pneumonia vaccine, if
appropriate. This vaccine is already a Medicare-covered service.
UCLA is referring patients to their physicians for these services, as appropriate.
SOURCE: Office of Technology Assessment, 1990. (Data from project proposals and personal communications with project HCFA personnel. See references.)
ing, and extensive organized counseling sessions,
but it offers only one laboratory screening test.
Control and experimental patients in this study are
stratified according to their usual level of health care
utilization.
San Diego also stresses immunization and uses a
specific, privately owned education program for the
counseling segment of the protocol. It is the only
project that includes a thyroid screening test. All
clinical screening in this project is provided by two
physicians and other supporting members of the
project team.
• The Los Angeles project is the only site offering
comprehensive dental screening and services in its
package of preventive services. All services are
provided at a single centralized health prevention
clinic. Physician involvement is minimal and centers on a review of the risk assessment results with
the patient, with followup services provided at the
physicians' and patients' discretion.
• The Pittsburgh project emphasizes disease-specific
screening and counseling, particularly for hypertension and diabetes. Services are provided through
rural physicians and health clinics, with two experi-
�Appendix C—The Medicare Preventive Services Demonstration Projects • 25
mental groups that differ according to the settings in
which subjects receive the screening and counseling
services.
• Finally, the Baltimore project includes a moderately
comprehensive array of services; unlike the Pittsburgh project, however, the setting is always the one
in which subjects receive their usual care. This
project differs from the others in that all counseling
is provided by physicians during the office visit.
Reimbursement for the services received by experimental subjects is, with only one exception, based on a
pre-set fee for a specified package of waivered services.
In Seattle and San Diego, the two sites at which services
are provided by pre-paid health plans, the package
includes all services; these sites receive annual perenrollee capitation payments. At the Baltimore and North
Carolina sites, payment is also based on annual rates per
enrollee. The North Carolina payment is made in two
parts, one for screening services and one for health
promotion services. The Baltimore payment is an inclusive rate for all services, but there can be an additional
payment for an optional follow-up counseling visit. In the
Los Angeles program, where all reimbursed services
under the waiver are provided at a single site, the provider
is reimbursed a set fee per visit for all clinical and
counseling services provided in that visit.
The exceptional program is Pittsburgh, where there are
two randomized experimental groups. Subjects authorized to receive services through a clinic or hospital are
covered through a single capitated amount (per enrollee
per year for all services) paid to the provider. Subjects
authorized toreceiveservices from private physicians are
covered through a fixed fee for each service (e.g., a pre-set
amount paid to the physician for providing counseling
regarding hypertension). Physicians may, at their option,
refer subjects to clinics for some counseling services; in
this case, the clinic is reimbursed for the individual
service.
Evaluation Plans
The law mandating the five demonstration projects
required the Secretary of the Department of Health and
Human Services (DHHS) to submit a preliminary report
to the Congress by April 7, 1989, regarding their status.
That report has been submitted. Public Law 99-272 also
required the Secretary to submit an evaluation of these
projects to Congress by April 7, 1991. This evaluation is
to include:
• an assessment of the short- and long-term costs and
benefits of providing these services to Medicare
beneficiaries,
• an assessment of how these services might be
financed under Medicare, and
• a recommendation to Congress regarding "appropriate legislative changes to incorporate payment for
cost-effective preventive health services into the
Medicare program" (Public Law 99-272).
The evaluation report due April 7, 1991 will include the
results of the North Carolina project as well as latest
results of the five mandated projects (24).
The five demonstration projects, awarded in April
1988, were scheduled for 6 months of planning, 2 years
of service provision, and 18 months of evaluation. The
five projects began delivering services in the spring of
1989. ConsequenUy, unless it is delayed, the report
planned for the spring of 1991 can only give interim
results of the five projects.
Each project is required to evaluate itself andreportthe
results of its experiment. In addition, HCFA will undertake a cross-cutting evaluation of the projects. The
primary experimental outcomes to be evaluated include:
• utilization of preventive services by the experimental groups;
• costs of providing the preventive services and any
associated treatment;
• changes over time in health status measures of
experimental patients (e.g., improved functional
status, improved self-assessment of well-being,
lower weight, lower cholesterol level); and
• changes in utilization of other (nonexperimental)
health care services (e.g., number of hospital days in
general, changes in hospital days associated with
specific diseases).
Abt Associates, under contract to HCFA, will work
with the individual projects to ensure comparability of
reporting of results among projects. In addition, this
contractor will monitor the Medicare claims of a sample
of individuals outside of the five projects in order to assess
the impact of background trends in health care utilization
and cost (51).
Evaluation Issues
Ability To Achieve Results
The ultimate goal of all six projects is to demonstrate
the costs and effectiveness of providing preventive health
services to elderly Medicare beneficiaries. All projects
hope to show both better health status and a trend towards
lower Medicare costs as a result of providing these
services. Unfortunately, the only project with a realistic
chance of yielding confident results on costs and health
outcomes is the North Carolina study. The other five
projects are likely to be most successful in providing
information on the feasibility of providing services and
the utilization of these services by the elderly under
various conditions.
�26 • Preventive Health Services for Medicare Beneficiaries : Policy Issues and Recommendations
The difficulty in obtaining meaningful results regarding costs and effectiveness from the demonstration
projects is due to the fact that only the North Carolina
project will likely have at least 2 full years of data on all
participants in the project by the beginning of 1991, when
HCFA will be composing its evaluation. It is highly
unlikely that any of the other five projects will be able to
show any significant trends towards lower costs by 1991,
even if cost savings might eventually accrue as a result of
lower utilization. It is possible that some improvements in
hospital bed-days for certain diseases (e.g., influenza),
functional ability, and self-assessed quality of life might
occur within the short time that exists, but the failure to
find an effect would not be surprising even if an effect
exists. Thus, a lack of evidence of lower costs and
improved outcomes could mean that the projects did not
run long enough for the effects (e.g., improved functional
status) to manifest themselves in individual patients in the
experimental group. HCFA has no funds budgeted at this
time for long-term followup of Medicare claims of study
subjects.
The short time frame for service provision and data
collection of the five mandated projects at the time of the
April 1991 mandated report to Congress can be traced to
two factors that contributed to a delay in initiating the
projects. First, the process of soliciting applications,
preparing and submitting proposals, and evaluating the
proposals and awarding funds occupied nearly 2 of the 5
years allotted in the law. Second, the five projects required
waivers of the usual Medicare coverage rules; those
waivers must be approved not only by HCFA but by the
Office of Management and Budget (OMB), which evaluates them as part of the budget process. The waiver
process thus added an extra administrative step to startup
time.
Design Issues
The design of the demonstration projects presents a
number of conceptual problems common to many experiments conducted in the community setting. The most
obvious of these is the difficulty of distinguishing
between the care received by control and experimentaJ
groups. There is no limit to the services that individuals
in the control groups receive; they may request and
receive all of the same clinical services provided to the
experimental group, as long as they pay the costs
themselves. Furthermore, in most cases the same physicians (and nonphysician examiners) will be seeing both
experimental and control patients. The physicians and
associated office personnel may change their own behavior as a result of the project, suggesting or providing more
preventive services as part of the "usual care" they
provide to the control groups.
The potential similarities between control and experimental groups could make an observed lack of difference
in outcomes difficult to interpret. Such a result could have
any of three explanations:
1. that the preventive services provided to the
experimental groups had no effect on health
outcomes,
2. that the provision of enhanced services to one
group leads health care providers to alter their
behavior and provide enhanced services to the
remainder of the population, or
3. that the "enhanced" services provided to the
experimentaJ group did not in fact differ from the
usual care physicians provide to their patients.
If an effect is found, the design issues will center on
what components of the enhanced service package
produced the effect Some of these components are tested
explicitly within the design of individual projects. Pittsburgh, for example, is testing the comparative effects of
providing services through a centralized clinic v. through
private physicians' offices. North Carolina is comparing
the relative effects of providing clinical screening only,
health promotion only, and both components. In this case,
however, it is unlikely that the sample size will permit
detailed comparisons of the effectiveness of different
components among groups. Significant results will most
likely be obtained only for combined screening and health
promotion/no screening comparisons.
The individual effects of other components, however,
will be more difficult to identify. For example, the role of
the health status assessment, what it covers, and how it is
administered are slightly different in each project. In
addition, some projects offer an opportunity for physicians to add to the information provided in this assessment by conducting their own patient history, while
others do not. It is uncertain how much the assessments
and clinical screening services in the project protocols
duplicate or replace a standard "history and physical
exam," what extra information they provide, and what
aspects they may miss. Finally, the type and manner of
services provided as a result of the information provided
by the patient in the assessment differ among the projects.
This diversity permits a wide variety of possible combinations to be tested, but it also increases the difficulty of
determining which components contribute to the effectiveness of disease prevention, and which do not.
Implementation Issues
The demonstration projects are artificial settings in
which certain services are packaged, promoted, and
provided. Whatever the results of the demonstrations
themselves, a major issue to be faced is whether those
results will be applicable to ordinary circumstances in the
general medical community, where providers will lack
special preparation, intensive monitoring, and ties to
�Appendix C—The Medicare Preventive Services Demonstration Projects •
academic research centers. This problem is, of course,
inherent in many experiments in medical care. A reasonable expectation is that the project outcomes will provide
a maximum estimate for what can be expected to occur
under ordinary conditions, where efforts to recruit and
retain patients do not at present exist. In addition, the
projects should provide important information about the
circumstances under which participation and utilization is
better or worse.
The failed Massachusetts demonstration project has
already provided some indication of potential feasibility
problems. In this project, a random sample of Medicare
beneficiaries was to receive services at specified sites that
were not linked in any way with the site where they
received their usual medical care. After 18 months the
project had not succeeded in recruiting enough patients to
enable it to proceed, and a followup survey suggested that
most individuals were unwilling to change providers,
even temporarily, in order toreceivepreventive services.
Two projects—the Los Angeles project, which uses a
central service site, and the Pittsburgh project, which has
experimental groups randomized either to a usual care
physician or to a designated clinic site—will be testing
this hypothesis further. Even if these projects do succee
in encouraging participants to receive care at sites oth<
than their usual providers, it will still be uncertain whetht
beneficiaries under ordinary conditions would do so.
Other areas in which translating project protocols i
real-world circumstances may be difficult are the use
project interviewers to perform health status assessme;
in all projects, and the use of special training for nurst
and physicians performing counseling. To duplicate the:
features of the demonstration projects, physicians ;
private practice might need to hire additional staff
coordinate with outside organizations to provide servict
such as extensive risk assessment and counseling.
Finally, there is some self-selection on the pan
physicians participating in the projects. These physiciai
may be more willing than others to adjust their style <
practice to include (or exclude) specified preventh
services for the elderly. Whether Medicare coverage i
specified preventive services will itself encourage th,
same level of utilization as provision of those services i
an experimental setting is a question that can be answere
only after the fact.
�Appendix D
Summary of Recommendations for Periodic
Health Examinations in the Elderly
Visit Frequency
In recent years the worth of a yearly, or regularly
scheduled, physical examination by a physician has been
questioned and for the most part rejected by health
professionals. Instead, the concept of a periodic health
examination for the delivery of certain proven preventive
measures at specific intervals has been promoted. Government agencies, professional societies, and consumer
groups have made or are developing recommendations
either directly about periodic health examinations, or
about specific screening or preventive technologies that
require physician visits. Since these types of recommendations are not always specific about when physician
visits are necessary or when care may be provided by a
nonmedical professional, OTA has attempted to review
some of the recommendations and assess how they
translate into physician visits for the elderly. Table D-l
summarizes the recommendations for physician visits
made by leading groups.
in 1984, 1986, 1988, and 1989, in which the appropriateness of screening for new conditions is assessed or older
recommendations are reassessed.
With similar goals in mind, the U.S. Government
established its own Preventive Services Task Force
(USPSTF). Appointed in 1984, the Task Force worked
closely with CTF to develop age- and sex-specific
recommendations for clinical preventive services in
addition to addressing "the behavioral and structural
barriers to the successful integration of preventive services into clinical practice" (57). The Task Force adopted
the rules of evidence and classification developed by
CTF. Since April 1987, the Task Force periodically
published its recommendations on specific preventable
medical conditions in the Journal of the American
Medical Association. In addition, itsfinalreport.Guide to
Clinical Preventive Services: Report of the U.S. Preventive Services Task Force, which contains all of its age- and
sex-specific guidelines, was published early in 1989.
1
The task force conveys its findings in two ways: by
constructing age-specific charts suggesting the optimal
frequency of physician visits for different age groups, and
by providing specificrecommendationsconcerning each
of the 60 illnesses and conditions reviewed and the
effectiveness of the screening interventions assessed.
The Canadian Task Force on the Periodic Health
Examination (CTF), which was established in 1976 and
issued its first report in 1979, was the first major
organization to formulate a plan for a lifetime program of
periodic health assessments for the Canadian people.
After studying more than 90 potentially preventable
conditions, CTF maderecommendationsfor preventive
services for 78 of them. CTF determined that for the most
part, procedures should be carried out as case-finding
rather than screening techniques (they should be performed during a physician visit for unrelated symptoms
rather than during preventive visits). There are exceptions
to this methodology, however. CTF recommends that
pregnant women, the very young, and the very old
schedule visits specifically for preventive purposes.
For the elderly, USPSTF recommends a yearly physician visit that includes screening, counseling, and immunization components. Screening, in turn, involves a
history, physical examination, and laboratory procedures. Counseling is geared toward diet, exercise,
substance use, injury prevention, and dental health.
Immunizations for tetanus-diphtheria (every 10 years),
influenza (annually), and pneumonia are suggested. In
addition, glaucoma testing by an eye specialist is recommended.
2
The main result of the CTF's 1979 publication is a set
of age- and sex-specific health packages designed to
ensure the delivery of proven preventive measures at
effective intervals. For the elderly, two health packages
were derived; one for men and women aged 65 to 74, and
one for men and women aged 75 and over. Both contain
the same basic set of tests, immunizations, and health
assessments with the main difference being the frequency
of physician visits recommended for the old and very old.
Since its first report in 1979, CTF has published updates
Other government-sponsored recommendations for
physician visits come from the National Cancer Institute
(NCI) whose published guidelines, "Working Guidelines
for Early Cancer Detection," promote physician visits by
encouraging physicians to use available cancer detection
maneuvers. The implication of the guidelines is that the
recommended tests would be done by a physician, or in
conjunction with a physician visit. Since NCI suggests
annual fecal occult blood tests starting at age 50 (both
'The Task Force is a non-Federal, muludisciplinary, national panel appointed by the government to make recommendations to the Public Health
Service.
Thc physical exam would include: height, weight, blood pressure, visual acuity, hearing, and clinical breast exam (annually for women until age
75, unless pathology detected); laboratory procedures recommended are: nonfasting total blood cholesterol, dipstick urinalysis, mammogram (every 1
to 2 years for women until age 75, unless pathology detected), and thyroid function tests (for women). The Task Force also makes specific screening
recommendations for elderly persons who arc at high risk for particular conditions; these include: fasting plasma glucose, tuberculin skin lesl.
electrocardiogram. Pap smear, fecal occult blood/sigmoidoscopy, and fecal occult blood/colonoscopy.
2
-28-
�Appendix D—Summary of Recommendations For Periodic Health Examinations in the Elderly •29
Table D-l—Recommendations for Physician Visits for the Elderly
Implications for
physician visits
Comments
Canadian Task Force, 1979, Extensive recommendations on ap- Biannual physician visit from
CTF also recommends certain tests
propriate components of physical age 65 to 74; annual physician be done annually between age 65
1984, 1986. 1988'
and 74: mammography (forwomen),
examination, immunizations, coun- visit from age 75 on
stool occult blood test, and examiseling, and laboratory investiganation of oral cavity and counseltions
ing on oral hygiene; these could be
done by other health professionals
Scope of
recommendations/study
Group
U.S. Preventive Services Task Extensive recommendations on ap- Annual physician visit recompropriate components ol physical mended from age 65 on
Force, 1989"
examination, immunizations, counseling, and laboratory investigations
For most tests screening frequency
is left to physician's discretion,
nonfasting cholesterol, urinalysis,
vision and glaucoma screening,
and thyroid function test
National Cancer Institute,
1987=
Guidelines aimed at encouraging
Annual physician visit implied
physicians to screen for cancer
for women starting at age 50
(melanoma and breast cervical,
and men starting at age 40
prostate, colorectal, testicular, and
oral cancer)
NCI emphasizes that these screening maneuvers are part of a physician visit
Project INSURE, 1988
Study participants age 65 or over Biannual physician visit from
received physician examination and age 65 to 74; annual physician
history, laboratory tests, immuni- visit from age 75 on
zations, and patient education according to Project INSURE S model
(based on age, sex, and risk factors)
Mammography and stool occult
blood test given annually; Pap
smears given for three consecutive negative results
American Cancer Society,
1988
Recommendations for screening Annual health counseling and
for colorectal, cervical, endomet- cancer checkup beginning at
rial, breast thyroid, testicular, ovar- age 40
ian, lymph node, oral region, and
skin cancer
In addition, ACS advises that certain tests be done at specific intervals: sigmoidoscopy—every 3 to 5
years after two satisfactory results; stool occult blood testannually; digital rectal examination-annually; Pap test—annually for 3
negative results then at physician's discretion; breast physical
examination—annually; and mammogram—annually
d
s
Health Policy Agenda for
Describes a minimum set of health
the American People, 1988' insurance benefits for Americans
Annual physical examinations
beginning at age 50
Specific recommendations for the
components of the physical examination are not made, but Project
INSURE and the Canadian Task
Force on the Periodic Health Examination are cited as sources for
determining the components
•Canadian Periodic Health Examination Task Force, "The Periodic Health Examination," Can. Med. Assoc. J. 121(9):1193-1254, 1979; 130(10):1276-1292,
1984; 134(7):724-727, 1988; 138(7):618-626, 1988.
bU.S. Preventive Services Task Force, Guide to Clinical Preventive Services (Baltimore, MD: Williams & Wilkins, 1989).
cEarly Detection Branch, Division of Cancer Prevention and Control, National Cancer Institute. National Institutes of Health, U.S. Department of Health and
Human Services, "Working Guidelines for Early Cancer Detection: Rationale and Supporting Evidence to Decrease Mortality" (Bethesda, MD: December
1987).
dLifecycle Preventive Health Services Project, "Final Report of the INSURE Project" (New York, NY: September 1988).
•American Cancer Society, Summary ot Current Guidelines for the Cancer-Related Checkup: Recommendations (New York, NY: ACS Professional Education
Publication. 1988).
'Ad Hoc Committee on Basic Benefits, Health Policy Agenda, "Basic Benefits Package" (Chicago, IL, June 1988).
SOURCE: Office of Technology Assessment, 1990.
�Table D-2—Published Recommendations for the Use of Selected Preventive Services by Older Adults*
Preventive
service
CDC
ACP
1
USPSTF
CTF*
NH"
Protessional
societies'
1
Tetanus
immunization
Booster every 10
Booster every tOyears
years i) primary
series has been done
Booster every 10 years
Influenza
immunization
Over age 65—every Ower age 65—every
year
year
Consumer
organizations'
1
r
re
Over age 65—every year Age 65 and over—
every year
Booster every lOyears
ACS. over age 50—
every 3 to 5 years after
2 negative tests
At physician's
discretion for those at
high risk
NCI: over age 50—
every 3-5 years
Sigmoidoscopy
s
!
Clinical breast
examination
Over age 40—every
year
NCI: Age 40-50—every Every year from age 50 to Over age 40—every
1 to 2 years with
59
year
mammography; age 50
and over—annually
Cholesterol
screening
Recommended al
5-year intervals for
asymptomatic, lowrisk men; optional for
women and elderty
persons
NHLBI over age 20—
every 5 years
Pap smear
:NCI: over age 10 or i» '-Evary 5 years torn age : Every 1 toa jwarsfor ^ACOG. AMA. ANA. AAFP. - ACS: supports NCI
i
r- sexually active—3:-' " i 35 to age 60: screenrtg women who have not 'AND AMWA support NCI guidelines ,
consecutive annual Pap? t i w M contnue i prior • 'hadprevious? ^ - .^guidelines
"
•iSS- smears and pehncexams smears have teen ••: • consistently negative
wilhnegattveresute then abnormal "
'tm"us
> »« * "
less frequently at
'
^
^
. discretign of physician
< ^
;
.. VT- ,
^.
Recommended only for
ADA: people at risk
Not recommended
Not recommended for
the markedly obese,
should be screened (no
without family history of
asymplomalic
persons with family
frequency specified) AHA
healthy adults
diabetes or previous
history of diabetes, or
every 5 years from age
circulatory problems
womenwhh history of
20 to 75; optional after
gestational diabetes
age 75 if baselines are
well-documented
ACR.ACOG, AMA: Age40 ACS: Age 40-50—every
50—every 1 to 2 years with 1 to 2 years with
mammography; age 50 and mammography; age 50
over—annually
and over—annually
AHA: supports NHLBI
recommendations
Recommended at
physician's discretion
I
2
1
w
v
f
Serum glucose
8
�Table D-2—Published Recommendations for the Use of Selected Preventive Services by Older Adults—Continued
Consumer
organizations'
Preventive
service
asymptomatic
persons
Recommenoea tor
symptomatic adults only
Recommended for
symptomatic adults
only and other other
specific
circumstances
1
AHA: at ages 20,40,
and 60
t
Vision examination »'•
including
screening
tonometry
ABBREVIATIONS: AAFP = American Academy of Family Physicians: AAO = American Academy of Ophthalmology: ACOG = American College of Obstetricians and Gynecologists: ACP = American
College of Physicians; ACR = American College of Radiologists. ACS = American Cancer Society: ADA = American Diabetes Association; AHA = American Heart Association;
AMA ° American Medical Association; AMWA = American Medical Women's Association; ANA American Nurses Association; AOA = American Optometric Association; CDC
= Centers for Disease Control; CTF ~ Canadian Task Force; EKG = electrocardiogram; NCI = Nalionai Cancer Institute; NIH = National Institutes of Health; NSPB = National
Society to Prevent Blindness: and USPSTF = United Stales Preventive Services Task Force.
•This table does not include screening recommendations for all adults; in some cases where recommendations for younger age groups differ from those for the elderly, only the recommendations
for the elderly are included.
Centers for Disease Control. Public Health Service. U.S. Department of Health and Human Services. Adult Immunizations: Recommendations o l the Immunization Practices Committee, undated.
'American College of Physicians—immunizations: American College of Physicians, Committee on Immunizations, Guide for Adult Immunization (Philadelphia, PA: 1985); clinical breast examination
and mammography: D M. Eddy, "Screening for Breast Cancer," Ann. Intern. Med. 111(5):389-399,1989; cholesterol: A.M. Garber, H.C. Sox, and B. Littenberg, "Screening Asymptomatic Adults
for Cardiac Risk Factors: The Serum Cholesterol Level." Ann. Intern. Med. 110(8) 622 639.1989; serum glucose: D E Singer, J.H. Samel. C M Coley et al., "Screening for Diabetes Mellitus, Ann.
Intern. Med 109:639-649,1988; EKG: H C Sox, A M Garber, and B. Littenberg. "The Resting Electrocardiogram as a Screening Test: A Clinical Analysis." Ann Intern. Med 111 (6) 489-502,1989
dancer: Early Detection Branch, Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services. "Wbrking
Guidelines for Early Cancer Detection: Rationale and Supporting Evidence to Decrease Mortality" (Bethesda, MD: December 1987), and "National Organizations Agree on Joint Mammography
Guidelines," press release from the National Medical Roundtable on Mammography Screening Guidelines, June 27,1989; cholesterol: National Cholesterol Education Program, National Heart,
Lung, and Blood Institute, National Institutes of Health, U.S. Department of Health and Human Services, "Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults," (Bethesda. MD: October 1987); blood pressure: Joint National Committee, "The 1988 Report of the Joint National Committee on Detection. Evaluation, and Treatment of
High Blood Pressure," Arch. Intern Med. 148(5)1023-1038, 1988.
•Canadian Periodic Health Examination Task Force, "The Periodic Health Examination," Can. Med. Assoc. J. 121(9):1193-12S4. 1979; 130(10):1276 1292. 1984; 134:721-729, 1986; and
141:209-216, 1989
'U.S. Preventive Services Task Force, Guide to Clinical Preventive Services (Baltimore, MD: Williams A Wilkins, 1989).
OCIinicai breast examination and mammography: AAFP, ACR, AMA, AMWA, "National Organizations Agree on Joint Mammography Guidelines," press release from the National Medical Roundtable
on Mammography Screening Guidelines, June 27, 1989; American College of Obstetricians and Gynecologists, personal communication with Lynne Lawrence. Government Relations
Representative. Washington, DC, Oct. 31,1988; Pap smear (ACOG. ACS, NCI, AMA, ANA. AAFP. and AMWA). D.J. Fink. "Change in American Cancer Society Guidelines for Detection of Cervical
Cancer," CA-A Journal tor Clinicians 38(2) 127 128, 1988; vision examination: American Optometric Association, "Optometry and the Nation's Health: Recommendations for the Implementation
of Congress' National Health Priorities," a working paper prepared by the National Health Division, February 1978; American Academy of Ophthalmology. Policy Statement. "Frequency of Ocular
Examinations." approved Feb. 6, 1983.
American Cancer Society, "Summary of Current Guidelines for the Cancer-Related Checkup: Recommendations" (New York: ACS Protessional Education Publication, 1988); D.J. Fink, "Change
in American Cancer Society Guidelines for Detection of Cervical Cancer," CA-A Journal tor C/iniC(ans38(2):127-128,1988; and "National Organizations Agree on Joint Mammography Guidelines,"
press release fromthe National Medical Roundtable on Mammography Screening Guidelines, June 27,1989, American Diabetes Association, " A D A . Policy on Screening for Hyperglycemia." June
1983; American Heart Association (cholesterol screening), "Public Screening Strategies for Measuring Blood Cholesterol in Adults—Issues for Special Concern," October 1987 (serum glucose,
blood pressure. EKG, and physical examination), SM. Grundy, P. Greenland, A. Herd et a l , "Cardiovascular and Risk Factor Evaluation of Healthy American Adults," C/rcu/af/on75(6):1340A 1362A,
1987; and American Society for the Prevention of Blindness, "Facts on Blindness and Prevention," February 1988.
SOURCE: Office of Technology Assessment. 1990.
8
1
3
-I
I
!
3-
h
it
�32 • Preventive Health Services for Medicare Beneficiaries: Policy Issues and Recommendations
sexes), annual mammography at age 50 (women), and
annual digital rectal examination of the prostate starting
at age 40 (men), an annual physician visit is implied for
all adults over age 65.
In recent years, several professional groups from the
private sector have taken an interest in investigating the
effectiveness of preventive services. The INSURE project
was an 8-year study of prevention in primary medical
care, sponsored by the industry wide Network for Social,
Urban, and Rural Efforts. Project INSURE provided
physicians with a model for providing early detection and
treatment of disease and the provision of health education
that is based on each patient's age, sex, and risk factors
(the model specifies the appropriate physical examinations, lab tests, immunizations, and x-ray studies to be
provided) and emphasized patient education as a means of
reducing the risk of coronary heart disease, cancer, stroke,
and automobile injuries. The INSURE project included
health packages for the study participants according to
age. The package for adults age 65 to 74 consists of five
physician visits (every 2 years) in addition to an annual
stool occult blood test and mammography (for women).
The four basic components of each visit were the
following:
• history and physical examination (monitoring of
weight, blood pressure measurement, breast and
rectal exam, and assessment of hearing problems);
• lab tests (plasma total cholesterol and glucose, and
a Pap smear every 3 years for 3 annual negatives
(for women));
• immunizations (tetanus and influenza shots); and
• patient education (counseling about risk factors of
cancer, heart disease, accidents, and aging).
For the elderly age 75 and over the components of the
physical exam are the same but the recommended
frequency is every year.
In June 1988, the Health Policy Agenda for the
American People (HPA), a public and private sector
initiative aimed at identifying and addressing health care
issues, and administratively supported by. the American
Medical Association, published its basic benefits package. It promotes periodic medical examinations based on
age, sex, and risk factors. HPA recommends annual
examinations for adults from age 50 onward. The content
of the examinations is based on both the INSURE project
model and Canadian Task Force on the Periodic Health
Examination 1984 Update.
Finally, the American Cancer Society's (ACS) recommendations for appropriate cancer screening suggests an
annual physician visit for men and women 40 and over for
cancer detection. In addition, ACS' disease-specific
cancer screening recommendations would also imply an
annual physician visit for the elderly.
Specific Preventive Services
Table D-2 summarizes the published recommendations for the use of selected preventive services by older
adults. It includes selected sets of recommendations made
by professional or expert groups for older adults, primarily for those over 65 years old. The summary is not
exhaustive; rather it includes a range of views on the use
of preventive services. As table D-2 indicates, there is
nearly complete agreement among the included groups
making recommendations for immunizations for the
elderly. For screening services there is a high degree of
consistency among groups, but some disagreement does
exist.
A more detailed comparison of recommendations for
colorectal cancer screening highlights the disparities that
can arise among recommending groups (see table D-3).
While the National Cancer Institute, American Cancer
Society, and the American Society of Gastroenterology
support periodic screening for colorectal cancer, the
USPSTF and Canadian Task Force are much less
supportive of this approach.
�Appendix D—Summary of Recommendations For Periodic Health Examinations in the Eld
Table 0-3—Recommendations lor Screening for Colorectal Cancer in the Elderly
Screening recommendation by procedure
Fecal occult
blood testing
Sigmoidoscopy
Country/organization
(date of organization)
United States:
N O (1987)
Digital rectal
examination
Considered part of routine physical examination
Annually
Every 3 to 5 years
ACS" (1988)
Annually
Annually
Every 3 to 5 years after two negative sigmoidoscopies 1 year apart
ASQE4 AGAC(1988)....
Frequency unspecified
SPSTF" (1989)
Digital rectal examination is not an effective screening maneuver, Task Force found insufficient evidence
to recommend for or against screening with fecal occult blood test or sigmoidoscopy in asymptomatic
persons, but notes it may be advisable to offer screening to persons 50 and older with risk factors; Task
Force does not specify a screening frequency
Canada:
CTF* (1988)
Qarmany:
Government* (1977)
Flexible sigmoidoscopy starting at
50, frequency unspecified
Not recommended unless specifiedriskfactors are present
Not recommended unless specified risk factors are present
Screening is suggested in those
over 45, frequency not specified
ABBREVIATIONS: ACS - American Cancer Society, AGA - American Gastroenterological Association, ASGE = American Society for Gastroinlestinal
Endoscopy, CTF • Canadian Task Force. NCI • National Cancer Institute, USPSTF - United States Preventiv
SOURCES:
•National Cancer Institute, Division of Cancer Prevention and Control. Early Detection Branch, "Working Guidelines for Early Cancer Detection: Rationale and
Supporting Evidence to Decrease Mortality," Bethesda. MD, December 1987.
Amertcan Cancer Society, "Summary of Current Guidelines for the Cancer-Related Checkup: Recommendations" (New York: ACS Professional Education
Publication), 1968.
Fleischer. D.. Goldberg, S., Browning, T, et al., "Detection and Surveillance of Colorectal Cancer," J.AM.A 261(4):580-58S. 1989.
<\i.S. Preventive Services Task Force, Guide to Clinical Preventive Services (Baltimore, MD: Williams & Wilkins, 1989).
•Canadian Task Force on the Periodic Health Examination, "Eariy Detection of Colorectal Cancer," accepted for publication in Can. Med. Assoc J.
141:209-216, 1989.
•F.W. Schwartz, H. Holstein, and J.G. Brecht, "Preliminary Report of Fecal Occult Blood Testing in Germany," Colorectal Cancer: Prevention, Epidemiology, and
Screening S. Winawer, D. Schottenfeld, and P. Shertock (eds.) (New York. NY: Raven Press, 1980).
b
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Status Assessment: An Approach to Tertiary Prevention," unpublished draft dated Feb. 8, 1988.
Joint National Committee, "The 1988 Report of the
Joint National Committee on Detection, Evaluation,
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Intern. Med. 148(5): 1023-1038, 1988.
Kane, R.L., "Health Promotion-Disease Prevention," hearing before the Subcommittee on Health,
Committee on Finance, Senate, U.S. Congress. June
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Printing Office, 1987).
Kane.R.L., Kane.R.A., and Arnold, S.B., "Prevention in the Elderly: Risk Factors," Health Services
Research 19(6,II):946-1006, 1985.
Kaplan, G.A., and Haan, M.N., "Is There a Role for
Prevention Among the Elderly," Aging and Health
Care: Social Science and Policy Perspectives, M.
Ory and K. Bond (eds.) (London, England: Tavistock Publishers, 1989).
Katz, P.R., Dube, D.H., and Calkins, E., "Use of a
Structured Functional Assessment Format in a
Geriatric Consultative Service," J. Am. Geriatr.
Soc. 33(10):681-686, 1985.
Kidder, D., Abt Associates, Cambridge, MA, personal communication, Feb. 17, 1989.
Kottke, T.E., Battista, R.N., DeFriese, G.H., et al.,
"Attributes of Successful Smoking Cessation Interventions in Medical Practice: A Meta-Analysis of
39 Controlled Trials," JA.MA. 259:2882-2889,
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Kottke, T.E., Brekke, M.L., Solberg, L.I., et al., "A
Randomized Trial to Increase Smoking Intervention
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1," JAMA. 261(14):2101-2106, 1989.
Kuller, L., University of Pittsburgh, Pittsburgh, PA,
personal communication, Feb. 21, 1989.
Last, J.M., "Scope and Methods of Prevention,"
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Mandelblatt, J.S., and Fahs, M.C., "The Cost
Effectiveness of Cervical Cancer Screening for
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1988.
Norbum, J., University of North Carolina, Chapel
Hill, NC, personal communication, Feb. 22, 1989.
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1989.
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Congress, Office of Technology Assessment, October 1988).
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et al., "Effectiveness of a Geriatric Evaluation
Unit," N. Engl. J. Med. 311(26): 1664-1670, 1984.
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76. Schweitzer, S., University of California, Los Angeles, CA, personal communication, Feb. 23, 1989.
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78. Skinner, A., Johns Hopkins University, BaItimore
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80. Sommers, A.R., Kleinman, L., and Clark, W.D.,
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81. Sox, H.C., Garber, A.M., and Littenberg, B., "The
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�For further information on this paper or others in OTA's series on
Preventive Health Services Under Medicare, contact:
Judith Wagner, Health Program, Office of Technology Assessment,
U.S. Congress, Washington, DC 20510-8025
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Health Care Task Force Records
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White House Health Care Task Force
Is Part Of
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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[Preventive Health Services for Medicare Beneficiaries: Policy and Research Issues] [loose]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
Is Part Of
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Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-003-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/d3dac84d9585d646e7b2cc57b702dd35.pdf
4fedd0654dd90a2c0e399943e5b5eb99
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1982
OA/ED Number:
FolderlD:
Folder Title:
[Political Power Structures Affecting Any National Health Care Reform Plan: Health care reform
concepts versus Social and Economic Values] [binder] [3]
Stack:
Row:
Section:
Shelf:
Position:
S
56
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universal
segment
Universal employer-provided,
with
implication,
6 8 2
Plan.
community-rated
$1,000)
should
be
To
�required
to d i s c o u r a g e
pervaded
the nation
facilities.
High
the c r e d i t - c a r d
and r e s u l t e d
would
preventive
be r e s e r v e d f o r m a j o r
coverage
i n overuse
d e d u c t i b l e s would
more r e s p o n s i b l e a b o u t
t r i g g e r e d when
mentality
which has
of medical
care
i n c e n t p a t i e n t s t o become
behavior.
illnesses,
out-of-pocket
Insurance
coverage
with c a t a s t r o p h i c
expenses
exceed
a
G33
pre-determined
percentage
of a d j u s t e d g r o s s
income.
GS4
pre-existing
2.
with
Individual
pretax
annually.
health
the
Med-Save
dollars,
with
T h i s would
individuals,
dollars
c o n d i t i o n s would
care
services.
Long-range
accomplished
.vhich
a form
direct
strong
should
of s e l f
coverage.
be
established
private
by s t a t u t o r i l y
insurance for
c o n t r o l of t h e i r
incentives
insurance
funding
health care
f o r prudent
The Med-Save a c c o u n t s
of a d d i t i o n a l
685
expenses.
3.
to
c o n t r i b u t i o n s o f $ 3 0 0 t o $5DC
purchase
medical
accounts
provide
g i v i n g them
and p r o m o t i n g
be i r r e l e v a n t
could
or f o r p a y i n g
of Medicare
requiring
buying
be u s e d f o r
uninsured
could
the purchase
of
be
o f an IRA
would p a r t i a l l y f u n d Medicare For t h e f u t u r e .
An IRA t h a t c o s t $ 1 2 5 a n d e a r n e d ... a n n u a \
i n t e r e s t w o u l d a c c u m u 1 a t e . . . by M e d i c a r e a g e .
T h i s money c o u l d t h e n be u s e d t o o b t a i n
p r i v a t e h e a l t h care insurance t o supplement-•r replace--gavernment (Medicare) f u n d s .
6 8 5
This
every
one-time
child
subsidized
•ver
i n the f i r s t
would
year
be a r e q u i r e d
oF l i f e ,
by t h e F e d e r a l g o v e r n m e n t
and i s e x p e c t e d
For t h o s e
budget
to continue
recommends b a s i n g M e d i c a r e
p u r c h a s e For
partially
the past t e n years, Medicare's
Cy $ 5 0 b i l l i o n
Bronow
cayment
premiums
or completely
at poverty
has d i m i n i s h e d
on t h a t
on
level
trend.
recipient's
Dr.
�incomes
rather
than
diminishing
t h e program
Further or r a i s i n g
taxes.686a
4.
oF
Long-term
Medicaid
number
care
separated
eligibility
oF M e d i c a i d
From M e d i c a i d
i s essential.
recipients
During
and
expansion
t h e 198Ds, t h e
i n c r e a s e d by 9 p e r c e n t a n d
687
expenditures
Medicaid
Funding
percent
this
increaeed
has i n c r e a s e d
oF b u d g e t
Fact,
123 p e r c e n t .
over
t o 14 p e r c e n t
Bronow
States'
that
same
oF b u d g e t
explains, "state
shareooF
p e r i o d From
i n 1990.
governments
and
9
Because
oF
hospitals
R Pi P
have
become a d v e r s a r i e s . "
initiated
a suit
Servicees
alleging
Forced
against the C a l i F o r n i a Department
that
and
has r e s t r i c t e d
and
d i a g n o s t i c medical
Bronow
Medicaid
Medicaid
everyone
employment,
eligibi
5.
and
rehabilitative
treatment,
care.
care
poverty
the primary
reason
that
i t dedicates
almost
h a 1F oF
The PWC
i s that
long-term
and Family
690
departments,
would
plan
and a l s o change
level
structure
would
would
i t s
seoarate
eligibility
be i n c l u d e d .
so
Age,
be i r r e l e v a n t t o
lity.
ScientiFic
physicians
Follow
explained that
below
Health
examinations.
to long-term
From
care,
oF
From M e d i c a r e s e r v i c e s h a s
c e n t e r s and emergency
neonatal
is in crisis
payments
that
underpayment
c l o s u r e oF t r a u m a
Dr.
H o s p i t a l s i n C a l i F o r n i a have
medical
and n o t i n s u r a n c e
i n providing
care
care
guidelines,
companies,
For every
e s t a b l i s h e d by
For t h e procedures
possible medical
to
condition
t r e a tment.
Accomplishing
t h e above
objectives
would
be p r e F e r a b l e t o
�installing
has
a C a n a d i a n - t y p e system because
removed
the medical
decision-making
purview
of the physician
and
resides
i n the government
the Canadian
process from
the patient.
and,
as
That
a result,
system
the
decision-making
"(p]atients'
needs
69 1
take
a backseat t o budget c o n s t r a i n t s . "
American
system
because
patients'
in
the system,
described
as
having
It
Medical
into
t h e autonomy
For
Association
between
oF
high
physicians
president
low.
not perFect,
with
restrictions
states
PWC
who
it.
on
another
away.
and
In
the
strange
lack
oF
practice physicians
i n the
in
United
a r e i n c r e a s i n g l y F r u s t r a t e d by
oF i n d i v i d u a l
693
t o note
p a t i e n t s by
government
t h e c o u n t e r p o s i t i o n oF
states: "...although
i t s users,
m e m b e r s oF
On
has
and
companies."
citizen
satisFied
restricts
technology
states "...the
private
Canadian
deFiciencies
physicians
692
all-time
comment, Bronow
is illuminating
Canadian
Bronow
physicians
t h e p u r c h a s e oF
r e a c h e d an
to this
American
insurance
go
Ontario
micromanagement
those
blames
restrains
to the
c o n t r o l s on p r o v i d e r s ,
i s i n stark contrast to the s i t u a t i o n
States.
is
and
The
counterpoint
Canada
to care,
Fee
the strained r e l a t i o n s
government
intrusion
a r e g e n e r a l l y apposed
i t imposes
access
equipment.
the
physicians
The
t h e Canadian
primary
the medical
the level
oF
"The
issue
the Canadian
public,
opponents
oF
are
system
very
the system
establishment
who
Fees
can
oF
oppose
694
are
charge.
they
c o n c e r n t o t h e community
that
a
any
physicians,
Dr.
of Doctor Greed i s n o t g o i n g t o
- 1 55a d v o c a t e s d e v o t i n g one day p e r m o n t h F o r h e a l t h
�care
For t h e poor.
Forms,
just
He a d v i s e d
provide
care.
physicians
"Government
not t o F i l l out
and i n s u r e r s
have
S95
nothing
t o do w i t h
•r.
Greed
Bronow's c o n c e r n
i s appropriate.
health
reForm
sabotaging
Future
cost
the-board
already
costs,
eFForts
services,
imposing
their
established
by e i t h e r t h e AMA
used
receive
to<lfcermine
From
and c o m m e r c i a l h e a l t h
637
more common
a doctor
perFormed
supposed
abuses,
bills
separately
annual
claim
Fee
5 9 6
Forbidden
procedure."
replacement
For example,
averages
the rules.
code,
the provider
Cross,
Blue
" I n o n e oF t h e
by F e d e r a l
rules,
that are
and t h a t a r e
comprehensive
t h e charge
as
limits;
F o r t w o o r more s e r v i c e s
as a s i n g l e
system
Government.
on t h e same p a t i e n t a t t h e same t i m e
t o be r e p o r t e d
69S
I t is
Forms and a r e t h e
Blue
insurers.
across-
billing
oF p a y m e n t
Medicaid,
clearly
oF
payment
or t h e Federal
t h e amount
Medicare,
and h o s p i t a l s
t o circumvent
on i n s u r a n c e
concerning
Fee l i m i t s .
has a n u m e r i c a l
own
oF w h a t
activities
t h e Medicare
as F o l l o w s ,
service
codes a r e entered
criteria
view
their
the extent
to the imposition
governmenta11y-set
eFForts,
providers are
physicians
annual
Doctor
i s considering
and p o s s i b l y
Given
are i l l e g a l
that providers
Each m e d i c a l
Shield
oF r i s i n g
themselves
our time."
t h e r e p u t a t i o n oF
the nation
governmental 1y-set
apparent
will
While
report
For Medicare
be e x p o s i n g
hence,
about
containment
auditors
payments
could
because
t o donate
c o n t r o l oF Fee s e t t i n g .
Federal
The
our decision
For a t o t a l
$5,889.
But i F t h e p h y s i c i a n
- 196-
knee
�'unbundles'
bills
t h e medical
services
provided,
he
Cillegally)
For:
..replacing
upper
p a r t oF k n e e
joint
$3,012
..replacing
lower
part
joint
2,844
..relining
oF k n e e
kneecap
2,677
5
$8,533
It
added
care
i s estimated
that
5 to 6 billion
costs.
Medicare
Twenty
claims
such
dollars
percent
For s u r g e r y
illegitimate
a year
9
p r a c t i c e s have
to the nation's
oF t h e 8,000 d o c t o r s
unbundled
9
health
who
Filed
the services
700
provided.
oF
O r . James S.
t h e AMA
deFended
"The
purely
and s i m p l y
Medicare
charges
Follows
Fee s c h e d u l e
s p e c i a l i s t s who
702
president
codes:
codes i s
t o g e t adequate
physicians
do...it
is a
that
and t h e A m e r i c a n
has been
oF
vice
when r e i m b u r s e m e n t g o e s
701
manipulation will
increase."
Todd's comment
Government
gaming
oF p r o c e d u r e
a method
For what
oF e c o n o m i c s
down, s u c h
Dr.
the i l l e g a l
manipulation
reimbursement
law
Todd, e x e c u t i v e
"...a b i t t e r
Medical
battle
between t h e
Association
over
F o r d o c t o r s . . .The u n b u n d l i n g
observed
tended
most
oFten
i n claims
t o be t h e h a r s h e s t
oF
Filed
critics
t h e new
by
oF t h e Fee
schedule."
A physicians'
accidentally
consultant
Fraudulent
said
because
that
they
-197-
many d o c t o r s a r e
do n o t know
how
to bill
�For
their
a number
services.
Another
consultant said
oF c o n s u l t a n t s r u n n i n g
physicians
around
how t o game t h e s y s t e m ,
that
"There are
the country
how t o j a c k up
teaching
their
703
reimbursement
through
A diFFiculty
here.
ments
From
their
i n interpretation
providers.
a detailed
Replacement"
thres-step
amounts
invest
costs,
centers.
reFerral
testing,
practice
more
expensive-
c a r e , and
the recent
are necessarily
on t h e i r
this
goal
investments.
i s t o reFer
and t r e a t m e n t s
i s called
7C 4
a
"physician
their
t o these
very
selF
arrangement."
relates
Medicare
have
entities
ventures
t o accomplish
McDowell
bill
i n these
For care,
This
Knee
and t e c h n o l o g i c a l e q u i p m e n t .
i n increasing the return
patients
to question
oF p h y s i c i a n i n v e s t m e n t s i n
interested
own
"Total
a r e d e r i v e d From
who
e a s i e s t method
lists
open
be p r o v i d e d .
Physicians
The
leave
oF u n n e c e s s a r y
unnecessary
Facilities
be a t w o r k
t h e more d e t a i 1 e d - - a n d
Fast-increasing practice
care
may
merely
explanation should
corresponding
may a l s o
t o o b t a i n "det.3ilfe.ol " s t a t e -
This
statement
or whether
Considerable
health
practices."
Consumers a r e e n c o u r a g e d
whether
and
abusive
t o which
nationally,
that
ownership
they
at least
"twelve
or investment
make p a t i e n t
25 p e r c e n t
laboratories,
27 p e r c e n t
laboratories,
and S p e r c e n t
percent
oF p h y s i c i a n s who
interests in
r e F e r r a 1s. . . ( w h i 1 e )
oF i n d e p e n d e n t
oF i n d e p e n d e n t
oF d u r a b l e
suppliers
clinical
physiological
medical
equipment
a r e owned i n w h o l e o r i n p a r t by r e F e r r i n g
705
physicians."
C l i n i c a l l a b o r a t o r i e s and d i a g n o s t i c
_ I a Q _
�imaging
other
centers
appear
investments
laboritories,
homes,
being
the
Favored
d i r e c t e d toward
home h e a l t h a g e n c i e s ,
ambulatory
investments
t o be
may
surgical
take
the
centers
Form
70
corporations,
oF
investment,
psychological
hospitals,
and
HMOs.
joint
which
enable
the
nursing
7 0 5
The
ventures,
7
p a r t n e r s h i p s ' ' '- - es p e c i a 1 1 y
partnerships
with
physicians
limited
to acquire
an
7 08
equity
and
interest
simple
It
the
and
competitive
that
beneFits
g u i d e l i n e s which
behavior
procedures.
eFFective
belieF
r e g u l a t i o n s should
structural
reFerral
liability
709
agreements.
contractual
i s McDowell's
balance
abuse,
w i t h minimal
1
eFFective
w i t h the
provide
F o c u s on
remedy
potential
must
For
"...extensive
the
physician's
method
limit
restrictions
on
investment
Disclosure
0
and
an
requirements
may
be
an
overuti1ization
oF
For
monitoring
an
7 11
investment
Facility
because
"...selF reFerral
a r r a n g e m e n t s . . .have t h e
potential
to produce
oF
undermine
the
medical
services
proFessional
documented
that
judgment
evidence
oF
drivers
i s the
physician
oF
extensive
unnecessary
selF-reFerraJ
and
may
Without
In other
o F the
deFensive
- 193-
well
believes
unnecessarily
deFensive
care.
symptom
7 1 2
abuse, McDowell
s e . l F - r s F e r r a l and
conspicuous
"independent
practitioners."
legislative prohibition
71
competition.
Physician
care
oF
rigid
healthy
two
and
overuti1ization
medicine
words,
stiFle
are
unnecessary
ma J a d i e s k n o w n
care.
the
as
�S . 1 2 2 7 i s an
symptom
instead
acutely
of t h e cause
actual
causes,
however,
merely
t h e symptom
constituents,
sounds
political bill
who
are
reasonable.
of t h e malady.
would
aFFects
not
which
provoke
addresses
Addressing
t h e AMA,
A summary
t o oppose
oF
that
apathetic
legislation
section
the
while addressing
only disorganized, mostly
likely
the
oF
which
the b i l l
states
U n n e c e s s a r y c a r e w i l l be r e d u c e d by [ 1 ] a
p r o g r a m oF o u t c o m e s r e s e a r c h t o d e t e r m i n e w h i c h
care i s necessary or unnecessary,
(2) developm e n t oF p r a c t i c e g u i d e l i n e s t o a s s i s t p h y s i c i a n s
i n p r o v i d i n g o n l y n e c e s s a r y c a r e and a s s i s t
i n s u r e r s i n d e c i d i n g w h a t c a r e s h o u l d be
r e i m b u r s e d , and [ 3 ) an e n h a n c e d p r o g r a m
oF
t e c h n o l o g y assessment t o help determine the
u s e F u l n e s s oF e x p e n s i v e m e d i c a l t e c h n i q u e s .
In
a d d i t i o n , the program w i l l help develop p r i v a t e
a n d p u b l i c managed c a r e p r o g r a m s , w h i c h
will
e n c o u r a g e p a t i e n t s t o u s e p r o v i d e r s who
practice
e F F i c i e n t , h i g h q u a l i t y medicine.' '''^
7
It
should
provisions
be
concerning
care—provisions
privacy
recalled
and
the
that
S.1227 h a s
u t i l i z a t i o n review
which
deeply
aFFect
conFidentiality
oF
very
stringent
to c u r t a i l
a patient's
the
unnecessary
right
to
physician/patient
7 15
relationship.
oF
rising
Physician se1F-reFerraI
costs
which
the Senators
usurping a patient's
beFore
health
right
t o seek
governmental
care
is yet
and
insurance
AMERICAN HOSPITAL
The
United
nursing
States
Hospital
and
medical
control
care w i t h o u t
interFerence.
and
and
A s s o c i a t i o n r e p r e s e n t s more
other patient
Canada,
s c h o o l s , over
organizations
should
cause
ASSOCIATION.
American
7,000 h o s p i t a l s
industry
another
SO
and
Blue
agencies,
care
institutions
than
i n the
a p p r o x i m a t e l y 300
hospital
Cross
35 0 o t h e r
and
-200-
has
p l a n s , over
more
than
19,000
�7 16
members.
From
ing
The
hospital
to
Since
the
'prestige'
the
oF
teaching
the
the
Administrators
paid
which
pay
higher
hospitals
generally
oF
dues
i t s Financial
are
dues,
p o l i c i e s estab1ished.by
institution,
complexity
most o f
7 17
a particular hospital's
hospitals
over
Large
derives
membership
size
larger
inFluence
AHA
oF
the
considered
to
quality
care
Facilities
large
administrators,
are
oF
and
assessed
accord-
expenditures.
they
the
have g r e a t e r
7 1a
AHA.
most p r e s t i g i o u s ,
emanate
From
provided,
the
and
with
size
oF
the
services
provided.
hospitals
teaching
are
support
are
considered
to
be
the
most
leaders
highly
i n the
Field,
7 19
and
drivers
oF
legislative
activity
at
state
and
Federal
levels.
Legislative activity generally
concerns:
1.
i n c r e a s i n g t h e demand For h o s p i t a l c a r e t o i n c r e a s e
t h e r e v e n u e s oF t h e h o s p i t a l ;
2.
i n s u r i n g t h a t t h e m e t h o d oF r e i m b u r s e m e n t t o h o s p i t a l s
w i l l a l l o w h o s p i t a l s t o make a s h o r t - t e r m p r o F i t , t h e r e b y
enabling
t h e m t o i n v e s t i n t h e F a c i l i t i e s and s e r v i c e s
preFerred
by b o t h t h e a d m i n i s t r a t i o n a n d m e d i c a l s t a F F ;
3.
[ s e c u r i n g ] government subsidies
(For)...manpower,
capital,
( e t c . ) thereby i n h i b i t i n g the r i s e i n h o s p i t a l
costs;
4.
decrease
l i m i t i n g s u b s t i t u t e s For h o s p i t a l
t h e demand F o r
hospitals;
aare
so
as
not
5.
r e s t r i c t i n g a d d i t i o n a i . h o s p i t a l s From e n t e r i n g
where t h e r e are e x i s t i n g h o s p i t a l s , t h e r e b y t h r e a t e n i n g
m a r k e t p o w e r o F t h e AHA's c u r r e n t m e m b e r s h i j ; . 7
Feldstein
oriented
makes
though
the
diFFerences
hospitals.
decisions
prestige
hospitals
they
the
non-proFit
i t s investment
increase
these
and
notes
enjoy
constitute
oF
the
many
a
in goals
A
based
on
Factors
organization.
Facilities
duplication
-20 1 -
and
oF
areas
the
0
between
non-proFit
to
proFit
hospital
which
Physicians
services,
Facilities
will
at
even
and
services
�provided
nearby
hospitals
services
or w i t h i n
tend
t h e same c o m m u n i t y .
t o compete
with physicians
7 2 1
For-profit
i n providing
a n d do n o t g e n e r a l l y d u p l i c a t e s e r v i c e s
which
already
722
exist
within
In
the
1 9 3 2 , t h e AHA
hospitalization
instability
Blue
demand
be
not
For h o s p i t a l
i twould
as B l u e
reinvested
be
that
imposes
were
t o a decrease i n
required that
had i t been
7 2 4
Cross
interested i n
which
Additionally,
was
as
any p r o F i t s w o u l d
be
oF t h e o r g a n i z a t i o n , a n d c o u l d n o t
Increasing t h e growth
which
Medical
set according
oF t h e
would
care.
Association,
beneFited
on a c o m m u n i t y
Blue
""
t h e AHA
Cross
Blue
rating,
t o the cost
7^~
community.
t h e same p r e m i u m
Blue
t o miniir, i z e c o s t s ,
the h o s p i t a l s beneFited.
to the entire
care
w e r e n o t c o v e r e d by
increasing enrollment,
premiums
the Financial
to hospital
non-proFit,
because Medicare
charged
coverage
remained
prepayment
during the
lead
oF t h e h o s p i t a l s .
For h o s p i t a l
by e x t e n s i o n ,
rates
The AHA
because,
t h e American
Medicare
always
care.
have
t o shareholders.
meant
demand
Unlike
and,
would
For t h e growth
organization
pro
that
Cross
to counteract
alternatives
have e n d e a v o r e d
Cross
distributed
increase
cost
agency
i n the interest
long
system
p r a c t i c e oF p h y s i c i a n s )
because
a non-proFit
proFit
insurance
~ Lower
private
Cross
e s t a b l i s h e d t h e Blue
h o s p i t a l s were e x p e r i e n c i n g
•7 p n
Depression.
(i.e.,
community.
was
interestc
Cross had
which
meant
oF p r o v i d i n g
Community
r a t e s on e v e r y b o d y ,
-202-
rating
whether
they
�are
Frequent
users
the
(those
oF
medical
under
30
years
l o w - r i s k people
rates.
With
1940s and
its
users
the
rapid
1950s, Blue
at
commercial
lower
premiums
oF
costs
the
the
oF
elderly
were
From
elderly,
have
Blue
the
people's
premium
insurers in
diFFiculty
obtain the
experience
Cross
because
and
the
were t o
had
the
to
C r o s s by
retaining
same
-rated
increase
would
paying
For
the
lose i t s
subsidy
demand
inFrequent
rating,
commercial
to
or
community
high-risk
able
would
rescued
With
experienced
IF Blue
they
Medicare
oF
who
insurers.
insureds,
reduced.
Cross
(elderly),
age).
the
growth
premiums
low-risk
oF
subsidize
l o w - r i s k people
coverage
care
the
have
the
hospital
been
hospital
services
increased.
With
the
advent
hospital
costs.
care
being
was
being
oF
Medicare
I t became n e c e s s a r y
provided,
overuti1ized.
capable
and
monitoring
quality
"collegial
atmosphere
that
lack
oF
criticize
ProFessional
AHA
i n c e n t i v e s on
each
opposed
that
Hospitals
oF
the
came r a p i d
exists
the
a major
Review
within
part
oF
the
increased
not
were
care,
but
hospital,
the
and
physicians
to
establishment
oF
imperative
(PSROs).
which
'
The
established
Q
screening.
When h o s p i t a l s u n d e r s t o o d
advocating
the
Organizations
legislative
preadmission
the
quality
was
they
q u a n t i t y oF
-7 P
PSROs a n d
that
in
that
hospitalization
other" necessitated
Standard
to ensure
insisted
and
inFlation
that
u t i l i z a t i o n as
-203-
they
could
a means oF
not
continue
increasing
�their
p r e s t i g e , they
incorporation
changed
so t h a t
t h e AHA's a r t i c l e s o f
"hospital
care"
was a m e n d e d
to "health
7 29
care
services.
hearing,
Providing
an AHA
testimony
at a
Congressional
representative stated:
"No l o n g e r c a n a h o s p i t a l ' s s e r v i c e p r o g r a m
be d e F i n e d i n t e r m s oF i n - p a t i e n t c a r e a l o n e .
The
h o s p i t a l m u s t assume i t s p r o p e r r e s p o n s i b i l i t y t o
e n s u r e a c o n t i n u u m oF p r e v e n t i v e , a c u t e , r e h a b i l i t a t i v e a n d . l o n g t e r m c a r e t o t h e p a t i e n t w h e r e v e r he
may be . ' . . . The n e e d F o r o u t - p a t i e n t c l i n i c s , d a y
c a r e p r o g r a m s , c o o r d i n a t e d home c a r e , c h r o n i c
i l l n e s s u n i t s , and l o n g term n u r s i n g care u n i t s
i s g r e a t , a n d we b e l i e v e t h e s e a r e b e s t p r o v i d e d
e i t h e r d i r e c t l y u n d e r t h e a u s p i c e s oF, o r i n
^
closer a F F i l i a t i o n w i t h , a general
hospital."
7 3 0
Medical
corporations attempt
market
by c o m b i n i n g
health
insurance
hospital
t o corner
ownership
the health
care
w i t h PPOs, HMOs, a n d
7 32
control.
I F t h e c o r p o r a t i o n owns t h e h o s p i t a l s , t h e y
get a u t o m a t i c c o o p e r a t i o n and...unFi11ed bed
s p a c e a t c o s t . ...When t h e y own ( o r Form j o i n t
ventures w i t h )
insurance companies, they
can p u t t o g e t h e r a t t r a c t i v e l y d i s c o u n t e d
rate
p a c k a g e s F o r . . . e m p 1 o y e r s a n d b u s i n e s s e s who a r e
the b i g customers For group plans.
They c a n
d i s c o u n t a v a r i e t y oF r a t e s m o r e e a s i l y b e c a u s e
t h e y have g r e a t e r n e g o t i a t i n g power w i t h t h e
p h y s i c i a n s whowork i n t h e i r
hospitals.
7
3
3
7 3 4
American
oF
America.
Medical
International,
Humana, M a x i c a r e ,
the Hospital
and N a t i o n a l
Corporation
Medical
Enterprises
735
are
They
the largest
have
Found
Voluntary
Hospital
The
joint
corporations
ventures
Corporation
oF A m e r i c a
Humana H o s p i t a l
United
joined
-204-
with
based
and t h e
Equitable.
itselF
7 3 5
in Louisville,
For-proFit hospital
I t has p l a c e d
States.
t o ownership.
with Aetna,
joined
Corporation
i s o n e oF t h e l e a d i n g
States.
i n the United
preFerable
H o s p i t a l s oF A m e r i c a
Kentucky,
the
hospital
chains i n
in a position
t o be
�of
interest
to Representative
House E n e r g y
began,
being
The
a n d Commerce C o m m i t t e e ' s
on O c t o b e r
practiced
problem
which
John D i n g e l l ,
D-Mich.,
o v e r s i g h t panel
17, 1 9 9 1 , t o e x a m i n e
the pricing
by a l l 77 oF t h e Humana-owned
Humana
are provided
i s Facing
concerns
to i t s patients.
I tern
pricing
oF
arm pads
Rubber
tips
Saline
For c r u t c h e s
'
7
P a t i e n t ' s Cost
$
103.65
.90
23.75
.71
15.95
.81
44.90
5.74
118.00
For c r u t c h e s
pad
Esophagus
7 5
A Few e x a m p l e s a r e :
solution
Heating
policy
products
$ 8.35
Rubber
which
hospitals.
Humana's C o s t
Crutches
and t h e
tube
151.98
1,205.50
Tylenol
tablets
N/A
9.00
Nursing
bras
N/A
455.00
Markups
on s u p p l i e s a v e r a g e d
733
127 p e r c e n t
oF a c t u a l
cost.
M o s t c u s t o m e r s do n o t p a y i n F l a t e d p r i c e s s i n c e
t h e i r h e a l t h i n s u r e r s - - w h e t h e r t h e y a r e c o v e r e d by
Medicare or a p r i v a t e plan--are able t o n e g o t i a t e
healthy discounts with hospitals.
To make up t h e
d i F F e r e n c e — and t o c o v e r t h e c a r e oF i n d i g e n t
p a t i e n t s a n d o t h e r s who p a y l i t t l e , i F a n y t h i n g —
h o s p i t a l s r o u t i n e l y s h i F t c o s t s t o c u s t o m e r s who
pay F u l l r a t e s .
Moreover, markups a l s o i n c l u d e
a l l o c a t e d overhead c o s t s .
I n a n y e v e n t , Humana i s
merely F o l l o w i n g standard h o s p i t a l
practice. 7
3 9
S u p p l y c o s t s s h o u l d n o t be v i e w e d i n
i s o l a t i o n because they a r e a d j u s t e d t o r e F l e c t t h e
t o t a l c o s t oF p a t i e n t c a r e a t a h o s p i t a l .
S u p p l i e s c a r r y n o t j u s t t h e i r own p u r c h a s e p r i c e
b u t t h e c o s t oF r u n n i n g t h e h o s p i t a l . . . . S u p p l i e s
make up F o r i t e m s c h a r g e d b e l o w t h e i r c o s t . ' !
7
4
0
7 4
The
Federal
established
analyze,
Expenditure
by S.1227 w o u l d
and d i s s e m i n a t e
evaluating
providers
Health
J7 4
the eFFiciency
-
have
data
Board
the authority
that
will
and q u a l i t y
Humana's e a r n i n g s
which
have
_ -v n _
.
would
be
to "collect,
a s s i s t . . .consumers i n
oF h e a l t h
grown
care
steadily
a t 18
�percent
annually
since
1987, and
they
enjoy
a 20
percent
743
average
return
Daniel
on
Fox
equity.
i s president
Former
proFessor
Health
Services
a t , and
oF M i l b a n k
director
at the State
oF,
Memorial
Fund
the Center
University
oF New
and a
For
York
Assessing
a t Stony
744
brook.
ern
Daniel
University
C.
SchaFFer
School
position
that
an
practice
patient
oF
Fox
and SchaFFer
take
Northwestthe
has p e r m i t t e d
hospitals
to
dumping.
ruling
hospitals
to
For a F e d e r a l
provide
Free
The
tax exemption
or below-cost
thereFore
hospitals
Law.
at
I.R.S. r u l i n g
qualiFy
I.R.S.
i s a law p r o F e s s o r
sanctions
even t h o u g h
c a r e to t h o s e
the reFusal
to t r e a t uninsured
analyze
allows
persons.
the r e s u l t
unable
they
t o pay.
by v o l u n t a r y
7 4 5
do n o t
7 45
The
nonproFit
SpeciFically,
and
SchaFFer
as s t e m m i n g From
the
Fox
a change i n
d e F i n i t i o n oF ' n o n p r o F i t '
hospitals.
The r u l i n g d e F i n e d t h e c h a r i t y p r o v i d e d by
n o n p r o F i t h o s p i t a l s as t h e p r o v i s i o n oF b e n e F i t s
t o t h e c o - m u n i t y as a w h o l e , s u p e r s e d i n g a 1956
r u l i n g w h i c h h e l d t h a t a h o s p i t a l was c h a r i t a b l e
o n l y i F i t was " o p e r a t e d t o t h e e x t e n t oF i t s
F i n a n c i a l a b i l i t y F o r t h o s e n o t a b l e t o pay F o r
t h e s e r v i c e s r e n d e r e d and n o t e x c 1 u s i v e 1 f o r
t h o s e who a r e a b l e arid e x p e c t e d t o p a y . "
7 4 7
They
assert
determining
and
which
According
junior
and
the d e F i n i t i o n ,
are very
concerned
do n o t a c k n o w l e d g e t h a t
indicates
t o Fox
member oF
t h e change
and SchaFFer,
i t sstaFF
contemporary
healthy
the
industry
hospital
by c h a n g i n g
health policy
tax attorneys
evidence
that,
policy
t h e IRS
Fact
t h e IRS h a d
assigned
the law, h i s t o r y
i trelated
For a change
-205-
that
i n t h e Face oF
748
in hospital
behavior.
to research
as
t h e IRS i s
to a request
i n the deFinition
a
and
From
oF
�'charitable
hospital.'
The
tion
term
junior
oF
the
employees
In
on
to
d i d not
1SS3,
question
the
legislation
the
industry provided
employee,
the
validity
H o u s e Ways and
which
would
and
oF
i t s own
senior
the
I.R.S.
deFinition.
Means C o m m i t t e e
have p r o v i d e d
deFini-
held
hearings
hospitals with
relieF
74°
From
The
the
1356
American
advocating
been
standard
Hospital
passage
considering
Congress
the
pending
ineligible
received
matters
the
a ruling
was
under
and
requests
iF p o s s i b l e
by
the
For
tax
testiFied
and
to
the
From
deny
at
the
hearing,
the
I.R.S.
bill
those
care
Medicare.
exemptions.
that
stated
similar
would
Medicaid
relieve
bill
pressure
legislation
For
eligibility
Association
oF
"Frequent
law...to
oF
since;
who
to
7 5 1
As
From members oF
oF
the
who
Congress
oF
that
the
to
under
necessity
7 5 0
were
a result,
administrative decision
Congress
1967.
asserted
those
had
IRS
resolve
existing
new
legisla-
752
tion."
and
Hence,
SchaFFer
reFlect
should
our
pay
system'
reForm
was
the
with
warn
the
that
nation's
For
health
e x i s t s today
meant
to
challenged
adoption
"the
care."
and
Supreme C o u r t
7 -
"
197Cs
deciding
1969
3
The
I.R.S. r u l i n g .
treatment
to reach
does n o t
the
the
special
inability
beneFit
i n the
oF
oF
'working
bode w e l l
For
consumer/patient.
i n diFFerent
hospitals
a consensus
same
Fox
on
oF
how
we
the
health
The
may
care
156 9
ruling
jurisdictions,
with
that
t h e r u l i n g "had n o t h i n g t o
754
e i t h e r tax or h e a l t h p o l i c y . "
The
1959 I . R . S . r u l i n g s t i l l h a s e F F e c t d e s p i t e t h e
7S-
do
r
Consolidated
requires
room
care
Omnibus B u d g e t
R e c o n c i l i a t i o n Act
hospitals participating
to p a t i e n t s unable
in Medicare
t o pay.
-207-
to
oF
15 85
provide
~~
which
emergency
�A
paradox
has
developed
care.
There
oF
similar actions.
two
should
be
around
the
a similarity
The
two
of
dumping
by
hospitals;
..patient
dumping
by
insurance
reFerred
utilization
review
Patient
by
to
society,
and
hospital
staFF,
dumping
i s being
•n
the
the
patient
by
and
other
stop
such
other
that
dumping
outside
people
takes
a reFusal
reFuge
Utilization
rationing
and
insures
actually
behind
review
care
will
i s an
and
not
by
honestly
much o f
support
the
advocate
patient
dumping
does n o t
Because
A
iF the
and
to
the
aFFected
on
voice
the
phone
voice
which
a
reFusal
is
is occurring.
label
problem
groups
the
challenged.
h y p o c r i t i c a l denial
accurately
the
insurer
From
services,
have
beFore
Politicians
what
will
the
that
is
have
to
issue
be
will
ever
addressed.
Congressional
insurers
ThereFore,
consumer
For
dumping
nor
patients,
when
divorced
Fight.
insidious
admit
to
politically
has.
and
policy
patient
immoral
attempt
to
actually visible
reimburse
company
occurring.
addressed
be
oF
to
i n an
was
patient
i s more d i F F i c u l t t o
pronounces
i t i s not
oF
treatment.
oF
premises,
is
label
labelled
employees
dumping
provider's
and
been
i t i s obvious
oF
insurer
hospital
occurs
companies--which
legislation
reFusal
hand,
and,
has
hospital
practiced,
are:
been passed
Because
occurrence
care.
hospitals
has
health
the
po1itica11y-correct
unnecessary
activity.
visibility
the
legislation
that
to
oF
dumping
prohibit
necessary
with
of
r e s u l t From
actions
..patient
commonly
provision
pending
legislation
utilization
pending
review.
legislation
-20B-
i s the
(S.1227
While
and
the
reduction
others)
stated
oF
the
and
intent
oF
�inflationary
spiral
be
a n d t e r m i n a t i on oP c a p e .
rationing
drastically
the
last
a custom
physician
physicians
future
will
altered
Lois
Wickline's
patient to suffer
becoming
her
of health care,
as a m a l p r a c t i c e
may n o t f a r e
increase
t h e number
Consolidated
rite
While
which
i s fast
d i dnot include
likely
that
of utilization
of malpractice
Omnibus Budget
n o t be
i n t h elawsuit, other
I tappears
i l l effects
will
peview
and s h e w i l l
Wickline
defendent
as w e l l .
of the bills
Utilization
life
this
by i n s u r e r s .
lawsuits concerning
The
from
the effect
review
suits.
Reconciliation Act of
75B
1385
[COBRA]
funding
care
and r e f u s e s
may be h e l d
emergency
room
provides
that
treatment
liable
a hospital
accepts
t o p a t i e n t s unable
f o r harm
medicare
t o pay f o r
t o a p a t i e n t who i s i n an
condition or i n labor.
medical
which
COBRA a l s o
requires
emergency
t o d e t e r m i n e w h e t h e r an emergency
757
condition actually exists.
S e c t i o n S 1 2 1 o f COBRA i s an i m p o r t a n t
m e a s u r e b e c a u s e i t c r e a t e s a f e d e r a l med i ca 1
^
ma 1 p r a c t i c e c a u s e o f a c t i o n i n t h e c a s e o f
p r e m a t u r e t r a n s f e r o r dumping o f emergency
w a r d p a t i e n t s ... t h i s s e c t i o n o f COBRA [ i s ] a
'litigation
t i m e bomb w a i t i n g t o e x p l o d e
comparable t o RICO.'...in t h eabsence o f f e d e r a l
or s t a t e f u n d i n g programs t o cover t h ec o s t s o f
uncompensated h e a l t h care, t h e shunning or
t r a n s f e r o f p a t i e n t s f r o m emergency rooms f o r
f i n a n c i a l reasons w i l l continue.
At present,
monetary p e n a l t i e s and c i v i l l i a b i l i t y measures
( i . e . , malpractice s u i t s ) represent t h e best
s h o r t term ansver t o t h edilemma o f premature
t r a n s f e r o f t h e poor and u n i n s u r e d from p r i v a t e
75 8
hospitals."
Smith
in
relates
that
1985, t h e p r o b l e m s
acute."
and
screening
Human
Part
"Despite
associated
o f t h eproblem
Services
has been
-209-
t h epassage
w i t h p a t i e n t dumping
i sthat
less
of this
than
t h e"Department
vigorous
measure
remain
of Health
i nseeking
civil
�i LI i—i—rcrr
Cost Per State and Local
Government Employee, 1984-89
Current Year $
$3500
$2836
$3000
$243/
$2500
$2000
$1589
$1755
$1906
$2071
i
01
V
$1500
Between 1984 and 1989,
Health Plan Costs Increased 50 Percent
Even After Adjusting for Inflation
$1000
$500
$o
1983
1984
1985
1986
1987
1988
1990
1989
Source: Foster Higgins annual
H e a l t h Care B e n e f i t s Surveys
Source:
"Trends
i n Employna
Hnnlth
Bnnnfit
C u ^
i n -,-
,
i'
1980s" (Chart
1 ^
i nnn
r)
�Average Annual Cost of Health
Premiums in State Government, 1980 -89
CHART
3
Indemnity Plans
Current Year $
$3500
$2500
$3,080
Family P k a n s ^ ^
-
$2000
o
i
$1500
$1,343
-
$976
Individual
V\zxx%^^^'
$1000
$500 _
$437__——"
I
1
1
l
1
1
1
L
.
$0
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
S o u r c e : M a r t i n E. Segal,
Annual Surveys of State
Employee H e a l t h B e n e f i t Plans
a our c n :
•TVends
in
Employee
Health
Onnefit;
Costs
i,-.
S t n t e
and
Loc.-il
G o v n n unf? ri (:
in
the
IROOn"
fChant
^1)
�CHART
Percent Increase in State
Government Employee Health Benefit Costs
Compared to Inflation (CPI), 1980-89
25\
20%
15% -
10%
r
Inflation (CPI)
5% r
0%
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
Indemnity Plans
Sourct:
M a r t i n E. S#g»l Company
Note: Martin E. Segal Company d i d not conduct surveys i n 1981,
1982, and 1984. T h e r e f o r e , i n t h i s c h a r t , the annual percent
change for the 1980-83 was period was c a l c u l a t e d by d i v i d i n g the
premium c o s t i n c r e a s e from 1980 to 1983 by t h r e e to get an
average annual percent i n c r e a s e .
L i k e w i s e , the annual percent
change f o r the 1983-85 p e r i o d was c a l c u l a t e d by d i v i d i n g the
i n c r e a s e from 1983 t o 1985 by two to get an average annual
percent i n c r e a s e .
D
cur ze:
"Trends i n Employee H e a l t h B e n e f i t Costs i n S t a t e and Lzzs
Government i n t h e 1980s" (Chart 3 ) .
P r e s e n t e d t o t n e S t a t e and Local G o v s r n m s r t Lacor-Managemar
C o m m i t t e e . J u n e 15. 1990
-25 1 -
�penalties
maximum
(against
the offending
recoverable
penalty
h o s p i t a l s ] because t h e
i s $25,000 and i s l e s s
than the
759
cost
of prosecution."
a recognized
deterrent
the
answer
Why
was t h e p e n a l t y
Association
with
Many
s e t a t such
members w e r e
state
must
m u s t be v e r y
regulations
emergency
hospitals
also
that
impose
common
statutes
t o end p a t i e n t
way
that
hospitals
will
get reimbursement
American
with
Tha
with
t h e dumping
sibility
tion
few
will
needing
care
on h o s p i t a l
which
insurers
care.
utilization
of malpractice
review
which
Requiring
will
otherwise
have
should
stated
every
be
t h e same
f o rpatients
based
begin
-2 10 -
duty
7 5 2
insurers
years.
no
i n d i v i d u a l who
or t o provide
correlated
The
moral
as
would
on h a r m
respon-
access
eliminate the
caused
surfacing
same
hospitals
to provide
review/dumping
claims
regulations
i s t o guarantee
are p e r p e t r a t i n g .
t o care
indigent
Waxman
f o r every
dumping
be d r a w n - - i n s u r e r s
imposing
class
care
cr v e r a g e . "
t o p r o v i . de a c c e s s
to provide
without
new
health
information
conclusion
have
facility
t o pay."
imposed
dumping
sure
built
t o a l l who
760
and
Judith
"The o n l y
comes t o t h e i r
care
to treat
1
that
Hospital
amount?
of a b i l i t y
law w h i c h
a l l patients. ^
which
a l l "hospitals
a duty
7
to treat
at that
emergency
A l l these
t o overcome
i.e.,
by t h e A m e r i c a n
regardless
patients.
were p r o m u l g a t e d
obvious:
w r i s t slap
provide
t h e community
is
hospitals,
a low r a t e ?
H i l l - B u r t o n Act requires
penalty
of v i o l a t i v e
influenced
t o set the token
within
and/or
on
t o punishment
H i l l - B u r t o n funds
reside
the insignificant
to the f o l l o w i n g question
Congressional
The
Since
by
utiliza-
w i t h i n the next
�Legislators
tion
review
refuses
and
process
complaint
The
a prime
that
paradox
visibly
life
hospital
that
man
occurs
turning
because
termination
away
actions
and
the
the
hospital
could
Society,
condemnation
which
of
the
from
the
i s , therefore,
easier
corporate
economic
summed
i n one
up
hospitals
by
i s refused
insurers
malpractice,
soon
become
and
justify
on
PROFITS!
the
hopefully
on
sees
Fact.
- 2 VI -
I t
unethical
voiced
its
dumping
the
by
that
patient
insurers-action
in
governmental
but
of
medical
action.
is
question
and
e n t i r e s i t u a t i o n can
care
be
i. n
termination
f i n a n c i a l grounds.
of
the
suit.
Termination
insurer
cause
is
because
e t h i c a l grounds,
i s condoned
a recognized
The
of
a
hospital
that
action
in a c i v i l
location
to
one
In
Everyone
services,
interests.
word:
to
first
i t is
unethical.
action--patient
geographic
tongue."
recognizes
the
is
Indian
condemns t h e
sufficiently
e f f e c t i v e l y terminates
removed
care
second
merely
'reasoning'
forked
witness
that
not
but
utiliza-
American
i n need.
liable
however,has
the
services--bQcause
are
acknowledged
be
old
with
staffer
commonly
and
That
therefore
then
that
care,
society
of
a patient
and
the
speaks
threatening
insist
care.
of
s e t t i n g , many p e o p l e
staffer's
It
for
will
terminate
example
"white
action—hospital
is
does n o t
reimbursement
doublespeak,
staffer
insurers
of
I t is
malpractice
still
will
�MALPRACTICE.
The
in
First
England
i n t h e year
many p e o p l e
(including
Associations]
awards,
m a l p r a c t i c e case
13 7 5 ;
i s b e l i e v e d t o have
7 53
i
n
t h e American
the late
Medica
are attempting t o place
shorten
statutes
20th
occurred
century,
and H o s p i t a l
c a p s on m a l p r a c t i c e
oF l i m i t a t i o n ,
place
limits
on
754
discovery
rules,
But
eFForts
those
problem
do
are not viable
they
solutions
Fees.
to the malpractice
on t h e r e s u l t s
oF m a l p r a c t i c e a n d
n o t F o c u s on t h e c a u s e s
oF m a l p r a c t i c e
suits--neg1igence
l a c k oF s u F F i c i e n t k n o w l e d g e
ordinarily
litigious
Malpractice
l a w s u i t s have
cost
eFFects
oF ma 1 p r a c t i c e - - t h e
deFensive
health
care
oF t h e h e a l t h c a r e
medicine—are
costs.
or s k i l l s
and t h e e x t r a -
American p o p u l a t i o n .
overall
as
on a t t o r n e y c o n t i n g e n c y
Focus
and/or
because
and l i m i t s
n o t s i g n i F i c a n t 1y
raised the
p r o v i d e r system.
repercussions
causing
And d e F e n s i v e
commonly
worrisome
medicine,
The s e c o n d a r y
reFerred t o
increases
i n turn,
to total
i s causing
r a t i o n i n g oF m e d i c a l c a r e .
The c o n t i n u u m i s a s F o l l o w s :
I n s u F F i c i e n t knowledge and/or s k i l l
levels
leads to
N e g l i g e n t p r a c t i c e oF m e d i c i n e , w h i c h
leads to
Malpractice
l a w s u i t s , i m p o s e d by an o v e r l y l i t i g i o u s s o c i e t y
lead to
The p r a c t i c e oF d e F e n s i v e m e d i c i n e ,
which
leads t o
Higher h e a l t h c a r e c o s t s , which
lead to
I n s u r e r s r e F u s i n g t o pay F o r c a r e and c a n c e l l i n g p o l i c i e s , w h i :
leads t o
U t i l i z a t i o n review,
which
leads t o
R a t i o n i n g oF h e a l t h c a r e .
The
ability
American
to monitor
Medical
Association insists
i t s own m e m b e r s h i p ' s
- 2 'I 2 -
on m a i n t a i n i n g i t s
capabilities,
b u t i t has
�amply
demonstrated
quality
level
practicing
the
AMA
even
in
proFessional
has been
juries
and m a i n t a i n t h e
The AMA
irresponsibility.
pushing
that
arbitration,
Richard
to p o l i c e
oF i t s own m e m b e r s h i p .
advocating
avoid
i t s reFusal
A t t h e same
F o r c a p s on m a l p r a c t i c e
a l l malpractice
r a t h e r than
sympathetic
has been
a c t i o n s be
time,
a w a r d s and
determined
i n a c o u r t oF l a w i n o r d e r t o
to injured
patients.
G e p h a r d t (•-MD.) h a s s t a t e d t h a t
Congressman
malpractice
s u i t s are
765
necessary
and Former
that
a c a p on m a l p r a c t i c e
putting
Surgeon General
C. E v e r e t t
awards
Koop
is deFinitely
warned
succombing
766
to
the pressures
Inept
position
the
is
oF t h e AMA.
physicians
be m o r e
oF p r o v i d i n g h e a l t h
d i m i n u t i o n oF s o m e o n e ' s
a matter
patient's
and
oF b a l a n c i n g
ability
the nation's
rationing
gainFully
capacity.
poor
continue
path
the doctor's
can F u r t h e r
harm
i n the medical
physicians
liFe,
are leading to
patients.
Terminating
enable
but i n a
may g a i n
will
unacceptable
enhance
h i m t o be
diFFerent
bask
5
-2 1 2 -
politician,
to a society
the elimination of
i n t h e aura
Act.' '
For a
t h e p r e s t i g e oF t h o s e
a new s e c t i o n e n t i t l e d
Service
points
Additionally,
t o p r a c t i . ce who w i l l
Health
which
still
Field,
and e c o n o m i c a l l y
physicians
the Public
against the
i n t h e c u r r e n t mode oF p r o t e c t i n g
health care.
S.1227 a d d s
but this
h e a l t h a n d , i n some c a s e s ,
which
trained
quality
liFestyle
costs
To c o n t i n u e
t o advocate
and l i F e s t y l e ,
h e a l t h care
employed
quality
career
rising
i ti s morally
seeking
I t i s unpleasant
l i c e n s e t o p r a c t i c e may
inadequately
but
q u i c k l y e l i m i n a t e d From t h e
care.
to maintain
oF c a r e
a physician's
to
must
oF
excellence.
Malpractice
Section
who
ReForm
3 0 6 oF t h e A c t
�provides
that grants
covering
medical
be
awarded
malpractice
receive
such
eFForts
to develop
disputes
may
grants,
they
reForm.
will
be
alternative
that Fairly
to
protect
States
However,
required
methods
the
For
to
programs
iF states
do
"...include
to resolve
i n t e r e s t s oF
liability
a l l parties
i n v o l v e d . . ."
This
provision
Association's
number
oF
desires
medical
courtroom
with
resolution
would
by
an
The
with
recourse
the
require
some F a c t i o n s
to
the
their
Providers
medicine
become
have
a major
this
country.
1980
were
are
saFer
way
an
perFormed
For
the
For
Juries
and
economic
juries
extent
the
number
oFten
dispute
parties,
a
retired
necessary
by
lawsuits
The
health
time,
care
in drastic
services.
practice
deFensive
unnecessary
1S.5
percent
oF
section.
Less r i s k
-£ 1A-
most
sometimes-excessive
provide
to
oF
providers.
costs
with
in a
p a r t i e s , oFten
deemed
rising
caesarean
inFant,
on
have r e s u l t e d
t h a t such
example,
by
are
the
e F F e c t s on
the
i t necessary
heard
Alternate
are
other
and
the
appeal.
that caregivers
an
are
between
binding
Medical
possible
which
jury.
excessive
d r i v e r i n the
As
much as
lawsuits
careers,
Found
to such
be
the
and
t o p l a i n t i F F s by
i n the
a
American
a d m i n i s t r a t o r , oFten
physicians
providers
changes
oF
to
oF
eFFects
awards
the
lawsuits
courts
methods
psychological
and
as
arbitration
would
because
against
with
p1 a i n t i F F / p a t i e n t .
decision
Alternative
levelled
in Front
independent
judge.
no
to reduce
malpractice
setting,
sympathetic
reFereed
i s i n accord
oF
care
health
care
in
a l l births
in
Caesarean
oF
has
serious
sections
�complications.
malpractice,
on
23.8
By
perFormed
oF
For
as
that
brought
This
4 percent
year.
the
a deFensive .response
perForming
a l l births.
comprised
caesareans
mostly
p h y s i c i a n s were
percent
operations
19S9,
oF
This
caesarean
total
increase
average
cost
sections
l a r g e number
the
oF
oF
surgical
surgical
i n the
that
to
procedures
number
oF
procedure
to
7B9
$7,186
whereas a normal
amount.
Estimates
For
delivery
the
medicine
depending
deFensive
on who t h e e s t i m a t o r i s and
•
m e_ • c • n e . 770
di i
to
only
way
a t t e n d to the
1.
Reduce
to respond
root
the
risk
oF
tion
From
requirements
$21
incidents
and
oF
actual
i n c r e a s i n g the
experience
oF
annually,
is included
as
increases
types
oF
care.
should
be
e s t a b l i s h e d which
w i t h o u t economic
m a l p r a c t i c e and
continued
levels
certain
is
medical
physicians
as
practicing
oF
For
and
Completely
new
state-sponsored
have
to the
educa-
oF
licensing
ties
the
as
i t s members
providing
sector
oF
review
only
the
establishment.
2.
Reduce
attorneys
possible
include
that
t o a l l Forms
billion
what
halF
causes .
m a l p r a c t i c e by
medical
about
to malpractice cost
t o renewed
those
due
t o $130
prerequisites
boards
cost
incurred
deFensive
The
range
costs
would
the
to alter
liability
a moral,
the
as
path
well
oF
actually
n e g l i g e n t or
oF
oF
claim.
evidence
Accidents
the
number
case
m a l p r a c t i c e l a w s u i t s by
they
Follow
Attorney
as
legal,
to determine
merely
circumstance
do
an
not
when c o n F r o n t e d
practice
whether
warrant
any
oF
by
a
g u i d e l i n e s should
examination
accident
requiring
oF
harm
the
Factual
caused
was
circumstance.
lawsuits.
IF a
suit
�is
warranted,
only
i n cases
physicians
the
root
to
cause
reduce
or
been
the
public
current high
p l a i n t i F F s to
instituting
which
data
which
would
inFormatio
1.
be
be
set
nor
removing
From
a
legislated
provided
For
and
the
ADR.
capability
reduction
oF
met.
that
cost
or
AMA
suits
oF
are
health
careFully
the
root
care.
consider
cause
oF
Encourage
the
circumstances
a lawsuit.
that
an
would
recommend
to
not
in
to beneFit
suits
employed
The
interest
l a w s u i t s when g o a l s
S.1227 r e q u i r e s
analyze
them
should
not
potential
For
in malpractice
have
be
incurred i s minimal.
malpractice
inhibit
the
r e s o l u t i o n should
exhibited suFFicient
Educate
3.
to
oF
harm
establishment
malpractice
prior
the
reduction
medical
much oF
where
have not
legislated
The
alternate dispute
independent
enable
ineFFective
or
collect
a r e p o r t t o be
additional
collected will
entity
malpractice
relate
unnecessary
and
made t o
reForms.
7 7
Congress
^
The
to:
medical
testing
and
p r a c t i ces;
2.
the
occurrence
(including
oF
number
oF
claims
the
adequacy
oF
existing
disciplining
4.
and
malpractice
and
Filed
malpractice
and
the
awards
number
oF
Findings
n e g 1 i gen c e ) ;
3.
and
the
oF
the
reasonableness
rate-setting
5.
any
procedures
practices;
other
issues
medical
p r a c t i c e s , oF
medical
malpractice,
medical
practices.
772
health
in preventing
oF
malpractice
relevant
the
provider
licensing
malpractice;
insurance
premiums
and,
oompensation
and
care
impact
to
For
oF
the
adequacy
injuries
legal
oF
current
resulting
liability
on
From
�S.1227 r e q u i r e s
ment B o a r d
maintain
out
whose p u r p o s e
and
improve
the S t a t e .
which
each
will
7 7 3
State to establish
will
be
t o r e v i e w and
the q u a l i t y
The
board
acknowledge
of health
will
a health
a Quality
conduct
Improve-
continue to
care
provided through-
a certification
care provider
as
being
process
an
774
outstanding
practitioners.
advisability
reconsider
insurance
zation
an
the c e r t i f i c a t i o n
company
incentive
performed
coverage
or s t a t e
benefit
certification
plan
may
o r o r d e r e d by
may
n o t be
7 7 7
a problem,
substandard
While
such
The
board
payment
and
would
on
grounds
that
often
methods
authori-
time.
7 7
"
'
As
Specifically,
i s medically
to deal
positively
for dealing
the subjects
1
service
the service
commendable
must
'outstanding,'
f o r any
pro v i der .
not mention
are
as
the
plan,
have
a t any
77£:
certified
i t i s always
who
periodically
t o become c e r t i f i e d
S.1227 d o e s
physicians
re-examine
of a provider
n o t deny
denied
will
upon r e q u e s t o f a h e a l t h
agency.
f o r physicians
unnecessary.
with
board
of continued c e r t i f i c a t i o n
t o suspend
a health
The
of
with
malpractice
litigation.
A method
different
change
f o r r e d u c i n g the problem
state
when t h e home s t a t e
to a national
licensing
investigate
physicians
the
licensing
federal
and
bureau
would
i f the physician
he
would
n o t be
licenses
same F e d e r a l
are
i n good
would
able to
emanate
bureau,
standing
and
were
regarding
notified
practice
the single
could
state: s
benefit
would preFer
-2 17-
i s to
licensure,
about
licensure
medicine
federal
state,
since
bureau.
those physicians
t o move
to a
would
t o move t o a n o t h e r
legally
from
however,
be
moving
his license
While
make d e c i s i o n s
Thus,
all
revokes
bureau.
statuS.
still
of physicians
to another
That
who
state.
�Since
Free
their
to
l i c e n s e would
p r a c t i c e anywhere
be
valid
they
i n any
state,
they
would
be
chose.
LABOR UNIONS.
Health care i s the major issue i n the vast
m a j o r i t y oF c o l l e c t i v e b a r g a i n i n g n e g o t i a t i o n s .
The l a b o r m o v e m e n t i s u n i t e d i n i t s d e t e r m i n a t i o n
to achieve u n i v e r s a l access, s i g n i F i c a n t cost
containment,
q u a l i t y c a r e and
progressive
Financing.778
IF c u r r e n t t r e n d s c o n t i n u e a t t h e b a r g a i n i n g
t a b l e , by t h e end oF t h e d e c a d e o n e - t h i r d oF t o t a l
c o m p e n s a t i o n w i l l go t o pay F o r h e a l t h c a r e a t t h e
e x p e n s e oF wages a n d o t h e r b e n e F i t
improvements. 79
7
There
i s broad
union
government
does n o t
play
ing,
will
there
health
care,
be
and
consensus
a broader
that
role
increasing inequity
costs
may
increase
so
iF the
Federal
i n h e a l t h care
among t h o s e
rapidly
that
Financ-
seeking
the
nation's
hearings
in eight
780
ability
t o compete
During
the
cities
i n order
health
care
aFFiliated
globally
Fall
oF
to spur
reForm.
unions
may
1990,
Founder.
the
interest
They
present
expect
AFL-CIO h e l d
i n and
build
consensus
For
t o h a v e r e p r e s e n t a t i v e s oF
the
90
Federation's views to a p p r o p r i a t e
7 81
c o m m i t t e e s oF t h E House a n d S e n a t e .
They i n t e n d t o d e v e l o p a
" . . . n a t i o n w i d e g r a s s r o o t s c a m p a i g n by
m o b i l i z i n g t h e i r m e m b e r s i n an a l l - o u t l o b b y i n g
eFFort t o win n a t i o n a l reForm.
To s u c c e e d i n
t h i s e F F o r t , t h e F e d e r a t i o n w i l l Form c o a l i t i o n s
w i t h consumer g r o u p s , e m p l o y e r s , community-based
o r g a n i z a t i o n s and p r o v i d e r s t o c a l l on C o n g r e s s
F o r e x p e d i t i o u s e n a c t m e n t oF F e d e r a l
legislation
that w i l l :
...guarantee Americans the r i g h t to h e a l t h care;
...establish a social insurance n a t i o n a l health
care program;
. . . c r e a t e a n a t i o n a l c o m m i s s i o n oF c o n s u m e r s , l a b o r
m a n a g e m e n t , g o v e r n m e n t and p r o v i d e r s t o
e s t a b l i s h a n a t i o n a l cost containment
program
w h i c h i s t o i n c l u d e a cap on h e a l t h e x p e n d i t u r e s , a v o i d d u p l i c a t i o n oF
technology,
i m p r o v e a l l o c a t i o n oF r e s o u r c e s , a n d n e g o t i a t e
uniForm reimbursement r a t e s ;
_? I S -
�...guarantee a core package o f b e n e F i t s , w i t h
supplementary b e n e F i t packages a v a i l a b l e ;
. . . a s s u r e c o v e r a g e r e g a r d l e s s oF a g e , i n c o m e , e m p l o y ment s t a t u s o r p r i o r h e a l t h c a r e h i s t o r y ;
. . . d r o p M e d i c a r e e l i g i b i l i t y t o age BO i n o r d e r t o
c o i n c i d e w i t h average r e t i r e m e n t age.782
The
health
this
Federation
care
reForm
_,
decade
explains
health
care
entity
to negotiate
rates,
providers
providers
eFFectively.
deemed
and
could
that
save
their
recommendations For
t h e n a t i o n $165 b i l l i o n i n
a, o n e . 7 8 3
l
Sheinkman
regulation
contends
that
control
under
costs.
and e s t a b l i s h
would
Medicare
the present
be F o r c e d
provides
By r e q u i r i n g
nationwide
t h e precedent
Medicaid--is
because
Such
F o r 40 p e r c e n t
Federal
cost
For government
r e g u l a t i o n was
t h e government--through
responsible
a
reimbursement
t o practice•more
oF p r o v i d e r r e i m b u r s e m e n t s .
necessary
system
Medicare
oF t h e n a t i o n ' s
784
health
oF
care
expenditures.
Sheinkman
justiFies
cost
this
c o n t r o l by e x p l a i n i n g :
C r i t i c s claim t h a t Medicare's e x i s t i n g
reimbursement system simply s h i F t s h o s p i t a l
c o s t s From t h e g o v e r n m e n t t o p r i v a t e p a y o r s
l i k e e m p l o y e r and u n i o n p l a n s because h o s p i t a l s
charge those plans h i g h e r r a t e s t o compensate
For t h o s e t h a t pay l e s s .
But i F t h e p r o p o s e d c o s t c o n t r o l s y s t e m s
w e r e made l a w , t h e l o o p w o u l d be c l o s e d : c o s t
s h i F t i n g would s t o p and c o s t c o n t a i n m e n t
would
be a c h i e v ab 1 e .
...
A s k i n g i n d i v i d u a l s t o F i n a n c e t h e i r own
h e a l t h care v i o l a t e s t h e basic p r i n c i p l e s of
pooling risk i n insurance.
I talso v i o l a t e s
o u r s o c i e t y ' s s e n s e oF d e c e n c y .
Health
care
c o s t s s h o u l d n ' t be F o i s t e d o n t h e s i c k a n d t h e
disenFranchised.
T h e y s h o u l d be d i s t r i b u t e d
r a t i o n a l l y and F a i r l y .
...
(T)he p o l i t i c i a n s won't l e a d t h e Government
i n t o h e a l t h care F i n a n c i n g .
Real l e a d e r s h i p
78
m u s t come f r o m b u s i n e s s a n d l a b o r .
c
-2 19-
method
�EMPLOYERS.
The
cost
t o employers
health
insurance
1989.
This
net
reached
represents
proFits.
"the
insurance
Factors
costs
additional
illnesses
$3,161,
contributing
From
and i n c r e a s e d
employees'
oF $ 5 6 1 o v e r
(average)
oF 1,355 e m p l o y e r s
are medical
pressures
an i n c r e a s e
a 26 p e r c e n t
A survey
principle
i n 1990 F o r t h e i r
oF e m p l o y e r s '
revealed
that
to escalating health
price inFlation
large claims
u s e oF m e n t a l
generally, with
For c a t a s t r o p h i c
h e a l t h and substance
787
abuse
beneFits."
Other
about
sources
claim
that
$4,500 F o r each employee
employees c o n t r i b u t e about
a 400 p e r c e n t
that
the"typical
increase
on
States
t o expand
on
employers.
legislators
increase
1980 t o t a l s .
i n cost
minimum
services
7
8
These F i g u r e s a r e
8
Butler
package
warns
implies
was e p p a r e n t l y
pressure
requirements
i m p o s e d on
l o b b y i s t s (A.M.A. a n d A.M.A.) t o
and r e d u c e
copayments
by i n s u r e d s .
Having t h e government r e q u i r e people t o
buy i n s u r a n c e t h a t p a y s F o r t h e s e r v i c e y o u
p r o v i d e i s a n i c e way t o i n c r e a s e demand F o r
t h a t s e r v i c e whether i t s orthopedic surgery
or acupuncture t r e a t m e n t .
State lawmakers...
have . . . e n a c t ( e d ) more t h a n 800 l a w s d u r i n g
t h e p a s t 15 y e a r s r e q u i r i n g i n s u r e r s t o c o v e r
speciFic providers or services—even
when
t h e r e was l i t t l e c o n s u m e r demand.
Butler
while
may h a v e come From
beneFits
The p r e s s u r e
by p r o v i d e r
dependents,
$1,300 a n n u a l l y .
over
p a r t oF t h e i n c r e a s e
including
c o m p a n y " now p a y s
that:
When i n s u r a n c e c o s t s g e t h i g h e n o u g h ,
e q u a l i n g o r e x c e e d i n g t h e c o s t s oF p a y i n g
i n t o t h e f p r o p o s e d pay o r p l a y
insurance
Funds) government i n s u r a n c e Fund,
business
e x e c u t i v e s w i l l e i t h e r F i n d ways t o c u t c o s t s ,
-220-
�o r d r o p t h e company i n s u r a n c e a n d p a y t h e
government's non-insurance t a x ( o f7 t o 9
percent of p a y r o l l ) .
Thus p l a y o r pay i s a w e i g h s t a t i o n on
the
road t o a g i a n t M e d i c a i d program f o r a l l
A m e r i c a n s - - a phony a l t e r n a t i v e t h a t w i l l
become so u n a t t r a c t i v e o v e r t i m e t h a t
e v e n t u a l l y w e ' l l g e t t h o s e long l i n e s and
w a i t i n g l i s t s , s o common i n Canada a n d B r i t a i n ,
despite ourselves.790
The
is
National
comprised
special
Leadership
o f about
interest
sixty
groups.
Coalition
large
f o r H e a l t h Care
companies,
Some o f t h e s i x t y
Reform
u n i o n s , and
companies
a r e Xerox,
7 91
Lockheed,
Southwestern
corporations;
Burger
ing
--
coverage.
K o d a k , 3M, a n d
membership
i n the
t o be d i s a g r e e m e n t
participation
The C o a l i t i o n
p r o v i d e coverage
concerni n cost
rocommends:
t o a l l employees
public
health
plan v i a
taxes; and,
uniform
Employers
compensation
fees f o rphysician
also
cost
shifting
insurance.
Those
employers
are i n s t i t u t i n g
services i n
insured
t o uninsured
increases i n their
premiums went
i n 1990.
attempts t o reduce
and h o s p i t a l
fromthe
f a c e premium
1985 t o $ 6 7 b i l l i o n
In
Other
t h e r e f o r m which i s
t o a government-sponsored
order t o e l i m i n a t e
«
p a t i e n t-s . 7 9 2
in
Eastman
o f government
a l l employers
contribute
payroll
extent
Electric.
from
over
The p r o b l e m a p p e a r s
and b e n e f i t
that
withdrawn
of apprehension
the appropriate
-or
because
advocated.
control
and G e n e r a l
i . e . , ATST, D u P o n t , A r c o ,
K i n g , have r e c e n t l y
coalition
being
Bell,
workers'
f r o m $35
billion
7 9 3
the costs of workers'
safety
-22 1 -
programs,
compensation,
light-duty
programs
�Work-Related Injuries in the Private Sector
(1980-1988)
10
1980 1981 1982 1983 1984 1985 1986 1987 1988
SOURCE U.S. Department ol Labor
"The U n i v e r s a l H e a l t h c a r e Almanac"
(Phoenix:
S i l v e r S C h e r n e r , L t d . , 1991), p . 89
Repr i n t e d :
Work-Related Illnesses in the Private Sector
(1980-1988)
350
300
1980 1981 1982 1983 1984 1985 1986 1987 1988
SOURCE. U.S. Department ot labor
pointed:
- i r l f l v ^ r S n e ? : " ^ ! ' ;
1901), P . 8 B
�for
injured
screening
ing
employees r e t u r n i n g t o work,
of prospective
process
record
includes
checks
has
filed
the
record
injury,
checks
checke
known
unions
as b e i n g
records,
because
however,
filing.
groups
claims
Also,
is filing
f o r t h e same
workers'
object
t o the record
of privacy
and "an a t t e m p t
to certain
classes
a r e n o t used
Thirty-eight
employer.
filing.
jobs
a potential
employee
any e m p l o y e e
insurance
screen-
but also
the prospective
whether
and consumer
t o deny
examinations
w i t h any o t h e r
and h e a l t h
an i n v a s i o n
of prior
reconsider
whether
reveal
as d o u b l e
some c o m p a n i e s
The
will
The p r e - e m p l o y m e n t
physical
comp c l a i m s
comp c l a i m s
Labor
not only
t o determine
workers'
workers'
workers.
and pre-employment
t o deny
comp c l a i m s ,
employee
states
of
workers."
employment
merely
b u t c a n be u s e d t o
who h a s p r a c t i c e d
provide
by
this
data
double
t o employers
734
upon
request.
In
stood
a discussion
that
However,
t h e employer
'employer'
companies
involved
equipment,
also
includes
of physicians,
cost-control
measures."
the
yrew
number
7.7
of Americans
pert: e n t ,
e t c . These
growth
t o support
I n the one-year
employed
t o 3.4 m i l l i o n .
-222-
those
medical
homes, and p r o f e s s i o n a l
the continued
and a r e u n l i k e l y
of
manufacture,
dentists,
expenditures
under-
retailer, etc.
consideration
i n pharmaceutical
" . . . b e n e f i t from
i t i s generally
i s a manufacturer,
h o s p i t a l s and n u r s i n g
corporations
all
of 'Employers,'
employers
of health
aggressive
period
i n the health
care
new
1389 t o 1 9 9 0 ,
care
Dr. Blumenthal.
industry
considers
�this
trend
t o be
a signal
that
the health
become a m o r e
Formidable
opposition
programs,
and
"political
consensus
tion
become more d i F F i c u l t
is
will
"...no c o n s e n s u s
among
achieve
the c r i t i c a l
support
regulation
[these
goal
or
oF
t h e as
care
to Federal
industry
cost-control
concerning Federal
to a c h i e v e . "
businesses)
controlling
7 9 5
To
about
costs:
y e t unproved
will
legisla-
date,
how
there
to
whether
strategy
to
oF
79G
camper, i t i o n . "
The
From
C o n g r e s s i o n a l Budget
the Subcommittee
Committee
on
on
H e a l t h oF
Energy
on
and
H e a l t h and
Commerce
the Committee
diFFerent
methods For
Expansion
oF
OFFice,
on
i n response
the Environment
and
From
Ways a n d
the
coverage
oF
the
Subcommittee
Means, s t u d i e d
r e d u c i n g t h e n u m b e r oF
employment-based
to requests
two
uninsureds.
or M e d i c a i d
were
the
797
options
covered.
From
the standpoint
emp1oyment-based
would
be
would
eFFectively
rolls
oF
coverage
p r o v i d e d For
Medicare,
an
remove
oF
the Federal budget,
expansion
i s p r e F e r a b l e because
additional
a number
Medicaid,
and
oF
17.3
coverage
million
those people
the Veterans
790
beneFits.
However, t h e r e i s a s t r o n g
oF e m p 1 o y m e n t - b a s e d c o v e r a g e .
oF
people,
From
and
the
Administration
downside
to
expansion
The p r i n c i p a l a d v a n t a g e oF t h e e m p l o y e r m a n d a t e
i s i t s m i n i m a l e F F e c t on t h e F e d e r a l b u d g e t d e F i c i t - r o u g h l y $1.8 b i l l i o n c o m p a r e d w i t h $15.4 b i l l i o n
For
the
Medicaid expansion.
The emp J o y e r m a n d a t e ' s m a j o r
.
d i s a d v a n t a g e i s i t s p o t e n t i a l e F F e c t on e m p l o y m e n t ,
b e c a u s e m a n d a t i n g c o v e r a g e w o u l d r a i s e l a b o r c o s t s For
a F F e c t e d F i r m s and w o r k e r s .
Some e m p l o y e r s m i g h t l a y
oFF w o r k e r s o r r e d u c e t h e h o u r s oF t h o s e who remai. n e d
employed t o below t h e mandated t h r u s h o l d For c o v e r a g e .
A F F e c t e d t h e m o s t w o u l d be s m a l l F i r m s , w h i c h e m p l o y
233-
�over h a l f of a l l uninsured workers.
Exemptions For
s m a l l Firms would p r o t e c t them, b u t would a l s o reduce
t h e e F F e c t i v e n e s s oF t h i s a p p r o a c h i n e x p a n d i n g c o v e r age.
S u b s i d i e s For s m a l l b u s i n e s s e s would
mitigate
t h i s problem, b u t they would i n c r e a s e t h e Federal
deFicit.
I n a d d i t i o n , e n F o r c i n g t h e employer mandate
w o u l d be a d m i n i s t r a t i v e l y d i F F i c u l t , e s p e c i a l l y F o r
i n d u s t r i e s where w o r k e r s changed j o b s F r e q u e n t l y o r
h a d F r e q u e n t s p e l l s oF u n e m p l o y m e n t .
F i n a l l y , an
e m p l o y e r m a n d a t e w o u l d l i m i t t h e c h o i c e s oF F i r m s a n d
workers.799
The p r i n c i p a l a d v a n t a g e oF e x p a n d i n g M e d i c a i d
w o u l d be t h a t a l l a d d i t i o n a l F e d e r a l a n d s t a t e s p e n d i n g
w o u l d be c o n c e n t r a d e d on i n d i v i d u a l s who a r e l e a s t a b l e
t o aFFord p r i v a t e c o v e r a g e - - t h o s e w i t h F a m i l y incomes
b e l o w 2 0 0 p e r c e n t oF p o v e r t y . 8 0 0
Hie Relationship of Wages to Providing Health Benefits
Otter health benelits
Percent ot emoloyees earning
Less than
$10,000
Size ol firm
Fewer
'0-24
25-99
100 or
Do not otter health benelits
Percent ot employees earning
man 10 employees
emoloyees
emoloyees
more emoloyees
$10,000$30,000
More than
$30,000
Less than
$10,000
$10,000$30,000
More than
$30,000
11
16
11
13
50
62
69
65
28
22
20
22
30
J7
J2
52
53
^1
•13
33
18
12
• • r s o r o e n i -.amD.*!
SOURCE, -eaun insurance Avsoaairfyi ol America
Dollar Outlay by Employers for
Employee Insurance Coverage (1988)
(from total compensation)
Group Life Insurance
S10
Worker s
Compensation
S31
Supplemental
Insurance
S4.6
Group
Health Insurance
S133
J. 5. Ceo.nnmem ol Commerce Bureau ol Economic Analysis. Survey ot C^rreM Business
Senate
Bill
700 h e l p s t h e s m a l l
employer's
p l i g h t but
30 1
doesn't
oF
go q u i t e
S.700 w i t h
Durenberger
Far enough.
Combining
the Cleveland Plan
objectives.
-224-
would
the
advantages
meet a l l t h e F u t u r e
�Small
Business
In
the
1973,
Council
insurance
Coalitions.
Cleveland,
of Smaller
Ohio's
Chamber o f Commerce
Formed
E n t e r p r i s e s (COSE) t o p u r c h a s e
F o r 8,000 s m a 1 1 - b u s i n e s s e m p l o y e r s
with
health
145,000
802
employees
was
oF
and d e p e n d e n t s .
increased
had
and a d m i n i s t r a t i v e
thecoalition.
2,000 s m a l l
been
insurance
health
The c o s t
employers
unable
membership
i n , COSE.
t o provide
will
encourage
decreased
by
t o t h eFormation
just
between
34 p e r c e n t ,
power
Formation
approximately
health insurance
rates increased
Nancy
purchasing
enabled
As a c o n t r a s t ,
rates increased
insurance
costs
savings
t o do s o p r i o r
Representative
which
The e m p l o y e r s '
when
they
oF, and t h e i r
1984 a n d 1990,
while
COSE
commercial
803
by 154 p e r c e n t .
Johnson
(R-Ct.)
t h e Formation
introduced a
oF s m a l l - e m p l o y e r
bill
purchasing
g r o u p s b a s e d on t h e C l e v e l a n d m o d e l b y :
.. e x e m p t i n g t h e c o v e r a g e From s t a t e - m a n d a t e d
health
beneFits;
.. e x e m p t i n g e m p l o y e r s From s t a t e t a x e s o n h e a l t h
i n s u r a n c e premiums; and,
..
e x e m p t i n g t h e p l a n c o v e r a g e From s t a t e
p r o h i b i t c e r t a i n t y p e s oF m a n a g e d c a r e
Individuals
who a r e s e l F - e m p l o y e d
small-employer
deductions
purchasing
groups
For h e a l t h i n s u r a n c e
will
l a w s t h a t QQQ
activities.
be e n c o u r a g e d
to join the
by i n c r e a s i n g t h e i r t a x
p r e m i u m s From
25 p e r c e n t
t o 100
805
percent.
John
explains
Polk,
that
t h eCleveland
under
Council's
executive
director
currentlaw:
C o r p o r a t i o n s c a n w r i t e oFF t h e e n t i r e c o s t
oF e m p l o y e e h e a l t h b e n e F i t s , w h i l e s o l e p r o p r i e t o r s
and p a r t n e r s h i p s c a n n o t .
Large companies t h a t
s e l F - i n s u r e a r e e x e m p t From a h o s t oF c o s t l y s t a t e
�r e q u i r e m e n t s , while small Firms are not. A l l
e m p l o y e r h e a l t h c a r e p l a n s s h o u l d be t r e a t e d
t h e same.
I n s u r e r s a r e b e h a v i n g t h e way t h e e n v i r o n m e n t
p e r m i t s them t o behave.
U n l e s s we c a n i n t e r j e c t
i n t o t h e m a r k e t p l a c e an o r g a n i z a t i o n l i k e o u r s
w h i c h s e r v e s as an a g g r e s s i v e a d v o c a t e F o r o u r
m e m b e r s , i n s u r e r s do n o t h a v e any g r e a t i n c e n t i v e
t o c l e a n up t h e i r
act."
3
A company
•"j.-
••' • •
^ r.-F- by
employers
t o Fund
their
Companies
with
Few
t h e y had
as
companies
costs
is
that
In
early
data
Maryland,
t o 30
would
oF
antitrust
be
valuable
. .
decisions.
the
with
premiums
Each
e m p l o y ees
was
Formed
plan
in
each
unions,
i n the
hospitals,
insurance c a r r i e r s
in coalescing
whether
was
lengths
changes
to
oF
in
and
share
stay,
and
health
beneFicial.
Justice
enable
pooled
r e i n s u r a n c e i s pirovided.
diagnoses,
had
oF
liability.
would
been
inFormally
queried
Forming
coalitions
without
The
DOJ
concurred that
dissemination
to a l l concerned
i n making
oF
the
purpose
i n F o r m a t i o n which
inFormed
health
would
care
803
A southwest
by
oF
small
plans.
insurers.
employers,
health
the p e r m i s s i b i l i t y
the group
p e r c e n t oF
and
purpose
be
are
poolinj
enables
beneFit
t o t h e t y p e oF
utilization,
Department
oF
charged
up
processed,
Their
packages
r e g a r d : , ng
oF
save
i n order to understand
The
care
that
F i F t e e n employees
third-party
hospital
beneFits
Fear
health
consisted
regulators.
charges
as
a service
a state-wide coalition
13SDs w h i c h
on
own
to respond
c l a i m s aare
physicians,
state
selling
smal1-employer
been p a y i n g t o t r a d i t i o n a l
custom-designed
company,
5
in Minneapolis assists
'
other
0
area
Michigan
hospitals
coalition's
For
g o a l was
to publish
rates
the t w e n t y - F i v e most F r e q u e n t l y - u s e d
-22B-
�hospital
services
so
costs.
The
procedure
compilation
antitrust
free
had
t o change
each
a competing
The
Stark
hospital
area
care
beneFit plans.
would
t o be
a i d them
be
subject
continue
to
to
be
being
provided
organization
which
was
made
not
intention
The
was
comprised
to compile
was
and
Department
plan, especially
8 11
inForma-
d e s i g n oF
to also
of
health
disseminate
oF
since
Justice
the
inForma-
public.
i n thousands
l o w e r e d and
was
i n the purchase
Their
These a r e m e r e l y
possible
the
were
whose g o a l
the procompetitive
was
would
Care C o a l i t i o n
inFormation to the p u b l i c .
tion
that
n o t be
the rates
t o an
Health
employers
which
lauded
would
compare
810
County
tion
can
and
able to
hospital.
twenty-Five
the
and
be
replied
a l l hospitals
prices,
,
Department
purpose
because
their
by
consumers would
Justice
a public
scrutiny
voluntarily
that
a Few
oF
money
examples
oF
localities
saved
the selF-help
around
that
the nation.
but c r e a t i v e
is
Costs
leadership
is
necessary.
Employers'
beneFits
at reasonable cost
sabotaged
lobby
eFForts to provide
by
groups
employers
state
and
must
beneFit
Dr.
is
partially
that
b e n e F i t s impose
contracts
annually
From
believes
responsible
For
who
diFFiculty
with
lebor
insurance
i s oFten
"bow
expands
statB-mandatod
that
health
employees
Federal l e g i s l a t o r s
legislation
8 12
provide."
s i g n i F i c a n t 1y
Bronow
to their
enact
State-mandated
must n e g o t i a t e
and
adequate
to
the
on
powerFul
coverage
employers
unions.
The
unions
beneFits.
state-mandated health
increases in health
-227-
care
care
who
costs.
�Mandated
care
includes drug
chiropractic
care,
and
counseling.
pastoral
raised
insurance
invitro
and a l c o h o l abuse
Fertilization,
Because t h e s e
r a t e s b y 20 p e r c e n t ,
treatment,
acupunture ,
m a n d a t e s may
many
large
wigs,
have
employers
813
have
decided
to selF-insure their
SelF-insured
Retirement
state
to
on m a n d a t e d
premiums.
employers
employees,
who a r e t h e n
t h e employer
prove
better
than
beneFits
translate
subjected
chooses
that
t h e Employee
able
and s t a t e
into
on
which
accrue
b e n e F i t s For
t o h e a l t h care
This
coverage
coverage
by a r e g u l a t e d
be s u b s t a n d a r d
t o avoid
taxes
the beneFits
to provide.
provided
b u t i t a l s o may
under
and a r e t h u s
UnFortunately,
do n o t a l w a y s
which
carrier,
operate
Q 14
Income S e c u r i t y A c t
regulation
insurance
employers
employees.
may
insurance
coverage.
As D r .
Bronow
states:
There are n e i t h e r standards t o ensure
a d e q u a c y oF h e a l t h c a r e c o v e r a g e n o r s a F e g u a r d s
t o g u a r a n t e e t h a t e m p l o y e r s w i l l be a b l e t o p a y
claims i F they close t h e i r business or t e r m i n a t e
the
h e a l t h p l a n . . . t h e r e m u s t be r e g u l a t o r y
s a F e g u a r d s F o r e m p l o y e e s oF t h e s e 1 F - i n s u r e d .
Another
companies
average
For
care
Who
Care.
mandated
process
i s that
Fewer c l a i m s
t h e community
which
oF t h e c o m m u n i t y
numbers
would
File
made by D r . B r o n o w
o p t For se1F-insurance.
selection'
the rest
higher
point
whose e m p l o y e e s
will
'adverse
interesting
oF c l a i m s
eliminate
However,
would
which
Filers.
That
than
would
cause
would
Eliminating
mandated
o r g a n i z a t i o n advocates
- P ^ a—
~>
oF
health
to the Physirian'
i n s t e a d oF t h e c u r r e n t s y s t e m
this
i n an
rates to rise
be c o m p r i s e d
se1F-insurers , eccordinq
h e a l t h care,
result
oF
mandator-/
�employer-provided
E.R.I.S.A. and
The
State
tion
who
oF
Se1F-Insurance
preemption
laws
oF
c o v e r a g e . 816
insurance
that
clause
relate
employee
selF-insure
to
pension
are
not
E R I S A , many s t a t e s
oF
ERISA
the
Funding,
beneFit
not
and
and
administra-
Because
to adhere
require
any
vesting
plans.
required
do
supersedes
to
employers
the
employers
a l l
imperatives
to
oFFer
health
817
insurance.
through
ERISA p r e e m p t s
the
surgical,
oF
purchase
or
accident,
beneFits,
states
insurance
h o s p i t a l care
sickness,
vacation
oF
the
or
or
otherwise--medica 1,
beneFits,
disability,
apprenticeship
From r e g u l a t i n g - -
or
death
or
beneFits
or
other
i n the
unemployment,
training
event
or
programs,
or
818
day
caree
centers,
S.1227 w o u l d
who
do
not
scholarship
levy
an
provide
government-imposed
or
prepaid
e s p e c i a l l y heavy
insurance
813
legislation.
Not
pending
Funds,
penalty
coverage
penalty
on
i n compliance
only
would
15
percent
oF
legal
employers
oF
employers
with
be
total
services.
the
liable
to
wages p a i d
a
For
820
the
year,
but
they
would
also
be
liable
For
a l l health
care
82 1
costs
This
ing
incurred
type
on
your
extended
and
oF
by
the
penalty
point
only
oF
token
politially
employee
may
appear
view.
and
on
his
Family,
commendable or
However,
penalties
powerFul
and/or
the
generous
damages.
excessive,
authors
insurance
plus
oF
the
companies — a
industry--For
dependbill
cohesive
digressions
on
82 2
its
part.
plans
1
t' )
which
are
instructions
( 2 ) pay
is
An
a modest
insurance
not
carrier
i n conformance
to cease
and
providing
with
desist
health
5.1227
From
such
care
is subject
violations;
beneFit
only
to
and,
c i v i l p e n a l t y ; and ( 3 ) o t h e r c o r r e c t i v e a c t i o n as
323
appropriate."
The p e n a l 2 3 - m e n t i o n e d i n ( 2 ] i s d e s c r i b e d
-2t y
as
�Follows:
" . . . a n y c i v i l money p e n a l t y i m p o s e d . . . s h a l l
n o t exceed $ 2 5 , 0 0 0 For each c a r r i e r w i t h r e s p e c t
t o w h i c h a v i o l a t i o n o c c u r s . "824
["underlining
supplied)
The
minimal
penalty
i s not
even
compared
to the
harsh
employers
the
For
noncompliance.
disparity
organized
imposed
"per
penalty
One
imposed
on
and
is
small
i s moved t o p o i n t
in penalties is in direct
political
violation"
out
that
proportion to
power.
CONSUMERS.
"This country i s a very i n d i v i d u a l i s t i c
s o c i e t y -- w i t h o u t s o c i a l c o n s c i o u s n e s s . " 8 2 5
to
"It
care
i s t o each p e r s o n ' s i n d i v i d u a l b e n e F i t
For h i s / h e r h e a l t h i n a r e s p o n s i b l e manner."
During
placed
been
all
the
on
who
That
President
January
1965
Medicare.
poor,
not
a i d , on
many
Lyndon
anyone's
government
oF
which
the
introduction
i t ' snot
have
oF
uneducated;
oF
become
conceived
Union
anyone's F a u l t
are
has
take: c a r e
t o have been
State
the
iF they
g r e a t e r emphasis
assistance
Johnson's
that
Fault
having
appears
proclaimed
stated
years,
F o r m s oF
phenomenon
which
He
twenty-Five
public
r e q u i r e the
available.
during
past
Message
Medicaid
oF
and
iF they
are
rather,
i t is
still
helping
82 7
government's
job to a i d those
While
many
many
truly
needy
values
aid.
person
has
There
good
people,
occurred
has
programs
been
an
i n need.
have
helped
unFortunate
and
change
are
in
traditional
nationwide
concurrently with
expansions
a decided
diminution in the
value
responsibility.
The
ISBOs and
-220-
1970s b r o u g h t
in
oF
with
them
an
�intensification
•n
into
to
of interest
t h e everyday
There
t h e 90s, the B i l l
person
i s nothing
themselves.
understand
rights,
that
with
increased
comes g r e a t e r
another.
The p a t h
their
We
sadly,
have,
nation
and
become
who
the surrounding
more e a s i l y
are also
recognized
concepts of
when
Rights
on t h e r i g h t s
of
f a r has been t o
others'
rights
o f 'me
The
of benefits.
first'
'me
instead
first'
i t i s viewed
attempt
i n order t o
interested in their
community.
important
few p e o p l e
and a c c u m u l a t i o n
a nation
more
as w e l l .
thus
or subjogate
own f r e e d o m s
of people
very
impinge
liberties,
d e v e l o p m e n t s by
and broadened
of Americans
downplay,
increase
often
and
part of t h e C o n s t i t u t i o n .
responsibility
by o n e w i l l
ignore,
any o t h e r
i s that
rights
h a s become
w i t h any o f t h e s e
i s wrong
exercised
to
of Rights
than
wrong
What
i n individual
of a
neighbors
syndrome i s
i n i t s inherent
form--greed.
The
in
generation-old
t h e demand
retribution
f o r excessive
i n t h e form
most p e o p l e - - i n
despite
by
leaps
despite
the deadliness
and bounds.
heartwarming
by
the people
own a c t s
impose
such
on f e t u s e s
nation
on o t h e r s ,
which
abuse
the refusal
i s now
spreading
are t h r i v i n g ,
and,
The
1990s h a s
by f u t u r i s t s .
I t would
t o see g r e a t e r
For t h e consequences
-23 1 -
by
f o r AIDS
on f a m i l i e s
and newborns.
whether
itself
t h e demand f o r
suits,
abuse wreaks
o f decency
manifests
be t e s t e d
and drug
and sou 1 - s a t i s f y i n g
of t h i s
care,
of l i f e - - t o
Alcohol
t h e decade
be
medical
system
of the disease
the devastation
labeled
value
of malpractice
a l l walks
most h e a r t r e n d i n g ,
been
skewed
those
others
be
concern
that
their
Family
�members
The
must
or neighbors
1990s,
First
o r unknown
i n order
reinvigorate
Fellow
Americans.
t o become t h e d e c a d e
the traditional
value
responsibility
For t h e consequences
responsibility
F o r t h e h e a l t h oF o n e s e l F
oF
decency,
oF
personal
oF i n d i v i d u a l
a c t s , and
and one's
Family.
"...(W)e a r e aFForded numerous o p p o r t u n i t i e s F o r p r o m o t i n g h e a l t h and p r e v e n t i n g
disease.
With these o p p o r t u n i t i e s ,
though,
c o m e s r e s p o n s i b i l i t y , a n d t h e F i r s t r o l e we m u s t
a l l u n d e r t a k e i s r e s p o n s i b i l i t y F o r o u r own
personal health habits.
Improving personal h e a l t h
b e h a v i o r c a n c o u n t among t h e m o s t p o t e n t means t o
p r e v e n t d i s e a s e and p r o m o t e h e a l t h .
Measurable
d e c r e a s e s i n r i s k s t o h e a l t h c a n r e s u l t From
changes i n d i e t , e x e r c i s e , tobacco use, a l c o h o l
and o t h e r d r u g u s e , i n j u r y p r e v e n t i o n b e h a v i o r ,
a n d s e x u a l h a b i t s , b u t e a c h oF u s m u s t c h o o s e t o
make t h e s e c h a n g e s a p e r s o n a l p r i o r i t y . " 8 2 8
" . . . ( W ) e c a n no l o n g e r a F F o r d n o t t o i n v e s t
in prevention.
F r o m t h e p e r s p e c t i v e oF a v o i d i n g
human s u F F e r i n g a s w e l l as s a v i n g w a s t e F u l
costs
For t r e a t i n g d i s e a s e s and i n j u r i e s t h a t c o u l d have
b e e n p r e v e n t e d , t h e 1 9 9 0 s s h o u l d be t h e d e c a d e oF
prevention i n the United
States."829
Studies
have shown t h a t
m o r e money
they
holds
across
true
points
out that
will
spend
t h e m o r e money
on h e a l t h c a r e .
national
people
That
have, t h e
relationship
and c u l t u r a l
Wesbury
to patient
"responding
boundaries.
expectations
i s one oF
330
the
costliest
example
required
in
t h e Fact
that
1
oF o u r system.' '
i n Great
t o w a i t one y e a r
t h e U.S.,
unacceptable,
Veterans
beneFits
not only
Britain
cite:
a patient
may
For a c a t a r a c t o p e r a t i o n .
would
most A m e r i c a n s
b u t i F i t happened
A d m i n i s t r a t i o n system,
331
investigation.
The U n i t e d S t a t e s
He
has a l s o
Find
to a patient
t h e r e would
been
that
as an
be
Here
wait
i nthe
be a c o n g r e s s i o n a l
ineFFective
i n dealing
�with
ethical
such
credence
"This
issues.
that
ambivalence
system.
W i t h no
Both
sides
ethicists
of every
dumps e t h i c a l
clear
are
to reach
are unable
issue
a
i s s u e s back
legislative
on
direction,
given
conclusion.
the health
the
care
only
832
solution
Far
i s t o spend
more d e c i s i v e .
terminal
to
patients
those w i t h i n
more money."
The
and
scarcity
understand
how
countries
are
Netherlands provides euthanasia to
Great
speciFic
understand
European
Britain
age
and
how
t o demand
limits
833
groups.
People
t o cope w i t h
more
and
certain
it.
procedures
in
Europe
Americans
then reFuse
t o cope
only
with
less.
ATTORNEYS.
In
annual
the
August
meeting
problem
October
to
1991,
23,
at which
oF
1991, P r e s i d e n t
with
encourage
The
Filed
Vice
the American
t a k e eFFect
agencies
the American
i n January
oF
every
year
and
Bush
m u s t be
established.
achieve
consensus
less
The
between
issued
which
oF
alternate
a
Dan
over-1itigious
1991
Federal government
Association
President
the development
t h e use
Bar
costly
administrative
policy
to
resolution.
i n about
50,000
dispute
i s to t r y every
with
On
an E x e c u t i v e O r d e r ,
means oF
parties,
addressed
society.
regulatory
i s a party
goal
Quayle
charges
dispute
held i t s
court
cases
resolution
method
being a
to
last
834
resort
For
and
every
dispute
a high
not the F i r s t .
agency
plan
to "designate a senior
resolution
enough
The
level
specialist.
The
i n t h e agency
-223-
ADR
to achieve t h i s
oFFicial
is
as i t s
specialist
t o promote
goal
m u s t be
at
ADR--bureaucratic
�A35
inertia
and
Frank
gladiatorial
instincts
Freedman,
chieF
H.
Massachusetts,
shake
hands"
the
lamented
and
Attorneys
now
"People
Americans
have p l a y e d
malpractice
milieu
oF
malpractice
suit
system
For
and
should
which
not
cases.
Neither
should
tion
caps
jury
oF
gross
on
negigence.
Filed
by
levied.
when no
The
sue
remedy
be
because
e x t r a o r d i n a r y procedures
be
a backlash
American
groups
their
path
detriment
Focus
attorneys
by
will
American
oF
v i a caps
turn
to
malpractice
the
Bush
cases.
to
our
They
might
the
tort
in a l l
by
imposi-
the
was
caused
suits
are
F a u l t can
have
be
occurred
physician
reForm
away
already
At
There
the
their
that
point,
power
contingency
the
will
the
oF
Fees
backing
oF
E x e c u t i v e Order.
837
t h e . N a t i o n a l Law J o u r n a l
states that
and t h e i r a l l i e s i n g o v e r n m e n t
o n l y t o o w i l l i n g t o see
lawyers
t h e i r woes.
But t h i s s t r i d e n t
- 334-
by
to
earning
have
no
establishment
turns
earnings.
an
employed.
Association,
medical
by
and
justiFiable..
other
evidenced
remedy
a p a t i e n t experienced
and
legislate
The
that
no
d i m i n i s h i n g the
A d m i n i s t r a t i o n , as
editorial in
"...doctors
and a c a d e m i a a r e
as t h e s o u r c e oF
on
the
physicians
and
Medical
and
and
t o ADR
curtailed
which
h e a l t h care
attempting
For
An
the
Hospital Association
iF the
Financial
outcome
i s understandable
From
oF
reduced
occurred
Filed
an
in
nation.
against
matter
Fear
the
role
i n cases where harm
attorneys
in
easily."
i t i s common k n o w l e d g e
are
judge
t h i n g s out
836
essential part
outcome,
Physicians'
to talk
too
unFortunate
what
district
legislatively
negligence
suits
used
gripped
awards
over-zealous
hospitals
has
the
But
U.S.
a consequential
i s an
be
notwithstanding."
�a n d by-now t r a d i t i o n a l r i f t b e t w e e n t w o l e a r n e d
p r o f e s s i o n s serves n e i t h e r the p u b l i c ' s nor the
professions'
interest.
What i s n e e d e d i s a c o n s t r u c t i v e d i a l o g u e .
E v e r y t h i n g s h o u l d be up f o r d i s c u s s i o n , s u c h as
whether t h e fees of both groups remotely r e f l e c t
r e a l i t y , t h e r o l e o f i n s u r e r s and a l t e r n a t i v e
systems of f i n a n c i n g care.
I n s t e a d o f s q u a b b l i n g , l a w y e r s and p e r h a p s
even d o c t o r s c o u l d c o n t r i b u t e toward t h e c r e a t i o n
o f a j u s t and e q u i t a b l e h e a l t h c a r e s v s t e m t h a t
r e f l e c t s the greatness of the n a t i o n .
8 3 8
Consider
5.1227 w h i c h
establishes a Federal
Health
S39
Expenditure
health
to gather
services,
as
access,
products,
842
oF s p i r a l l i n g
conjunction with
data,
below.
Consider
note
durable
The new
laboratory
equipment,
h a s become
c o s t s , some oF w h i c h
necessary
were caused
the detail
oF t h o s e
to gather
by
as t h e p a t i e n t - - i n
Federal
government
to speciFically
monitor
quality
achieve
the aForementioned
c o s t and
requirements,
The
rates--to
medical
Board
on h e a l t h
expenditure
t h e r a m i F i c a t i o n s For t h e r i g h t
requirements.
able
separate
the requirement
t h e p h y s i c i a n as w e l l
data
data
i s also
attorneys.
quality
For
national
The B o a r d
and q u a l i t y
with
other health services.
In
8 4 0
For
services, physician services,
pharmaceutical
a result
goals
and q u a l i t y .
and p u b l i s h c o s t
84 1
For h o s p i t a l
over-zealous
be
i s t o develop
p r o v i d e r s and p u r c h a s e r s
breakdowns
and
which
expenditures,
required
care
Board
goal
quoted
to privacy--
relation
would
oF c a r e
as
to the
n o t , however,
and p r o v i d e r
oF c o s t
control--
w i t h o u t u s e oF t h e F o l l o w i n g i n F o r m a t i o n .
"Sec.
2 7 7 1 . UniForm B i l l i n g and M a n d a t o r y R e p o r t i n g .
Ca)
I n General.
The ( F e d e r a l H e a l t h E x p e n d i t u r e ) B o a r d
s h a l l e s t a b l i s h a s y s t e m oF u n i F o r m b i l l i n g a n d r e p o r t i n g . . .
t h a t w i l l e n a b l e t h e B o a r d t o d e t e r m i n e t h e p r o g r e s s made i n
m e e t i n g t h e g o a l s e s t a b 1 i s h e d ... a n d t o r e d u c e a d m i n i s t r a t i v e
costs of the h e a l t h care system.
-235-
�(bj
...The B o a r d s h a l l - ...
(3)
a u d i t i n F o r m a t i o n p r o v i d e d by h e a l t h c a r e p r o v i d e r s
on a s a m p l e b a s i s o r i n s i t u a t i o n s w h e r e t h e r e e x i s t s r e a s o n a b l e
c a u s e F o r s u c h an a u d i t ;
and,
(4)
i s s u e p u b l i c r e p o r t s c o n c e r n i n g h e a l t h c a r e c o s t s and
t h e e F F e c t i v e n e s s oF t h e h e a l t h c a r e p r o v i d e d by h e a l t h c a r e
prov i ders.
(c)
Data C o l l e c t i o n .
(1)
Data sources s h a l l submit t o the B o a r d . . . a l l data
required. . .
(2)
D a t a s h a l l be c o l l e c t e d by t h e B o a r d t h r o u g h t h e u s e
oF one o r m o r e F e d e r a l U n i F o r m C l a i m s and B i l l i n g F o r m s d e v e l o p e d
by t h e B o a r d a n d u t i l i z e d by p r o v i d e r s and p u r c h a s e r s oF h e a l t h
c a r e t h a t s h a l l , a t a minimum, i n c l u d e - (A)
a uniForm p a t i e n t i d e n t i F i e r ;
(B)
t h e d a t e oF b i r t h oF t h e p a t i e n t ;
(C)
t h e g e n d e r oF t h e p a t i e n t ;
(•)
t h e z i p c o d e oF t h e p a t i e n t ;
(E)
t h e d a t e oF a d m i s s i o n oF t h e p a t i e n t F o r
inpatient hospital services;
(F)
t h e d a t e oF d i s c h a r g e oF t h e p a t i e n t r e F e r r e d
to i n subparagraph
CE);
CG)
t h e p r i n c i p a l a n d s e c o n d a r y d i a g n o s e s oF t h e
pati ent;
(H)
t h e p r i n c i p a l a n d s e c o n d a r y p r o c e d u r e s t o be
Followed i n t r e a t i n g the p a t i e n t ;
Ci)
a uniForm h e a l t h care F a c i l i t y
identiFier;
(J)
u n i F o r m i d e n t i F i e r s oF p h y s i c i a n s t r e a t i n g t h e
patient;
(K)
F o r s e r v i c e s p r o v i d e d i n an i n p a t i e n t s e t t i n g ,
t h e t o t a l c h a r g e s oF t h e h e a l t h c a r e F a c i l i t y
treating
the p a t i e n t , segregated i n t o major c a t e g o r i e s determined
a p p r o p r i a t e b y the Board;
(L)
t h e a m o u n t s oF a c t u a l p a y m e n t s made t o t h e t r e a t i n g
h e a l t h care F a c i l i t y ;
(M)
t h e a m o u n t s oF t h e c h a r g e s oF e a c h p h y s i c i a n o r
proFessional rendering s e r v i c e to the p a t i e n t ;
(N)
t h e s e r v i c e s p r o v i d e d i n an i n p a t i e n t s e t t i n g ;
CO)
t h e a m o u n t s oF a c t u a l p a y m e n t s made t o e a c h
p h y s i c i a n or p r o F e s s i o n a l r e n d e r i n g s e r v i c e t o the p a t i e n t ;
CP)
a u n i F o r m i d e n t i F i e r oF t h e p r i m a r y p a y o r ;
CQ)
t h e z i p c o d e oF t h e F a c i l i t y w h e r e s e r v i c e i s
rendered to the p a t i e n t ;
(R)
the p a t i e n t discharge status;
and,
CS)
s u c h o t h e r m a t e r i a l as t h e B o a r d d e t e r m i n e s
n e c e s s a r y o r u s e F u l t o c a r r y o u t t h e d u t i e s oF t h e B o a r d
o r t o p r o v i d e a d e q u a t a e i n F o r m a t i o n t o p u r c h a s e r s oF
h e a l t h care t o a s s i s t such purchasers i n a p p r o p r i a t e l y
p a y i n g For s e r v i c e s .
While
numbers
provides
are
the
the
speciFicity
not
within
the
means t o t h a t
oF
names, a d d r e s s e s ,
required
and
phone
inFormation, subsection
inFormation.
Additionally,
(S)
patients
�with
unusual
could
be
illnesses
readily
The
legal
living
proFession,
been
a prime
its
role
in malpractice
an
mover
Far-reaching
considered
entire
actions
as
being
nation's
could
not
many s i n g l e a c t s
similar
actions
results
are
caused
and
by
a speciFic
zip
code
identiFiab1e.
has
have had
within
with
i n opening
suit
oF
have been
Foreseen,
countless
to occur.
The
the
over
never
But
oF
when
decades,
the
oF
their
consequences
t o mend
e s t a b l i s h i n g and
of
oF
actions
Financial health
to predict.
times
because
probably
result
since
I t i s time
by
Box
were
the
system.
culture,
Attorney's
which
aFFecting
impossible
taken
a t t o r n e y greed
more d e t a i l e d
Pandora's
acceleration.
h e a l t h care
i s oFten
bound
this
eFFects--eFFects
capable
are
i t s w i n - a t - a 11 - c o s t s
adverse
wound
adhering
to
stricter
attorney practice guidelines.
ADDITIONAL SPECIAL INTEREST GF10UPS AND
ORGANIZATIONS.
" E a c h one p l a y s t h e game oF h i s own
Faction,
i g n o r i n g t h e i n t e r e s t s e n d t h e a c h i e v e m e n t s oF a
collective
strategy."343
And
;
n
and
For
the
Instead
oF
common g o o d ,
to steadFastly
this
seeking
Country,
conciliation
i t appears
adhere
and
t o be
to t h e i r
own
w i t h human
on
common
more n a t u r a l
concepts,
beings
ground
For
interests,
pursuits.
An
o r g a n i z a t i o n ' s advantage
is
derived
oF
the
[3)
i t is throughout
general.
people
and
so
the
From
group,
(2) the
strategic
political
the
ease
economy."
oF
dominance
position
The
oF
in wielding political
o r g a n i z a t i o n and
oF
the
an
economic
group
-227-
maintenance
incentive,
i n s o c i e t y and
more d o m i n a n t
the
pressure
economic
in
and
the
incentive,
�the
easier
A group
t h e group
will
break
may
organize
apart
and m a i n t a i n
gradually
i f o r when
i t s membership.
8 4 5
i tloses i t s
center .
Health
Insurance
Association
o f America
National
Association
of ManuFacturers
National
Association
oF C h i l d r e n ' s
and
Related
Children's
Institutions
DeFense Fund
American
Medical
Association
American
Academy
oF P e d i a t r i c s
American
Dental
American
Hospital
Blue
Association
Cross-Blue
United
States
above
organizations
Chamber
For t h e purpose
oF
which
would
Association
oF
Commerce
organizations
Formed
expressly
a bill
Association
Shield
What do a l l t h e a b o v e
The
Hospitals
have
the Children's
i n common?
Medicaid
Coalition
oF
lobbying
Congress
t o assure
expand
Medicaid
t o cover
a l l poor
passage
children
S47
through
t h e a g e oF 18.
The
Carl
oF
Children's
J . Schramm,
America.
instigated
persistence
clamor
president
Coalition
the coalition
oF
partly
l a r g e numbers
Libassi,
health
senior
was t h e b r a i n c h i l d
oF t h e H e a l t h
The HIAA r e p r e s e n t s
For n a t i o n a l
F. P e t e r
Medicaid
Insurance
commercial
insurance.
vice
Association
i n s u r e r s and
o u t oF c o n c e r n
oF u n i n s u r e d
that the
people
might
Elaborating
president
oF
lead
to a
on t h e t h o u g h t ,
oF t h e T r a v e l e r s
Health
Insurance
Corporation
explained:
" . . . I F we d o n ' t F i n d a way t o p r o v i d e c o v e r a g e
F o r t h e n a t i o n ' s 31 m i l l i o n u n i n s u r e d , t h e F e d e r a l
G o v e r n m e n t may move t o a d o p t some F o o l i s h , i l l - a d v i s e d ,
i11-conceived national h e a l t h insurance
strategy."848
Robert
Pear
wrote
that
"The s u c c e s s
oF t h a t
campaign
is a
�lesson
...
i n t h e value
T h e i r success
achieved
from
as p a r t
of p o l i t i c a l
i s a l l t h e more r e m a r k a b l e
of a deficit-reduction
t h e nation's governors
for
expansion
tion
coalition-building
oF M e d i c a i d
at this
coverage.'
An A d m i n i s t r a t i o n
over o b j e c t i o n s
mandate
The B u s h A d m i n i s t r a -
expansion
oFFicial
i t was
any F e d e r a l
time.
a l s o o b j e c t e d t o 'the mandatory
because
bill
who o p p o s e d
i n Washington
oF
described
Medicaid
the coalition
849
as
an ' u n b e a t a b l e
A group
is
political
which
seeks
Common C a u s e , h e a d e d
that
over
medical
industry
by F r e d
contributed
i n oFFice.
industry
t o guard
t h e welFare
Wertheimer,
t h e 1980 t o 1 9 9 0 p e r i o d ,
Representatives--For
still
combination."
Health
Congressional
contributed
members.
over
t o S e n a t o r s and
companies
$14 m i l l i o n
and i n s u r a n c e
to current
The p h a r m a c e u t i c a l
$5 m i l l i o n ;
i n the
$ 8 0 , 0 0 0 p e r member--who a r e
insurance
associations provided
who d i s c l o s e s
v a r i o u s groups
$43 m i l l i o n
an a v e r a g e o F
oF c o n s u m e r s
industry
and t h e American
PACs
Medical
Associa350
tion
PAC
While
i s r e p o r t e d t o have
$1.7 m i l l i o n
incumbents
oF t h a t
who c o u l d h e l p
4102,000 went
health
care
44.8
oF
t h e PACs
t o pass
industry.
Ways a n d Means C o m m i t t e e
million,
amount Found
t o 19 c h a l l e n g e r s .
members a r e now s e e k i n g
the
contributed
and t h e Senate
3
5
1
million,
causes,
T h o s e same
legislation
membership
million.
i t s way t o 3 5 9 H o u s e
legislative
Wertheimer
Finance
n e a r l y $8
which
only
Congressional
will
reForm
singles
o u t t h e House
as h a v i n g
r e c e i v e d $6.3
Committee
as h a v i n g
received
w h i c h i s an a v e r a g e oF $ 2 5 0 , 0 0 0 F o r e a c h member
352
t h e Committee.
I n response t o t h e above i n f o r m a t i o n , W e r t h e i m e r posed
- 229-
�the
to
Following
questions
to
readers:
1.
Why d i d t h e m e d i c a l i n d u s t r y w a n t t o g i v e
m e m b e r s oF C o n g r e s s d u r i n g t h e l a s t 10 y e a r s ?
2.
What a r e t h e c e r t a i n t h i n g s
t h e medical industry?
For
members w i l l
$43
million
have
t o do
3.
And how much w i l l i t c o s t y o u a n d me a n d e v e r y o t h e r
A m e r i c a n when t h e t i m e comes F o r members oF C o n g r e s s t o make
d e c i s i o n s a b o u t m a j o r r e F o r m oF o u r h e a l t h c a r e s y s t e m ? 3 5 3
Mark
Fred
with
Shields,
a syndicated
Wertheimer
columnist,
apparently
agrees
and has s t a t e d :
854
"PACs a r e l e g a l
Because
social
tion
conditions,
behind
clauses.
In
se1F-interest
encouraging
reForm
groups,
those
ultimate
The
issues
areas
oF s o c i e t y
which
user
oF r e F o r m
benefitting
will
have
eFFects
also
truly
beneFit
will
which
the large
have
motiva-
health
care.
particular
oF t h a t
on s p e c i a l
beneFit
From
accept
interest
those
For passage
the consumer/patient--the
oF any F u t u r e
deserve
the
questionable
t o reForm
i s t o s o r t o u t and o n l y
and b e n F i c i a r y
which
may
members t o p a s s
have b e n e F i c i a l
The t a s k
bills
which
i ti s i n e v i t a b l e t h a t p o r t i o n s
will
makeup a n d
t o consider
i s needed
Congressional
b u t most
reForms.
oF t h e human
prudent
legislation
legislation
measures,
legisllation
i s part
i ti s only
pending
Major
extortion."
system,
good
t h e most s c r u t i n y w i l l
an a d v e r s e
corporations
eFFect
or bad.
be
those
on c o n s u m e r s
and o r g a n i z a t i o n s
while
and
assoc i a t i ons.
Recalling
author
on
may
health
urge
care
words
oF w i s d o m
and w a r n i n g
a few more c o n s u m e r s
reform
to their
- 540-
by a f i n e
t o express
elected
their
American
opinions
representatives:
�" I t h i n k I can s a y , and say w i t h p r i d e , t h a t
we h a v e some l e g i s l a t u r e s t h a t b r i n g h i g h e r p r i c e s
t h a n any i n t h e w o r l d . "
Samuel
(Mark
The
AMA
could
more p h y s i c i a n s
its
New
would
membership.
casts
votes,
York.
individual
have
less
vote
At p r e s e n t ,
with this
Merely
inFluence
only
i t now w i e l d s i f
which
25 p e r c e n t
dwindling
a common
From
3 5 5
than
issues
percentage
sharing
physicians
Twain)
o n AMA
[1873)
L. C l e m e n s
vastly
oF t h e m e m b e r s h i p
t o 10 p e r c e n t i n
interest
holding
are submitted to
does
not preclude
opposing
viewpoints
857
From
the majority.
vote,
Were a g r e a t e r
t h e outcomes might
reForm
beneFicial
diFFer
sense
oF p o w e r 1 e s s n e s s
participation,
able
while
to participate
Presently,
votes
not
tends
are inextricably
t o produce
the existence
about
count.
They
overshadowed
special
It
cannot
interest
that
oF d o l l a r s
their
than
encourages
858
those
population
s i n g l e vote
vote
counts
does
when i t i s
c o n t r i b u t e d by p o w e r F u l
climate
take
that
their
r e o r 2 z ^ .. t - t i v s s by l i t t e r
-
are regarding
Washington.
the time
h e a l t h care
will
around
rather
oF t h e A m e r i c a n
Few A m e r i c a n s
positions
a
groups.
i s in this
elected
linked:
t o do s o . "
believe their
by t h o u s a n d s
apathy
oF p o w e r
50 p e r c e n t
i n e l e c t i o n s a n d many F e e l
o p p o r t u n i t y For
result.
i n i t s exercise
only
oF p h y s i c i a n s t o
and a g r e a t e r
t o p a t i e n t s may
"Power and p a r t i c i p a t i o n
number
o r make t h e e F F o r t
t h e many r e F o r m
Some w i l l
-24 1-
reForm
merely
or phone
bills
vote
must
evolve.
t o inForm
what
their
now F l o a t i n g
on e l e c t i o n
day and
�consider
that
steps
members o f
of
An
effort
Diego
on
the
s u b j e c t of
and
Selling
sufficient
to guide
the
political
Congress.
interesting
San
t o be
speech
February
was
delivered
15,
and
"Money
1991.
the P o l i t i c s
to the
G e o r g e S.
City
Club
Mitrovich
of Betrayal
of
addressed
--
the
Buying
859
in
the
of P o l i t i c a l
1990
races
were
a number
were
able
In
oF
For
the
U.S.
incumbents
to raise
CaliFornia
A c c e s s and
alone,
Four
House oF
who
more t h a n
Favors."
opponents
million
unopposed
revealed
that
Representatives there
F a c e d no
$28
He
For
and
still
campaign
incumbents
Funds.
received
$1.4
850
million.
care
who
Senator
reForm--raised
raised
Texas
Banking,
and
won
$1.7
Senator
oF
the
bank;
and
Phil
amounts
oF
the
lost
million
active
in
health
a g a i n s t an
is the
action
p a r t iplays ,
t t e e ed
comm
the American
stated
i s on
38
more t h a n
a g a i n s t an
percent
the
opponent
oF
the
and
that
spent
political
these
8 5 4
who
862
raised
$4
"At
million
a deeply
But
i h e t h e - r a i s i n g P oFC s . " s e
tn
so called
A the
million
the
in
"...extraordinary
reFlects
scene.
$15
votes.
Gramm h a d m o r e t h a n
863
$1,581.38."
concern
Appropriations,
opponent
Senator
monies r a i s e d
oF
(R)--who
votes
with
expresses
aspect
has
Gramm
h i s opponent,
oF
$3.B
Committees--raised
the campaign
Mitrovich
Dole
more t h a n
Budget
percent
million
end
RockeFe11er--very
$2 1 , 3 4 1 .
and
52
Jay
disturbing
more ominous
yet
F u n d s e n a t opro l i t i c a l
As S by
Robert
"When t h e PACs g i v e money, t h e y
expect
something
,,865
in
return
In
other than
1990,
$147.8 m i l l i o n
good
H o u s e and
from
government.
Senate
PACs, w h i c h
-242-
c a n d i d a t e s r e c e i v e d more
amounts
t o 33
percent
than
of a l l
�monies
contributed
by
Congress r e c e i v e d
PACs.
50
More t h a n
percent
or
half
more o f
the
their
members
of
campaign
contribu-
866
tions
From
PACs.
Federal
the
limits
requirement
insuFFicient
that
the
on
that
to
both
those
control
Federal
personal
a m o u n t s be
inFluence
Election
and
PAC
contributions,
reported,
peddling.
Commission
has
have
been
Mitrovich
exhibited
and
contends
"appalling
867
incompetence."
He
a regulatory
agency
Republicans,
with
views
which
r e c o m m e n d s "A
the
to
establish
congressional
races,
new
with
From
t h e most s e v e r e
.
868
oFFice.
Failure
to
criminal
Democrats
too
Few
Election
campaign
r e s u l t i n g From
and
members.
Commission
Financing
observe
(with)
For
these
all
limits
penalties
or
disqua1iFication
system
campaign
Jrr
The
is
on
as
between
p o w e r s and
Federal
limits
exacting
incompetence
is divided
insuFFicient
Mitrovich
power
this
the
true
cost
reduced
oF
the
current
conFidence
which
accountability
oF
oFFicials.
representative
government,
replace
the
elected
current
system
the
public
oF
oF
American
To
has
reestablish
Financing
special
voter
oF
Financing
in
a
truly
campaigns
interest
the
must
group
869
Financing.
The
with
those
American
elected
dollars
or
oFFicials
communications
congressional
From
consumer
the
From
arrive
encouraged
letters
and
powerFul
will
have
that,
i n t e r e s t groups,
voter.
to
phone
in suFFicient
members u n d e r s t a n d
registered
Senator
via
m u s t be
To
-243-
the
communicate
calls.
numbers
although
they
r e t a i n the
consider
to
Only
will
they
derive
job,
that
constituents'
when
may
their
derive
jobs
Representativ(
viewpoints.
�In
this
plus
way,
one
occasional
vote
will
'votes'
count...one
i n the
Form
oF
vote
on
election
opinions
on
day,
important
i ssues.
Americans
process
as
shopping
minimal
From
The
they
and
are
For
care
reForm
that
consumer
Because
r .
r
Financial
change
toward
diFFiculty
Each
the
and
the
by
that
and
cost
oF
take
part
health
lives
Health
aFFect
car.
ways
legislation
d e c i s i o n and
and
anywhere
same
health insurance
insured beneFits.
should
them
a new
passage
h e a l t h care
the
insurance
Comparison
w a l l e t s i n the
Yet,
Fact
individual
a beneFicial
will
i m p o r t a n t - - t h e h e a l t h and
removed
(
Policymaking
and
oF
legislative
considered
t o 30,000 For
aFFect
will.
employer-provided
coverage.
t o $10-
will
purchases
more
i s oFten
a d e c i s i o n which
legislation
the
home a p p l i a n c e s .
health insurance,
something
members.
Familiar with
Consumer R e p o r t s
a microwave
oF
as
at purchasing
perusing
purchase
•"'• i\'.i
become
p r e p a r a t i o n For
$100-t-
aFFect
should
the
of
will
Family
i s pro-,
protected
reForm
From
may
extent
~
oF
in guiding
the
process
cutccme.
i s oFten
370
stalemate.
Brown
a F F l i c t e d by
chronic
deadlock
states:
Perhaps the d i s c o n n e c t i o n between problems
and p o l i t i c s r e F l e c t s a d e e p e r d i s j u n c t i o n
b e t w e e n s o c i a l e n d s a n d p o l i c y means.
A society
t h a t i n p r i n c i p l e wants t o r e s p o n d t o t h e needs
oF t h e d i s a d v a n t a g e d
m i g h t n o t a g r e e e i t h e r on
j u s t w h a t i t w a n t s t o t e l l g o v e r n m e n t t o do o r
t h a t g o v e r n m e n t s n o u l d be e n c o u r a g e d t o e x e r c i s e
i n t h i s s p h e r e t h e d i s c r e t i o n i t has u s e d
on^^
o t h e r occasions t o advance o t h e r causes..."
He
states also
and
be
yet
lack
that
u n c e r t a i n about
conFidence
although
Fashioning
that
the
p u b l i c may
means t o e n d s ,
government
will
deliver
want
they
change
may
i t wisely
�and
Fairly
-- w h i c h
may
i n d i c a t e a proFound
F a i l u r e oF
S72
political
nation
trust.
would
a national
reject
health
"re1uctance...to
sphere
the u n i v e r s a l entitlements
insurance
quote
program.
incorporate
oF c i t i z e n s h i p
To
so
I t was B r o w n ' s b e l i e F i n 1990 t h a t t h e
Joseph
The
inherent i n
reasoning:
policy entitlements
87 3
within the
rights..."
CaliFano,
because
only
h i s w o r d s c a n be
basic
and s u c c i n c t :
"So what c a n we do t o a r r e s t t o w e r i n g
health
c a r e c o s t s and p r e s e r v e and e n h a n c e o u r m i r a c u l o u s
medical
system?
Plenty.
We c a n s h a p e t h i s i n c i p i e n t r e v o l u t i o n i n t o
a Fundamental t r a n s F o r m a t i o n
oF t h e p e r s o n a l
m o t i v a t i o n s , F i n a n c i a l i n c e n t i v e s , and i n s t i t u t i o n a l
r o l e s and r e l a t i o n s h i p s oF d o c t o r s , h o s p i t a l s ,
p a t i e n t s , and p u r c h a s e r s oF h e a l t h c a r e .
To do s o , we've g o t t o s t o p b l a m i n g t h e
other guy--the p a t i e n t , doctor, h o s p i t a l a d m i n i s t r a t o r , h e a l t h i n s u r e r , m e d i c a l equipment m a n u F a c t u r e r ,
d r u g company, m a l p r a c t i c e l a w y e r , u n i o n ,
corporate
employer, government b u r e a u c r a t .
A l l oF u s must
l o o k t o o u r s e l v e s , t o what we c a n do d i F F e r e n t l y . Q
We must c h a n g e t h e way we t h i n k a b o u t h e a l t h c a r e .
7 4
CONCLUSION.
The
oF
health
personal
maniFested
and
It
health
overzealous
does
c a u s e s oF h e a l t h
health
care
consumer
responsibility
oF a
which i s
demand, p h y s i c i a n
attorneys,
n o t seek
care
lack
incompetence
and o p p ) o r t u n i s t i c
ways
to correct the
cost problems
will
not provide
and
individual
reForm
oF t h e
rsForm.
i s imperative that
care
i s a consequence
consumer
Any p l a n w h i c h
social
spiral
and c o r p o r a t e moral
selF-reFerral,
eFFective
cost
i n excessive
insurers.
root
care
every
understand
- 2 '-I 2 -
interest
that
group
eFFective
�American
health
care
industry
tion,
or other
Those
who a r e b e n e f i t t i n g
be
called
organization,
upon
spent
were
complete
care.
mOst.
The p a s t
forty
number
of visits
will
with
have
insurance
sacrifices.
that
to give
they
f o r (2 v e r y
stays
were
o f each
a
and
dollar
to physicians
a rarity for
has seen a s i g n i f i c a n t r i s e
of health
will
up e x p e c t i n g
ago, v i s i t s
to caregivers, but without
has improved,
corpora-
reform.
coverage
and h o s p i t a l
years
i n the state
person,
now may f i n d
One g e n e r a t i o n
few and f a r between
health
t h e most
medical
each
t o make some e c o n o m i c
and f a m i l i e s
on h e a l t h
increase
require
t o s a c r i f i c e t h e most
Individuals
demanding
will
i n the
corresponding
individual.
b u t n o t a t t h e same r a t e
that
To be
costs
sure,
have
increased.
Employers,
insurable
premiums
especially
groups
which
larger
Physicians,
to
lower
required
so t h a t
they
groups
can b e n e f i t
will
from
have
t o form
t h e lower
are able
t o enjoy.
providers
on e c o n o m i c p r o s p e r i t y .
an e n t i r e
more-than-camfartab1e
employers,
and o t h e r
hospitals,
their sights
that
small
national
standard
population
of living
will
be
required
I ti s not
subsidize
an
f o r one segment
already
of
i t s
p o p u l a t i on.
Insurance
addition
carriers
to the legal
are
written,
there
not
t o abandon
will
obligations
i s also
now u n d e r s t a n d
drawing
f o r decades
he I p f u t u r e
t o understand
they
a moral
incur
that in
when
and s o c i a l
policies
responsibility
patients.
Unions
been
have
emp I o y e e s ,
that
the well
has almost
union
from
run dry.
demands w i l l
have
which
they
have
I n order to
t o be
i n Line
�with
the requests
tottering
health
Federal,
stand
t h a t everyone e l s e w i l l
care
be making on a
industry.
s t a t e and l o c a l l e g i s l a t o r s w i l l
t h a t they
No l o n g e r w i l l
are dealing with
submission
a more s o p h i s t i c a t e d
In
order
F o r any o f t h e reForm p l a n s
economically
and s o c i a l l y - - a l m a s t
will
be a d v e r s e l y
a F F e c t e d by some a s p e c t
We w i l l
each e x p e r i e n c e
to
n o t be i n s u r m o u n t a b l e ,
but w i l l
a s s u r e t h a t t h e chosen p l a n w i l l
Health
c a r e reForm w i l l
power s t r u c t u r e
disinclination
t o be
every
eFFective--
p e r s o n i n t h e U.S.
o f t h e p l a n t o some
some Form o f d i s s a t i s F a c t i o n
w h i c h we a r e n o t now e x p e r i e n c i n g .
will
results in
of society.
both
extent.
consumer.
t o p o w e r F u l i n t e r e s t g r o u p s by
l e g i s l a t o r s be t o l e r a t e d when such s u b m i s s i o n
detriment t o the health
have t o u n d e r -
require
However, t h e d i s s a t i s F a c t i o n
be r e a s o n a b l e
and n e c e s s a r y
remain economically
Feasible,
t h a t t h e most p o w e r F u l
oF a l l has t o be o v e r c o m e . . . t h e b a s i c human
t o change.
u»
un • un
-247-
�CHART
Health Care Costs as a
Percent of Payroll for
State and Local Governments
10.3%
5.2%
i
C
O
OJ
i
1982
989
S o u r c e s : 1982: C e n s u s Bureau, 1982
Census of G o v e r n m e n t s ; 1989: Foster
Higgins H e a l t h Care B e n e f i t s Survey
Source:
"Trends i n Employee H e a l t h B e n o F i t Costs i n S t a t e and L o c a l Government i n t h e 1980s" ( C h a r t
P r e s e n t e d t o t h e S t a t e a n d L o c a l n o v e r n m e n t L a b o r - M n n a c j e m e n t C o m m i t t e e , J u n e 12, 1990
1)
�CHART
average Annual Health Plan
Cost Per State and Local
Government Employee, 1984-89
2
C u r r e n t Year $
$3500
$2836
$3000
$243j
$2500
$2000
$1906
$1755
$1589
$207t
01
nj
i
$1500
Between 1984 and 1989,
Health Plan Costs Increased 50 Percent
Even After Adjusting for Inflation
$1000
$500
$0
1984
1983
1985
1986
1987
1988
1989
1990
S o u r c e : Foster Higgins annual
H e a l t h Care B e n e f i t s Surveys
Source:
"Trraridc
in
P r e s e n t -.^,1
Emp
to
t h n
S f ^ t n
^n-
n r
,H
,
,
Locnl
n
n
n
r
G o v P r,,
m
„,,,
•
L
l
t
n
„,,
t
"
0
n
^
_
M
n
n
'
,
^
L
r
o
,„
n
m
1
^
Govemmer.t
„ „ ,.
,
. „
r
n
m
r
i
l
M
in
t h /
1980G"
1 ^
1 C| n p
( C h a r t
nl
�CHART
Average Annual Cost of Health
Premiums in State Government, 1980-89
3
Indemnity Plans
Current Year $
$3500
$3,080
$3000
Family Plans
$2500
i
$2000
$1500
$1,343
$976
Individual Plans
$1000
$437
$500
$0
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
Source.- M a r t i n E. Segal,
Annual Surveys of State
Employee H e a l t h Benefit Plans
Sourcn:
"Trendp,
in Employee
^
„
P r m e r i !; r? i
(
t
U
Health
1
D
R
L
r
n
r
a
F
U
0
l
:
n
t
a
R
n
r
l
,
c
n
I
i
t
Costs
in
Government
State
anrl
Local
L n b n r - M a n n r . i o m e r , I;
Government
Comm i t h e e ,
in
the
June
1S80s"
12
1930
(Chart
4
�CHART
Percent Increase in State
Government Employee Health Benefit Costs
Compared to Inflation (CPI), 1980-89
25%
20*
-
Health Benefits
^S%r
10% h
Inflation (CPI)
5% r
0%
1980
1981
1982
1983
1S84
1985
1988
1987
1988
1989
1990
Indemnity Plans
Sourct: Martin E. S«g»l Cotnpmny
Note: Martin E. Segal Company d i d not conduct surveys i n 1981,
1982, and 1984. T h e r e f o r e , i n t h i s c h a r t , the annual percent
change for the 1980-83 « s p e r i o d was c a l c u l a t e d by d i v i d i n g the
premium c o s t i n c r e a s e from 1980 to 1983 by t h r e e to get an
average annual percent i n c r e a s e .
Likewise, the annual percent
change for the 1983-85 p e r i o d was c a l c u l a t e d by d i v i d i n g the
i n c r e a s e from 1983 t o 1985 by two to get an average annual
percent i n c r e a s e .
S our ~e :
" T r a n d s i n Employee H e a l t h B e n e F i t C o s t s i n S t a t s and L o c a l
Government i n t h e 198Qs" ( C h a r t 3 ) .
P n e s e r . t s d t o t n e S t a t e a n d L o c a l G o v e r n m e n t L a o o r - M a r . age." er.
C o m m i t t e e . J u n e 1 2 . 19 S C
-25 1 -
4
�APPENDIX
Insurer
Substituted
THE
Judgment
NEW YORK TIMES,
F e b r u a r y 26, 1991
Letters
The Bane of Medical Second-Guessing
To the Editor:
In "Medical Second-Guessing — In Advance," Feb. 24, Glenn Kramon makes the point that medical necessity reviews protect patients from unnecessary procedures while cutting costs to insurance companies. My personal experience is that case review is an
open invitation to insurers to deny or indefinitely delay treatment
where (costly) medical intervention ts legitimately requried.
I suffer from a genetic disorder — Gaucher's disease. Unable to
produce an essential enzyme, my body allows a fatty material to accumulate uncontrollably in various places. My liver, bones and
bone marrow are most severely affected and I continue to deteriorate at a frighteningly rapid pace. I am essentially homebound except for infrequent forays on my motorized scooter.
Last year, a miracle occured. The Genzyme Corporation of Boston developed Ceredase, the enzyme replacement necessary to
treat Gaucher's disease. Initial studies have shown remarkable results and in June 1990, the F.D.A. decided to expand access to this
promising new treatment in cases like mine where a patient is seriously ill. Ceredase is the only treatment for Gaucher's disease and
my only hope for survival.
In September, my physician and a representative from Genzyme sent exensive information about my case and the Ceredase
treatment to my insurer. For six months now I've been waiting for
the insurer to fulfill its end of our contract and agree to pay for my
treatment The insurer maintains that it will decide on my claim
only after studying treatment results on several other Gaucher's
sufferers to determine the efficacy of enzymerela cement therapy.
Since Gaucher's is an uncommon disorder with a wide range of diversity among cases, garnering sufficient data for its review may
take my insurer years. It is likely that by the time the insurer is finished second-guessing I will be either completely debilitated or, the
ultimate In cost-effectiveness, deceased.
LINDA SHAFARMAN
New York, N.Y., Feb. 20
�NOTES
1.
D o n a l d G. M c N e i l , J r . , " W a s h i n g t o n T r i e s t o S o r t
H e a l t h I n s u r a n c e P r o p o s a l s , " The New Y o r k T i m e s ,
1 9 3 1 , p. E2.
1 and
Out
Nov.
17,
2.
I d . cols.
2.
3.
I d . c o l . 2.
4 .
Id .
5 .
Id. , cols.
6.
P. A. P a u l - S h a h e e n , " O v e r l o o k e d C o n n e c t i o n s : P o l i c y
D e v e l o p m e n t and I m p l e m e n t a t i o n i n S t a t e - L o c a l R e l a t i o n s , "
15 J o u r n a l o f H e a l t h P o l i t i c s , P o l i c y a n d Law 8 3 3 , W i n t e r
1990.
(Hereinafter,
Paul-Shaheen)
7.
Id . at
836 .
8.
Id . at
334 .
9.
Id . at
855 .
10 .
Id . at
835 .
11 .
Id .
12 .
Id .
13 .
Id . at
14 .
Id .
15 .
Id .
16 .
Id .
17.
R a s h i I- e i n , 'The H e a l t h S e c u r i t y P a r t n e r s h i p , " J o u r n a l oF
t h e A m e r i c a n M e d i c a l A s s o c i a t i o n , May 15, 1 9 9 1 , a t 2 5 5 5 .
18.
Id.
19.
F a i t h P o p c o r n , "The P o p c o r n R e p o r t , " (New Y o r k : D o u b l e d a y ,
1 9 9 1 ) a t 7.
F a i t h P o p c o r n i s a m a r k e t i n g c o n s u l t a n t and
F u t u r i s t , a t r e n d F o r e c a s t e r F o r b l u e - c h i p compEsnies s u c h
as E a s t m a n K o d a k , N i s s a n , a n d IBM.
She p r e d i c t e d t h e
F a i l u r e oF New C o k e , a n d t h e demand F o r F r e s h F o o d s a n d
Four-wheel d r i v e .
She h a s c o i n e d d e s c r i p a t i v e p h r a s e s s u c h
as C o c o o n i n g ( t h e s t a y - a t - h o m e s y n d r o m e ) a n d the. D e c e n c y
• ecade (1 330s) .
2 and
3.
83S .
-25S-
�20.
Exception:
See W i c k l i n e v. S t a t e , 192 C a l . A p p . 3 d
239 C a l . R p t r . 810 ( 1 9 8 6 ) , i n f r a p.
149.
21.
David WilsFord, "Doctors
U n i v e r s i t y Press, 1991).
22.
R e g i n a E. H e r z l i n g e r ,
M o n t h l y , August 1991,
23.
Robert
The
New
and t h e S t a t e , " (Durhcam: Duke
(Hereinafter, WilsFord)
" H e a l t h y C o m p e t i t i o n , " The
p. 69 a t 7 8 .
Potts,
"Who
Asked
York
Times,
Nov.
1630,
a F a v o r ? Who
21,
1991,
Wrote
Dp-Ed p.
the
A19,
Atlantic
Law?"
cols.
2,
3,
24.
I d . c o l . 2.
25.
Id.
25.
J o s e p h A. C a l i F a n o , J r . , " A m e r i c a ' s H e a l t h C a r e R e v o l u t i o n ;
Who L i v e s ? Who D i e s ? Who P a y s ? " (New Y o r k : Random H o u s e ,
1986).
(HereinaFter, CaliFano)
27.
WilsFord,
23.
Id.
29.
I d . at
30.
M a l c o l m G. T a y l o r , " I n s u r i n g N a t i o n a l H e a l t h C a r e ;
C a n a d i a n E x p e r i e n c e , " ( C h a p e l H i l l : The U n i v e r s i t y
C a r o l i n a P r e s s , 1 9 9 0 ) , a t 16.
31.
Id.
32.
I d . at
33.
Id.
34.
I d . at
18,
19.
35.
I d . at
19,
20.
36.
I d . at
20.
37.
Id.
38.
I d . at 2 1 .
39.
Id.
40.
I d . at
• 1.
a
42 .
supra
note
21,
at
2.
26.
17.
22.
Id. at 23.
I d . at
137.
- 257-
the
oF N o r t h
�43.
I d . a t 1 8 7 , 188.
44.
I d . a t 187.
45.
I d . a t 29.
46.
I d . a t 1 8 8 , 189.
47.
I d . a t 189.
48,
S t u d i e s by Woods G o r d o n
a t 194 e t s e q .
49.
I d . a t 197.
50.
I d . a t 198.
51.
I d . a t 199, 200.
52.
I d . a t 198.
53.
I d . a t 202.
54.
a t 192 e t s e q . , a n d J o h n
Horne
Id.
55 .
I d . a t 2 1 .0.
56
I s a a c E h r l i c h , e d i t o r , " N a t i o n a l H e a l t h P o l i c y ; What
Role For Government?" ( S t a n f o r d : Hoover I n s t i t u t i o n
P r e s s , 1 9 8 0 ) , a t 38.
(HereinaFter, Ehrlich)
57.
Id.
58.
I d . a t 39.
39.
I d . at 41.
60.
I d . a t 54.
6 1.
I d . a t 54, 55.
62.
I d . a t 55.
S3.
I d . a t 57.
64.
Id.
65.
Id.
66.
Id.
67.
L i g h t a n d S c h u l l e r , e d i t o r s , " P o l i t i c a l V a l u e s oF H e a l t h
C a r e : The German E x p e r i e n c e , " ( C a m b r i d g e : M . I . T . P r e s s ,
1 9 3 6 ) a t 103, 125.
-2!
�58 .
Id . at
254 .
59.
Id . at
28
70 .
Id . at
28 .
7 1 .
Id . at
35 .
72 .
I d . a t 45 .
73 .
Id . at
46 .
74 .
Id . at
49 .
75 .
Id . at
55 .
75 .
Id . at
63 .
77 .
Id .
78 .
Id . at
79 .
B r a d f o r d L. K i r k m a n
I m p l e m e n t a t i o n i n t h e N e t h e r l a n d s and t h e F e d e r a l R e p u b l i c
o f G e r m a n y , " 265 J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n
1 4 9 6 , May 15, 1 9 9 1 .
80.
Id.
81.
Senator
82.
Id.
83.
I d . at
5.
84.
I d . at
4.
85.
I d . at
5.
86.
Id.
37.
Id.
38.
I d . at
89.
Id.
90.
Id.
91.
S e n a t o r Bob K e r r e y , H e a l t h USA A c t o f
Cost Containment P r o v i s i o n s , J u l y 11,
92.
Id.
and
fn
3.
64 .
Bob
K e r r e y , News R e l e a s e ,
July
11,
1991,
at
4.
6.
-259-
1991,
1991,
Over-view o f
p.1 and n . 1 .
�•3.
I d . a t 2.
94.
I d . a t 3.
95.
96.
97.
Id.
Senator
Bob
Kerrey,
News R e l e a s e ,
July
1 1 , 1 9 9 1 , a t 5.
Id.
98.
I d . a t 7.
99.
CaliFano,
supra
n . 26, a t
179.
100.
I d . a t 184..
101.
Tom W i c k e r , " I n t h e N a t i o n : A C o s t l y 10 P e r c e n t , " The New
Y o r k T i m e s , J u l y 2 1 , 1 9 9 1 , a t 17E, q u o t i n g J o h n B u r r y , J r .
102.
I d . ,paraphrasing
103.
John B u r r y , J r .
Id.
104.
C l a r k C. H a v i g h u r s t , " H e a l t h C a r e Law a n d P o l i c y , "
[ W e s t b u r y : The F o u n d a t i o n P r e s s , 1 9 8 8 ) a t 1 1 6 3 .
(HereinaFter
Hav i g h u r s t )
105.
Health
Health
106.
I d . a t 37.
107.
I d . a t 36.
108.
I d . a t 33.
109.
A s s o c i a t i o n oF A m e r i c a ,
D a t a 1990" a t 35.
" S o u r c e Book
oF
Id.
110.
Insurance
Insurance
Id.
111.
P e p p e r C o m m i s s i o n H e a l t h C a r e A c c e s s and ReForm
S.1177, a t §421.(HereinaFter, S.1177)
112.
I d . at
113.
A c t oF
1991,
§2101(a).
Id.
114.
I d . at
§2108(d).
115.
I d . at
§2105(c).
116.
The H e a l t h A m e r i c a :
A F F o r d a b l e H e a l t h Care For a l l A m e r i c a n s
A c t , S . 1 2 2 7 , was i n t r o d u c e d by S e n a t o r s M i t c h e l l ,
Kennedy,
Riegle,
and R o c k e F e l l e r
on J u n e
-250-
5,
1991.
�117.
S . 1 177 a t
§2106(b).
118.
I d . a t §2102Ca)CA).
119.
I d . a t §2102(a)C B) .
120.
I d . a t §2204(3) and
121 .
I d . a t §2204(d).
122 .
I d . a t §2224(a).
123.
I d . a t §2312(b)(2) (A) .
124.
I d . a t §2254(a) and
125.
I d . a t §2303(a)(2)(A) .
125 .
S . 1 177 , T i t l e X X I I , c o v e r s Acc
Basic H e a l t h Through a P u b l i c H e a l t h
(d)(2)(B).
(b)(1).
Insurance
Plan.
127.
S.1177, §2251(b)(2).
128.
I d . a t §2261 ( c ) .
129.
I d . a t §2263(b). P r o v i s i o n t o t a k e eFFect
y e a r s a F t e r t h e e n a c t m e n t oF 3 . 1 1 7 7 .
130.
I d . a t §306.
131.
I d . a t §305.
132.
Foster
133.
Summary oF S . 1 2 2 7 , p r o v i d e d by S e n a t o r s M i t c h e l l , K e n n e d y ,
R i e g l e , a n d R o c k e F e l l e r , J u n e 5, 1 9 9 1 , a t 3.
(HereinaFter,
Summary)
134.
I d . a t 2.
135.
Higgins
i s an e m p l o y e e
beneFit
Id.
135.
Summary,
supra
137.
S. 1 2 2 7 , §270 1 ( a ) ( 1 ) .
133.
I d . a t §2701 ( a ) ( 2 ) .
139.
Summary,
140.
S.1227, §2722(b).
14 1.
I d . a t §2722(a).
supra
n . 1 3 3 , a t 5.
n . 1 3 3 , a t 6.
-26 1 -
January
consulting
1, s i x
Firm.
�142.
Id.
at
§27E2(aH6)
143.
Id.
at
§27220).
144.
Summary, s u p r a
145.
Additional discussion
in included infra.
of the actual
146.
Summary, s u p r a
a t 3.
147.
I d . a t 5.
148.
I d . a t 7.
149.
I d . a t 6.
150.
I d . a t 7.
151.
I d . a t 5.
152.
See
infra,
p.212 f o r f u r t h e r
153.
See
infra,
p p . 5 7 a n d 198 f o r f u r t h e r
154.
See
infra,
p.230 f o r f u r t h e r
155.
Summary, s u p r a
156.
Id.
157.
158.
159.
160.
161 .
n . 1 3 3 , a t 7.
n.133,
n.133,
sections
discussion
of the b i l l
of malpractice.
discussion
discussion
of technology
o f consumers.
a t 5.
Id.
Pamela J. B l a c k , " T u r n i n g O f f Renegade T C e l l s , "
Week, Nov. 18, 1 9 9 1 , a t 6 9 .
Business
Id.
Business
Week, Nov.
18, 1 9 9 1 , R e a d e r s R e p o r t ,
a t 14.
Id.
Califano,
163.
Summary,
:
§ 272 1 ( b ) ( 3 ) .
a t 6 .
162.
154.
and
supra
supra
n . 2 5 , a t 102.
n . 1 3 3 , a t 6.
Id.
165 .
S.700
i s covered
166.
Senator
157.
H.R.
1S3.
infra,
I d . at 1 .
Gurenberger,
3205,
Summary,
p. 140.
Press
August
release,
2,
- 2E2-
p.2. n o t d a t e d .
1 9 9 1 , a t 4.
�169.
I d . at
2.
170.
I d . at
4.
171.
I d . at
5.
172.
I d . at
7.
173.
I d . at
8.
174.
M a r k T h o r n t o n , " A l c o h o l P r o h i b i t i o n Was a F a i l u r e , "
I n s t i t u t e P o l i c y A n a l y s i s N o . 1 5 7 , J u l y 17, 1 9 9 1 , p.
(HereinaFter, Thornton)
175.
Id.
175.
Id.
CATD
14.
177.
I d . at
2.
178.
I d . at
13.
179.
I d . at
9.
189.
I d . a t 6, q u o t i n g L a w r e n c e W. R e e d , " W o u l d L e g a l i z a t i o n
I n c r e a s e Drug Use?"
F r e e M a r k e t , Feb.
1990.
181.
Thornton, at
182.
Id.
183.
L u d w i g v o n M i s e s , "Human A c t i o n , "
Henry R e g n e r y , 1 9 5 6 ) , a t 733.
184.
Id.
185.
R i c h a r d H a r r i s , "A S a c r e d T r u s t , " ( B a l t i m o r e :
1 9 6 9 ) , a t 35.
(HereinaFter Harris)
185.
Id.
187.
Supra,
183.
J . H o l a h a n , S. Z e d l e w s k i , " I n s u r i n g L o w - I n c o m e A m e r i c a n s :
I s M e d i c a i d t h e Answer?"
(The Urban I n s t i t u t e , W o r k i n g
P a p e r , J u l y 1 9 9 0 . ( H e r e i n a F t e r , Ho 1 a h a n / Z e d 1 e w s k i )
189.
I d . at
190.
6.
n o t e 56,
2.
Id.
191 .
I d . at
3.
192.
I d . at
3.
at
3d r e v i s e d
ed.,
(Chicago:
Penguin
Books,
416-417.
�193.
I d . a t 19.
194.
I d . a t 10.
195.
I d . at
196.
I d . a t 1.
197.
19.
Id.
198.
I d . a t 2.
199.
K r i z a y a n d W i l s o n , "The
L e x i n g t o n Books, 1974),
200.
Id.
201.
Ho 1 a h a n / Z e d 1 e w s k i , s u p r a
202.
I d . at
203.
P a t i e n t As
a t 80.
n.188,
Consumer,"
(Lexington:
a t 2.
14.
Id.
204.
I d . a t 20.
205.
I d . at 21.
206.
207.
Id.
I d . a t 22.
208.
Id.
209.
D a v i d B l u m e n t h a l , "The T i m i n g a n d C o u r s e o f H e a l t h
ReForm,§ The New E n g l a n d J o u r n a l oF M e d i c i n e , J u l y
a t 138.
(HereinaFter,
Blumenthal)
210.
Id.
211.
Id.
212.
Id.
Care
18, 1 9 9 1 ,
213.
W i l l i a m Roper,
W h i t e House,"
2 14.
Id.
215.
I d . at
2 16.
Id.
217.
Lynn Etheredge, " N e g o t i a t i n g N a t i o n a l H e a l t h
Insurance,"
16 J o u r n a l oF H e a l t h P o l i t i c s , P o l i c y a n d Law 127,
Spring
" F i n a n c i n g H e a l t h C a r e : A V i e w From t h e
H e a l t h A F F a i r s , W i n t e r 1989, pp. 97, 99.
100.
1991.
-254-
�218.
I d . a t 158.
2 13.
I d .
220.
I d .
221.
I d . a t 160.
222.
S t u a r t M. B u t l e r , "A T a x ReForm S t r a t e g y t o D e a l W i t h t h e
Uninsured,"
J o u r n a l oF t h e A m e r i c a n M e d i c a l
Association,
May 1 5 , 1 9 3 1 , a t 2 5 4 1 . ( H e r e i n a F t e r , B u t l e r )
223.
I d .
224.
I d .
225.
225.
I d . a t 2542.
I d .
227.
I d . a t 2543.
228.
S.84 § 2 5 A ( a ) ( 2 ) ( A ) , w h i c h w i l l a F F e c t
Code C h a p t e r 1 ( a ) ( I V ) ( A ) (§ 25A) .
229.
S .84,
230 .
.
I . R . S Code
231 .
s .84,
§25A(2)(B)(b)(2)(A).
232 .
s .34,
§25A(2)(B) ( b ) ( 2 ) ( B ) .
233 .
s .85,
§40a(1)(a)(7)(A).
234 .
s. 35 , § 4 3 2 ( a ) .
235 .
s .85,
§433(b)(2)(A).
235 .
s .37,
§25A(a).
237 .
I . R . 5 Code
.
238 .
A l a i n E n t h o v e n and R i c h a r d
H e a l t h P l a n F o r t h e 1 9 9 0 s , " 3 2 0 New E n g l a n d
M e d i c i n e 2 9 , J a n u a r y 5, 1 9 8 9 . ( H e r e i n a F t e r ,
the Internal
Revenue
§ 2 5 A ( 2 ) (B) (b) (1 ) .
§213(F).
§25A(c ) ( 1 ) .
J o u r n a l oF
JAMA 1 / 5 / 3 9 ) .
239.
A l a i n Enthoven and R i c h a r d K r o n i c k , " U n i v e r s a l
Health
I n s u r a n c e T h r o u g h I n c e n t i v e s R e F o r m , " 2S5 J o u r n a l oF
t h e A m e r i c a n M e d i c a l A s s o c i a t i o n 2 5 3 2 , May 1 5 , 1 9 9 1 .
( H e r e i n a F t e r , JAMA 5 / 1 5 / 9 1 ) .
240.
Missouri
p.4.
Citizen Action
(HereinaFter,
Report,
QEA)
-255-
Question
and Answer
section,
�241.
J.A.M.A. 5 / 1 5 / 9 1 ,
supra
n. 2 3 9 , a t 2532.
242. I d .
243.
I d . a t 2533.
244.
I d . a t 2534.
245.
I d . a t 2533-2534.
245.
I d . a t 2534.
247.
A m e r i C a r e i s t h e p r o g r a m e s t a b l i s h e d by t h e H e a l t h A m e r i c a
A F F o r d a b l e H e a l t h Care F o r A l l A m e r i c a n s A c t , S.1227,
i n t r o d u c e d J u n e 5, 1 9 9 1 .
243.
T h e H e a l t h I n s u r a n c e C o v e r a g e a n d C o s t C o n t a i n m e n t A c t oF
1 9 9 1 , H.R. 3 2 0 5 , was i n t r o d u c e d by R e p r e s e n t a t i v e Dan
R o s t e n k o w s k i ( C - I l l . ) o n A u g u s t 2, 1 9 9 1 .
249.
J.A.M.A., 5 / 1 5 / 9 1 ,
supra,
note
250. I d .
251 . I d .
252. I d .
253. I d .
254.
I d . a t 2535.
255. I d .
255.
I d . a t 2536.
257.
4 2 C.F.R. § 4 3 3 . 1 0 ( a ] ( b ] .
258.
42 C.F.R. § 4 3 3 . 1 4 ( b ) ( 6 ) ( i ) .
259.
4 2 C.F.R. § 4 3 3 . 3 3 ( b ) .
250.
4 2 C.F.R. § 4 3 3 . 3 3 ( c ) ( 2 ) .
251 .
4 2 . U.S.C. §2102(g) .
252.
5.1227
§ 2742(a) ( 1) (A) .
263.
S.1227
§2742(b ) ( 1 ) ( 3 ) ( 1 ) .
254.
S.1227
§2742(b ) ( 1 ) ( 3 ) ( i i ) .
265.
3.1227
§2742(c)(1).
-2E5-
239, a t 2534.
�2SS.
S.1227
§2781(a).
2G7.
S.1227
§2781(b)(2).
268.
6.1227
§2781(d).
269.
6.1227
§2781(F).
270.
S.1227
§2781(g).
271.
J o n e s v . R a t h P a c k i n g Company, 4 2 0 U.S. 5 9 1 ( 1 9 7 7 ) , as
s t a t e d i n M a n d e l k e r , N e t s c h , S a l s i c h , Wegner , " S t a t e
and L o c a l G o v e r n m e n t i n a F e d e r a l S y s t e m , " ( C h a r l o t t e s v i l l e :
The M i c h i e Company, 1 9 8 3 ) , p . 5 1 9 .
(HereinaFter, Mandelker)
^
272.
S i l l ^ w o o d v . K e r r - M c G e a C o r p o r a t i o n , 4 6 4 U.S.
s t a t e d i n M a n d e l k e r , s u p r a , n. 2 7 1 , a t 5 1 9 .
273.
F i d e l i t y F e d e r a l S a v i n g s S L o a n A s s o c i a t i o n v . De La C u e s t a ,
458 U.S. 1 4 1 , 153 ( 1 9 8 2 ) , as s t a t e d i n M a n d e l k e r , s u p r a n o t e
27 1 , a t 5 19.
275.
M a r y l a n d v . L o u i s i a n a , 4 5 1 U.S. 7 2 5 , 746 ( 1 9 8 1 ) ,
i n M a n d e l k e r , s u p r a n. 2 7 1 , a t 520.
274.
P a c i f i c Gas S E l e c t r i c Company v . E n e r g y R e s o u r c e s
C o n s e r v a t i o n S D e v e l o p m e n t C o m m i s s i o n , 4 6 1 U.S. 1 9 0 , 204
( 1 9 8 2 ) , as s t a t e d i n M a n d e l k e r , s u p r a n o t e 2 7 1 , a t 5 1 9 .
275.
S.1227 §471 oF t h e H e a l t h A m e r i c a A c t w h i c h w i l l a F F e c t
§§2791 a n d 2 7 9 3 oF t h e P u b l i c H e a l t h S e r v i c e A c t .
277.
InFra,
273.
Missouri
279.
See W i c k l i n e
230.
The D u r e n b e r g e r
23 1.
p. 1 4 9 .
Rev. S t a t u t e
375 . 935( 1 1 ) ( b ) .
v. S t a t e ,
Report,
inFra
p. 1 4 9 .
April
1 9 9 1 , a t 2, c o l . 2.
Id.
233.
S.700,
234.
Julie
March
§5000(d).
235.
I d . a t 7C3, c o l . 1.
285.
I d . a t c o l . 2.
2 3 7.
I d . a t 7 0 9,
K o s t e r l i t z , "Seeking
24, 1990, a t 708.
t h e Cure," N a t i o n a l
c o l . 1.
-2S7-
as
as s t a t e d
Id.
232.
238 ( 1 9 8 4 ) ,
Journal,
�238.
283.
Paul-Shaheen, supra
note
S a t 834.
I d .
290.
M i s s o u r i C i t i z e n A c t i o n R e p o r t on t h e M i s s o u r i U n i v e r s a l
H e a l t h A s s u r a n c e P l a n ( H . B . 1 1 2 7 ) , i n t r o d u c e d by S t a t e
R e p r e s e n t a t i v e G a i l L. C h a t F i e l d ( 6 9 t h D i s t r i c t ) i n 1 9 9 0 .
( H e r e i n a F t e r , MCA R e p o r t )
291.
QSA, s u p r a
292.
MCA R e p o r t , a t j .
293.
QSA , s u p r a
294.
QSA a t
295.
note
note
240,
240,
a t 2.
a t 2.
1.
I d .
296.
MCA R e p o r t ,
supra
note
290,
a t 2.
297.
QSA, a t 3.
298.
MCA R e p o r t ,
299.
QSA a t 4.
300.
"The H e a l t h
G r a y , 1991)
301.
Thomas W. G r a n n e m a n n , " P r i o r i t y S e t t i n g : A S e n s i b l e
A p p r o a c h t o M e d i c a i d P o l i c y ? " 28 I n q u i r y 3 0 0 , 3 0 1 , F a l l
1991 ( H e r e i n a F t e r , G r a n n e m a n n )
302.
D a v i d M. E d d y , " O r e g o n ' s P l a n , S h o u l d I t Be A p p r o v e d ? "
26 J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n 2 4 3 9 , 2 4 4 3 ,
Nov. 6. 1 9 9 1 . ( H e r e i n a F t e r , E d d y )
a t 2.
Care 500,"
a t 159.
(Washington,
D.C:
F a u l k n e r and
303. I d .
304.
305.
R e h a b i l i t a t i o n A c t oF 1 9 7 3 ,
306.
C h a r l e s J. D o u g h e r t y , " S e t t i n g H e a l t h Care P r i o r i t i e s ,
O r e g o n ' s N e x t S t e p s , " 2 1 H a s t i n g s C e n t e r R e p o r t 1 , 6,
May-June 1991 ConFerence R e p o r t .
307.
f
Age D i s c r i m i n a t i o n A c t , 4 2 U.S.C. § 6 1 0 , a n d Age D i s c r i m i n a t i o n i n E m p l o y m e n t A c t 2 9 U.S.C. § 6 2 1 .
Grannemann,
supra
308.
Eddy,
note
supra
note
302,
301,
42 U.S.C.
a t 302.
a t 2442.
-268-
§6000.
�309.
B u s i n e s s Week, S e p t e m b e r 3 0 , 1 9 9 1 , "The 1 9 9 1 B u s i n e s s
WeeK S y m p o s i u m o f H e a l t h C a r e CEOs," a t 1 2 5 .
310.
Eddy,
supra
note
302, a t 2442.
3 11. I d .
312.
I d .a t 2444.
313.
S t . L o u i s M e t r o p o l i t a n M e d i c a l S o c i e t y s p o n s o r e d a Forum
on N o v e m b e r 2 0 , 1 9 9 1 , i n F r o n t e n a c , M i s s o u r i , o n t h e F u t u r e
oF H e a l t h C a r e .
The s p e a k e r was an a t t e n d e e , s p e a k i n g From
t h e a u d i e n c e . ( H e r e i n a f t e r , S t . L o u i s Med. S o c i e t y F o r u m )
314.
S t u a r t M. B u t l e r , D i r e c t o r o f D o m e s t i c P o l i c y S t u d i e s a t
t h e H e r i t a g e F o u n d a t i o n , W a s h i n g t o n , D.C., was a s p e a k e r a t
t h e S t . L o u i s M e t r o p o l i t a n M e d i c a l S o c i e t y Forum.
315.
R o n a l d B r o n o w , M.D., s p o k e s p e r s o n f o r t h e N a t i o n a l O r g a n i z a t i o n o f P h y s i c i a n s Who C a r e a t t h e S t . L o u i s M e d i c a l
S o c i e t y ' s Forum, o f f e r e d t h i s comment.
31S.
Eddy,
317.
I d . a t 2440.
318.
319.
320.
321.
322.
supra
note
302, a t 2439.
I d .
I d . a t 2445.
I d .
Paul-Shaheen,
supra
note
6, a t 3 4 7 .
I d .
323.
I d .
a t 837.
324.
Id.
a t 838.
325.
I d .
32S.
Id.
a t 8 3 8 , n . 5.
327.
" H e a l t h Care f o r t h e U n i n s u r e d Program
D.C.: The A l p h a C e n t e r , J a n u a r y 1 9 9 0 ) ,
Alpha ) .
Update,"
(Washington,
a t 1.
(Hereinafter
The R o b e r t Wood J o h n s o n F o u n d a t i o n was e s t a b l i s h e d i n 1935
i n P r i n c e t o n , New J e r s e y , a n d e x i s t s t o i m p r o v e h e a l t h
s e r v i c e s i n t h e U.S. w i t h e m p h a s i s on i m p r o v i n g a c c e s s t o
h e a l t h care f o runderserved groups.
#
328.
Alpha,
supra
note
3 2 7 , a t 1.
-259-
�329.
I d . at
7.
330.
Id.
331.
Id.
332.
Id.
333.
I d . at
334
J u d i t h G l a n z e r , SCOPE P r o j e c t D i r e c t o r , as s t a t e d
M e d i c i n e a n d H e a l t h P e r s p e c t i v e s , e d i t e d by J a n e t
W i e n e r , J u n e 13, 1 9 9 0 , a t 4.
335 .
Alpha,
336 .
Id .
337 .
Id . at
4.
338 .
Id . at
6.
339 .
Id . at
3.
340 .
Id . at
6.
341 .
Id . at
5.
342 .
Id .
343 .
Id . at
344 .
Id .
345 .
Id .
346 .
Id .
347 .
Id .
348 .
Id .
349 .
Id . at
350 .
Id .
351 .
Id . at
3.
352 .
Id . at
a.
353 .
Id .
2.
SL
7.
8.
-270-
in
Ochs
�354.
" T r e n d s i n Employee H e a l t h B e n e F i t C o s t s i n S t a t e and
L o c a l Government i n t h e 1980s," p r e s e n t e d t o t h e S t a t e
and L o c a l Government Labor-Management C o m m i t t e e ,
J u n e 12, 1 9 9 0 .
355.
David Warner, "Costs Rise For Medical P l a n s , "
B u s i n e s s , A p r i l 1 9 9 1 , a t 3 2 . See a l s o i n F r a ,
and A p p e n d i x , pp. 2 4 8 - 2 5 1 .
355.
A r e e n , K i n g , G o l d b e r g , a n d C a p r o n , "Law, S c i e n c e a n d
M e d i c i n e , " f W e s t b u r y : The F o u n d a t i o n P r e s s , 1 9 8 4 ) , a t 3 0 1 .
357.
I d . a t 300.
358.
W a d l i n g t o n , W a l t z , a n d D w o r k i n , "Law a n d M e d i c i n e , "
( W e s t b u r y : The F o u n d a t i o n P r e s s , 1 9 8 0 ) , a t 8 0 .
359.
Id.
360.
Nation's
p. 2 2 0 ,
Id.
361.
43 A m . J u r . 2 d ,
362.
P u b l i c S e r v i c e M u t u a l I n s u r a n c e Company v . L e v y ,
87 M i s c . 2 d 9 2 4 , 387 NYS3d 9 6 2 , a s r e p o r t e d i n 43 Am . J u r . 2 d
I n s u r a n c e §22.
353.
I d . a t §26, p . 1 0 2 .
354.
I d . a t 103.
365.
E n c y c l o p e d i a oF A s s o c i a t i o n s , ( D e t r o i t :
Company, 1 9 9 1 ) .
356.
R o b e r t P e a r , "2 B i l l s Seek A F F o r d a b l e H e a l t h I n s u r a n c e , "
The N e w Y o r k T i m e s , O c t . 2 5 , 1 9 9 1 , p. A 1 0 , c o l . 5.
367.
I d . at cols.
368.
Insurance
§22.
Gale
Publishing
3 a n d 4.
Id.
369.
G i n s b e r g v . D e n v e r , 164 C o l . 5 7 2 , 4 3 6 P.2d
i n 43 A m . J u r . 2 d I n s u r a n c e § 2 2 .
3 7 0.
C e n t r a l T r a n s p o r t a t i o n Company v . P u l l m a n ' s P a l a c e Car
Company , 139 U.S. 2 4 , 35 L.Ed. 5 5 , 11 S . C t . 4 7 3 ;
U n i o n T r u s t S S a v i n g s Sank v. K i n l o c k L o n g D i s t a n c e
T e l e p h o n e Company, 2 5 8 1 1 1 . 2 0 2 , 101 N.E. a 5 3 5 ; as r e p o r t e d
i n 34 A m . J u r . 2 d P u b l i c U t i l i t i e s §26.
3 7 1.
Id.
-27 1 -
6 8 5 , as
reported
�372.
373.
U n i t e d Gas P i p e L i n e Company v. L o u i s i a n a P u b l i c S e r v i c e
Company, 241 La. 687, 130 S.2d 652, as r e p o r t e d i n
64 Am.Jur.2d §192.
374.
B l u e F i e l d W a t e r w o r k s S I m p r o v . Co. v. P u b l i c S e r v i c e
C o m m i s s i o n , 262 U.S. 6 7 9 , 67 L.Ed. 1176, 43 S.Ct. 675, as
r e p o r t e d i n 64 Am.Jur.2d §192.
375.
64 Am.Jur.2d §28.
376.
" S o u r c e Book o f H e a l t h I n s u r a n c e Data 1990" [ W a s h i n g t o n ,
D.C.: H e a l t h I n s u r a n c e A s s o c i a t i o n o f A m e r i c a , 1 9 9 0 ) , a t
103.
C H e r e i n a f t e r , S o u r c e Book)
377.
Id . at
103- 104.
378 .
Id . at
104 .
379 .
Id . at
105 .
380.
Id .
381 .
43 Am . J u r . 2 d ,
382 .
Id . at
§ 1 8 , p. 9 1 .
383.
Id . at
§57, p p .
1 4 2 , 143
384 .
Id . at
§60, p p .
1 4 5 , 146
385 .
Id . at
§61 , p.
146.
386 .
Id . at
§63, p.
147.
387 .
Id . at
§ 6 4 , p.
148.
388 .
I d . a t §64, p. 148, c i t i
I n s u r a n c e Company v . Pag
389 .
Id . at
§73, p.
154.
3,90 .
Id . at
§77,
157.
391 .
Source
Book ,- s u p r a
392 .
f
P e n n s y l v a n i a R a i l Company v. P h i l a d e l p h i a C o u n t y ,
220 Pa. 100, 68 A. 676, as r e p o r t e d i n 64 Am.Jur.2d §190.
Id . at
16 .
393.
Id .
394 .
Id . at
6.
p.
Insurance
note
�396.
397.
S o u r c e Book, s u p r a
393.
I d . at
15.
399.
I d . at
14.
400.
I d . at
15.
401.
Id.
402.
I d . a t 30,
403.
Id.
404.
I d . at
7.
405.
I d . at
15.
406.
I d . at
6.
407.
"Industry
S Poor's,
SSP]
408.
"1991 B u s i n e s s R a n k i n g s A n n u a l , ( D e t r o i t : Gale R e s e a r c h ,
Inc.,
1991), q u o t i n g Best's Review, L i F e / H e a l t h e d i t i o n ,
D e c e m b e r 1 9 8 9 , p. 3 1 5 .
409.
SSP,
410.
Source
Book, s u p r a
411.
I d . at
20.
412.
Id.
413.
Id.
414.
M i s s o u r i Rev.
415.
Source
416.
W i c k l i n e v.
417.
f
Dr. R o n a l d Bronow, s p e a k i n g a t t h e November 20,
S t . L o u i s M e t r o p o l i t a n M e d i c a l S o c i e t y F o r u m on
F u t u r e OF H e a l t h C a r e .
The M c C a r r a n - F e r g u s o n
( 1988) .
418.
E d w a r d 0. C o r r e i a , "The
Applying Federal Policy
A n t i t r u s t Laws a n d I n s u r a n c e :
to a State-Regulated
Industry,"
25 T o r t S I n s u r a n c e Law
(HereinaFter, Correia)
Journal
table
note
note
Book,
at
14.
2.14.
Surveys,
J u l y 12,
supra
376,
1991
the
I n s u r a n c e and I n v e s t m e n t , "
1 9 9 0 , S e c t i o n 2, p. 1-32.
407,
Stat.
at
note
88.
376,
§375.936
inFra note
Standard
(HereinaFter
376,
S t a t e , i n F r a p.
Act,
-273-
a t .19,
20.
(I1)(b).
at
20.
149.
59
Stat.
793,
33,
15
813;
U.S.C.
Summer
1011-1015
1991.
�419. I d .
420.
15 U.S.C. § 1 0 1 2 ( a ) .
421.
15 U.S.C. § 1 0 1 2 ( b ) .
422.
15 U.S.C.
423.
U n i o n L a b o r L i F e I n s u r a n c e Company v . P i r e n a , 4 5 3 U.S. 119
( 1 9 8 2 ) , as s t a t e d i n H a v i g h u r s t , s u p r a n o t e 104, a t 1 1 5 1 .
§1013(b).
424. I d .
425. I d .
42S.
I d .at
1158.
427. I d .
428.
I d .at
1159.
429.
American Bar F o u n d a t i o n Working Paper S e r i e s #8801,
" A e t n a , We're S o r r y We M e t W i t h Y a ? " by I a n A y r e s a n d
P e t e r S i e g e l m a n , 1 9 8 8 ( H e r e i n a F t e r , A y r e s / S i e g e 1 man)
430.
I d .at
431.
I d . a t 2.
432.
A r i z o n a v. Maricopa County
102 S . C t . 2 4 S 6 . ( 1 9 8 2 ) .
1.
Medical Society,
433. I d .
434.
Correia,
supra note418,
a t 814.
435. I d .
436.
I d . a t 8 1 5 , n.S.
437. I d .
438. I d .
439.
I d . a t 815.
440.
I d . a t 8 1 8 , n.20 .
44 1.
I d . a t 816.
442.
I d . a t 316,
443.
I d .at
n.13.
19.
-274-
4 5 7 U.S. 3 3 2 ,
�444.
I d .
445.
I d .a t 821, notes
446.
I d .
at 821.
447.
I d .
a t 830.
448.
I d .at 831.
449.
L i s a D r i s c o l l , " I n s u r e r s Are Giving a L i t t l e t o Avoid
G i v i n g a L o t , " B u s i n e s s Week, J u n e 3, 1 9 9 1 , a t 2 7 .
(HereinaFter,
Driscoll)
450.
I d .
452.
34. 38.
Id.
451.
a t 20.
Id.
453.
454.
M a r g a r e t Levy, " C u r r e n t Coverage Issues i n H e a l t h
Insurance
Law:
I s T h e r e C o v e r a g e When T h e r e I s No C o v e r a g e ? " 26 T o r t
S Insurance
law J o u r n a l 621 (1991) ( H e r e i n a F t e r , Levy)
I d .
455.
Id.
456.
I d .at 621.
457.
Id.
458.
a t 622.
a t 622.
I d .
459.
Id.
a t 624.
450.
Id.
a t 622.
45 1.
R o b e r t H. J e r r y I I , " U n d e r s t a n d i n g I n s u r a n c e Law," (New
Y o r k : M a t t h e w B e n d e r , 1 9 8 7 ) , p. 109, n . 1 5 , q u o t i n g
ProFessor Rahdert's a r t i c l e , "Reasonable
Expectations
R e c o n s i d e r e d , " 18 C o n n . L .Rev.
3 2 3 , 344 ( 1 9 8 6 ) .
(HereinaFter,
Jerry).
462.
J e r r y , a t 107.
453.
Id.
a t 111.
454.
Id.
a t 110.
453.
Id.
465.
Id.
457.
I d . a t 111.
-275-
�468.
I d .
469.
I d . a t 106, n.6., q u o t i n g K i e v i t v. L o y a l P r o t e c t i o n
I n s u r a n c e Company, 170 A . 2 d a t 24 ( 1 9 6 1 ) .
470.
J e r r y , s u p r a n o t e 4 6 1 , a t 107, n.4., q u o t i n g E s t r i n
C o n s t r u c t i o n Company v . A e t n a C a s u a l t y S S u r . Co., 6 1 2 S.W.2d
413 (Mo.App. 1 9 8 1 ) .
471.
Levy, supra note 453, a t 628, r e F e r r i n g t o Kunin v . Senef i t
T r u s t L i F e I n s u r a n c e Company, 6 9 6 F.Supp. 1 3 4 2 ( C . O . C a l . 1 9 8 8 )
472.
SSP,
473.
note
4 0 7 , a t 1-33.
I d .
474.
supra
LiFe
Id.
475.
I d . a t 1-35.
476.
I d . a t 1-34.
477.
I d .
478.
C o t t o n , " P r e e x i s t i n g C o n d i t i o n s 'Hold Americans Hostage' t o
E m p l o y e r s anD I n s u r a n c e , " J o u r n a l oF t h e A m e r i c a n M e d i c a l
A s s o c i a t i o n 2 4 5 1, May 1 5 , 1 9 9 1 .
379.
B u s i n e s s Week, S e p t e m b e r 3 0 , 1 9 9 1 , "The 1 9 9 1 B u s i n e s s
S y m p o s i u m o F H e a l t h C a r e CEOs," a t 1 2 3 + .
480.
Havighurst,
481.
S.700
482.
The D u r e n b e r g e r
483.
S.700
§5000A(u)(3).
484.
S.700
§5000(B)(d).
485.
The D u r e n b e r g e r
486.
I d . a t 2.
487.
S.700 § 5 0 0 0 ( B ) ( D ) ( 1 ) a n d ( 3 ) .
483.
S.700 § 5 0 0 0 ( B ) ( d ) ( 2 ) a n d ( 4 ) .
489.
S.700
§5000(B)(d)(5).
490.
S.700
§5000(a)(1)(c)(ii)(II).
491.
S.700
§5000(C)(c).
supra
note
104, a t 1133, n.7.
§5000(b)(1)(C).
Report,
Report,
A p r i l 1991.
A p r i l 1991.
-276-
Week
�492.
S.70Q
§5000(3)(b)(2)(A).
493.
S.1227
§2723(b) a t p . 4 0 .
494.
S.1227
§2723(c)(1).
495.
S.1227
§2723(c)(2), a t p. 4 1 .
495.
S . 1 2 2 7 Summary
497.
S.1227
§2722(c), a t p. 3 4 .
493.
S.1227
§2722(d).
499.
S.1227
§2743(c)(1)(B).
500.
Havighurst,
501.
Bronow, B e l t r a n , Cohen, E l l i o t t , Goldman, and S p o t n i t z ,
"The P h y s i c i a n s Who C a r e P l a n , " 2 6 5 JAMA 2 5 1 1 , 2 5 1 4 ,
May 1 5 , 1 9 9 1 . ( H e r e i n a F t e r , B r o n o w / J A M A )
502.
Wickline
(1986).
503 .
Wickline,
504 .
Id .
at
812 .
505 .
Id .
at
813 .
506 .
Id .
507 .
Id .
at
814 .
508 .
Id .
at
815 .
509 .
Id .
at
817 .
510.
Id .
at
8 16 .
511.
Id .
5 12 .
Id .
5 13.
Id .
at
8 17.
5 14.
Id .
5 15.
Id .
a t 817,
5 15.
Id .
a t 3 16.
5 17.
Id .
a t 3 17.
a t 9.
supra
note
104, a t
1058.
v . S t a t e , 192 C a l . A p p . 3 d
(HereinaFter, Wickline)
2
-277-
1630, 239 C a l . R p t r .
810
�518.
Id . at
814.
5 13.
Id . at
815 .
520.
Id . at
817.
521 .
Id . at
819.
522 . I d . a t
819 ,
523.
S l i p o p i n i o n , W i c k l i n e v . S t a t e o f C a l i F o r n i a , No. B 0 1 0 1 5 S ,
( C a l . C t . App. 2d C i s t . , J u l y 3 0 , 1 9 8 B ] , a t 2 9 , 3 0 .
524.
W i c k l i n e , 239 C a l . R p t r . 810, a t 320.
525.
S.1227,
§2725(eHl)
52S.
S.1227
§2725(e)(3).
527.
C.
528.
W i l l i a m s v . H e a l t h A m e r i c a , 4 1 O h i o A p p . 3 d 2 4 5 , 5 3 5 N.E.2d 7 1 7
( 1 9 8 7 ) , as e x p l a i n e d by W i l l i a m A. C h i t t e n d e n I I I , " M a l p r a c t i c e
L i a b i l i t y a n d Managed H e a l t h C a r e : H i s t o r y a n d P r o g n o s i s , "
26 T o r t S I n s u r a n c e I I r n l . 4 5 1 , a t 4 7 4 , S p r i n g 1 9 9 1 .
(HereinaFter, Chittenden)
529.
W i l l i a m s v. H e a l t h A m e r i c a
530.
I d . a t 722.
531.
Chittenden,
532.
I d . a t 476.
533.
I d . a t 477.
534.
I d . a t 478.
535.
I d . a t 4 7 8 , n. 136.
536.
2 2 2 C a l . App. 3d 6 6 0 , 2 7 1 C a l . R p t r . 7 8 7 6
i n C h i t t e n d e n , supra n o t e 528, a t 478.
537.
I d . a t 479.
538.
supra
TV,
note
June 30, 1991.
a t 720.
528, a t 475.
(Cal.Ct.App.
1990),
Id.
539.
E v e r e t t K o o p , NBC
and ( 2 ) .
Id.
540.
2 6 3 C a l . R p t r . 850
n o t e 528, a t 480.
34 1 .
( C a 1 .Ct . App.
I d . a t 480.
-279-
1989),
Chittenden,
supra
�542.
I d .
543.
See a l s o A p p e n d i x , p . 2 5 2 , F o r a d d i t i o n a l a n e c d o t a l
c o n F i r m a t i o n oF t h e d e t r i m e n t a c c r u i n g t o p a t i e n t s
From i n s u r e r s ' s u b s t i t u t e d
judgments.
544.
U.S. C o n g r e s s , O F F i c e o f T e c h n o l o g y A s s e s s m e n t ,
" I n s u r i n g t h e U n i n s u r e d : O p t i o n s and A n a l y s i s , "
( W a s h i n g t o n , O.C:
Government P r i n t i n g OFFice, 1388).
545.
D e b o r a h S t o n e , " P r e d i c t i v e M e d i c i n e : I m p l i c a t i o n s and
E F F e c t s , " i n " D r i v i n g Down H e a l t h C a r e C o s t s , " e d . by
M a r t i N C e n s o r ( G r e e n v a l e , N.Y.: P a n e l P u b l i c a t i o n s , 1 3 8 3 )
a t 5-2.
( H e r e i n a F t e r , Stone)
546.
Stone,
547.
P a t r i c i a A. B a i r d , " G e n e t i c s S H e a l t h C a r e : C h a l l e n g e
a n d C h o i c e , " i n " D r i v i n g Down H e a l t h C a r e C o s t s , " e d . by
M a r t i n C e n s o r ( G r e e n v a l e , N.Y.: P a n e l Pub 1 i ceat i o n s , 1 3 8 3 )
a t 6-2.
(HereinaFter, Baird)
548.
Baird,
543.
I d . a t 6-2.
550 ,
U.S. C o n g r e s s , O F F i c e oF T e c h n o l o g y A s s e s s m e n t , " G e n e t i c
M o n i t o r i n g and S c r e e n i n g i n t h e W o r k p l a c e , "
(Washington,
D.C:
U.S. G o v t . P r i n t i n g O F F i c e , O c t o b e r , 1 9 3 0 ) p . 1 1 .
( H e r e i n a F t e r , OTA)
551.
J e a n E. McEwen, a s q u o t e d b y R o r i e S h e r m a n i n " E m p l o y e r
Use oF G e n e t i c T e s t s t o be R e s t r i c t e d ? " N a t i o n a l Law
J o u r n a l , Nov. 2 5 , 1 3 3 1 , a t 18, c o l . 1 . ( H e r e i n a F t e r ,
Sherman)
552.
OTA,
553.
I d . a t G.
554.
I d . at71.
555.
a t 505.
a t 6-4.
supra
note
5 5 0 , a t 5.
I d .
5 5 6.
I d .
a t 5.
Similar
quote
557.
Id.
a t 32.
558.
I d . a t 33.
559.
L. B. A n d r e w s a n d A. S. J a e g e r , " C o n F i d e n t i a l i t y oF
G e n e t i c I n F o r m a t i o n i n t h e W o r k p l a c e , " 27 A m e r i c a n
J o u r n a l oF Law £ M e d i c i n e 7 5 , 1 9 9 1 ( H e r e i n a F t e r , A J L S M ) .
560.
Id.
a t 32.
-220-
appears
a t p. 3 2 .
�5S1.
I d .
562.
I d . a t 83.
563.
I d . a t 82.
564.
OTA, s u p r a
555.
Id. at
566.
note
5 5 0 , a t 14.
12.
I d .
567.
Id.
558.
The O c c u p a t i o n a l
29 U.S.C. §650.
559.
AJLSM, s u p r a
570.
29 C.F.R. § 1 9 1 0 . 2 0 ( a ) ,
57 1.
AJLSM a t 9 8 .
572.
at
15.
SaFety
note
and H e a l t h
Act (Public
Law
91-595),
559, a t 96.
AJLSM
a t 98.
I d .
573.
E m p l o y e e R e t i r e m e n t I n c o m e S e c u r i t y A c t , 29 U.S.C. § 5 1 0 ,
as m e n t i o n e d i n S t o n e , s u p r a n o t e 5 4 5 , a t 5 - 6 .
574.
Stone,
575.
National
576.
OTA, s u p r a
577.
42 U.S.C.
573.
OTA, s u p r a
579.
Stone,
Annot.
580
Americans With D i s a b i l i t i e s
42 U.S.C. § 120 1 .
531.
OTA, s u p r a
532.
a t 5-6.
note
Relations
550, a t
A c t , 29 U.S.C. §151 e t s e q .
IS.
§2000e.
note
5 5 0 , a t 15.
s u p r a n o t e 5 4 5 , a t 5-7, q u o t i n g
§10:5-12a ( W e s t S u p p . 1 9 8 8 ) .
note
New J e r s e y
Act, Public
Id.
at
534.
Sherman,
5 5 0 , a t 16.
17.
supra
note
I d . a t 13, c o l .
55 1, a t 13, c o l s .
3.
-23 1 -
Stat.
Law 10 1-336,
I d .
533.
535
Labor
3, 4.
�586.
537.
538.
589.
Telephone
i n t e r v i e w , December
10, 1 9 9 1 .
Id.
Sherman,
supra
note
5 5 1 , a t 13, c o l . 1 .
Id.
590.
Baird,
supra
note
5 4 7 , a t 5-9.
591.
Areen,
supra
note
355, a t 295.
592.
Id.
393.
I d . a t 295.
594.
WilsFord,
595.
supra
note
2 1 , a t 25.
Id.
595.
R i c h a r d H a r r i s , "A S a c r e d T r u s t , "
B o o k s , I n c . , 1 9 S 9 ] , p. 1 .
59 7.
I d . a t 2.
598.
Id.
599.
Id.
500.
I d . at 1 .
501.
I d . a t 9.
502.
Id.
303
I d . a t 10.
504.
I d . a t 11.
505.
Id.
505.
I d . a t 13.
507.
I d . a t 14.
503.
I d . a t 15.
503.
I d . a t 16.
5 10.
Id.
5 11.
I d . a t 13, 17.
5 12.
I d . a t 17.
(Baltimore:
Penguin
�513.
Id.
at
18.
514.
Id.
at
32.
615.
Id.
at
33.
6 16.
Id.
at
34 .
617.
Id.
at
39.
618.
Id.
at
40.
619.
Id.
620.
Id.
at
50.
521 .
Id . at
51 .
622.
Id.
at
52.
623.
Id.
at
72,
624.
Id.
at
73.
625.
Id.
at
72.
625.
Id.
at
77.
527.
Id.
at
83.
528.
Id.
at
84.
529.
Id.
at
85.
630.
Id.
631 .
Id . at
109.
632.
Id.
at
113.
533.
Id.
at
134.
534.
Id.
at
125,
635.
Id.
at
14 1.
536.
Id.
at
79.
537.
Id.
at
SO.
538.
Id.
at
79.
539.
Id.
at
145.
73.
136
-23::-
�640.
I d . at
150.
541 .
I d . at
151 .
542.
I d . a t 153, 154,
Post column.
543.
I d . at
544.
Id.
545.
I d . at
545.
Id.
547.
I d . at
175.
548.
I d . at
180.
549.
I d . at
180.
550.
I d . at
181.
55 1.
I d . at
185.
552.
I d . at
187.
553.
I d . at
192.
654.
I d . at
209.
555.
I d . at
188.
656.
I d . a t 2 16.
657.
I d . at
553.
Id.
559.
J . 5. T o d d , S. V. S e e k i n s , J . A. K r i c h b a u m , L . K. H a r v e y ,
.
"HealthAccess
A m e r i c a - - 5 t r e n g t h e n i n g t h e U. 3. H e a l t h
CarE S y s t e m , "
J o u r n a l of the American Medical A s s o c i a t i o n
2 5 0 3 , May
15, 1 9 9 1 . ( H e r e i n a f t e r , T o d d )
560.
I d . at
55 1.
Id.
552.
D r . Thomas R e a r d o n , s p e a k i n g F o r t h e AMA
at the St.
M e t r o p o l i t a n M e d i c a l S o c i e t y F o r u m on t h e F u t u r e o f
H e a l t h C a r e , November 20,
1991.
553.
Todd,
quoting William
V.
Shannon's
New
York
170.
174.
217.
2504.
supra
note
659,
at
2503.
_p34-
Louis
�BS4.
B65.
Id.
I d . a t 2505.
BBS.
Id.
SB7.
Id.
SB8.
BBS.
P a u l J . F e l d s t e i n , " H e a l t h A s s o c i a t i o n s a n d t h e Demand
For L e g i s l a t i o n , " (Cambridge:
Ballinger Publishing
Company, 1 S 7 7 ) .
(HereinaFter, Feldstein)
B70.
I d . a t 4.
671 .
I d . a t 5.
B72.
I d . a t 9.
673.
I d . a t 10.
674.
t
5 . 1 2 2 7 Summary, a t B.
New Y o r k T i m e s , May 2 6 , 1 9 9 1 , L e t t e r t o t h e E d i t o r , by
O l i v e r A l a b a s t e r , M.D., D i r e c t o r o f t h e I n s t i t u t e f o r
Disease P r e v e n t i o n a t George Washington U n i v e r s i t y .
675.
Id.
676.
Id.
677.
Source
678.
T e l e p h o n e i n t e r v i e w w i t h K a t h y S u t t o n oF P h y s i c i a n s
C a r e , San A n t o n i o , T e x a s , D e c e m b e r 6, 1 9 9 1 .
579.
Bronow/JAMA, s u p r a
680.
I d . a t 25 13,
681.
S t . L o u i s M e t r o p o l i t a n M e d i c a l S o c i e t y F o r u m on t h e
F u t u r e oF h e a l t h C a r e , F r o n t e n a c , M i s s o u r i , N o v e m b e r
20 , 1 9 9 1 .
682.
Book, s u p r a
note
note
376, a t 47.
Who
501, a t 2511.
c o l . 2.
Id.
683.
684.
I d . a t 25 1 1 .
685.
t
Bronow/JAMA, s u p r a
I d . a t 2 5 1 3 , c o l . 2, a n d c o m m e n t s made a t t h e S t . L o u i s
M e t r o p o l i t a n M e d i c a l S o c i e t y Forum.
636.
note
5 0 1 , a t 2 5 1 2 , c o l . 3.
Id.
-235-
asss
�3
686a. I d .
587.
I d .
588.
I d . a t 2513,
683.
I d . a t 2 5 1 4 , c o l . 2.
690.
I d . a t 2 5 1 4 , c o l . 2.
691.
I d .
692.
2514.
I d .
693.
I d . a t c o l . 3.
594.
The New Y o r k T i m e s , N o v e m b e r 2 1 , 1 9 9 1 , L e t t e r t o t h e
E d i t o r by M i l o u
Erickson.
695.
S t a t e m e n t s made a t t h e S t . L o u i s M e t r o p o l i t a n M e d i c a l
S o c i e t y F o r u m on t h e F u t u r e o f H e a l t h C a r e , Nov. 2 0 , 1 9 9 1
696.
Robert Pear, "Federal A u d i t o r s
M e d i c a l B i l l i n g , " The New Y o r k
a t 018.
697.
I d . a t A 1 , c o l . 2.
698.
I d . a t C18, c o l . 1 .
699.
I d . a t C.18, c o l s .
700.
I d . a t C18, c o l . 1 .
70'1 .
I d . a t C18 , c o l s . 1 , 2 .
702.
I d . a t C18, c o l . 3.
703.
I d . a t C18, c o l . 4 .
704.
T h e o d o r e N. M c D o w e l l , J r . , " P h y s i c i a n S e l F
ReFerral
Arrangements: L e g i t i m a t e Business or Unethical
E n t r e p r e n e u r i a l i s m , " 15 A m e r i c a n J o u r n a l oF Law S
M e d i c i n e 6 1 , S p r i n g 1990.
705.
I d . a t 6 1 , n o t e 1 , q u o t i n g a r e p o r t From t h e O F F i c e oF
t h e I n s p e c t o r G e n e r a l , D e p a r t m e n t oF H e a l t h sand Human
S e r v i c e s , " F i n a n c i a l A r r a n g e m e n t s B e t w e e n Phy s i c i J:-. ..
.
_:,]-.' .'i_-oluii C u r e b u s i n e s s e s , " p p . i i i a n d 1 1 , May 1 9 8 9 .
706.
I d . a t 6 2 , n . 5.
5, 6.
-286-
HEHSS
R e p o r t R i s e i n Abuses i n
Times, December 2 0 , 1 9 9 1 ,
�707.
I d . at
B2, n. 7.
708.
I d . at
63 .
709 .
I d . at
62,
710 .
I d . at
61 .
711.
Id . at
107 .
712.
Id .
713 .
Id .
714.
S . 1 2 2 7 ,, Summary
715 .
Supra,
pp.
88 , 8
715.
Feldstein,
supra
717.
Id . at
133 .
718 .
I d . at
134.
719.
Id .
720 .
I d . at
721 .
Id .
722.
Id .
723 .
I d . at
136.
724 .
I d . at
137 .
725.
Exp
I d . a t 137.
i n s u r e r s , e s t a b l i s h e s p r e m i u m s b a s e d on t h e u t i l i z a t i o n
o f c a r e e x p e r i e n c e d by t h e p a r t i c u l a r g r o u p b e i n g i n s u r e d .
725.
I d . a t 138.
727.
I d . a t 139.
728.
n. 7.
135 .
Id.
729.
I d . a t 140.
730.
I d . a t 1 4 0 , r e g a r d i n g t h e U.S. C o n g r e G S , S e n a t e S p e c i a l
C o m m i t t e e on A g i n g , S u b c o m m i t t e e on H e a l t h oF t h e E l d e r l y ,
" B a r r i e r s t o H e a l t h C a r e F o r O l d e r A m e r i c a n s , P a r t 5,"
9 3 r d Cong., 1 s t s e s s . , J u l y 1 1 , 1973.
731.
Feldstein,
supra
note
6 6 9 , a t 140.
-237-
�732.
WilsFord,
supra
note
21,
a t 208,
209.
733.
I d . at
211.
734.
I d . at
209.
735.
Id.
735.
I d . at
737.
S t . L o u i s P o s t D i s p a t c h , "A H e a l t h y M a r k u p , " O c t o b e r
1 9 9 1 , a t 11D, F o l l o w i n g a L o s A n g e l e s T i m e s a r t i c l e .
738.
Id.
739.
Z a c h a r y S c h i l l e r , S u s a n G a r l a n d , and J u l i a S i l e r ,
Humana F l a p C o u l d Make A l l H o s p i t a l s F e e l
Sick,"
B u s i n e s s Week, Nov.
4, 1 9 9 1 , c o l s . 2, 3.
740.
Id.
741.
St.
742.
S.1227,
743.
D a n i e l M. Fox and D a n i e l C. S c h a F F e r , "Tax A d m i n i s t r a t i o n
as H e a l t h P o l i c y : H o s p i t a l s , t h e I n t e r n a l R e v e n u e S e r v i c e ,
a n d t h e C o u r t s , " 15 J o u r n a l oF H e a l t h , P o l i t i c s , P o l i c y S
Law 251 , Summer 1 9 9 1 .
744.
Id . at
745 .
I d . a t n . l . , r e g a r d i n g Rev. R u l . 5 9 - 5 4 5 , 1 9 6 9 - 2 C B .
117,
a l s o r e l e a s e d as t . I . R . 1022, d a t e d O c t o b e r 2 8 ,
1969.
745 .
Id . at
25 1 .
747 .
Id . at
251,
748 .
Id . at
252 .
749 .
I d . a t 2 6 1 , n. 2 0 , H e a r i n g s on Tax R e F o r m , 1969, P a r t I V ,
beF o r e t h e H o u s e C o m m i t t e e on Ways and M e a n s , 9 1 s t C o n g . ,
1 s t s e s s . 1425,
1438
(1969).
750 .
Id .
751 .
Id . at
164 .
752 .
Id . at
262,
753 .
Id . at
263 .
754 .
I d . a t 25 3 and
We 1 F a r e R i g h t s
211.
Louis
Post
§441,
Dispatch,
and
Summary
at
11D,
at
col.
20,
"The
3.
11.
437 .
252
n.3.,
Rev.
Rul.
56-185,
1956-1
CB.
202.
253.
n.S,
r e g a r d i ng S i m o n v. E a s t e r n K e n t u c k y
O r q a n i z a t i o n , 425 U.S.
26 ( 1 ^ 7 5 )
�755.
I d . a t 253 and n.7, r e g a r d i n g C o n s o l i d a t e d Omnibus B u d g e t
R e c o n c i l i a t i o n A c t of. 1 9 8 5 , P u b . L. 9 9 - 2 7 2 , 100 S t a t . 8 2 ,
164 ( 1 9 8 6 ) , 42 U.S.C. §1395dd.
755.
The C o n s o l i d a t e d Omnibus Budget R e c o n c i l i a t i o n A c t o f
1 9 8 5 , P u b . L. No. 9 9 - 2 7 2 § 9 1 2 1 , 100 S t a t . 164 ( 1 9 8 6 ) , a s
s t a t e d by D a v i d R a n d o l p h S m i t h , " M e d i c i n e a n d Law: A I D s ,
C o n s t i t u t i o n a l C h a l l e n g e s t o T o r t Reform and Medical
M a l p r a c t i c e , " 23 T o r t S I n s u r a n c e Law J o u r n a l 3 7 0 , 4 0 2 ,
n. 2 1 0 , W i n t e r 1 9 8 8 .
757.
Id . at
4 0 3 , and
758 .
Id . at
404 .
759.
Id . at
403 .
760 .
Id . at
403 , n . 2 1 2 ,
761 .
Id . at
4D3 , n . 2 1 2 .
762 .
I d . a t 404 , n . 2 2 4 ,
Law Pr o g r a m
753.
Schmidt, Heckert, and Mercer, " F a c t o r s A s s o c i a t e d With
Medical M a l p r a c t i c e : Results from a P i l o t
Study,"
7 J o u r n a l o f C o n t e m p o r a r y H e a l t h Law a n d P o l i c y 1 5 7 ,
Spring
1991.
764.
I d . , q u o t i n g P. D a n s o n , " T h e F r e q u e n c y
Medical Malpractice Claims," 7 Journal
H e a l t h Law a n d P o l i c y 1 5 8 , n . 7.
765.
Comments made a t G r o u p H e a l t h I n s u r a n c e f o r u m
Care R e f o r m , June 1991, S t . L o u i s , M i s s o u r i .
765.
C. E v e r e t t K o o p , c o m m e n t s J u n e
on h e a l t h c a r e r e f o r m .
767.
S.1227 §906, 42 U.S.C. 2 9 9 e t s e q .
768.
S.1227,
769.
Source
770.
I d . a t 256.
771.
5.1227
772.
S.1227 " 4 4 2 ( a ) .
773.
S.1227 §451,
Service Act,
n .2 1 2 .
42
U . S C. §291 ( 1982 ) .
Judith
Waxman o f t h e N a t i o n a l
and S e v e r i t y o f
o f Contemporary
30, 1991,
on H e a l t h
NBC TV p r o g r a m
"90S(a).
Book, s u p r a
note
375,
a t 47.
§442(a)(b).
which
Title
w i l l be §2785(a) o f t h e P u b l i c
XXVII.
-289-
Health
�774.
S.1227
§27B5Co)(3)[•).
775.
S.1227
§2785(a)(4).
776.
S. 1227
777.
§2785(d) .
Id.
778.
S t a t e m e n t made by L a n e K i r k l a n d , AFL-CIO P r e s i d e n t ;
A F L - C I O D e p a r t m e n t o f I n F o r m a t i o n S t a t e m e n t on H e a l t h
C a r e ReForm, F e b r u a r y
19, 1 9 9 1 .
779.
AFL-CIO E x e c u t i v e C o u n c i l H e a l t h Care S u b s t i t u t e
R e s o l u t i o n No.2, Book Dne, p a g e 1 .
Undated, but
p r o b a b l y F e b . 19, 1 9 9 1 .
780.
J a c k S h e i n k m a n , "How t o S o l v e t h e H e a l t h C a r e C r i s i s , "
The New Y o r k T i m e s , J u l y 2 8 , 1 9 9 1 , Op-Ed c o l u m n .
Jack
S h e i n k m a n i s P r e s i d e n t oF t h e A m a l g a m a t e d C l o t h i n g a n d
T e x t i l e Workers Union.
[ H e r e i n a F t e r , Sheinkman)
781.
Id.
782.
A p a r t i a l l i s t i n g oF l e g i s l a t i v e g o a l s s o u g h t by t h e
A F L - C I O , a c c o r d i n g t o t h e S t a t e m e n t by t h e AFL-CIO
E x e c u t i v e C o u n c i l on N a t i o n a l H e a l t h C a r e R e F o r m ,
February
19, 1 9 9 1 , p . 2.
783.
AFL-CIO D e p a r t m e n t o f I n F o r m a t i o n
R e F o r m , F e b . '19, 1 9 9 1 .
784.
Sheinkman,
785.
supra
note
State
on H e a l t h
Care
780, a t
Id.
785.
David Warner, "Costs Rise For Medical P l a n s , "
Nation's
B u s i n e s s , A p r i l 1 9 9 1 , a t 32.
D a t a p r o v i d e d by A. F o s t e r
H i g g i n s S Company, a n d u t i l i z e d by D a v i d W a r n e r .
787.
Id.
788.
S t u a r t M. B u t l e r , " P l a y o r Pay H e a l t h C a r e P l a n i s
B o u n d t o be a L o s e r , " W a l l S t r e e t J o u r n a l , J a n . 3. 1 9 9 2 ,
a t A6, c o l . 3., r e F e r r i n g t o a H a y / H u g g i n s S Company
estimate.
Hay/Huggins i s a beneFits c o n s u l t i n g Firm.
(HereinaFter, Butler)
789.
Butler,
790.
791.
•
c o l . 5.
Id.
Susan
Isn't
B. G a r l a n d , "AL.-JM..:,, ^ : ^ • • i n - . r ' H e a l t h P l a n
F e e l i n g So H o t , " B u s i n e s s Week, Nov. 16, 1 9 9 1 , a t 43
-290-
�792.
793.
794.
I d .
David Warner, " T a c t i c s For C u t t i n g
B u s i n e s s , A p r i l 1 9 9 1 , p. 33.
Costs,"
Nation's
I d .
795.
I d . a t 200.
79B.
Blumenthal,
797.
C o n g r e s s i o n a l Budget OFFice, " S e l e c t e d O p t i o n s f o r
Expanding H e a l t h I n s u r a n c e Coverage," J u l y 1991, PreFace.
798.
I d . at xi i i.
799.
I d . a t xx.
800.
Id. at xxi .
801.
S.700, s u p r a a t
802.
R. A. Z a l d i v e r , " C l e v e l a n d S m a l l B u s i n e s s G r o u p F i n d s
T h e r e ' s S t r e n g t h a n d S a v i n g s i n N u m b e r s , " The J o u r n a l o f
C o m m e r c e , May 2 2 , 1 9 9 1 , a t 9A .
(Hereinafter, Zaldiver)
803.
N a n c y L. J o h n s o n
HeALth I n s u r a n c e
804.
note
2 0 9 , a t 198.
( R - C t . ) Summary o f t h e " S m a l l E m p l o y e r
I n c e n t i v e Act of 1991" (undated).
I d .
805.
supra
I d .
80G.
Zaldiver,
supra
note
807.
S h e l l e y Neumeier, "Companies
Nov. 4, 1 9 9 1 , a t 1 0 2 .
808.
A m e r i c a n B a r A s s o c i a t i o n s e c t i o n on A n t i t r u s t
" I n f o r m a l A n t i t r u s t E n f o r c e m e n t Agency A d v i c e
C a r e , " 1 9 9 1 . ( H e r e i n a f t e r ABA/AL).
809.
ABA/AL, D e p a r t m e n t o f J u s t i c e b u s i n e s s r e v i e w l e t t e r t o
t h e M a r y l a n d H e a l t h C a r e C o a l i t i o n , F e b r u a r y 19, 1982 a t 3 1
810.
ABA/AL, D e p a r t m e n t o f J u s t i c s b u s i n e s s r e v i e w l e t t e r t o
t h e S o u t h w e s t M i c h i g a n H e a l t h S y s t e m s , I n c . , M a r c h 3, 1 9 8 2 ,
p. 3 2 .
811.
ABA/AL, D e p a r t m e n t o f J u s t i c s b u s i n e s s r e v i e w l e t t e r t o t h e
S t a r k County H e a l t h Care C o a l i t i o n , August 30, 1985, p.38.
812.
Mary
F. C a l l a n a n d D a v i d
Care
Cost
Spiral,"
802, a t
C. Y e a g e r ,
(New Y o r k :
-291-
•KM&aes..
waSiiS*-
t o Watch," F o r t u n e
Magazine
Law,
on H e a l t h
"Containing the Health
McGraw-Hill,
1991),
p. 7.
�813,
Bronow/JAMA
814 ,
Employee R e t i r e m e n t
Income S e c u r i t y A c t (E.R.I.S.A.,
29 U.S.C. §1001-1451 ( 1 9 8 2 ) .
815 ,
Bronow/JAMA
81G ,
Id . a t cols.
817,
29 U.S.C. § 1 1 4 4 ( a ) , 1 9 7 5 , a n d Comment, " F e d e r a l
Preemption
oF S t a t e M a n d a t e d H e a l t h I n s u r a n c e P r o g r a m s U n d e r ERISA-t h e H a w a i i P r e p a i d H e a l t h Care A c t i n P e r s p e c t i v e , "
8 S t . L o u i s U n i v e r s i t y P u b l i c Law R e v i e w 3 3 9 ( 1 9 8 9 ) .
818 ,
Id.
819,
S.1227,
820,
§2732(a)(1).
821 ,
§2732(b).
822 ,
S.1227 §2741(b)(9).
The b i l l s t a t e s : "The amount o f any
c i v i l money p e n a l t y i m p o s e d . . . s h a l 1 n o t e x c e e d $ 2 5 , 0 0 0
For each c a r r i e r w i t h r e s p e c t t o w h i c h a v i o l a t i o n
occurs.
823 ,
S. 1227
824.
§2741(b)(9), p . 5 9 .
825 .
Thomas R e a r d o n , M.O., c o m m e n t i n g o n t h e AMA n a t i o n a l
h e a l t h r e F o r m p l a n a n d i t s p o s s i b i l i t y oF a c c e p t a n c e a s
t h e c h o s e n p l a n , a t a F o r u m on t h e F u t u r e oF H e a l t h C a r e
s p o n s o r e d by t h e S t . L o u i s M e t r o p o l i t a n M e d i c a l
Society,
Frontenac,
M i s s o u r i , Nov. 2 0 , 1 9 9 1 .
825
CaliFano,
827 ,
P r e s i d e n t L y n d o n B. J o h n s o n ' s
J a n u a r y 4, 1 9 5 5 .
828
" H e a l t h y P e o p l e 2 0 0 0 -- N a t i o n a l H e a l t h P r o m o t i o n a n d
D i s e a s e P r e v e n t i o n O b j e c t i v e s , " U.S. D e p a r t m e n t oF H e a l t h
a n d Human S e r v i c e s , P u b l i c H e a l t h S e r v i c e ( 1 9 9 0 ) , p . 8 5 .
( H e r e i n a F t e r , HHS)
829 ,
HHS , s t a t e m e n t
For H e a l t h .
830 ,
S t u a r t A. W e s b u r y , J r . , "Why O t h e r N a t i o n s '
W o r k , " The W a s h i n g t o n P o s t , M a r c h 18, 1 9 9 0 ,
831
Id .
a t 342,
supra
supra
note
note
501,
501,
a t 2511.
a t 2513,
c o l . 2.
1 , 2.
n. 19.
§2732(a) a n d ( b ) , p.
§2741 ( b ) ( 4 ) ,
supra
note
61.
p.57.
25,
at
State
oF t h e U n i o n
b y D r . James 0. M a s o n , A s s i s t a n t
-292-
Message,
Secretary
Rx Won't
a t B1, c o l . 3 .
�832. I d .
833. I d .
834.
Marshall
National
J . B r e g e r , " L a w y e r s M u s t L e a d t h e Way,"
Law J o u r n a l , N o v . 1 8 , 1 9 9 1 , p . 1 6 , c o l . 3.
835. I d .
836.
I d . , a t 1 6 , c o l . 2.
837.
National
Law J o u r n a l
Editorial,
August
1 2 , 1 9 9 1 , a t 16.
838. I d .
839.
S.1227 " 2 7 6 1 .
84D.
S.1227
§2762.
841.
S.1227
§2764.
842.
S.1227
§2763.
843.
W i l s F o r d , supra note 2 1 , a t 84, q u o t i n g Jacques Beaupere,
P r e s i d e n t , C o n f e d e r a t i o n des S y n d i c a t s Medicaux F r a n c a i s ,
L e C o n c o u r s M e d i c a l , 1 0 8 - 4 0 , Nov. 15, 1 9 8 6 , r e g a r d i n g t h e
d i s s e n s i o n between s p e c i a l t i e s i n t h e French medical
proFession.
844.
WilsFord,
845.
I d . a t 89.
846.
R o b e r t P e a r , " D e F i c i t o r No D e F i c i t , U n l i k e l y A l l i e s
B r i n g A b o u t E x p a n s i o n i n M e d i c a i d , " The New Y o r k T i m e s ,
Nov. 4, 1 9 9 0 , p . 1 .
a t 86.
847. I d .
848.
I d . a t 14, c o l . 1.
849. I d .
850.
Common C a u s e
'Circulation
Letter'
85t.
Common C a u s e M a g a z i n e ,
852.
Common C a u s e c i r c u l a t i o n
853.
I d . a t 3.
854.
M a r k S h i e l d s , c o m m e n t made on M c N e i l L e h r e r
T e l e v i s i o n , Oct. 25, 1991.
July/August
Oct. 22,
1991.
1991, a t 43, 44.
letter.
-293-
Report,
PBS
�855.
M a r k T w a i n [ S a m u e l L. C l e m e n s ) , " A F t e r D i n n e r S p e e c h , "
S k e t c h e s , New a n d O l d [ v o l . 19 o f t h e W r i t i n g s o f Mark
T w a i n ) , p.235 [ 1 8 7 5 ) , as s t a t e d i n " R e s p e c t F u l 1 y Q u o t e d , "
e d . , Suzy P i a t t , C o n g r e s s i o n a l R e f e r e n c e
Division
( W a s h i n g t o n , D.C: U.S. G o v t . P r i n t i n g O f f i c e , L i b r a r y o f
C o n g r e s s ) 1989.
856.
no
857.
Wilsford,
858.
G e r a l d E. F r u g , " T h e C i t y a s a L e g a l
Law R e v i e w 1 0 5 9 , 1 0 7 0 , A p r i l 1 9 8 0 .
Concept,"
859.
G e o r g e S. M i t r o v i c h , " P u b l i c F u n d i n g
and t h e P o l i t i c s o f B e t r a y a l , " V i t a l
May 1 , 1 9 9 1 , p . 4 3 5 , 4 3 6 .
o f E l e c t i o n s ; Money
S p e e c h e s o f t h e Day,
860.
supra
note
2 1 , a t 98.
93 H a r v a r d
I d .
861.
856...misnumbered.
I d .
862.
D o l l a r f i g u r e s f r o m p.436 o f M i t r o v i c h ' s speech;
f i g u r e s f r o m W o r l d A l m a n a c o f U.S. P o l i t i c s (New
S c r i p p s Howard, 1991).
863.
Mitrovich,
864.
supra
note
Percentage
York:
859, a t 436.
I d .
865.
I n n u m e r o u s TV i n t e r v i e w s
866.
Mitrovich,
867.
I d . a t 438.
868.
by M i t r o v i c h ,
p.
a t 436.
I d .
869.
and q u o t e d
I d .
870.
L a w r e n c e 0. B r o w n , " T h e D e c o n s t r u c t e d C e n t e r : Of P o l i c y
P l a g u e s c n P o l i t i c a l H o u s e s , " 15 J o u r n a l o f H e a l t h P o l i t i c s ,
P o l i c y a n d Law 4 2 7 , Summer 1 9 9 0 .
871.
I d .
872.
I d .
873.
L a w r e n c e D. B r o w n , " T h e M e d i c a l l y U n i n s u r e d :
P o l i c i e s , a n d P o 1 i t i c s , " 15 J o u r n a l oF H e a l t h
P o l i c y a n d Law 4 1 3 , 4 1 5 , Summer 1 9 9 0 .
874.
CaliFano,
supra
note
2 5 , a t 185.
-294-
Problems,'
Politics,
�POLITICAL POWER STRUCTURES AFFECTING
ANY
NATIONAL HEALTH CARE REFORM PLAN
HEALTH CARE REFORM CONCEPTS
versus
SOCIAL AND ECONOMIC VALUES
Synopsis
The
l a w a f f e c t s and i s a f f e c t e d by s o c i e t y
that society
thinks, believes
and e v e r y t h i n g
and a c c o m p l i s h e s .
T h i s r e s e a r c h paper c o n s i d e r s power s t r u c t u r e s t h a t
a f f e c t reForm o f o u r h e a l t h
project
i st o provide
a reform
First
care system.
a p a n o r a m i c view o f t h e p o s s i b i l i t i e s
Providers
needs o f p a t i e n t s , and t h e i r
of individuals.
structure
of the health
or m u t u a l
insurers
it
will
for
and i n s u r e r s e x i s t because o f t h e
profits
insurance industry
a f f e c t n o t only
plan
that health i s
i s t o transform
or public health
health reform
s h o u l d be s e c o n d a r y t o t h e
One way o f a s s u r i n g
v a l u e d ahead o f i n s u r e r p r o f i t s
Any
The p u r p o s e o f t h e
p r o g r a m w h i c h aims t o b e n e f i t t h e c o n s u m e r / p a t i e n t
and f o r e m o s t .
health
will
will
the organizational
into either non-profits
insurance u t i l i t y
be p o l i t i c a l l y
volatile
t h e b o t t o m l i n e F o r many
and
organizations,
but also
and
economic s e c u r i t y w i l l
their
companies.
because
corporations
spheres o f i n f l u e n c e .
n o t be e a s i l y r e l i n q u i s h e d .
Power
The p l a n
of c h o i c e w i l l
have t o b a l a n c e t h e i n t e r e s t s o f t h e s e
while
t h e primary goals o f providing s u f f i c i e n t q u a l i t y
health
assuring
c a r e f o r an e n t i r e p o p u l a t i o n
a t reasonable
factions
cost.
�-2-
Reconsideration
activity
i n p o l i c y Formulation.
the a F F e c t s
clearer
of the s t a t u s quo
will
spur major
U n d e r s t a n d i n g and
of the v a r i o u s power s t r u c t u r e s w i l l
view of the soundness and
Congressional
attempts at h e a l t h care reform.
p l a y e r s i n the p r o c e s s
will
Insurance
acknowledging
provide
a
of
The
primary
be:
F e d e r a l , S t a t e , and
the
justifiability
political
L o c a l Governments
industry
the American M e d i c a l
the American H o s p i t a l
the American Bar
Association
Association
Association
Labor Unions
E m p l o y e r s , both l a r g e and
small
Consumers, the r e c i p i e n t s of h e a l t h
Much has
been s a i d about the Canadian p l a n and
Play-or-Pay plans.
plan w i l l
more and
Few
people r e c o g n i z e
t h a t the
the
American
Play-or-Pay
become, by d e f a u l t , an A m e r i c a n i z e d C a n a d i a n p l a n when
more employers e l e c t to pay
t h e i r employees.
i n the h e a l t h and
system s h o u l d
the government to
E v e n t u a l l y , the government w i l l
major i n s u r e r i n the U n i t e d
to e x i s t
care.
S t a t e s , and
insurance
a l w a y s be encouraged.
industries.
to be r e q u i r e d ,
imperatives,
The
A Free
cease
market
However, i n c o n s i d e r i n g
insurance
individuals.
become the
a F r e e market w i l l
perFormance of the p a s t decade, the
through l e g i s l a t i v e
insure
i n d u s t r y may
u n u s u a l c o n c e p t of s t r u c t u r a l
the
have
to i n s u r e a l l
transFormation
�-3oF the h e a l t h i n s u r a n c e
Utility
Company
pervasive
and
into a Public Health
be the most v i a b l e s o l u t i o n to
Insurance
the
problems oF p o l i c y c a n c e l l a t i o n of h i g h - r i s k p a t i e n t s
exorbitant
restricted
may
industry
insurance
rates.
to s u b s i d i z a t i o n oF
Insurers•
established.
A two-tiered
The
governmental r o l e s h o u l d
insurance
health
premiums For the
insurance
I n s u r e r s would be r e q u i r e d
poor.
program s h o u l d
to p r o v i d e
be
be
the
l e g i s l a t i v e l y - e s t a b l i s h e d BASIC p l a n a t a community r a t e to
every
person applying
negotiated
Federal
annually
insurance
providers,
with
For c o v e r a g e .
by a F e d e r a l
administrator,
community r a t e would
insurance
The
r e p r e s e n t a t i v e s oF
second t i e r
i n s u r e r s and
of h e a l t h
majority
insurance
a d d i t i o n a l coverage, l a r g e l y unregulated,
and
p r i c e d a t p r e v a i l i n g market r a t e s .
E m p l o y e r s would no
c o v e r a g e , but
provide
would merely a d m i n i s t e r
Employers s h o u l d
business.
longer
not be r e q u i r e d
to be
A l t e r i n g t h i s long-standing
complete p o r t a b i l i t y oF h e a l t h
health
i n the
i n d i v i d u a l s to p u r c h a s e t h e i r own
oF
claims.
insurance
p r a c t i c e would
coverage so
i n d i v i d u a l s would be F r e e to move From one
w i t h o u t F e a r oF l o s s oF c o v e r a g e .
insurance
the F i l i n g
insurance
provide
that
employer to another
Additionally,
permitting
coverage would e l i m i n a t e
the
c u r r e n t e x i s t e n c e oF c o n t r a c t s oF a d h e s i o n to which a l l
employees a r e s u b j e c t .
Attorneys
must be h e l d to a h i g h e r
be
board, composed oF a
consumer r e p r e s e n t a t i v e s c o m p r i s i n g the
of the board membership.
would p r o v i d e
The
ethical
standard
where
�-4medical
m a l p r a c t i c e c l a i m s are concerned.
They must
discourage
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Political Power Structures Affecting Any National Health Care Reform Plan: Health care reform concepts versus Social and Economic Values] [binder] [3]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-002-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/9ab3505baab8c5666f720479f6badbc6.pdf
0f60aaf2a161eb5fab9571afedb9804b
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1982
FolderlD:
Folder Title:
[Political Power Structures Affecting Any National Health Care Reform Plan: Health care reform
concepts versus Social and Economic Values] [binder] [2]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
1
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procedures
and t r e a t m e n t s were
insurance,
broadened
From
considered.
the concepts
eligibility
over
coverage.
the l i s t
to
oF d i F F e r e n t
The p u b l i c ' s
oF m a n d a t e d
managed c a r e , a n d s e r v i c e
is
care
eFFectiveness
used
value
t h e decisions."^ ''
utilizes
controversy
were
0
drove
Oregon
meetings
oF h e a l t h
prioritization
services.
sysstem
Those
with i t s
be b l a t a n t
For Medicaid
the elimination
The m o s t
oF s e r v i c e
priorities."^
but stirred
priorities,
However,
part
which
0 2
The p l a n
up much
oF many m e d i c a l
controversial
rationing.
emp1oyer-based
procedures
oF O r e g o n ' s
program
i s c o n s i d e r e d by many
a s Eddy
a n d many o t h e r s h a v e
pointed out:
(Medicaid already r a t i o n s by) w i t h h o l d i n g
c o v e r a g e oF a l l s e r v i c e s F o r a b o u t 40 p e r c e n t oF
p e o p l e under t h e F e d e r a l p o v e r t y l e v e l and a l l o w i n g
3 3 0 , 0 0 0 oF t h e n e a r - p o o r i n O r e g o n t o go w i t h o u t
insurance.
...
Oregon's p l a n a t t e m p t s t o s h i F t r e s o u r c e s
From l o w - p r i o r i t y s e r v i c e s F o r c u r r e n t 1 y - c o v e r e d
individuals to help provide h i g h - p r i o r i t y
services
F o r p e o p l e who c u r r e n t l y h a v e no c o v e r a g e .
That
i s r a t i o n i n g , b u t i t i s a m o r e j u s t i F i a b l e t y p e oF
r a t i o n i n g t h a n w h a t i s o c c u r r i n g now.- 30
Oregon's
plan
3
i s c o n s i d e r e d by some t o be v i o l a t i v e
oF t h e
304
Age
•iscrimination
those
with
less
rehabilitation
ments
are
which
because
than a year
statute"^
0 3
i t provides merely
to live;
because
and v i o l a t i v e
disabled
people
comFort t o
oF t h e
require
a r e n o t c o s t e F F e c t i v e , a n d some oF t h o s e
treat-
treatments
not provided.
The
list
Act
Oregon
i n February
H e a l t h S e r v i c e s Commission
1991
3 0 S
oF o v e r
-95-
established
700 c o n d i t i o n s
a
Final
and t r e a t m e n t s
�which
were c a t e g o r i z e d
Acute
Fatal
on
a scale
with treatment
"17"
was
of
1 to
preventing
recovery;
while
Condition
treatment
p r o v i d i n g minimal
or
no
17.
death
Fatal
or
" 1 " was
and
providing
NonFatal
improvement
Condition
Full
with
in quality
oF
11 Fe .
E a c h oF
17
o u t c o m e s and
condition's
ranking
are
This
by
the
From
plan
Emotions
run
has
are
oF
are
not
oF
w i t h one
established
main p r o b l e m
cut, the
The
plan,
the
and
not
media
oF
which
number
thereFore,
covered
the
the
with
in suFFicient
because
oF
700+ c o n d i t i o n s
nationwide
dying
at such
The
diminished
or
paired
pairing
1 t o 700.
subject
at r i s k
the
budget.
are
the
high
Oregon
oF
are
reduced
was
was
c o n d i t i o n s was
result
procedures
boy
700
when b u d g e t s
w i t h the
method
little
the
is that
which
over
ranking
covered
comply
on
the
concentrates
who
is
coverage
a denied
to
covered.
when
a
procedure.
times.
attempted
to
prioritize
and
oFFer
587
out
oF
the
303
709
considered
the
list
quality
were
oF
procedures.
those
liFe,
The
plan
that
and
primary
which
emerged,
with denial
i n the
For
birth
the
list
low
procedures
based
For
thereFore,
measures employed
oF
were
g r e a t e s t good
care,
extremely
The
oF
on
the
placed
increased
at
the
coverage
priority
For
oF
longevity,
g r e a t e s t n u m b e r , and
gave h i g h
top
to
equity.
preventive
extraordinary
last
m o n t h s oF l i F e a n d h e r o i c
eFForts
309
weight babies.
Procedures at the top
are
considered
For
example,
t o have
the
g r e a t e s t h e a l t h and
social
3 10
values.
p'r o v i d e d , " ^ ^
covered.^
oF
the
1 -
liFe
Anencephaly
brain.
hepatitus
while
but
Liver
not
For
surgery
support
i s the
For
For
a ruptured
anencephaly
congenital
transplants will
those
who a r e
-97-
be
spleen
will
absence
provided
alcoholics.
not
oF
For
3y
will
be
be
p a r t or a l l
those
these
with
rankings,
�Oregon
of
h a s made s o c i a l
Finite
Field
administrator
expressed
with
t h e warning
25 y e a r s
A diFFerent
oF e x p e r i e n c e i n
that:
" . . . r a t i o n i n g i s going t o
l i F e a n d I n F o r m a t i o n s h o u l d be
e d u c a t e t h e A m e r i c a n p u b l i c oF
s h o u l d be i n F o r m e d s o t h a t t h e y
Face t h e s i t u a t i o n i n t h e near
Heritage
and r a t i o n i n g
care.
A hospital
the
d e c i s i o n s on t r a n s p l a n t s
become a F a c t oF
c i r c u l a t e d now t o
that Fact.
They
can a d d r e s s and
Future."
v i e w p o i n t was a i r e d
by S t u a r t
Butler
oF t h e
Foundation:
" I t i s n o t inconceivable that our society
may d e c i d e t o s p e n d 20 p e r c e n t oF GNP o n m e d i c a l
care i n order t o avoid r a t i o n i n g .
As we become
a r i c h e r s o c i e t y , we s p e n d m o r e on h e a l t h c a r e .
O r d i n a r y p e o p l e s h o u l d be i n v i t e d t o d e c i d e how
much s h o u l d be s p e n t t o a v o i d r a t i o n i n g .
By
comparison,
i n t h e 1 3 6 0 s , we s a i d we c o u l d n o t
s p e n d s o much o n M e d i c a r e a n d M e d i c a i d , a n d y e t
now we d o . "
3 1 4
Currently,
Oregon
60 p e r c e n t
i s spent
The
eleven
oF t h e c o s t oF m e d i c a l
on l o n g - t e r m
Oregon D e p a r t m e n t
waivers
From
5
care."^
oF Human R e s o u r c e s
the requirements
security
Act.
Medicaid
program
Services
A c t and s t i l l
n _,•
M e d i c a i•
d
oF
people
also
a
oF
oF § 1 1 5 [ a ) oF t h e S o c i a l
p e r m i t Oregon
to coincide with
remain
t h e Oregon
eligible
to alter
Basic
their
Health
to receive
Federal
F u n _ s . 3 15
di
two most
eligible
reduce
Five-year
that
important waivers
For Medicaid
'demonstration'
not only
may w i s h
would
3 1 7
For Oregon,
t o determine
b u t as a m o d e l
or adapt
-98-
b u t would
Oregon has s u g g e s t e d
be i n i t i a t e d
t o adopt
i n c r e a s e t h e number
by 3 0 , 0 0 0 p e o p l e ,
the services provided.
t h e program
states
would
has r e q u e s t e d
T
The
The w a i v e r s
care i n
. .,
a similar
that
t h e succe:
For o t h e r
3 18
program.
�Eddy
considers that
O r e g o n ' s P I an s h o u l d be p r o v i d e d t h e
opportunity
t o demonstrate
emphasizing
that
the plan
i t s w o r t h For F i v e y e a r s ,
i s not ideal
but i s a
deFinite
319
improvements
For
over
considering
imagine
that
consider
risk
i s already
i t would
eliminating
line;
3.
citizen
be b e n e F i c i a l
coverage
200,000
list
people
For
and
inFurance
idea
one
then
to eradicate
For 330,000
developed
to
be n o t w o r t h t h e i r
It
i s an
interesting
greater
who
122 s e r v i c e s
surveys, medical
encourage
by s u g g e s t i n g t h a t
an a c t u a l i t y ,
a l l coverage
an a d d i t i o n a l
priority
presents a novel
i t by:
and t h e h i g h -
people;
120,000 p e o p l e
undar
the
and,
giving
Medicaid
He
t h e employer-based
p o o l by d i s c a r d i n g
poverty
the
the Plan
dismantling
2.
quo.
t h e w o r t h oF t h e P l a n
whether
1.
the status
currently
that
qualiFy
For
are a t the bottom
oF
through extensive public hearings,
specialists,
320
and
legislative
debate
costs.
and n o v e l methodology
s u p p o r t For t h e Plan
which
From
this
is likely
to
viewpoint.
Michigan
A problem
local
oFten
governments
reFuse
those
exists
governments
are t o provide services,
t o , or are unable
services.
when s t a t e
t o , appropriate
I n some s t a t e s
and
mandate
then
the states
the necessary
when a s e r v i c e
that
Funds
For
i s m a n d a t e d by
32 1
that
state,
local
When a s e r v i c e
cannot
always
entities
i s deemed
be r e l i e d
have g r e a t e r
optional,
upon.
assurance
Funding
ThereFore,
-99-
i s less
oF
Funding.
deFinite
i n designing a
and
program
�of
health
broad
mandate
In
local
with
i n the late
delivery
was o f t e n
i n local
obviously
prefer
limited optional
1960s,
of services
implementation
support
entities will
of services,
Michigan
mandated
for
care,
state
but placed
levels
not forthcoming
a
very
services.
3 2
"
l e g i s l a t i o n often
complete r e s p o n s i b i l i t y
o f government.
because
little
Financial
o r no
state
323
revenues
this
it
were
could
would
appropriated
be v e r y
appear
services,
and
the
to
many
health
services
monitor
This
lack
department
already
without
expand
In
with
departments
t h e program's
i n documenting
324
to provide
program
considerable
q u a l i t y , access,
i n turn,
needs
programs
state
services,
and t h e i n F o r m a t i o n
I n eFFect,
deFinitions
and
impeded
discretion in
they
the state
health
oF t h e d o l l a r s
occurred,
and i m p r o v e d
maintained
eFFectiveness.
and t h e i m p a c t
a dilemma
thus,
with
"locals
accountability
support,
and t h e s t a t e
reFusing to
additional
3 5
allocations." "
documentation
on t h e u s e oF
without
t h e 1970s,
however,
legislation stating
local
because
f i n a n c i a l l y competent t o
exercised
oF a c c o u n t a b i l i t y ,
additional
unwilling
had n o t been s t a n d a r d i z e d ;
delivered
t o expanded
officials
services.
( s t a t e - ) mandated
they
Politically,
elected
were e i t h e r
requirements
support
current
the
spent."
objecting
they
to local
o r were n o t s u f f i c i e n t l y
reporting
local
damaging
that
manage p r o v i d i n g
"For
f o r t h e programs.
unit
oF g o v e r n m e n t
Michigan
that
remedied
the state
to provide
"could
a new
this
situation
not require
a
service...unless
3 25
the
state
as
willing
t o bear
the Full
-10 0-
cost
of i t s
provision."
�After
federal
experiencing, throughout
deficit,
have t o bear
and
situations
h e a l t h care
such
health
reform
planned
with
s t a t e s are acknowledging
increasing financial
expanded
t h e 19803,
as t h i s
plan
or reform
Inadequate
planning of implementation
reality
or
i t may
t o any a t t e m p t
reform
merely
be
plan
at actual
be s u f f e r i n g
lead
carefully
and p r o c e d u r a l
to the belief
is fatally
from
once a
imp1ementaiton.
could
or system
I t is
flawed,
inadequate
when i n
p l a n n i n g and/
implementation.
Denver
and S a l t
Nine
Lake
City.
s t a t e s and c i t i e s
provide
health insurance
working
uninsured.
Tennessee,
supported
expected
to
measures.
appropriations, regulations,
prior
the entire
f o r a l l new
i t s implementation
guidelines
that
expect t o
make i t i m p e r a t i v e t h a t
i s chosen,
specific
they
responsibility
proposals
which
that
the increasing
Utah,
some b r o a d
coverage
Arizona,
Wood
which
fifteen
Florida,
and W i s c o n s i n
oF e a c h s t a t e
questions
about
plans
program
3 2
"
"will
t h e most
will
Maine,
Johnson F o u n d a t i o n .
the experiences
policy
through
Colorado,
Washington,
by t h e R o b e r t
that
have begun p r o j e c t s
f o r the
Michigan,
planning
7
I t
is
provide
eFFective
was
answers
ways t o
3^8
increase
the
plans
coverage
provide
For t h e w o r k i n g
basic
beneFits
The p l a n s
incorporate diFFerent
329
c o i n s u r a n c e , and copayments.
The D e n v e r
the
of
and S a l t
other projects
local
government
Lake
because
uninsured
through
population. "
managed
care
A l l
systems.
structures
For d e d u c t i b l e s ,
City Versions
are different
Denver's r e s u l t e d
i n conjunction with
- 101-
local
from
from
the efforts
private
�organizations,
solely
From
the
by
private
s t a t e or
existence
both
and
areas
the
Salt
Lake
City project
organizations.
Neither
Federal
government.
of
innovation
this
3 3 0
was
begun
r e c e i v e s any
The
reasoning
i s explained
by
Funding
behind
the
Fact
that
are:
" . . . p o l i t i c a l l y and F i s c a l l y c o n s e r v a t i v e , w i t h
a s t r o n g t r a d i t i o n oF i n d i v i d u a l i s m and
vo1unteerism.
T h e i r l e g i s l a t u r e s are g e n e r a l l y
a v e r s e t o g o v e r n m e n t r e g u l a t i o n and r e l u c t a n t
to i n c r e a s e tax r e v e n u e s For s o c i a l s e r v i c e
p r o g r a m s . . . t h e d e s i g n e r s oF t h e D e n v e r and U t a h
p r o j e c t s never sought s t a t e Funds; they
r e c o g n i z e d From t h e s t a r t t h a t t h e y w o u l d h a v e
t o F i n d a l t e r n a t i v e ways t o make t h e i r
insurance
p r o j e c t s a F F o r d a b l e to t h e i r t a r g e t m a r k e t s u n i n s u r e d s m a l l b u s i n e s s e m p l o y e e s and
their
Families.
I F these p r o j e c t s are s u c c e s s F u l ,
they w i l l h e l p to d e m o n s t r a t e t h a t a F F o r d a b l e
b e n e F i t p a c k a c e s c a n be d e v e l o p e d w i t h o u t s t a t e
subsidies."
3 3 1
The
imposed
two
cities
managed
providers.
utilizing
Dne
care
oF
the
First
deductible
tions
that
patients
merely
care
a return
a 50
percent
hospital
For
to the
From
to
1S50s-type
coinsurance
care,
admissions
high coinsurance.
become m o r e
services i n order
and
s t r a t e g i e s they
inpatient
hospital
providers
a l i m i t e d choice
innovative
$ 5 , 0 0 0 oF
will
with
most
require
in addition
primary
the
i s charged
discounts
arrangements
is actually
management--they
on
negotiated
interested
to avoid
The
are
health
payment
and
and
oF
a
$250
prescrip-
theory i s
in preventive
the p o s s i b i l i t y
and
oF
332
costly
hospital
Denver's
Program
with
pays
a $15
or
specialty
Shared
100
Cost
percent
copayment
For
cara.
Option
oF
the
visits
For
costs
to
- 102-
Private
oF
Employers
preventive
physicians
which
(SCOPE)
services,
are
not
�Far
preventive
catastrophic
per
person
care.
care,
a r e covered
project
male
businesses
employees
i s meant
t o provide
expenses above
$2,750
i n Full.
was a n n o u n c e d
1 9 9 0 , 41D s m a l l
healthy,
t h eplan
a l l out-oF-pdcket
per year
Denver's
June,
Because
on A u g u s t
2 2 , 1 9 8 9 . By
h a d e n r o l l e d 3,7B4
and t h e i r
dependents
young,
i n t h e program
334
because
the
will
oF t h e l o w c o s t
90,ODD u n i n s u r e d
then
total
A very
reaching
interesting
a SCOPE s u r v e y
target
to
eFFects
with
thereFore,
concerning
on h e a l t h
small
that
risk
others
arehigh
believing
oF i n s u r i n g
actual
authorship
small
be t h o r o u g h l y
special
growth
businesses.
Small
3 3 5
i s that
oF t h e
risk
I ti s surprising
Forty
and o n l y
Four
insurers
b i d on t h e
t h a t ' s m a l l employers
limit
and t h e i r
insurers' ability
groups.
The r a t i o n a l e
t o spread
For these
search
oF t h e p r o v i s i o n s t o s p e c i F i c a l l y
involved.
While
may h a v e
appeared
now d e t r i m e n t a l a n d , i n t h e i n t e r e s t
restrictions
reForm
t h eadverse
investigated, with that
interests
markets
t o have F a r -
t h ec h a r a c t e r i s t i c s
oF i n s u r e r s a n d t h e s p r e a d i n g
segmented
dependents,
risk.
should
the
insurance
SCOPE h a d c o n t a c t e d
Many s t a t e s c u r r e n t l y
the
may d e v e l o p
u n d e r w r i t i n g oF t h e P l a n ,
project--the
employees
which
that
i st o enroll
3 3 5
do n o t seem t o p r e s e n t
associated
learn,
Fact
The g o a l
who, w i t h t h e i r
persons.
disclosed
population
usually
employees
250,000
positive
oF p r e m i u m s .
should
restrictions
oF t h e i r
risk
beneFicial
oF c o s t
laws
t o include
determine
on t h e
across
a t one t i m e ,
i t
containment, t h e
be r e m o v e d .
businesses
which
are generally considered
- 103-
toogreat a
i s
�PROGRAM UPDATE
TABLE 1
? i a n Features
Alabama: Basic Care Pnvaie
Ootion—A
DEDUCTIBLE
SERVICE DELIVERY
NETWORK
INSURANCE
PROJECT
:
i
1
COINSURANCE CAP. 1 MAXIMUM BENEFIT !
PRE-EXISTING
AMOUNT
CONDITION CLAUSE'
OUT-OF-POCKET ;
i
i
MAXIMUM
StOO per maiviouai per j St 080 per person per
contact year. S300 per year—:eouct:Die pius
family
i coinsurance
S3.2AO per family
and private nosoitais anc pnvate
physicians
Unlimited (Limited
oenetit cacnagei
Same as aoove
; NetworK moce: HMO Ot DUDliC
Same as appve
Same as aoove
S-t 000 oe- oe-son per
year oaricioani's cpinS'j'ance
S250.00C per person per 12-12 'or inpatient
year
services ipregnancy:
normal cenvery not
covered 'pr "0 mon;ns
from enronmemi
t2-6t2
ODIIOD—3
NetMjrx moaei HMO ot ouoiiciy
supponeo nospaais ana county
pnmary care dimes
Arizona: ^.eaitn Care Grouo
Oction One
'JerAorn moaei HMO in 2 : : j n iies. IP In 1 cpunry
None
Arizona: Heaitn Care Grous
Ociion Two
Sane as apove
.'Jone
None
S250.000 per person oer Same as a:eve
year
Arizona: Heaitn Care GrouD
Oaiion T^ree
Same as aaove
None
None
S20.000 oe person per
year
Arizona: Heaitn Care GrouD
Ootion Four
Same as acove
Alabama: Basic Care PJDIIC
4
Denver: SCOPE
inpatient care-S250
per inaividuai oer caiencar
year. S500 per family
Outpatient prescnption
onjgs-S50 per year
EPO. co-payments 'A-aivea tor
low-income oe'sons using
puDiiciy-supponea nosoitais
Florida: Fionoa Heaitn Access
S'.anca'c Ootion
S2.000 per individual
per contract year
IPA .-nooe! HMO. inonproiili
None
Same as apove
r
S2.000 -axirn-jm outof-opc>e: oe person
per year
Same as aoove
S250.000 oer pe-son per i Same as aocve
year
-
!
i
S2.750 per person per Unlimited (Exceptipns.
year oecuctipie plus
mental neaitn. SUPcoinsurance. S5.500 per sance aouse. nospice
family
care, convalescent care,
person over 70)
St.500 per person per
caiencar year—total
c:oayme.~:s. $3,000 per
3-3-6 employee
3-3-12 dependent
Unlimited
None
Unlimited
None
family
None
:
Florida: F oriaa Heaitn Access i Same as asove
None
Maine: MameCare
IPA mocei HMO
Michigan: Blue Cross Blue
Siue Cross. B:ue Snieio artiiiatea , StOO per individual per
None
St.tOO ce: person per
Si.000.000 per
5-6 'or groups - or less
oenetit. an causes
270 davs trcm enronmemi no cause for
groups 5 or more
None
Mixed .Ttoos! HMO. start ana
Exists 90 davs after
enrollment, out does
not aopiy to pregnancy
Unlimited
coinsurance. SI.200 per
family
family
Michigan: Blue Care Neiworn
Oction
Same as aoove
Ncne
None
S500 per oe-son pe'
year or Sf250 oer tamily
maximum out-ot-oocnet
Ncne
Unnmitec isome
penetits umiteoi
networx components
I
Tennessee: MecTrust
:
HMO inducing :::nics ana pnysicians trom Tenn. P'imarv Care j
NetworK
j
5-3--2
Unlimited
i
Utah: Ccnmumty Heaitn Plan
\etworn nose: rMO inc:uomg
cpmrnumty nea::n centers ano
None
•.'c.-e
private oR-.-sicia.'.s
SI.000000 lifetime
!
oenetit maximum an
causes
Conc::ions 'Cr wnicn
meoica; acuce was
! receive: 2- mo. oetere
en.'oiiment. or treatment .
for 12 mo are covered
at SO : lor first 12 mo
3
Washington: Basic Heaitn
Plan
Vanety ot start, network ana IPA |
moaei HMO's
Srrvice OeYverv Hewon ieprMaiions
None
None
MMO — "fit'.' V.ainienaice Orcanijanon :PO - :«c:js:vt Prwicer O.'ca-i.-anrn
Unlimited
i?i - maiviouai Practice Assocui'On
6-12 •
�risk
by h e a l t h
shops,
exterminators
operations,
the
insurers are,
taxi
and crop
p o l i c e and F i r e
industry,
3
F o r example, barber
3
7
dusters,
workers,
mining
and beauty
and q u a r r y i n g
proFessional
h o t e l s and motels,
athletes,
medical
and d e n t a l
338
oFFices,
and p r o p e r t y
Fortunately,
management
United
States
project
and has i n c r e a s e d
intense
competition.
the
project
Exclusive
patients
the
because
Provider
preFerred
LiFe
accepted
i t s market
United
States
i t provided
the
Organization
u t i l i z e only
plan.
Firms.
share
LiFe
i n an a r e a
I t i s more r e s t r i c t i v e
means t o s t u d y a n
mandates
oF p r o v i d e r s
i nthat
provider organizations.
with
was i n t e r e s t e d i n
CEPO) w h i c h
the services
t h e SCOPE
that
l i s t e d by
respect
than
A t i n c e p t i o n oF t h e
SCOPE
339
Plan,
1,500 p h y s i c i a n s
The
Utah
nonproFit
itselF
Salt
was
Community
HMO d e v e l o p e d
a private,
Health
nonproFit
h e a l t h care
The R o b e r t
For planning
a t a cost
and development
oF a b o u t
private,
Health
Care
provider
which i s
system i n
Wood J o h n s o n
Foundation
oF UCHP
, and the
Plan
i nthe
S a l t Lake
City
businesses
40 p e r c e n t
enlisted.
(UCHP) i s a
by I n t e r m o u n t a i n
made a v a i l a b l e t o s m a l l
area
Plan
F u n d s From
Lake C i t y .
provided
a n d 12 h o s p i t a l s w e r e
less than
comparable
plans
340
in
the
area .
The
network
initial
oF p r i m a r y
secondary
and
care
hospitals.
system
plan
was " t o e s t a b l i s h
care
system
c 1 i n i c s . . .and
then
link
by n e g o t i a t i n g d i s c o u n t s
... I F UHCP d e m o n s t r a t e s
oF m a n a g e d c a r e
a private,
can c o n t r o l
- 104-
that
a
utilization
nonproFit
i t t oa
with
specialists
private1y-Funded
and keep t h e
�program
For
within
i t s budget,
p u b l i c Funds t o expand
uninsured
the
population.
able
the
to attract
plan
o
Private
Health
beneFits,
oF m i d - 1 9 9 0 ,
clinics,
the
attempted
which
would
primary
care
For
on
screens
care
i norder
coverage
were k e p t
have
cannot
solve
i t w o u l d be
t o sign
deductibles.
included
catastrophic
how t o m e e t h e i g h t
t o change
high-risk status
plan.
F o r example,
and weight
G hospitals,
physicians.
individuals
the
up F o r
l o w i n l i e u oF
increased
network
t o cover
t o shed
under
that
o u th i g h - r i s k i n d i v i d u a l s .
t o encourage
behavior
and ask
s e g m e n t s oF t h e
alone
oF e m p l o y e r s
oF c o v e r a g e
and two p r i m a r y
i t also
determined
number
UCHP i s n o t i n t e n d e d
and
t o other
initiatives
Care
a greater
i F t h e cost
increasing
t h e program
legislature
3 4 1
problem."
InterMountain
As
we c a n go t o t h e
criteria
illnesses,
They
their
have
health
a n d become
people
eligible
are counselled
a n d how t o c h a n g e
343
dietary
habits
to control
waiting
period,
covered
i nFull.
aFter
diabetes.
which
FiFty
time
percent
There
preexisting conditions are
oF c h a r g e s
are
paid For p r e e x i s t i n g c o n d i t i o n s during
. , 344
period.
UnFortunately,
the
wiFe
i sexperiencing
delivery!
not
that
3 6 7
a disease!
prenatal
startling
obvious
UCHP w i l l
n o tcover
At a time
i svery
t o discover
inFormation
For covered
that
an e n t i r e
that
Fact
when t h e e n t i r e
cost-eFFective
that
waiting
Family, i F
until
aFter
pregnancy i s
nation
i s recognizing
treatment,
i t is
this
plan
does n o t c o n s i d e r
and p r o v i d e
care
which
- 1 05-
services
one-year
a ' p r e e x i s t i n g pregnancy,'
I t i sa well-recognized
care
i s a twelve-month
such
i s so i m p o r t a n t t o
�an
infant's future health.
encourage
enrollees
services
before
And y e t ,
t o obtain
a medical
preventive
problem
to
"UCHP i s d e s i g n e d
and p r i m a r y
necessitates
care
expensive
hospitalization."358
UCHP d o e s c o v e r
laboratory
and x-ray
diagnostic
tests,
surgery
(except
nonsurgical,
services,
care
a l l o f t h e charges
services,
health
nonemergency
due t o a c c i d e n t a l
drugs,
immunizations,
services
outpatient
and m a t e r n i t y
and hospice
injuries.
care
minor
including
s e r v i c e s ) , and
ambulance
services,
There
for
services
outpatient services,
some home h e a l t h
prescription
p h y s i c i ans'
i n p a t i e n t care,
mental
for
and d e n t a l
i s a $5 c o p a y m e n t
and a $10 copayment f o r p r i m a r y
care
for
office
369
visits
which
include
well-baby
Premiums f o r a f a m i l y
per
of
month,
have been
through
lower
ten
premiums,
market
toward
independent
also
the
capable
would
percent
premium
higher
payment.
i f the
Plan
a t small
3 7 1
plan
an i n - h o u s e
monitoring
Also,
Premiums
h a d been
i t s plan
offered
t oprovide t h e
marketing
risk
businesses,
$176
t o c o n t r i b u t e a minimum
brokers.
used
exams.
be a p p r o x i m a t e l y
insurance
UCHP h a s p r o m o t e d
targeted
372
physical
arerequired
that
of closely
trends.
campaigns
of four
and employers
$50 p e r month
would
is
3 7 0
and a d u l t
staff
and d i r e c t l y
which
accessing
by d i r e c t - m a i l
with
few paid
advertisements.
The
April
and
Plan
1990,
had been
introduced
had e n r o l l e d
dependents.
December 1992,
3 7 3
with
150 s m a l l
The g o a l
businesses
i st o reach
a breakeven
6,000 a n d 7 , 0 0 0 m e m b e r s .
i n September
point
1989,
with
a n d by
800 employees
5,000 p e r s o n s by
estimated
T h e r e a r e 2D,000 s m a l l
-106-
t o be b e t w e e n
businesses i n
�374
the
area.
areas,
to
UCHP i s c o n s i d e r i n g
to S a l t
uninsured
State
Lake
County's
Medicaid
i n d i v i d u a l s , without
and l o c a l
governments
providing
health insurance
insurance
cost
similar
expanding
population,
to r u r a l
and
the involvement
directly
of e m p l o y e r s .
a r e a l s o r e s p o n s i b l e For
For government
For government
the plan
employees.
employees have
t o t h e n a t i o n as a w h o l e ,
so s t a t e
risen
Health
at a
agencies
rate
are well
35 4
aware
care
oF t h e e F F e c t s
costs
as a p e r c e n t
ments r o s e
cost
to
$2,836 For t h a t
the
by
5.1 p e r c e n t
per government
increased
oF h e a l t h c a r e
rose
same p e r i o d .
these
employer
employee.
That Figure
n e t p r o p - ^t s . 3 5 5
Fi
problems
must
which
proFessional
issues
continuing
Boards
than
oF M e d i c a l
medicine,
which
than
mirrors
those
Faced
$3,161 per
oF some
apparatus
Although
States
i s renewed
employers'
t o address
t h e AMA
require
upon
health
currently
registra-
evidence
oF
3 5 6
Examiners
p h y s i c i a n s who a r e a p p o i n t e d
an
administrative
with
beneFits
avoided...eFFective
regulations.
oF
body
are lower
26 p e r c e n t
being
education.
$1,200
oF P h y s i c i a n s .
a n n u a l l y ) which
medical
t h e average
oF h e a l t h
inFlation,
more e F F e c t i v e
are currently
govern-
approximately
The c o s t
represents
licenses to practice
(sometimes
and l o c a l
who, by 1 9 9 0 , was p a y i n g
establish
licensure
From
Figures
M o n i t o r i n g For L i c e n s u r e
States
oF s t a t e
Health
1982 t o 1989, w h i l e
employee
However,
the private
tion
From
a t a Far g r e a t e r r a t e
nation.
State
oF p a y r o l l
inFlation.
currently
are comprised
by t h e G o v e r n o r .
quasi-judicial
- 107-
mostly
The B o a r d i s
Functions,
subject
3 7 5
�to
court review,
state
and
governments.
i s under
3 5 7
The
the control
of branches
Board's Functions
establish
educational standards
standards
For
For
initial
c o n t i n u e d p r o F i c i e n c y and
are
of
to
licensure
and
proFessional
353
conduct.
the
Pursuant
Board
such
as
to standards
a d m i n i s t e r s peer
suspension,
states
permitted a
proFessional
tended
to
moral
3 6 0
1980s,
and
Although
this
corrected
area
not
the
oF
physicians
which
and
and
medical
a majority
(i.e.,
The
board
and
1.
education
2.
oF
oF
be
oF
connected
investigate
the
would
the basis
care
board
or
reForm.
be
a minority
physicians'
the
and
should
and
patient
during
oF
industrial
consumers
insurance
oF
boards
conduct
researched
should
only
a physician's
substandard
board
on
to the medical
monitor
to
1380,
broadened
knowledgeable
should
as
time, state
health
review
and
license
to criminal
scrutiny
part
care
late
to that
should
business
Additionally,
oF
as
a
challenged
quality
oF
law
health
p h y s i c i a n s which
renewal
Focus
as
oF
i n c l u d e s i n i t s membership
education
medicine.
For
to the
individuals
representatives
advocates).
t o be
conduct,
recommends a c t i o n s
that
activities
where necessary
established
and
Up
state
A state-Funded
complex,
license
359
policing
turpitude
care.
to note
incompetence!
limit
proFessional
r e v o c a t i o n or reFusal
practice medicine.
I t is extraordinary
15
review
oF
and
group
consumer
continuing
practice
establish
require,
as
prerequisites
completion
oF
valid
oF
regulations
to
licensure:
annual
prooF
oF
continuing
coursework;
diFFerent
Forms o r
g r a d a t i o n s oF
- 108-
licensure
For
medical
�diFFerent
l e v e l s of
3.
testing
The
American
voluntary
withdrawal.
it
For
the
From
is against
k n o w s he
to admit
also
a code
subject
oF
health
oF
their
a
Far
curable
then
health
oF
disease.
To
establishes
and
not
oFten
are
tested
For
disease
should
permitted
a double
have even
All
not
merely
on
no
For
ThereFore,
only
income
the
oF
selF-
For
liFe,
strength
oF
withdrawal.
knowledge
oF
their
about
IF
they
Fewer
AIDs,
but
the'
be
placed
withdrawal'
and
increase
i t i s so
would
a
exalted
For
a
deadly
unrealistic,
i s a mere c o n t i n u a t i o n
problem.
Not
dealing
malpractice
unlikely,
contract
qualms about
the
as
having
with
suits
oF,
the
stemming
providers
HIV
not
case,
i n the
is
is
i s also
in that
to p o l i c e themselves
standard,
will
than
not
voluntary
t o , the
t u b e r c u l o s i s , which
i s conducted
annua 1 1 y .
t
virus.
exceptional
to
damaging
makes a l l p a t i e n t s w o n d e r
workers
'request
that
HIV
p a t i e n t s w i t h no
testing
being
procedures
i s tantamount
oneselF
ostracism
recommending
invasive
proFessiona11y
deprive
Since
illness.
claim,
should
care
oF
recommends v o l u n t a r y
dangerous
eFFectively
this
to
skills;
physicians.
a solution
problem
From
own
disease.
position
to
leaves
workers
less
and
c a r r y i n g the
c o n d i t i o n , and
Social
only
oneselF
withdrawal
physician's
perFormance
p r e s t i g e , an
e t h i c s which
Voluntary
to
surgical
p r a c t i c e oF
is HIV-positive
human n a t u r e
esteem , p r o F e s s i o n a l
but
the
and
virus.
Association's
I t is personally
individual
experience,
AIDs
Medical
withdrawal
when a p h y s i c i a n
any
education,
virus,
so
then
themselves
they
tested
,
p a t i e n t s should
be
tested, a l l health
-103-
care
workers
�should
be t e s t e d .
testing
i s not r e l i a b l e ,
negatives
False
occurring
test
provide
tion
results
a l l health
care
positives
and
laboratory
False
Insurance
Some oF
an
the disease
s i x months
workers
False
aFter
does
t o be
tested
many
catch
not
i t s introduc-
the p o s s i b i l i t y
work, e l i m i n a t i n g
that
will
oF
result
the
in
False
negatives.
Commissions.
the Functions
to protect
and
that
Testing annually w i l l
i s even
oF
r e g u l a t e and s u p e r v i s e
order
excuse t o c o n t e n d
positives
since
until
There
more c a r e F u l
False
especially
t h e body.
requiring
..to
with
Frequently.
results,
positive
into
State
I t i s not a viable
a State
insurance
the i n t e r e s t s
..to
provide
..to
promulgate
..to
r e s o l v e or prosecute
..to
i s s u e , renew,
Insurance
oF
insurance
rate
insurance
laws,
the
transactions in
public;
structure;
rules,
violations
withhold,
industry
Commission a r e :
revoke,
and r e g u 1 a t i o n s ;
oF
insurance
or suspend
laws;
and,
the license
oF
36 1
a domestic
The
insurance
company.
t h e above
Functions
and e F F e c t i v e
rates
p u r p o s e oF
i s t o ensure e q u i t a b l e
insurance
c o v e r a g e For t h e i n s u r e d
policy362
holder
It
in return
For premium
i s i n the public
payments
interest
power
t
For t h e i n s u r a n c e
For each
state
company.
to retain
the
t o r e g u l a t e t h e k i n d a n d c h a r a c t e r oF i n s u r a n c e c o n t r a c t s
363
t h a t may be F o r m e d .
The l e g i s l a t u r e may r e q u i r e i n s u r e r s t o
use a s t a n d a r d i z e d p o l i c y o r r e q u i r e t h a t a p o l i c y must c o n t a i n
. .
.
. .
364
or m u s t e x c l u d e c e r t a i n p r o v i s i o n s .
In conFormity w i t h these powers, i t appears reasonable t o
- 1 10-
�consider
that
states
insurers
From
imposing
New
Federal
policies.
one
t o purchase
ability
to revoke
tion
bills
oF
payment
oF
renewal
dates
in
is
would
or
the
assistance to
industry,
pressures
on
any
laws
health
will
severely c u r t a i l
d e c l i n e renewal
The
only
this
oF
1991
oF
in the
oF
the
impact
and
new
Further Federal
on
on
oF
health
event
oF
non-
the r e t e n t i o n
oF
resulting
goals.
state
legislators
insurers'
reasons
a tradition,
Insurance
35
every-
permit cancella-
intent,
perpetuate
reForm
For
majority
in Fall
oF
insurance
require
Legislators,
N a t i o n a l A s s o c i a t i o n oF
insurance,
opposes
will
policy
health
i s comprised
insurance
group
and
N a t i o n a l ConFerence
Commissioners,
provide
merely
on
reForm
I n view
oF
with
dates
i n Congress
premiums.
aFFiliated
t h e power t o p r o h i b i t a l l
experiences.
insurance
a misstatement
The
health
policies
pending
a health
have
renewal
insurance,
high-cost/high-risk
reForm
would
which
Insurance
groups
which
work
subjects concerning
constituents,
trends
i n the
regulation
oF
the
consumer
industry.
the
to
The
insurance
industry.
Insurers
insurance
insurers
commission
over
considering
be
about
Health
h a v e b e e n r e g u l a t e d by
those
individual
commissions
are
the consumers
they
are
expected
the p o s s i b i l i t y
that
the
Federal
to take
Insurance
responded
and
each
hold
oF
the reins,
A s s o c i a t i o n oF
the
America,
vice
known
state's
to
Favor
t o champion.
government
may
p r e s i d e n t oF
Linda
5.
Kenckes,
with:
"We
h o p e t h e i n t r o d u c t i o n oF
encourage s t a t e s t o a c t next year
For F e d e r a l
legislation"
- 1 11-
these b i l l s
will
t o n e g a t e t h e need
In
now
the
�and
noted also
that
300
commercial
insurers--wauld
the
type of standards proposed
to
companion
25,
1991,
bills
by
the group—which
introduced
Senator
Lloyd
represents
prefer
by
t o see
t h e two
jointly
Bentsen,
more
states
adopt
b i l l s , r e f e r r i n g
t o Congress
and
than
on
October
R e p r e s e n t a t i v e Dan
Rostenkowski .
Blue
result
Shield
of Federal l i m i t s
increase
"If
Cross-Blue
you
the cost
reduce
maintained that
on
variation
"the
i n premiums would
of insurance f o r healthy,
rates
people
go
Health
I n s u r a n c e as
for high-risk
inevitable
low-risk
people, rates
be
to
groups."
f o r healthy
up."
a State-Regulated Public
Utility.
"Public u t i l i t i e s are those
facilities
which are necessary f o r the maintenance of l i f e
and o c c u p a t i o n o f t h e r e s i d e n t s , t h e s e r v i c e s
o f w h i c h a r e a v a i l a b l e t o a l l , and w i t h r e s p e c t ^ ^ ^
t o w h i c h a l l h a v e t h e r i g h t t o demand s e r v i c e . "
If
into
health
public
heirarchy
delegate
local
health
would
power
government
and
would
The
public
would
use
compensation
insurers
have
state
regulate
Legislation
for
industry
set rates
would
corporation
a different
and
under
the authority
intrastate,
interstate
and
would
the fourteenth
are undoubtedly
involved
- 1 12-
to regulate
have
the
the
and
the
power
federal
commerce.
considered a taking
insurers
commissioner,
would
imposing u t i l i t y 'status
be
S t a t e s would
utility
legislature
reconfigured
authoritarian
behavior.
to the public health
locally.
regulate
utilities,
oversee
governments
utility
to
i n s u r a n c e c o m p a n i e s w e r e t o be
have
on
a
private
of p r i v a t e
t o Pe
amendment.
property
provided
just
Although
i n a business which
is
3 6 7
�inherently
impose
utility
insurers
status
reFuse
providing
ability
and
i n the public
that
public
are brought
public
service
whom s u c h
to
those
its
oF t h e p u b l i c .
and
i s to provide
health
utilities,
stockholders,
Courts
return'
7
0
yields
no m o r e
plant,
provide
assure
pay a f a i r
Courts
profit
have
a utility
held
rate
373
attractive
to
investors.
individuals
a public
impair,
properly."
do e a r n
would
yield
service
the public
a
their
IF health
oF
with
must
i t s e l F oF, o r
that
3 7 1
proFit
primary
insurers
were
n o t be t o t h e i r
utilities
To a c h i e v e
"a s y s t e m
i s Fairly
fund
that
earn
that
renders
'Fair
return,
that
t o maintain
expenses, t o
t h e payment
a rate
a
oF c h a r g e s
and o p e r a t i n g
for
Fair
requisite
t o t h e owners o f t h e
also
i f that
duty
oF t h e
interests
interests
service.
charges
sinking
the private
deprive
t o impose
t o pay F i x e d
consumers
policyholders.
investment.
a suitable
with
private
t h e i r primary
than
t o protect
and b o n d h o l d e r s ,
the public
income
has t h e
"When t h e i n t e r e s t s
corporations
t o stock-
are permitted
government
i n order
t o serve
service
generally
r e s p o n s i b i l i t y oF
Accordingly,
but to their
on t h e i r
utilities
for
such
by c o n t r a c t
public
are responsive
duty
to
3
However, i F
o r oF p r i v a t e
power t o p e r f o r m i t s d u t y
Although
the
conFlict
deal,
work t o
interest.
corporations
cannot
then
t o note t h a t
into
companies
corporation
care,
For t h e p u b l i c
cannot
corporations.
industry
i s interesting
Fact
to the social
t o health
t o regulate
It
on s u c h
t o respond
access
provide
interest, that
o f d e b t s , and
3 7
property."' ^
of return
the u t i l i t y ' s
i ssufficient
securities
�The d i f f e r e n c e
insurance
"no
utility
would
constitutional
anticipated
those
who i n v e s t
providing
whether
That
they
insurance
but
spector
appealing
they
surely
i n t h e next
oppose
being
may make c u r r e n t l y
t o accept
considered
pending
prospect
t o i n s u r e r s from
that
to
a customer
which
i s liable
debate
such
a
service
Health
utility,
legislation
more
as t h e l e s s e r o f t w o e v i l s .
industry
utility
would
two y e a r s .
i s pro-insurance
A public
high
t h e business
to provide
S.1227, h o w e v e r ,
of evil
have
Indeed,
that
undertaken
to the public
adamantly
t o them
3 7 4
know a n d u n d e r s t a n d
policies,
may be d e c i d e d
would
would
as a r e r e a l i z e d o r
enterprises..."
companies have
have a d u t y
insurers
such
utility
of the t e r r i t o r y .
insurance
question
that
profitable
inutilities
i n s u r e r s and a h e a l t h
the public
to profits
are not part
Although
private
be t h a t
right
i n highly
divididends
of
between
so t h e r e
i s no
quarter.
has c o n t r a c t e d t o supply
f o r damages f o r b r e a c h
service
o f duty t o
375
perform
that
refusing
also
contract.
A h e a l t h insurance
t o p a y b e n e f i t s when
find
itselF
liable
utility
premiums have been
paid
would
i n damages.
INSURANCE COMPANIES
Brief
Hi s t o r y .
In
Boston
1847, t h e M a s s a c h u s e t t s
became
the f i r s t
Sy 1 8 5 0 , t h e f i r s t
in
Massachusetts,
insurer
insurance
Rhode
Health
Insurance
t o issue
'sickness'
supervisory boards
Island,
Company o f
New H a m p s h i r e ,
were
insurance.
initiated
and Vermont.
�Between
1890
oF
selected diseases
only
By
First
and
1910,
group
In
(which
health
health
the
and
ing
1938,
surgical
World
health
By
War
employee
3 7 6
i t s employees.
oF
Insurance
Commissioners
law
Insurance
which
attempted
to
was
assure
'operating conditions'
of
the
3 7 7
caused
expansion
oF
hospitals
insurance
and
the
coverage,
Cross
p l a n was
initiated
private
insurers
were
and
i n Sacramento,
oFFering
plans
which
expenses.
I I and
insurance
For
Blue
coverage
a l l diseases.
P r o v i s i o n s Law
the Depression
citywide
CaliFornia.
covered
For
model
i n the
t o demand
From
N a t i o n a l A s s o c i a t i o n oF
contract."
1930s,
public
First
policy
The
Fairness
For
grew
S Company, I n c . , e s t a b l i s h e d t h e
a Standard
most s t a t e s .
the
general
Ward
the
draFted
insurance
In
t o coverage
insurance
k n o w n as
Commissioners
''uniFormity
beneFits
the National Convention
i s now
by
disability
Montgomery
1912,
adopted
1900,
the r e s u l t a n t
"...an
wage F r e e z e s
i m p o r t a n t component
beneFits."
The
term
of
'wages'
made
group
collective
was
bargain-
determined
to
379
include
both
pensions
and
insurance
beneFits.
380
19G5
brought
Industry
Insurance
Medicare
Power
Insurers
only
those
are
and
beneFits
to the
nation.
laws
are p e r m i t t e d
Base.
organized
powers which
Medicaid
under
are
state
conFerred
and
e x p r e s s l y or
impliedly
38 1
by
the
legislature.
A state
regulate
insurers,
including
regulate
relations
between
ing
to the p u b l i c
has
a sovereign
t h e power
the
382
insurer
interest.
- I ' 5
1
duty
to establish
and
the
to
and
insured
accord-
�CLAIMS PAYMENTS BY TYPE OF INSURER: 1950-1988
YEAR
INSURANCE COMPANIES
BLUE CROSS-BLUE SHIELD
SELF-INSURED & HMO PLANS
Billions Of Dollars
TOTAL
1950
0.8
0.6
NA
1J
1955
1.8
1.4
NA
3.1
1960
3.0
2.6
NA
5.7
1965
5.2
4.5
NA
9.6
1970
9.1
8.1
NA
17.2
1975
16.5
16.9
NA
32.1
1980
37.0
25.5
16.2
76.3
1981
41.6
29.2
18.9
85.9
1982
49.2
32.2
21.6
97.1
1983
51.7
34.4
24.1
104.1
1984
56.0
35.7
26.1
107.5
1985
60.0
37.5
32.5
117.6
1986
64.3
40.6
36.8
128.5
1987
72.5
44.5
56.5
151.7
1988
83.0
48.2
62.8
171.1
souRcr- SOURCr: HOOK OF HEALTH INSUKANCL DATA, I ' m 1 KiAL II I INSURANCE ASSOCIATION Ol" AMERICA.
91-1
The Universal
nllhcare
Almanac
~ible 6.3
�HEALTH INSURANCE
KEY HEALTH INSURANCE STATISTICS:
1984
1985
1984-1988
1986
%CHANGE
1987-1988
1987
1988
240.5
208.7
181.1
146.7
31.8
243.1
211.6
188.4
153.3
31.5
1.1
1.4
4.0
4.2
-.01
MILUONS
PERSONS WITH AND WITHOUT HEALTH CARE COVERAGE
Total Population
233.4
Persons with Public and Private Coverage
202.1
Private Health Insurance
177.4
Employer Related
144.3
Persons without Coverage
31.3
235.5
204.2
180.1
147.1
31.3
238.2
204.7
180.1
145.8
33.5
BILLIONS
PRIVATE HEALTH INSURANCE CLAIMS PAYMENTS
Total
Insurance Companies
Blue Cross/Blue Shield
Other Plans'
5117.6
59.9
37.5
32.5
S128.5
64.3
40.6
36.8
5151.7
72.5
44.5
56.5
5171.1
83.0
48.2
62.8
12.8
14.5
8.3
11.2
PRIVATE HEALTH INSURANCE PAYMENT BY CATEGORY OF SERVICE
Total
S12I.6
S 133.2
Hospital Care
56.9
59.3
Physicians' Servires
30.4
33.7
Dentists' Services
8.5
9.1
Other Professional Services
46
5.2
Drugs and Medical Nondurables
4.7
5.2
Vision Products and Other Medical Durables
U<.
0.7
Nursing Home Care
03
0.3
Program Administration and Cost of Private Insurance
17.4
20.0
5142.6
63.5
38.3
9.9
6.8
6.0
0.8
0.3
17.7
5155.8
69.3
43.9
S174.6
75.0
50.0
12.4
8.3
7.7
1.0
0.5
19.7
12.1
8.2
139
12.7
18.6
11.6
11.1
25.0
20.1
$107.5
55.9
35.7
26.0
2
n.o
7.0
6.9
0.9
04
16.4
'Olher plan* include i«lf insured plans, leK adminiMrred plum, pl.ins cmplnyiiig Ihird p.my .idminiMriiinrs .ind hciilih in.nniin.imL- organiulions.
Oihcr prolcuion.il services include lees lor chiropraciors, podialnsis. lAythnlognls, ihcrnpiM*, audmlogiMs, npiomcinsis, ponnhlc < r;iv suppliers, ambulance service suppliers, and KSKI) Luihiu-v
SOURCE: HEALTH INSURANCE ASSOCIATION OK AMI-RICA
9
r
'
_
.
Reprinted:
...
"The
Univr
( P h o e n i x:
., _
,
,
^1 H e a l t h c a r e
Almanac"
i l v e r S Cherner, L t d . , 1991)
TaWe 6 9
�An
(is)
i n s u r e r ' s c h a r t e r i s "merely
not r e s t r i c t i v e
However,
a c h a r t e r may
permitting
which
of a general
engagement
liait
enabling
power t o e f f e c t
t h e c o r p o r a t i o n by
in a particular
i s not reasonably
i n c h a r a c t e r and
incidental
contracts..."
not expressly
transaction
or
t o the purposes
business
f o r which i t
was i n c o r p o r a t e d .
There
and
are three types
mixed.
holders
I n a stock
may
earnings
invest
insurance
3
by t h e b o a r d
of d i r e c t o r s . " ^
stock
o f an i n s u r a n c e
payment
of a l l the debts
not a trust
c o r p o r a t i o n i n which
mutual
stock-
distribution
of
as b e t w e e n s t o c k h o l d e r s a n d p o l i c y h o l d e r s i s
capital
and
companies--stock,
i n the corporation, "...the
or p r o f i t s
determined
of insurance
fund
and
simply
4
However,
company...is a t r u s t
legal
liabilities
or even p r i m a r i l y
(T)he
fund
of the
f o r the
company,
f o r t h e payment
385
of
obligations
growing
out of contracts of
Although
p o l i c y h o l d e r s may
in
insurer's profits,
their
shareholders
share--according
they
to their
are not considered
385
policies-t o be
i n the corporation.
Premiums
unexpired
insurance."
a r e r e c e i v e d and r e t a i n e d
risks
and
occur
are accounted
risks
are barred
losses which
387
for.
from
by t h e i n s u r e r
are reasonably
Sums e q u i v a l e n t t o
inclusion
as p r o f i t s
until a l l
expected
to
unexpired
for distribution
dividends to shareholders.
"Upon no i m a g i n a b l e h y p o t h e s i s
i s i t p r o p e r t o t r e a t t h e w h o l e amount o f t h e premiums
o b t a i n e d f r o m r i s k s t h a t a r e s t i l l p e n d i n g as p r o f i t s f o r
388
distribution
to stockholders."
Insurers'
insureds
recent
i s an a t t e m p t
p r o p e n s i t y t o termirvte
t o rescue
funds
- - 151
from
high-risk
the unexpired
as
�risk
account
for
distribution
would
not
there
would
of
care
with
be
parties,
equitable
is
the
no
insurance
receive
the
or
route
and
which
of
be
dividends,
to
found
the
must
than
problem
be
of
investment,
Nevertheless,
risks
past.
which
less
adequate
investors
Without
become
health
benefit a l l
With
had
must
With
will
consumer/insured.
the
Without
uninsurable
only
achieve
s o l u t i o n to
form
companies.
belonging
m e t h o d s must
dividends.
companies.
non-renewals,
including
will
i n the
in insurance
a past,
reform,
party
profits
invest
terminations,
words
d i s t r i b u t i o n as
reform,
been
each
hoped,
uninsureds
and
but
an
uninsurables
followed.
"The c o n t r a c t o f i n s u r a n c e w i t h a m u t u a l
company i s a p e c u l i a r c o n t r a c t , f o r a l t h o u g h i n
t e r m s a c o n t r a c t w i t h t h e company, i t i s i n
s u b s t a n c e a c o n t r a c t b e t w e e n t h e i n s u r e d and a l l
o t h e r members of t h e company.
Members o f m u t u a l
i n s u r a n c e companies s u s t a i n a dual r e l a t i o n s h i p
i n t e r s e , and t h e i r i n t e r e s t s a r e t w o f o l d :
they
a r e b o t h i n s u r e r s and i n s u r e d , who c o n t r i b u t e t o
t h e p a y m e n t of l o s s e s , a r e e n t i t l e d t o h a v e
p a y m e n t made i n c a s e o f l o s s o r d e a t h , and a r e
e n t i t l e d p r o p o r t i o n a l l y t o t h e p r o f i t s made by
t h e company.
E a c h p e r s o n i n s u r e d i n s u c h a company
t h u s becomes s u b j e c t t o t h e same o b l i g a t i o n s t o w a r d
t h e o t h e r members t h a t t h e y b e a r t o w a r d h i m . "
3 8 9
The
of
above-quoted
a mutual
relative
insurance
to health
insurance
mutual
insurance
cost
may
contractual
company
care
might
i s appealing
reform.
be
control.
of
The
unnecessary
unnecessary
claims.
health
The
The
to
structure
dual
of
care
and
liability
companies
is joint
and
eliminate
o f members
- 1 1 7-
several.
the
to
health
insurer/insured
f o r insureds
390
insurance
of
benefit
nature
members
contemplate
significant
provide a greater incentive
seeking
r e l a t i o n s h i p between
to refrain
those
of
mutual
from
�Most
to
an
or
even
people
unknown
resist
quantity.
old
i s retained
new
concept
majority
from
and
expanding
life
about
minor
incorporated i n with
never
i n v o l v e d i n and
the concept
been
to different
Insurance
Companies'
1988,
Financial
the l a t e s t
year
quo
process
changes, t h e r e i s
i f some o f t h e
accepted
affected
o f t h e mutual
interest
any
t h e new.
i n s u r e r s t o h e a l t h i n s u r e r s may
palatable
In
the status
o f s u c c e s s f u l change
has h i s t o r i c a l l y
of those
preferring
In attempting to reform
i n attempting to bring
a greater possibility
Thus,
change,
by
An
entirely
by t h e
those
changes.
insurance
render
company
the idea
more
groups.
Considerations.
f o r which
data
i s available:
391
.. h e a l t h i n s u r e r s e a r n e d
.. $ 8 7 . 6
billion
premiums,
which
of that
$98.2
amount
i s 89 p e r c e n t
.. 52
percent
o f t h e $87.6
group
arrangements;
billion
was
i n premiums;
derived from
o f t h e premiums
billion
was
group
policy
collected;
d e r i v e d from
self-insured
and,
393
.. $ 1 0 . 6
The
expenditures
disposable
.7 p e r c e n t
individual
disclosed
over
$2,124.
family
f o r both
This
after
policy
figure
taxes,
premiums.
private
and
represents
and
i s an
public
6
percent
increase
employers
o f $119
Insurance
paid
A s s o c i a t i o n of America
an a v e r a g e m o n t h l y
for individual,
and $268
premium
payment
f o r family
395
coverage.
Organization
of
1987.
by t h e H e a l t h
that
employee
was
and
f o r 1988
p e r s o n a l income
394
A survey
per
from
p e r capita e x p e n d i t u r e s
health
of
billion
Dr. R o n a l d
Bronow,
of Physicians
President
Who C a r e
- 1 18-
of the National
disputes
those
figures,
�contending
that
some e m p l o y e r s
pay $600 p e r month p e r
.
396
employee.
Also
paid
during
1988, p r i v a t e
and c o m m e r c i a l
health
insurers
a total of:
397
.. $ 1 7 1 . 1 b i l l i o n
.. h o s p i t a l ,
For medical
surgical,
care
physician,
and d i s a b i l i t y
and m a j o r
claims;
medical
insurance
398
claims
accounted
.. B l u e
For $63.3
Cross-Blue
Shield
billion
paid
oF t h a t
amount;
$48.2 b i l l i o n
i n claims;
and,
399
.. s e l F - i n s u r e d
Another
was
the
Health
conducted
insurers.
group
o u t $62.8 b i l l i o n
Association
1 9 3 9 oF t w e n t y
insurers
health
individual
The
Insurance
i n July
These
total
total
a n d HMOs p a i d
receive
insurance
health
health
55 p e r c e n t
p r e m i u m s a n d 35 p e r c e n t
insurance
premiums
a commercial
oF 4.5 p e r c e n t
For group
insurance,
experienced
survey
commercial
approximately
disclosed
loss
oF A m e r i c a
leading
study
writing
i n claims.
paid.
insurer
4
0
health
oF t h e
0
underwriting
a n d an 8.4 p e r c e n t
For i n d i v i d u a l
oF
loss
under-
insurance
policy
40 1
claims.
L o s s e s s u s t a i n e d i n 1988 by 6 4 6 c o m m e r c i a l i n s u r e r s
402
t o t a l e d $3,780.9 m i l l i o n .
H o w e v e r , F o r t h a t same y e a r , 43
B l u e C r o s s - B l u e S h i e l d o r g a n i z a t i o n s e x p e r i e n c e d a g a i n oF
403
$1,086.7 m i l l i o n .
warrants
study
concessions)
That
disparity
b e F o r e any c o n c e s s i o n s
are accorded
t o those
i n Financial
(especially
commercial
success
legislative
insurers
claiming
hardship.
0
404
National
The
Health
health
For
care
a total
health
expenditures
Care F i n a n c i n g
spending
rose
i n 1988 w e r e $ 5 3 9 . 9
Administration
estimates
t o 12.2 p e r c e n t
oF $ 6 6 6 . 2 b i l l i o n .
Per c a p i t a
- 1 1 9-
oF GNP
health
that
during
billion.
total
1990
expenditures
�were
$2,566.
Insurers
loss
state
that
they
o f 4.6 p e r c e n t
From
group
percent
underwriting
a r e e x p e r i e n c i n g an
l o s s From
health
underwriting
i n s u r a n c e , a n d an 3.4
individual
health
insurance
405
policies.
provides
1.
and
thus
The H e a l t h
three primary
increases
Insurance
reasons
i n coverage
greater increases
A s s o c i a t i o n oF
America
For t h e l o s s e s .
raised
levels
oF e x p e c t a t i o n ,
i n demand;
2.
i n c e n t i v e s For p r o v i d e r s and consumers have:
. . e n c o u r a g e d h i g h l e v e l s oF u t i l i z a t i o n ;
..discouraged cost
consciousness;
. . c r e a t e d t o l e r a n c e For i n e F F i c i e n c y and p r o v i s i o n
oF m a r g i n a l l y u s e F u l c a r e .
3.
new
improvements
treating
t e c h n o l o g i e s have
along
insurance
increases
companies r a i s e d
h i g h e r d e d u c t i b l e s over
nevertheless,
i n quality
i n t h e c o s t oF
percent
that
i t suFFered
Metropolitan
premiums w i t h
rise
i n premium
income
an u n d e r w r i t i n g
LiFe,
however,
a proFit
top ten liFe
Prudential
r a t e s and
l o s s oF o v e r
$140
and h e a l t h
experienced
i n 1988 a t t h e same
experienced
oF o v e r
premium
t h e 1988-1330 p e r i o d and a r e ,
experiencing losses.
22.5
The
substantial
resulted
illness.
Many h e a l t h
imposed
with
usually
$190
rise i n
million.
companies
nation are:
P r u d e n t i a l I n s u r a n c e Company oF A m e r i c a
M e t r o p o l i t a n L i F e I n s u r a n c e Company
American Family LiFe
M u t u a l oF Omaha I n s u r a n c e Company
Connecticut General LiFe Insurance
H e a l t h Care S e r v i c e C o r p p r a t i o n
A e t n a L i F e I n s u r a n c e Company
P r i n c i p a l Mutual LiFe
T r a v e l e r s I n s u r a n c e Company
C o n t i n e n t a l Assurance Company. ^
4 0
- 120-
time
million.
a 19.3 p e r c e n t
407
insurance
a
i nt h e
�In
and
efforts
t o maintain
nation's
own
up
top
t o slow
their
health
health
following
been
share
o f the
market,
stable
cost
several
increases
of the
t o introduce
necessary
smaller
resources
t o achieve
care
have a t t e m p t e d
prohibit
Even t h e
suffficient
of health
Economies o f s c a l e
networks
suit.
rate
insurers
HMOs a n d PPOs.
these
the
for
health
o f Aetna
sources
their
setting
insurers
from
a n d CIGNA h a v e n o t
of profit
from
their
409
HMO a n d PPO n e t w o r k s .
Health Maintenance
Organizations.
Health
in
the
Organizations
Maintenance
Organizations
1930s a n d d i d n o t
1 9 7 0 s when h e a l t h
4 1 0
increase.
ability
care
Their
and P r e f e r r e d
experience
costs
success
t o manage c a r e
Provider
(HMOs] w e r e
first
a rapid growth
across
the
appears
nation
t o derive
f o r economies
formed
until the
started a rapid
mainly
of service,
from
their
and p r o v i d e
411
reduced
hospital rates.
HMOs a r e o r g a n i z e d
either
employees o f the
services
through
physicians
either
with
Medicaid
by
the
By
1989,
the
encouraged
late
were
their
Physicians
their
with
Some
the
o n e HMO.
so s u c c e s s f u l
Provider
or with
and e n r o l l m e n t
4 12
people.
t o two m i l l i o n
13 p e r c e n t o f
48 s t a t e s .
Organizations
- 12 1-
contract
t h a t Medicare and
beneficiaries to join
covering
HMO.
HMOs w i l l
of physicians,
close
may b e
o r may p r o v i d e
BOO HMOs h a d e n r o l l e d m o r e t h a n
population
Preferred
than
group
19B0s h a d r e a c h e d
nearly
American
negotiated
more
an e s t a b l i s h e d
individual
physicians.
HMOs' c o s t e f f o r t s
ways.
organization,
contracts
contract
with
i nvarious
(PPOs) w e r e
a
later
�development,
between
appearing
i n t h e 1980s.
HMOs a n d PPOs i s t h a t
incursion
The m o s t
the latter
oF a p e n a l t y - - g r e a t e r
patient
notable
diFFerence
p e r m i t s«-- a 1 be i t w i t h t h e
Freedom
i n the selection
413
oF
a personal
physician.
I n Missouri,
does e x i s t and i s s t r o n g l y
Gephardt,
his
Full
" I t i s unFair
Freedom
physician,
pharmacist,
an
oF a n y d u l y
chiropractor,
414
care
Richard
insured
licensed
dentist,
or p o d i a t r i s t . "
M o s t PPOs a r e o r g a n i z e d
caregivers
by i t s U.S. S e n a t o r
i n theselection
optometrist,
pharmacy
managed
d i s c r i m i n a t i o n t o not permit
oF c h o i c e
surgeon,
advocated
where
t o provide
by i n s u r e r s
service
who c o n t r a c t
with
according
t o a negotiated
Fee
r
4 1-
schedule.
It
Providers
i s conceivable
a r e chosen
that
based
on d e m o n s t r a t e d
t h e d e F i n i t i o n oF ' e F F i c i e n c y '
eFFiciency.
could
work
t o t h e d e t r i m e n t oF a p a t i e n t b e c a u s e i t r e F e r s t o c o s t e F F i c i e n c y
p r i m a r i l y For t h e o r g a n i z a t i o n , and s e c o n d a r i l y t o t h e p a t i e n t .
The p r i m e e x a m p l e oF s u c h d e t r i m e n t a l e F F i c i e n c y i s t h e o u t c o m e
ex p e r i e n c e d b y t h e p l a i n t i F F i n W i. c k 1 i n e v . S t a t e 41B
Antitrust
Exemption.
4 17
The
McCarran-Ferguson
limited
exemption
Fixing,
agreements
agreements.
protection
4 1 8
From F e d e r a l
on t e r m s
Protection
uniForm
setting.
the
the insurance
'business
antitrust
o f coverage,
i s evidence
boycotting.
regulate
grants
The A c t d o e s n o t p r o v i d e
i F there
rate
Act
oF
laws
states
industry,
insurance.
- 122-
such
and o t h e r
insurers
oF c o e r c i o n ,
was a c c o r d e d
Because
insurance
insurers
companies
as p r i c e
horizontal
with
i n t i m i d a t i o n , or
to Facilitate
r e t a i n t h e power t o
Federal
laws
do n o t a p p l y t o
�The
McCarran-Ferguson
(a)
therein
which
The
business
shall
relate
(b)
be
oF
No A c t
oF C o n g r e s s
supersede
purpose
oF
regulating
Sherman
any
Nothing
Act
or
the
taxation
be
business
contained
every
oF
person
by
oF
oF
any
t o any
States
such
business.
to
invalidate,
State
For
the
i n s u r a n c e u n l e s s
to the business
in this
engaged
several
construed
enacted
relates
inapplicable
and
laws
shall
law
the
speciFically
(c)
insurance
to the r e g u l a t i o n
or
Act
provides:
subject to the
impair,
such
Act
Act
shall
agreement
oF
insurance..."
render
the...
to b o y c o t t , coerce,
or
422
intimidate,
or
Insurers
From
a c t oF
b o y c o t t , c o e r c i o n , or
must meet t h r e e r e q u i r e m e n t s
the
McCarran-Ferguson
1.
Their challenged
boundaries
oF
insurance.'
what would
The
cooperative
(a)
eFForts
that
would
risks
beneFit
oF
Cb]
insured
includes
The
primary
to
oF
and
(policy]
oF
the
the
'business
oF
i s considered
concern
From
the
to include
policy
and
be
the
cooperative
antitrust
i t would
inFormed
the
in enacting
insure that
relationship
core
type
interpretation,
contractual
insurance
intra-industry
i s the
the
considered
oF
immunity,
i n an
within
beneFit
exemption:
be
was
exempt
w i t h o u t such
underwrite
the
be
Act
to
eFForts.
Congress'
McCarran-Ferguson
i n order
a c t i o n s must F a l l
business
ratemaking
intimidation."
laws.
too
ratemaking
They b e l i e v e d
diFFicult
r e s p o n s i b l e way
423
to
without
cooperation.
between
business
oF
the
insurer
insurance,
which i s issued,
424
enForcement.
the
which
i t s reliability,
ThereFore,
agreement i s d e F i n i t e l y
- 123-
and
although
within
the
the
�definition
of the business
ments
c o r p o r a t i o n s other than
to
with
l i e within
that
of
t h e realm
business
i s collateral
a
agree-
are not considered
of insurance
and concerns
merely
because
t h e 'business
,425
companies.'
(c)
the
insurers
of t h e business
.
insurance
of insurance, contractual
One o f t h e i n d i s p e n s a b l e c h a r a c t e r i s t i c s o f
business
of insurance
policy-holder's
i s the spreading
and u n d e r w r i t i n g o f
risk.
2.
Those
same a c t i o n s m u s t be r e g u l a t e d b y s t a t e l a w ;
3.
Those
same a c t i o n s c a n n o t
coercion,
or
be c o n s i d e r e d
boycotting,
intimidation.
Efforts
by i n s u r e r s
t o c o n t a i n or reduce
costs arenot
425
protected
by M c C a r r a n - F e r g u s o n
"...(E)ven
business
though
an a l l e g e d
from
antitrust
restraint
falls
scrutiny.
within the
t h e exemption w i l l apply only i f t h e
•427
state regulates the a c t i v i t y . "
T h e r e a r e some who c o n s i d e r
t h e M c C a r r a n e x e m p t i o n t o be "a s t a t e - a c t i o n e x e m p t i o n f o r a
428
p a r t i c u l a r l y favored state-regulated industry."
In
Act
of insurance,
March
antitrust
Aetna
and June
actions against Hartford,
Insurance
Companies
collusion
t o boycot
insurance
coverage
legal
o f 1988, e i g h t e e n s t a t e s
specific
affected
f e e s , and l o n g - t a i l
during
'states
which
c l a i m s may
Massachusetts,
New
York,
Ohio,
types
Allstate,
reinsurers
(i.e.,
be made a f t e r
Colorado,
Michigan,
Pennsylvania,
- 124-
CIGNA, a n d
coverage.
charges,
the length
an i n j u r y ) .
California,
Minnesota,
Sherman
alleging
of insurance
was f o r p o l l u t i o n
claims
were Alabama, A l a s k a ,
Maryland,
Jersey,
and t h e i r
brought
4
high
of time
2
9
The
Connecticut,
Montana,
Washington,
The
West
New
�430
Virginia,
and W i s c o n s i n .
liability
and n o t h e a l t h
the
expansiveness
industry
care
of a c t i o n s taken
i n the health
boycotting
coverage
of high-risk
(was c a u s e d
involved
against t h e insurance
field;
which
are also
i.e., refusing/
individuals
" t h e breakdown
by) j u d i c i a l
commercial
i t i s a reflection of
of practices
insurance
professor theorizes that
markets
this; suit
insurers,
and i s an i n d i c a t i o n
occurring
law
While
expansion
and groups.
One
i n insurance
of l i a b i l i t y
fand
431
therefore)
The
certain
argument
'special'
on
under
i n Arizona
Supreme
Court
public
that
and s h o u l d
industries
Court
types
of insurance
the health
be t r e a t e d
the antitrust
v. M a r i c o p a
intimated
that
s e r v i c e or e t h i c a l
care
c o v e r a g e ... u n r a v e l ( l e d ) . "
industry
differently
laws
County
i s somehow
from
was r e j e c t e d
Medical
professional
norms m i g h t
other
by t h e S u p r e m e
432
Society.
restraints
escape
The
premised
automatic
433
condemnation
Studies
had
adversely
a n d be e n t i t l e d
d u r i n g t h e 1980s
affected
t o more s y m p a t h e t i c
indicate
that
scrutiny.
antitrust
competition i n the f i e l d
and
immunity
antitrust
r e f o r m i s now a d v o c a t e d b y t h e F e d e r a l T r a d e C o m m i s s i o n ,
b u s i n e s s e s , s t a t e a t t o r n e y s g e n e r a l , t h e A m e r i c a n Bar
434
Association,
Chief
on
Counsel
Antitrust,
and consumer
and S t a f f
groups.
Director
Monopolies
be d i f f i c u l t
Mr. C o r r e i a ,
o f t h e Senate
and Business
t o withdraw
former
Subcommittee
Rights, states
antitrust
small
that
i t will
from
i n s u r e r s because:
"The i n s u r a n c e i n d u s t r y i s p o l i t i c a l l y
p o w e r f u l , i n p a r t because i t i s e c o n o m i c a l l y
s i g n i f i c a n t i n e v e r y s t a t e and i n p a r t because
it i s politically active.
The i n d u s t r y i s made
o f a number o f i n d i v i d u a l ' s u b i n d u s t r i e s , ' each
of which i s s u b s t a n t i a l i n s i z e - - l i f e i n s u r a n c e ,
- 1 25-
however
immunity
�h e a l t h i n s u r a n c e , a n d p r o p e r t y and c a s u a l t y
insurance.
I n a d d i t i o n , a g e n t s , b r o k e r s , and
r e i n s u r e r s , whose p r o F i t s a r e t i e d t o t h e s u c c e s s
oF t h e p r i m a r y c a r r i e r s , a r e g e n e r a l l y a l l i g n e d
w i t h them i n t h e p o l i t i c a l c o n t r o v e r s y o v e r
McCarran-Ferguson.
T r a d i t i o n a l l y , the major
c o m p o n e n t s oF t h e i n s u r a n c e i n d u s t r y h a v e b e e n
w e l l r e p r e s e n t e d by l o b b y i s t s i n W a s h i n g t o n and
in state c a p i t a l s , p o l i t i c a l action committees,
and F i n a n c i a l s u p p o r t For
candidates.'"^
3 5
The
Federal
deceptive
supplies
acts
Trade
or
Commission p r o h i b i t s
practices,
immunity
to
and
unFair
and
the McCarron-Ferguson
i n s u r e r s From t h a t
consumer
Act
protection
435
law.
to
P r i c e - F i x i n g immunity
property
laws
and
are oF g r e a t e r
In
rate
low
casualty
19S1,
oF
return
interest
"successFul1y
an
the
FTC
to other
unpleasant
legislate
Health
care
owes t o
on
the
to yield
one
which
to
achieve
to that
and
power
4 3 8
that
so
they
one
willingly
agency's
the
Function.
consumer
F a c e oF
to uphold
with
eFFectively
they
a Congress t h a t
than
the
insurance
be
that
a Federal
i n the
that
I t leaves
can
group
beneFit
protection
a provision prohibit-
Congress
oF
concern
extraordinarily
study
t o adopt
that
would
hand,
was
a
4 3 7
Found
LiFe
t h e FTC
insurance."
disempowerment
reForm
such
will
be
bald
use
Finds i t
the
loyalty i t
i t s constituency.
Divesting
antitrust
imposed
by
e special interest
diFFicult
power
easier
by
the
massively
oF
realization
Commission
investments.
incensed
studying
insurers.
insurance
l o b b i e d Congress
From
manipulated
liFe
oF
w h i l e consumer
to health
Trade
From w h o l e
c o m p a n i e s became so
ing
insurers,
the Federal
when c o m p a r e d
i s g e n e r a l l y more
by
the
immunity
the
insurance
industry
oF
involves conFronting
insurers,
but
also the
- 125-
the
not
comForts
only
"...dilemma
the
oF
obstacles
(oF)
how
to
�reconcile
with
the
the
every
Federal
e x t e n s i v e system
The
permit
the
oF
For
not
now
i n place
in
i n t e n t oF
to the
intervention.
oF
providing
government
state
action
articulated policy
Federal
to
over
determine
doctrine,
t o which
to
occupy
i n order
whether
For
to regulate
There
are
a state
i t adheres
that
antitrust policy.
a n t i t r u s t laws.
4 4 0
I t
the
4
4
1
have
and
state
policy
Each s t a t e
itselF
two
must
or
submit
components
to
has
take
the
to
to the
state
doctrine:
1.
the
challenged
aFFirmative1y
2.
the
supervised
r e s t r a i n t m u s t be
expressed
by
the
state
are
reluctant
antitrust
immunity
about
possibility
the
From s t a t e
the
eliminate
oF
the
oF
and,
conduct
m u s t be
actively
current
4
4
2
to relinquish
but
they
losing
There
level.
articulated
policy;
are
just
as
between
current
concerned
they
discussions
insurance
Achieving
conFlict
their
the p r o t e c t i o n
have been
transFerring
Federal
clearly
state
itselF.
status,
regulation.
possibility
to
as
anticompetitive
Insurers
state
Federal
the purpose
desire
Federal
the
precedence
action
without
For
the
antitrust scrutiny."
implements
Federal
From
without
conscientiously
power
evolved
a n t i t r u s t issues.
a clearly
the
regulation
competition
insurers
extended
to operate
According
and
state
to Function
was
license
not
Field
immunity
states
immunity
"broad
was
oF
Favoring
state."
Antitrust
to
a n t i t r u s t policy
enjoy
concerning
regulation
that
state
reForm
From
the
would
policies
and
443
Federal
a n t i t r u s t laws.
However,
- 127-
as
Correia
aptly
points
�out:
"The l o n g
and
difficulty
political
the
regulators
Bills
laws
of transFerring
oF r e t a i n i n g
oF
regulation,
currently
responsibility,
to provide
harbor'
4 4 5
immunity
From
F o r " d e v e l o p m e n t oF c 1 a s s i F i c a t i o n
collection
a n d d i s s e m i n a t i o n oF h i s t o r i c a l
the
use
of voluntary,
the
competitive beneFits
standardized
oF t h e s e
various
antitrust
The b i l l s
violations
and
a l lpoint i n
between F e d e r a l
oF i n s u r e r s .
'saFe
change,
i n Congress advocate
the conFlict
regulation
and t h e
4 4 4
pending
oF r e c o n c i l i n g
the complexity
t h e s t a t e s as t h e p r i n c i p a l
insurance."
and s t a t e
continue
of state
o p p o s i t i o n t o such a wholesale
direction
methods
tradition
antitrust
standards,
l o s s oF
policy
would
inFormation,
Forms...(because)
p r a c t i c e s outweigh
the
44B
competitive
risks..."
Correia
regulation
concludes
that
do n o t c o n F l i c t
incompatibility
i s even
Federal
and t h a t
weaker
when
antitrust
"(t)he
laws
argument
and
state
oF
i t comes t o c o n s u m e r
447
protection."
Additionally:
" . . . ( T j h e r e i s no p r i n c i p l e d a r g u m e n t t h a t
t h e F e d e r a l b a r o n d e c e p t i v e p r a c t i c e s i s somehow i n a p p r o p r i a t e b e c a u s e oF u n i q u e c h a r a c t e r i s t i c s oF t h e i n s u r a n c e b u s i n e s s .
Virtually
every
i n d u s t r y i n t h e U n i t e d S t a t e s must c o m p l y w i t h
b o t h F e d e r a l and s t a t e consumer p r o t e c t i o n
s t a n d a r d s . ... I F a n y t h i n g , t h e i m p o r t a n c e oF
i n s u r a n c e t o c o n s u m e r s , a n d t h e e x t e n s i v e u s e oF
n a t i o n a l m a r k e t i n g p r a c t i c e s , makes a m o r e p o w e r Ful
case For a p p l y i n g F e d e r a l s t a n d a r d s t h a n For
most i n d u s t r i e s .
Thus, t h e anomalous
exemption
F o r t h e i n s u r a n c e i n d u s t r y From t h e c o n s u m e r
p r o t e c t i o n s t a n d a r d s oF t h e F e d e r a l T r a d e
C o m m i s s i o n A c t s h o u l d be r e p e a l e d a l o n g w i t h a n y
legislation dealing with the antitrust
exemption.
One l e s s o n oF t h e M c C a r r a n - F e r g u s o n e x p e r i e n c e
i s t h a t Congress s h o u l d speak c l e a r l y i F i t i s a t
all possible.
A n o t h e r l e s s o n i s t h a t an e x e m p t i o n ,
once g r a n t e d , i s d i F F i c u l t t o t a k e away.
Not only
-128-
�does t h e i n d u s t r y spend enormous p o l i t i c a l
eFFort
t o p r o t e c t i t s i m m u n i t y , t h e u n c e r t a i n r e s u l t s oF
e l i m i n a t i n g i t becomes an a r g u m e n t F o r t h e s t a t u s
quo.
Another l e s s o n , however, i s t h a t t h e i n d u s t r y
d e s e r v e s some c l a r i t y a b o u t t h e s t a n d a r d s oF
conduct i t i s expected t o Follow...IF s t a t e
r e g u l a t i o n h a s n o t w o r k e d w e l l i n some r e s p e c t s ,
a n d i F t h e F e d e r a l g o a l oF c o m p e t i t i o n i s deemed
more i m p o r t a n t t h a n c e r t a i n s t a t e r e g u l a t o r y
p r a c t i c e s , Congress s h o u l d say s o . "
4 4 8
Representative
to
a b o l i s h most
possess.
had
H.R.
been
Jack
oF t h e a n t i t r u s t
9 was i n t r o d u c e d
introduced
Committee
Brooks
but,
last
year
(D-Tex) has i n t r o d u c e d
exemptions
i n June
due t o i n s u r a n c e
bill
i n s u r e r s now
1991.
and approved
a
The same
bill
by t h e J u d i c i a r y
industry lobbying,
i t never
449
reached
a Floor
vote.
As a r e s u l t
public
criticism
insurer
May
that
Council
actuarial
standardized
pooling
research
the
"give
are intent
now b e g i n s
to avoid
property
stated:
Federal
mitigation
on r e t a i n i n g
halF
when p u b l i c c r i t i c i s m
i F some
oF some
a century."
l o t . "
4
antitrust
ability to
developing
u n d e r w r i t i n g and
oF an
the beginning
insurance
oF a new e r a
Driscoll
' saFe h a r b o r s '
oF t h e s e c u r i t y
452
a
and t h e American
by j o i n t
and s t a t e r e g u l a t i o n . "
"Even
giving
their
The v i c e p r e s i d e n t
the unraveling
For n e a r l y
risk
"We're s e e i n g
by s t a t i n g :
and
and c a s u a l t y
and b u i 1 d i n g - i n s p e c t i o n d a t a ,
4 5 1
vecal
policies,
Association--
proposed
Forms, and s p r e a d i n g
Firm
events
a little
Insurance
and more
industry i s beginning t o
representing
Insurance
arrangements.
combined
enjoyed
i t must
They
r a t e s , canceled
the insurance
American
oF L i F e
exemptions.
in
high
1991, t h e lobby
insurers--the
share
over
bankruptcies,
understand
In
oF i n c r e a s i n g l y s t r o n g e r
blanket
Congress
becomes s u F F i c i e n t l y v o c a l .
- 1 29-
simpliFies
survive,
i n s u r e r s have
does
respond
5
0
�Termination,
Health
Non-renewal,
insurance
former-insureds
which
Cancellation,
companies
Uninsurabi1ity.
are expressing
who a r e s u b m i t t i n g
have e i t h e r been
and
terminated
claims
concern
under
about
group p o l i c i e s
or modified.
Insurers
453
contend
t h a t coverage
Insurers
are
"already
termination
no l o n g e r
explain
exists.
t h a t many o r m o s t o f t h e s e
seriously
i l l ,
i n j u r e d or disabled
o r m o d i f i c a t i o n " and a r e t h e r e f o r e
new, s u b s t i t u t e h e a l t h
insurance
coverage.
former-insureds
"argue
that
for
t h a t commenced o r i n j u r y
any i l l n e s s
policy
that
pay
was i n f o r c e
" i fthis
benefits
or before
argument
without
a t t h e time
unable
have a v e s t e d
they
former-insureds
For t h i s
that
i s successful,
receiving
to obtain
reason, the
right
to benefits
occurred
i t was m o d i f i e d . "
Levy
i t requires
of
while the
explains
the insurer to
any p r e m i u m s w h a t s o e v e r
even i f
454
the
p o l i c y has teen
The
s o l u t i o n , of course,
premiums
which
and c o n t i n u e
i s at present
insurance
no
It
tan
Under
any f u r t h e r h a r m
the c i v i l i t y
receives
in distress.
i s obliged
to the injured
insurers
rule
our s o c i e t y
no p a y m e n t
f o r a moment
of health
B u t once
that role i s
to continue
aidto
party.
Samaritans.
a legal
adheres
has a t t a i n e d .
he r e c e i v e s by a i d i n g
- 1 30-
a concept
one i s u n d e r
i s n o t merely
f o r his troubles.
t o accept
Rule,
a r e n o t Good
our c u l t u r e generally
which
satisfaction
Consider
t h e Good S a m a r i t a n
t h e Good S a m a r i t a n
a r u l e t o which
innate
that
be f o r t h e i n s u r e r s
t o any c o n s i d e r a t i o n
t h e Good S a m a r i t a n
i s granted
However,
of
foreign
o b l i g a t i o n t o a i d another
minimize
would
coverage.
coverage.
undertaken,
but
terminated."
premise
as an
expression
The g o o d
Samari-
His reward
another.
i sthe
�It
not
been
since
to
that
a i d has a l r e a d y
with
commenced.
the injured
i t so c h o o s e s .
I tretains
condoned
that
such
behavior
by t h e e n t i r e
will
acknowledge
obliterated
In
really
rule
oF
the insurer
a strange
and d i s a b l e d
i n i t s journey
and u n i q u e
i s p e r m i t t e d and
I t s power
i s oppressive
the existence
has
Insurers are permitted
a t any p o i n t
nation.
e n d s F o r i t s own b e n e F i t
payment
a i d t o t h e weakened
up a n d d r o p
society
none
even
obliged to continue
such
pick
that
in
i s a paradox
position
thereFore
t o accomplish
these
and y e t e t h e r e a l because
oF t h a t
power
over
an
civilization.
t h e F a c e oF r a p i d l y
i n c r e a s i n g h e a l t h care
costs
which
began
to spiral
i n 1980, i n s u r e r s have
Found i t
economically
necessary
t o increase
Group h e a l t h
insurance
Forced
plans
have been p a r t i c u l a r l y
insurance
-- r a i s e
premiums.
problematical
and have
companies t o :
premium
rates;
-- m o d i F y e x i s t i n g p o l i c y p l a n s t o make t h e m
a F F o r d a b l e as p o s s i b l e t o e m p l o y e r s ;
-- t e r m i n a t e e x i s t i n g
as
policies;
455
-- w i t h d r a w
Margaret
From
Levy,
t h e group
health insurance
who p r i m a r i l y
deFends
business.
insurance
companies
455
in
'bad F a i t h '
litigation,
or
modification
of group
explains that
health insurance
oFten " t e r m i n a t i o n
policies
can c r e a t e
457
more p r o b l e m s
than
former
insureds
should
be e x p l a i n e d
accepted
Health
by
i t solves."
have
vested
that
by t h e c o u r t s
insurance
the c o u r t system
rights
in their
the vested
i n cases
benefits
When c o n s i d e r i n g
have
right
involving
whether
beneFits, i t
concept
i s generally
accident
insurance.
n o t been c o n s i s t e n t l y
to maintain that
- 1 21 -
vested
quality.
considered
458
�Generally,
the courts
will
strictly
construe
in
oF t h e i n s u r e r .
Favor
study
the policy contract
i t s p r o v i s i o n s , which
However,
will
and
generally
i n the event
oF
will
then
be
contract
45 9
ambiguity,
also
the insured
consider
reasonable
public policy
t h e same
That
insurance
tions
and
to prevail.
"provides
principle,
coverage.
will
insured's
continue
i n Force
4 5 0
policy contracts
the Foundation
are oFten
contracts
oF
For t h e r e a s o n a b 1 e - e x p e c t a -
unconscionabi1ity
reliance provides
Courts
i n t e r e s t s and t h e
reliance that a policy will
providing
adhesion
is likely
supplies
the rudiments
the motivation,
oF a s t a n d a r d
For
measurement."
Insurance
policies
employee's choice
the
oF c a r r i e r .
policy negotiated
insurance
policies
individual
contract
oF a d h e s i o n
any i n p u t
between
a t what
insurer
the reasonable
the extent
insurance
policy, there
among
the courts
i n determining
doctrine
that
the policy provide
believed
by
the
oF r e a s o n a b l e
imposing
coverage
and i n s u r e r .
cost.
and
t h a t an i n s u r e d
which
The r e s u l t
is a
insured.
expectations
oF an
a v a i l a b l e under a
diFFiculty
t h e d e F i n i t i o n oF a n d e x t e n t
Another
that
accept
as t h e
has been c o n s i d e r a b l e
t h e coverage
the requirement
an
ThereFore,
[as well
concerning
expectations.
had been p u r c h a s e d .
preclude
employee must
oF c o v e r a g e
health
the
employers
by e m p l o y e e s
are covered
When c o n s i d e r i n g
concerning
employer
to
consumer) p r e c l u d e
services
through
The i n s u r e d
between
agreed
provider
insured
obtained
One
view
requires
that the insured
view
modiFies
the insurance
would reasonably
- 1 32-
oF
the First
policy
expect
reasonably
provide
t o be
�covered
after
reasonable
For
eFFort
individuals
There
take
into
Favor
versus
are generally
consideration
oF c o v e r a g e
1.
recovery
known
commercial
three
or the insured
a reasonable
coverage."
and
that
may
have
coverage
"The e x t e n t
c o u l d have
have
3
t o hold i n
over t h e
actually
which
understood
expected
precludes
the limits
4 6 6
IF the insured
clariFied
or should
i n t h e i n s u r e d ' s shoes
i s an o b j e c t i v e
or a c t i v i t y
oF
have
would
inquiry
which
oF t h e i n s u r e r o r
c r e a t e d an o b j e c t i v e l y
467
reasonable
exists.
t o which
gained
knew
the insured
through a reasonable
an u n d e r s t a n d i n g oF t h e
could read
and u n d e r s t a n d
h a d s u F F i c i e n t t i m e t o do s o , b u t F a i l e d
would
6
policy.
the insurer
This
which
policy).
a
4
the courts
i n a dispute
inquiry
clearly
person
its
eFFort
parties.
which
an i n s u r e d
t o which
words, c o n d u c t ,
3.
under
t o which
considers
impression
insured
464
i n Force.
expected
agent
on t h e r e a d i n g oF t h e p o l i c y
Factors
i s a subjective
"The e x t e n t
that
d i F F e r e n t s t a n d a r d oF
i n d e t e r m i n i n g whether
by an i n s u r e d who
465
policy
2.
This
be a p p l i e d
available
"The e x t e n t
coverage."
have
would
oF t h e i n s u r e r
extent
the
reading the p o l i c y . A
the situation,
(contract/
the policy
t o take steps
that
the insured's claim i s
weaker."
"When members oF t h e p u b l i c p u r c h a s e p o l i c i e s oF i n s u r a n c e
t h e y a r e e n t i t l e d t o t h e b r o a d m e a s u r e oF p r o t e c t i o n n e c e s s a r y
469
to
Fulfill
that
their
coverage
reasonable
and e x c l u s i o n
expectations."
provisions
exist
p o 1 i c y . . .does n o t p r e c l u d e a r e a s o n a b l e
- 132-
Also,
"Knowledge
i n an i n s u r a n c e
expectation
that the
�exclusion
does n o t n u l l i f y
transaction.
reasonably,
t h e dominant
... The 1 aw ... p r o t e c t s
as c o n s o n a n t
with
purpose
of the
expectations
t h e purpose
objectively
of the standard
,,470
contract..."
While
of
the insurance
i t s burdensome
the
termination
industry
p o l i c i e s , and consumers have
of their
a precautionary
has been r e l i e v i n g
measure
insurers
to explicitly
coverage
will
above s p e c i f i c m o n e t a r y
their
why
catastrophic
i s necessary
which
of pre-existing
The
industry
they
expect
Insurers
health
care
appears
t o dwell
illness'
within
Without
coverage
experiencing
f o r mental
i n the lack
-- a d e f i n i t i o n
the four
corners
any e x p l i c i t
determinants,
.mental
illness
being
person
a t the time
illnesses.
which
i s most
of the health
the term
ofttimes
"understood
the
This i s
of
coverage.
reform
plan
o f 1992.
difficulty
'mental
not
insurance
deny
concerning
of
often
the courts
definition
half
The
of a d e f i n i t i o n
guidelines,
and t h e i r
i t s own h e a l t h
difficulty
their
coverage o f
f o rfuture
i n the f i r s t
included
policy.
are usually the
comes down t o
by a
reasonable
47 1
the contract
was
made."
Insurance
from
companies are f a c i n g
hospitals
because o f t h e f o l l o w i n g event.
- 133-
as
increasing
coverage.
require
conditions
public
be
and t h e e x c l u s i o n
i s developing
t o make
are also
will
illness,
consideration
which
their
will
that
terms
By r e d u c i n g
o f consumers, they
and l o n g - t e r m
insurance
be r e f o r m u l a t i n g
limits.
t o c o n t i n u a l l y reduce
legislation
challenging
and i n c l e a r l y u n d e r s t a n d a b l e
expectations
ability
been
p o l i c i e s , i t i s t o be e x p e c t e d
policies
reasonnable
itself
increasing c o s t - s h i f t i n g
Hospital
care
�is
the
Fact,
highest
health
physicians
patients
on
an
cost
have
For
expenditure.
years
outpatient
Because
been t r y i n g
basis.
The
to
result
of
this
care
has
For
been
a
their
decline
472
in
occupancy
hospital
rates
stays
at h o s p i t a l s .
declined
From
"[T)he
8.3
days
in
average
19S7,
to
length
7.2
oF
days
in
473
1987."
Rather
declines,
provided
state that
account For
From a l m o s t
1987
(the
the
latest
oF
by
the
monetary
cost
Health
oF
l o s s From
outpatient
Insurance
"community h o s p i t a l
these
services.
Association
occupancy
rates
oF
(which
more t h a n 80 p e r c e n t oF a l l h o s p i t a l s ) plummeted
80 p e r c e n t i n 1973 t o j u s t u n d e r 65 p e r c e n t i n
Insurers
because
suFFer
h o s p i t a l s r a i s e d the
Statistics
America
than
statistics
have been
other
available).
Faced
Factors
as
with
well,
s e r v i c e s and
increasing
some oF
costs
oF
claims
which
costs
are:
1.
increased
outpatient
services;
2.
i n c r e a s e d number oF d i a g n o s t i c t e s t s and p r o c e d u r e s
b e c a u s e oF p h y s i c i a n s ' F e a r s oF m a l p r a c t i c e
suits;
3.
' a n t i - s e 1 e c t i o n ' process wherein h e a l t h i e r
people
j o i n HMOs a n d PPOs a n d t h e i n s u r e r s r e t a i n h i g h - r i s k
high-cost clients.
Most i n s u r e r s b e l i e v e t h a t s m a l l
b u s i n e s s e s pose h i g h e r h e a l t h r i s k s t h a n l a r g e
corporations;
4.
AIDS-related
The
problem
474
insurmountable.
extended
on
to
i s the
From
the
costs
However,
clients
provision
of
pharmaceutical
direct
route
can
oF
drugs
because
the
the
the
i t s AIDS c l i e n t s
a l l i t s other
that
oF
claims.
save
as
oF
incurred
John Alden
the
with
AIDS p a t i e n t s
Insurance
same b e n e F i t
catastrophic
a l l necessary
manuFacturer
much as
the
by
which
elimination
oF
has
i t bestows
i11nesses...and
patient.
200-300 p e r c e n t
- 124-
Company
pharmaceuticals
to the
seems
directly
This
oF t h e p r i c e
475
markup!
When
�the
drug
costs
$30,000 per
passing
the
to
by
comprise
These
end
raise
coverage
4 7 6
10
1990s.
high
OFFice has
reach
percent
billion
as
as
$20,ODD t o
10
oF
during the
numbers have caused
high-risk
as
485,000
claims
are
a l l health
percent
oF
oF
expected
insurance
claims
span
each
projected that
high
AIDS-related
This
premiums For
as
is
this
expected
one
decade.
insurers to attempt
to
i n d i v i d u a 1 s , o r reFuse
altogether.
Having
insurers,
considered
the
m u s t a l s o be
solved
could
1991.
i n s u r e r s $35
run
Accounting
approximately
incredible
either
oF
can
becomes more i m p o r t a n t w i t h
AIDS c a s e s
during the
cost
step
General
oF
the
AIDS p a t i e n t s
this
The
incidence
claims
to
year,
day.
persons
For
by
other side
h e a l t h care
oF
insurers'
oF
considered.
pre-existing
policies
some F a c t o r s
the
are
substituted
problems
[1] insuring
(2) e l i m i n a t i n g
high-cost patients,
judgments
increase
health insurance
Three major
reForm
conditions;
which
and
the
costs
problem
which
those
the
must
cancellation
treating
be
with
(3) e l i m i n a t i o n
over
For
oF
oF
physician's
d e c i s i ons.
Patients
with
pre-existing
mercy
oF
insurance
wrote
oF
her
experience
expenses
For
a condition
husband
had
poignantly
honest
worked
wrote
Americans
companies.
For
with
Mary
an
which
being
had
Bush
held
E v a n s oF
insurer
a diFFerent
to President
are
c o n d i t i o n s are
that
existed
hostage
Columbus,
reFused
when M r s .
employer.
that
presently at
Mrs.
"Millions
by
the
Ohio,
to
cover
Evans'
Evans
oF
insurance
hardworking,
companies.
478
I am
one
oF
them."
The
reFusal
- 1 35-
to
issue
a policy
to
cover
�Mrs.
Evans*
savings
health
account
Under p r e s e n t
able
to
ever.
Education
is
legal
Uwe
health
staFF
For
liFe-saving
i s going
cover
Disability
the
will
some t i m e ,
CaliFornia,
i s any
cost
James M a d i s o n
at Princeton
University
insurance
by
treatment
evidence
insurer
be
iF
Rights
states " I t
that
Ca
money,
they
you."
Reinhardt,
contract
quite
the
For
there
to
cancer
For
in Berkeley,
IF
their
i t i s u n l i k e l y she
insurance
attorney
DeFense Fund
to
deregulated
social
any
Kilb,
and
have
pay
i n a n n i h i l a t i o n of
statutory conditions,
condition)
economy
to
discrimination.
medical
don't
resulted
i n order
purchase
Linda
costs
industry
proFessor
oF
proclaims:
has
political
"The
partially
been b r e a c h i n g
p r i c i n g insurance
to reward
the
the
healthy
473
and
by
maneuvering
should
that
and
be
mentioned
opposed
President
the
wall
are
and
children
aroused
similar
insurers
to
that
overcome
people
of
this
to
i s the
Roosevelt's
are
starting
to
supporting
expansion
to
themselves
the
oF
Uncertainty
To
that
coverage
the
social
protect
the
purchase
will
Canadian
impose
see
oF
i l l . "
I t
same i n s u r a n c e
security
Johnson's Medicaid/Medicare
nation
out
deny
President
Insurers
an
to
handwriting
to
From t h e
a national
system...which
program
programs.
the
aid
industry
elderly
on
people
possibility
health
that
program
could
put
health
Factor
For
most
Future
may
bring,
business.
i s the
biggest
uncertainties
insurance.
stress
that
The
i n s u r i n g , assumes a n o t h e r ' s
-136-
the
insurance
risk
industry,
in return
For
people.
i n the
payment.
act
�Purchasing,
should
be
and
remain
t h e r a f o r a assuming
liable
For
the
p e r m i t t e d t o t e r m i n a t e an
a situation
been
has
turned
originally
insurers
nation.
which
not
and,
by
not
the
risk
insurer
and
should
not
c o n t r a c t merely
because
advantageous
had
as
to
may
i s a two-way
Insureds
impose
extension,
In return,
a policy
that
insurance
one
however,
responsibility.
responsibility
oF
risk,
as
expected.
Insurability,
personal
into
cost
that
unnecessary
to
oF
have a moral
a l l the
i n s u r e r s must n o t
be
street
costs
other
seek
social
and
on
and
social
their
insureds
loopholes
in
the
through
repudiated.
" M o s t h e a l t h i n s u r a n c e p l a n s a r e oF t h e
Fee-For-service type.
Under t h e t y p i c a l
insurance
plan, the i n s u r e r agrees w i t h the insured to
r e i m b u r s e t h e i n s u r e d F o r ' u s u a l , c u s t o m a r y , and
reasonable' medical charges.
The
third-party
i n s u r e r . . . b e a r s the economic r i s k t h a t the i n s u r e d
w i l l r e q u i r e medical
treatment."
4 a D
However,
climb,
the
'usual,
customery,
exceeded
not,
on
not
and
high
want
limit
the
that
oF
t o be
the
those
individual
costs
medical
policy
i s then
an
has
have
suFFicient
(1) whether
For
and,
been r e a c h e d
1990
and
the
costs;
to
exceeded
charges
non-renewable
asked:
begin
or
is cancelled.
medical
and,
(2)
i s treatment
banned, r a t h e r than
p l a c i n g the
which
costs
reduced
providers
to reduce
issue
are
For
reasonable'
policy
need
why
whether
insurers
and
p e r m i t t e d are
then
The
and
the
questions
charges
costs
i n s u r e r contends
thereFore,
Two
when m e d i c a l
the
can
those
i s too
be
even
though
iF
ban
may
costs.
oFten
i n s u r e r may
debated
whether
terminate
discovering various
- 12 7 -
other
the
costs
policy.
methods
are
excessive
Thus,
oF t e r m i n a t i n g
�policies.
One
o f these
short-term
coverage
methods
i s the practice of
imposing
•
f o rpolicies;
renewable
every
insurance
c o n t r a c t s i s p e r m i t t e d by s t a t e s t a t u t e s .
utilizing
this
protect
level
from
Health
Security
(for health
election
of the e l i g i b l e
contract
i s terminated
cause'
refers
merely
misrepresentation,
costs
to
N e g o t i a t i n g new
method,
c o n t r a c t s which
has been p r o p o s e d
contract
the
12 m o n t h s .
By
i n s u r e r s can
show
a
suddenly-increasing
of costs.
American
"The
or every
statutorally-protected
themselves
A remedy
The
6 months
i . e . , the p o l i c i e s are
provide
Durenberger
(R-Mn).
A c t o f 1991 ( 3 . 7 0 0 ) r e q u i r e s
insurance)
m u s t be r e n e w e d
sma11-business employer
4
f o rcause." ^
t o nonpayment
1
The t e r m
o f premiums
and n o t t o t h e p o s s i b i l i t y
i n c u r r e d by e m p l o y e e s .
sma11-business
by S e n a t o r
Although
employer,
i t
this
i s a step
p r o t e c t i o n t o consumers
a t the
unless the
'terminated f o r
or f r a u d or
of high
bill
medical
only
covers
i n the right
as o p p o s e d
that
direction
to protection f o r
i nsurers.
The
-or
salient
may no l o n g e r
self-employed
status
many
points
2.
t o issue
no l o n g e r
health
u n i 1 a 1 1 e r a 11y , l e a v i n g g r o u p s
3.
coverage
may
no l o n g e r
under
t o small
as p o o r
Insurers
high-risk
insurance
groups
health
consider
operations.
contracts
unprotected.
exclude
an e m p l o y e r ' s
such
occupation.
t o be i n h e r e n t l y
cancel
insurers:
policies
f o r reasons
i n a high-risk
businesses
may
refuse
individuals
or working
small
o f S.700 a r e t h a t
individual
group
- 12a -
plan
employees
just
from
because t h e
�employee had poor h e a l t h ,
o r had a dependent
child
i n poor
health.
4.
may
periods
no l o n g e r
For coverage
establish excessively
oF e m p l o y e e s who
long
waiting
have p r e - e x i s t i n g
medical
problems.
Additionally,
regulation
1.
health
oF i n s u r a n c e
nationally
insurance
employed
2.
lating
S.700 a d d r e s s e s
the t r a d i t i o n a l s t a t e
c o m p a n i e s by
uniForm
products
requiring:
consumer
sold
protection
t o small
standards
businesses
For
and s e l F -
people.
states are to r e t a i n
the insurance
accomplish
market
t h e same d e g r e e
their
traditional
as l o n g as t h e y
role
enact
oF c o n s u m e r p r o t e c t i o n
oF
laws
reguthat
a s S.700
prov i des.
3.
insurance
which
Failed
abide
by F e d e r a l
companies
t o enact
37 m i l l i o n
p r o t e c t i o n s would
t o remedy
Americans
determined
coverage
make
age
this
that
For these
i n order
people,
i t more e c o n o m i c a l l y
than
i t would
objective
t h e Fact
Ctwo-thirds
who do n o t h a v e h e a l t h i n s u r a n c e
has
products
i n any
state
be r e q u i r e d t o
rules.
S.700 i s i n t e n d e d
than
such
selling
coverage.
Senator
Durenberger
t o incent insurers to provide
attractive
by i m p o s i n g
t h e r e a r e more
oF whom a r e e m p l o y e d )
legislation
be t o d e n y
that
i s needed
For them
coverage.
an e x c i s e
which
will
to provide
The b i l l
will
t a x on i n s u r a n c e
cover-
accomplish
companies
483
iF,
due t o ' w i l F u l
policy
products
neglect'
which
they
a r i called
t o oFFer two s p e c i F i c
484
MedPlans.
Any i n s u r a n c e
- 139-
Fail
�company
which
be F a c e d
v i o l a t e s these
with
a Federal
gross
accident
Force
during
product
excise
and h e a l t h
requirements
tax penalty
premiums
o f S.700
oF 2 0 p e r c e n t
For small
group
would
oF
contracts i n
4S5
that taxable
Senator
to
Durenberger
an i n s u r e r
and
year.
explains
t o deny o r c a n c e l
that " I t i s highly
coverage
i n d i v i d u a l s because t h e i n s u r e r
claims
such
e x p e n s e s down s i m p l y
groups
or i n d i v i d u a l s .
oF h i g h e r - r i s k g r o u p s
i s (then)
by a v o i d i n g
proFitable
able
the risk
Consequently,
t o keep
oF
enrolling
the level
oF S . 7 0 0 ' s
48E
tax
penalty
The
under
be h i g h
enough
which
insurers
beneFits
t h e MedPlan
MedPlan
are
must
policies
and t h e S t a n d a r d
will
t o deter
will
these
be r e q u i r e d
be d i v i d e d
MedPlan.
practices."
to
provide
b e t w e e n t h e Core
The C o r e M e d P l a n
beneFits
to include:
Inpatient
and o u t p a t i e n t :
Diagnostic
and s c r e e n i n g
Prenatal
hospital services
surgical services
physicians'
services
services
care
Ambulance s e r v i c e s
4B7
Durable medical equipment.
The
Standard
The
MedPlan
beneFits
beneFits
are to include:
i n t h e Core
MedPlan,
I n p a t i e n t or o u t p a t i e n t treatment
c h e m i c a l dependency d i s o r d e r ^ Q B
There
i s t o be no d e d u c t i b l e
$500 d e d u c t i b l e
per
c os t
Family.
oF t h e s e r v i c e ,
will
For mental
For p r e n a t a l
per i n d i v i d u a l
Copayments
plus:
care,
disorder or
a n d a maximum
a n d $ 1 , 0 0 0 maximum
deductible
be e i t h e r 20 o r 5 0 p e r c e n t
depending
on t h e t y p e
oF
oF t h e
service
489
involved.
national
Copayments
eFFort
t o reduce
a r e an i m p o r t a n t
the overall
- 140-
component
costs
i nthe
oF h e a l t h
care.
�Copayments
incent
treatment
behavior
and
health
also
to avoid
Under
care
consumers
to practice
potential
S.700, i n s u r e r s
t o Forego
preventive
and
unnecessary
cautionary
illnesses.
will
n o t be p e r m i t t e d t o :
--
e x c l u d e any e m p l o y e e who w o r k s more t h a n 30 h o u r s
p e r week, n o r t h e e m p l o y e e ' s spouse o r c h i l d r e n
--
e x c l u d e any p e r s o n F r o m c o v e r a g e F o r l o n g e r t h a n s i x
m o n t h s F o r any p r e - e x i s t i n g c o n d i t i o n .
Pre-existing
conditions
during
is
are only
those
the three-month
First
--
"cause
covered
by
terminate
period
the
an
conditions
which
preceding the date
themselves
an
insured
contract.
insurance contract
to terminate."
maniFest
An
unless there i s
insurance contract
cannot
be
490
terminated
At
Senator
that
For
F o r any r e a s o n
least
Durenberger's
the b i l l
providing
also
37 m i l l i o n
has
remain
articles
and
to
within
have
and
tax
been
t h e y have
detriment
oF
unemployment,
immediate
I t is interesting
For becoming
may
be
i n need
oF
passage
to consider
the precedent
could
provisions.
also
be
written
regulated
about
percentage
recently
their
oF
i t s guaranteed
by S.70D a n d a r e
49 1
t h e " a c c e p t a b l e premium
paying a larger
which
S.700.
characteristics.
t h o s e same b e n e F i t s t o a l l A m e r i c a n s who
Premiums w i l l
to
to risk
A m e r i c a n s need
the p o t e n t i a l
b e n e F i t From
eligibility
related
oF
begun
employees.
a return
requiring
Many
employers
t h e premium
to
payments
practices
greater
on e m p l o y m e n t .
bill
comes t o t h e s m a 1 1 - b u s i n e s s e m p l o y e r s '
- 14 1-
to the
increasing
is likely
even
return
From
to release themselves,
I n t h e s e t i m e s oF
to those
negative impact
range."
required
t o have
Senator
rescue
an
Durenberger'
and
wisely
�turns
t h e issue
First
by
around
bill
requires
speciFied
rate
insurers,
the b i l l
those
insurance
oF i n c r e a s e .
will
t o both
premiums
available
price
a
larger
is
also
sales
a t a reasonable
the price
would
be i F t h a t
company
required
be
addressed
same
so t h a t
opportunity
on
t o themselves
a s an
and t h e n
maintain
level.
a t which
insurers
employers
contract
t o be made
contract
than
available to
oF b u s i n e s s .
t h e same l e v e l
The
insurer
oF m a r k e t i n g a n d
owner as i t does t o t h e
t h e sma11-business
to learn
make a
m u s t n o t be g r e a t e r
were
t o t h e sma11-business
corporations
t o look
oF p r e m i u m s
within a
requirement
or c o l l e c t i v e l y
w i t h i n t h e same c l a s s
t o extend
this
insurers
t h e cost
t o sma11-business
eFForts
larger
will
premiums r e m a i n
By i m p o s i n g
require
reduce
Additionally,
the
that
as i n d i v i d u a l c o r p o r a t i o n s
industry
the
t h e problem
insurers.
The
either
so t h a t
about
owner
the availability
will
have
oF t h e
492
health
insurance
Insurer
Cost
The
Kennedy,
coverage.
and R e s p o n s i b i l i t y
Health
America
Riegle
ShiFting.
and R o c k e F e l l e r
prohibiting
health
contract
limitations
conditions.
Act introduced
also
by S e n a t o r s M i t c h e l l ,
addresses
on i n s u r a b i l i t y
t h e problem
oF
due t o p r e e x i s t i n g
SpeciFically:
"A h e a l t h b e n e F i t p l a n s h a l l n o t e x c l u d e o r
o t h e r w i s e l i m i t a n y i n d i v i d u a l From c o v e r a g e u n d e r
t h e p l a n on t h e b a s i s t h a t t h e i n d i v i d u a l h a s
( o r a t any t i m e has h a d ) any d i s e a s e , d i s o r d e r ,
or c o n d i t i o n . "
4 9 3
However,
another
drawback
t o S.1227 i s e n c o u n t e r e d
- 1 42-
i n the
�very
next
s e c t i o n of
the
bill.
SpeciFically:
I n t h e c a s e oF a l e s s . - t h a n - F u l 1 - t i m e o r
p a r t - t i m e e m p l o y e e who i s s u b j e c t t o , a n d i s •
c h a r g e d , an i n c r e a s e d p r e m i u r n . . . t h e e m p l o y e e
may , n o t w i t h s t a n d i n g any o t h e r p r o v i s i o n oF
t h i s p a r t , waive e n r o l l m e n t . ..(and) such
•w a i v e r . . . s h a l 1 t e r m i n a t e on t h e d a t e t h e
e m p l o y e e i s no l o n g e r b e i n g s u b j e c t t o , a n d
c h a r g e d , s u c h an i n c r e a s e d p r e m i u m .
4 9 4
I n t h e case ( s t a t e d a b o v e ) , t h e e m p l o y e r
s h a 1 1 . . . m a k e a p a y m e n t u n d e r T i t l e V oF t h e
H e a l t h A m e r i c a A c t e q u a l t o t h e minimum amount
t h e e m p l o y e r w o u l d h a v e made t o w a r d t h e
a c t u a r i a l c o s t oF c o v e r a g e oF t h e e m p l o y e e i F
t h e e m p l o y e e had n o t w a i v e d s u c h e n r o l l m e n t .
4 9 5
In
other
amount t h a t
words,
the
iF the
employee
employee
may
waive
does n o t
pay
a premium
oF
paying
the
plan.
t o be
That
taxes.
an
The
occurs
The
this
insurer.
share
oF
under
legislatively
and
the
oF
insurance
the
the
§ 2 7 2 3 ( d ) oF
interpretation
oF
§ 2 7 2 3 ( c ) by
any
From
the
health
paid
For
Further
This
relieF
oF
r u l e s oF
i n biased
stating:
to
aFFairs
risk
From
has
the
should
Fair
play.
selection
conduct.
to bolster t h i s
- 1 43-
be
itselF
s t a t e oF
is abetting that
S.1227 a p p e a r s
For
to
insurer's responsibility
i n a n y b o d y ' s book
legislation
and
premium
will
individual.
That
i n d u s t r y i s engaging
the
plan,
in order
oF
an
emp 1 o y e r - - i n s t e a d
health plan
( v i a S.1227) s h i F t e d
'Foul'
i n the
government-sponsored
high-risk
because
premium,
employee's
relieved
s t a t e governments.
a cry
pending
this
the
The
t o AmeriCare
insurer is. thus
responsibility
elicit
the
amount
t o pay
to enrollment
government-sponsored
For
Federal
to
covered
responsibility
been
i s unable
his right
employer's
insurer--pays
employee
by
the
i n s u r e r r a i s e s premiums t o such
writer's
and
�I F an e m p l o y e e ' s c o v e r a g e o r c o v e r a g e F o r
t h e F a m i l y members oF a n e m p l o y e e w o u l d n o r m a l l y
t e r m i n a t e d u r i n g a p e r i o d oF h o s p i t a l i z a t i o n ,
such coverage s h a l l c o n t i n u e u n t i l t h e employee
o r F a m i l y member i s d i s c h a r g e d From t h e h o s p i t a l .
Health
insurance
nonpayment
coverage
oF p r e m i u m s !
consumer/patients
a consumer
Most
passible
by r e d u c i n g
dollar
However,
health
w h a t a p p e a r s t o be a
concerning
are estimated
logical
p r o v i d e r s have
For years,
For each p a t i e n t
insurer's
Form
and s u b m i t t e d
is--iF
administrative
why
change
is legislation
center
are
on t h e i d e a
legislators
Form.
that
a u n i v e r s a l Form F o r
a
Filled-out
c a n be a t t a c h e d
For payment
physicians
quietly
which
which
astonishing heights.
each p h y s i c i a n has i s s u e d
Form
then
savings
t o reach
been u s i n g
beneFit.
industry-wide claim
t o remind
universal
question
the cost
a d m i n i s t r a t i v e costs
i t seems o n l y
For
§2723(c) o r ( d ) , b u t r a t h e r i s d e F l e c t i n g
oF a u n i f o r m / s t a n d a r d
savings
care
years!
by w i t h
discussions
n o t be t e r m i n a b l e e x c e p t
S.1227 i s p r o v i d i n g no a i d t o
o u t c r y by s t a t i n g
oF u t i l i z a t i o n
The
should
i n that
were a b l e
manner.
to institute
a n d a l l by t h e m s e l v e s
now r e q u i r e d t o make
to the
The
this
years
ago,
i n s u r e r s do t h e same
thing?
Additionally,
state-regulated
comprised
the
insurance
oF s m a l l
t h e number
deal.
This
claims
will
i s advocating
consortia.
insurance
p u r p o s e oF p a y i n g
reduce
in
S.1227
oF
The c o n s o r t i a w o u l d
be
c o m p a n i e s who a r e t o " c o m b i n e F o r
providers
oF p a y m e n t
the establishment
( i n order
entities
to)
with
make p o s s i b l e s i g n i F i c a n t
processing,
Facilitate
electronic
dramatically
which
e c o n o m i e s oF
claims
496
and
reduce
administrative costs
oF p r o v i d e r s . "
- 144-
providers
must
scale
processing,
�S. 1227 a l s o
states:
"...a
h e a l t h b e n e f i t p l a n s h a l l p l a c e no
497
l i m i t s on t h e a m o u n t , s c o p e , o r d u r a t i o n o f b e n e F i t s . "
That
number
oF
clause
i s commendable,
oF c o n s u m e r s who
t h e c o s oF
especially considering the
are dropped
illnesses
which
by t h e i r
extend
beyond
considers
t o be a " r e a s o n a b l e "
amount
the
section
by t h e v e r y
above
is curtailed
insurers
what
the insurer
or d u r a t i o n .
next
because
However,
s e c t i o n oF t h e
bill:
"A h e a l t h b e n e F i t p l a n may l i m i t t h e a m o u n t ,
s c o p e , a n d d u r a t i o n oF p r e v e n t i v e s e r v i c e s . . .
p u r s u a n t t o r e g u l a t i o n s oF t h e S e c r e t a r y
speciFying
t h e a m o u n t , s c o p e , a n d d u r a t i o n oF s u c h c a r e .
The
S e c r e t a r y s h a l l d e v e l o p such r e q u l a t i o n s a F t e r
498
c o n s u l t a t i o n w i t h a p p r o p r i a t e medical
experts.
The
questions
1.
What
services
2.
the
bill
Why
be a s k e d a r e :
preventive
s e r v i c e s , and
which
limited?
will
the regulations state?
the l e g i s l a t i o n ,
no
oF c o u r s e ,
were r e g u l a t o r y g u i d e l i n e s n o t i n c o r p o r a t e d
What
have
must,
are the allowable
a r e t o be
bill?
within
which
idea
what
legislators
i t i s they
3.
Who
are the "appropriate
4.
How
connected
are those
who
Without
vote
into
guidelines
For or a g a i n s t t h e
a r e v o t i n g For o r a g a i n s t .
medical
medical
experts?"
experts
to the
insurance
industry?
Section
able
to place
legislators.
reducing
2722(d]
i s t o o easy
a way
limits
on c o v e r a g e
by a p p l y i n g
This
health
Preventive
care
Long-term
costly
provision
insurance
illnesses
is a built-in
plan
i s important
o u t F o r i n s u r e r s t o be
pressure
legal
on
loophole
beneFits
For p r e v e n t i v e
as a m e t h o d
For r e d u c i n g
and s h o u l d
- 145-
n o t be
For
care.
Futi
curtailed.
�S.1227
individuals
and
lose
does n o t h i n g
who
their
t o ease t h e burden
change employment
health
of those
o r move f r o m
i n s u r a n c e as a
state
to state
result.
" N o t h i n g i n t h i s p a r a g r a p h s h a l l be c o n s t r u e d
as r e q u i r i n g a h e a l t h b e n e f i t p l a n i s s u e d t o a
s m a l l e m p l o y e r by a c a r r i e r t o make c o v e r a g e
a v a i l a b l e t o an i n d i v i d u a l who no l o n g e r h a s an
employment r e1 a t i o n s h i p . .. w i t h r e s p e c t t o t h i s
p l a n . "499
A national
health
insurance plan
ment t h a t
insurance follows
or
The f a c t
live.
irrelevant
included
reform
struggling.
Much
with
care
which
And so S.1227
o f S.1227 n e g a t e s
health
to
t h e problems
reform policy.
feature
which
t h e people
i s once
the entire
again
principle
of a
no one w i l l
Provision
must
be made f o r i n s u r a n c e c o v e r a g e
citizen
system
of the United States.
does
quo.
Reform
little
f o r t h e consumer
5.12 27 i s a p o l i t i c i a n ' s
society
adheres,
the nation.
5.1227
nation are
of reform i s
t o be
ongoing,
of every
i s i n t e n d e d t o impose a
currently
which
will
not reform
Laws r e f l e c t
i s not: 2 f f 2 c t i v a
hodge
improve
t o s e t s t a n d a r d s o f decency
and t h o s e
merely
insurance.
or replacement
bill,
n o t be
national
f o r the lifespan
imposes a d d i t i o n a l
L a w s a r e made
of
health
i n place of t h e c o n g l o m e r a t i o n which
S.1227 m e r e l y
and
interruption
m u s t be
a disappointment.
that
without
will
will
The p r i m a r y c o n c e p t
be w i t h o u t
work
i snot
of this
ensure
continuing
s/he may
the result
situation
the require-
o f employment
I f this
of a l l plans,
include
wherever
or lack
t o insurance coverage.
b u t a m i n i m a 11y-a 1 1 e r e d
prolong
now
t h e person
of employment
f o r a l l facets
must
exists.
podge
the status
legislation.
to which
t h e mora),
stature
i n a d v a n c i n g •.:•
:-:
�oeliefs
needs
oF
of
consumers
Fraction
oF
insurers
i t s policyholders
stockholders.
tive
that
Senator
oF
the
the
are
i n Favor
oF
Durenberger's
length
oF
disregarding
proFits
bill,
S.1227 b u t
insurance
industry,
assurance
programs
and
more
For
its
S.700,
i s Far
the
is a
less
protect-
i n agreement
with
consumers.
Quality
oF
hospital
to
protect
care,
but
and
patients
also
unnecessary
physicians
oF
their
physician
to
derive
and
services
and,
There
are
already
whether
IF
the
any
wil
insurer
to
event,
insurers
amounts
in
order
the
only
health
about
rarely
charged
to
types
takes
For
believes
problem
encouraged
and
pay
cover
consideration
The
two
been p r o v i d e d .
they
determine
thereFore,
costs
place
At
the
the
which
1
is
aFter
charges
amount
are
has
been
and
utilization
review
is
review.
medical
services
insurers
oF
the
provided
oF
determine
care
excessive,
a c e r t a i n percentage
care
From
reasonable-cost
that point,
Full
result
consumer
utilization
only
hospital
Hospitals
From
review
i s not
and
utilization
oF
utilization
purpose
hospitalization.
beneFit
oF
surgical
excessive
utilization
reimbursement
study
The
unnecessary
Financial
Retrospective
have
services.
eliminate
surgery
necessary.
based
From
include
they
the
prior
provided.
may
cost.
to
In
any
payment.
with
retrospective
denied
claims,
nor
by
health
care
the
providers
maximize
to
utilization
sought
to
providers.
overtreat, overtest,
proFits
For
themselves.
- 14 7-
review
pay
is
less
than
These
and
that
the
circumstance;
overhospitalize
Eventually,
�consumers
began
services.
This
for
t o demand
state
providers
review
While
a remedy
utilization
takes
place
pr ior
t h eintention
economically
difficult
i nprospective
i i s that
throws
the cost
n o table
utiliza-
of that
payment,
receive
the
the
care.
permanent
health
care
physicians
readily
oFten
actual effect
onto
coi. n c i d e
pressured
i s to
of that
type o f
t o pay f o r
patient.
a portion
the
of that
patient
does n o t
death.
Health
the
time
and q u a l i t y
this
5 0 0
review.
Maintenance
Organizations
quality
goal.
order
The b a s i c
oF a n d access.i. bi. l i t y t o
t o each
patient,
ProFessional
oF p r i o r i t i e s .
sanctions
imposes
HMOs r e q u i r e member
allocated
oF c a r e .
by e c o n o m i c
can lead
utilization
with
care
I f a patient
and even
goal,
with
review
w i t h h o l d i n g o f care
services a secondary
t o reduce
the
i sthat
prospective
primary
access
utilization
care.
effective
of for-profit
as t h e
care
result
disability
proFit
the
for
prospective
p r o v i s i o n of medical
t o pay f o r even
This
HMOs p r a c t i c e
structure
theincentive
a d e c i s i o n by t h e i n s u r e r n o t
to afford
refused
t o the
cost,
removes
p a t i e n t s because
of prospective
unnecessary
review
reducing
review
to overtreat their
sliminate
to
sought
proved
care
review.
Prospective
is
of affairs
i n s u r e r s who t h e n
tion
i n c r e a s i n g amounts o f h e a l t h
thereby
e t h i c s do n o t
Physicians are
and r e p r i s a l s
to limit
time
501
.vhiie
simultaneously
Profit
determining
and h e a l t h care
a method
arediFFicult
or t r e a t m e n t .
t o blend
F o r tine p a t i e n t ' s
beneFit. .
All.
position
potential
oF r i s k
patients,
thereFore,
oF h e a l t h a n d e v e n
- 1 43-
liFe
areplaced
whenever
ina greater
their
insurer
�or
provider
instead
It
opts
f o r using
of t h e l e s s - r i s k y
i s clear, then,
that
counter-productive,
patient
prospective
may
they
has been c h o s e n
which
own
Medicare
determine
plan.
with
related
payment
power
regarding
case
payment
uses almost
5 0 0 DRGs t o
procedures.
could
example
not
already
for
both
The W i c k l i n e
on
diagnostic
would
not
warrant
can happen
tragic
t o make
decisions
h a s become
case.
This
t o happen w i t h
Wickline
when
i s permitted to
t h e power t o
provision of health
i s going
country.
care.
case
i s the
increasing
i s becoming,
become, t h e s t a n d a r d
i f i t has
of
behavior
a n d p r i v a t e i n s u r e r s , h o s p i t a l s , HMOs a n d PPOs.
case
i s many
malpractice
a defendent
The p o w e r
the
surreptitiously
public
be r e i n s t a t e d
o f what
review
ultimately
another
o f what
in this
utilization
f o r care
i s not just
care
i s an e x a m p l e
carriers.
regarding
i sthe
by i n s u r e r s .
5 0 2
of prospective
make d e c i s i o n s
medical
This
specific
Canada a n d G e r m a n y , a n d
r e t r o s p e c t i v e review
to providers
i n insurance
frequency
A
(DRG).
and t h e r e f o r e e x c e s s i v e
The W i c k l i n e
prime
by b o t h
of providers
f o r each
a d i f f e r e n c e - - t h a t p a y m e n t be b a s e d
groups
Wickline
group
Medicare
payment f o r P a r t
Alternatively,
reside
i s n o t merely
the greed
are to receive
remedy
the
review.
interference i n the doctor/
diagnostic related
full
review
l i e i n containing
procedure.or
but
review
retrospective utilization
but i s also
r e g u l a t i n g t h e fees
our
utilization
relationship.
The r e m e d y
by
prospective
case
things.
I t i s most
obviously
a
(although
Wickline's
physician
was n o t
i n t h e case) b u t i t i s also
economica 11y-imposed
�substituted
care
of
judgment,
and h e a l t h care
health
health
receiving
most
containment
program
judgment
f o r harm
5
0
3
that
Lois
Court
private
behind
those
five
years,
impression.
has l e g a l
The
responsibility
t o a p a t i e n t when
ofthe treating
i s alleged to
physician's
t o discharge
payer
a cost
the patient
i s Medi-Cal,
program.
I ti s this
which
fact--
i s a p u b l i c e n t i t y - - w h i c h may be t h e
that
reversed
Medi-Cal
t h e Los Angeles
was n o t l i a b l e
County
f o r the
decision.
Wickline
was a m a r r i e d
who was b e i n g
s u f f e r e d from
artery
ventrical
t o have
i n a manner w h i c h
o f Appeal
and h e l d
the terminal aorta
parts
payor
when
resulted in
the next
of f i r s t
assistance
payer
t h e Court
her f o r t i e s ,
Wickline
which
of rationing.
The t h i r d - p a r t y
medical
was t h e v i c t i m
immediately
caused
i s applied
the third-party
discharge
main
party
in' d e t e r m i n i n g
the h o s p i t a l .
Superior
of
was a c a s e
a third
case
some f o r m
of health
the current benefits of
Within
affected the implementation
reason
in
v. S t a t e
California's
that
enjoying
and M e d i c a i d .
was w h e t h e r
medical
Wickline
judgment
are i n line
experience
a malpractice
from
But those
Medicare
Wickline
have
substituted
insurance
o f us w i l l
issue
Lois
rationing
b e c a u s e s h e was n o t f o r t u n a t e e n o u g h
insurance.
private
is
facilities.
economica11y-imposed
rationing
in
economica11y-imposed
o f t h e body.'"'
04
with a limited
t r e a t e d by h e r g e n e r a l
an o b s t r u c t i o n ( c a u s e d
i n her r i g h t
o f t h e body
of the heart
woman
which
from
i n a l l organs
Her p h y s i c i a n
- 15D-
blood
obtained
practitioner
arteriosclerosis
l e g . The a o r t a
carries
to arteries
by
education,
i s the
the l e f t
and t o a l l
the services
�oF
a specialist
E.
Po1onsky--because
treatment.
Far
in peripheral
Dr.
advanced
Wickline's
According
Daniels,
For
G,
clot
had
in
her
Later
problems
Formed
surgery
that
groin,
removal
pain
with
hallucinatory
lumbar
a chain
oF
she
From
the
attempt
practitioner,
authorization
and
which
vessels
a
ten-day
the
vessels.
causing
had
expected
and
such
Dr.
oF
on
experienced
that
to undergo
the
a
additional
incision
restitching.
severe
For
spasmodic
Daniels
had
to
is a severing
and
removal
the
spinal
i n the
3 0 5
"The
lower
open p o s i t i o n
spasms w h i c h
blood
cord.
patient's
Spasms s t o p
the
Wickline
Wickline
i n a wide
to r e l i e v e
Mrs.
Polonsky
that
blood
vessels
on
clot,
l i e along
i n those
the
so
graFt.
For
reopening
which
t o become p a r a l y z e d
blood
the
episodes
extremity
experiencing
the
sympathectomy
nerves
surgery
experienced
causes
i n an
oF
surgery
Wickline
oF
procedure
done
the
l e g and
necessitating
thereaFter,
oF
a part
general
aFternoon,
graFt.
days
a
the
that
Five
perForm
was
a TeFlon
the
other
disease
to Medi-Cal
approved
in that
i n the
day,
right
a request
perFormed
1977.
circulatory
i t with
the
to
Gerald
period.
Polonsky
January
t o remove
procedure,
Medi-Cal
hospitalization
responded
that
replace
submitted
not
necessary
to normal
treatment.
Dr.
and
had
surgery--Dr.
concluded
i t was
artery
•r.
Wickline
Polonsky
that
vascular
and
was
Wickline
the
t o back
was
outFlow
up
oF
into
the
506
graFt.
Failure
While
was
assisted
Dr.
by
to r e l i e v e
such
spasms can
cause
Polonsky
perFormed
a l l three
a board
certiFied
specialist
- ' ~z 1 -
clotting."
surgeries,
i n general
he
surgery
�(Or.
Kovner),
and Dr. D a n i e l s
observed
the First
and
third
o p e r a t i ons.
By
January
condition
made
hospitalized
15, a l l t h r e e
i t medically
the appropriate
requesting
the eight-day
surgeon
denied
a
employed
a 4-day
telephoned
registered
extension.
until
he s i g n e d
As
additional
in
days,
discharging
third
her
pain
by M e d i - C a l
l a t e r .
5
oF t h e M e d i - C a l
a l l three
obtained
was t h e p e r s o n
0
who
He w o u l d
only
h i s decision not
o u t Form,
b u t merely
t o h i m by a M e d i - C a l
s e e t h e Form
decision to allow
the hospital
physicians
on J a n u a r y
pain
only
Four
concurred
21st.""^^
By h e r
was s o e x c r u c i a t i n g
From D r . K o v n e r
practitioner
adverse
2Sth,
i n h i s oFFice.
substantial
Wickline's
hospital,
change
discharge
However,
Wickline
From
by J a n u a r y
where
every
was e x a m i n e d
His records
the hospital
30th,
eFFort
by h e r g e n e r a l
do n o t i n d i c a t e any
i n the condition
oF t h e l e g s i n c e
one week
Wickline
7
earlier. ''"
was b a c k
was made t o s a v e
that
t o increase the
medication.
On J a n u a r y
on
7
oF W i c k l i n e ' s
permission
general
d i dnot actually
d a y a t home, M r s . W i c k l i n e ' s
husband
extension.
Dr. Classman based
Dr. Glassman
h e r From
t o Medi-Cal
extension.
Filled
Wickline's
As p e r r e q u i r e d
certiFied
For d e c i s i o n p l a c e d
i t days
a result
a board
and c o r r e c t l y
nurse.
days.
that
she r e m a i n
was s u b m i t t e d
F o r an e i g h t - d a y
request
that
hospitalization
a t t h e time
the completely
eight
Form
S. C l a s s m a n ,
the request
approve
on
William
concurred
necessary
F o r an a d d i t i o n a l
procedure,
Dr.
doctors
in
the
the heavily
�infected
leg.
wound had
broken
of
infection
on
to
the
Because
The
open,
t o the
stage
of
the
do
i n Dr.
the
death
After
knee
clot
from
on
of
cooler
changed
than
groin,
Dr.
To
B.
from
Death
the
other
leg.
Polonsky
have
heat
then
5
1
0
was
attempted
have r e s u l t e d
throughout
the
to
in
body,
in repetitive
through
clotting
and
5
blood
Polonsky
the
and
poisoning. ''''
attempting to treat
Dr.
that
marble
the
o p i n i o n , would
septicemia,
February
infected
blue-gray
resulting
condition,
so
l e g had
infection
system,
was
surgically.
unsuccessfully
deteriorated
the
the
graft's
circulatory
possible
the
i n the
Polonsky's
the
area
appearance
infection
t o remove
spreading
and
of becoming
unable
so,
incision
the
amputated
badlyleg
below
have o c c u r r e d
would
the
had
he
not
5 12
sacriFiced
ended
here.
Failed
to
another
the
the
leg.
However,
improve
i t does n o t .
on
the
l e g on
" I n Dr.
certainty,
Polonsky's
had
her
Wickline
other
treating doctors,
5 14
her l e g . "
Dr.
chieF
Kovner,
surgeon
certiFied
Dr.
he
though
at the
specialist
Polonsky
d i d not
hospital
days,
was.
Feel
caused
Van
or
enough
February
17,
opinion, to
remained
would
not
this
a
i n the
Kovner
Wickline's
have
c o n t r i b u t e d to the
_ i - ~> -
by
discharge
and
board
as
trial
From
her
and
the
surgeon
a
the
For
him
suFFered
surgery
l o s s oF
above
hospital
not
stated at
early
time
requested
N u y s H o s p i t a l , was
perForm
reasonable
a board-certiFied general
Dr.
iF i t
were r e q u i r e d t o
originally
she
bad
i n peripheral vascular
Yet,
that
as
be
Wickline's condition
physicians
eight additional
oF
would
the
the
loss
saga
and
amputation
5 13
knee.
medical
The
that
the
leg.
This
�testimony
i s i n c o n s i s t e n t w i t h h i s concurrence
Polonsky's
eight
original
request
days h o s p i t a l i z a t i o n
All
the
that
the
d e c i s i o n was
medical
in
his
the
medical
conForm
permitted
without
First
discussing
•r.
"Dr.
agreed
in
that
testiFied
that
consultant's rejection
acute
a Four-day
care
and
extension
He
the
patient,
d i d not
would
care
oF
not
c
in
be
a patient
reviewing
patient's condition with
oF
his
stated that,
a physician
regarding
the
trial
standards
standards.
seeing
^
Polonsky
oF
additional
subsequent
medical
standards,
the
5 1
an
Dr.
the p a t i e n t ' s
the
treating
. .
p h y s i c i a n s . ,,517
or
Glassman
w i t h help
treatments
the
the
extension
medical
w i t h those
at
Medi-Cal
t o make d e c i s i o n s
.
.
p h y.s i c i a n
walk
usual
For
Wickline.
yet,
a u t h o r i z a t i o n oF
either
or
And
eight-day
to the
accordance
chart
within
opinion, the
requested
substituted
For
witnesses
community.
medical
t o Medi-Cal
with
assumed
and
that
that
because
day,
that
she
because W i c k l i n e
was
Four
scheduled
additional
was
For
days
able
to
whirlpool
would
be
5 1S
adequate.
He
peripheral
vascular
However,
and
be
not
this
any
complete
d i d not
surgery
neglect
Failing
consult
on
may
the
understanding
a Medi-Cal
prior
be
a problem
part
by
t o making
one
of
Dr.
who
specialist
in
his decision."'
w i t h Medi-Cal's
Glassman.
does n o t
There
have
1 5
procedure
cannot
comparable
expertise.
The
State
not
negligent
the
B-day
oF
CaliFornia
(Medi-Cal) contended
i n a u t h o r i z i n g the
extension.
Medi-Cal's
Four-day
view
- 1 34 -
that
extension
is that
the
i t
rather
three
was
than
�physicians
made t h e d e c i s i o n
Cal's
decision
only
hospitalization.
citing
was t o r e F u s e
the patient.
payment For Four
A d d i t i o n a l l y , Medi-Cal
the "doctrine
CaliFornia
t o discharge
deFends
Code
days'
itselF
oF d i s c r e t i o n a r y i m m u n i t y "
Government
Medi-
by
provided
§820 a n d §818.4 w h i c h
by
"provide(s)
520
the
state
The
with
absolute
court
insurer--bore
immunity"
had t o d e c i d e
responsibility
in this
which
matter.
party--the
For d i s c h a r g i n g
physician
or t h e
t h e p a t i e n t From
the h o s p i t a l .
The C a l i F o r n i a A d m i n i s t r a t i v e Code s t a t e s t h a t
"The
d e t e r m i n a t i o n oF n e e d F o r a c u t e c a r e s h a l l be made i n
accordance
with
t h e usual
standards
oF m e d i c a l
practice in
..521
the
cnmmunity.
Medi-Cal
submitted
by
t o them
the phsycian
physicians
on
procedures
she
required
have
submitted
d a y oF d i s c h a r g e
Further
oF
sought,
h o s p i t a l care
physicians
that
no o p p o r t u n i t y
t o do s o .
discharge
decision
The
also
without
protest
such
with
Wickline's
additional
iF, i n their
medical
request
opinion,
A d d i t i o n a l l y , "while
against
522
the nature
was oF p a r a m o u n t
t h e medical
a t t h e time
oF a c t i o n
court
just
that
For t h e Funds t o pay For t h e
t o be p r o v i d e d
treating
cause
contend
and i t s i n p u t r e g a r d i n g
d i d not override
viable
necessary
hospitalization.
Medi-Cal
given
t o be
deemed m e d i c a l l y
They
M e d i - C a l .. .was t h e r e s o u r c e
treatment
a d d i t i o n a l requests
For t r e a t m e n t s
i n charge.
should
t h e planned
permit
judgment
importance,
oF
oF h e r d i s c h a r g e .
ThereFore,
and l e n g t h
Wickline's
I t was
there
c a n be no
i t For t h e consequences of
"
stated:
"The p h y s i c i a n
the limitations
imposed
who
complies
by a
third-party
�payer,
avoid
when h i s m e d i c a l
his ultimate
cannot
goat
point
judgment
dictates
responsibility
to his health
care
For h i s p a t i e n t ' s
payer
go s o u r . . . M e d i - C a 1 was
decision
to discharge Wickline)
to
i n t h e harm
share
made."
Following
1.
How
not a party
i F such
scape-
medical
t o ( t h e medical
and t h e r e F o r e c a n n o t
q u e s t i o n s may
many t i m e s ,
a protest
decision
be
was
held
negligently
how
court
For a p h y s i c i a n
The
court
s h o u l d have
interFerence,
2.
and w i t h
the protest
be
himselF
considered that
would
conversation
requirements
oFten,
t o remove
Mr^ . W i c k l i n e
What Form
telephone
n e e d t o be
posed:
how
much
vehemence
be made i n o r d e r t o be c o n s i d e r e d a d e q u a t e
the
Would
determinative
He
5 2 3
The
must
resulting
care.
as t h e l i a b i l i t y
when t h e c o n s e q u e n c e s oF h i s own
decisions
o t h e r w i s e , cannot
would
have
suFFicient?
h a v e t o be
satisFied
Followed
liability?
b u t For t h e
n o t have been
the protest
be
From
up
iF a registered
insurer's
discharged
to take?
Would
i t be
Would
early.
a
recorded?
in writing?
nurse
by
Would
executed the
Form?
3.
How
A.
to
to
many
per
t o pay
B.
what
would
oF
tney
these p r o t e s t s
the protest
a malpractice
would
consume?
a physician
be
expected
be c o n s i d e r e d
suit,
and
suFFicient
(b) persuade
third-party
For t h e c a r e .
Should
cost?
these protests
day?
When w o u l d
(a) avoid
payers
At
How
Field
5.
much t i m e w o u l d
proFessional medical
Who
need?
would
train
them?
care p r o t e s t e r s
What k i n d
of
be
hired?
training
�The
above
questions
have
ridiculous,
in a ridiculous
prospective
utilization
by
physicians,
price.
There
reached
the point of
situation.
review,
and r e q u i r i n g
a r e as b a d as u s e d - c a r
i s something
Associate
else
J u s t i c e Rowen
Insurers
being
imposing
numerous
protests
dealers n e g o t i a t i n g
going
on h e r e
concluded
by
besides
price!
stating:
T h i s c o u r t a p p r e c i a t e s t h a t what i s a t
issue here i s t h e e f f e c t of cost containment
programs
upon t h e p r o f e s s i o n a l judgment o f p h y s i c i a n s t o
prescribe hospital treatment f o r patients requiring
t h e same.
W h i l e we r e c o g n i z e , r e a l i s t i c a l l y ,
that
c o s t c o n s c i o u s n e s s h a s become a p e r m a n e n t f e a t u r e o f
the h e a l t h care system, i ti s e s s e n t i a l t h a t cost
l i m i t a t i o n p r o g r a m s n o t be p e r m i t t e d t o c o r r u p t
medical judgment.
We h a v e c o n c l u d e d ,
from t h e f a c t s
i n i s s u e here, t h a t i n t h i s case i t d i d n o t . For t h e
reasons expressed h e r e i n , t h i s court Finds
that
( M e d i - C a l ] i s n o t l i a b l e F o r ( W i c k l i n e ' s ) i n j u r i e s as
a m a t t e r oF
law."
5 2 4
Prospective
economically
thus
review
victimizes patients
a n d p s y c h o l o g i c a l l y when t h e y
From p h y s i c a l
and
utilization
inFirmities.
Wickline
encourages p r i v a t e
sets
are already
an u n F o r t u n a t e
insurers to treat
same m a n n e r a s t h e g o v e r n m e n t a l
suFFering
example
patients i nthe
bureaucracies,
and t h e c o u r t
system.
It
is
i s not reasonable
not being
procedure
•ue
iF
re-examined,
which
to that
i s being
result,
diagnoses,
Insurers
should
position
they
that
denied,
the cost
For t h e r e s u l t
incorrectly
decision
oF t h e
i s t h e same,
suFFer
just
as s u r e l y as
made.
IF a physician
t h e p a t i e n t sues For m a l p r a c t i c e .
be no l e s s
have
the physician's
i ti s merely
the patient will
t h e d e c i s i o n had been
incorrectly
t o say t h a t
liable
than
usurped.
- 1z 7 -
the physician
whose
�S.1227, t h e b i l l
Riegle
aND
which
introduced
RockeFeller,
has been
states
that
review
does n o t h i n g
illustrated
each
oF s u c h
by S e n a t o r s
denial
to resolve
by t h e W i c k l i n e
oF a c l a i m
M i t c h e l l , Kennedy,
will
t h e problem
case.
The
be a c c o r d e d
bill
a
timely
525
denial.
However:
In cases i n which t h e F a i l u r e t o p r o v i d e
h e a l t h c a r e p r o m p t l y w o u l d be 1 i F e - t h r e a t e n i n g o r
r e s u l t i n a r i s k oF p e r m a n e n t d i s a b i l i t y , t h e
b e n e F i c i a r y . . . s h a 1 1 be e n t i t l e d t o a d e c i s i o n . . .
n o t l a t e r t h a n 1 day a F t e r s u p p l y i n g t h e i n s u r e r
with a l l requested inFormation.
I n t h e e v e n t oF
a d e n i a l oF c o v e r a g e F o r s u c h c a r e , t h e b e n e F i c i a r y
s h a l l be e n t i t l e d t o an e x p e d i t e d r e v i e w oF an
a p p e a l oF s u c h d e n i a l w i t h i n 5 d a y s . 3
Although
processing
Five
d a y s may
and d e c i s i o n
making,
interval
F o r one t o s u F F e r
position
oF r i s k
Senators
o r an i n s u r e r
but
merely
the
nation
with
our health
merely
prolongs
C.
dilemma
oF p e r m a n e n t
Everett
i s Far t o o long
disability.
t h e care
oF l a c k
oF t h e p r e s e n t
care
5 days
to state
i s interested
For i n F o r m a t i o n
i n a 1iFe-threatening
the p o s s i b i l i t y
a continuation
be n e e d e d
3
Koop, Former
would
problem--and
reimbursement
or i n a
For e i t h e r t h e
n o t be
oF r e i m b u r s e m e n t ,
i n establishing
the problem
mode
an
withheld,
i s merely
o n e oF t h e r e a s o n s
health
system.
care
reForm--
Once a g a i n ,
S.1227
a n d o F F e r s no s o l u t i o n .
Surgeon
General,
summarized t h e
succinctly:
3?7
making."
M
"Cost
control
should
n o t mean r e m o t e
control
decision
32 3
In
Williams
her
primary
her
to a specialist.
Failure
the
care
v. H e a l t h A m e r i c a ,
physician
to deliver
right
because
The c l a i m
they
against
quality health
t o be r e f e r r e d
a patient
sued
had d e l a y e d
t h e HMO
beneFits
to a specialist.
t h e HMO
i n reFerring
was b a s e d
as p r o m i s e d ;
The c o u r t
and
on
i.e.,
restated
�the
cause
of action against
the
HMO a s a t o r t
claim
For breach
529
oF
the
The
oF
duty
court
the
described
points
the
out
(managed
provide
rights
that
care
it,
in
claims
or
oF t h e
injury
the
Although
involving
analysis
causal
3
3
Function
i st o Finance
physician t o
0
Chittendon
oF m o s t MCOs
health
oF F i d u c i a r y
duty
care,
would
not to
seem t o
m a n a g e m e n t oF h e a l t h
with
greater
care
provides
Frequency,
includes
quality
care.
"negligent
oF c o s t - c o n t r o l m e c h a n i s m s may a F F e c t t h e
judgment
whether
primary
beneFiciary
the
as p a t i e n t s . "
b u t a t t h e same t i m e
physician
t o the
For economic
medical
the
required
Faith.
5 3 1
Financial
judgment
physical
which
For breach
as i s o c c u r r i n g
implementation
medical
contract
organizations)
containment,
However,
i n good
p a t i e n t as a " t h i r d - p a r t y
"(b]ecause
deFensible."
cost
p l a i n t i F F ' s claim
oF e n r o l l e e s
claims
EFFective
the
the
HMO-physician
promote
be
t o handle
and e m o t i o n a l
injuries"
was a c o n t r i b u t i n g F a c t o r
there
have
judgment
been
insurers' reFusal
i sthat there
was n o t
t o provide
the
whether
533
the
provider's
i nplaintiFF's
532
i n issue."
beneFits,
t o Wickline
Chittendon's
malpractice
The i n h e r e n t
a
and t h e
diFFicultyi s
a p t l y d e s c r i b e d by t h e C a l i F o r n i a M e d i c a l A s s o c i a t i o n i n
amicus c u r i a e b r i e F which s u p p o r t e d
including third-party
5 34
p a y e r s as m a l p r a c t i c e d e F e n d a n t s :
The C a l i F o r n i a M e d i c a l A s s o c i a t i o n h a s a n
o b l i g a t i o n t o describe p a t i e n t r i s k s with badlyconstructed or maintained
systems present.
CMA
i s a l s o c o n c e r n e d t h a t p h y s i c i a n s n o t be o l a c e d
1 - Q _
injury
diFFiculty " i n proving
physician's
MCOs c o s t - c o n t r o l m e c h a n i s m ' . '
resulting
may r e s u l t i n
Few c a s e s s i m i l a r
i s an i n h e r e n t
between
provider,
patient...(which)
provider's
connection
or other
its
�b e t w e e n t h e p r o v e r b i a l r o c k and h a r d p l a c e .
The
p a t i e n t who i s i n j u r e d when c a r e w h i c h s h o u l d
h a v e been p r o v i d e d i s n o t p r o v i d e d w i l l
recover
f r o m someone.
I f the t h i r d - p a r t y payer imposing
t h e s e c o n t r o l s i s p e r m i t t e d t o a v o i d l i a b i l i t y by
m a i n t a i n i n g t h e f i c t i o n t h a t the mechanisms have
o n l y f i s c a l c o n s e q u e n c e s , so t h a t p a t i e n t c a r e i s
s o l e l y the p h y s i c i a n ' s r e s p o n s i b i l i t y , the
p h y s i c i a n becomes t h e i n s u r e r .
I f rationing
m a l f u n c t i o n s , t h e p h y s i c i a n who c o m p l i e s w i t h t h e
program i s l i a b l e to t h e p a t i e n t .
I f the p h y s i c i a n
does n o t comply, t h e p h y s i c i a n i s p u n i s h e d or f a c e s _
r e s o o n s i b i l i t y for incurring (un)authorized
costs." '
(underlining
supplied)
-
Interestingly,
held
i n Wilson
refusal
primary
the p a t i e n t ' s
under
The
v. B l u e
theories
insurer's
1.
successful
of t o r t i o u s
defensive
decided
of S o u t h e r n
suicide
breach
physician's
Wickline
California
stay
with
attempt.
of c o n t r a c t
i n conduct
by t h e
causative
Plaintiff
and
factor"
claimed
negligence.
i s nondelegable;
or u t i l i z a t i o n
considerations warrant
utilization
that the
included:
decision
the c a r r i e r
5 3 6
recommended
was a " s u b s t a n t i a l
reasoning
public policy
engaged
that
r e s p o n s i b i l i t y f o r damages r e s u l t i n g from
be s h a r e d
2.
court
for a hospital
physician
a treating
therefore,
cannot
Cross
to pay b e n e f i t s
patient's
in
t h e same
3
review
the d e c i s i o n
review
protecting
activities
firm;""
the p u b l i c
i n order t o
the
withhold
It
p h y s i c i a n had n o t a p p e a l e d
costs.
the decision to
beneFits.
is interesting
companies
and
i n t e r e s t i n c o n t r o l l i n g medical
contend
that
y e t i n s u r e r s usurpe
also
t o note
physicians
that,
first,
decisions
the physician's
duty
are
insurance
nondelegable,
t o make
decisions.
Second,
insurers proclaim
a public
controlling
medical
costs,
the stronger
but ignore
- I GO-
7
insurers
:; 3 s
uphold
0
those
interest in
public
�interest
in receiving
individual
patient's
'decision'
which
an
appeal.
appears
Allowing
and
increase
While
considerations
there
their
would
but
i t
t o diagnose
any
Further
usurpation.
public
because
policy
i t involved
i td i s t i n g u i s h e d
For a s i m i 1 a r
a
of course.
prerogative
had Found
plan,
was no s u p p o r t
subject,
preclude
to the
not require
as a m a t t e r
to the insurer
health
should
due t o i n s u r e r ' s
i n Wickline
Favorable
Third,
rendered
appeals
litigation
a state-administered
because
expect
own p a t i e n t s
the court
attuned
a litigious
to retain
i n medical
care
status.
health
is this
insurers
their
medical
i s responsibly
physicians
treat
personal
Not only
that
competent
public
Wilson
policy in
539
the
prrivate
insurer
context.
540
Hughes
the
v. B l u e
same d e n i a l
care
physician
was b a s e d
Fair
a standard
oF N o r t h e r n
oF h o s p i t a l
as o c c u r r e d
on b r e a c h
dealing
Cross
oF
because
which
stay
CaliFornia
prescribed
i n Wickline.
implied
care
was n o t i n a g r e e m e n t
by t h e
The c a u s e
covenant
t h e managed
involved
oF g o o d
oF
action
Faith
organization
with
primary
and
had
employed
t h e community
54 1
standard.
MCO
must
Those
the
The c o u r t
be c o n s i s t e n t
concerned
potential
communities
which
their
Currently,
negligence
with
that
own
insurers
view
breach
oF h e a l t h
when
that
oF c o m m u n i t y
standards.
care
should
oF m e d i c a l
care
by t h e
542
consider
care
ina l l
i s d i c t a t e d by
organizations, a l l
standards.
breach
or implementation
-1G1-
utilized
standard
a n d managed
oF c o n t r a c t ,
in the design
medical
i. n t h e standard
is possible
oF
the standard
community
the Future
alteration
a proJ. i . F e r a t i o n
espousing
about
held
oF
oF
warranty,
quality
assurance
�and
cost-containment
tortious
are
interFerence
a l ltheories
upon
stemming
From
so
to their
vital
which
was
cost
i n.s u r e r s
physician
with
sclerosis
victims
oF t r u s t ,
relationship
may Face
liability
review
goals.
and
that
appears
I t i s a problem
solution.
sclerosis
unsuccessFul
breach
utilization
containment
in su r a r rarused
multiple
Fraud,
the doctor/patient
the prospective
n o t and w o u l d
were
with
which
demands p r o m p t
One
with
mechanisms,
coverage
based
on t h e F a c t
n o t improve
in their
accepted
For t r e a t m e n t
From
that
oF a
h i s condition
the treatment.
attempts
t o impress
Physicians
the insurer:'^
medical
knowledge
improve
don't
patient
that
multiple
but the treatment
i s necessary
543
to
assure
that
Medical
~: am1ne
<
the condition
underwriting
appl icants
does n o t d e t e r i o r a t e .
i s t h e process
and d e t e r m i n e
u t- o n e - h a I F m i l l i o n a n n u a l
receive a risk
being excluded
coverage
v/hethsr
applicants
by
h1 • i
:
'• ur ri
o r not. t _ i - - s • >
For h e a l t h
insurance
c1 a s s i F i c a t i o n w h i c h condemns them t o e i t h e r
From a n y i n s u r a n c e c o v e r a g e o r a c c e p t e d F o r
544
but with
exorbitant
premiums.
S p e n d i n g F o r p r e v e n t j . ve m e d i c i n e , i n c l u d i n g g e n e t i c
GENETIC ENGINEERING.
t e s t i n g , w i l l provide inescapable long-term beneFits.
Genetic
research
and t e s t i n g
preventable
•ue
already
and
must
conditions
be e n c o u r a g e d
i s essenti. a l t o Future
to the discrimination
e x h i b i t i n g when
tendencies,
genetic
because
they
which
obtain
inFormation
- 152-
health.
insurance
knowledge
m u s t be
k n o w l e d g e oF
companies are
oF g e n e t i c
legislatively
traits
�excluded
From r e v i e w
respond
negatively
the
inFormation
For
high
costs,
by F u n d i n g
ScientiFic
objections
is
From
everyone
Genetic
into
research
t o achieve
the greatest
aspects
Genetic
best
deFective
genetic
productive
n o t be a b l e
Future
insurance
during
health
Genetic
good
health
when
testing
reveals
be t r e a t e d p r i o r
genetic
and wide
race.
engineer-
publicity
which
oF t h e
i s a problem
care
which
must
reForm.
to the beneFits
through
i t may
i s the
oF
retaining
be
Genetic
and t e s t i n g
be p o s s i b l e
preconditions
t o the onset
- 1 S3-
carriers
although
many
counter-
oF p r e d i c t i v e m e d i c i n e
oF t h e p o s s i b i l i t y
genetic
oF
addressed
I t i s d i s c r i m i n a t o r y and
engineering
because
i s using the
i n t h e F a c e oF k n o w l e d g e
advantage
achievable
cost.
on t h e human
that
i t
will
a t lower
c o n t r a c t i n g a disease,
access
t o take
Yet,
which
The d i F F i c u l t i e s
health
become i l l .
t o deny
support
medicine.
oF e v e n t u a l l y
never
and l i F e
care.
has r a i s e d
groups.
i s p r e d i c t i v e medicine
material
Formed
preventive
and e n g i n e e r i n g
God b e s t o w e d
potential
inFormation
engineering
religious
oF
breakthroughs.
engineering
genetic
at risk
carriers
and
oF a l l
and h e a l t h
policies
are
diligent
a i d to preventive
employment
the
expensive
a healthier liFe
giFt
view
For h a r b o r i n g
i s n o t ' p l a y i n g God,' i t
projects receive
beneFicial
can
t h e Far l e s s
chosen t o
and n a r r o w
oF u t i l i z i n g
i s e s s e n t i a l t o human h e a l t h
ing
by
persons
many c o n s e r v a t i v e
engineering
human m i n d ,
I n s u r e r s have
a short-term
instead
research
precisely genetic
enable
It
and w i t h
by c o n d e m n i n g
medical
positively
by i n s u r e r s .
oF
improved
engineering.
actually
aid in
t o avoid
oF s e r i o u s
oF d i s e a s e .
serious
diseases
promoting
illness
which
IF the p o l i t i c a l
�power
of
testing
It
insurance
would
i s only
be
companies
a huge p o s i t i v e
the
power
of
a specter
into
t o be
avoided.
employers
to reFuse
deFects.
In that
acknowledge
corrective
the
could
negative
action
discounted,
i n the
i n s u r e r s which
to hire
very
be
who
sense,
genetic
to assure
are
positive
as
health
the
even
care.
testing
influencing
carriers
insurers'
Findings
of
i s making
I n s u r e r s are
those
real
Future
genetic
oF
genetic
reFusal
to
o p p o r t u n i t i e s For
Future
h e a l t h borders
on
pathogenic.
There
should
employment
Found
and
t o be
progressed
would
be
logical
genetic
and
with
employees
oF
insurance
oF
p o i n t to which
oF
the
insurance
the
From
i t has
coverage
or
would
not
economic
necessity
workForces
reduce
long-term
--
reduce
h e a l t h and
--
reduce
workers'
--
reduce
potential
are
had
not
be
and
thereFore
secure.
now
when
Future
eliminating
i n order
I t i s not
i t is
health.
g e n e r a l l y agree.
oF
there
They
high
are
risk
to:
absenteeism;
--
who
arrived,
gene
alter
those
science
IF
insurance
continued
oF
now
would
however,
reduce
coverage
deFective
employment
their
permitting
disease.
possible to beneFicially
Employers,
Faced
question
carriers
knowledge
to reFuse
becoming
no
continued
to the
no
employment
be
More c o m p a n i e s
health
disability
compensation
liability
are
pre-employment
genetic
that
are
the
tests
problems;
oFten
costs;
payments;
For
becoming
and
insurance
occupational
interested
in
enzyme s c r e e n i n g
inaccurate.
- 1 E4-
The
accidents.
instituting
despite
the
Fact
current targeted
�conditions
kidney
are atherosclerosis;
and l u n g
disease;
high
diabetes; hypertension;
cholesterol;
urinary
liver,
tract
546
infections;
and p e r i o d o n t a l
Approximately
disease.
4 , ••• d i f f e r e n t
diseases
have
been
identified
547
which
of
a r e each
these
caused
single-gene
by a s i n g l e
diseases
defective
gene.
c a n be d e t e c t e d
Seventy
through
548
diagnostic
occur
testing.
as a r e s u l t
Most
diseases
of i n t e r a c t i o n
between
genetic
to
are " m u l t i f a c t o r i a l "
make up ( p r e d i s p o s i t i o n ]
, ^
54S
external
factors.
with
an
and
individual's
the addition
of exposure
The i n f l u e n c e o f t h e e n v i r o n m e n t ,
however,
r e m a i n s t h e w i l d c a r d i n most c a s e s , because
possess ion o f t h e g e n e t i c p r e d i s p o s i t i o n alone
may be i n s u f f i c i e n t t o c a u s e d i s e a s e .
I t is
l i k e l y t h a t f o r some t i m e m o d e r n s c i e n c e w i l l be
more s u c c e s s f u l i n i d e n t i f y i n g t h e genes and t h e
markers than i n i d e n t i f y i n g t h e environmental
a g e n t ( s ] necessary f o r a c t i v a t i o n of t h e
p r e d i s p o s i n g g e n e s . ... O f t e n , p r e d i s p o s i t i o n
o n l y m a n i f e s t s i n d i s e a s e when t h e r e i s
a c c o m p a n y i n g e n v i r o n m e n t a l i n s u l t , e.g. t o x i c
substances, viruses, or other disease. ^
5 5 1
(underlining
supplied)
"Conceivably
everybody
carries
genes t h a t
are associated
55 1
with
it
some p r e d i s p o s i t i o n
i s imperative that
to certain
h e a l t h care
from t e r m i n a t i n g p o l i c i e s
p a r t i c u l a r di. s e a s e s .
of those
Many o b j e c t t o g e n e t i c
paternalistic
heritable
involved.
testing
and d i s c r i m i n a t o r y ,
c o n d i t i o n s a r e beyond
Others
ing
benefits
the
worker
both
with
diseases."
reform
prohibit
insurers
who a r e p r e d i s p o s e d
on t h e b a s i s
and p a t e n t l y
the control
counter
that
workers
and i n d u s t r y
valuable
laws
Therefore,
argument
that
i ti s
unfair
because
of the individual
by s t a t i n g
because
i n f o r m a t i o n which
to
may
that
test-
i t provides
be u s e d
�preventively
endangered
sick
and,
by
days
or
thereFore,
illness,
nor
disabiliity
the
employee's
i s the
job
employer
payments
or
is
not
inconvenienced
worker
by
replacement
555
concerns.
lower
Additionally,
rate,
the
levels,
lower
claims,
and
employer
insurance
medical
would
enjoy
premiums
Fewer p o t e n t i a l
bills
could
higher
and
at a
productivity
workers'
lawsuits.
remain
compensation
Insurance
companies
c o u l d e n c o u r a g e and p r o v i d e c o v e r a g e For p r e v e n t i v e c a r e
which
c o u l d k e e p p r e m i u m s and b e n e F i t s a t l o w e r l e v e l s .
Those
p 5 3
are
beneFits
made oF
use
oF
which
genetic
knowledge
could
accrue
inFormation
which
t o s o c i e t y j_F p o s i t i v e
r a t h e r than
i n s u r e r s are
the
more
use
likely
were
negative
employing.
Occupational exposures to c e r t a i n substances
can a l t e r g e n e t i c makeup t h r o u g h s t r u c t u r a l
damage t o b o t h g e n e s a n d c h r o m o s o m e s .
Genetic
d a m a g e - - r e g a r d l e s s oF c a u s e - - a p p e a r s as
r e c e s s i v e and d o m i n a n t m u t a t i o n s , l a r g e r e a r r a n g e m e n t s oF ONA,
p o i n t m u t a t i o n s , a n d l o s s oF g e n e t i c
m a t e r i a l , l e a d i n g t o d i s t o r t i o n s oF e i t h e r t h e
e x p r e s s i o n o r b i o c h e m i c a l F u n c t i o n oF g e n e s .
B u t n o t a l l m u t a t i ons c a u s e d i s e a s e . 5 5 4
Reports
result
not
so
in heritable
clearly
the
that
most o c c u p a t i o n a l
damage.
understood
Former
There
and
suggest
between
b e l i e F may
diFFerence
do
the r e l a t i o n s h i p
mutations
e v e n t u a l l y be
is a signiFicant
genetic
However,
exposures
and
proven
between
health
not
is
eFFects""
erroneous.
genetic
screening
monitoring.
With screening, a one-time t e s t to d e t e c t a
s i n g l e t r a i t i n a w o r k e r or j o b a p p l i c a n t i s u s u a l l y
s u F F i c i e n t , w h i l e m o n i t o r i n g ( F o r chromosomal damage)
g e n e r a l l y i n v o l v e s m u l t i p l e t e s t s oF a w o r k e r o v e r
time (For s u s c e p t i b i l i t y to o c c u p a t i o n a l
illness).
M o s t i m p o r t a n t l y , g e n e t i c s c r e e n i n g F o c u s e s on t h e
p r e e x i s t i n g ( i n h e r i t e d t r a i t s which are u n r e l a t e d t o
the
w o r k o l a c e ) q e n e t i c makeup t h a t w o r k e r s o r j o b
_ 1E5-
3 -
�Biological Consequences of Exposure to
Mutagenic Agents
Components of Genetic Testing in the
Workplace
Exposure
Genetic monitoring
j
!
immediate
:— ettects ot
exposure
Genetic
damage
Occupationally related
exposure
! Cell oeain
Repan
Mutation
Womers
j
j
I
Delayed
adverse
heaitn
outcomes
Somatic cell
change
I Reproauctive
!
loss
I
Nonoccupationaliy
related disease
Woikers
Cancel
Heritable
disoraer
|
Genetic screening
Somatic cells
Germ cells
Occupationally relateC
disease
Job applicants
1
Occupationally related
disease
J
[ )
Occupationally relatec
susceptibility
SOURCE: Otlice ol Tecnnoiogy Asssssmem. aaaoiea trom J.B. Wara.
"Issues in Monilonng Population ELxposures." Cascmogens and
Mutagens in the Environment Volume II. The Worx&lace. Hans
F. Sticn iod.i (Boca Raton. R_: CRC Press. 1985).
p.3
Nonoccupationaliy
reiatea susceptiDili!>
SOURCE: CWioe ot Tecfinology Assessman'.. 199C.
p . 3?
Genetic Tests Available and Total
Americans Affected
Genetic condition
Total cases
Currently
available:
Adutt polycystic kidney disease
Fragile X Syndrome
SickJe cell anemia
Duchenne muscular dystrophy
Cystic
fibrosis
Huntington's disease
Hemophilia
Phenylketonuria
Retinoblastoma
500.000
100,000
65.000
32.000
30.000
25.000
20.000
16,000
10,000
Total
Potential future
Hypertension
Dyslexia
Atherosclerosis
798,000
tests:
58,000.000
15.000,000
6,700,000
Cancer
5,000.000
Manic-depressive illness
Schizophrenia
Type 1 diabetes
'imiliaJ Alzheimer's
jltiple sclerosis
.Myotonic muscula/ dystrophy
2,000.000
1,500.000
1,000.000
250,000
250,000
100.000
Totai
89.800.000
SOURCE: MedicaJ WondNews. p. 58, Apr. 11, 1988.
p.
15
Source :
U.S. C o n g r e s s , O F F i c e oF
Technology Assessment,
" G e n e t i c M o n i t o r i n g and
Screening i n t h e
Workplace"
OTA-BA-455
( W a s h i n g t o n , DC:
U.S.
Government P r i n t i n g OFFice,
October, 1930)
pp.
9, 15, 33
�applicants bring to the job.
This i s d i s t i n c t from
g e n e t i c m o n i t o r i n g w h i c h f o c u s e s on h a z a r d o u s w o r k p l a c e
exposures t h a t induce changes i n the g e n e t i c m a t e r i a l
i n an e x p o s e d p o p u l a t i o n as a w h o l e . o 5 B
Genetic
screening
For
occupationa 11y-re1 ated
nonoccupationa11y-re1 ated
1.
to
improve
compensation
traits
employee
costs
through
could
be
productivity
traits
and
For
perFormed:
and
lower
b e t t e r worker h e a l t h
workers'
[beneFits
the
employer) ;
2.
to
eFForts,
improve
employers'
e s p e c i a l l y For
health
health
through
exclusion
with
gene s t r u c t u r e b e c a u s e
health
to promote
and
the
genetic
also;
(This
i . e . , not
oF
the
could
hiring
potential
be
those
drain
on
insurance);
3.
cost-containment
insurance.
accomplished
altered
care
through
use
oF
4.
who
to
are
determined
diseases;
5.
ensure
(oF
to
to
and
to
health
interest
determine
lead
death
mation
are
to
employees
need
to
hazards;
_
to
worrkers'
suits.
which
Genetic
can
necessary,
be
both
lower
(oF
areas
5
precautions. ''
advocate
worksite
susceptible
i d e n t i F y work
Employers
can
be
general
counselling
appropriate
previously-unknown
B.
encourage
7
(oF
genetic
i n the
exposure
and
oF
employees
occupational
levels
to
need
and
employee);
unions)
interest
monitoring
to
to certain
testing
the
placements
and
which
awareness
(beneFits
interest
compensation
used
health
unions)
increased
to
oF
saFety
unions)
because
health
sometimes
screening
even
-167-
and
For
wrongful
provide
i n d i c a t e when p r e v e n t i v e
workplace
risks
employee
inFor-
actions
health
�558
care.
For
tested
would
could
the
him
physician
An
an
individual
know w h e t h e r
render
producing
he
susceptible
could
occupational
and
exist.
counsel
so
physician
a strict
A n d r e w s and
unauthorized
disclosure
oF
either
a p p l i c a n t or
job
possibility
and
oF
suit
violation
employee
bargaining
The
may
r u l e .
Fitness
at
5
6
are
3
will
There
an
the
this
knowledge,
in a
dust-
employee's
one's
could
treating
however,
be
inFormation
employee.
tortious
Occupational
held
liable
right
his union's
For
concerning
public disclosure
under
that
In addition to
constitutional
does
oF
to
the
private
privacy,
collective
or
Medical
Association
Code
oF
r e c o m m e n d s t h a t c o n F i d e n t i a l i t y be
maintained
inFormation to the employer r e g a r d i n g
552
For
the
subject
based
type
to
the
the
on
oF
work
intended.
doctor/patient
current status
are
genetic
test
Free
oF
conFidentiality
the
to reFuse
results
SpeciFic
which
employment
and/or
may
not
terminate
be
reliable.
present,
directly
With
point out,
medical
a claim
B e c a u s e oF
employment
At
oF
i s not
employers
d o c t r i n e , employers
accurate
which
agreement.
ethical.
conduct
by r e l a t i n g o n l y
diagnoses
For
File
American
medical
deFiciency
working
to avoid
Jaeger
and
an
a genetic
been g e n e t i c a l l y
physician/patient relationship
550
physicians
Facts
had
t o emphysema.
him
occupational
a
had
who
environment.
physician
not
example,
with
there
the
is a
subject
is considerable
case
very
oF
limited
genetic
body
oF
monitoring
law c o n c e r n i n g
- 1S8-
drug
law
or
and
dealing
screening.
alcohol
�testing,
This
and t h e body
o f law r e l a t e d
i s t h e law c u r r e n t l y
cases.
I t i s expected
concerning
genetic
medical
testing
being
that
issues
i si n c r e a s i n g .
applied t o genetic
changes
testing
t o AIDS
testing
i n t h e common l a w
o f workers
i n t h e near
generally will
future,
inFluence
a n d may h e l p
shape
565
legislation.
--
The m a j o r
privacy
issues
concerns
a t present a r e :
surrounding
unwanted
monitoring or
screening ;
--
conFidentiality
--
potential
--
Future
--
oF t h e i n F o r m a t i o n
discrimination
obtained;
i n employment
5 6 5
h e a l t h oF t h e t e s t e d w o r k e r s .
u s e , by h e a l t h and l i F e
inFormation
t o determine
Fortunately,
insurance
risk
some p r o t e c t i o n
opportunities;
and.
companies,
oF g e n e t i c
and coverage;
i s a f f o r d e d employees
by a d a p t i n g
567
federal
legislation
t o t h e issues.
^63
The
Occupational
to
an e m p l o y e e ' s
to
communicate
unions
to
Actual
medical
provided
and
with
5 6 9
because
authority
5 7 1
records,
with
Act"
and a l s o
regulates
requires
Under
o f each
employee, however,
OSHA r e q u i r e s , h o w e v e r , t h a t
medical
interest
t h e government
Federal
t o access
employers
OSHA
i n f o r m a t i o n on e m p l o y e e s '
access
rules,
exposures
and a n a l y s i s o f r a t e s o f exposure.
employees'
confidential
and H e a l t h
t o i t s employees.
records
governmental
benefits.
and
hazards
hazards,
confidential.
strong
medical
areprovided
potential
Safety
ity.''
i nensuring
provides
agencies
medical
5
7
records, ' ^
have
records
-
- 163-
g o v e r n m e n t be
based
safe
remain
on t h e
workplaces,
h e a l t h and d i s a b i l i t y
statutory
despite
grants of
claims
of privacy
�The
Employee R e t i r e m e n t
prohibits
already
Income S e c u r i t y
From d i s c r i m i n a t i n g a g a i n s t
employers
medically
h i g h - r i s k employees,
employees
who
The
must u n d e r g o
National
examinations
collective
protected
Labor
and
From
Act^
testing
be
subjects.
genetic
but
does n o t
pre-employment
Relations
medical
bargaining
574
7 5
but
(ERISA]
screening.
requires
that
physical
mandatory
employees
job
. ,
potential
protect
considered
Thus,
testing,
Act
could
applicants
and
be
non-union
575
employees would
Title
genetic
group'
civil
not
V I I oF
testing
which
the
the
against
by
could
578
Civil
by
Rights
oF
render
a
this
Act
oF
'disparate
testing
Civil
Rights
employers
Act
or
to
Act.
1364
impact
violative
L e g i s l a t i o n i s being
inFormation.
include
i n s u r e r s on
oF
5 7 7
on
an
considered
those
the
New
suspect
Jersey's
class.
The
s t a t u t e which
may
a
apply
to
protected
individual's
which
would
discriminated
basis
oF
These p o t e n t i a 1 1 y - h i g h - m e d i c a 1 - r i s k
become a p r o t e c t e d
resemble
protected
because
rights.
expand
be
Federal
prohibits
genetic
people
could
legislation
an
employer
From r e F u s i n g t o " h i r e o r e m p l o y . . . b a r
o r . . . d i s c r i m i m a t e " a g a i n s t a p e r s o n on
"...atypical
The
hereditary cellular
Americans With
discrimination
who
contract
assistance.
Disabilities
against
with
In
the
1994,
handicapped
Federal
this
businesses
which
employ
time
1994,
a cause
aFter
or
Act
prohibits
individuals
government
legislation
FiFteen
oF
or...discharge...
t h e b a s i s oF
any
579
blood
trait."
580
or
or
will
by
receive
aid
Federal
extend to a l l
58 1
more w o r k e r s .
a c t i o n may
- 1 70 -
employers
in
Some
determining
may
�whether
a genetic
mrker
or t r a i t
would
c o n s t i t u t e an
impairment.
Section
504 o f t h e R e h a b i l i t a t i o n A c t o f 1973 g u a r d s t h e
handicapped
that
this
person.
not
Act w i l l
discrimination, but i t i s not likely
protect the potentially
The A c t ' s d e f i n i t i o n
coincide
risk
and
against
with
by g e n e t i c
may n e v e r
State
harm
takes
decades
of a handicapped
that
a person
o r enzyme t e s t i n g
become
laws
incur
the fact
ill
provide
high
medical
person
deemed
i s not i l l ,
a high
risk
does
medical
n o t handicapped,
or handicapped.
n o - f a u l t compensation
of their
as a r e s u l t
t o w o r k e r s who
However,
f o r genetic
employment.
damage t o o c c u r b e c a u s e
i t often
ofthe
582
employment
North
environment.
Carolina
genetic
As o f 1 9 8 3 , F l o r i d a , L o u i s i a n a , a n d
limited
testiing
t h e u s e oF i n F o r m a t i o n
anemia
against
carriers.
Pennsylvania,
anemia.
Tay-Sachs c a r r i e r s
Arizona,
Rhode
cell
Montana,
New
From
Flatly
583
b a n n e d e m p l o y m e n t d i s c r i m i n a t i o n b a s e d on g e n e t i c t r a i t s .
C a l i F o r n i a a n d s e v e n o t h e r s t a t e s p r o h i b i t i n s u r e r s From
discriminating
For s i c k l e
gleaned
Jersey
or s i c k l e
New Y o r k ,
I s l a n d and Texas e i t h e r
cell
Oregon,
have
laws i n
584
place
or are currently
Given
grounded
t h e u n c e r t a i n t y oF o u t c o m e s
on e x i s t i n g
Representative
the
w o r k i n g t o pass
John
laws
federal
privacy
persons
are assured
From
court
decisions
but pertaining to genetic
Conyers
Human Genome P r i v a c y
them.
(D-Mich.)
recently
A c t (H.R.2045).
act to include
genetic
of t h e ' r i g h t
introduced
The a c t e x t e n d s t h e
i n f o r m a t i o n so
t o determine
- 1 71 -
testing,
that
the disclosure
�SELECTED VITAL STATISTICS AND
DEMOGRAPHICS
STATE HEALTH RANKINGS
RANK
39
50
39
39
22
10
5
25
44
34
4
33
34
20
7
10
38
45
12
23
7
25
1
47
25
18
5
47
3
16
DO-4
STATE
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW H A M P S H I R E
NEW JERSEY
LIFESTYLE'
ACCESS'
DISABILITY
42
23
34
40
31
12
16
29
50
38
5
8
40
29
12
17
39
41
2
6
45
4
46
6
34
26
3
4
49
6
48
32
40
12
22
1
16
29
29
5
46
36
23
16
7
38
45
19
7
3
24
6
47
28
41
14
34
2
19
4
21
42
46
11
34
17
The Universal
Healthcare
*
6
21
21
45
12
1
12
12
28
45
28
28
12
41
12
28
21
28
28
45
12
41
9
28
Almanac
3
DISEASE
19
44
47
30
39
4
25
42
45
30
19
13
26
14
10
9
28
27
19
43
30
14
3
19
37
7
4
MORTAL
45
45
21
34
21
13
9
40
27
48
2
34
30
29
3
9
40
44
14
30
6
34
3
49
i. I
16
g
48
12
41
40
X
19
Table '
�SELECTED VITAL STATISTICS AND DEMOGRAPHICS
STATE HEALTH RANKINGS - CONTINUED
RANK
45
34
32
12
19
25
43
20
17
39
23
34
30
1
12
15
30
49
7
25
LIFESTYLE'
STATE
NEW MEXICO
NEW Y O R K
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
R H O D E ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
31
4X
3K
2
26
23
26
22
23
44
9
44
31
1
12
20
12
34
9
20
ACCESS'
DISABILITY
3
i
50
12
25
44
20
25
36
11
HI
33
43
31
34
20
14
9
25
49
16
42
12
21
28
28
21
21
45
41
12
28
28
5
6
28
12
11
45
28
9
DISEASE
4
MORTAL
19
45
30
2
16
28
50
40
37
30
40
37
1
211
37
21
21
9
50
18
37
36
7
30
24
6
16
16
49
30
11
1
21
5
14
21
16
45
6
30
' L I F E S T Y L E F A C T O R i n c l u d a lha»e componenU (hat reflecl on Ihc way wc live and accounlj lor M)% of the overall ranking The componenu and respective percenugej arc: Prevalence o(
Srooking-10%, M o l o r Vehicle Deaitu 5%. Vtolenl Cnme Rate 5%, Risk (or Mean Disease 5%. and Percent ol High Scfu-ol f.raduaies 5%.
ACCESS F A C T O R meuures Ihe avaiUbtlily o( healih care lo the population o( the slate and accounts lor 2 0 ^ of the overall ranking. The componcnis and rapectrve percrnLages are
Unempteiyment R»te -5%, Kesuier Index (mejuure of accoa l o prenatal care) 5%, Health Manpower Shortage Areas 5%. and Resource I n d a (tneaiures l u t e ' s expenditures OA health care) 5%.
' D I S A B I L I T Y F A C T O R meuures Ihe impact of disability on a state s health and associated lost time, but because the data on a slate by sine level was poor, only 5% was assigned to this factor
The componenu and rapeciive percentages are: A c l m l i e s U m i l a l i o n Status 2.5% and Acute Illnesses 2 5 ^
*DISEASE F A C T O R measures Ihe burdens thai diseases and illnesses place on the overall health of the populaiion and accounts for 20% of the overall ranking The components and respenivr
percenlages are: Heart Disease 7.5%. Cancer Cases 7.5%, and Infectious Disease 5%.
M O R T A L I T Y F A C T O R consists of three oomponcnls measuring death rales and accounts (or 25% of Ihe overall ranking
Ihose componenls and respective percenlages arc: Total Mortality
Rate 10%, Inlanl Mortality Rale 7.5%, and Years of Potential U l e Lost 7 5%
SOURCE:
90-4
T H E N O R T H W E S T E R N N A T I O N A L L I F E I N S U R A N C E C O M P A N Y S T A I I I H f c A L T H R A N K I N G S . 1990 E D I T I O N
"The
Universal
Healthcare
Almanac,"
(Phoenix:
Silver
S Cherner,
Ltd.)
1991
l a t }
i
e 1 1
.g2
�585
of
their
own
testing
records.
attorney
for Representative
does n o t
address
the
privacy
privacy
it
of
genetic
of r e c o r d s
to
are
this
legislate
the
privacy
employers
and
occupational
reason,
even
by
13,
the
there
has
insurance
1 9 9 1 , and
587
present.
the
genetic
under
testing
the
by
real
industry.
intent
i s to
Americans
to
private
insurers.
were
support
this
held
Disabilities
For
bill
on
From
legislatively
With
October
those
expand
Act
to
include
not s p e c i F i c a l l y
588
provide protection against genetic d i s c r i m i n a t i o n .
The A m e r i c a n C o u n c i l oF L i F e I n s u r a n c e r e p r e s e n t s
BOO
c o m p a n i e s w h i c h w r i t e a b o u t 93 p e r c e n t oF t h e n a t i o n ' s l i F e
insurance
America
early
policies.
represents
Together,
in
they
1992,
availability
to
iF Forthcoming
by
As
records
f a r as
objection to
broad
assures
government.
so
and/or
Hearings
received
go
bill
maintaining
public
established
physicians
no
the
of
does n o t
records
the
H.R.2045 m e r e l y
privacy
bill
been
bill
Conyers'
protection
of
the
that
concerning
maintained
assure
staff
stated
information.
that
private records,
this
Conyers,
Sherille,
585
a l l p e r t i n e n t issues
i s much e a s i e r
than
Mr.
The
Formed
generate
of
genetic
establish their
Health
commercial
have
r e g u l a t i o n s do
the
Insurance
health
a special
insurers
task
Force
Insurers
to genetic
oF
nationwide.
which
industry's position
information.
"right"
Association
on
will,
the
will
information in
seek
order
589
to
a p p r o p r i a t e l y assess
oF
view,
however,
appropriate
risk,
i t may
risk.
appear
From
that
i n s u r e r s w i l l be
- 1 72-
an
insured's
rather
than
attempting
to
point
assessing
exclude
as
�much r i s k
as
is scientifically
Legislation
prime
importance
health
care
should
at
their
least
to the
interest
used
The
an
of
involved
in
activist-oriented
r e p r e s e n t a t i v e s of
l e a d p r o v i d e d by
and
By
the
of the
industry
not
of
on
i s making
and
able
and
becomes
tools
of
their
macro-data,
monitoring
privacy.
the
insurance
(be
contain i f
demographic
gaining control
genetic testing,
refusing
might
current
monitoring information
poses
i n the
of unobtrusive,
tables
i s already
effects
provided
in establishing
these
here
industry
will
range
becomes p a r t
becomes s t i g m a t i z i n g
society
are
of g e n e t i c screening
negative
insurance
what
and
associated with
care.
testing
be
knowledge of c o n s t i t u e n c y
pages w h i c h
invasive right
insurance
imposing
health
not
the
insurers
information
micro-data
represents
momentum
Without
the broad
by
Consider
to i n s u r e r s ,
the
The
are
follow
facing
genetic screening
industry.
(and)
two
data
criteria.
available
the
will
groups
Congressional
issue.
of d e m o n s t r a t i n g
non-personal
while
their
should
industry.
Refer
future
the
legislators
insurance
is
on
activist
C o n s u m e r s who
notify
position
genetic testing
t o consumer
reform.
positions,
risk
concerning
possible.
and
future
of
to those
sure
that
socially
that
and
control
American
with
defects,
"...genetic
handicapping...
to) benefit
from
new
590
approaches
to disease
is
unacceptable.
totally
industry
and
control
will
with
a
placed
have
legislative
prevention."
with
This
C o n t r o l m u s t be
the
indivual
consequences.
mandate
is imperative.
73-
wrested
control
from
himself--where
positive
- 1
negative
Individ ua1
the
that
control
�AMERICAN MEDICAL
ASSOCIATION.
"The
Medical
American
A s s o c i a t i o n i s perhaps
the
53 1
strangest
trade union
The
AMA
and
students,
ing
has
thus
throughout
i n the
t h e power
United States."
to r e s t r i c t
t h e number
the n a t i o n .
oF
By
t h e number
licensed
of
medical
physicians
restricting
entrance
practicinto
the
592
Field,
incomes
The
AMA
Hospitals
adhere.
he
oF
the proFession
e s t a b l i s h e d the
which
No
members oF
Council
sets standards
one
may
i s a graduate
obtain
oF
a
t o which
license
a medical
on
remain
Medical
medical
Education
schools
to practice
school
approved
elevated.
must
medicine
and
and
unless
a c c r e d i t e d by
593
the
Council.
In
care
the
U n i t e d S t a t e s , government
industry
regulatory
group
and
thereFore
oF
AMA
the
control
cally
been
weak
594
statements.
Control
and
has
insurance
the health
positioned
independence
care
AMA
i s an
care
the
such
industry
body
pressures
political
will
as
to
structural
gained
The
was
oF
by
stated
" t o promote
public
belieF
such
purpose
oF
the
AMA
the science
and
a r t oF
health."
that
the
a major
society
5 9 S
only
Over
way
time,
ambiguous
care
reForm
and
cohesive
Field.
must
the
place
strategi-
oF m a i n t a i n i n g
insurers.
probably
views
be
gained
and r e v i e w s
595
beneFits
change.
when
i t was
medicine
Founded
in
and
betterment
the
t h e AMA's p o s i t i o n
to achieve
- 1 74-
health
a s t r o n g and
t h e AMA
control
the
resides within
i s capable
merely' i n i n c r e m e n t a l stages
be
health
care
with
which
oF
with
currently
Health
oF
ideologically
i n the
industry
industry.
governing
From
UnFortunately,
The
Fragmented
a s t r o n g Force
the health
oF
and
control
their
stated
goal
1347
included
was
to
the
�assure
that
through
anything
private
having
t o do
means, w i t h o u t
w i t h medicine
any
semblence
was
of
accomplished
government
597
intrusion.
AMA
even
This
belieF
was
carried
t o such
extremes
that
the
opposed:
--President Roosevelt's
S o c i a l S e c u r i t y Program
- - P r e s i d e n t Truman's n a t i o n a l h e a l t h c a r e program
- - P r e s i d e n t J o h n s o n ' s M e d i c a i d and M e d i c a r e p r o g r a m s
-- c o m p u l s o r y v a c c i n a t i o n a g a i n s t
smallpox
- - m a n d a t o r y r e p o r t i n g oF t u b e r c u l o s i s c a s e s
- - e s t a b l i s h m e n t oF p u b l i c v e n e r e a 1 - d i s e a s e
clinics
- - e s t a b l i s h m e n t oF Red C r o s s b l o o d b a n k s
- - F e d e r a l g r a n t s For m e d i c a l s c h o o l c o n s t r u c t i o n
- - F e d e r a l g r a n t s For m e d i c a l s t u d e n t
loans
- - B l u e C r o s s and o t h e r p r i v a t e h e a l t h i n s u r a n c e p r o g r a m s
- - g o v e r n m e n t s u b s i d i e s t o r e d u c e m a t e r n a l and i n F a n t d e a t h s
- - F r e e c e n t e r s For c a n c e r d i a g n o s i s .
5
Richard
195Cs a n d
which
H a r r i s , a staFF
19BDs, was
occurred
writer
primarily
For
The
interested
p r e d i c t a b l y whenever
9
3
New
Yorker
in political
a major
issue
in
the
warFare
surFaced.
599
One
oF
oF
the
h i s books
American
Truman's
disclosed
Medical
proposed
Harris'
the
Association
national health
opening
massive
statements
and
successFul
i n opposing
insurance
describe
eFFort
President
program.
the
mission
oF
special
interest
groups:
Since the p o l i t i c i a n ' s F i r s t p r i n c i p l e i s to
a v o i d t a k i n g on any m o r e o r g a n i z e d o p p o s i t i o n t h a n
he h a s t o , t h e F i r s t p r i n c i p l e F o r t h o s e
who
want t o i n F l u e n c e p o l i t i c i a n s i s t o o r g a n i z e . . .
In a sense, the Washington r e p r e s e n t a t i v e s
oF s p e c i a 1 - i n t e r e s t g r o u p s c o n s t i t u t e a t h i r d
h o u s e oF C o n g r e s s , s i n c e h a l F oF a l l t h e
m e a s u r e s i n t r o d u c e d i n t h e S e n a t e and t h e
H o u s e oF R e p r e s e n t a t i v e s w e r e o r i g i n a l l y
written
in t h e i r oFFices."600
The
AMA
existence
One
a
oF
gathered
to
become
i t s earliest
proposal
to
study
s t r e n g t h over
a major
i t s First
national political
'accomplishments'
national health
was
the
insurance
90
years
Force
by
in
1925.
d e s t r u c t i o n oF
as
a o a r t oF
the
�Social
Security
campaign
of
program.
I t was
misinformation,
said
t h a t the
f a l s e rumors,
AMA
and
led
scurvy
a
attacks
,. .
S01
on p e r s o n a l i t i e s .
In
1935,
(Secretary
and
were b o t h
also
advocates
the
Borden
and
Millbank
by
on
the
committee
studying
physicians
boycott,
supported
t h a t he
0
insurance . S1935
announced
a busy
passage
that
i n s u r a n c e .'
The
AMA
of
national
a
underwriting
and
encouraged
to t u r n his
elim-
boycott
desirable
costs
6 0 2
care.
of
So
supported
national
the
While
on
a
many
patients
back
was
health
that a
have
n a t i o n a l medical
longer
Millbank
effectively
journals
was
forced
year
of
6 0 4
for
the
i t was
advocated
level.
Their
against
a l l Forms o f
that several
quarter
the
compulsory
motivations
years
of
AMA.
to
his
beliefs
health
Congress
social security b i l l ,
Nevertheless,
bravely
a
no
insurance.
i n f a n t s would
boycott,
was
Fund, r e s p e c t i v e l y ) ,
advocates
which
Millbank
3
was
considerin
for
of
the
that Millbank
announce
as
Fund,
costs
health
i n medical
milk
Millbank
A l b e r t G.
Company.
editorializing
evaporated
and
Millbank
national
the
Borden's
spend
of
of
Kingsbury
effect
AMA
Kingsbury
of
insurance
and
John
Chairman
Chairman
inated
of
Dr.
were
later
so
the
a million
Medical
insurance
completely
CMA
on
the
'sickness
Association
state
eradicated
deemed
d o l l a r s to
AMA
compulsory
California
health
the
was
by
i t necessary
defeat
its
the
to
own
505
program.
As
early
interests
apposed
to
such
as
the
19203,
attempts
establish prepaid
attempts
and
by
group
1934
had
- 1 75-
w e r e made by
health
various
plans.
adopted
a
5 0 5
private
The
statement
AMA
of
�principles
which
come b e t w e e n
relation."
health
declared
Harris points
insurance
out that
have a r g u e d
interFeres with
pocketbook ."
p a r t y must
t h e p a t i e n t and h i s p h y s i c i a n
6 0 7
necessarily
"no t h i r d
BOS
that
be p e r m i t t e d t o
i n any
"Advocates
t h e only
Richard
oF
government
relationship i t
i s t h e one b e t w e e n
Additionally,
medical
Carter
a p a t i e n t and h i s
609
exp1 a i n s . t h a t :
" . . . ( T ) h e AMA's o p p o s i t i o n t o a n y l a r g e s c a l e h e a l t h i n s u r a n c e p r o g r a m has been based
on t h e F e a r t h a t e c o n o m i c p l a n s oF t h a t s c o p e
w o u l d r e q u i r e p u b l i c s u p p o r t so e x t e n s i v e a s t o
necessitate public control.
The k n o w l e d g e
that p u b l i c control w i l l c u r t a i l the proFession's
Fee p r i v i l e g e s u n d e r l i e s o r g a n i z e d m e d i c i n e ' s
p o s i t i o n on h e a l t h i n s u r a n c e and on e v e r y
other
c o n t r o v e r s i a l issue i n t h e Field."610
During
Washington
who
cared
their
t h e Depression,
was F o r m e d .
t h e Group H e a l t h
This
was a g r o u p
F o r 2,500 l o w - i n c o m e
Families
who p a i d
A s s o c i a t i o n oF
oF s e v e n
physicians
government employees and
$2.20 p e r month
i n r e t u r n For
61 1
assured
medical
society
tried
abar-don
t h e group
persuaded
patients
Society
to
over
persuasion
a n d , when
physicians
persuaded
discovered
elderly
The D i s t r i c t
t o t h e group.
morphined
agreed
simple
other
t h e seven
patient
care.
area
oF C o l u m b i a
t o g e t t h e seven
that
d i d n ' t work,
n o t t o reFer
When
even
that
w i t h acute
t o withdraw
staFF
woman h a d b e e n
by a c a r a n d t h e n ,
privileges
One p a t i e n t h a d a l r e a d y
From
the operating
t h e Group H e a l t h
rushed
theater.
care
until
Association.
to a hospital
despite coercion
- ! 77-
been
when h e r d o c t o r
a p p e n d i c i t i s was d e n i e d
From
higher-paying
d i d n ' t work, t h e
i n p r e p a r a t i o n F o r an o p e r a t i o n
he was b a r r e d
doctors to
the Society
other
h o s p i t a l s t o reFuse
physicians.
Medical
after
A
he
An
being run
by t h e h o s p i t a l t o
�denounce
her
refused
association
treatment
with
when s h e
the
kept
Group H e a l t h
insisting
Plan,
that
her
she
own
was
group
G 12
doctor
treat
her.
Finally,
patients,
both
after
the
the
decided
of
the
above m i s t r e a t m e n t
J u s t i c e Department's A n t i t r u s t
AMA
violation
learning
and
the
oF
the
Sherman
i n the
District
oF
Columbia Medical
Antitrust
Supreme C o u r t ,
Division
Act.
The
case
of
indicted
Society
was
For
ultimately
when J u s t i c e Owen J . R o b e r t s
stated:
" . . . ( P r o F e s s i o n a l l i c e n s i n g does n o t )
justiFy
c o n c e r t e d c r i m i n a l a c t i o n to p r e v e n t the people
From d e v e l o p i n g new m e t h o d s oF s e r v i n g t h e i r n e e d s .
The p e o p l e g i v e t h e p r i v i l e g e oF
proFessional
monopoly and t h e p e o p l e may
take i t away."SlJ
The
AMA
do
had
no
above
placed
on
a great
their
deal
about
how
much v a l u e
oFt-repeated
ethical
standard,
end
War
the
"First,
Governor
harm."
Shortly
Warren
oF
bill.
The
pending
aFter
firm
CMA
Blue
plans.
By
advocating
them
an
Cross-Blue
The
the
PR
Shield
and
a plan,
v o l u n t a r y , versus
health
the
campaign
firm's
alternative
such
II,
Association hired
lead
legislation.
proposing
World
a compulsory
Medical
to help
propose
support
oF
supported
California
state
the
the
California
relations
that
says
a public
against
bill
commercial
CMA
insurance
the
recommendation
to the
the
Earl
which
would
health
would
government's
was
insurance
appear
to
be
required, health
6 14
insurance
The
the
plan.
public relations
California
$100,00 0
support
Medical
that year
From
on
firm,
by
assuring
A s s o c i a t i o n would
newspaper
1 D0 California
spend
advertising,
newspapers
- 1 73 -
newspapers
was
t o 432
that
approximately
able
For
the
to
increase
CMA.
�Governor
Warren's
When
to
t h e AMA
the defeat
profession,
That
firm
which
"The
6 1 6
to resign
has y e t t o seek
of medicine,
of
i t s physician
(to
wage)...the
which
with
Congressional
lobby
t h e AMA
rejected,
the explanation
the truth
that
on t h e e c o n o m i c a n d
first,
and t o
6 1 5
t o i m p o s e d u e s o f $ 2 5 on e a c h
members t o r a i s e
greatest
of t h e medical
to put the public
decided
reacted
public relations firm.
to i t s responsibilities."
1 9 4 9 , t h e AMA
public
distrustfu1ness
recommendations
the firm
become a d e q u a t e
a
with
a different
made s e v e r a l
aspects
defeated.
r e a l i z e d t h a t t h e American
i t engaged
Association
In
was
of the b i l l
prompted
social
bill
a $350 m i l l i o n
grass-roots
lobby
"war
chest
in history."
i n v e s t i g a t i n g committee
5 1
'
called the
5 13
fee
" b l a t a n t , undisguised
explained
could
that
t h e AMA
coercion."
One
physician
was n o t a p r i v a t e c l u b
from
w h i c h one
resign.
Membership i s almost i n d i s p e n s a b l e t o t h e
p r a c t i c i n g p h y s i c i a n , b e c a u s e many p r i v i l e g e s
and o p p o r t u n i t i e s s u c h a s h o s p i t a l a p p o i n t m e n t s
and a d m i s s i o n s t o e x a m i n a t i o n
by t h e s p e c i a l t y
b o a r d s a r e c o n t i n g e n t o n s u c h m e m b e r s h i p . 5 19
That
year,
t h e AMA
spent
$ 1 , 5 2 2 , 5 8 3 on
$ 5 5 0 , 0 0 0 on n e w s p a p e r
advertisements,
$250,000
advertisements. ^
firm
f o r magazine
developed
small
businesses
advertising
supportive
owner
reaped
o f t h e AMA
own.
who w e r e
position,
$19 m i l l i o n
with
included
space
- 1 73-
those
t o provide to
to afford
copy
much
which
was
f o r the cusiness
a t t h e bottom.
from
f o r r a d i o and
The p u b l i c r e l a t i o n s
unable
The l a y o u t s
t o a d d h i s name a n d l o g o
a bonanza
1
advertising layouts
nationwide
on t h e i r
$300,000
5
ready-made
l o b b y i n g . 620
The n e w s p a p e r s
prepared
layouts.
�In
1350,
t h e AMA
spent
$250
r e l a t i o n S j and t h e d e f e a t
and
four other
health
which
provided
on
lobbying,
Claude Pepper
members who
submitted
the b i l l
had
nursing
public
(D-Fla. )
supported
was
From
which
Social
would
also
$4,200
Security
have
hospital
major
national
have
t o $5,000,
taxes
a
were
care
recipients.
(D-RI),
5
1957.
5 2 4
The
including
been
imposed.
The
insurance
Means. Forand
paid
oF
The
increase
tax rate
plan
surgery,
between
t h e amount
10 p e r c e n t
health
Aime F o r a n d
diFFerence
i t would
provided
security
i n August
oF
that
own
on Ways a n d
The
home c a r e .
others
social
days
i t s
to Representative
i n Congress
For s i x t y
and
formulated
t h e House C o m m i t t e e
increasing,
to
t h e AFL-CIO
was
introduced
plan
o f Congressman
Congressional
1955,
a member oF
and
dollars
insurance.
In
plan
million
this
For
by
income
tax
on
increase
i n payments
For e m p l o y e r s
625
and
employees
The
would
because
had
increased
and
For s u r g e r y
medical
5
would
raised
from
2
6
The
impose
private
t h e 1950s
63
million
policies
AMA
From
Toward
percent.
also
had
socialized
this
medicine
AMA
decided
enlisting
this
to organize
the assistance
end, s h o r t l y
as
hospitalization
91 m i l l i o n
doubled
opposed
the plan
i n that
bill,
of doctors
b e f o r e t h e 1958
- 1 80-
t o 72
contending
The
lengthy
i t sfight
million,
General
time
nationwide.
and
being
policies
t o 121
t o 109 m i l l i o n .
by i n c r e a s i n g d i s c u s s i o n s
fi?7
1958.
The
by
.50
insurance
alive
during
bill
during
insurance
million.
kept
been
Eisenhower A d m i n i s t r a t i o n opposed
unnecessary
it
have
against
that
bill
was
hearings
the Forand
nationwide.
Congressional
elections,
�t h e AMA
every
developed
a q u e s t i o n n a i r e which
state
and c o u n t y
medical
questiions
illustrate
that
details
of persuasion
was d i s t r i b u t e d t o
society.
The w o r d i n g
t h e AMAs a b i l i t y
had reached
a peack
of the
to attend to the
of
efficiency.
1.
"Who i s t h e p e r s o n o r p e r s o n s i n e a c h w a r d o r c o u n t y
i n t h e C o n g r e s s i o n a l d i s t r i c t who i s m o s t i n f l u e n t i a l
with
Congress?
L i s t t h e names, a d d r e s s e s , and b u s i n e s s o r p r o f e s s i o n
of each."
each
2.
"Who i s t h e p h y s i c i a n who k n o w s a n d c a n w o r k
o f t h e above?"
with
3.
"Who a r e t h e f o u r o r f i v e men i n t h e C o n g r e s s m a n ' s
d i s t r i c t who r e a l l y i n f l u e n c e h i m ?
L i s t t h e i r names,
a d d r e s s e s , and b u s i n e s s o r p r o f e s s i o n . "
A.
"Who
are the p r i n c i p a l
contributors
5.
"Who i s t h e C o n g r e s s m a n ' s p e r s o n a l
home a n d i n W a s h i n g t o n ? "
t o h i s campaign?"
physician at
6.
"What a r e t h e C o n g r e s s m a n ' s h o b b i e s ,
c h a r i t i e s , boards or o r g a n i z a t i o n s , church?"
his
7.
last
"What n e w s p a p e r s i n t h e d i s t r i c t
campaign?
What i s t h e i r p r e s e n t
his favorite
s u p p o r t e d him i n
a t t i t u d e toward him?"
8.
"What c o n t a c t d o e s t h e m e d i c a l p r o f e s s i o n h a v e w i t h
any o r a l l o f t h e s e n e w s p a p e r s , e i t h e r d i r e c t l y w i t h t h e
-go
e d i t o r s or through other i n f l u e n t i a l c i t i z e n s or a d v e r t i s e r s ? "
Fortunately,
Congressional
public
more
when
members
not only
t h e q u e s t i o n n a i r e became
became
questioned
importantly,
elected
wary
oF t h e AMA,
the sincerity
an a d d i t i o n a l
public,
and t h e g e n e r a l
oF p h y s i c i a n s b u t ,
16 D e m o c r a t s
to the
629
Senate
a n d 48 t o t h e H o u s e .
The
AMA
encouraging
was t h e n
the growth
a "judicious,
this
they
Forced
tolerant,
t i m e , t h e AMA
to mildly
oF p r i v a t e
alter
health
i t s p Q S i t i o n by
insurance
and p r o g r e s s i v e a t t i t u d e . "
had opposed
plans
with
Prior to
any i n s u r a n c e p l a n s u n l e s s
6 30
h a d b e e n a d m i n i s t e r e d by p h y s i c i a n s .
D e s p i t e a l l t h e i n t e n s e a c t i v i t y on t h e F o r a n d
bill,
-1 81 -
�6
C o n g r e s s s t i 11 r e j e c t e d
i t i n 1960. '
j 1
I n response
defeat,
Senator
J o h n F. K e n n e d y
introduced
Senator
Clinton
Anderson
Mexico,
than
t h e Forand
coverage.
major
bill
The AMA
newspapers
o f New
by m a n d a t i n g
responded
which
with
to that
a bill,
which
along
went even
considerably
with
further
more i n s u r a n c e
Full-page advertisements i n
warned:
When g o v e r n m e n t s t a r t s t e l l i n g t h e d o c t o r
how t o p r a c t i c e m e d i c i n e , t e l l i n g t h e n u r s e s how
t o n u r s e , t e l l i n g t h e h o s p i t a l how t o h a n d l e i t s
p a t i e n t s - - t h e q u a l i t y oF m e d i c a l c a r e i s s u r e t o
decline."632
The
AMA
wanted
t o be a b l e t o c o n t r i b u t e
t o Congressional
c a m p a i g n s b u t , as a n o n - p r o F i t o r g a n i z a t i o n ,
lost
i t s tax-exempt
candidates.
Political
an
To a v o i d
Action
initial
status
i F i t p r o v i d e d Funds
the constriction,
Committee
contribution
i t would
oF $ 5 0 , 0 0 0 From
directly to
t h e American
(AMPAC) was F o r m e d
have
Medical
i n 1961, with
t h e AMA
For 'educational
633
purposes.'
Followed
all
Within
suit
t h e PACs
a y e a r , 46 s t a t e
and o r g a n i z e d t h e i r
was t o d e F e a t
One oF t h e AMAs m a i n
Medicare
are
i n poor
Financial
ment
was t h a t
"Surveys
medical
own l o c a l
any M e d i c a r e
arguments
show
hea1th . . .(and ) t h a t
circumstances than
that
those
other
PACs.
plan.
against
s o c i e t i e s had
6
3
4
t h e need For
relatively
over
The g o a l oF
Few oF t h e a g e d
55 a r e i n b e t t e r
age g r o u p s . "
was r e p e a t e d i n a d v e r t i s e m e n t s n a t i o n w i d e
6 3
-
J
This
state-
despite
s t a t i s t i c a l evidence t o t h e c o n t r a r y which i n d i c a t e d :
- - 8 0 % oF a l l p e o p l e w i t h i n d i v i d u a l h e a l t h i n s u r a n c e p o l i c i e s
had t h e i r i n s u r a n c e c a n c e l l e d a F t e r t h e f i r s t c l a i m ;
--10 m i l l i o n p e o p l e o v e r age 65 h a d a n n u a l i n c o m e s o f l e s s
t h a n $ 1 ,000; 6 3 6
- - I n t h e e n t i r e p o p u l a t i o n , t h a s e w i t h i n c o m e s oF $ 1 , 0 0 0
a n n u a l l y o r l e s s r e c e i v e d no m e d i c a l t r e a t m e n t ;
-iez-
�- - I n t h e e n t i r e p o p u l a t i o n , t h o s e w i t h incomes o f $5,000 or
more, 90% r e c e i v e d m e d i c a l t r e a t m e n t ; 5 3 7
--The e l d e r l y w i t h i n d i v i d u a l h e a l t h p o l i c i e s F a r e d w o r s e
t h a n e l d e r l y on g r o u p p l a n s ;
--19%
had
One
to
policies
point--which
the American
oF
would
The
Committee
doubts
your
about
oF
smoking.
tobacco
companies
actually
Thompson
paid
a health
(D-NJ),
which
Americans
have
exhiPit
"a
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t h e AMA
legislative
oF
thirty
d o c t o r won't
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as
your
which
days
decide.
have
any
doctor,
ask
announced
warnings
AMA
i m m e d i a t e l y , t h e AMA
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their
mutual
$10
million
has
with
which
powerFul
made a d e a l w i t h
c o n s i d e r e d t o be
stated
placed
an
interest
oF
"an
to
the
Six
establish
tobacco
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was
assault
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appeared
like
1
o 4 C
in a
to
1
even
- P3-
Faith
t h e AMA
the study-For-a-promise
groups
against
doctors."
which
they would
tobacco
to vote
in their
editorial
i n t e g r i t y .
pollution
and
beneFit.
dollars
t o b a c c o - s t a t e Congressmen
more
about
A c c o r d i n g t o R e p r e s e n t a t i v e Frank
sidsd
little
moral
to
committees
i n excess
"Your
General
traditionally
journal
two
objected
I i m p l o r e you
hazard.
"The
he
physicians
medical
the
AMA
research i n s t i t u t e " t o study whether
Medicare"
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brought
i s being considered i n
i t meets.
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joined
i n d u s t r y . ..to get
Many
that
decide--when
t h e Surgeon
industry
"tobacco
warned
stay
Amis,
50.
S 3 9
tobacco
a
hospital
t o age
Square Garden i n
u t i l i z a t i o n review
these plans,
1964,
dangers
The
Annis
will
doctor."
In
the
Dr.
which
any
Dr.
a t Madison
a situation
hospital
scrutinize
duration.
at a r a l l y
legislation.
1991-1992 p e n d i n g
about
w e r e n o n c a n c e l l a b l e up
t h e AMA's s p o k e s p e r s o n ,
public
^ 362--has s h a d e s
provisions
which
aFFected
deal
elected
between
�legislators.
American
Medical
Program
Committee,
bill
lators
Mills,
medical
they
voted
For Medicaid,
elderly
that
by k e e p i n g
election,
they
bill
by t a k i n g
would
In
i F they
"mandate
usual
seven
o u t oF t e n R e p u b l i c a n
pro-AMA
seats,
seats
From
constituenciesiF
n o t want
5
i t .
Johnson
senior
Republican
states
i n theSenate.
5 4 6
AMA's $ 1 t o $2 m i l l i o n
Physicians
started
gained
This
voted
their
true
attended
t h e AMA's a n n u a l
courage
to state
y o u do i t .
the
United
change
And y o u ' r e
States
want
you t o . "
Mills
the b i l l ,
6 4 4
switched
t o Democratic,
Democratic.
6 4 5
lost
and
Three
their
i n t h e House, and 4
despite the
campaign.
t o t h e campaign
convention.
going
3
citizens
occurred
opinions
"The ( M e d i c a r e ]
4
achieved h i s
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who h a d c o n t r i b u t e d
t o voice
how
44 s e a t s
nationwide
t o Face t h e
beFore t h e
members oF t h e Ways a n d Means C o m m i t t e e
as t h e D e m o c r a t s
legis-
n o t want t o
i n the F u t u r e .
President
pattern
any v o t e on
For d e l a y i n g
Two m i l l i o n
their
would
against
himselF
every
whether
o u t oF t r o u b l e
support
For Medicare."
voting
would
voted
t h e blame
t h e 1964 e l e c t i o n ,
they
industry
Friends
owe h i m t h e i r
t o delay
His reasoning:
and they
his
5 4 2
For d i s c u s s i o n
i n order
and i n s u r a n c e
or t h e unions
and t h e
oF t h e M e d i c a r e
Committee."
were For o r a g a i n s t M e d i c a i d ,
their
industry
oF t h e H o u s e Ways a n d Means
to election.
Face
knew
t h e deFeat
t o and s u b m i t t e d
oF t h e M e d i c a r e
prior
t h e tobacco
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Chairman
objected
provision
between
A s s o c i a t i o n caused
i n the-House
Wilbur
the
"The a l l i a n c e
aFter
Finally
theelction
as t h e y
One p h y s i c i a n h a d t h e
problem
i s n o t what
t o do b u t
t o do i t t h e way t h e p e o p l e
Another
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oF
p h y s i c i a n , who b e l i e v e d
�that
the
AMA
should
governmental
compromise
control,
care
For
proclaimed:
i n matters
oF
liFe
t h e aged
"We
and
do
death,
even
not,
nor
by
with
some
proFession,
with
honor
and
5 4 7
duty."
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State
support
January
oF
the
19G5,
Union
immediately
aFter
message a d v o c a t i n g
President
the
quick
Johnson's
passage
oF
rr A Q
Medicare,
which
the
they
elderly
AMA
announced
contended
than
the
would
the
Eldercare
Plan.
had
Congressman
government
was
known
1965,
on
the
the
Ways a n d
5 4 9
the
an
along
Mills
astounded
oF
choosing
to
amend
with
that
anyone
plan
would
health
bill.
the
a l l oF
basic
industry
which
proposed
policies.
19B1
and
64 1
their
5
5
0
I t
February
witnesses
speak
and
Medicare
pending
bill
Eldercare
by
bills,
bill.
under
bills,
proposing
they
There
Congressman
that,
should
was,
considera-
instead
combine
then,
no
them
way
could
oppose t h e r e s u l t because each F a c t i o n ' s
652
enacted.
The m e a s u r e p a s s e d t h e House 313
be
to
C! /\
and
response
introduce
plan
heard
f —,
115.
two
1
Washington
Medicare
to
the
enlisted
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insurance
Kerr-Mills
Byrnes
Program
to
insurance
Between
Medicare. ^
among t h e
the
the
Means C o m m i t t e e
expanded
tion,
later,
5
s u b j e c t oF
plan.
introduce their
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Ways and
With
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Eldercare
greater beneFits
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s u b s i d i e s For
as
provide
administration's
members oF
their
i t s Doctors'
the
was:
5enate
" I never
by
68
to 31.
thought
we'd
The
end
AMA's
up
lobbyist's
spending
several
655
million
dollars
President
the
presence
oF
in advertising
Johnson
Former
signed
t o expand
the
President
the
Medicare
Harry
S.
b i l l . "
bill
into
Truman,
in
law
in
Independence
�Missouri,
now
part
on J u l y
30, 1 9 5 5 .
Despite
of t h e law o f t h e l a n d ,
physicians
patients
decided
to b o y c o t t
not to s i g n
refused
to t r e a t
the Fact t h a t
90 p e r c e n t
t h e program
up f o r M e d i c a r e .
those
p a t i e n t s who
the plan
was
of t h e n a t i o n ' s
by u r g i n g
their
elderly
Many o f t h e d o c t o r s
did sign
up f o r t h e
556
program.
At
a special
Medicare
had b e e n
process,"
that
collaborators
political
AMA,
opposition
'expected
proclaimed
mockery
of t h e
that
by
labor bosses,
I n s t e a d of a d v o c a t i n g
the v i t a l ,
had a n o t h e r
power-hungry
t h e camp
the vulnerable s p o t s . "
and p o i n t e d
who
out t h a t
and women,
t o medicine
however,
of the
6 5 7
The
spoke i n
p h y s i c i a n s were
t h e p r e s s , and t h e C o n g r e s s
and m a t u r e men
i s as d e l e t e r i o u s
Democratic
boycotts,
member, D r . A p p e l ,
by t h e p u b l i c ,
that
"appeasers,
and
p h y s i c i a n s get " i n s i d e
to Dr. Annis
reasonable
by e v e r y
t h e enemy,
leaders."
(and) find
crisis
"passed
with
however,
m e e t i n g , Dr. Annis
p h y s i c i a n s had b e e n b e t r a y e d
he r e c o m m e n d e d
enemy
AMA
(and) that
no
to a c t as
political
as one b r o u g h t a b o u t by
,.658
its
members.
In
which
of
are
1 9 9 1 , t h e AMA
would
improve
six principles
similar
proposed
health
to health
and s i x t e e n
care plans.
improvements
2.
affordable
assured
access
a plan,
"HealthAccess
care.
key p o i n t s .
to generally-accepted
1.
7 .
.
developed
The p l a n
0 0 9
access
i n many
other
They a r e :
forall,
to health
consists
The s i x p r i n c i p l e s
goals included
should preserve strengths
coverage
America,"
regardless
care
of our current
of
income;
For t h e e l d e r l y :
system;
�4.
high
quality
5.
p a t i e n t autonomy r e g a r d i n g c h o i c e o f p r o v i d e r
in which h e a l t h care beneFits are d e l i v e r e d ;
S.
a l l p h y s i c i a n s s h o u l d be c o m m i t t e d t o t h e h i g h e s t
s t a n d a r d s i n t h e d e l i v e r y oF c a r e t o p a t i e n t s . S B O
Concerning
'3'
governments
care
For
health
above,
"...must
a l l persons
care
t h e AMA
ensure
with
Bacause
u n r e a 1 i s t i c a 11y
access,
Medicaid
Medicare
are
level."
a t 45
should
the
maintains that
access
provider
reimbursement
5
0
1
poverty
to
nation,
health
HealthAccess
i n s u r a n c e For
Employers
would
oF
would
and
t h e AMA
37
t a x b e n e F i t s t o ease
state
medical
level.
...
levels
reduce
increased to the
only
those
believes
who
Medicaid
level.
5 5
'
-
uninsured across
employers
employees
manner
ethical
For
poverty
million
the
and
the poverty
s h o u l d be
require
a l l Fulltime
receive
Funding
10 0 p e r c e n t oF
help solve the problem
Federal
Medicaid covers
level
costs:
and
reimbursement
levels
Presently,
p e r c e n t oF
t o and
incomes below
low
p r o v i d e coverage
To
provided at appropriate
to provide
and
their
their
Families.
financial
.
,
663
burden .
The
stated
is
HealthAccess
i n 5 . 1 3 2 7 and
for states
private,
help
plan
5.700.
to enact
t h a n 23
The
created
would
which
benefit
oF
the proposals
t h e AMA
would
advocates
establish
pools s p e c i f i c a l l y
small
to
businesses
with
employees.
i n every
state
risk
by
the medically
the
opportunity
the
premiums
group
health
which
t h e u n i n s u r e d , and
not-for-profit
cover
w i t h some
A variant
legislation
not-for-profit
the uninsurable,
fewer
coincides
to
join
state
a group
The
be
inBurance
legislation.
uninsurable,
f o r insurance.
insurance rates.
p o o l s would
plan,
those
and
would
who
those
Premiums would
state
The
pay
be
programs
risk
do
who
equal
pool
not
have
cannot
afford
to standard
t h e premiums
f o r those
�who a r e u n e m p l o y e d , n o t c o v e r e d
between
100 and 15D p e r c e n t
Funding
For the r i s k
1.
would
be r e q u i r e d
tand
assessments
state,
3.
with
would
able
level.
come From:
a percentage
oF t h e b e n e F i c i a r i e s
t o pay;
on i n s u r a n c e
a tax credit
general
e m p l o y m e n t , o r who a r e
of the poverty
t h e premiums w h i c h
2.
the
pool
through
carriers
to ease
doing
their
business in
burden;
tax revenues;
RGB
4.
t a x on h o s p i t a l p a t i e n t
The
eFFect
problems
prior
be
now F a c e d
by many
to i n s u r e t h e i r
AMA
plan
long-term
would
be t o e l i m i n a t e t h e
uninsurable
c o s t s and s m a l l
employees through
a l s o recommends M e d i c a r e
care
encouraging
pool
oF b e i n g
excessive health care
able
The
oF t h e r i s k
revenues.
For s e n i o r
citizens,
s e n i o r s to purchase
BS7
employers
this
reForm
with
b e c a u s e oF
risk
would
pool.
and e x p a n s i o n
oF
conditions For
p r i v a t e insurance For
themseIves.
The
which
the
AMA
will
HealthAccess
be h e l p F u l
coming
months.
America
Plan
to l e g i s l a t o r s
I t noticeably
contains
i n Formulating
lacks,
however,
or r e q u i r e m e n t
that physicians, hospitals,
curb
their
or reduce
concepts
r a t e s For s e r v i c e s ,
b i l l s in
any m e n t i o n
and o t h e r
nor does
caregivers
i t impose
any c o s t - r e d u c i n q r e c o m m e n d a t i o n s on p r o v i d e r s .
The AMA would
be o p p o s e d t o t h a t s e c t i o n oF 3 . 1 2 2 7 w h i c h p r o p o s e s a F e d e r a l
Health
E x p e n d i t u r e Board
negotiating
cars
which
will
expenditure
incentive
rates
which
between
purchasers
be r e q u i r e d
goals.
to curb
would
t o remain
Health care
their
establish
and p r o v i d e r s
within
providers
own c o s t s b e c a u s e
- i ao-
a process For
oF h e a l t h T l
national
have
no
health
current
oF t h e o p e n - e n d e d
�reimbursement
beneFits
For
Th-3 H T - I t h c a r e
decades.
beneFiciaries
pays
oF h e a l t h
t h e premiums.
insurability
oF w h i c h
Thus,
reForm
Metropolitan
Medical
the
plan
a t a Forum
Society
For peer
such
presented
review
a speech
sponsored
review
i sprohibited
i n t h e reForm
Plan."
that
Congress
which
when t h e y
understanding
makes
care
because
oF i t s
inFormed
members
a view
HealthAccess
t h e AMA
this
6
type
individuals
their
oF t h e p r o c e s s
5
9
bills.
u s e d by
instead
H i s views
t h e AMAs own H e a l t h A c c e s s
oF
c a n be a p p l i e d
Plan
Feldstein
as w e l i
states:
" . . . ( T ) h e amount an i n t e r e s t g r o u p i s
w i l l i n g t o pay For l e g i s l a t i v e b e n e F i t s i s r e f e r r e d
t o as t h e demand f o r 1 e q i s 1 a t i o n . . .Ths c o s t o f
- 1S9-
that
a n d t h e AMA a n d
instruct
become a d v o c a t e s ,
Favored
t o be
position.
1 egis1 ation .
industry's
oF
oF t h e
i timperative that
reForm
their
presents
oF p e n d i n g
insurance
and " t h e c r e d i b i l i t y
Congressional
concerning
Feldstein
structures
toward
"want(s)
I ti sprecisely
groups
representatives
oFFice
s m a r t " by
on t h e AMAs s i d e . "
a v i e w p o i n t on h e a l t h
opponents,
street
theorganization
antitrust
D.C.
have
between
interest
power
t h e Washington,
process"
For health
Members oF C o n g r e s s
interaction
Paul
by t h e S t . L o u i s
by F e d e r a l
t o be " e x t r e m e l y
to legislators
about t h e
on F e e s c h a r g e d
itselF
are " s t i l l
other
oF
on N o v e m b e r 2 0 , 1 9 9 1 . D r . R e a r d o n
has proven
America
the
M.D.,
i s a t i t s highest with
with
be a s t r o n g a d v o c a t e
that
a player
oF
t h e AMA w i l l
a s much t h e
a s t h e c o n s u m e r who
stated
conveying
they
policies
Dr. Reardon
AMA
AMA
t h e need
but that
laws.
the beneFiciaries
For a l l consumers.
AMA's h e a l t h
care,
have been
providers are just
insurance
Thomas R. R e a r d o n ,
expressed
they
as
�o b t a i n i n g l e g i s l a t i o n w i l l d e p e n d , among o t h e r
t h i n g s , on t h e a c t i o n s o f o t h e r i n t e r e s t e d
670
p a r t i e s a f f e c t e d by t h e p r o p o s e d l e g i s l a t i o n .
The d e t e r m i n i n g f a c t o r f o r a h e a l t h
association in interpreting legislation is
whether i t w i l l have a p o s i t i v e , n e g a t i v e , or
n e u t r a l e f f e c t on t h e m e m b e r s h i p ' s i n t e r e s t s . "
Fedlstein
interest
promote
counsels
will
group
that
the
use
legislation.
As
should
guise
an
of
providers
are
have
access
also
provided.
ing
such
while
Providers'
disclosure
their
generated
their
true
by
fear
such
reduction
The
in
motivation
composed
Responsible
replacing
to
out
of
of
charged
by
legislation
requirement
competition
reduction
services
would
be
adversely
some p h y s i c i a n s
would
requir-
is "unethical,"
which
could
to
providers
against
i n f o r m a t i o n which
not
been
enable
changes
and
fees
of
care i n order
673
has
sufficiently
healthy
a l l o w i n g consumers
incent
t o compensate
affect
state that
them
to
f o r any
a
impose
perceived
income.
AMA
important
to
health
quality
i n c o m e s . A d d i t i o n a l l y ,
unnecessary
relates that
an
to
the
the
i s the
fee
that
stance
public
is that
competition-imposed
more
much o p p o s e d
information concerning
expect
'public interest'
information concerning
and
always
e x a m p l e , he
care
to
very
one
AMA
when
On
decades-old
w i t h new g r o u p s
The o l d g r o u p s :
The new g r o u p s :
accept
i t opposes
May
the
8,
its restrictive
relatively
offices.
doctors,
Medicine.
to reform
knowledge
doctors'
medical
the
i t to
i n medical
of
the
able
which
One
would
must
another
Physicians
1331,
the
simple
yet
keep
question
people
the
organization
Committee
PCRM
four-basic-food-group
outlook
for
recommended
categories
>
674
which r e f l e c t c u r r e n t d i e t a r y knowledge.
M e a t , D a i r y , V e g e t a b l e s , and
Fruits
W h o l e G r a i n s , L e g u m e s , F r u i t s , and V e g e t a b l e s
- 130-
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An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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Title
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[Political Power Structures Affecting Any National Health Care Reform Plan: Health care reform concepts versus Social and Economic Values] [binder] [2]
Creator
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Reproduction-Reference
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3/16/2015
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42-t-12092971-20060885F-Seg3-038-001-2015
12092971
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https://clinton.presidentiallibraries.us/files/original/7ea19070437b41adcaeb4ae42d090607.pdf
f4563ba128402aebd99b2419ee22ead4
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1982
OA/ID Number:
FolderlD:
Folder Title:
[Political Power Structures Affecting Any National Health Care Reform Plan: Health care reform
concepts versus Social and Economic Values] [binder] [1]
Stack:
Row:
Section:
Shelf:
Position:
s
56
2
3
1
�POLITICAL POWER STRUCTURES AFFECTING
ANY
NATIONAL HEALTH CARE REFORM PLAN
Health Care ReForm Concepts versus S o c i a l and Economic Values
�•
R A F T
POLITICAL POWER STRUCTURES AFFECTING
any
NATIONAL HEALTH CARE REFORM PROGRAM
Elissa
Ornato
Delaney
J a n u a r y 1932
�C O N T E N T S
Introduction
Types
Policy
One
1
o f ReForm
Plans
2
F o r m u l a t i o n and
Implementation
Group
3
7
PersonalResponsibility
1C
Writer's
1E
ReForm
Suggestions
Canada
24
Germany
35
Cost
Containment,
Reducing
Cost
InFlation
S.144G, S e n a t o r
Robert
S.1177, S e n a t o r
Jay R o c k e F e l l e r
S.1227, S e n a t o r s
Riegle,
and
39
Kerrey
Mitchell,
47
Kennedy,
RockeFeller
50
S.700, S e n a t o r
David
61
H.R.3205, Rep.
Dan
Durenberger
Rostenkowski
S u b s t a n c e Abuse
Federal
Health
Care
62
S3
Programs
5B
Medicare
67
The
Tax
and M e d i c a i d
Administration
72
Bush
Treatment
Federal
State
oF H e a l t h
Financial
Care
BeneFits
Suggestions
Administration
oF
F e d e r a l Programs
State
L i c e n s u r e oF
State
I n s u r a n c e Commissions
State
and L o c a l H e a l t h
Physicians
Care
Plans
75
80
35
107
110
91
Missouri
92
Oregon
95
Michigan
99
Denver
and S a l t
Lake
City
H e a l t h I n s u r a n c e as a S t a t e - R e g u l a t e d
Pub l i e U t i l i t y
101
112
�Insurance
Companies
Brief
^4
History
Insurance
I n d u s t r y Power
Financial
Base
Considerations
115
118
HMOs a n d PPs
121
Antitrust
122
Exemption
Termination,
and
Cost
Cancellation
Uninsurabi1ity
130
and R e s p o n s i b i l i t y S h i f t i n g
Wickline
Genetic
American
Non-renewal,
v. C a l i f o r n i a
Engineering
Medical
142
143
1S2
Association
174
H i s t o r y , O r g a n i z a t i o n a l T e n e t s and
National Health
Insurance
HealthAccess
America
18S
Phy s i c i a n s
American
131
Hospital
Association
200
Malpractice
212
Labor
218
Unions
Employers
Small
220
Business C o a l i t i o n s
E.R.I.S.A. a n d S e l f - I n s u r a n c e
225
229
Consumers
230
Attorneys
233
Additional
Special
Interest
Groups and
Organizations
237
Conclusion
245
Appendix
243
Bibliography
Notes
253
2SS
1 1
�POLITICAL
POWER STRUCTURES AFFECTING
ANY
NATIONAL HEALTH
Health
Care
CARE REFORM
ReForm C o n c e p t s v . S o c i a l
PLAN
and Economic
Values
INTRODUCTION
Law d o e s
affected
by s o c i e t y
believes,
not
i n a vacuum.
and e v e r y t h i n g
paper
will
a f f e c t change
intended
cover
that
i nour current
t o provide
indepth
health
already
provide
t o provide
which
care
will
that
a more p a n o r a m i c
problems
during
care
reform
discussion,
that
has f i n a l l y
must
eration,
tion.
politics
Special
be s t u d i e d
this
t o play
i n t e r e s t groups
is
care
t h epurpose
political
attempt
here
power
a generation
fact.
of
When
now h a v e , p o l i c i e s
At t h e p o i n t
a major
struggles
a t reform.
After
as t h e y
and r e f o r m e d .
begin
health
become an u n d i s p u t e d
point,
I t
of the currently existing
i snecessary.
a critical
be r e c o n s i d e r e d
view
and t h e v a r i o u s
o r may o c c u r
reach
Rather,
system.
that
on any a s p e c t
concerning
information.
Health
problems
i s
thinks,
structures
care
information
b e c a u s e many p u b l i c a t i o n s
health
society
some o f t h e p o w e r
covered
is
The l a w a f f e c t s a n d
and a c c o m p l i s h e s .
This
will
notexist
role
and t h e power
of reconsid-
i npolicy
they
forma-
wield
must
carefully.
A national
health
care
plan
-1-
will
be t e c h n i c a l l y
complex,
�will
and
be d i f f i c u l t
must
aided
to formulate
be f i s c a l l y
by l e g i s l a t i o n
t o avoid
responsible.
which
will
conflicting
Fiscal
alter
criteria,
viability
c a n be
some o r g a n i z a t i o n a l
power s t r u c t u r e s .
Any
affect
plan
will
not only
organizations,
not
be p o l i t i c a l l y
t h e bottom
but also
line
balance
because
and
of influence.
will
The p l a n
Power
of choice
will
t h e i n t e r e s t s o f many o r g a n i z a t i o n a l a n d
factions
while
adequate
health
assuring
care
i t will
f o r many c o r p o r a t i o n s
spheres
be e a s i l y r e l i n q u i s h e d .
volatile
the primary
f o r an e n t i r e
goal
have t o
corporate
of providing
population
a t reasonable
cost .
It
system
remains
will
reform,
t o be s e e n
d r i v e t h e economic
or vice
categories
c u r r e n t l y before
of plans,
Canadian-style
insurance
business,
of
care
health
Play
with
value
of health
care
be r e q u i r e d
would
contribution
toward
to fall
a r e opposed
basic
insure
health
employers
government
within
of types
insurers
of
of their
tax increases,
waiting
to either
subject
tend
three
plans.
1
government-administered
relieve
t o heavy
due t o l o n g
a government-sponsored
option
advocate
could
lead
o r Pay p l a n s
Congress
some o v e r l a p p i n g
plans
which
insurance
would
considerations
social
Plans.
Bills
health
the Nation's
versa.
o f Reform
Types
whether
health
and r a t i o n i n g
lists.^
by s m a l l
their
care
businesses
employees
plan.
who
o r pay
into
The 'Pay'
t o a 7- t o 9 - p e r c e n t - o f - p a y r a l l
support
-2-
of premiums.^
The
high
�Tha
Policy
Policy
Formulation
Agenda S e t t i n g
Phase
Opportunity
is created
3
Evolving
Policy
Window
when
"procasa
streams"
converge
--problems
- - p o 1 i c i es
--politics
Cycli
'olicy
• eve 1 opment
Phase
Implementation
Policy Operation
Phase
Legislative
E n a c t men t
Critical
Vari ables:
- o r g a n i z a t i on
-goals , o b j e c t i ves
- a p p r o p r i a t i ons
-standards
Policy
Reactive
>
ModiFication
Phase
changes
--amend
- - e l i m i nate
--reformulate
(P.A. P a u l - S h a h e e n , " O v e r l o o k e d C o n n e c t i o n s :
P o l i c y D e v e l o p m e n t and I m p l e m e n t a t i o n
inStat-Local Relations"
15 J o u r n a l o f H e a l t h P o l i t i c s , P o l i c y a n d Law 8 3 3 , a t 8 3 4
a n d 8 3 5 , W i n t e r 1 9 9 0 . M o d e l d e v e l o p e d by K i n g d o n , 1 9 8 4 .
�number
of businesses
overwhelm
the
which
might
opt
For
the
'Pay'
plan
could
system.
Insurance
Market
ReForm
plans
"...may h a v e
the
best
oF
plan
4
political
would
into
chance
oF
r e q u i r e the
one
lower
insurance
or
those
America's
issues
has
and
prolong
the
picture
oF
oF
will
be
base
For
a new,
The
components
illustrates
interactive,
linking
the
The
policy
and
policy
eFFective
Further
viability
Major
the
FiFty
high-risk
h e a l t h care
years.
addressed
at the
and
the
and
can
solved
by
to adopt.
To
merely
and
an
s e l e c t e d reForm
will
and
A l l the
outset will
provide
process
( F a c i n g page)
process
which
oF
policy-making
model
Formulation
analysis.
reFusing
plan
a strong
system.
as
evolutionary."
continuum
oF
oF
conditions.
reForm
we 1 1 - s t r u c t u r e d
S
oFFering
current conglomeration,
u n a s c e r t a i n a b 1e.
Paul-Shaheen.
policies
companies
From
the n a t i o n decides
problems
the
oF
the
dealing with
m u s t be
plan
the
oF
the past
us
a l l the
agony
insurance
prohibited
pre-existing
over
Facing
to solve
be
type
Implementation.
h e a l t h reForm
accurate
many s m a l l
terminating
with
evolved
neglect
by
or
This
to Facilitate
c u r r e n t method
currently
whatever
i n order
revoking
Formulation
insurance
oF
A l l i n s u r e r s would
or
individuals
soon..."
Formation
l a r g e group
rates.
Policy
passage
7
one
that
is
Additionally,
"dynamic,
Paul-Shaheen
used
as
described
succinctly
implementation
be
are
explains
creates
a Framework
administrative
and
^
that
an
For
political
8
interaction
and
power
shifting
become m o r e e v i d e n t .
-3-
Too,
the
�model
i s an
aid
to
implementation,
understanding
i t is far
that
easier
to
" I n the
defer
world
the
of
program
proposed
than
to
g
dismantle
the
Using
three
existing."
the
process
model,
the
streams:
Agenda-Setting
problems,
Phase
i s composed
p o l i c i e s , and
1
politics.
P r o b l e m s " a d v a n c e t o t h e p o l i t i c a l f o r e f r o n t i n two
a.
"through the s y s t e m a t i c monitoring of
key
i n d i c a t o r s " w h e r e t h o s e key i n d i c a t o r s m i g h t
be t h e d e v e l o p m e n t o f a p a t t e r n o f u n u s u a l
b u t r e c u r r i n g e v e n t s ; i . e . , t h e AIDS e p i d e m i c
has t r i g g e r e d a demand f r o m t h e p u b l i c f o r
t r e a t m e n t and
cure.
b.
of
0
ways:"
" f o c u s i n g e v e n t s " s u c h as n a t u r a l d i s a s t e r s .
When e v e n t s r e c e i v e w i d e s p r e a d m e d i a c o v e r a g e ,
t h e p u b l i c i s s p u r r e d t o demand a c t i o n . ' ' ' '
Policy
analysis,
Development
includes
generation
of
ideas,
research,
1
and
reformulation. ^
P o l i t i cs
includes
plus
the
opinion
polls,
"the
special
i n t e r e s t groups,
mood o f
the
public
demands, p o s i t i o n s ,
key
changes
as
and
reflected
actions
in
of
in administrations,
and
1 3
election
results."
Each
whether
of
a window
facilitate
primary
the
of
and
Once
program,
of
will
play
a part
opportunity
will
occur
are
and
constituents
legislation
to
are
the
and
the
government
formulation
variables
factors
authoring
variables
branches
groups
those
enactment
roles
their
goals
and
-A-
will
legislation.
executive
a
this
assigned
with
and
shifts
point,
to
objectives,
"The
legislative
special
legislative
activity
At
determining
which
interface
i s enacted,
organizations
program's
the
in developing
implementation.
the
of
of
in
proposal."
from
"(t)he
carry
out
program
interest
1 4
policy
critical
the
�appropriations,
and t h e r u l e s ,
standards,
and
policies
15
established
t o guide
Policy
to
tion
The
"covers
internal
design.
implementation
1
ment
nation
Rashi
1 7
Fein
coverage
merely
and b e n e f i t s ,
review'
cntrol
pressures
solution
with
language.
policy
parts
of t h e h e a l t h care
broad
agenda
some
that
'gains*
sector, the historical
Without
t h e complete
and l o c a l
e m p h a s i s on
t o expand
Similarly,...
lead)
access.
f o r presumed
to control
program. . .the
costs.
various
are i n t e r r e l a t e d . ..Without
o f compromise
that
o f t h e many p a r t i c i p a n t s
gridlock
and c o n t i n u e d
governments
to control the
be c r i t i c i z e d
the kinds
f o r each
leave the
p r o t e c t i o n ... ( w o u 1 d
a comprehensive
enables
would
and p r o v i d e r s .
controls
sector
Depart-
t h e problems of
s e r v i c e s t o a l l and/or
develop
School's
[ n e c e s s i t a t i n g ) cutbacks
without insurance
we m u s t
state,
legisla-
during formulation of
increased
patients
t o ease c o s t
to provide
Medical
and s t r o n g e r e f f o r t s
Thus,
health
formal
the original
one o f t h e g o a l s
Furthermore, . . . p r o v i d e r s would
provide
affect the
statutory
solving
a t t h e same t i m e ,
of individual
expenditure
advocates
an " u n s t a b l e
'utilization
failure
which
initiate
the original
of t h e Harvard
Attaining
with
behavior
may
i n response
6
and c o s t
reform.
changes adopted
p h a s e s may m o d i f y
of S o c i a l Medicine
access
stages."
and e x t e r n a l ,
Others
t o amend o r e l i m i n a t e
•r.
to
both
policy
intent! "
in
Modification
conditions,
original
the implementation
will
might
i n the
18
continue."
support
and c o r p o r a t e
a
and
of federal,
organizational
�interest
process
groups, the p o l i c y
o f any
national
Formulation
health
and
c a r e reForm
implementation
program
will
not
succeed.
The
primary
the
players
Federal
i n the process w i l l
government
State
governments
Local
governments
the
Insurance Industry
the
American
Medical
the
American
Hospital
•Labor
Association
Association
Unions
Employers,
problems
both
Consumers,
State
the r e c i p i e n t s
and
local
during
implementation
with
downturns,
tax revenues
oFten
when C o n g r e s s
approved
It
Fall
elects
so
that
subject
insurance
changes,
dollars
oF
health
care.
will
health
or l o c a l
cost
Face
care
Fiscal
program.
economic
Additionally,
entitlement
cutting
not to appropriate
necessary
oF
small
any
prey t o heavy
be
major
oF
regional
Fall.
will
The
and
Funds
i n such
For
times,
already-
programs.
constantly
use
national,
program
care
large
governmental e n t i t i e s
When F a c e d
programs
be:
one
to thoughtFully
i t s Fiscal
integrity
to the vagaries
industry
the least
universal
oF
claim
in administrative
will
be
oF
required
-S-
be
i n order
expenses.
will
economic
which w i l l
Form
Formulate a
not
be
Fluctuation.
to
undergo
a changeover
t o save
There
must
health
to the
millions
be
oF
legislation
�prohibiting
expenses,
client
prohibiting
professional
population
One
one
group.
medical
would
It
medical
physician's
the e n t i r e
nation's
group.
each
person
component
be
community
which
one
reflect
and
be
another
there
by
would
insurance
into
be
insured
group,
be
need
f o r Basic
n o t be
state
income
were r e q u i r e d
no
necessary
because
to f i l l
insurance.
Changing
f r o m one
with
person
pending
a
Basic
an
the
burdens
national
group.
a national
productive
scale.
to continue
arbitrary
high-risk
level.
groups,
I f a l l were
to insure
Pre-existing
history
conditions
i n s u r a n c e company
employers
would
.
•
f o r Basic
out a medical
when c h a n g i n g
each
of
under
segmented,
status,
or
considered
c o n s i d e r e d as
the e n t i r e
small,
be
goals
i n s u r a n c e , on
sex,
adequately
population
national
rated
age,
would
irrelevant.
a different
purchase
or
to
moving
his
own
policy.
Insurers
employees
render
will
borne
insurers
when a p p l y i n g
would
U.S.
employment
location,
group
coverage,
form
n o t been
s h o u l d be
o f one
individuals
has
i s not e c o n o m i c a l l y or s o c i a l l y
geographic
of
that
of the current
everyone
separate individuals
groups
to
i s that
high-risk
This
the e n t i r e
B e c a u s e one
plan,
individual
in
one
of excessive
of attending
requiring
of reform which
is that
legislation
to
and
c o n s i d e r e d as
aspect
considered
of
substitution
judgment,
be
because
Group.
An
as
desertion
claim
t o be
the plan
t h e need
insured
economical
to
impose minimums
within
For
a particular
them
-7-
to provide.
on
the
group
The
number
i n order to
concept
of
�Government expenditures for health as a percent of total government expenditures: 1965-97
Feae'ai
Slate ano local
25 -
2C -
i
is
a
10 -
1955
1985
1995
Years
SOURCE rieann Care rmancmg Aommistration. Ottice 01 :ne Actua'v
1
Daia trorr. T.e O^ice o' Natronai Hea;: - Statistics
13
Itallh C a r t Financini; Revievt Kail I W I
National health expenditures aggregate and per capita amounts, percent distribution, and average
annual percent growth, by source of funds: Selected years 1965-2000
Projectec
Item
1965
1975
1980
1985
1989
Naiiona: neaim exoenditures
Private
PuDilC
Feaera
Slate and loca:
S41.6
31.3
10.3
4.8
5 5
Si 32.9
77.6
55 1
36 4
16.7
S249 1
143.9
105.2
72.0
33.2
S420.1
245.0
175 1
123 6
51.5
S504 1
350.9
253.3
174 4
78.8
U.S. poouiation'
204.0
224.7
235.3
247.2
257.0
1990
1991
1992
1995
2000
S736.2
421 i
317 1
215 7
101.4
S809.0
457 4
351.6
236.6
112.8
Si.072.7
592.2
480.5
324.6
155.7
Si.615.9
859 4
756.5
517 6
236 8
262.1
264.6
272.0
282.9
5.650
6.045
7.284
9.865
2.817
1.607
1.210
823
387
3.057
1.729
1.329
902
426
3.944
2.176
1.767
1.194
572
5.712
3.035
2.674
1.830
844
100 0
57.0
43 0
29.2
13.7
100.0
56 5
43.5
29.5
13.9
100.0
55.2
44.6
30.3
14.5
100.0
53.2
46.8
32 0
14.8
13.4
14 7
16.4
9.9
9.0
11.0
10.8
1 1.3
0.9
6.4
8.5
7.7
9 5
9.8
8.9
0.8
6.3
Amount in billions
S670.9
389.3
281.6
192.2
89.4
Number m millions
259.6
Amount in billions
Gross nalionai oroauc;
705
1.598
2.732
4.015
5.201
5 463
Per capita amount
Nationa neailh expenditures
Private
Public
Federal
State and locai
204
154
50
24
27
592
346
245
162
83
1.059
612
447
306
141
1.699
991
708
500
206
2.351
1.365
985
679
307
National health expenditures
Private
Publi:
Feaerai
State and local
100.0
75.3
24.7
11.6
13.2
100.0
58.5
41.5
27.4
14.1
100.0
57.8
42.2
28.9
13.3
100.0
58.3
41.7
29.4
12.3
100.0
58.1
41.9
28.9
13.1
vJationai health expenditures
5.9
8.3
9.1
10.5
2.585
1.500
1.085
741
344
Percent distribution
100.0
58.0
42.0
28.7
13.3
Percent of gross national proauct
11.6
12.3
13.1
Average annual percent growth trom previous year shown
National health expenditures
Private
Public
Feaerai
State and local
J.S. population'
Sross national product
—
—
—
—
—
—
—
12.3
9.5
18.3
22.4
13.1
1.0
8.5
13.4
13.1
13.8
14.6
12.1
0.9
11.3
11.0
11.2
10.7
11.4
9.2
1.0
8.0
9.5
9.4
9.7
9.0
11.3
1.0
67
11.1
11.0
11.2
10.2
13.3
1.0
5.0
10.0
8.2
12.6
12.2
13.4
1.0
3.4
9.6
8.6
10.9
10.7
11.3
1.0
7.0
July 1 Social Security area poouialion estimaies.
'iOTE: Columns may not add to totals because ot rounding
SOURCE Heatlh Care Financing Administration. Office ot me Actuary Data trom tne Office ot National Health Statistics
Health Carr Financing Review Tall 199r\„iim
�considering
solve
the entire
national
population
as one g r o u p
would
t h e problems o f :
..
t h e a b o v e - s t a t e d minimum
the
..
smal1-business
t h e unemployed
of
..
paying
percentage requirement;
employer
who h a s t o o f e w
employees;
who a r e o r a r e n o t f i n a n c i a l l y
capable
premiums;
t h e s e l f - e m p l o y e d who p a y h i g h e r - t h a n - g r o u p - r a t e
premiums; and,
..
t h e segmented
different
The
by
the
Basic
insure
theory
which
benefit
One
promote
services
establish
which
Employers
find
i t
necessary
blocks of persons,
method
Consumers w o u l d
representative
and s u p p l e m e n t a r y t o
may w a n t
i n s u r a n c e p l a n s as p e r k s
of services
to protect
health
be b a s e d
plan
would
n o t on t h e
on t h e m e d i c a l
purposes,
insurers
g e o g r a p h i c a l areas or
wards m i g h t
f o rdividing
their
f o r employees.
but instead
to define
t h e n have
to offer
benefit
and would
voting
purchased
i s being considered to
I f ,f o radministrative
non-discriminatory
holders.
not apply t o insurance
who make up t h e g r o u p ,
covered.
still
plan
related to
groups n a t i o n w i d e .
n a t i o n w i d e and a B a s i c
uniformity
individuals
problems
be i n a d d i t i o n
nation.
health
group
need
would
health
the entire
supplemental
would
and d i s p a r a t e
one-group
individuals
administrative
prove
t o be a
blocks of policy
a specific
interests
legislative
i n dealing
with
insurers .
Insurance
of
medical
those
policies
bills.
premiums
are a form
Everyone
of financial
pays h i g h
g e t h i g h e r each
year
-8-
monthly
because
a i d f o r payment
premiums, and
many
people
overuse
�insurance
For b i l l s
insurance,
For
which
c a n and s h o u l d
and t h e u n i n s u r e d .
would
pay For
scale
oF a b i l i t y
Basic
health
insurance
t h e advantage
spread
the cost
across
the entire
become
involved i n insuring
medical
an
oF p r e m i u m s
care
W i t h i n each
because
while
period
, the situation
itselF
t h e Following year.
The
terms
become
term
by
'pre-existing
that
would
income s c a l e ,
o f premiums
share
portion
Person
public
sector
The
just
We
year
between
costs
one-group
incapable
page
plan
rates
year
aFter
risk'
burden,
year.
should
insurance.
The
t o and
limited
t o pay premiums.
premiums would
which
oF b e a r i n g
reverse
reality.
unable
premium
no
one-year
t h e same
be d i m i n i s h e d
be l i m i t e d t o
the individual
himself.
The
infor-
indicates the current dispersion of
p u b l i c and p r i v a t e
should
or
B may r e q u i r e
completely
become a
f o r those
of those
high-risk
d u r i n g t h e same
must each b e a r
would
individuals
n o t have t o
and P e r s o n
as e a s i l y
should
would
A may r e q u i r e v i r t u a l l y
care
of the monthly
on t h e f a c i n g
expenditures
sliding
t h e premium
t o a n y d i s c u s s i o n oF h e a l t h
be F i n a n c i a l l y
mation
to a
nationwide
c o n d i t i o n s ' and ' h i g h
government's r o l e
government's
only
care
American
and h i g h - r i s k
t h e same b e n e F i t s
'portable insurance'
t h e payment
The
may
and e n j o y
irrelevant
The
according
o r c a r i n g For e i t h e r
e x o r b i t a n t a m o u n t oF m e d i c a l
same r i s k ,
each
Government would
d u r i n g one c a l e n d a r
the
reform,
oF o n e g r o u p
For poor
population.
individuals.
be e q u a l
With
oF
t o pay.
Additionally,
would
without
and i n s u r e d p a t i e n t s s u b s i d i z e t h e c o s t
t h e poor
poor
be h a n d l e d
sectors.
Under
reform,
decrease.
i s capable
-9-
of r e l i e v i n g
t h e government
�of
bearing
too great
An o v e r b u r d e n e d
population
socially
with taxes
the process
Personal
since
President
include
personal
Johnson
limit
care
program.
overburden i t s
services.
t o Formulate
t o solve
I t
a plan
a n d manage
initiated
government
and M e d i c a i d ,
each
is
which
will
t h e problem.
reducing
smoking.
continued
h a s t h e p u b l i c become
F a t and s a l t
alcohol
I n these
groups
nationwide.
and F i t n e s s
oF a n d r e s p o n s i b i l i t y
conduct w i l l
to
a i d increased,
has t h e a b i l i t y
lower
Security
For c a r i n g For p a r t i c u l a r
years
own h e a l t h
Foods w i t h
content,
eliminating
Five
Social
involvement
government has
decreased
individual
on h i s / h e r
control
Roosevelt
expanded
i n the past
eating
this
inevitably,
I n r e t r o s p e c t , as g o v e r n m e n t
that
Fiber
itselF
responsibility
Only
are
wiser
i t s responsibility
people.
impact
will,
or severely
President
Medicare
broadening
aware
i n a national health
Responsibility.
Ever
oF
government
and e c o n o m i c a l l y
require
and
a role
t o have
levels.
ways, t h e y
For t h e i r
a meaningFul
Many
content,
consumption
more
people
greater
and c u t t i n g
back o r
are assuming
own w e l l
have p o s i t i v e
impacts
on F u t u r e
the traditional
value
oF p e r s o n a l
greater
being,
hie a 1 t h
and
care
costs .
Rekindling
in
our c u l t u r e
political
values
medical
The
would
have
a positive
responsibility.
can have
The r e g e n e r a t i o n
a s a l u t a r y impact
malpractice,
re-establishment
health
eFFect
cost
oF s o c i a l
on c o r p o r a t e
of strong
on e x c e s s i v e
containment,
responsibility
- 10-
responsibility
and
social
litigation,
and s u b s t a n c e
can spur
us
abuse
along
�the
road
to a
'kinder, gentler
as d e t e r m i n a t i v e o f q u a l i t y
health
of l i f e
Social values
are
as a r e e c o n o m i c and
issues.
Health
hospitals,
care
i s a social
against
the risks
insurance
of health
contract,
i t i s a contract
attendant
moral
witness
service.
I t i s provided
p h y s i c i a n s , and o t h e r c a r e g i v e r s .
made a c c e s s i b l e by
companies.
care
costs
considerations.
The
has been
beneficial.
to protect
decade
The
interest
past
prevailing
the insurance
decade
a
legal
with
has
been
c o n t r a c t s whenever
policy
industry.
o f excess has y i e l d e d
people
i s not merely
i n the public
by
But i t i s a l l
Insuring
to the dispatching of insurance
economically
1980s
nation.'
i n the
Now
that
U.S.
the
t o t h e 1990s d e c a d e o f
19
decency,
we
are f i n a l l y
seeing
disappointing
corporate conduct
Congressional
legislation.
but
may
industry
During
premiums
to
this
i n t h e form
of
pending
Health
would
circumstances
refusing
contract,
shift
reform
the protections
of health
care
n e g o t i a t e on
that
insurance
are greater than
t o honor
their
unexpected
abrogation.
As
of
risk,
assessing
may
i n that
include,
policy
of
protectionism.
preserve
the risk
costs
care
t h e 1980s, c o n s u m e r s had e x p e c t e d
economically
that
to
not, a status-quo-a 1tering
insurance
against
challenges
they
that
had
their
own.
Yet, i t i s under
these
companies have been p r o c l a i m i n g
expected
and, t h e r e f o r e ,
obligations.
expenses are not a v i a b l e
they
purchased
e x p e n s e s t o o g r e a t f o r them
contractual
insurance
increased
have
-11-
a reduced
I n any
reason f o r
companies are experts
should
they are
i n the
business
expectation of
�being
relieved
While
caps
question
the
with
any
the
their
i t is true
monetary
generally
of
on
cost
and
such
massive
that
i n s u r e r s should
their
financial
as
bills.
be
hospitals
policies
will
ne*. e r
them
I t i s under
on
to confront
susceptible to
circumstances
t o i n s u r s . as
as
not
lives
have
such
insurance
do
are
(2) everyone
render
pressured
are,
insurance
consumers
savior
from
are
barred
refuse
only
homeowners
prohibited
to
issue
from
i n most cases,
from
prohibited
I n Massachusetts .
from
insurance
doing
automobile
insurance
picking
prohibited
c o m p a n i e s must b s
dumping/desertion.
they
any
business
policies
policies.
and
from
i n the
but
state i f
prefer
to
issue
I n s u r s r s must
which
choosing
be
they
persons
will
to insure.
Consider
public
the
utilities
service.
measures
A l l are
of
need
only
refer
carry
as
paid
security
for security
must
modern
such
upon
owner
would
sole reliance
dumping,
companies
deign
which
and
they
place
most c c n s u m e r s
(1) insurance
that
policies
ruin.
Just
client
insurance
adhesion,
hope
medical
most
contract.
reimbursement,
c o n t r a c t s of
health situation
patient
that
caps because
belief
proclaim
legal/social
by
fire
gas,
by
relied
consumers.
consumers.
to the
state
insurance
before
upon
Any
who
will
- 1 2-
telephone
~or
different
i s also
issue
a
that
-.-.at e v e r y
t o r e g : £ter a
against
by
=nd
question
requirements
insurance
provided
Insura.~~e
i n order
they
l i ' s
electricity,
f o r and
Banks r e q u i r e homeowners
devastating
n e c e s s i t i e s of
rbe
relied
premise
automobile
vehicle.
possibility
Tvcrtgage
loan.
of
�Health
insurance
Many
to life
s t a t e s have n e g l e c t e d
consumers
i n dealing with
motivations
of state
to
determine
on
the benefits
extent
i s as n e c e s s a r y
that
how
insurers.
insurance
deeply
their
responsibility
be
t h e commissions
by i n s u r e r s - - o f t t i m e s
t h e needs o f t h e g e n e r a l
public
utility.
to
The p e r f o r m a n c e
commissions must
dependent
bestowed
as a n y p u b l i c
and
questioned
have
t o such
have
become
an
n o t been
considered.
There
impose
are
of
i s no q u e s t i o n
a primary
legal
risk
gamblers
to their
benefits.
however,
duty
that
and p u r c h a s e
are purchasing
and
their
They
T h o s e who p u r c h a s e
against risk.
concerning
t o shareholders.
investment.
them
laws
shares
knowing
bet their
to
may
be n e c e s s a r y
t h e 'goods'
and
bad b a i t h
health
produce
responsibility
child
to
Manufacturers
i s held
perceived
four
wheels
could
t h e laws
a r e n o t so o u t r a g e o u s l y
do n o t o p e r a t e
defect.
merely
on
perceived
to protect
liable
have
of product
industry.
foreign
t o issues of
to their
when p r o d u c t s ;
should
or are expected
in tort
f o r t h e damage
because
their
n o t be
product
p a r t s which
on t h e m .
perform.
- 1 3-
They
immune
does
they
t o , the*
c a u s e d by
from
n o t r u n on
a r e so s m a l l
have
liability
Negligence
t h e same d u t y
I n s u r e r s should
choke
f o r investment
However,
as t h e y
o r does n o t have
easily
reasons
t h e odds
policies,
i s meant
by t h e i n s u r a n c e
as i n s u r e r s d o .
manufacturer
the
t o apply
produced
insurance.
shareholders
are opposite
money
company
which
shareholders
purchase.
It
These
However,
insurance
a product
corporations
that
a comparable
a
duty
�Physicians
incongruous
to
sufficiently
sever
it.
have a d u t y
contend
into
to
that
this
relationship
as
denying
a physician
to
prescribe
treatment.
be
tolerated
i f e f f e c t e d by
of
rights
As
widespread
rationing
to
and
into
based
Insurers
Insurers'
treatment
of
susceptible
has
not
health
have
caused
procedures
This
attempts
m u s t be
of
the
the
Yet
his
would
one
situation
i t is a
to the
duty
not
of
of
dictator
i n making
of
to
patient,
such
pay
ethical
f o r care
thus
secondary
damage by
effect
of
effects
expanding
do
i t s root
begin
any
the
is
the
physicians
provider
spiraling
by
use
of
itself,
cost, o f
malpractice
the
the
the
harm."
Malpractice,
health
to reduce
- 14-
no
suits
tests
further
highly detrimental
Therefore,
by
takes
is
moral c o n s t r a i n t s .
protection against
costs.
have
interest
which
alter
of
providers
more
physician
may
already
is proving
ways t o
whose
and
rendering
a f f e c t e d the
far
his decision,
for malpractice.
the
at
least,
of
p a t i e n t to
proposition, "First,
devoid
a method
addressed
out
possibility
the
to minimize
several
patients.
the
very
greater
secondary
same
position
i s becoming,
the
a suit
But
as
The
payor
appreciably
care.
but
2 0
third-party
refusal
the
to
government.
At
operate
i s the
to carry
the
on
effectively
f o r care
by
account
ethically
to
themselves
insurer's position
against
detrimental
economic.
individual
as
opportunity
not,
rail
their
imposed
insert
i t is
care.
a n a t i o n , we
care
so
t o pay
The
should
to health
rationing
purely
payor
the
p a t i e n t s and
i n s u r e r s may
Insurers' refusal
third-party
their
lawsuits.
to
malpractice
reform
malpractice
and
plan.
any
problem
One
is to t r a n s f e r
�the
policing
The
function.
power
o f t h e American
mammoth p r o p o r t i o n s .
its
se1f-po1icing
physicians'
decline.
has
n o t been
will
wrested
carried
from
With
to that
professional
conduct
professional
structure,
ability
care
there
original
will not
the policing
Because
reform,
the function
t o a body
that
which
p o w e r m u s t be
incorrectly believes
require
review,
state
with
control
i t has a
federal
of health-care-
control
and a c c r e d i t a t i o n .
licensing
will
t o move h i s p r a c t i c e
practice
neglect of
2 1
licensure
federal
body.
has reached
policing of
whether
i t m u s t be moved
which
should
adequate
be d e b a t e d
health
function.
of studied
of malpractice
t o another
out,
t h e body
Legislation
care
Without
the specter
be moved
perform.
right
duties.
conduct,
will
Association
I t has a h i s t o r y
I t c a n no l o n g e r
function
Medical
remove
from
to a different
when h i s c o n d u c t
With
health
that
new
a physician the
state
consist
that
Professional
of a certain
number b e i n g
consumers
and a c a d e m i c i a n s
who a r e n o t
of a state
Reform
It
should
50 p e r c e n t o f
decision
suspend
Board
in his
o f members, w i t h
i n the health
agency
Review
wanting
number
employed
federal
Conduct
found
t o resume
state.
Each s t a t e ' s
has been
of
would
care
field,
t o remove
or a r e l a t e d
a physician
be n o t i f i e d
and t h a t
industry.
from
practice, the
body
would
revoke or
licensure.
Suggestions.
may be h e l p f u l
f o r t h e reader
- 1 5-
Upon
t o know
the position
�advocated
by t h i s
Consequently,
are
writer
concerning
the following
health care
suggested
policies
reform.
and
rationale
stated.
Insurance
Companies.
a.
provide Basic
Would
minimum
benefit
insurance
coverage t o every American according t o f e d e r a l 1 e g i s J a t i o n .
A i l B a s i c p o l i c i e s w o u l d c o v e r c a t a s t r o p h i c and long-term i l l n e s s e s .
b.
Would
health
not
insurance.
Health
be c o n s i d e r e d
c.
from
Would
government
would
be c a l c u l a t e d
than
risks.
experience
with
would
premium
checks
section.
negotiation
o f premiums.
on n a t i o n w i d e
or industry,
rated,
status
individual.
or quarterly
based
f o r Basic
risk
or geographical
would
be c o m m u n i t y
the entire
factors,
area
rated
nation being
rather
d e f i n e d as
commun i t y .
e
-
which
Will
would
be r e p r e s e n t e d
study,
health
care
reduce
incidents
f.
plans
cost
May
which
marketp1
control,
judgment
provide
will
bear
to reimburse
a treating
education
boards
concerning
of providers to
health care
a t premium
insurance
r a t e s s e t by t h e
t o achieve
Insurers
dinosauers
They
will
that
be
their
judgment.
are i n t h e business
a r e t h e most
logical
to
organizational
of providing
accessibility
individual.
the benefit
i n the twentieth
a Canadian-type
tightening
companies
t h e d e s i r e d goal
have
not.
would
p h y s i c i a n ' s medical
They
f o r every
will
f o r treatment
n o t be p e r m i t t e d t o s u b s t i t u t e
Insurance
against risk.
h e a l t h care
a belt
including
Insurers will
over
structure
under
a n d make r e c o m m e n d a t i o n s
any s u p p l e m e n t a l
t h e market
Rationale.
become
and s t a t e
of malpractice.
Refusal
permitted.
insure
analyze,
on t h e f e d e r a l
ace.
g.
ing.
any
i n annual
The p r e m i u m s
apply
and employment
premium
participate
n o t on i n d i v i d u a l ,
presumed
to
insuring
Would
Premiums
and
when
history
receive monthly
the federal
d.
the
be r e q u i r e d t o i n s u r e a l l who
plan--but
they
will
century--as
they
would
will
the entire
n o t be a l o n e ;
o f knowing
experience
nation will
become
a cut in profits,
also
in profit reduction.
- 1G-
not
be
experienc-
�•F
health
from
primary
care
concern,
services of
p h y s i c i a n s over
diagnoses
i n s u r e r s cannot
the
future.
treatments
made i n a b s e n t i a .
has
contributed
for
consumers
Federal
a.
to the
and
and
State
Upon r e c e i p t
employers,
the
provided
misplaced
current crumbling
m u s t be
allowed
to define
They have w r e s t e d
t o be
This
be
based
control
on
management o f
state
of health
care
care
terminated.
Governments.
of premiums from
I.R.S. p r e m i u m
individual's
premium
are
individuals
s e c t i o n would
b.
Monthly
disperse
having
one
unable
the
quarterly,
premium
p r e m i u m s due
c.
be
or
from
the
s u b s i d i z e d by
the
that
the
federal
premium
agency
insurer
represented
would
as
subscribers.
who
full
premiums
each
t o each
check
Individuals
t o pay
including
credit
contributed.
employer
account,
and
are
unemployed
premium
or
government
any
and/or
part
f o r the
of
financially
the
premium,
will
unaffordable portion
of
premiurn.
d.
An
independent,
representative,
Board
the
premium
insurance
..negotiate
providers
Would
provision
of
geographical
but
with representatives
industry;
procedures
with
annually;
premiums
e.
rates annually
r a t e s f o r s e r v i c e s and
..negotiate
to
non-political,
would:
..negotiate
from
non-profit,
rates annually
f o r Basic
perform
expensive
area.
health
contributions
insurance.
certificate
technology
Close
f o r employer
of
need
and
reviews
concerning
services within
monitoring to avoid
a
unnecessary
duplication.
f.
Federal
physician
Forty
review,
percent
and
State
and
o f each
board
companies,
the
members s h o u l d
no
way
i n f l u e n c e d by
g.
any
Social security
wages/salaries
to
and
f o r the
would
control
cost
insurance
board
boards
of
should
i n c r e a s i n g percentages
officials.
of
the
contributions
entire
year
review,
health care p r o v i d e r s .
knowledgeable
segment
facility
c o n s i s t of p r o v i d e r s ,
government
be
oversee
with
f o r higher
Sixty
consumers
h e a l t h care
should
be
who
are
of
in
industry.
deducted
deductions
salaried
percent
set
persons.
From
according
�Rationale.
Government
should
not
be
business.
Government's r o l e
in insuring
unemployed
should
a minimum
premiums.
For
perform
be
kept
other
to
consumers,
the
role
as
Health
Care
Would
be
pose a c o n f l i c t
investment
These
own
the
by
poor
merely
government
precluded
of
from
engaging
and
the
subsidizing
may
merely
premiums.
interest;
i n medical
investment
for
insurance
Providers.
a.
conduit
the
i n the
i.e., physician
technology
activities,
patients for testing
i n businesses
or
care,
or
laboratory testing
to which
and
ownership
physicians
are
which
services.
guide
commonly
their
referred
to
as
'self-referral.'
Such
if
the
enter
physicians
friend's
and
into
so
b.
schools.
would
no
each
physician
business.
and
would
taught
longer
care
to
increase
for
overusage
utilization
of
with a l l other
Physicians
medical
because--even
informal networking
to monitor
courses
permitted
physicians
that
medical
be
therefore increasing profits),
investment
impossible
not
p r a c t i c e were m o n i t o r e d
p r e s c r i b i n g unnecessary
business
could
should
i n v e s t o r ' s medical
[i.e.,
the
investment
only
Course
meet
be
the
would
Over
costs
agreements
steer
p a t i e n t s to
utilization
would
be
out
would
of
work
the
premises
which
annual
in
of
i s taught
be
control.
required to e n r o l l
on
a
annual
recognized
in resort
settings
s t a t e l i c e n s u r e renewal
require-
ments .
Unnecessary
medicine
by
possibility
required
and
of
physicians
of
i n order
a malpractice
medical
course
intellectually
Improved
procedures
work
importance
of
to
performed
avoid
suit.
would
the
increase
as
only
be
d i l i g e n c e i n the
a l l annually-
provided
in a
classroom
o p p o r t u n i t i e s and
physicians'
defensive
all-too-real
Therefore,
challenging university
continuing education
l i c e n s u r e should
are
p r a c t i c e of
setting.
annual
awareness
serious
of
control
the
medicine.
Emp1oyers.
a.
time
Would c o l l e c t
and
full-time
premiums
being
from
identically
- 18-
a l l employees,
administered.
with
part-
�b.
to
an
Wbuld
income
Wbuld
premium
Federally-negotiated,
exacted
income.
Figure
A lower
From s m a l l e r
a l l premium
according
percentage
businesses.
F u n d s t o t h e I . R . S . 's
section.
Finding
and
the cost
become
w o u l d be
transFer
Rationale.
ing
employee's premiums
to the employer's taxable
taxable
c.
oF
toward
annually-established,
according
oF
contribute
E m p l o y e r s would be r e l i e v e d
negotiating
oF
selF-insuring.
insurers.
a larger
negotiated
rate
oF
percentage
Additionally,
coverage
which
required
by
oF
or bear the F u l l
providing
Federal
with
cost
insurers
supplemental
than
corporate
oFFer
or
bear-
n o t have t o
oF p r e m i u m s
job-enhancing
responsibility
be p e r m i t t e d
t h e premium
e m p l o y e r s may
w o u l d be
the
Employers should
Employers would s t i l l
contribute
as a m e t h o d
group p o l i c i e s
oF
to
the
For
Federally
employees
beneFits.
or p r o v i d e
to the Basic
insurance
coverage
law.
Consumer/Patients.
a.
health
Would
care
b.
just
Would
Freedom
be a b l e
must
t o choose
decision
than
be
able
t h e Freedom
and
satisFaction
ProoF
s h o w n on
coverage
will
which
case
d.
be
order
and
that
income
be
rated.
Family
can
Basic
Fairly
Factors
soup
according
which
will
Failure
important
to
quality,
produce
insurance
rates
- 13-
tax return,
be
be
premiums.
a
each
would
level
in
individual
t o pay.
diFFerent
2 2
certain
t o income
which
in
insurance
i s below
expected
should
the
care
set according
reasonably
required
t o purchase
health
coverage at prices
be
society
insurance
would s u b s i d i z e
income
oF
to maintain
t h e income
whose
The
or a slab
i s i n Force w i l l
For B a s i c
would be
premium/deduct ible/copayment
physician.
i s a Far more
Inability
through
those
and
own
carrier
consumption i n a Free market
government
premiums
to provide
t o choose
i n penalty.
For
their
insurance
a c a n oF
tax returns.
premiums
own
physicians
insurance
discerned
Insurance
level,
oF
health
the Federal
community
minimum
price--three
result
co.verage w i l l
and
t o choose
at the point
be
to purchase Basic
their
t o choose
the r i g h t
reliability,
to
statute
t o choose
insurers
Consumers have
c.
by
insurance.
as p e o p l e
meat.
be r e q u i r e d
For
The
each
�$1,000 o f
From
income
For
$30-50,000,
$ 2 , 0 0 0 oF
increase
e.
t h e p/d/c
income.
For
every
t o pay
subsidized
F.
by
rates
$ 1 0 , 0 0 0 oF
the
can
employed,
..iF
the
h.
basic
Not
i.
in
care
and
the
aFForded,
with
s/he
the
would
be
remainder
be
the
individual:
deductions;
employer
section
Service.
with
him/her;
For
another,
i . e . , a l l health
portable.
care
services
insurance.
will
by
will
Diseases
which
(common c o l d )
be
encouraged
manner t o a v o i d
be
placing
insurable
under
are reasonably
would
n o t be
to conduct
covered.
themselves
unnecessary
costs
on
system.
the employer
insurer
whether
It
i s not
oF
adhesion
chooses
either
i n an
the
will
he
be
portable.
current
For
This
situation
consumer
company
what
For
choosing
the sole
or
to sign
same
oFFered
by
i t will
a
Y.
contract
employer
the c a r r i e r ,
oF
purview
i n S t a t e X or
had
the
to
employer
the policy
eliminate
employees t o remain
purpose
the
that
t h e e m p l o y e e has
insurance policy
requires
to retain
interest
i s p r e F e r a b l e because
which
From
o c c u r s when an
Historically,
By
insurer
A o r B,
employee's
is actually
coverage.
employer
each
individual
subscribe to the
without
t h e c h o i c e oF
allow
works
insurer.
go
single
Removing
which
or
be
would
to a specia11y-organized
travels
will
A l l persons
Rationale.
oF
premiums,
Revenue
not serious
a responsible
every
income.
l e a v e s one
individual
a l l health
health
rates
through payroll
the I n t e r n a l
policies
preventable
be
unemployed,
insurance policy
insurance
t h e p/d/c
t o pay
paid
..iF
IF the
i n c r e a s e For
less.
government.
P r e m i u m s would be
g.
would
i s $30,••• or
additional
i s unable
whatever
oF
income
Above $ 5 0 , 0 0 0 ,
IF a person
required
t h o s e whose
retaining
with
will
the
a
the a b i l i t y
to
insured.
There
will
preparation
For
plan.
oF
Each
be
scores
oF
the Formation
these
bills
bills
oF
will
-20-
introduced
a national
have
by
Congress i n
health
advantages
and
care
reForm
disadvantages
�to
each
o f t h e power
a result,
process,
hoped
there
benefit
will
and dead
that
Potts,
new
attempts.
emerge
at the least
a former
the source
i s there
the l e g i s l a t i o n
bill
because
will
i s a group
have
i ti s
the
greatest
cost.
author
staff
of every
He
effort,
member,
provision in
contends
someone w a n t e d
and
i t i s often
i t svaried
clear
provisions,
which
i t
each
that
there."
individual
"Every
2 3
Even
should
specific provisions.
consider
that
disclose
these
Freedom
i t does
not
to subject
medical
sources.
not apply
itself
greater
the
income
of physicians
always
can a f f o r d h e a l t h
a decline.
advocate
insurability
to
executive
regulatory
because
that
Congress
agencies.,
preferred
2
t h e incomes
other
care,
experience
refuse
to Federal
of hea1th-insured
and
usually
requirements. ^
the lower
t h e number
members
and
the government r e g u l a t i o n
prrofessions,
actually
i n t e r e s t i n g t o note
independent
t o FOIA
greater
could
and
t o Congress
The
people
Act applies
indiscernible
who
Congressional
I t i s very
the Pentagon
but
The
were
t o be p r i v i l e g e d i n f o r m a t i o n
of Information
departments,
l e g i s l a t o r s approve of a
i t i s generally
the i n d i v i d u a l s or i n t e r e s t groups
authored
the
which
As
stalled
Ultimately,
Congressional
and
care.
identified.
Although
who
will
by h e a l t h
discussion,
l a w be p u b l i c l y d i s c l o s e d .
provision
be
affected
considerable
legislative
t o consumers
recommends t h a t
if
be
legislation
Robert
every
structures
imposed
of a l l providers.
people,
caregivers.
physicians'
For t h i s
on t h e
the
Thus,
income
reason,
and
i f fewer
prestige
providers
and r e j e c t r e g u l a t i o n ,
-2 1 -
higher
will
including
�regulations
With
of
concerning
providers
t h e h e a l t h care
quickly
evolve
peer
review.
a n d i n s u r e r s g e n e r a l l y on t h e same
reForm
Fence,
a c o u n t e r v a i l i n g Force
consumer
advocates
which
strength
t o aFFect
and c o n t r o l
countervailing
but
should
political
Force
hold
there
oF c o n s u m e r s a n d
be o r g a n i z e d
a n d oF
t h e reForm
process.
suFFicient
The
may n o t be i n o p p o s i t i o n o n a l l p o i n t s ,
a position
oF c o n s i d e r a b l e ,
consumer h e a l t h c a r e
the process
health
will
that
i F not equal,
strength.
Ideally,
in
i t i s imperative
side
care
oF p o l i c y
services
interests
Formulation.
have
already
Basic
been
will
be
Foremost
minimums For
outlined
by p e n d i n g
legislation.
As e x a m p l e s
considered,
order
oF some oF t h e l e g i s l a t i o n
a number
to p r o v i d e
oF b i l l s
an i d e a
oF
consideration
here
'what
by C o n g r e s s .
bills
covered
process
For passage
will
t o occur
with speecial
advocacy
oF a n y p a r t i c u l a r
the
be b r i e F l y
into
law.
because
interests
reForm
plan.
insight
currently
oF p r i m e
interest
i n Washington
detriment
contact
oF c o n s u m e r s .
thei. r l e g i s l a t o r s
preFerable.
into
which
i n the
unresolved
and a r o u n d
most
know w h i c h
the Nation.
a r e more
to the
be up t o i n d i v i d u a l
t o l e t them
e a c h oF
areas are
i n d u s t r y , sometimes
I twill
oF t h e
Nevertheless,
a r e p r o t e c t i v e oF c o n s u m e r s ,
oF t h e i n s u r a n c e
none
and i n s u F F i c i e n t consumer
valuable
protective
that
oF t o o many
provides
the b i l l s
and under
I ti s too early
bills
While
being
described i n
i s out there'
I t i s expected
pass
problems
will
currently
voters to
bills
are
�HEALTH INSURANCE
SELECTED SOURCES OF HEALTH INSURANCE,
BY WORK STATUS AND FAMILY INCOME: 1990
- PRIVATE COVERAGE EMPLOYER COVERAGE
DIRECT
INDIRECT
TOTAL
PUBLIC COVERAGE
NO HEALTH
INSURANCE
MEDICAID MEDICARE CHAMPUS COVERAGE
TOTAL
TOTAL
PRIVATE
213.7
160.4
140.8
71.2
69.6
19.7
26.2
18.5
3.2
5.9
34.4
Family-Head Workers
74.9
60.9
54.6
51.2
3.4
6.3
4.3
2.1
0.3
2.0
11.6
Other Family Workers
48.1
39.8
35.0
17.7
17.3
4.8
2.3
0.9
0.2
1.3
7.2
Nonworkers
27.5
15.2
11.7
2.2
9.5
3.5
8.4
5.4
2.7
1.3
5.7
Children
63.2
44.4
39.4
0.1
39.4
5.1
11.2
10.1
0.0
1.3
9.9
Under 55,000
12.6
2.3
0.9
0.5
0.4
5.9
5.6
..
$5,000-59,999
14.8
4.1
2.4
1.5
0.9
6.4
5.7
--
--
5.0
510,000-514,999
16.5
8.0
5.9
3.7
2.2
3.7
3.0
--
--
5.6
$15,000-519,999
16.9
10.8
8.8
5.1
3.7
2.3
1.6
--
$20,000-529,999
33.8
26.4
23.1
12.1
11.0
2.6
1.4
$30,000-539.999
32.0
18.2
25.5
12.3
13.2
1.7
$40,000-549,999
26.0
23.7
22.0
10.3
11.6
$50,000 and over
61.0
57.0
52.3
25.7
26.6
TOTAL
OTHER
PRIVATE
IN MILUONS
TOTAL
W O R K STATUS
F A M I L Y INCOME
4.7
4.6
5.9
0.5
-.
1.2
0.3
--
2.4
0.5
3.2
-._
1.9
3.3
SOURCE: FOLEY. JILL D. UNINSURFD IS THE VNTTED STATES: THE NONF.I.Dt.Hl.Y FOPULATIOS W n i l O U J HF^LTH INSVHiNCE. ANALYSIS OF THE MARCH /WO CURRENT
POPULATION SURVEY. EMPLOYfil: ULNIiFIT RLSLAKCII I N S I I H I I I . W/VSII IN( i I ON. I) C. AI'Kll. I ' ^ l .
91-3
The Universal Healthcare Almanac
(Phoenix:
S i l v e r
K
Cherner,
Table 6.7
Ltd
199 1 )
�Each
of the b i l l s
and
assures
The
facing
and
uninsured
approve
such
plan--such
will
health benefit
f o r t h e 37 m i l l i o n
of coverage
maintain
i n the nation.
the viability
that
industry.
launch
severely
Insurers
because
of the health
health
limit
I t i s expected
i t s own f u l l
of insured
uninsured
a national
insurance
insurance
or destroy the
that
h e a l t h care
plan
uninsured.
f o r t h e number
to insure the currently
as C a n a d a ' s - - w o u l d
will
a minimum
the figures
i s concerned
insurance
industry
the insurance
reform
campaign
1992.
Basic
coverage
meant
will
i n which
whatsoever.
purchase
Those
consumers
many h a v e
Nevertheless,
not provide
t h e Basic
no c o v e r a g e
t o do s o w i l l
health insurance
o f h e a l t h care
f o rreform
primarily,
and b u s i n e s s e s
t o make money, b u t c o n s u m e r s
facilities
greatest
to stay
to lose
alive
i f provision
the greatest to gain
choices
and w e l l .
f o rreform.
utilize
They,
health
will
their
benefit
Businesses
care
therefore,
their
be d i f f i c u l t
t o make
legislators in
secondarily.
o f h e a l t h care
-23-
care
be a b l e t o
attempt
to their
by v o c a l i z i n g
I twill
the current
coverage.
should
known
plans
a n d r e c e i v e no
f o r a p p r o p r i a t e d e c i s i o n s t o be made w h i c h
consumers
They a r e
i s an i m p r o v e m e n t o v e r
who c a n a f f o r d
and c h o i c e s
will
f o r some p r e v e n t i v e , l o n g - t e r m , a n d
and t h a t
supplemental
All
beliefs
everyone
plans
s e r v i c e s and p r o c e d u r e s .
catastrophic care.
situation
exist
health insurance
t o be u s e d m a i n l y
cover
order
national
f o r a l l medical
possibly
and
by t y p e
which
coverage
provides
of efforts
industry
in
page
action
health
insurance
advocates
have t h e
i s inadequate,
d e c i s i o n s and
t o f o r m u l a t e new
�health
of
care
plans, programs,
conflicting
concerned
interests,
with
and p r o c e d u r e s
a l l o f which
given the plethora
a r e so
basically
t h e outcome.
In
t h e words
o f Joseph
problem
of r i s i n g
health
we f i x
C a l i f a n o , "How
i t . "
care
c o s t s may
we
well
define the
determine
how
CANADA.
Differences
success
In
the
i n power
or f a i l u r e
Canada
o f an o t h e r w i s e
and Germany,
health
care
structures
system
i s a prime
viable
t h e government
and i t i s s u e s
reason f o r
health
care
i s strongly
clear
system.
in control
and e f f e c t i v e
27
of
policy
28
statements
"...the
its
i n order
interests
are permeable,
rather
Despite
than
those
of a Canadian-type
f o r t h e U.S.
financed
health
America,
however,
available
with
requirements
would
industry
plans
denied
programs
contributes
ond
two
very
adoption
would
well
tend
because
availability
health
t o which
t h e groups'
i s not a
and
viable
nationally-
i n other countries.
to reject
of the plan
of services.
Additionally,
i n the health
insurance
t h e Canadian
program
federal
In
t h e success
the r i g i d i t y
a n d i s a d m i n i s t e r e d by e a c h
territories.^^
abet
by t h e U n i t e d
i f the American
continuation
Canada's n a t i o n a l
twelve
about
be g r e a t d i f f i c u l t y
were
fragmented,
of the State."
p l a n , Canada's p l a n
work
people
reduces
are
Centra 11y-administered
plans
such
In contrast,
and i t s t r a d i t i o n s
29
a l l the rhetoric
solution
there
control.
A m e r i c a n ... [ g o v e r n m e n t a l ) s t r u c t u r e s
processes
States
to maintain that
insurance
insurance
field.
is actually
government
of the ten provinces
�The
on
the
Canada H e a l t h
provincial
monetary
Act
of
programs which
g r a n t s would
imposed
had
Five c o n d i t i o n s
t o be
met
before
BeneFits
a l l medically necessary
were r e q u i r e d t o
inpatient
services,
inpatient
dental surgery,
and
m e d i c a l l y necessary
surgery.
Because each
the
provinces
Financed
mental
psychiatric
Mental
mainstream
the
U.S.
oF
wards w i t h i n
oF
had
health services, hospitals
h e a l t h care
any
occur.
Comprehansive BeneFits.
include
1984
thus
the
conFines
became
h e a l t h care
and
oF
cosmetic
previously
had
included
general
hospitals.
incorporated into
i s not
separated
the
as
i t is in
3 1
Un i v e r s a l i t y .
One
hundred
percent
oF
the
population is
32
entitled
to h e a l t h care
Accessibi1ity.
physicians
and
government
deducts
provinces
For
"user
Financial
poorest
patients.
Portabi1i ty.
accrue
dependent
on
citizen
seeking
country
will
diFFerence
dollar
dollar
"extra
hospitals,
From
extra
accessibility
billing"
the
Federal
i t s grants to
billed.
by
This
the
method
t o h e a l t h care
For
even
the
3 3
B e c a u s e oF
to the
place
discourage
F e e s " by
one
every
insures
beneFits
To
beneFits.
oF
care
a highly
person,
residence
and
or
in a distant
have b i l l s
p a i d , and
between
are
mobile
not
society,
completely
employment.
province
may
be
the
or
A
a
liable
Canadian
Foreign
only
For
the
t h e p r o v i n c e ' s b e n e F i t a l l o w a n c e and t h e
34
hospital's actual
charges.
P u b l i c A d m i n i s t r a t i o n . C a n a d a ' s g o a l was t o a c h i e v e
25
�administrative
capability
non-political,
non-profit,
Department maintains
advisory
committees
the
myriad
2.5
percent
of
total
official
fees
fee
negotiated
agencies
between
and
Physicians
each
Canada's p l a n
States
but
will
will
politically
be
over
percent
the
of
with
necessary
met
with
physicians
are
an
who
choose
rewarded
under
Hospitals
eliminated
Each
year
physicians
adjustments
for
have been
over
a higher
operate
receive
fee
new
i n the
Association
rural
because
on
or
problem
which
each
hospitals.
Deficits
northern
-26-
now
payments
there
and
those
areas
are
3 7
a
which
line-item
increase
which
volume
expanded
have
basis.
of
considers
services
programs.
with hospitals
d u p l i c a t e programs
are
50
year
3 8
nearby
which
available,
i n p a t i e n t days,
new
the
more t h a n
"global budgets"
and
United
Canada's p r o v i n c i a l
schedule.
a growing
programs
administering
nation.
a percentage
system,
are
increase
o p p o s i t i o n from
physicians
under
f o r changes
i s , however,
initiating
of
There
The n e g o t i a t e d - f ee aspect
impose
budget
p r a c t i c e i n the
life-support
There
i n the
fees,
by
association.
Medical
administrative control
they
government
270,ODD member p h y s i c i a n s ,
i n c r e a s i n g number
to
costs
percentage
massive
American
to
expenditures."^
annual
to
by
amount
hospitals.
medical
Health
advised
and
provincial
Even w i t h n e g o t i a t e d
to
an
care
3 5
be
The
I t utilizes
are
plan
f ee - f o r - s e r v i c e .
powerful
represents
insurance
province's
receive
independent,
Administrative costs
to physicians
the
an
w i t h and
c o n t r o l s heath
schedules,
by
responsibility.
consult
health
paid
cost
r e p r e s e n t a t i v e body.
groups.
Canada c a r e f u l l y
regulating
low
overall
which
interest
at
occurring.
offered
by
of
�Instead
hospitals
of receiving
receive
payments
monthly
Because
of this
method
itemize
prices
amounts
on a p e r - p a t i e n t
installments
o f payment,
of administrative
or b i l l s
hospitals
to patients
costs
of their
allotment.
do n o t h a v e t o
and save
f o r them
basis,
considerable
and
insurance
39
carriers.
The
financing
nationalized.
companies
covered
and
Canadian
access
percent
a plan
Canadian
provincial
federal
income
t o medical
according
provinces
f o rnursing
services,
and a m b u l a t o r y
--
appeal
the federal
After
effect
relinquished
t a x a n d one p e r c e n t
This
care.
$20 p e r c a p i t a ,
This
home, a d u l t
care
plan
contributions
some
trial
i n 1977.
12.5
of corporate
a m o u n t was c h o s e n
o f t h e 1975-197B
t o t h e GNP.
of this
f o r services
contribution tothe
and h o s p i t a l
are granted
increases
The
system.
i s completely
insurance
insurance
government
o f 50 p e r c e n t
provinces
private
the federal
tax to the provinces.
contribution
services
was l e g i s l a t e d a n d t o o k
of personal
representative
the
refuse
of health
i n determining
provinces,
The
laws
t o sale
by t h e f e d e r a l
error
income
o f Canada's h e a l t h
as
federal
Additionally,
with
amount
annual
i s used
by t h e
r e s i d e n t i a l a n d home
care
services.
i s that:
are n o t dependent
on p r o v i n c i a l
expend!tures;
--
the provinces
which
--
may
t h e method
are solely
exceed
responsible
t h e annual
o f payment
increase
eliminates
-27-
f o r a l l expenditures
i n GNP;
pilotage
by t h e f e d e r a l
�government
completely
--
a n d a l l o w s d e c i s i o n m a k i n g t o be
by t h e p r o v i n c e s ;
the Federal
i
i
in control
oF i t s
40
budget.
Each
province
residents
methods
government remains
retained
determines
For t h e h o s p i t a l
t h e method
insurance
oF p a y m e n t
plan.
by
Some oF t h e
used a r e :
--
increasing retail
sales
--
i n c r e a s i n g income
taxes;
--
payroll
--
individual
t a x p a i d by
anywhere
payment
From
t a x From
employers
oF
and
insurance
8 t o 38 p e r c e n t
3 to 5
percent;
employees;
premiums
oF
which
the cost
oF
yields
the
programs.
Those
From
are
provinces
payment
on
public
subsidies
those
using
r e s i d e n t s who
assistance
t o those
t h e premium
with
method
are over
65
have
and
p r o g r a m s , and p r o v i d e
incomes
t o o l o w t o be
exempted
those
who
premium
able
to
handle
41
the
entire
premium
amount.
Currently,
h e a l t h care
province's
annual
consumes a b o u t
30 p e r c e n t
of
42
each
budget.
Taylor
advises
that:
. . . ( T ) h e p r e s s u r e s For i n c r e a s e d s p e n d i n g
a p p e a r i n e x o r a b l e : t h e a g i n g oF t h e p o p u l a t i o n ,
the expanding p h y s i c i a n supply, the d i s i n c e n t i v e s
For e F F i c i e n c y i n h e r e n t i n t h e F e e - F o r - s e r v i c e
m e t h o d oF p a y i n g p h y s i c i a n s , l a c k oF i n c e n t i v e s
For h o s p i t a l e F F i c i e n c y , b r e a k t h r o u g h s i n
m e d i c a l t e c h n o l o g y , a n d t h e d i F F i c u l t i e s oF
i n t r o d u c i n g p o t e n t i a l i n n o v a t i o n s i n h e a l t h care
d e l i v e r y b e c a u s e oF t h e u n i F o r m t e r m s a n d
c o n d i t i o n s r e q u i r e m e n t s oF t h e Ganada H e a l t h
Act. 4 3
Additional
—
cost
the shiFting
concerns are:
emphasis
From
sickness
care
to
wellness;
�--
the possibilities
health
of
services
high
of introducing
d e l i v e r y system
i n the
(From) r a p i d
expansion
technology;
--
increasing
--
the diFFiculties inherent
hospital
--
innovations
costs
oF m a l p r a c t i c e
budget
and t h e unknown
litigation;
i n Fee n e g o t i a t i o n s a n d
setting;
impact
oF t h e AIDS e p i d e m i c
on h e a l t h
44
care
resources.
To
For
care
Taylor
2.5
by
those
which
about
that
From
three
styles
oF w a i t i n g
mortality rates
1931 t o 1 9 8 5 , a n d l i F e
years
For both
rate
oF n u t r i t i o n ,
or t o t h e eFFects
Taylor
reports
a s t o be d e t r i m e n t a l
infant
The i m p r o v e m e n t
knowledge
about
a r e so l o n g
explains
percent
1985.
concerned
expectancy
increased
men a n d women b e t w e e n
better
housing
oF a g o o d
R. G. E v a n s o f t h e U n i v e r s i t y
to health,
d e c r e a s e d by
may be a t t r i b u t e d
relates material
periods
to greater
and i m p r o v e d
health
provided
1971 and
care
system.
t o h i m by
of B r i t i s h
liFe45
Professor
Columbia
concerning
the
c o n t r i b u t i n g f a c t o r s f o rthe differences
and
Canadian
the
i n c r e a s i n g u s e o f e x p e n s i v e t e c h n o l o g y by h o s p i t a l s .
D u r i n g t h e p e r i o d 1971-82, t h e volume o f
s e r v i c i n g p e r c a p i t a r e c e i v e d by C a n a d i a n s f r o m
t h e h o s p i t a l s y s t e m r o s e D.B p e r c e n t p e r y e a r ,
w h i l e i n t h e U n i t e d S t a t e s i t r o s e 3.7 p e r c e n t
annually.
Over t h e e l e v e n y e a r s t h e d i f f e r e n c e
c u m u l a t e d t o S.4 p e r c e n t v e r s u s 4 8 . 8 p e r c e n t .
With respect t o physicians, t h e d i f f e r e n c e i s
a c c o u n t e d f o r a l m o s t e n t i r e l y by t h e d i f f e r e n c e
in fees, which, a f t e r extraordinary increases i n
1 9 6 9 - 7 1 ( w h e n M e d i c a r e was i n t r o d u c e d i n C a n a d a ) ,
-29-
cost
levels.^
Some o f t h e s e
between
factors
American
include
�d u r i n g t h e e l e v e n y e a r s 1972-1382 a c t u a l l y d e c l i n e d
r e l a t i v e to the general p r i c e l e v e l 2 percent
per
y e a r on a v e r a g e , w h i l e F e e s i n t h e U n i t e d S t a t e s
w e r e o u t s t r i p p i n g i n F l a t i o n by 1.4 p e r c e n t
per
year.
T h i s d i F F e r e n c e oF 3.3 p e r c e n t p e r y e a r
c u m u l a t e d o v e r t h e p e r i o d as a w h o l e t o 33.8
percent."
Canada
i s now
American
considering
concept
oF
that
health
the
introduction
maintenance
oF
the
o r g a n i z a t i o n s may
be
47
a
v i a b l e method
There
citizens
2021.
For
holding
i s concern
will
double
However,
that
the
costs
the
cost
down.
i n c r e a s i n g number
oF
h e a l t h care
i t is speciFically
noted
high-cost
e q u i p m e n t , and
the
care
senior
between
that
p e r c e n t a g e oF t h e e l d e r l y r e q u i r e e x t e n s i v e
T h o s e h o s p i t a l s t a y s do n o t i n c l u d e t h e use
oF
only
2001
a
and
small
hospital stays.
oF
high-technology
is usually provided
at
small
48
local
lower-cost
Taylor
hospitals.
Based
on
two
major
studies,
states:
The e l d e r l y p o p u l a t i o n ' s use oF h e a l t h
c a r e r e s o u r c e s i s s t r o n g l y i n F l u e n c e d by
Factors
o t h e r than "need."
The a v a i l a b i l i t y oF h o s p i t a l
b e d s , how p h y s i c i a n s p r a c t i c e m e d i c i n e , a n d t h e
increase i n p h y s i c i a n supply over the next
s e v e r a l decades w i l l undoubtedly
inFluence
h o s p i t a l c o n s u m p t i o n more t h a n w i l l t h e a g i n g
of s o c i e t y . "
4 3
Canada
expects
a S,032-physician
surplus
by
the
year
Each
one
oF
50
2000,
new
with a projected supply
physicians
annually
to the
overhead,
and
oF
the
i s expected
t o add
provincial
medical
diagnostic tests,
like.
physicians
British
billing
oF 5 6 , 9 7 3 .
care
hospital
Columbia
the
$ 1 5 0 , 0 0 0 and
bill
government
-30-
$250,000
For
admissions,
attempted
For
to
those
income,
prescriptions
limit
services
the
by
number
�restricting
was
t h e issuance
challenged
of b i l l i n g
numbers.
and r u l e d u n c o n s t i t u t i o n a l .
The p r a c t i c e
Within
one
51
w e e k , 2 , 0 0 0 new n u m b e r s
is
expected
surplus
the
the United
issued.
States
oF 7 0 , 0 0 0 p h y s i c i a n s ,
year
It
that
that
were
2 0 0 0 oF 1 2 0 , 0 0 0
i s a recognized
Fact
oF e v e r y o n e
but also
environment,
advances.
cultures
At t h i s
make c o n c e s s i o n s
Further
depends n o t o n l y
liFe
biological
point
diverge.
and a p r o j e c t e d
52
styles,
s u r p l u s For
and a c c e p t
residents
individual
oF a d e q u a t e
on
medical
and t e c h n o l o g i c a l
however,
appear
t h e two
more w i l l i n g t o
burdens
care
States
c l e a n l i n e s s oF t h e
research,
oF a g r e e m e n t ,
Canadian
t h e common g o a l
a 1990
i n Canada and t h e U n i t e d
on i n d i v i d u a l
earth's
i s experiencing
physicians!
the health
care,
As c o m p a r i s o n , i t
i n order to
For a l l a t reasonable
cost .
Canada
has imposed
a Federal
carton
oF c i g a r e t t e s i n o r d e r
reduce
the costs
and
lung
Antipollution
are
disenchanted
t o discourage
i n c u r r e d For care
cancer.^"
t a x oF F o u r
d o l l a r s per
smoking
and
thus
oF r e s p i r a t o r y d i s e a s e s
3
c o n t r o l s on i n d u s t r y h a v e
with
American
reFusal
increased.
to enter
into
They
an a c i d
54
rain
a
treaty.
treaty,
power
There
except
and l e s s
environment
that
moral
than
i s no r e a s o n
American
interest
For America
t o reFuse
i n d u s t r y has g r e a t e r
i n the health
e x i s t s i n Canada.
-3 1 -
such
political
oF p e o p l e
and t h e
�In
C a n a d a , h o s p i t a l i n s p e c t i o n and
accomplished
by
the
accreditation.
This
Canadian
Hospital
tion
the
and
i n the
public
would
oF
Far
interest
eFFective
tion
Canadian
t o be
be
as
too
the
great
such
quality
well
as
costs.
health
care
sensitive
handling
diFFicult
to
would
this
be
reason,
tax
but
U.S.,
annual
i t s own
more
likely
not,
membership
For
by
those
that
and
there
conFlicts
and
For
accredita-
Canadian-style
plan
would
to
keep
i s not
budget.
health
the
interests
care
to r e t a i n
up
with
known
spending
For
be
its
more
than i t
environment.
a
For
competitive
to a governmental
c o n t r o l costs
eventually
I t would
in a competitive
commit
may
croniism
basis,
annual
i t i s more r e a s o n a b l e
i n d u s t r y than
oP
paid
appear
a
government
c o n t r o l government
with
insurer
which
a resultant
burden.
According
choice
care
oF
are
special
insurance
Our
to c o n t r o l spending
insurance
may,
costs.
hospital's
For
oF
I n the
an
Associa-
costs
hospital inspection
on
maybe e v e n
Medical
The
I t would
a consortium
raise
the
m i n i s t r i e s consider
5 5
health
rising
each
Facilities
members o f
Canadian
a possibility
government-administered
taxes,
of
Association,
health
States.
Health
Association.
c o n t r o l oF
United
the
Hospital
operating
From
i n the
Nur s e s
process,
on
consists
Association,
Funds because
charges
Council
council
Canadian
accreditation
dues
Canadian
accreditation is
oF
under
to c u r r e n t
providers
Basic
and
health
providers
insurers
or
Free
insurance
Supplemental
t h i n k i n g about
choice
and
oF
limits
are
given
Free
insurer--with limits
on
insurance—consumers
whose r a t e s
reForm,
too
reimbursements
would
high.
avoid
on
under
those
Government
�control
never
equals
become
Free
Canadian-type
be
Rather
their
be
be
by
t h a n have
oFF
The
Farmer
waiting
to
which
illustrations
Koop, t h e
and
For
method
oF
oF
care.
has
been
To
all.
accept
The
waiting
lists
are
way
pay
hospitals
pay
diFFerence
occur
will
with
a
employees
administration.
the nation
insurance
insurance
would
industry.
industry
readily
very
For
would
U.S.
are
legendary.
available
Surgeon
radiation
The
in
periodi-
General,
treatment
waiting
apprehensive
c a r e , even
For
lists
about
though
relates
are
an
rationing
the
rationing
years.
i s to accept
planned
scarcity
to avoid the r a t i o n i n g
For
oF
t o the U n i t e d S t a t e s or o t h e r
care
partially
between
to provide care
the American
that
endure
non-oFFicia 11y-sanctioned
plan
their
the Canadian
between
the
For
Canadians
agreements
P r o v i n c e pays
would
For
For
are
health
the poor
i s to travel
contractual
American
The
and
on
oF
Canadians
are
oF
a Canadian
only
countries
we
employees c o n t i n u e
government,
Former
imposing
rationing
imposed
industry
by
wait
Americans
oF
would
insurance
heart surgery.
eFFective
possibility
as
the competitive
i s a Four-month
cancer
health
which
consumers.
lists
Everett
there
breast
employed
government r e g u l a t i o n
C.
From
jobs unless those
For
insurance
retaining
Many a n e c d o t a l
cals.
eliminate
the government
more b e n e F i c i a l
that
would
Functions while
EFFective
a deFicit
insurance companies,
plan,
hired
better
and
Free.
Eliminating
would
spending
For
and
-33-
with
oF
at the
There
and
re (questing i t .
same r a t e i t
the p a t i e n t
the actual
pocket.
provinces
Canadians
hospital
Facility,
rate
Canadian
out
rate
bearing the
charged
by
the
�American
States
provider.
adopted
experiencing
Where w o u l d
t h e same s y s t e m
A m e r i c a n s go i f t h e U n i t e d
which
a n d , i n some c a s e s ,
t h e Canadians
enduring?
Canada d o e s n o t p r o v i d e t h e s t a t e - o f - t h e - a r t
care
services
States.
which
are currently
I F t h e U.S.
technological
detrimental
nations
were
advances
which
Canada h a s r e c e n t l y
inFlation
rate
annual
health
proven
that
Canadian
be
oF g r o w t h
by m e r e l y
plan.
Additionally,
That,
tally
oF t o t a l
i n itselF,
diFFerence
We
values.
be
does n o t i n c l u d e
health
explain
are a diFFerent nation
The A m e r i c a n
anothep
adequate
to a
care
oF
between t h e
oF g r o w t h
could
system,
Canadian-type
a s many
expenses
at least
rate
statistically
t o our c u r r e n t
changeover
care
items
as A m e r i c a
a percentage
does.
oF t h e
i n cost.
to- o u r n a t i o n a l
advocate
could
rate
other
expertise.
a health
diFFerence
changes
Canada
be t o many
I t has n o t been
a complete
an o u t c o m e as
inFlation
and t h e American
making
than Facing
their
t h e U.S.
care spending.
rather
in
experiencing
i s twice
system, our
on o u r m e d i c a l
t h e 2.5 p e r c e n t a n n u a l
rate
oFFset
which
depend
been
diminish,
as i t w o u l d
health
i n the United
t h e Canadian
likely
t o o u r own w e l F a r e
oF t h e w o r l d
available
t o adopt
would
are
reForm
concerns.
nation's
For t h a t
From C a n a d a ,
plan
with
s h o u l d be u n i q u e l y
I ti s insuFFicient
plan
merely
nation.
-34-
diFFering
because
geared
reasoning to
i t happens t o
�GERMANY.,
In
G e r m a n y , almost a l l are covered by comprehensive h e a l t h
insurance.
The
initiatives,
and
to
governmental
Financing
capital
p r o v i d i n g compulsory
W e s t Germany
within
a
total
number
oF
provided
oF
is limited
expenditures
arbitration.
( i n 1980)
had
only
increased
beds per
1,000
to
to
by
5 7
hospitals,
120,000
physicians
proFessiona1s.
1 9 0 , 0 0 0 by
people
legislative
5 6
about
700,000 h e a l t h c a r e
physicians
11.5
role
1990.
w i t h 3.7
The
Hospitals
oF
those
58
allocated
For
There
oF
are
physicians
practice,
and
hospitals.
on
an
long-term
actually
those
who
Because
oF
private
practitioners.
service
to-private
payers.
A private
hospital
"loses
during
receives
choice
Uwe
Economy
as
but
at
the
are
this
maintain
employees
diFFerence,
that
Eight-Five
a
categories
private
oF,
and
h o s p i t a l s do
would
be
percent
oF
the
sends a p a t i e n t t o
and
economic
hospital
events.
a hospital
Princeton
stay."
The
not
allowed
i n the
the
For
the
over
the
merely
their
private
same F r e e d o m
oF
physician.
James M a d i s o n
"to exercise
Face
choose
that
59
treat
third-party
physician
ProFessor
U n i v e r s i t y , summarizes
mandate
From
control
P a t i e n t s may
not
Fees
who
medical
work i n ,
i n F r i n g i n g on
physician
Reinhardt,
resources"
who
salaried
because
g e n e r a l l y are
a statutory
care
statutora11y-contro11ed
is derived
both
concerning
E.
two
care.
practitioners
a r e p o r t oF
physician
special
i n Germany...those
o u t p a t i e n t basis
patient
or
economy
of p h y s i c i a n s '
-35-
the
oF
Political
German
i n the
use
plan
oF
health
"Fiscal incentive
�BO
to
service
free
of
voucher
are
patients
insured
All
their
services
charge
reimbursed
physician
which
on
between
annual
this
the
rate
mandate,
federal
negotiation
which
the
of
government
pharmaceutical
on
give
to
received
with
state
health
gross
and
the
level.
are
a National
of
rate
drugs.
t h a t the
rate
exceed
Consistent
annually
with
at
to accomplish
Conference
both
this
convened
representatives
from
sickness
physicians,
funds,
and
Ministry
6 1
does n o t
negotiated
Health
diem
The
requires
budget
In order
funds
sheets.
national product.
prices
fees
a per
prices
Act
care
on
a
Physicians
sickness
paid
the
patients
physician.
cost
Containment
f o r the
the
approved
by
Individuals receive
the
are
authorizes
Cost
process,
includes
are
delivery.
Hospitals
and
a l l fees
and
of
they
based
1977
increase
growth
supplies
government-administered
Economics reviews
the
point
associations.
German
and
a fee-for-service basis,
is negotiated
The
of
the
q u a r t e r l y which
negotiated
of
at
generously."
a l l the
is
interest
groups:
hospitals,
the
r e p r e s e n t a t i v e s , employers,
52
. . .
and s t a t e and f e d e r a l g o v e r n m e n t .
Compulsory a r b i t r a t i o n
is
. • .
53
r e q u i r e d i f n e g o t i a t i o n s are
non-productive.
The
government
Committees
which
"Physicians
per
i n d u s t r y , consumer
has
screen
exceeds
selected
for further
tion
the
are
can,
cut
Economic
Monitoring
the
profile"
of
every
services
or
prescriptions
average
by
30
whose a v e r a g e
case/voucher
for
established
observed
accordingly.
t h e r e f o r e , be
"charge
number
their
of
class
examination.
In the
d e v i a t i o n , these
Under
held
absence
physicians'
percent
of
are
justifica-
reimbursements
this
system
the
fiscally
liable
for excessive
- 36-
physician.
individual
physician
prescribing
�64
of
drugs."
Reinhardt
an
attempt
of
market
to replace
forces
professional
toward
summarizes:
provided
left
a new
of market--one
and e c o n o m i c
by s t a t u t e . "
market
5
sees
in this
should
they
people
refuse
In
are
covered
earns
that
to negotiate
national
collectively
constraints
replaces
Although
those
espousing
individual
are
different--
t o i n d i v i d u a l freedoms
90 p e r c e n t
insurance
(gross
coverage
companies.
monthly
that
o f t h e common
of the population
insurance
by l a w t o c o n t r i b u t e
Reinhardt
unilateral regulation, i t
f o r the benefit
DM3,000.•• o r l e s s
required
that
the cultures
health
by p r i v a t e
i n which
generally
sector."
a r e so d e v o t e d
West G e r m a n y ,
compulsory
care
t o impose
be c o n s i d e r e d
American
by c o n t r a s t ,
difference
a r e so r e a d y
a set of
erosion
by d i r e c t a n d o f t e n u n i l a t e r a l
BE
of the health
freedom
within
States,
forces
by t h e s e c u l a r
5
regulation
irony
type
represents
i n t e r e s t groups b a r g a i n
consensus
The U n i t e d
"eroding
t h e vacuum
with
a national
" I n e f f e c t , t h e law
a percentage
has
and 9
percent
Everyone
earnings,
good.
who
1/1/79), i s
of the gross
salary
through s p e c i a l taxes t o t h e n a t i o n a l h e a l t h i n s u r a n c e coverag:
,
p l a n . 68
I n t h e F e d e r a l R e p u b l i c o f Germany (FRG, West
G e r m a n y ) , t h e s t a t e i s t h o u g h t o f as a s u b s y s t e m o f
t h e s o c i e t y ... The p r i o r i t y o f t h e i n d i v i d u a l a n d
s o c i a l forces i s expressed i n a r t i c l e 1 of the Basic
Law o f t h e C o n s t i t u t i o n o f t h e FRG.
The d i g n i t y o f man i s i n v i o l a b l e .
I t i s the
d u t y o f a l l s t a t e power t o r e s p e c t and p r o t e c t t h i s
d i g n i t y . . .''69
-37-
�. . . ( A ) r t i c l e 2 r e q u i r e s t h a t the r i g h t s of
o t h e r s n o t be v i o l a t e d - .
and) p o l i t i c a l Freedom
e n d s w h e r e t h e F r e e d o m oF o t h e r s b e g i n s .
The
B a s i c Law p r o c l a i m s t h e e q u a l i t y oF a l l . ^ ...
( w h i l e ) the Fact t h a t unequal r e s u l t s Follow
F r o m t h e same e F F o r t s i s n o t o n l y t o l e r a t e d b u t
F u l l y a c c e p t e d , s i n c e i t i s v i e w e d as an
e x p r e s s i o n o f t h e " n a t u r a l " i n e q u a l i t y oF
individuals.
. . . v a l u e s i n t h e FRG ( i n c l u d e )
t h e t r a d i t i o n a l v i r t u e s QF i n d u s t r i o u s n e s s ,
t h r i F t , and
Fruga1ity."73
7 0
7 2
Erik
(MIC)"
in
K l i n k m u l l e r uses
to describe
health care,
The
not
term
"medica1-industria 1
a l l o r g a n i z a t i o n s and
including
medica1 - i n d u s t r i a 1
government
the
only
insurers,
complex
i n the
individuals
schools
maintains
Form
oF
and
complex
involved
even p u b l i s h e r s .
representation in
a cabinet-1eve1
the
minister,but
74
also
in a parliamentary
our
own
who
represent
an
system
entire
industry
e l e c t e d and
individual
industry.
are
The
oF
committee.
also
appointed
However,
i s i n contrast to
government o F F i c i a l s
c o n s t i t u e n t s and
c o r p o r a t i o n s , but
c o m p o n e n t s oF
c o n s t i t u e n t s and
are
the
health
represented
acquires
i t s Financing
through
s u b s i d i e s , compulsory
budget
German MIC
This
contributions
For
voluntary
insurance
compulsory
contributions,
contributions
are
and
product
e s t a b l i s h e d as
by
not
care
lobbyists.
general
health
insurance,
sales.
7 5
a percentage
The
oF
net
76
income.
Klinkmuller
limit
the
people
to
dollars
1.
demand
want
they
time
states that
For
there
health care"
to maximize
the
are
"three
i n a system
s e r v i c e s they
spend:
expenditure
-38-
main
Factors
which
receive
that
encourages
For
the
�2.
justifying
time
lost
a t work
because
o f medical
treatment;
3.
fear
While
and
brief
those
treatment.77
p a t i e n t s contend
session
requiring
services
o f medical
people
them
hours
i nwaiting
Klinkmuller
t o pay s p e c i f i c
taxes
rooms
believes
for
that
health
t o make m o r e d e m a n d s f o r p r o v i s i o n o f
services.
I f those
of their
taxdollar
portion
long
with physicians,
frugal
spurs
with
services
From
were p a i d
t h e general
for outofa
budgetary
fund,
78
demand
could
decrease.
79
•r.
Bradford
Kirkman-Liff
states:
"The
h e a l t h c a r e system i n t h e . . .Federa 1
R e p u b l i c o f Germany [ i s ) b a s e d on a s e t o f v a l u e s
t h a t i n v o l v e mutual o b l i g a t i o n s between p r i v a t e
p a r t i e s . . . A d i s c u s s i o n t h a t f o c u s e s on
" o b l i g a t i o n s " r a t h e r t h a n " r i g h t s " may be a more
u s e f u l approach f o r t h edesign o f reforms o f t h e
A m e r i c a n h e a l t h s y s t e m i n t h e 1990s.
Such a
d i s c u s s i o n w o u l d f o c u s on t h e m u t u a l r e s p o n s i b i l i t y
of a l l p a r t i e s t o c r e a t e and m a i n t a i n a u n i v e r s a l
p r i v a t e h e a l t h care s y s t e m "
8 0
COST CONTAINMENT, REDUCING HEALTH CARE COST
U.S. S e n a t o r
care
reform
German p l a n .
of
bill
Bob K e r r e y
i nJuly
Kerrey's
[D-Ne.) i n t r o d u c e d
1991 which
bill
and u n i v e r s a l
administered
Kerrey
financing
i smodelled
i se n t i t l e d
1 9 9 1 " [S.144E) and i s i n t e n d e d
equitable
INFLATION.
after the
the"Health
t o provide
national health
a health
care
USA A c t
f o r an
program
by t h e S t a t e s .
states
health
that
care
o u r "employment-based
i s a t t h ecenter
-39-
system o f
of our s p i r a l i n g
�Health U S A
Change In Household Health Care Spending
FAMILY INCOME
A V E R A G E CHANGE
Under $10,000
- $611
61%
$10,000 - $14,999
- $841
65%
$15,000 - $19,999
-
$969
58%
$20,000 - $29,999
-
$492
53%
$30,000 - $39,999
-
$479
50%
$40,000 - $49,999
+ $53
41%
Over $50,000
+ $1,320
26%
A L L FAMILIES
-
% WITH REDUCED SPENDING
50.2%
$236
Source: Illustrative Projection based on Lewin/ICF Estimates
Source •
News
media
release
From
Steve
J a r d i n g ,
Press
Secretary
to
U.S.
Senator
Robert
Kerrey
(p. 12)
•
•
(
�health
care
of
firms
to
make
c o s t s because
and i n s u r e r s
i t r e q u i r e s hundreds
each
d e c i s i o n s about
t o become e x p e r t s
benefit
packages,
of
thousands
on h e a l t h
to evaluate
care,
risk,
81
to
worry
"(A)n
about
and u t i l i z a t i o n ,
employment-based
we c a n ' t
ability
spend
of
costs
control
care--one
poor — t h a t
some,
health
t o decide
on h e a l t h
how
care
much
care,
system
Americans
Payments
costs...It
f o r t h e employed
degrading
shifting,
risk
82
plan
will
care
income
means
we w a n t t o
a two-tier
and i n a d e q u a t e
system
f o r the
care f o r
and h e a l t h
i s intended
f o r p r e v e n t i v e and l o n g - t e r m
o f premiums
health
and a n o t h e r
skimming,
care
forms."
precludes our
of our n a t i o n a l
i n f l a t i o n f o r the rest."
Kerrey's Basic h e a l t h
all
of financing
a n d i t l o c k s us i n t o
guarantees
and c o s t
system
t o process
care
t o cover
83
care.
be made t o f e d e r a l
and
state
84
Health
will
T r u s t Funds.
be p r o h i b i t e d
coverage.^
5
from
A l lplans
utilization,
order
I n s u r e r s a n d managed c a r e
will
t o stay
within
their
plan
that
quality
will
simply
any a p p l i c a n t
be r e q u i r e d
administrative
"Any
on
rejecting
programs
f o r Basic
to control
c o s t s , and m a r k e t i n g
budgets
over-restricts
drive
and m a x i m i z e
utilization
expenses i n
profits.
or
i t s subscribers to a
scrimps
competing
86
plan."
This
requirement
Kerrey
binding
statement
i s r e m i n i s c e n t o f t h e German
B7
t o p r o v i d e a d e q u a t e and q u a l i t y c a r e .
a l s o a d v o c a t e s n e g o t i a t e d f e e s and r a t e s w i t h
expenditure
targets
f o r p h y s i c i a n s and
-40-
.
38
hospitals.
�Health USA
C o s t Control
1400
i
Sivisgt
$717
Blon
Under Current Policy .
looo
Under Health USA
1091 1002
1M3
1094
1006 1000
On LnrtrvXF E*lmo*t
Source:
Ziir*^
r e l e a s e
F r o m
5 t e v e
j
1097
1098
1999 2000
d i
- ^ - p-3 s
B
ecr-etary
t o U.
S.
Senator
Robert
K e rr e y
er
(•-Ne)
�This
method
will:
" ( E ) n a b l e us t o i m p r o v e t h e w o r k e n v i r o n m e n t
F o r h e a l t h p r o f e s s i o n a l s , who i n c r e a s i n g l y h e a r
t h e i r c l i n i c a l d e c i s i o n s q u e s t i o n e d by a new
i n d u s t r y o f t h i r d - p a r t y c o s t managers whose
mission i s to slash u t i l i z a t i o n .
Health
USA
moves us away f r o m a r e l i a n c e on t h e s e
invisible
s c r u t i n i z e r s , and i n s t e a d t r u s t s o u r h e a l t h
p r o f e s s i o n a l s t o make t h e b e s t d e c i s i o n s a b o u t
q u a l i t y and u t i l i z a t i o n w i t h i n t h e i r o v e r a l l f e e
s c h e d u l e s and
budgets."
8 3
Financing
revenues
civil
from
for
accomplished
f o r Medicare,
service health benefits,
employers
FICA,
a new
and
health
care
shares
into
Kerrey
saving
of
expansion
and
top
bracket
of
income
distilled
costs,
plus
an
on
USA
r a t h e r than
billion
taxes,
that
a s i n g l e payer
to
CHAMPUS
5%
payroll
of
income
increased
system,
which
tax
wage
taxes
drive
trust
on
up
States'
h e a l t h care
base
tax,
excise
because they
a l l the
the
and
Medicaid
fund.
above m o n i e s ,
plus
would
a
enable
a l l Americans.
a budgeted
open-ended
government
a new
a l l federal
in administrative costs
i s t o be
an
Medicaid,
c o n t r i b u t i o n s from
i s convinced
coverage
shifting
expansion
spirits
and
by
personal
a federal dedicated
$11.2
Health
federal
employees,
corporate
cigarettes
be
be
appropriated
increased
is)
will
spending
with that
will
program
[as
Germany's
commitment.
s i n g l e payer
provide
funds
I t will
being
the
for state health
9 1
programs.
a
formula
state's
health
in
of
average
h e a l t h care
plans
their
targets
Funds w i l l
be
per
trust
a l l o c a t e d to the
capita cost
fund
will
a r i s k - a d j u s t e d amount
plan,
will
negotiate
for physician
fee
of
then
services.
pay
will
on
Each
"participating
for individuals
schedules
s e r v i c e s , and
_4 1 -
s t a t e s based
and
enrolled
expenditure
negotiate
budgets
�92
For
hospitals."
For
the
to
use
oF
To
demand F o r
care
which
Basic
would
be
covered
$1,500 For
or
more.
and
reduce
would
a
Family
From
months
exact
80
with
the
oF
and
$2,000 For
will
not
be
oF
Free
percent
oF
Kerrey
bill
nursing
an
cost
Fee
There
individuals,
and
a Family
required
barriers.
For
coinsurance
$100D F o r
low-income
94
9 3
deductible.
two;
and
order
encourage
stays.
percent
a $100
charged
necessity
oF
Financial
be
members i n
sharing
Cost
three
their
hospital
a 20
and
limits
hospital services,
protected
be
services
cost-sharing
will
hospital services
would
there
plans
by
imbue c o n s u m e r / p a t i e n t s
consciousness,
For
health
hospital services
c o n t r o l the
physician
Managed
For
oF
three
preventive
i n d i v i d u a l s would
AFter
home c a r e ,
the
such
i n d i v i d u a l ' s Social
be
First
care
would
Security
beneFits .
The
should
be
I t has
portions
oF
in
which
meetings
Kerrey
by
took
Oregon's p l a n
were
held
period.
From
Nebraska's
as
a practical
the
basis
be
bill
For
rather
more p o l i t i c a l l y
a Canadian-sty1e
great
care
plan
had
across
Farmers,
been
the
developed.
s t a t e oF
into
the
parents,
Nebraska
plan
were
doctors
hospital administrators
-42-
Over
and
and
which
health
than
care
adopted
palatable
would
in Formulating
i t i n a manner s i m i l a r
Incorporated
Faculty,
be
German p l a n ,
i t could
developing
year
school
the
i n t e r e s t s than
Senator
USA
adapted
i t , and
American
Health
to
seriously considered
reForm.
to
appears
the
to
be.
plan
the
way
100
over
a
2^
suggestions
medical
patients,
For
�insurance
e x e c u t i v e s and p o l i c y h o l d e r s ,
Democrats
and
Republicans.
Senator
a free
Kerrey
makes v e r y
clear
that
" H e a l t h USA
ride.
I twill
i n c r e a s e c o s t s on some
individuals.
I twill
highlight
i snot
businesses
the responsibility
and
each o f
96
us h a s t o t a k e
expects
objections
increases,
with
care
o f o u r own h e a l t h . "
from
small businesses
a n d i n s u r e r s who
97
different
contemplate
rules."
'creative
The
"will
disruption'
immediacy
of t h e problem
long-term
national
which
operate
B u t he a p p e a l s
Senator
will
in a
marketplace
t o a l l who
t o look beyond t h e
t o the long-term view,
interest
see c o s t
ahead
o f your
and " p u t t h e
own s h o r t - t e r m
98
interest ."
Many
plea
same
Congressional
in different
aware
of the fact
ultimately
goal
It
Office
reach
in
our
which
health
has been
that
each
care
what
Medicare
t h e U.S.
automobile
must
work
That
become
will
i sthe
t o achieve
reform.
by t h e C o n g r e s s i o n a l
and M e d i c a i d
by 1 9 9 5 .
are expected
cost
must
f o r the nation
individual.
individual
t o make t h e
a l lcitizens
i s good
t o each
projected
$300 b i l l i o n
The
ways. . . t h a t
be b e n e f i c i a l
toward
effective
that
members a r e b e g i n n i n g
by
health
care
Total
t o reach
of American h e a l t h
and s t e e l
spending
$1 t r i l l i o n
care
industries
-43-
Budget
itself
will
expenditures
by 1 9 9 6 .
so a d v e r s e l y
a n d so many
affects
other
�products,
the
at
global
the
those
the
we
are
reasons
In
here
cost
barred from
often,
product
express
Part of
they
less i s that
national
Americans
imports.
i s because
competing
cost
and
spends
health
anger
reason
less,
t h e U.S.
on
the
care
in
one
of
12
while
Japan
percent!
America,
available
poor.
they
of gross
S
Too
of Japanese
imports are
spends
effectively
marketplace.
presence
percent
health
to the
What
recently
for
that
care
has
always
and
has
often
wealthy
is disturbing
Secretary
As
Joseph
that
A.
playing
King
p u t , Uncle
Solomon
rationing
and
Sam
with
our
readily
i s now
Welfare
will
to
the
Americans
Califano, Jr., a
of Health, Education,
"Bluntly
more
been r a t i o n e d
a g r e a t number o f
i s the r e a l i z a t i o n
a l l of us.
been
soon
fathers
looming
former
stated:
be
and
99
mothers
and
Califano
because
their
increases
stagnant
in health
been
and
i s burdened
we
will
have
by
allocate
30
could not
costs.
dollar
debt.
percent
to h i g h - t e c h medical
y e a r t o l i v e . ,.100
"
of
of
whether
Reality
health
" . . . i t
care
s e r v i c e s f o r those
who
strongly
which
reform.
Medicare
have
U.S.
recession
makes s e n s e
mu1tibi11ion-do11ar
-44-
i n the
the n e c e s s i t i e s with
i n developing
our
Britain
major
of a double
trillion
questions
absorb
economy
out
i s one
i n Great
The
itself
to contend
blatantly
began
to pull
rationing
Califano
rationing
economy
care
struggling
that
us."
explains that
has
suggests
with
to
bill
less than
a
�"The
health
h e a l t h problems
care
utilizers
of
the
top
d r i v e the
few
overall
p e r c e n t i l e s of
h e a l t h care
costs
101
of
the
entire
of
Ohio's
insured
$794
group."
Blue
Cross/Blue
persons
annually
remaining
benefit
10
are
million
of
of
figures
f o r the
the r e m a i n i n g
the
top
correspond
90
percent
Those
figures,
that
the
entire
such
people
of
who
While
who
insured
burden
of
the
use
the
90
share
the
burden
$79.7 m i l l i o n
10
the
i n the
i t is important
still
of
mere
the
litany
of
of
care
cost
have
physicians,
1
decreased
-45-
that
that
the
who
cost
have
paying
been
hospitals.
bearing
i t i s only
insurers
there
health
is
the
fair
also
profits.
i n the
3
million
and
and
severe
healthy. ^
to those
physicians
t o remember
the
mental
37
i . e . , the
containment
for
indicate
and
the
for
group
s u f f e r e d from
f o r years,
of
million
this
spent
i s always
h e a l t h care
$79.7
figures
were r e l a t i v e l y
insurance;
form
of
further,
percent
is transferred
hospitals,
When c o n s i d e r i n g
field,
of
annual
$53.3
1 percent
a r i s e concerning
uninsured's
with reform,
just
services
consumers
totals
down t h e
percent
group
the
overall
d i s t r o p h y , cancer
to carry
that,
a
In contrast,
Breaking
the
uninsured,
funds
average
versus
translated
muscular
for this
sufficient
patients
as
percent
percent,
the
discussions
are
caring
of
group,
while
Whenever
ten
shows t h a t
group.
disorders^J
1 0 2
90
r e q u i r e d average
to
percent.
million
illnesses
and
executive
$10,529.
$29.1
of
that
insureds
high-cost
for
requires
found
healthy,
relatively
percent
ten
Shield
Jr., chief
in benefit payments.
payments
These
John B u r r y
care
strong
�precedent
f o r the p r a c t i c e of insurer-imposed
stated
Havighurst:
by
Ordinarily,
that
businesses
reflects
above
irrelevant
setting
than
price
c o n d i t i o n s a n d may
o f any p a r t i c u l a r
comparable
basis
t o t h e methods
rates.
are motivated
1
0
4
and
rates.
used i n
(.emphasis
t o demand
full
The
on p r o v i d e r s , and t h a t
nationwide
be
seller.
made s u p p l y
cost
supplied.)
r e i mbursement
imposition of negoti-
r a t e s a r e an e x c e l l e n t d e v i c e
consciousness
the price
t h e market
however,
As
h o s p i t a l s on a
insurer-imposed
ated p r o v i d e r
determines
and p a i d
public u t i l i t y
Hospitals
supported
the costs
Cross systsem,
nonmarket
rather
a n d demand
or below
demand
can c h a r g e ;
supply
The B l u e
competition
pricing.
f o r imposing
s t r a t e g y needs
by p u b l i c a n d p r i v a t e
cost
t o be
i n s u r e r s , and
employers.
Providers
consumers care
unquestioning
fact
that
about
h a v e no i n c e n t i v e t o r e d u c e
so l i t t l e
acceptance
insurance
paying
f o r h e a l t h care
reform
must
adherence
Placing
of governmental
that
from t h e
of the concern
The
Health
h e a l t h care
and e x p e c t e d
restrictions
government
much
infinite.
when
Consumers'
i s derived
has removed
Americans
A number o f t h e p e n d i n g
expansion
cost
h a s become
and t h e p r o p e r
t o new
subject.
o u t o f o n e ' s own w a l l e t .
demand
commodity
that
of high
coverage
f o r care
convince
about
costs
response
is a
will
consumer
care
finite
be
on i t s a v a i l a b i l i t y .
health reform
roles
in the role
i n t h e area
bills
propose t h e
of subsidies.
of i n s u r e r i s encouragement
-46-
�to
insurers
t o abandon
care
costs
will
turn
to public
public
In
coverage,
1988, t h e l a t e s t
Federal,
"spent
T h o s e who
as t h e i r
state,
$227.5 b i l l i o n
services,
research
government
share
causing
date
and l o c a l
are not p r i v a t e l y
health
sector.
the
increase.
more and more p e o p l e
For which
levels
t o Fund
cost
data
shiFting to
i s available.
oF g o v e r n m e n t
medical
and m e d i c a l
represented
major
combined
and h e a l t h
Facility
insured
care
construction.
42.1 percent
The
oF t h e t o t a l
105
national
health
Federal
expenditures."
spending
on M e d i c a i d
in
s e r v i c e s which
beneFited
is
a result
in
1 9 8 7 oF $ 5 2 . 1 b i l l i o n .
oF F e d e r a l
23 m i l l i o n
budget
1
0
F o r 1988 was
cutbacks
6
people.
1
0
7
This
billion
Figure
From a s e r v i c e
The F e d e r a l
M e d i c a r e i n 1988 was $ 8 5 b i l l i o n .
and t h e i r d e p e n d e n t s ,
and v e t e r a n s
$48.7
share
level
For
M i l i t a r y personnel
c o s t $ 2 . 8 b i l l i o n . '108
10 9
Federal
civilian
Americans
employees,
beneFited
$5.1 b i l l i o n ,
From $1.2
b i l l i o n .
1
1
and N a t i v e
0
Nitlonal Hitltli Eiptndlturet in Blllloni iseifcreu calendar yurc i970-:9Mi
1970
1975
19M
19S5
1986
1987
1988
$74 4
46.7
27.7
17 7
99
$132 9
778
55 1
36 4
18.7
$249.1
143 9
105.2
72.0
332
$420 1
2452
174 9
123 4
51 5
$450.5
259 8
190.7
132.8
57 9
$4888
280 5
208 3
144 0
64 3
$539 9
312 4
227 5
157 8
66 63
StalionaJ heaim
Bnponditures
Prrvaie
Public
Feoeral
State, local
SOURCE
L S O X C Tnmn
ntwm
• - " S o u r c e b o o k oF H e a l t h I n s u r a n c e D a t a 1 9 9 0 "
H e a l t h I n s u r a n c e A s s o c i a t i o n oF A m e r i c a
Senate
Bill
Senator
p.35
S.1177.
John
0. R o c k e F e l l e r
-
17-
[D-W.Va.) i s t h e C h a i r m ;
�of
t h e Pepper
which
would
was named
•-Fla.,
Commission
provide
aFter
the late
concerned
catastrophic
Health
with
through
to provide
employer
Claude
bill,
who
insurance
t h e Pepper
reForm.
Commission
1931 ( S . 1 1 7 7 ) ,
access
health plans
was
oF t h e e l d e r l y ,
A c t oF
universal
I t
Pepper,
oF h e a l t h r e F o r m
and c h r o n i c c a r e
RockeFe11er's
a plan
For a l l Americans.
the plight
C a r e A c c e s s and ReForm
intended
t o Formulate
Representative
advocate
illness,
Senator
worked
health insurance
t h e well-known
especially
which
t o basic
and a p u b l i c
is
health
health
care
insurance
11 1
plan.
Managed
diminished
care
i s encouraged
Freedom t o choose
S.1177 i s a P a y - o r - P l a y
by
statute
employees
qualiFied
his
to enroll
who
all
the public
Full-
does have
plan
private,
health
or p r i v a t e
gives
a l l public,
care
Senator
coverage
plans i s
oF e n r o l l i n g
1 14
year.
oF e n r o l l i n g
and t h e i r
and t h e i r
t h e employer
to enroll
the cost
F o r one
and p a r t - t i m e e m p l o y e e s
Feature
and p a r t t i m e
113 •
p e r week
in a
who n e g l e c t s
a choice
( 2 ) a l l p a r t - t i m e employees
This
employers r e q u i r e d
employees '
An e m p l o y e r
i n the public
The e m p l o y e r
or
with
t o a p e n a l t y oF t h r e e t i m e s
employees
all
Plan,
t e n o r more h o u r s
in either
translates to
o n e ' s own p h y s i c i a n .
Fulltime
health plan.
employees
subject
work
which
either
Family
Family
(1)
members,
members.
1 1 5
t h e o p t i o n oF p r o v i d i n g a l l
or a mixture
oF p u b l i c
and
to diFFerent
groups
employees.
Rockefeller's b i l l
oF
i s more d e t a i l e d
private
ini t s
A16
proposals
regarding employers
-48-
and e m p l o y e e s
than
S.1227 i s .
�S.1177 a d d r e s s e s
the
needs o f
small
employers
and
"small
117
employers
that
are
not
very
small
employers"
seasonal
118
and
temporary
part-time
employees,
119
will
p u b l i c or
penalty
1 2 0
annually
cost-sharing
far
too
based
on
high
of
on
insurance
the
health
the
has
chosen
to
Premiums w i l l
"very
pain
premium
on
in
of
public
coverage
will
return.
1
2
services.
1 2 2
should
be
amended
to
f o r incomes below
$5 0 , 0 0 0
be
1
limit
to
be
and
community
or
basic
of
enroll
impose a $3,000 a n n u a l
c o n d i t i o n s are
denial
under
insurance
Pre-existing
from
plans
annual
health
f o r many p e o p l e
scale
required to
f e d e r a l income t a x
f o r basic
a sliding
$75,000.
statutorily
to double
Proof
Rockefeller
on
be
private
amounting
insurance.
required
and
employees."
Individuals
either
p a r t - t i m e employees
health
not
rated.
1
grounds
insurance
This
2
limit
is
limits
3
for
after
exclusion
the
passage
of a s i x - m o n t h w a i t i n g p e r i o d , f o r b a s i c p u b l i c
125
insurance
or f o r b a s i c e m p l o y m e n t - r e l a t e d
insurance.
1 2 4
'1 'B
Hospitals
will
not
be
which
choose
permitted
to participate
to charge
more t h a n
under
the
Title
XXII
deductible
and
1
coinsurance
The
same r e q u i r e m e n t
One
the
payments
of
the
requirement
which
are
stipulated
i s imposed
cost
control
that
insurance
on
i n the b i l l .
12B
physicians.
measures p r o v i d e d
claims
by
be
submitted
t o be
submitted
S.1177 i s
129
electronically.
uniform
claims
A l l claims
form,
which
are
uses
-43-
uniform
on a
1 ^0
definitions.
�Medical
the
malpractice
A d m i n i s t r a t o r For
would
For
develop
persons
availability
providers
provide
There
care
which
requirement
oF
to undergo
appropriate
defensive
a f F o r d a b i 1 i t y of
schools.
results
assuring
reducing
more s t r i n g e n t
medical
are
C a r e P o l i c y and
practitioners,
quality
attend
the
and
and
i s no
Health
means o f
injured,
issues
and
will
i n the
malpractice
which
compensation
malpractice
assuring
insurance
For
providing incentives to
reduce
bill,
this
by
Research
medicine,
malpractice
however,
continuing education
I t skirts
studies
issue
and
i n s t e a d oF
suits.
that
1
3
1
physicians
at q u a l i F i e d
merely
addresses
i t s causes.
1 32
A Foster
employers
in
1383,
that,
Higgins
For
and
iF the
reFormed,
by
health
was
survey
insurance
over
$3,100
conglomerate
indicates that
For
in
to
employees averaged
1330.
'system'
costs
we
The
survey
currently
$2,GOO
projected
have
is
not
the
year 2000 t h e a v e r a g e c o s t per employee w i l l
13 3
be $ 2 2 , 0 0 0 p e r y e a r .
D u r i n g 1390, 78 p e r c e n t oF l a b o r
134
disputes concerned h e a l t h beneFits.
The U.S.
s p e n d s 40
p e r c e n t m o r e t h a n Canada on h e a l t h c a r e , 30 p e r c e n t m o r e
1 35
than
W e s t G e r m a n y , and
Senate
•
Bill
Americans
Public
1391,
Senators
and
RockeFeller
(D-NY),
entitled
the
Hea 1 t h A m e r i c a :
Act."
Health
Internal
what
Japan
spends.
1227.
I n June,
Riegle
double
The
Service
Mitchell
(D-W.Va.) i n t r o d u c e d
AFFordable
Hea1thAmerica
Act,
R e v e n u e Code oF
(D-Me.), Kennedy
the
bill
Social
198B.
-50-
Health
Care
legislation
For
CS.1227) w i l l
Security
Act,
(D-Ma.
All
amend
and
the
the
�S.1227 i s b a s i c a l l y
HealthAmerica
health
and
insurance
the other
program
provides
plans.
will
and t h o s e
replace
One
cover
plan
Medicaid
those
pay.
AmeriCare
will
will
persons.
The b i l l
necessary
to insure
an e f f e c t i v e
credits
methods
of State
and
to
f o rmalpractice
addressing
that
their
each
families
coverage
employees,
basic
p o i n t s covered a r e :
under
t h e employer
AmeriCare
businesses
inflation
health expenditure
purchasing
may
board
consortia
reform.
shall
enroll
AmeriCare.
either
benefit
enroll
the b i l l
full-time
i n a h e a l t h b e n e f i t plan
137
f o r them
system f o r
cost
employees
o_r c o n t r i b u t e
For p a r t - t i m e
them
i n a health
p l a n o r c o n t r i b u t e t o c o v e r a g e f o r them under
38
AmeriCare.
The r e q u i r e m e n t t o p r o v i d e c o v e r a g e o r c o n t r i b u t e t o
1
-5 1 -
to
f o r l o w - and
of the issues
health benefits f o r a l l ,
employer
services.
to ability
o f premiums
h e a l t h care
of a Federal
requires
according
h e a l t h care
establishment
In
care
and medium-sized
establishment
methods
do n o t o f f e r
insurance
f o rsmall-
f o r reducing
insurance
long-term
health b e n e f i t s f o r a l l through
of small-group
employers,
i s intended
a d d r e s s e s many
Some o f t h e i m p o r t a n t
reform
tax
cost
by
AmeriCare
except
subsidize
o f two basic
be p r o v i d e d
be a p u b l i c
be c h a r g e d
no-income
basic
The c o n e o f t h e
whose e m p l o y e r s
f o r a l l care
f o r AmeriCare
future.
will
who a r e u n e m p l o y e d .
Premiums
the
Plan.
For t h e e s t a b l i s h m e n t
p1an--AmeriCare--wi11
which
coverage
to
bill
a Play-cr-Pay
�AmeriCare w i l l
voluntarily
139
n o t be i m p o s e d
on any s m a l l
of
i n s u r e s 75 p e r c e n t
their
business
which
previously
uninsured
workers .
An
e m p l o y e r may
enrolling
to
meet t h e r e q u i r e m e n t s
i n any h e a l t h
140
employees
the b i l l ' s
of t h i s
p l a n which
requirements
benefit
bill
and i n c l u d e s c o v e r a g e
(1)
inpatient
and o u t p a t i e n t
hospital
(2)
inpatient
and o u t p a t i e n t
diagnostic
(4)
prenatal
conforms
for:
physician services
(3)
by
who
(5)
tests
care
and w e l l - b a b y
a r e one y e a r
-- w e l l
child
-- pap
by
the b i l l ,
but are subject to
a r e some
(1)
items
(2)
routine
than
very
the b i l l
explicit
does
bill
health
and s e r v i c e s t h a t
physical
care
are l i m i t e d t o :
necessary
limitations.
exceptions to
payment f o r :
are not medically
necessary;
or p r e v e n t i v e
Items
[other
1 4 3
part
an i n c r e a s i n g
t o a system
-52-
included i n
of the overall
and s e r v i c e s t h a t
become
c o n s u m e r s h a v e become u s e d
procedures.
t o payment have been
t o reduce
have
coverage.
i n ( 4 ) and [ 5 ] , a b o v e ;
three exceptions
i n an a t t e m p t
or c o u n s e l i n g are covered
142
examinations
described
expenditures.
medically
younger;
not include
e x p e r i m e n t a l s e r v i c e s and
These
provided to children
care
141
-- mammograms.
disorders, psychotherapy
Specifically,
the
which
care
smears
There
(3)
o f age o r
preventive services,
Mental
care
national
are not
problem
because
of t h i r d - p a r t y
payers.
�The
Pepper Commission
ineffective
estimated
h e a l t h care
added
that
"unnecessary or
as much as $ 1 8 b i l l i o n
annually
144
to
health
care
insurance
tend
costs."
companies
will
cost
as t h e 1 3 5 0 s a n d 1 9 6 0 s ,
t o those
have
be l i f e
which
services
b u t may
serious
side
saving
limits
offer
four
experimental
their
their
of
view
also
view
very
will
problem
leaves
broad
wherever
as
having
one
assenting
of accurate
analysis
the b i l l ,
intent
their
and p u r p o s e
was
used.
The
f o u r p a r t s o f t h e h e a l t h care
cost
problem a r e :
. .
cost
..
..
shi fting
unnecessary care
excessive a d m i n i s t r a t i v e costs
. ,
open-ended
The
accept.
b u t d i s t r e s s e d by some o f
in drafting
explaining the b i l l ' s
to
with
expenses
explanation
In the interest
of the Senators
treatment
be d i f f i c u l t
the health cost
problems,
o r may
t h e s e c t i o n o f S.1227
increasing costs
of their
remedies.
Summary
are not only
some e x p e r i m e n t a l
people,
procedures
of four overall
the intentions
Executive
S.1227 a d v o c a t e s a
methods o f d e c r e a s i n g
A reading
suggested
As
bore t h e
benefit to the patient,
However,
America's
The S e n a t o r s
parts.
no r e a l
and f o r t h e s e
at different
possible.
people
system.
consumers r o u t i n e l y
and p r o c e d u r e s
effects.
S.1227 a d d r e s s e s
attempts
services,
days.
Experimental
expensive
that
d e m a n d s on t h e p r o v i d e r
of r o u t i n e physical examinations.
return
to
pay f o r a l l p r o v i d e r
t o make m o r e f r e q u e n t
recently
can
When i t i s p e r c e i v e d
Senators
state that
cost
reimbursement
shifting--the
-53-
146
to providers.
cost
of the uninsured
�is
passed
and
on t o t h e i n s u r e d
higher
i n t h e Form o f h i g h e r
provider services--wou1d
premiums
be e l i m i n a t e d by u n i v e r s a l
147
coverage.
But, t h e u n i v e r s a l coverage
AmeriCare
care
by
(replacing Medicaid]
coverage
w i t h premiums
t h e Federal
considered
method
provide
oFten
such
reductions
will
tions.
Neither
occur
would
would
subsidized
can h a r d l y
be m e r e l y
oF t h e c o n s u m e r
that
t h e Federal
be F i n a n c e d
when g o v e r n m e n t
one more
higher
taxes t o
under
Medicaid
i s insuFFicient indication
however,
i s the obvious
be
paying
pay h i g h e r
BeneFits
nor t h e pending
will
citizens
be
itselF
by s t a t e a n d F e d e r a l
the currently
The
contribu-
1
3
which
uninsured.
S.1227 Summary s t a t e s :
Universal h e a l t h insurance coverage i t s e l F
s i g n i F i c a n t 1 y r e d u c e s t h e c o s t oF h e a l t h c a r e t o
b u s i n e s s e s and i n d i v i d u a l s c u r r e n t l y
purchasing
insurance.
Uncompensated care r a i s e s p r i v a t e
h e a l t h i n s u r a n c e p r e m i u m s an e s t i m a t e d 10 t o 15
percent.
...
The p u b l i c p r o g r a m w o u l d be F i n a n c e d by s t a t e
and F e d e r a l c o n t r i b u t i o n s .
States would r e c e i v e
an e n h a n c e d F e d e r a l m a t c h , p h a s e d o u t o v e r t i m e ,
For c o v e r a g e o f n e w l y e l i g i b l e p e r s o n s and o t h e r
new p r o g r a m c o s t s i n t h e p u b l i c p r o g r a m . ^
This
e n h a n c e d m a t c h w o u l d be a s p e c i F i e d
percent
i n c r e a s e over a s t a t e ' s c u r r e n t matching r a t e For
the Medicaid
program.
The S e n a t o r s ' " s o l u t i o n " F o r u n n e c e s s a r y c g r e ' i s
-54-
devised
explains
c o s t - s h i F t i n g addressed
1 5 0
that
Neither the
legislation
insures
have
The
Financing w i l l
148
deFicit.
by
medical
be e l i m i n a t e d i n t h e F u t u r e .
not increase
t h e program
they
and t h e r e
could
Summary
Instead
be p r o v i d e d
be B a s i c
arrangement
subsidies.
do s t i p u l a t e ,
Executive
will
reduced,
This
Fees,
For government
been
which
shiFting.
would
o f low-income
when A m e r i C a r e
and p r o v i d e r
Senators
how
a solution
oF c o s t
premiums
government.
which
would
�Frightening
a lack
because
i t exhibits
inadequate analysis
oF u n d e r s t a n d i n g oF t h e c a u s e s
other
oF u n n e c e s s a r y
The
only
the
Senators preFer n o t t o acknowledge
unnecessary
reason For t h e i n c o r r e c t
c a r e For Fear
Association.
eration
but
By
has r e s u l t e d
does
undermine
permitting
decision
the provision
third
parties
even
necessary
t o make
S.1227
accurate
a program
which
While
in
there
this
those
remedy
and
care
care w i l l
t h e causes
care.
with
power t o
For
third
i n absentia.
be r e d u c e d
research
passed
until
unnecessary
oF t h e b i l l
would
imposed
the practice
have
care.
oF d e F e n s i v e
-55-
oF
patient,
i s paid to
Four
Fortitude,
proposed.
considered that
unnecessary
oF:
m e d i c i n e by
oF m a l p r a c t i c e
care
be
IF these
or g r e a t e r
because
1
the d r i v e r s
care t o a
n o t have been
on p a t i e n t s
by t h e s p e c t e r
c a r e must
attention
insight
5
oF u n n e c e s s a r y
to c u r t a i l
care unnecessary,
greater
1
o r u n n e c e s s a r y . . ."
to limit
oF t h a t
by
to determine
oF u n n e c e s s a r y
the Senators should
has been
concerned
consid-
nothing
I t i s not possible
i s necessary
had e i t h e r
section
a.
Medical
health
i s provided
medical decisions
legislation
t h e causes
Instead,
oF
the physician/patient
I t makes no s e n s e
that
politicians
this
which s o l v e s
has been a g r o w i n g i n c i d e n c e
causes.
labelling
causes
t h e American
oF a d e q u a t e
party
oF o u t c o m e s
care
country,
adddressed
i s that
states:
"Unnecessary
(1)
the true
t o oversee
care.
"solution"
care.
oF t h e l e g i s l a t o r s '
in a "solution"
process, the t h i r d
eliminate
parties
oF a n g e r i n g
The i n s u F F i c i e n c y
and/or
suits;
physicians
152
�b.
investments
manufacturers
and
by
providers
technological
i n medical
services
equipment
providers,
and
153
laboratory
own
services.
patients
to
The
these
subsequent r e f e r r a l
businesses
i s commonly
of
their
known
as
'self-referral . '
1 54
c.
consumers'
Therefore,
the
unnecessary
overruns.
care
to
second
guess,
and
malpractice
be
of
judgment
should
not
to
services.
address
which
cause
detrimental
a third
1984
should
which
party
of
a
not
to
to
the
individual
oversee,
patient's
inhabit
become p a r t
suits
the
what
and
only
in avoiding
care
be
every
of h e a l t h
care
practice
physician
to
for
which
but
-5G-
help
expertise
avoid
necessary
requirements
are
care
S.1227.
"assist
1 5 6
than
is
insurers
is
insurers
insurance
a treating
or
guidelines
guidelines
These two
i t legal
owning
technological
skills
will
from
practice
reimbursed"
for procedures
No
and
unnecessary
which
should
makes
physicians
maintain
care.
guidelines
which
payment
unnecessary.
the
unnecessary
Practice
legislation
to
knowledge
are
point
prohibit
interest,
physicians
medical
eliminate
refuse
and
in conflictsof
improve
deciding
duty
i n which
problems
i t could
Orwell's
office,
require
to
the
s u b s t i t u t e the
guidelines
investing
more
solve
increased
D e v e l o p m e n t o f p r a c t i ce g u i d e l i n e s t o a s s i s t
p h y s i c i ans i n p r o v i d i n g o n l y n e c e s s a r y c a r e
and a s s i s t i n s u r e r s i n d e c i d i n g w h a t c a r e
s h o u l d be r e i m b u r s e d . 1 5 5
Practice
to
manner
i t the
physician.
reform.
(2)
and
sensible
i s to
consider
physician's
which
demand f o r
Additionally
health
primary
only
infinite
in
to
in
reality
continue
physicians
physician
can
to
deem
know
�what
treatment
treatment
One
oF
would
the
insurers
are
wrest
be
main
reForm
From
Yet
the
that
No
should
care
m u s t be
b l e s s i n g oF
this
oF
protective
inFlation
Senators
incensed
legislation
control
not
and
has
be
reForm
is
insurers to
could
be
and
insurance
the
should
lobby
practice
consumers
oF
protective
been
more
Instead,
consumers
the
written
oF
late--
legislaunder
cost r e d u c t i o n !
an e n h a n c e d p r o g r a m oF t e c h n o l o g y a s s e s s m e n t
to h e l p determine t h e useFu1ness o F expensive
med i c a 1 t e c h n i q u e s . 157
Orwellian
oF
medical
to solve
one
problem.
determine
on
techniques
the
how
highly
useFulness
Attention
may,
lift
can
be
be
cure
paid
be
leFt
research.
country
a potential
must
i n t i m e , prove
never
oF
the
they
also
Fight against a t o t a l l y
I t should
unlikely
of
Findings
disease
useFulness
to
cannot
ScientiFic
investigation.
more b e n e F i c i a l i n t h e
is
oF
so
useFulness
agree
protective
has
with
will
S.1227 i s .
reimbursement--which
guise
health
legislation
that
and
that
For
Four
And
meant
a mandate
than
time.
concerning
the
continued,
given
is
and
The
(3)
The
will
decisions
industry
be
any
what
consumers t o s u p p o r t
pending
insurance
and
c o n s u m e r s now
S.1227 p r o v i d e s
practice.
oF
For
at
reimbursed.
t o be
the
Facing
i n s u r e r s oF
o b v i o u s l y persuaded
tion.
necessary
reason
legislation
denying
is
or
A major
this
legislate
has
unnecessary
patient,
d e c i d i n g what c a r e
reimbursement.
protective
a particular
diFFiculties
control
continue
For
already
reimbursed.
to
i s best
to
-57-
out
relied
are
t o be
even
diFFerent
cannot
to
even
a r e c e s s i o n , so i t
upon
f o r AIDS o r
the
which
an
to bureaucracies
They
of
suFFer
benefits
to determine
the
cancer.
of
cost
cutting
�in
a l l businesses.
would
be
But
disastrous to
consider
two
to consider
the
i n c i d e n t s oF
Future
cutbacks
h e a l t h oF
in
technology
mankind.
Merely
technological expertise:
1.
"The
m o s t e F F e c t i v e way t o t r e a t a u t o - i m m u n e
diseases
s u c h as m u l t i p l e s c l e r o s i s i s t h r o u g h d r u g s t h a t
s u p p r e s s t h e immune s y s t e m .
But t h e s e d r u g s a l s o
l e a v e p a t i e n t s a t r i s k For i n F e c t i o n s .
• r . H o w a r d W e i n e r , c o - d i r e c t o r oF t h e C e n t e r F o r
N e u r o l o g i c D i s e a s e s a t B r i g h a m S Women's H o s p i t a l i n
Boston i s t r y i n g to t r e a t m u l t i p l e s c l e r o s i s ,
r h e u m a t o i d a r t h r i t i s , a n d o t h e r d i s e a s e s by F e e d i n g
patients certain proteins.
In multiple sclerosis,
For
e x a m p l e , T c e l l s - - t h e b o d y ' s key deFense a g a i n s t
Foreign invaders--atack a myelin p r o t e i n sheath
on
nerves.
... The s c i e n t i s t s t h i n k o r a l i n g e s t i o n oF
t h e r i g h t p r o t e i n t u r n s oFF t h e T c e l l s , n e g a t i n g t h e
immune s y s t e m ' s a t t a c k .
"The e l e g a n c e oF t h i s a p p r o a c h
i s i t s s p e c i F i c i t y a n d l a c k oF any u n l i k e l y s i d e
e F F e c t s " e x p l a i n s D r . D a v i d H a F l e r oF H a r v a r d U n i v e r s i t y .
I t c o u l d a l s o s t a v e oFF r e j e c t i o n oF t r a n s p l a n t e d
organs.
R e s u l t s From human s t u d i e s s h o u l d be a v a i l a b l e
w i t h i n a year."''SB
2.
" E v e r s i n c e t h e v i r u s was d i s c o v e r e d ,
scientists
h a v e b e e n t r y i n g t o u n d e r s t a n d how AIDS d i s a r m s t h e
body's deFenses.
The p r e v a i l i n g t h e o r y i s t h a t HIV
i n F e c t s t h e immune s y s t e m t h r o u g h t w o r e c e p t o r s on
t h e s u r F a c e oF c e l l s t h a t n o r m a l l y F i g h t oFF i n F e c t i o n s .
But r e s e a r c h e r s a t Medarex, I n c . , a b i o p h a r m a c e u t i c a 1
c o m p a n y i n P r i n c e t o n , N.J.,
and D a r t m o u t h
Medical
S c h o o l h a v e F o u n d t h a t one oF t h o s e s i t e s a c t u a l l y
r e s i s t s HIV i n F e c t i o n .
The s c i e n t i s t s s a y t h a t w i t h
t h e h e l p oF a new c o m p o u n d , t h e s o - c a l l e d Fc r e c e p t o r
c a n t u r n t h e immune c e l l i n t o a h i g h l y e F F i c i e n t k i l l e r
oF t h e v i r u s . ... M e d a r e x i s h o p i n g t o s t a r t t e s t s oF
b i s p e c i F i c a n t i b o d i e s on humans n e x t
year."'-'
3
The
anyone
to
above
to
impose
are
too
the
radical
crucial
cost
For
that
comprise
utilization
that
are
reductions.
survival.
oF
while
5 percent
these
suFFicient
technology
the
oF
i s not
H.
the
area
Magazine,
Association
purchase
may
in
p r i c e oF
h e a l t h care
technologies
example
Technological
Alan
Industry ManuFacturers
explained
devices
developments
comprehend
Health
D.C.
two
which
advances
President
oF
Washington,
technological
costs,
increase
in
For
the
that
percentage
�From
10
t o 40
percent.
Thus,
to
F o c u s on
technological
160
innovation
For
cost
cutting
Over u t i l i z a t i o n
deFensive
Fear
oF
result
medicine
the
advanced
adequate
available.
physician
usage
oF
never
and
less
be
a result
and
Over u t i l i z a t i o n
American
whatever
ails
public
them,
c o s t l y m e t h o d s may
Forementioned
technological
who
care
blame
waste.
the
incentives
They
patients
will
For
be
the
a
most
though
readily
practice
the
oF
increased
procedures.
Fruits
techno1ogy--For
the
i s also
even
also
oF
hospitals in
se1F-reFerra 1 c o n t r i b u t e s g r e a t l y to
Fix
oFFer
For
can
goal.
physicians
the
A d d i t i o n a l l y , the
"Those
health
i n s i s t a n c e oF
Far
by
litigation.
treatments
and
technology
practiced
malpractice
oF
oF
i s a misplaced
innovation--that i s ,
sins
i n our
only
longer,
the
oF
oF
system
stop
the
utilization,
that
lead
medical
more p r o d u c t i v e ,
to
will
overuse
innovations
and
higher
that
quality
lives."
On
Fact
the
that
opposite
the
U.S.
scanners
while
scanners
enable
oF
the
body.
dollars
and
Fact
provides
Canada has
The
costs
are
passed
only
to break
incentive to
possible
oF
on
adding
to
issue,
15.
three-dimensional
i n order
as
this
2,000 m a g n e t i c
a h o s p i t a l must
day
oFten
has
oF
Each s c a n n e r
each
as
side
the
For
new
costs
scan
even
resonance
Nuclear
viewing
between
$2
on
the
potential
lies
resonance
soFt-tissue
and
oF
4
e i g h t people
162
investment.
to prescribe
devices
parts
million
This
such
patients...oFten
technological
the
imaging
magnetic
oF
a minimum
providers
consumer.
-59-
however,
testing
unnecessarily
i n each h o s p i t a l
�American
For
these devices which
equipment
Thus,
i n hospitals
Americans
Hospitals
cost
to
units
this
expensive
equipment
with
consumer
exorbitant
guidelines
which
their
hospitals
Center
a l l their
Stand-alone
For
to
other.
access.
the highFurther
are within--For
other--shou1d
n o t be
permitted
on a d a i l y
b a s i s For
Duplication
oF
such
when t h e n a t i o n i s
bills.
i n conjunction
with
t o deal
hospital
and
hospitals are
Current certiFicates
insuFFicient
oF
with
p e r c e i v e as e F F e c t i n g b o t h
Funded
patients
be t o h a v e
require
Centers
such
would
t h e a m o u n t oF d u p l i c a t i v e
beFore
speciFically
would
n o t reduce
medical
care.
prescribing
because
a centrally
by a l l t h e h o s p i t a l s
who
Technology
Full-service
Fees
easy
should determine which
might
area, b u t would
pause
each
need
this
mounting
their
prestige
pocketbooks.
Technology
given
which
necessary.
oF
a little
i s not u t i l i z e d
commission,
equipment.
An a l t e r n a t i v e
reducing
to travel
oF e a c h
medical
are obviously
which
nearby
i s economically wasteFul
representatives,
receive
to duplication
by s u c h
Hospitals
which
locations
t o have t o s h a r e
have
i s deFinitely
A governmental
by
'spoiled'
will
drive
equipment
which
and
has l e a d
are r e l a t i v e l y
technology.
a 30-minute
duplicate
problem
which
have become
treatment
to
oFten
and consumers
utilize
Faced
demanded c o n v e n i e n t
oF t h e F u t u r e a r e g o i n g
example,
to
consumers have
and
expensive
have
located
Frequented
procedures.
the beneFits of
equipment
available
t h e t y p e s oF e q u i p m e n t
The C e n t e r s
may
treatments u t i l i z i n g
in their
- SO -
proFit
base
needed
cause
providers
such
equipment
i ti s not immediately available
n o t be i n c l u d e d
in a
which
t o them, and
may
reduce
�the
incidents
break
even
of
on
unnecessary
their
Considering
in
S.1227, and
patient
care
of
the
reform.
a huge
the
everyone
the
use
in a
that
this
the
containment
proposals
Expenditure
Board
of
of
health
rate
care
goals.
The
quality
data
others
can
use
Senate
Bill
Senator
Health
imposes
i n S.1227.
will
be
this
providers
which
the
most
gather
48
While
insurance
state
insurance
in
place.
some
valid
cost-
Health
will
"establish
and
a
providers
health
expenditure
publish
cost
patients,
efficient,
1 6 3
American
purchasers
and
that
by
solution, i t is
included
between
so
solved
A Federal
created
also
legislation
already
within overall national
will
appeasement
forms.
more t h a n
have
of
t o be
billing
health
pending
of
h i s t o r y of
of
Senators
Ourenberger's
Act
of
high
requirements
as
equally
on
players
wno
and
as
legislative
1931
c o n t r i b u t i o n to
industry
other
are
for
and
insurers,
quality
and
providers."
S.700
Security
industry's
to
included
of
statement
s o l u t i o n i s not
negotiations
Board
on
150-year
challenge
form
e f f i c a c y of
f o r decades
Fortunately,
process
dangerous
the
protection
meet t h e
standardized
with
of
a political
in the
of
existence
i n order
protectionism
lack
a d m i n i s t r a t i v e costs
that
commissions
insurer
S.1227 d o e s n o t
agrees
astonishing
and
of
correspondent
industry
requiring
amount
I t i s merely
Excessive
imposed
investment.
the
rights,
procedures
(S.700) addresses
the
health
penalties
i t imposes
lack
offering,
on
the
the
American
insurance
care
problem,
this
power-packed
regulations
such e x t e n s i v e
-6 1 -
and
and
penalties
influence.
1 E 5
�As l o n g a s h e a l t h c a r e c o s t s c o n t i n u e t o
r i s e a t e i g h t t o t e n percent a year Faster than
t h e r a t e oF i n F l a t i o n - - a s l o n g a s h e a l t h s p e n d i n g
c o n s u m e s 12 p e r c e n t o r m o r e oF o u r g r o s s n a t i o n a l
product--doomsday i s j u s t around t h e corner.
How
can A m e r i c a hope t o c o m p e t e i n t h e w o r l d economy i F
m o r e a n d more oF o u r n a t i o n a l r e s o u r c e s a r e b e i n g
c o n s u m e d on h e a l t h c a r e ?
Clearly, real cost control
must F i g u r e p r o m i n e n t l y i n any r e F o r m e F F o r t - - a n d
r e a l c o s t c o n t r o l i s a m a j o r p a r t oF t h e b i l l I am
i n t r o d u c i n g today.
-- Rep. Dan R o s t e n k o w s k i , C h a i r m a n
C o m m i t t e e on Wgyg a n d Means
A u g u s t 2, 1 9 3 1
The H e a l t h I n s u r a n c e C o v e r a g e a n d C o s t C o n t a i n m e n t A c t oF
1 9 9 1 , H.R. 3 2 0 5 , w o u l d c o n t a i n c o s t s b y p l a c i n g a n a t i o n a l
1 5 5
limit
on h e a l t h e x p e n d i t u r e s ,
national
be
product
permitted
through
are
through
2000.
control
and
growth
using
i n 2 0 0 1 , h e a l t h care
This Act
statutorily
cost
is
elects
r quired
For payment
t o pay a minimum
plan,
that
o p t For the
pay p l a n .
i n t i e public
medical
insurance
plan
penalty
which would
168
p l a n . 169
would
be d o u b l e
unemployed
Failure
subject
A
to
by i n s u r e r s
with
167
employers
oF t h e
i s expected
oF
employer;
would
to enroll
the individual
the cost
-62-
increases
t h e employer
15 p e r c e n t
The
GNP
providers
oF t h e t a x - - w h i c h
It
i s expected
over
oF 80 p e r c e n t
oF p a y r o l l - - w h i c h e v e r
would
be e x p e c t e d
rates with
a pay-or-play
o r 80 p e r c e n t
GNP
a s GNP.
would
9 percent
t o do.
enrolled
basically
above
cost
oF g r o w t h
Commission
r a t e s as c e i l i n g s
oF p r e m i u m s
be a b o u t
would
Containment
t o gross
t o one p e r c e n t
by n e g o t i a t i n g a n n u a l
those
be t i e d
increase
1994, d w i n d l i n g
Starting
Care Cust
would
A 4 percent
t o be l i m t e d t o t h e same r a t e
Health
to
(GNP).
which
oF p r e m i u m s .
be
in a
to a
170
basic
�Standards
Plans
not
would
pr •
be
For
Vi
coverage
ding
"sub j e c t
m u s t be
s e t For
the e s t a b l i s h e d
to a tax equal
minimum
to FiFty
premiums
c o l l cted
and
employer
p l a n 3 For
purposes
oF
the plan
would
and
a health
Financin
taxes
on
empl y e r s
corporation^
surtax
with
in
For
the
the
hospiti1
taxable
tax
Substance
an
to
derived
surtax
and
as
qualiFied
From
the
imposed
trusts.
171
payroll
on
The
health
liability
172
t o 9 p e r c e n t by
The
199S.
tax would
Social
climb
to
eFForts
Increases
be
imposed
Security
1 .55
on
hospital
percent
both
insurance
1
i n 1996.
'
and
7 3
po i n t s
ov e r c r o w d e d ,
t h e r e s e e ns no
overcome tne
the
is actually
health
care
children,
a result
abuse
oF
oF
'substance
drugs
end
and
oF
newer
and
-63-
on
an
police,
whom
suFFer
abuse.'
health
care
alcohol.
oFFicials
spending
Prohibiting
oF
can
As
increases, prisons
public
t o government
problems.
dev e l o p m e n t
oF
abuse
oF
by
term reFers to
Facilities,
many
out, organized crime
corruption
undermined
correct
increase i n spending
to increased
174
the p o l i t i c a l l y
unborn
as
the
c o n t i n u e t o be
the a c t i v i t y
innocent
h a l F oF
traced
spurs
be
estates
aFFects
b i r t h deFects
One
and
status
the
a 6 percent increase i n tax
Though
which
socie
Thornton
p e r c e n t oF
i n c r e a s e From $ 1 2 5 , 0 0 0 t o $ 2 0 0 , 0 0 0
•ate w o u l d
a SL b s t a rn e e ,
oF
become
would
abL se
Families,
be
ase
hea1thcoverage
the pay-or-play requirements.
insurance payroll
c o r t a inment
substance
severe
their
insurance,
Abt s e .
Cost
entire
be
and
and e m p l o y e e s .
wage
SSHI
abuse
ndividuals,
19 33 w o u l d
lose
also
b u r d :n c l i m b i n g
emp1oyers
the
For
would
health
each
increases,
i n vain
substance
more p o t e n t d r u g s .
attempts
merely
The
�methods
u s e d i|n t h e
r e c o g n i zed
the
p rovides
his philosophy
i n merely
a general
lesson
that
i n the
United
must
be
one
sentence:
s o c i e t y can
States
no
than
in
175
Union
As
Auburn
abuse
engineered
succes|s F u l l y
Soviet
substance
n e F F e c t i ve.
provides
"Prohibition
t o stem
175
as
Thornton
more be
past
A s s i s t a n t ProFessor
oF
Economics
at
Universi
ty , Thornton
that
heeded
the
lessons
oF
the
of
problems
urges
1 9 2 0 - 1 9 3 3 be
Prohibition
a
on
ational
scale.
today,
Thornton
when we
Face
drug
contends:
1.
Proh ib i t i o
2 .
Consumpt i o
3 .
a c t u a l l y r o s e s t e a d i l y a F t e r an i n i t i a l
drop.
G o v e r n m e n t 1 s p e n d i n g i n c r e a s e d s i g n i F i c a n t 1y d u r i n g t h e
p r oh i b i t i
p e r i o d t o c o v e r t h e e x p e n s e s oF:
did
a.
b.
t h e Bu
Coast
over $
Custom
Police
c.
d .
Thornton
not
e l i m i n a t e the
consumption
oF
alcohol.
eau oF P r o h i b i t i o n ( o v e r $13
million);
5uard a c t i v i t i e s d e v o t e d t o p r o h i b i t i o n
[also
13 m i l l i o n p e r
year.
S e r v i c e b u d g e t i n c r e a s e d 123 p e r c e n t .
173
F o r c e b u d g e t i n c r e a s e d more t h a n 11 p e r c e n t .
1 7 7
also
explains
that
p a t t e r n s of
alcohol
consumption
c h anged d u r i n g P r o h i b i t i o n .
Alcohol's
ness
yo j n g
i t b e c a m e "a
to
a s s o c i ated
product
oF
the
sellers
increased^
and
i n c -eased
higher
reFused
drinking
Also,
and
intrigue."
Prohibition
because
proFits.
t o be
told
defiantly,
a k i nft o f d e d i c a t e d
today .
. . .by
w re
because
excitement
during
i n c d e n c e oF
drink..."Men
oF
heightened
with
immi g r a n t s
newer
purpose,
was
drinking
attractive-
Also,
that
glamour
The
oF
the
older
they
with
you
Americans
could
a sense
that
number
of
not
high
don't
see
much
1 80
"P r o h i b i t i o n
i n c r e a s i ig t h e
may
actually
availability
-64-
of
have
increased
drinking
a l c o h o l " i n many
more
�e s t a b 1 i shment
than
there
had been p r i o r
Prohibition,
Additionally,
regu1ated the
number o f l i q u o r
and
t i m e s o f day
prior
which
liquor
those
political
speakeasies
And s 3 we s e e t h a t
occurred
wi t h
jrohibition
private
regula ion
reduced
absent e i s m ,
was
tried
of
tools
sold,
and l e d t o t h e
middle-
were
formerly
t h e e x a c t same s i t u a t i o n
drug
reduced
use.
•181
drinking
In
improved
industrial
has
contrast,
the
productivity,
accidents
wherever
1 82
b
during
and a f t e r
prohibition,
the af
ermath
Mi s e s
be
locations that
employees'
and
fore,
In
of
could
i n business d i s t r i c t s ,
c l a s s n e i g h b o r noods , a n d o t h e r
d r y ..."
l a w s had
l i c e n s e s and t h e l o c a t i o n s
during
e s t a b 1 i shment
it
to Prohibition,
eL i m i n a t e d
"Prohibition
t o the onset of
of P r o h i b i t i o n ,
economist
Ludwig
von
wrote,
Ince t h e p r i n c i p l e i s a d m i t t e d t h a t i t i s t h e
o f gov e r m ;ent
t o p r o t e c t t h e i n d i v i d u a l a g a i n s t h i s own
s e r i o u s o b j e c t i o n s c a n be a d v a n c e d
against
foolishness, n
duty
further
183
encroa hments."'
voluntary
1i b e r t y
in
now
as i t s
the Progres ive
For
than
too
e x c h nge
the m
enactment
Era."
close to advocating
t h a t may
evil
downturn
to the restoration
t o t h e cause
there
of
of
of b i g
government
1 8 4
timid
prospect of legalizing
the release
not prove
Though
i n u s a 3 e,
was
of a l l p r o h i b i t i o n
of Americans--more
Mark T h o r r t o n - - t h e
unleashed
•N
F
i s as i m p o r t a n t
jority
a society
The r e p e a l
of a deeply
capable
legalization
is likely
-65-
of soul,
drugs
appears
evil
f o r c e on
of containing
may
surely,
eventually
t o be an e a r l y - o n
that
see a
increase.
�"Ordinarily,
approve
the
i
takes
a generation
a ma j o
piece
oF s o c i a l
c u r r e n t be i e F s
laws h e l d
by a m a j o r i t y
suFFicient
numter
a c k n o w l e d g e th<
would
drug
legislation."
abuse and d r u g
oF A m e r i c a n s ,
agree
accuracy
time
i s not et
y
As a r e s u l t ,
enForcement
correlation
H a r r ii s
s
For implementation
h da 1 t h c a r e
costs
will
continue
The
cost
to society will
too
retarded
continue
as t h e s e
a productive
place
t o pay For i t s d i s i n c l i n a t i o n
between
6
i s right.
views.
t o climb For
w i t h d r u g - r e l a t e d and a 1coho1-re1 ated
continues
that a
oF T h o r n t o n ' s
newborns
t o take
Considering
w i t h o r have t h e c o u r a g e t o
oF T h o r n t o n ' s
ripe
1 8 5
i t i sn o t l i k e l y
^. t o
a n d d r g u s e a n d p r o h i b i. i. n .
alcohol
The
about
o r more F o r C o n g r e s s t o
birth
babies
within
deFects.
grow,
a society
t o change
many
which
t h e unworkable
s t a t u s quo.
FEDERAL HEALTH CARE PROGRAMS.
During
proposed
succeeded
and
insurance
that
issue
For t h e presidency,
For t h ee l d e r l y .
he w o r k e d
Caspar
environment
a national health
t o pass
campaign
t h e Medicaid
When L y n d o n
on e n a c t m e n t
i n h i ssuccessFul
i n 1964.
political
legislate
was a b l e
F. K e n n e d y ' s
t o t h e Presidency,
Goldwater
difficult
to
health
included
Barry
John
campaign
Weinberger
surrounding
care
plan.
Johnson
oF M e d i c a r e
against
described the
t h e many
President
plan by:
" . . . e 1 i m i n a t ( i n g ) t h e o p p o s i t i o n oF t h e
v a r i o u s h e a l t h c a r e p r o v i d e r s by a g r e e i n g i n
advance t h a t t h egovernment would n o t t r y t o
r e g u l a t e or c o n t r o l t h eh e a l t h care s e r v i c e t o
be p a i d F o r by t h e g o v e r n m e n t ; a n d a s e v i d e n c e
oF g o o d F a i t h . . . t h e r e w o u l d be no g o v e r n m e n t
challenge t o t h en e c e s s i t y For t h e service--no
-66-
he
attempts
Johnson
�government i n q u i r y i n t o the p r i c e of the
s e r v i c e o r t h e q u a l i t y oF t h e s e r v i c e F u r n i s h e d .
The o p p o s i t i o n c r u m b l e d s u F F i c i e n t l y so t h a t t h e
n e c e s s a r y v o t e s w e r e s e c u r e d , and we h a d
Medicare.
For s e v e r a l years t h e government k e p t i t s
p a r t oF t h e b a r g a i n .
T h e y d i d n ' t make any
inquiry
i n t o t h e need o r t h e c o s t o r t h e q u a l i t y , and
we
w e r e w e l l l a u n c h e d on t h e r o a d t o h e a l t h c a r e c o s t
inFlation.
OF c o u r s e , t h e r e a r e s e v e r a l o t h e r
c a u s e s , and I w o u l d n o t w a n t t o say t h a t
Medicare
was t h e s o l e c a u s e , b u t i t s u d d e n l y i n j e c t e d t h i s
e n o r m o u s new demand i n t o t h e s y s t e m , a c c o m p a n i e d
by a g u a r a n t e e d p a y m e n t F o r w h a t e v e r t h e s e r v i c e .
T h a t s i m p l y m e a n t t h a t t h e r e was now h e a l t h c a r e
a v a i l a b l e t o be u s e d n o t as n e e d e d , b u t s i m p l y
b e c a u s e i t was
there."
I n a d d i t i o n , b e c a u s e oF t h e d e s i g n oF t h e
M e d i c a r e i n s u r a n c e ... t h e r e was a h e a v y e m p h a s i s
on t h e u s e oF t h e m o s t e x p e n s i v e a n d , I s u p p o s e ,
s o m e t i m e s t h e m o s t u n n e e d e d t y p e oF c a r e
(namely,
h o s p i t a l i z a t i o n ) w i t h o u t s u F F i c i e n t e m p h a s i s on
o t h e r t y p e s oF c a r e . " ' '
8 7
-Pending
inFlationary
Most r e F o r m
rates
For
Medicare
care
Fee-For-service
plans
are
oF
Medicaid
relation
to health
Congress
because
would
insight
currently
For
providers.
annua 1 1 y - n e g o t i a t e d
study
on
those
study
into
plans
plans
the eFFects
the
costs
oF
that
and
are
any
state
being
paper
being
address
potential
out
Federal
now
such
has
set
eFFects
oF
the
oF
expansion
government
in
in
n e e d s oF
the
provides a
reForm
of
plans.
Medicaid
expenses,
"elsewhere
of
the
value
considered
expansion
impacts
borne
-67-
the
to the problem
Their working
reForm
points
considered
a solution
a l l these
Noting
impact
method
the
hospitals.
as
of u n i n s u r e d .
The
payment
addresses
Medicaid.
millions
uninsured.
Weinberger
legislation
proposing
Hoiahan/Zedlewski
expansion
better
reForm
p h y s i c i a n s and
and
The
health
Caspar
i n the
while
health
�Percent: I n c r e a s e s i n M e d i c a i d Caseloads and Costs b y S t a t e
A f t e r Program Expaflion t o 100 P e r c e n t o f P o v e r t y ^
-
1989
Caseload
(Thousands)
1989
Cost
(Millions)
Enrollment
Scenar i o ^
(2)
(3)
(1)
Enrollment
Scenario^
(2)
(3)
(1)
21,410
128%
-79%
38%
S25,700
85%
59%
35%
460
520
85%
87
40%
45
24%
15
S840
690
54%
47
30%
27
21%
13
Middle A t l a n t i c
New J e r s e y
New York
Pennsylvania
550
2,020
980
91%
82
83
52%
50
43
25%
25
22
$860
3 , 980
1,240
68%
49
53
47%
33
33
27%
21
20
East N o r t h C e n t r a l
Illinois
Indiana
Michigan
Ohio
Wisconsin
1,240
310
1, 150
1, 150
400
88%
247
68
80
93
51%
126
36
45
53
26%
61
22
24
31
$1,080
530
1,200
1, 350
430
69%
138
55
60
59
48%
81
39
37
39
32%
49
28
24
25
400
390
580
95%
138
171
54%
80
110
23%
38
41
S480
360
650
60%
113
128
41%
71
89
20%
42
39
720
510
420
270
300
260
440
254%
153
179
159
177
119
103
170%
90
100
101
106
76
60
66%
52
49
50
64
43
27
$770
710
580
280
350
180
690
180%
119
110
100
139
91
61
132%
81
75
75
92
71
46
63%
57
49
45
65
43
25
340
450
330
390
229%
104
144
173
143%
57
93
115
83%
39
47
56
$260
480
260
420
148%
92
106
141
103%
58
73
108
71%
48
44
58
510
1,040
450
165%
281
240
114%
197
173
78%
86
89
$510
970
480
132%
192
169
99%
148
138
77%
77
81
262%
159%
65%
S690
158%
104%
53%
83%
108
165
52%
69
110
21%
38
52
S3, 540
490
350
61%
61
117
44%
43
87
23%
26
52
U.S. T o t a l
New England
Mass
Other (Conn,
Maine, N.Hamp,
R . I . , Verm)
West N o r t h C e n t r a l
Minnesota
Missouri
Other (Iowa,
Kansas, Nebr.,
N.Dak, S.Dak)
South A t l a n t i c
Florida
Georgia
No. C a r o l i n a
So. C a r o l i n a
Virginia
West V i r g i n i a
Other ( D e l . ,
D.C, MD)
East South C e n t r a l
Alabama
Kentucky
Mississippi
Tennessee
West South C e n t r a l
Louisiana
Texas
Other (Ark.,
Oklahoma)
Mountain States
(Colo., Idaho,
590
Mont., Nev., N.Mex
Utah, Wyom.)
1
1
1
1
1
I
I
1
.
3
I
Pacific
California
Washington
Other (Alaska,
H a w a i i , Oregon)
SOURCE:
(CPS) .
3,510
440
320
The Urban I n s t i t u t e ' s T r a n s f e r Income Model
(TRIM2), based on t h e March 19BB C u r r e n t P o p u l a t i o n Survey
, e
NOTES:
1.
I n c l u d e s persons e l i g i b l e f o r M e d i c a i d f o r at l e a s t one month d u r i n g t h e y e a r and persons e l l o " ~
under 1989 r u l e s who do not e n r o l l .
2.
E n r o l l m e n t S c e n a r i o (1) I n c l u d e s a l l persons under t h e p o v e r t y l i n e ; E n r o l l m e n t S c e n a r i o (2)
I n c l u d e s o n l y persons below p o v e r t y who do not c u r r e n t l y have e m p l o y e r - s p o n s o r e d I n s u r a n c e ; S c e n a r i o (3) I n c l u d e s
o n l y persons below p o v e r t y who do not c u r r e n t l y have e m p l o y e r - s p o n s o r e d I n s u r a n c e and work l e s s t h a n 25 hours a
el
et
*' -
SOURCE:
J. Holahan
Americans:
Institute,
and S h e i l a Z e d l e w s k i , " I n s u r i n g Low-Income
I s M e d i c a i d t h e Answer?"
(Wash.DC: The U r b a n j
J u l y 1 9 9 0 ) , p a g e .15.
�189
sector
"
(i.e.,
"Medicaid
h i g h e r i n s u r a n c e premiums)
expansion
third-party
would
payments
reduce
private,
o u t - o f - p o c k e t and
t o p r o v i d e r s . . .(and) also
1 90
t h e a m o u n t oF
care."
reduce
Additionally,
1 9 1
Such
expense
uncompensated
may
increase taxes,
already-too-prevalent
entitlement.
As
and
Holahan
unacceptable
(i.e.,
above
200
...and
and
would
counter-productive
and
"politically
those
care
s i g n i F i c a n t 1y
p e r c e n t oF
expand
notion
Zedlewski point
to insure
charity
oF
o u t , i t would
higher-income
poverty
the
level)
be
Americans
through
public
192
programs.
To
poverty
would
level
insure
a l l persons
reduce
below
t h e n u m b e r oF
200
percent of
u n i n s u r e d by
61
193
percent
( i . e . , From 37 m i l l i o n down t o 1 4 , 4 3 0 , O D D ) ; b u t
w o u l d a l s o i n c r e a s e M e d i c a i d e n r o l l m e n t by 6 1 . 1 m i l l i o n p e r s o n s ,
—
194
w h i c h w o u l d be a 283 p e r c e n t i n c r e a s e .
F e d e r a l and s t a t e
Medicaid
c o s t s would
more
than double
iF a l l e l i g i b l e
persons
1 95
actually
did
•ne
adverse
oF
enroll.
the major
eFFect
such
expansion
and
ultimately
are
c o n s i d e r e d t o be
employer
which
beneFits
insurance
j|p^
the consumer.
t o employee
result
concerns
i n reduced
disproportionately
or,
on
have
on
m a n d a t e s and
through
( 3 ) Fewer
expansion
i s the
employers,
employees,
Medicaid
expansions
they
passed
are
From
(1) increased deductions
wages;
the cost
small
Medicaid
c o s t s oF
take-home
i n o r d e r t o bear
charge;
would
The
employer
either
about
oF
jobs.
the
196
(2) r e d u c t i o n
i n other
increased Medicaid
Costs
b u s i n e s s e s , nfiich o F t e n
-68-
tend to
do
not
Fall
even
�Percent I n c r a a a o a i n Medicaid Ca«elo«d» and Costa by S t a t e
A f t e r Program Expaalon to 100 Percent of Poverty*
2 98 9
Caseload
(Thousands)
'J.S.
Total
2 1 , 410
New England
Mass
Other (Conn,
Maine, N.Hamp,
R . I . , Verm)
11 )
: 98 5
: o r. t
! 1 -.c.r.r)
t?)
. 2 t! i
En r i i - i ment
J8V
J
/ i
X
;25,70:
851
851
87
40*
24*
15
S840
690
54%
47
30%
27
21%
550
2, C2C
980
91%
82
85
52%
5C
25%
25
22
S860
3, 980
1,240
68%
49
5 3
47%
33
27%
i , 24C
310
1,150
1, 150
400
88%
247
68
80
93
51%
126
36
45
53
26%
61
22
24
31
51,080
530
I , 200
i , 350
430
69%
138
55
60
59
48%
31
39
:7
39
32%
49
28
24
25
400
390
580
95%
138
171
54%
80
110
23%
38
41
S4 30
360
650
60%
113
128
89
20%
42
39
720
510
420
27C
300
260
440
.Middle A t l a n t i c
New J e r s e y
New York
Pennsylvania
460
520
254%
153
179
159
177
119
103
170%
90
100
101
106
76
60
66% ' 1
52
1
49
1
50
1
64
1
43
1
27
|
S770
710
580
280
350
180
690
180%
119
110
100
139
91
61
132%
81
75
75
92
71
46
63%
57
49
45
65
43
25
I.
r-
20
East N o r t h C e n t r a l
Illinois
Indiana
Michigan
Ohio
Wiscons i n
West N o r t h C e n t r a l
Minnesota
Missouri
Other (Iowa,
Kansas, Nebr.,
N.Dak, S.Dak)
South A t l a n t i c
Florida
Georgia
No. C a r o l i n a
So. C a r o l i n a
Virginia
West V i r g i n i a
Other ( D e l . ,
D.C, MD)
!
I
1
1
1
id:
if,:
i
East South C e n t r a l
Alabama
Kentucky
Mississippi
Tennessee
340
450
330
390
229%
104
144
173
143%
57
93
115
83%
39
47
56
1
1
1
!
S260
480 •
260
420
148%
92
106
141
103%
58
73
108
71%
43
44
58
1
West South C e n t r a l
Louisiana
Texas
Other (Ark.,
Oklahoma)
t'
510
1, 040
450
Mountain S t a t e s
(Colo., Idaho,
590
Mont., Nev., N.Mex
Utah, Wyom.)
165%
281
240
114%
197
173
78%
86
89
1
[
1
3510
970
480
132%
192
169
99%
148
138
77%
77
262%
159%
65%
1
S690
158%
104%
53%
83%
108
165
52%
69
110
21%
38
52
I
I
1
S3,540
490
350
61%
61
117
44%
43
87
23%
26
52
0 "
.
Pacific
California
Washington
Other (Alaska,
H a w a i i , Oreoon)
SOURCE:
(CPS) .
3, 510
440
320
The Urban I n s t i t u t e ' s T r a n s f e r
Income Model
(TRIM2),
based on t h e March :988 C u r r e n t
P o p u l a t i o n Survey
; e
NOTES:
1.
I n c l u d e s persons e l i g l o l e f o r M e d i c a i d f o r at l e a s t one month d u r i n g zhe year and p e r s o n s e : i a " "
under 1989 r u l e s who do not e n r o l l .
2.
E n r o l l m e n t S c e n a r i o (11 i n c l u d e s a l l persons under t h e p o v e r t y l i n e ; E n r o l l m e n t S c e n a r i o (2)
i n c l u a e s o n l y persons below p o v e r t y who do not c u r r e n t l y have e m p l o y e r - s p o n s o r e d I n s u r a n c e ; S c e n a r i o (3) i n c l u d e s
o n l y persons below p o v e r t y who do not c u r r e n t l y have e m p l o y e r - s p o n s o r e d I n s u r a n c e and work l e s s t h a n 25 hours a
wee>1
-
SOURCE :
J . H o l a h a n and S h e i l a Z e d l e w s k i , " I n s u r i n g L o w - I n c o m e
Americans:
I s Medicaid the Answer?"
(Wash.DC: The U r b a n
I n s t i t u t e , J u l y 1 3 9 0 ) , page .15.
�197
insure
their
The
mandate
actually
have
own e m p l o y e e s
because
of the cost.
F o r F i n a n c i n g s u p p o r t oF M e d i c a i d i n s u r a n c e
has t h e eFFect
oF b e i n g i m p o s e d
on e m p l o y e e s
no i n s u r a n c e F o r t h e m s e l v e s , a n d who a l s o
who
are n o t covered
under
Medicaid.
M e d i c a i d expanded
large
proportion
oF t h e s e u n i n s u r e d may a c t t o r e d u c e ,
avoid,
t h e adverse
eFFects
suFFiciently
on e m p l o y e r s
and
t o cover a
iFnot
1 9Q
employees.
199
Although
share
the costs
revenue
would
each
also
currently
and
eFFect
historically
aggressive
by
governments
able t o Finance.
Thus,
i n Federal Medicaid requirements
oF M e d i c a i d c o v e r a g e
oFFered
higher-income enrollees
be r e q u i r e d
t o pay p a r t
how many p e r s o n s
201
and Z e d l e w s k i e x p l a i n
been
to provide
(who a r e
oF
would
generous
i n containing
Central
states
costs
lower
than average,
would
approaches
(with
that
in their
i n c r e a s e s i n t h e New
North
their
be
eligible
" S t a t e s which
eligibility
p o l i c i e s and
be r e l a t i v e l y
than other
England,
have
less
states.
The
Middle A t l a n t i c ,
the exception
oF I n d i a n a )
aFFected
and E a s t
would
be
and t h e i n c r e a s e s i n t h e S o u t h e r n and
202
Mountain
The
regions
states
which
by
i n t h e program.
Medicaid expansion
caseload
whether
and ( 3 ) aFFect
enroll
Holahan
i t is
the extent
u n i n s u r e d ) would
would
local
has a u t h o r i t y
oF a n y c h a n g e
( 2 ) aFFect
costs,
and sometimes
state
coverage
( 1 ) aFFect
state,
coverage
and each
additional
overall
state,
oF M e d i c a i d , a l l F u n d s come From g e n e r a l
Funds
whatever
the
Federal,
would
be g e n e r a l l y
would
bear
higher
the largest
-69-
than
average."
i n c r e a s e s would
be
�Coverage Under Medicaid: The Current Role of Medicaid in Insuring the Nonelderlv
Type of Insurance: Percent Distribution
Population
Characteristics
Population
*2
Medicaid''
Other
Insurance
Uninsured
Income Relative to Poverty
Threshold
Less than 100%
100%-200%
200% - 300%
Greater than 300%
32.9
35.0
38.3
106.4
51.4%
8.9
2.5
.5
20.3%
65.7
84.4
93.6
28.3';
25.4
13.1
5.9
Total
212.6
10.1
76.0
13.9
1.1
5.9
2.5
75.2%
64.9
30.1
13.1%
15.2
31.3
11.7%
19.9
39.6
4.9
9.6
0.8
72.5
64.7
30.0
12.3
15.3
23.2
15.2
20.0
46.8
3.1
1.3
3.7
11.7
24.0
31.2
24.7
34.9
57.1
53.0
41.1
1.1
4.4
5.4
2.9
5.0
5.5
2.2
1.3
5.1
64.0
43.6
44.8
35.4
61.5
48.3
34.7
59.6
18.0%
16.2
23.1
23.5
19.5
18.1
30.3
30.7
15.6
Persons with Income
Below Poverty Threshold
Pregnant Women
Mothers
Fathers
Children, age:
under 5
6-17
18+
Other Adults, age:
under 30
30-39
40 and older
Persons with Income
Below Poverty Threshold
by Region
New England
Middle Atlantic
South Atlantic
East South Central
West South Central
East North Central
West North Central
Mountain
Pacific
SOURCE:
Notes:
19.8
31.7
45.1
20.4
21.4
34.6
24.8
The Urban Institute's Transfer Income Model, based on the March 1988 Current Population Survey.
1.
2.
Millions; Estimates for the nonelderly (under age 65) excluding persons in institutions and in Puerto Rico.
Includes persons with other insurance.
SOURCE:
J. Holahan and S h e i l a Z e d l e w s k i , " I n s u r i n g Low-Income
Amerxcans:
I s Medicaid t h e Answer?"
(Wash .OC: The C r b a n
I n s t i t u t e , J u l y 1 3 9 0 ) a a r \ P EL
�Indiana,
and
Florida,
outlay
Alabama
F i g u r e s would
and Texas,
although their
caseload
be c o u n t e r e d by h i g h e r - t h a n - a v e r a g e
203
Federal
matching
The
oF
Table,
coverage
indicates
that
uninsured,
program
coverage
covered
only
by o t h e r
employers
employee's
"Even
would
3.
"Would
care reForm
drop
women
with
women a r e
health
plan
coverage
Medicaid
would
rely
insurer.
Medicaid
For employees
would
t o such
they
an e x t e n t
to retain
also
current
by a l l
program,
or
perhaps
increase the
that
than employment-based
were e s a e n t i a l l y
participation
as
oF a n e x p a n d e d
oF t h e c o s t
were
which
import
i n s u r a n c e c o s t s Faced
Or, a l t e r n a t i v e l y ,
employees
oF t h e c u r r e n t
government
group
i F employers
participation
pregnant
q u e s t i o n s oF p r i m a r y
t h e expansion
more a t t r a c t i v e
low-income
The
F u t u r e g e n e r a t i o n s by
13.1 p e r c e n t o f t h o s e
pose
and t h e p r e s e n c e
become
The T a b l e
insurance.
the increasing
share
increases.
by M e d i c a i d .
t h e v a l u e oF p r o t e c t i n g
on t h e F e d e r a l
dependents?
would
increases.
11.7 p e r c e n t a r e c o v e r e d
a health
employers
the percentages
5 7 . 1 p e r c e n t oF p o v e r t y - 1 e v e 1 a d u l t s a r e
and Z e d l e w s k i
with
"Given
would
that
as M e d i c a i d c o v e r a g e
as income
a t a t i m e when o n l y
extensively
2.
declines
juxtapositioning
program
indicates
7 5 . 2 p e r c e n t oF be 1 o w - p o v e r t y
Holahan
when
page,
be r e d u c e d
while
reFlects
providing
For
Facing
u n i n s u r e d would
Medicaid
1.
rates.
group
apply For M e d i c a i d
204
Medicaid
coverage?"
coverage,
coverage i F
Free?"
decline
i ntroduced?"
-70-
substantially
as p r e m i u m s a r e
�4.
"Would
only
in
a severe
individuals
Medicaid?
average
t h e most s e r i o u s
costs per enrollee
premium
5.
Are s t a t e s
contributions
an i n s u r e r
Three
1.
with
from
i n t h e U.S.
reasons
health
o f adverse
the healthier
capable
health
occur
i n which
problems
enroll
have h i g h e r
selection
system?
government
costs are generally
without
enro11ees."
oF a c c e p t i n g a l a r g e r
care
For encouraging
as o p p o s e d
problem
Medicaid would
because
Financially
Administrative
Medicaid,
selection
I n t h e worst case,
the
as
adverse
role
2 0 E
control
would be:
3 p e r c e n t oF r e v e n u e s
For
t o 1 2 - t o 15 p e r c e n t F o r c o m m e r c i a l
i nsurers .
2.
Expansion
oF M e d i c a i d
same t y p e oF p a y m e n t
those
hospitals
elderly.
to
3.
payer
a l l those
mandates
third-party
Under
this
enable
oF a l l r a t e s
control
and
t o impose t h e
as M e d i c a r e
who p r o v i d e s e r v i c e s
power
p l a c e s on
tothe
t o t h e government
to a l l providers
as
oF a l l s e r v i c e s
Medicare.
oF t h e m a r k e t
oF M e d i c a r e
the states
on p r o v i d e r s
p r o v i d e market
on M e d i c a i d
Establishing
state
policy
and p h y s i c i a n s
This would
third-party
would
could
also
and M e d i c a i d payment
"...permit
rules
For a l l
insurers.
t y p e oF b r o a d
control:
" ( T ) h e r e w o u l d be no s y s t e m a t i c d i F F e r e n c e s
i n p r o v i d e r r e i m b u r s e m e n t ; t h e r e F o r e , t h e r e w o u l d be
no a d v a n t a g e s t o F a v o r i n g some p a t i e n t s o v e r o t h e r s .
S i m i l a r l y , t h e c o s t s h i F t i n g t h a t now o c c u r s From
M e d i c a i d t o p r i v a t e i n s u r e r s b e c a u s e oF l o w M e d i c a i d
p a y m e n t r a t e s w o u l d be e l i m i n a t e d .
P r o v i d e r s would
have l i t t l e c h o i c e b u t t o c o n t r o l c o s t s i n l i n e w i t h
r e v e n u e s p e r m i t t e d by p a y m e n t p o l i c y .
I n t h e long
r u n , t h i s t y p e oF a p p r o a c h s h o u l d p e r m i t t h e n a t i o n t o
c o v e r t h e u n i n s u r e d w i t h much l e s s oF a n i n c r e a s e i n
the a l l o c a t i o n oF r e a l r e s o u r c e s t o t h e h e a l t h s e c t o r . " "
-7 1 -
�It
i s not
governments
an
answer
to the problem
t o become i n s u r e r s .
For
Federal
I n s u r e r s must
be
and
state
required
to
insure .
The
Bush
Administration.
209
•avid
President
changes
Blumenthal
Bush
appears
advocates
in health
care
to express
when he
cautions that
should
not
be
the
same v i e w
wholesale
made e a r l i e r
than
the
l a t e 1990s.
He b a s e s h i s a s s e r t i o n s on t w o o b s e r v a t i o n s :
1.
" . . . t h e p o l i t i c a l r e q u i r e m e n t s For s u b s t a n t i a l h e a l t h
r e F o r m a r e n o t y e t i n p l a c e " and
2.
In
that
care
"American p o l i t i c a l i n s t i t u t i o n s Favor i n c r e m e n t a l over
r e v o l u t i o n a r y c h a n g e , m a k i n g i t l i k e l y t h a t any r e F o r m e d
s y s t e m w i l l p e r p e t u a t e a t l e a s t some oF t h e c u r r e n t
s y s t e m ' s i n e q u i t i e s and i n e F F i c i e n c i e s . " ^ ^
c o n s i d e r i n g the
eFFective
reForm,
n o t - y e t - i n - p 1 ace
Or.
Blumenthal
political
requirements
For
explains:
B o t h c o s t c o n t r o l and e x p a n d e d a c c e s s c a r r y
major p o l i t i c a l r i s k s .
Cost c o n t r o l i s not
i n h e r e n t l y p o p u l a r w i t h t h e p u b l i c a t l a r g e , and
i t has t h e p o t e n t i a l t o r e d u c e t h e a v a i l a b i l i t y
oF s e r v i c e s as p r o v i d e r s c u t b a c k i n t h e F a c e oF
lower reimcursement.
E x p a n d i n g a c c e s s t o care:
F o r t h e u n i n s u r e d w i l l r e q u i r e h i g h e r t a x e s on
m i d d l e c l a s s A m e r i c a n s ( i F i t i s F u n d e d by
g o v e r n m e n t ) o r i n c r e a s e t h e F i n a n c i a l b u r d e n s oF
small businesses ( i F i t i s achieved through
mandating
t h a t employers p r o v i d e h e a l t h care
insurance) . ^
To b r a v e t h e s e a d v e r s e c o n s e q u e n c e s i n h e a l t h
c a r e r e F o r m , p o l i t i c a l l e a d e r s w i l l h a v e t o be
convinced t h a t the v o t i n g p u b l i c , i n c l u d i n g a
s u b s t a n t i a l s e g m e n t oF t h e m i d d l e c l a s s , i s
deeply d i s c o n t e n t e d w i t h the h e a l t h care
system.
T h a t l e v e l oF d i s c o n t e n t d o e s n o t y e t seem t o e x i s t . 212
The
Bush
addressing
politically
WoFFord
as
the
Administration
issues
necessary
Democratjc
oF
had
health
t o do
so
Governor
been
care
aFter
oF
rather
reForm
the
reticent
until
victory
Pennsylvania.
72-
they
oF
The
about
Found i t
Harris
Governor-
�elect
r a n on
a platform
a week
after
health
care r e f o r m would
State
election
advocating health
of the Union
William
domestic
Policy
day,
the Administration
be
address
and
addressed
assistant
director
Development,
wrote
that
1392.
t o P r e s i d e n t Bush f o r
of the White
of three
announced
within
i n P r e s i d e n t Bush's
i n January
Roper, deputy
policy
c a r e r e f o r m and
Bush
House O f f i c e
initiatives
of
which
213
reflected
Those
initiatives
expansion
and
"careful
concerned
of Medicaid
"setting
national
t h o u g h t and
well-chosen
physician
coverage
research into
214
payment
t o poor
effective
priorities."
reform,
women a n d
medical
children,
practice
as
a
priority."
Mr.
Roper
explains
what
the nation
f a c e s when i t
considers
reform.
Our h e a l t h s y s t e m h a s p l e n t y o f money; we a r e
j u s t n o t s p e n d i n g i t w i s e l y . ... E x p a n d i n g
access
t h r o u g h M e d i c a i d r u n s up a g a i n s t t h e p r o b l e m o f
l i m i t a t i o n s on t h e s i z e o f s t a t e a n d f e d e r a l b u d g e t s .
E x p a n d i n g a c c e s s by way o f m a n d a t i n g
employer
insurance p r e s e n t s r e a l problems t o small
employers
a n d makes more d i f f i c u l t t h e i r t a s k o f c o m p e t i n g
w i t h f o r e i g n companies i n our i n c r e a s i n g l y g l o b a l
economy.
Changing our t a x t r e a t m e n t of c u r r e n t l y
u n l i m i t e d t a x - f r e e h e a l t h b e n e f i t s t o w o r k e r s , and
u s i n g t h e t a x revenue produced t o expand h e a l t h care
access, runs counter t o the long-standing t r a d i t i o n
o f p r o v i d i n g t h e s e b e n e F i t s t a x f r e e . ... We m u s t
undertake serious-cost containment to permit
expanded access .
Mr.
between
Roper
Canada
also
and
the
Canadian
has
a parliamentary
radical
balances
as
a possibility
system
while
shared
out a major
t h e U n i t e d S t a t e s as
program
changes,
and
pointed
which
t h e U.S.
powers
political
reason
f o r our
i s capable
has
which
-73-
a
i s Far
of
system
difference
f o r discounting
own
nation.
more
oF
rapid,
checks
more v u l n e r a b l e
and
to
Canada
�<r
pressures
from
Because
exercise
tive
Enacted
during
much-needed
of
1.
i ssatisfactory
tradition
choice
t h e Bush
Reconciliation
has t h e a b i l i t y t o
of physician
t h e American
and f r e e
groups.
government
control
t h e i r system
with
'216
interest
t h e Canadian
markets
Budget
special
monopsony
services,
variance
• , •
and h o s p i t a l
for
them
but at
of advocating
by h e a l t h
care
Administration
competi-
consumers.
was t h e O m n i b u s
A c t o f 1 9 9 0 (OBRA ' 9 0 ) w h i c h
protective
health
care
and s o c i a l
provided
policy.
Some
i t s benefits are:
Creation
families
o f an e a r n e d
income
taxcredit
for
low-income
t o use s p e c i f i c a l l y f o r
purchasing
private
health
insurance;
2.
Expansion
below
3.
up
4.
of Medicaid
poverty
insurance
authority
"Fundamental
public
the
by
that
policy
pervasive
seeks
people
payment
within
to
include
t h e next
o f employee
decade;
health
to establish
that
t h e enactment
n o t an a b e r r a t i o n
but,
rather,
shiFts
there
inpolitical
a r e "...two
thinking."
power
One v i e w
The o t h e r
be t h e d e c i d i n g
Factor
view
o f OBRA'90
a r e f l e c t i o n of
•218
and p r o c e s s . "
ideologies
(entity) i n national
Canada's s y s t e m .
should
insurance
1
deFinitely
explains
for
health
premiums.^ ''
Etheredge
was
o f government
million additional
Medicaid
a tor
level;
The i n c r e a s e
to five
t o cover a l l chi 1dren i i v i n g
that
i s that
health
She
dominate
government
policy,
i s that
as
consumer
i n the Formation
-74-
oF a
much
should
be
illustrated
choice
national
�2 19
health
policy.
broad-based
Leadership
I n between
proposals
such
Commission,
and
"recommendations
For
in
political
the
For
irreconcilable
the
issues
which
are
a l l supposedly
as
behind
been
health
care
politically
the
National
about
to
are
negotiated
care
centered
system
whereas
money, p o w e r ,
to
previous
the
debates
in
and
on
the
status
negotiation.
is diFFerent
neither
Formulas
that
ideology,
on
whose
makes c l e a r
health
which
Commission
action
amenable
opposed
B u s h has
are
Etheredge
centered
a d d i t i o n a l Factor
President
Force
are
two
Pepper
a national
1990s
views
Waxman b i l l ,
e
government
diFFerences
administration
t h
the
consensus."
1970s a b o u t
An
as
these
during
this
administrations,
initiator
legislation.
nor
Instead,
the
is
that
propelling
"...health
I
policy
leadership
branch--with
Tax
views
has
health
on
oF
Stuart
strong
moved
impressive
Treatment
Or.
has
Health
M.
on
Butler
the
care
decisively
221
results."
Care
the
legislative
i
BeneFits.
oF
the
eFFects
cost
to
Heritage
the
problems.
Foundation
Internal
Revenue
has
Code
Currently:
"The
tax code s t r o n g l y e n c o u r a g e s . . . e m p l o y e r p r o v i d e d c o v e r a g e as a F r i n g e b e n e F i t b e c a u s e s u c h
p l a n s a r e e x c l u d a b l e w i t h o u t l i m i t From t h e
employee's t a x a b l e income.
While l i m i t e d tax r e l i e F
i s a l s o a v a i l a b l e t o t h e se 1 F - e m p 1 o y e d and
those
incurring unusually
heavy m e d i c a l c o s t s , For most
A m e r i c a n s t h e c o m p a n y p l a n i s t h e o n l y way
oF
r e c e i v i n g a t a x b r e a k For m e d i c a l c o s t s .
The
tax
exclusion
. . . i s . . . a m a j o r c a u s e oF u n i n s u r a n c e
and
rapidly excalating health
costs."
"Policymakers should recognize t h a t the
d e f i c i e n c i e s i n t o d a y ' s h e a l t h c a r e s y s t e m as dus i n
l a r g e p a r t t o p o w e r F u l and p e r v e r s e i n c e n t i v e s
r e s u l t i n g From t h e c u r r e n t t a x t r e a t m e n t
oF
health
care."223
2 2 2
c
_7 -
�The
1.
remedy
Replace
reFundable
packages
income
tax
who
today's
tax exclusion
tax credits
provided
credits
by e m p l o y e r s
would
W-2
would
who
oF
Health
beneFit
as
taxable
Simultaneously,
For out-oF-pocket
premiums and p r e p a i d
d i d n o t spend
system
be i n c l u d e d
t a x Form.
be p r o v i d e d
a v a i l a b l e t o those
w i t h a new
For h e a l t h expenses.
on t h e e m p l o y e e ' s
insurance
be
is to:
health plans.
costs
new
For
The c r e d i t s
would
do n o t i t e m i z e d e d u c t i o n s .
as t h e a l l o w e d
as much
Those
receive
credit
would
224
a reFund
would
t h e I.R.S.
household
would
be
Care
would
initiate
hospital,
basic
a
correspondingly
deductibles
of Features
and p r e v e n t i v e
and c o p a y m e n t s
a d j u s t e d g r o s s income would
.
g o v e r n m e n t . 226
The
Heritage
the
best
health
encouraging
portable,
Plan
consumers
utilize,
would " ( 1 )
insurance
would
their
have
exceed
premiums,' and ( 5 ) a l l o w
catastrophic,
Cut-oF-
10 p e r c e n t
consumersto
t o change
beneFits
oF
F o r by t h e F e d e r a l
cost,
shop For
thereby
would
at
be
will;
be r e d u c e d ; [ 4 )
i n order
the uninsured
would
employers
an i n c e n t i v e t o l i m i t ,
h e a l t h care
a Federally-
(2) the insurance
a d m i n i s t r a t i v e costs
Family
insurance.
at the least
a l l o w i n g t h e employee
head
a l l
to enroll
care
encourage
plan
Each
including
which
be p a i d
insurer competition',
employers'
Contract .
containing at least
package
physician,
Social
r e q u i r e d by law
i n a health plan
prescribed
•sv
"-
oF t h e F a m i l y
credit.
members
(3)
oF t h e c r e d i t
health costs
E s t a b l i s h a "Health
pocket
The a m o u n t
t o a percentage
according
but higher
higher
of
From
be d e t e r m i n e d
income,
2.
check
instead
oF
to avoid
t o be p r o t e c t e d
overhigher
at a
�Far
lower
cost
Senator
to
the
5.84
to the
Durenberger
Federal
would
term
government
tax
than
(R-Mn) h a s
other
approaches."
proposed
six
2 2 7
amendments
code.
provide
a tax c r e d i t
h e a l t h care
For
For
insurance
selF-purchase
taxpayer,
oF
long-
spouse,
and
parents;
5.85
would
allow
premiums
IRA
S.8S
5.87
IRAs, and
that
be
gross
employers'
provides
Senate
taxpayers
a
100%
Bill
who
84
The
amendment w o u l d
exceed
or
more
The
oF
income
not
be
by
From
the
the
I.R.S.;
to retirement
considered
as
part
savings
account
trusts
For
insurance;
deduction
For
premium
costs
For
individuals;
deduction
oF
is intended
purchase
employment
the
amount removed
gross
will
insurance
health insurance
premiums
se1F-emp1oyed .
the
oF
that
health
contributions
For
h e a l t h care
a permanent
provides
the
plans
tax c r e d i t s
provides
For
long-term
income;
se1F-emp1oyed
S.8S
oF
considered
insurance
long-term
5.88
oF
not
provides
oF
payment
out
would
health
the
arena
long-term
t o ease
long-term
For
qualiFying
and
a credit
health insurance,
$ 3 0 0 f o r one
burden
h e a l t h care
themselves
provide
the
For
For
oF
i t does
or
outside
aging
percent
providing
qualiFying individual,
older
insurance
their
15
on
parents
the
cost
not
$300 f o r
two
individuals.
term
'qualifying
individual'
long-term
h e a l t h care
insurance
-77-
means t h e
i f such
beneFiciary
individual
is
the
�taxpayer,
t h e spouae
taxpayer
or parent
of
the taxpayer,
or t h e p a r e n t
of the taxpayer's
spouse
of the
i f a joint
return
will
to a
229
is
Filed.
The
beneFit
parent
oF
the taxpayer
parent
oF
a tax credit
or the taxpayer's
spouse
apply
even
iF
that
i s not a dependent.
230
The
term
'long-term
health care'
means n e c e s s a r y
preventive,
t h e r a p e u t i c , and
rehabilitative
maintenance
or personal
s e r v i c e s r e q u i r e d by
ill
individual
An
individual's
the
cost
cost
the
oF
oF
in a qualiFied
the care
individual
Facility
home i s c o n s i d e r e d
the care
treating
care
provided
provided
have
s e r v i c e s , or
a
chronically
a qualiFied provider.
a qualiFied
t h e r e would
Facility
t o be
and i F
w i t h o u t horns c a r e
that
cared
iF
n o t exceed the
i n a state-1icensed Facility
physician certiFies
would
by
diagnostic,
For
the
i n a state-1icensed
Faci1i ty. " ^
Senate
Bill
85
i s intended
speciFic
amounts
accounts
For payment
premiums.
their
The
spouses
which
t o exclude
are withdrawn
oF
long-term
amendment w i l l
who
have
From
gross
beneFit
t h e age
oF
income
individual
h e a l t h care
only
reached
From
insurance
those
59
retirement
taxpayers
years
and S
and
months
233
on
or beFore
Also,
t h e annual
31,000
For
joint
oF
payment
e x c l u s i o n From
individuals
Retiree Health
1991
employees
care
oF
o r 32,000
oF
the insurance
gross
income
premium.
i s n o t t o exceed
For m a r r i e d
couples
Filing
a
return.
The
Act
the date
(Senate
Bill
to p a r t i c i p a t e
insurance
P r o t e c t i o n and Long-Term
85) p r o v i d e s
economic
i n employer-provided
For r e t i r e e s .
-73-
When e m p l o y e r s
Care
Insurance
i n c e n t i v e s For
long-term
contribute
health
to a
2 3 1
�qualiFied
voluntary retiree
h e a l t h plan, those
contributions
will
income
by an i n d i v i d u a l
earned
when t h o s e
the
n o t be c o n s i d e r e d
long-term
employee
those
oF t h e g r o s s
or h i s spouse.
h e a l t h care
retires,
as p a r t
employer
beneFits
beneFits
Additionally,
are received
also
will
aFter
n o t be i n c l u d e d
234
in
t h e gross
income
employee
must
disabled
i n order
have
consideration
employee
the
either
as g r o s s
was a l r e a d y
t o t h e death
Senate
bill
oF
up t o $ 2 0 0 a n n u a l l y
trust
Legislation
the
Financial
people.
would
long-term
such
economic
employee
The s a v i n g s
accounts.
to that
account
must
each
many
in
the interest
or
$600 c r e d i t
oF t h e s e
le-islators
insurance
i n order
premiums
citizens
purchase
i n order
wind
long-term
and w i l l
as p o s s i b l e t o v o t s
oF t h e F e d e r a l
insurance
- 79-
notto
_
be p a r t o r a
only
t o ease
on o l d e r
at
(A.A.R.P.]
persuading
For passage.
to provide
the p o s s i b i l i t y
up on t h e M e d i c a i d
care
work
government
to avoid
oF
3
i s necessary
bills
credits
care." ''
The A m e r i c a n A s s o c i a t i o n oF R e t i r e d P e r s o n s
Favor
Tax
account
F o r t h e p u r p o s e oF p a y i n g
as t h i s
consumers
For t h e e s t a b l i s h m e n t
contributions
health
only iF
immediately
i n c e n t i v e s For
savings
From
deceased
beneFits
235
employee.
be g r a n t e d
b u r d e n oF h i g h
as
senior
will
exclusively
individual's
oF a
these
h e a l t h cars
accounts
created
The s p o u s e
receiving
with
236
$2,000 p e r y e a r .
exceed
one
long-term
t o be e x c l u d e d
t h e same as t h e F o r m e r
37 p r o v i d e s
establish
savings
income.
However, t h e
t h e age oF 70 o r be
beneFits
oF t h e F o r m e r
to
such
attained
For these
i s considered
spouse
prior
oF a n i n d i v i d u a l .
rolls.
are Fortunate
I t
is
t h e 3300
of having
People
who
t o have t h e
�Financial
their
capability
independence
Federal
Financial
t o make t h a t
From
purchase,
government
and/or
thus
their
children.
Suggestions
"The
h e a l t h c a r e e c o n o m y oF t h e U n i t e d
a p a r a d o x oF e x c e s s and d e p r i v a t i o n . "
2
is
maintaining
3
States
8
"The
American h e a l t h care Financing
and
d e l i v e r y system i s becoming i n c r e a s i n g l y u n s a t i s F a c t o r y
a n d c a n n o t be s u s t a i n e d . " ^
2 3
The
$125
Joint
billion
annually
Economic
Committee
i n unnecessary
because
oF
oF
tests
economic
Congress
and
estimated
procedures
i n c e n t i v e s which
are
are
that
perFormed
inherent
in
2 40
our
present
h e a l t h care
Enthoven
based
on
and
Financing
Kronick
system.
explain that
"cost-unconscious
health
d e m a n d " as
care
t h e system
Financing
contains
is
more
241
incentives
system
to
i s an
spend
open-ended
more
treatment
they
are
are
than
and
they
and
are
spend.
invitation
impose
appropriate
insured,
to not
more and
necessary
not
cost
t a n g i b l e purchases.
and
believe
choose
their
bargaining
provider
This
the
power."
writer
could
to
They
as
choose
ultimately
provide
more p r o c e d u r e s
whether
or
not.
Because p a t i e n t s
as
they
Additionally,
"deprives
thereFore
a built-in
believes
to
p e r m i t t i n g consumers
physician
insurance
Freedom
which
own
that
that
their
-an-
the
Freedom
insurer
recommend
price
are
to
oF
preFerred
242
rgulator.
physician...it
whether
usually
Enthoven
consumers s h o u l d
own
aFFect
Fee-For-service
to providers
conscious
when m a k i n g
Kronick
The
they
live
be
permitted
is a
choice
healthy
�lives
or
die
From
the
or
lack
oF
knowledge
e F F e c t s oF
i t .
Fees c o u l d
be
negotiated
Fees c o u l d
be
established
ments
which
the
'purchasing
make s u c h
an
care
access
(HMO,
1.
important
to
PPO)
drive
the
system
For
Managed
as
decision
annual
'recommended'
procedures
a guideline
and
in
making
individual's
has
greater
are
designed
treat-
Freedom
priority
than
proposals
choice
oF
to
give
eFFicient,
managed
Fallows:
reForm
by
oF
economic
imposing
incentives
strong
incentives
which
to
would
give
value
money ;
Z.
use
a subsidized
as
Comprehensive
various
or
care,
power.
Enthoven/Kronick
everyone
For
physician's
managed
C e r t a i n l y an
insurer's bargaining
The
an
than
providers,
can
decisions.'
to
Rather
For
consumer
a particular
care
at
competition
relatively
3.
Restructure
the
uninsured,
which
low
tax
and
would
high-quality
cost;
subsidies
to
provide
to
encourage
create
the
incentives
insursd
to
to
be
cover
cost
conscious;
4.
Create
subsidized
public
institutions
coverage
For
those
to
not
broker
and
accessing
market
plans
through
243
their
employers.
Enthoven
provided
and
health
Kronick
care
are
strong
insurance.
They
e.FFect
is irresponsible behavior"
insure
their
the
cost
oF
employees
care
Falls
because
on
advocates
-a 1 -
should
and
those
employer-
that
when e m p l o y e r s
i F one
taxpayers
contend
oF
do
become
"the
not
i l l ,
consumers
who
�are
insured.
" [ i ] t
Those e m p l o y e r s
i s hard
to
justiFy
For
"are
raising
For
coverage
the employed
are
required to contribute
taking
taxes
a Free
on
uninsured
the
ride"
and
insured to
unless
those
pay
uninsured
244
advocate,
however,
that
their
these
Fair
share.
employers
They
apply
to
the
do
Public
245
Sponsor
i n order
The
the
by
P u b l i c Sponsor
Federal
subsidize
their
PuBlic
to provide
Reserve)"
enrollment
emp1oyers.
Sponsor
AmeriCare
would
be
For
"a
their
i n insurance
2 4 6
by
plans
What E n t h o v e n
identical
Senators
employees.
q u a s i - p u b l i c agency
e s t a b l i s h e d i n each
i s almost
authored
coverage
state
For
and
those
state
would
not
Kronick
to the
Mitchell,
which
covered
call
the
agency
Kennedy,
(like
named
Riegle,
and
247
RockeFeller.
I t i s also
be
provided
by
Representative
Cost
by
the Health
1
Act
and
provide
Funds For
persons.
Their
play
plans
pending
cover
employers
less,
or
circulsting
Full-time
seasonal
have
enough
employer
oF
reForm
employees
people
or
who
attachment
to provide
t o be e s t a b l i s h e d
Insurance
imposing
Coverage
the
tax
i s very
Washington
i n the
SpeciFic
warning
that
be
too
who
are
are
and
s t r o n g an
249
t o one
employer
-32coverage."
2 5 0
to
oF
numerous
and
incentive
state,
who
age
justiFy
pay-or-
employers
They
under
would
uninsured
to Enthoven
requiring
and
which
to the
Form
se1F-emp1oyed,
retired
to
similar
bills.
would
a tax
to disperse
to p a r t - t i m e workers.
"(m)any
work,
recommend
around
is their
to shiFt
that
Health
the P u b l i c Sponsors
concept
however,
T r u s t Fund
would
1391.
Kronick
h e a l t h care
Kronick,
oF
to the s e r v i c e which
Insurance
Rostenkowski s
248
Containment
Enthoven
similar
55
to
For
neverthe-
have p a r t t i m e
years
requiring
do
the
not
�Enthoven
choice
of
either
$22,500 o f
or
early
employment
An
the
or
would
gross
be
of
For
on
payroll
tax
p a r t - t i m e and
an
employer
on
the
seasonal
other
who
are
r e q u i r e d t o pay
an
First
privately-
se1F-emp1oyed,
reasons not
covered
8 percent
the
employees,
i n a Federally-approved
Those
are
through
tax
on
income.
c o n s i d e r a t i o n which
include in their
contribution
Federal
imposing
8 percent
plan.
are
essential
to
personal
an
propose
employees
medical
retirees,
careFul
paying
those
basic
adjusted
Kronick
wages/salaries
enrolling
insured
and
level
tax
proposal
would
in order
be
is that
levied
to deter
From t h r e a t e n i n g t o move t o
Enthoven
by
and
the
payroll
and
collected
large corporate
another
state
Kronick
which
are
and/or
at
employers
does not
impose
.
^
251
such a t a x .
Enthoven
income
tax
employee
be
the
that
those
and
and
payroll
maximum
people
plans
who
with
this
change
that
amount
their
both
other
own
equity
and
that
costly
about
"Thus,
impose
Congress
a limit
on
tax-Free
percent
permitted i n order
h e a l t h care
plans
2 5 2
Enthoven
and
budget
applied to
Finance
subsidies
the
tax
h e a l t h care
tax
change would
and
would
reForm
The
Enthoven/Kronick
-83-
$11.2
Congressional
plan
would
For
From
estimate
the
on
Budget
be
and
the
make p e o p l e
is deFensible
assure
billion
For
improve
would
to
pay
Kronick
Federal
this
change
Eighty
the
eFFiciency."
the
that
money, w i t h o u t s u b s i d i z a t i o n
save
Additionally,
care.
estimated
be
to
contribution
taxpayers.
could
could
conscious
laws
d e s i r e more
that
uninsured.
recommend
to health insurance.
tax-Free
or
managed
tax
contributions
employers
cost
Kronick
more
market
grounds
OFFice
budget
For
oF
has
neutral.
2 5
"^
�Enthoven
benefits
because
which
c a n be a c h i e v e d
artery
rate
77C
rate
coronary
and median
administrators
providers
a result
similar
with
satisfaction
within
costs
system
each
they
lower
with
sometimes
a 3.8
Managed
exorbitant
would
result
geographic
lower
and
system
must
administrative
be s i g n i f i c a n t l y
because
i n which
improve
or
area.
-84-
i s often
t h e same o r
of the
and
expertise.
reduced
insurer
patient
experienced
and K r o n i c k
and n o n - p r o f i t
the
HMOs
efficient
f a i l . " ^
5
costs currently
o f an e v e n t u a l
i n a minimal
percent
which
level
Enthoven
of profit-oriented
market
hospital
i s superior to the
of the satisfaction
utilization
11.4
out those
s u p e r i o r knowledge
28 p e r c e n t
an
care
and seek
perform
care
California,
Another
cost because
a solo p r a c t i t i o n e r .
of the Future
would
which
with
and t h e i n e f f i c i e n t
insurers
with
to recognize
o f managed
i s 95 p e r c e n t
broader
The
grafts
performance
with
fee-for-service/so1o practice/third-party
a "restructured
prosper
with
i s consonant
s e r v i c e s from
propose
o f $59,000.
includes high q u a l i t y ,
coupled
efficiency
i n the
bypass g r a f t s
o f $16,•••.^
the a b i l i t y
procedures,
traditional
bypass
charges
performance
which
charges
artery
of the frequency
Often,
in
have
whose
efficiency-
method,
and m e d i a n
occur
system
44 c o r o n a r y
death
may
care
I n 1986, a Los A n g e l e s ,
"performed
which
a managed
of the
providers.
performed
which
through
example
variations
percent
by
a striking
o f t h e wide
hospital
with
relate
of different
levels
death
and K r o n i c k
5
being
by t h e m a n a g e d
borne
care
" c o m p e t i t i v e shakedown"
number o f managed
care o r g a n i z a t i o n s
�State
A d m i n i s t r a t i o n of Federal
States
toward
medical
Funds a r e
MedlCal
capita
then
depend
payments
exceeds
the
i s 55
with a statutory
per
capita
income would
States
by
are
percent.
minimum
the
oF
5D
provide
to
IF
the
per
Federal
A
For
75
per
capita
share
income,
capita
diminishes,
1ower-than-average
s t a t e w i t h a maximum
government. '
even s u b s i d i z e d
Federal
a s t a t e ' s per
2 5
Federal
a
These
IF a s t a t e ' s
percent.
the
For c o n t r i b u t i o n s
i t s citizenry.
n a t i o n a l average
n a t i o n a l average,
but
Funding
For
computation.
to the
share
government
states according
Percentage
i s equal
Federal
percent
Federal
a l l o c a t e d among t h e
income
income
the
assistance
Assistance
the
on
Programs.
oF
83
7
percent
oF
the
cost
oF
258
medical
The
and
utilization
states, in turn,
States
must
bear
at
review
must
by
peer review
provide
least
40
local
percent
oF
organizations.
governments
the
cost
with
oF
Funds.
medical
259
assistance,
However,
with
lack
local
local
oF
duration,
scope,
under
plan
the
political
Funds c a n n o t
or
quality
i n any
part
Under S.1227, t h e
addition
then
to
have
those
oF
result
services
the
or
the
s t a t e s may
without
Full
cost
Federal
to
ensure
requirrements.
enForcement
and
would
oF
the
oF
install
with
would
Federal
a system
remainder.
in "lowering
level
the
amount,
oF a d m i n i s t r a t i o n
elect
to provide
but
the
such a d d i t i o n a l
2G1
beneFits
states
in
will
coverage
by
subsidies.
compliance
States
the
State.
S.1227 o u t l i n e s r e g u l a t i o n s w h i c h
states
bearing
Federally-required basics,
to bear
themselves,
oF
entities
have
Federal
For
be
imposed
health beneFit
to provide
standards
For
would
plan
guidelines to
health plan
r e c e i v i n g customer
-35-
on
ensure
beneFits^
263
complaints
5 2
�and
provide
carriers
information
that
regulatory
state
of Health
t o meet
membership
insurance
and
be
about
c o v e r e d by
care
states
2 5 7
of valid
(d)
attempt
t o reduce
and
providers
uniform
billing
administrative
payment
would
and assessments
and c l a i m
costs
would
companies f o r
submitted
the funding
contributions
and employ
claims
labor,
of the consortia
a claim
2 5 6
of health
business,
insurance
(b) establish
G 5
consortia
and p u r c h a s e r s
including
i f they
Act.^
purchasing
health
t o review
t o determine
The p u r p o s e
to the consortium;
develop
form
i n the state,
by t h e c o n s o r t i u m
[c]
be s u b j e c t
of the HealthAmerica
a l l small-share
and p r i v a t e
would
a l l providers
i n the cortium;
enrollees
public
that
organizations.
to (a) enroll
membership
or
i n t h e area
S Human S e r v i c e s
t o include
and h e a l t h
consumer
payment
plans
programs
the standards
S.1227 r e q u i r e s
with
benefit
regulatory
the Secretary
continue
health
e m p l o y e r s and consumers
author ity.
The
by
offer
t o small
by
fund f o r
providers
be d e r i v e d
on
from
enrollees;
form
procedures;
and b u r d e n s
on
enrollees
2S8
of health
services.
2B9
States
will
S.1227 p r o v i d e s
regulaating
power
small
However,
S.1227 " s h a l l
under
cost
to regulate
borders.
this
invokes
insurers
Act."
according
t o form
containment
insurers.
states
that
Thus,
regional
industry
do n o t c o m p l y
t o receive
S.1227 w h i l e
with
assistance
to utilize i n
have
to federal
states
legislation.
without
had t h e
within
its
the strictures of
made
acknowledging
to require
the states
-86-
states
residing
of t h e purse
contra], over
consortia."
methods f o rs t a t e s
Traditionally,
the insurance
be i n e l i g i b l e
270
t h e power
maintaining
be p e r m i t t e d
available
state
powers,
to regulate
small
I t i s a method o f
actually
pre-empting
�state
powers.
The
Federal
review
which
states
do F a c e p r e e m p t i o n
government
programs.
determine
under
There
government
state's
power
Congress
2.
Implied
p o w e r s by t h e
§2793 r e g a r d i n g
are several principles
preemption.
Federal
1.
S.1S27
oF t h e i r
would
Preemption
result
i n loss
utilization
oF
preemption
oF t h e F i e l d
by t h e
oF a s e g m e n t
oF a
structure.
may
preempt
state
l a w by e x p r e s s
statement.
2
7
^
272
preemption
may
be d e t e r m i n e d
i n two ways:
(a)
C o n g r e s s i o n a l i n t e r e s t may s o d o m i n a t e a F i e l d t h a t t h e
F e d e r a l g o v e r n m e n t w i l l be a s s u m e d t o h a v e p r e c l u d e d
e n F o r c e m e n t oF s t a t e l a w s on t h e same s u b j e c t . 2 7 3
(b)
S t a t e law w i l l
conFlicts with
There
not
i s an o v e r r i d i n g
intend
t o preempt
Senators
in
their
However,
eFFort
that
presumption
state
Mitchell,
Summary
health
be p r e e m p t e d ^ t n
Federal law.
2
law. '
Kennedy,
oF S.1227 t h a t
care
reForm
implied
will
preemption
Feel
state's
sections
§2793.
rights
laws
likely
have
government d i d
n o t been
stated
preempted.
be a F e d e r a 1 1 y - i m p o s e d
i s expected
t h e eFFects
a t the very
the Federal
7 5
state
will
S.1227 c o n t a i n s t w o c l e a r
into
that
R i e g l e , and R o c k e F e l l e r
a n d , as p e r v a s i v e as r e F o r m
the states
the extent that i t
t o be, i t i s l i k e l y
through the p r i n c i p l e
oF
least.
illustrations
and i n d i v i d u a l s '
lives
oF F e d e r a l
intrusion
and p r i v a c y . ^
The
are quoted:
Favorable
Treatment
oF U t i l i z a t i o n
Review
Programs.
(a)
PREEMPTION OF STATE LAWS R e s t r i c t i n g U t i l i z a t i o n R e v i e w
P r o g r a m s T h a t M e e t F e d e r a l S t a n d a r d s . -- I n t h e c a s e oF a h e a l t h
b e n e F i t p l a n t h a t i n c l u d e s a u t i l i z a t i o n r e v i e w p r o g r a m , no S t a t e
law o r r e g u l a t i o n s h a l l p r o h i b i t o r r e g u l a t e a c t i v i t i e s u n d e r
such
p r o g r a m , e x c e p t i n s o F a r as such law o r r e g u l a t i o n i s c o n s i s t e n t
w i t h t h e s t a n d a r d s e s t a b l i s h e d under s u b s e c t i o n ( b ) .
-87-
�Cb)
ESTABLISHMENT OF STANDARDS F o r U t i l i z a t i o n R e v i e w P r o g r a m s .
(a)
I n G e n e r a l . -- The S e c r e t a r y s h a l l p r o v i d e , by
r e g u l a t i o n , F o r t h e e s t a b l i s h m e n t oF F e d e r a l s t a n d a r d s F o r
u t i l i z a t i o n r e v i e w p r o g r a m s oF h e a l t h b e n e F i t
plans...to
assure, within a plan, the cost-eFFective
and m e d i c a l l y a p p r o p r i a t e u s e oF s e r v i c e s . ...
(c)
U T I L I Z A T I O N REVIEW PROGRAM DEFINED. -- ... t h e t e r m
' u t i l i z a t i o n r e v i e w p r o g r a m ' means a s y s t e m o F :
r e v i e w i n g t h e m e d i c a l n e c e s s i t y and a p p r o p r i a t e n e s s
oF p a t i e n t s e r v i c e s ( w h i c h may i n c l u d e i n p a t i e n t a n d
outpatient services] using speciFic guidelines.
Such
a s y s t e m may i n c l u d e :
preadmission c e r t i f i c a t i o n
t h e a p p l i c a t i o n oF p r a c t i c e
guidelines
continued stay review
[See inFra, Wickline)
discharge planning
p r e a u t h o r i z a t i o n o f a m b u l a t o r y p r o c e d u r e s , and
retrospective
review.
According
will
be a b l e
t o t h e above-quoted
to require
to
reappraise
In
consideration
as
i s deFined
derived
would
From
each
and r e v a l u e
i n the b i l l
deFensive
s t a t e government
every
oF t h e F a c t
decision
t h a t such
strategy
physician
physician
and a t t o r n e y
oF m a l p r a c t i c e
physician
Such r e v i e w
should
tion
because
the
is
review
impose
investment
escalation
selF-reFerral,
require
be r e q u i r e d
prior
oF t h e g r e a t e r
on p a t i e n t ' s r i g h t s ,
an i n v a s i o n
the r i g h t
oF a p a t i e n t ' s
p r a c t i c e s which
within
doctor/patient relationship.
with
review
i t
review
oF:
cases; and,
(c)
would
physician.
competence;
(b)
the right
utilization
t o the cost
to statutorily
(a)
number
strenuous
and p h y s i c i a n
government
t o reserve
made by e v e r y
i s due i n p a r t
medicine
be a m o r e p o i n t e d
s e c t i o n j . t h e Federal
the medical
t o imposing
detrimental
Revaluation
oF c o n F i d e n t i. a 1 i t y b e t w eon
-38-
medical
utiliza-
such
oF c a r e ,
and an
physician
review
a n d on
oF p h y s i c i a n
privacy,
the
Field.
eFFects
eFFsctiveness
individual
excEiserbate
decisions
interFerence
and p a t i e n t .
�The
can
devastating
already
discussed
potential
be
2 7 7
discerned
in this
For
eFFects
by
the
reading
text.
harmFul
oF
The
health
conditions
.Wickline
strictures
care
v.
oF
imposed
State,
by
a
§2793
case
§2793 i m p o s e a
p r a c t i c e s and
should
not
strong
be
underestimated.
The
rights
second
imposed
§2791.
by
National
(a)
health
illustration
or
Federal
S.1227 c o n c e r n s
intrusion
managed
into
states'
care.
Standards.
P r o h i b i t i o n s . --
care
oF
any
other
No
law
requirement
or
oF
any
State
regulation shall
insurance,
--
(1)
p r o h i b i t a m a n a g e d c a r e p l a n From F r e e l y s e l e c t i n g
t h e h e a l t h c a r e p r o v i d e r s , o r t h e t y p e oF h e a l t h c a r e
p r o v i d e r s i n a l o c a l e , as t h e p a r t i c i p a t i n g p r o v i d e r s ; o r
(2)
l i m i t t h e a b i l i t y oF a m a n a g e d c a r e e n t i t y t o
n e g o t i a t e , e n t e r i n t o c o n t r a c t s or e s t a b l i s h a l t e r n a t i v e
r a t e s o r F o r m s oF p a y m e n t F o r p a r t i c i p a t i n g p r o v i d e r s , o r
r e q u i r e o r p r o v i d e i n c e n t i v e s t h a t p r o m o t e t h e use
oF
participating providers.
(b)
U t i l i z a t i o n R e v i e w S e r v i c e s . -- N o t w i t h s t a n d i n g
S t a t e l a w , an i n s u r e r o r o t h e r p e r s o n o r e n t i t y may
oFFer
u t i l i z a t i o n r e v i e w s e r v i c e s i n any S t a t s i F s u c h i n s u r e r ,
o r e n t i t y h a s e s t a b l i s h e d --
to
any
person
(1)
a procedure that adequately
evaluates
the
n e c e s s i t y and a p p r o p r i a t e n e s s
oF t h e p r o p o s e d o r d e l i v e r e d
h e a l t h care s e r v i c e s ;
( 2 ) a p r o c e d u r e t h a t p e r m i t s p a t i e n t s and p r o v i d e r s t o
a p p e a l any a d v e r s e d e c i s i o n s by t h e p e r s o n o r e n t i t y p e r F o r m ing the u t i l i z a t i o n review s e r v i c e s . . . ;
...
(4)
a procedure t h a t ensures t h a t a l l a p p l i c a b l e
F e d e r a l and S t a t e l a w s t h a t a r e d e s i g n e d t o p r o t e c t t h e
c o n F i d e n t i a 1 i t y oF i n d i v i d u a l m e d i c a l r e c o r d s a r e
Followed.
Under
or
ignore
paragraph
[a)(l)
above,
a s t a t e s t a t u t e which
Missouri
prohibits
would
have
to
repeal
restrictions
on
an
278
individual's
choice
requirements
similar
resulted
oF
to
provider.
those
in a devastating
Paragraph
in existence
c h a n g e i n one
-89-
(b)
imposes
in CaliFornia
person's
state
oF
which
�279
health.
s . 1 2 2 7 §2791 ( ^ 4 )
h a v e no
effect
is a pacifying
g i v e n the mandates
of other
clause which
provisions
in
will
this
bill.
Given
the fact
a co-author
the
Pepper
advocate
which
of
patient
Rockefeller's
writer
would
have
rights.
expected
been
With
name
that
lineup
of health
David
Security
on
he
says,
of
regulating
of
1991
that
(hereafter,
"S.700 p e r m i t s s t a t e s
market
t h e Chairman
and
a
of
stronger
t h e e x c e p t i o n o f a few
assures
r i g h t s to regulate
this
as
ideas
beginning i n the
reform proposals.
Durenberger
Act
the s t a t e s '
care
is listed
pro-consumer
p o t e n t i a l , S.1227 i s a d i s a p p o i n t i n g
Senator
Health
Senator
o f S.1227, t h i s
Commission
have
current
that
the
S.700),
does
the
not
American
impinge
insurance industry.
to maintain
i f they
his b i l l ,
enact
Rather,
their traditional
state
laws
that
role
accomplish
230
the
same d e g r e e
thought
by
explaining
protections,
the
federal
other
way
of consumer
that
protection."
i f "any
intrude
Lastly,
upon
continues the
s t a t e . . . f a i l e d to enact
i n s u r a n c e companies. . .would
23 1
rules.
He
be
required
to abide
S.700 d o e s n o t o v e r r i d e
the states'
traditional
role
such
or
of
by
i n any
regulating
f i n a n c i a l s o l v e n c y and r e l a t e d s t a n d a r d s f o r i n s u r a n c e
companies.""
A d d i t i o n a l l y , t h e S e c r e t a r y o f H e a l t h a n d Human S e r v i c e s h a s
discretion
to
permit
to enter
state
laws
into
s e p a r a t e agreements
to p r e v a i l
over
federal
with
states
standards.
i n order
These
a g r e e m m e n t s w o u l d o n l y be a v a i l a b l e t o t h o s e s t a t e s w h i c h e n a c t
standards which are s u f f i c i e n t t o carry out the purposes of the
'233
American
Health Security
U n d e r S.700,
benefit
laws.
Act
of
1991.
"MedPlans" would
Senator
Durenberger
-90-
be
exempt
from
state-mandated
estimates that
state-mandated
8 2
�beneFits
increase
Surprisingly,
business
t h eSenator
employers
STATE AND LOCAL
In
by a s much
claims
signficantly
a s 2 0 t o 30 p e r c e n t .
that
less
MedPlans w i l l
than
other
cost
small
insurance
products
HEALTH CARE REFORM PLANS.
t h e Face
legislators
answers
premiums
oF B u s h
and governors
A d m i n i s t r a t i o n ambivalence,
are experiencing
to exhorbitant health
care
pressure
costs.
State
t o provide
Kosterlitz"
reports:
To a l a r g e d e g r e e , ( s t a t e s ) a r e b e i n g d r i v e n
by c o n c e r n a b o u t h e a l t h c a r e ' s g r o w i n g i m p a c t on t h e
b o t t o m l i n e . . . a s c o s t s a n d demand F o r h e a l t h c a r e
c o n t i n u e t o o u t s t r i p t h ^ i a t i o n ' s w i l l i n g n e s s t o pay
For i t , s t a t e s have i n c r e a s i n g l y F e l t t h e p r e s s u r e
t o be t h e p a y e r oF l a s t r e s o r t , g e t t i n g s t u c k w i t h
c o s t s t h e Fedecal government and p r i v a t e i n s u r e r s
reFuse t o p a y .
The r e s u l t , s t a t e o F F i c i a l s s a y , i s n o t o n l y
chaos For s t a t e b u d g e t s , b u t a l s o a s t e a d i l y
d e t e r i o r a t i n g s t a t e h e a l t h n e t w a r k - - e s p e c i a 11y i n
i n n e r c i t i e s and r u r a l areas--and l o u d e r
complaints
From h e a l t h c a r e p r o v i d e r s , l a r g e and s m a l l
b u s i n e s s e s , and a d v o c a t e s F o r consumers a n d l o w income Americans."286
2 8 5
M a s s a c h u s e t t s was o n e oF t h e F i r s t
a health
plan,
recession
a n d was u n s u c c e s s F u l
which
began
CaliFornia,
Michigan,
Washington,
Oregon,
widespread
insurance
Maine,
Colorado,
and H a w a i i
t o attempt
oF t h e d e e p
a t that
Connecticut,
a r e a Few e x a m p l e s
attempts
time.
at health
Missouri,
oF t h e
care/health
reForm.
points
and o t h e r
negotiating
reaching
because
t o h i tt h enortheast
state-initiated
Kosterlitz
hospitals
states
outthat
groups
compromises,
s o l u t i o n s than
within
they
such
when e m p l o y e r s ,
a single state
may p r o v e
a group
-9 1 -
more
would
doctors,
start
successFul i n
achieve i F
�negotiating
on a F e d e r a l
level.
state
level
will
a precedent
easier
to
Follow.
provide
Too, e a c h
success
which
others
at the
will
Find
2S7
Q Q
Shaheen"
relations
oF
has r e c e i v e d
Federal/state
many
in
points
respects,
these
poocess
which
a t the-Federal
Missouri
would
The
plan
all
Universal
have
Canadian
government
Yet,i n
play
key r o l e s
a f t h e same
i d e n t i F i e d as a F F e c t i n g
provided
program
been
and
departure
From
a l l Missourians
with
a basic
t o be p o r t a b l e ,
was m o d e l l e d
have r e p l a c e d ,
insurance
because
plan.
on t h e
Although
conglomeration,
oF w h a t
health
programs.
i t was b e l i e v e d
as an e x a m p l e
which
a t the basic
or deductibles.
the current
here
level,
There
would
the
proposal
t o be -1oo r a d i c a 1 a
i t i s a good
individual
plan
states are
t o accomplish.
Missouri
Funded
(H.B.1127J
private health
enacted
appear
Plan
and w o u l d
was n e v e r
trying
also
the policy
Assurance
no c o p a y m e n t s
recount
level
Health
was m e a n t
public
have
would
by more
For
health
1.
Money
have
t h e areas
relationships.
services...(M)any
have been
oF s t a t e / l o c a l
attention...than
t w o u n i t s oF
oF human
area
t o be r e F l e c t e d i n
28 9
p o l i c y p r o c e s s a t t h e s t a t e and l o c a l
level."
I n 1990 t h e M i s s o u r i l e g i s l a t u r e c o n s i d e r e d t h e
290
the
to
Far less
"(T)he
or F e d e r a l / l o c a l
the delivery
dynamics
out that
eFFicient
care.
spent
had t h e i r
spending
health
assurance
oF money
already
program
allocated
For example:
by e m p l o y e r s
been r e d i r e c t e d
employers.
have
on e m p l o y e e
t o a $.75 p e r h o u r
The p a y r o l l
t a x would
-92-
health
payroll
have r a i s e d
beneFits
t a x on
$3.5
would
those
billion.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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[Political Power Structures Affecting Any National Health Care Reform Plan: Health care reform concepts versus Social and Economic Values] [binder] [1]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
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Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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42-t-12092971-20060885F-Seg3-037-017-2015
12092971
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https://clinton.presidentiallibraries.us/files/original/9eeae3429c1f974300e0a7ff49433511.pdf
04edb0b41b1967e0712fa0fc0ca5de20
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
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Collection/Record Group:
Clinton Presidential Records
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Health Care Task Force
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Tarmey
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OA/ID Number:
1967
FolderlD:
Folder Title:
[Policy Review] [loose]
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Section:
Shelf:
Position:
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56
1
9
1
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�policy
Winter 1994
Number 67
$5.50
The Gory Details of the Clinton Health Plan
Robert E. Moffit
America's Revolt Against God
William J. Bennett
Do Republicans Have A Future?
William Kristol
Who's Afraid of the Religious Right?
Dick Armey
EPA's Wizards of Ooze
James M. Strock
Salamander the Great
The Imperial Reach of the Endangered Species Act
What the Dickens Are College Students Reading?
�
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Health Care Task Force Records
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White House Health Care Task Force
Is Part Of
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
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2006-0885-F
Text
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[Policy Review] [loose]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
Is Part Of
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Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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3/16/2015
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42-t-12092971-20060885F-Seg3-037-016-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/d0d5d4e9de5a2fd09addc177a72bd7c0.pdf
777060e812198d595ff9984b5a263c1b
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1983
FolderlD:
Folder Title:
[A Policy Maker's Guide to the Health Care Crisis Part 11: The Heritage Consumer Choice Health
Plan] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
2
�s HERITAGE s
A POLICY MAKER'S GUIDE TO
THE HEALTH CARE CRISIS
PART II:
THE HERITAGE CONSUMER
CHOICE HEALTH PLAN
By Stuart M. Butler, Ph.D.
^Heritage ^oundatiori
�Heritage ^oundatioii
The Heritage Foundation was established in 1973 as a nonpartisan, tax-exempt policy
research institute dedicated to the principles of free competitive enterprise, limited government, individual liberty, and a strong national defense. The Foundation's research and study
programs are designed to make the voices of responsible conservatism heard in Washington,
D.C, throughout the United States, and in the capitals of the world.
Heritage publishes its research in a variety of formats for the benefit of policy makers; the
communications media; the academic, business, and financial communities; and the public at
large. Over the past five years alone The Heritage Foundation has published some 1,500
books, monographs, and studies, ranging in size from the 927-page government blueprint,
Mandate for Leadership Ilf: Policy Strategies for the 1990s, to the more frequent "Critical Issues"
monographs and the topical "Backgrounders," "Issue Bulletins," and "Talking Points" papers.
Heritage's other regular publications include the SDI Report, U.S.S.R. Monitor, Business/Education Insider, Mexico Watch, and Policy Review, a quarterly journal of analysis and
opinion.
In addition to the printed word, Heritage regularly brings together national and international opinion leaders and policy makers to discuss issues and ideas in a continuing series of
seminars, lectures, debates, briefings, and conferences.
Heritage is classified as a Section 501(c)(3) organization under the Internal Revenue Code
of 1954, and is recognized as a publicly supported organization described in Section 509 (a)(1)
and 170(b)(l)(A)(vi) of the Code. Individuals, corporations, companies, associations, and
foundations are eligible to support the work of The Heritage Foundation through taxdeductible gifts.
Note: Nothing written here is to be construed as necessarily relfecting the views of The Heritage
Foundation or as an attempt to aid or hinder the passage of any bill before Congress.
The Heritage Foundation
214 Massachusetts Avenue, N.E.
Washington, D.C. 20002-4999
U.S.A.
202/546-4400
�March 5, 1992
A POLICYMAKER'S GUIDE TO THE HEALTHCARE CRISIS
PART H: THE HERITAGE CONSUMER CHOICE HEALTH PLAN
By Stuart M. Butler, PhD.
INTRODUCTION
Part I of this Talking Points series on health care explained that proposals to
reform America's health care system generally are based on one of three approaches. Each approach uses a different mechanism to allocate health care
resources and to determine what services a familyreceives.These three methods
are:
1) The Single-Payer (or "Canadian") Approach. The government becomes the monopoly provider of health care financing. Itfixesa budget for
health care and allocates money to hospitals, and it sets physician fees.
2) The "Play or Pay" Approach. The government gives employers a choice:
either provide at least a specified health insurance plan to employees and
their families, or pay a payroll tax to finance a public program for their
health benefits, as well as for those Americans not currently insured. The
government runs the public program and employers are responsible for
financing and managing private insurance.
3) The Consumer Choice Approach. Americans are allowed to choose the
health care plan they want. Unlike today, where government help to obtain a
plan effectively is restricted to employer-sponsored plans, families would
receive the same amount of government help wherever they obtained
coverage. Further, there would be more help for the sick and the low-paid,
less for the healthy and the high-paid. No national budget for health care
would be set by the government, and efficient allocation and cost control
would be determined by consumer choice and competition among providers.
Many of the key features of a consumer-based system already exist in the
Federal Employee Health Benefits Program (FEHBP). This covers congressmen
and their staff, agency heads and employees, and judicial branch employees—in
all over nine million workers, their dependents, and retirees. Several proposals
are versions of a consumer-based system. The Bush Administration's recent
health proposal would establish such a system for today's uninsured.
�A comprehensive proposal has been introduced in the Senate (S. 2095) by
Steve Symms and Larry Craig, both Idaho Republicans, and elements of a consumer-choice model are included in a bill (S. 1936) introduced by Senator John
Chafee, the Rhode Island Republican.
In addition, The Heritage Consumer Choice Health Plan has been developed
by The Heritage Foundation.
This Talking Points examines the Heritage plan in detail. It reviews the plan's
features and implications. It also contains the findings of an analysis of the
Heritage plan by Lewin/ICF, a leading Washington-based econometric firm
specializing in health economics. The Lewin/ICF study was commissioned by
Heritage. Lewin/ICF conducts similar analyses for the Administration, Congress, and the private sector.
HOW THE HERITAGE CONSUMER CHOICE
HEALTH PLAN WORKS
The Heritage plan would create a health care system in America in which all
families would have access to an affordable health plan and would choose the
plan they wanted. Today a family normally must change its plan, or even lose
coverage, when the head of household changes jobs or faces unemployment.
Under the Heritage proposal, the family would keep the same insurance without
interruption when changing jobs—much as families keep the same life insurance, car insurance, homeowner's insurance or mortgage. In addition, the tax
code would be changed to give more help to lower-paid or sick families to afford health care. This change would not increase the federal deficit.
Reduced to its central elements, the Heritage plan involves two principal steps:
Step #1: Convert the tax exclusion for company-sponsored plans into a tax
credit for plans from any source.
When a family is covered by an employer-sponsored health plan as part of the
breadwinner's total compensation, the value of the benefits is not included in the
family's taxable income. This is like a tax deduction for the family. This is
known as a "tax exclusion." For the vast majority of Americans, this is the only
See Stuart M. Butler and Edmund F. Haislmaier, eds., A National Health System for America (Washington,
D.C: The Heritage Foundation, 1989); Stuart M. Butler, "UsingTax Credits to Create an Affordable Health
System," Heritage Foundation Backgrounder No. 777, July 20,1990; Stuart M. Butler, "A Tax Reform Strategy
to Deal With the Uninsured," The Journal of the American Medical Association, Volume 265, May 15,1991.
It is actually more generous than a tax deduction for lower-paid families and many middle-income families,
because Social Security taxes are not applied. Tax deductions by contrast are free of income tax, but not of
Social Security taxes.
�way they can obtain a tax break for health care costs (for the implications of
this, see Talking Points, Parti: The Debate Over Reform, February 12, 1992).
Under the Heritage plan, the current exclusion for company-provided plans,
as well as other minor health tax deductions, would be replaced with a new tax
credit available to all non-elderly and non-Medicaid families for the purchase of
health insurance and out-of-pocket medical costs. The cost to the Treasury for
the credit would exactly equal the cost of current tax breaks. In Washington jargon, this makes the plan "budget neutral."
Q : What does that mean for employees who have a company plan?
Would they pay higher taxes?
A: Generally no. It just means families would gain tax relief in a different
way. If they had a company-sponsored plan, the cash value of that plan now
would appear as a taxable item on their end-of-year W-2 tax form from the
employer. But the family then would be able to claim a credit for the cost of
employer-sponsored plan and for out-of-pocket costs, such as deductibles. Further, if the family chose a plan from a source other than their employer, the
employer would berequiredto "cash out" their current benefits by adding the
value of those benefits to the worker's paycheck. As described below, the
Lewin/ICF analysis of the proposal indicates that most families would pay
slighdy lower total taxes after this switch. And while some families would pay
higher taxes, it would be because they had found ways to cut their medical insurance costs and thus gained more (taxable) income for other purposes.
Q : What about families without a company plan?
A They would receive a credit for buying insurance and out-of-pocket
medical care. Today these families normallyreceiveno tax help or any other assistance, unless they go on welfare.
Q : What about the working poor, who pay little or no tax?
A : The new credit would be refundable. This means that if the family's
credit exceeded its tax liability, it wouldreceivethe difference from the government, in the form of a voucher that could be used only for health care.
Three smaller tax breaks are available for some Americans. The self-employed can deduct 25 percent of the cost
of insurance. Americans with high out-of-pocket medical costs can deduct the amount in excess of 7.5 percent
of their adjusted gross income if they itemize their taxreturn.And low-income working Americans can obtain a
credit for certain insurance to cover their children, through the earned income tax credit (EITC).
�Step #2: Require all households to purchase at least a basic package of insurance, unless they are covered by Medicaid, Medicare, or other
government health programs.
All heads of households would be required by law to obtain at least a basic
health plan specified by Congress. The refundable credit system partially would
offset the cost of such a plan for most Americans, as the exclusion does today
for those with company-sponsored plans.
In addition to these core steps, the Heritage plan would institute reforms to
smooth the transition to the consumer-based national system and to enable the
market for health insurance and medical care to operate more effectively.
Among these, the plan would:
X Reform the insurance market: The private insurance market would
be reformed to make a standard basic package available to all at an acceptable price (see below).
X End State insurance mandates: Most states mandate that insurance
sold within their borders must cover certain services. These mandates
would in effect be preempted, to allow the basic plan to be marketed
throughout the United States and to permit new types of group sponsors
to sell plans. In addition, plans could not be made subject to state restrictions on managed care. These state mandates could be preempted by
federal law, as they are for the Federal Employee Health Benefits Program. Or the federal government could widen current exemptions from
state mandates for self-insured company plans to include any plan that
complies with the insurancerequirementsof the Heritage proposal.
4
X Place requirements on employers: In a system based on the
Heritage proposal, employers would be required by law to do two things:
1) "Cash out" benefits during a one-year transition period. Employers
would have to add the cash value of their existing plan to the
paychecks of any employee wishing to switch to an alternative plan or
if the employer decided to terminate the plan. This means employees
would be what economists call "held harmless" by the change. After
Heritage analysts believe that today's concerns about state mandates actually would decline or even disappear
in a full-scale consumer based system. The reason is that voters would have a strong incentive to resist new
insurance mandates since these would translate directly into higher insurance premiums they would pay. Today
the higher costs due to mandates are buried in "free" company plans. Significantly Congress, which could
mandate services in the federal employee system, chooses not to do so in large part because employees would
face higher premiums if there were congressional mandates. See Robert E. Moffit, "Consumer Choice in
Health: Learning from the Federal Employee Health Benefits Program," Heritage Foundation Backgrounder
No. 878, February 6,1992.
�the transition, employers and employees would bargain for compensation packages as they do today.
2) Introduce a payroll deduction for health insurance and adjust
withholdings. Employers would be required to make a payroll deduction each pay period, at the direction of each employee, and send the
amount to the plan of the employee's choice. This would be like the
payroll deduction that many employees instruct their employers to
make for contributions to a 401 (k) or similar savings plan. In the
federal employee health system, a worker's agency or congressional
office makes a similar payroll deduction to pay for premium costs.
Employers also would be required to adjust the employee's withholdings to
reflect their estimated health credit, just as they do now when, say, an employee
buys a house and becomes eligible for the mortgage deduction. This means that
employees would not have to wait until the end of the year to claim the credit.
Q : What about a low-paid worker who does not have taxes withheld?
A: Actually even the low-paid normally have Social Security taxes withheld.
In any case the employer would estimate the refundable credit available to the
employee and send this, plus any contribution by the employee, to the
employee's chosen plan.The employer would adjust the total withholdings sent
to the IRS to reflectrefundablecredits for any employees.
Q : What about the unemployed?
A : If an individual became unemployed, normally he or she would become
eligible for a larger credit, since family income would fall. For the unemployed,
the government would send the value of the credit to the individual's plan. In addition, the unemployment check could be adjusted toreflectthe contribution, if
any, due to the plan by the individual. Further, since the paperwork for this
change in the payment method would take time, health plans would not be permitted to drop coverage if a working family became unemployed. When the
paperwork is complete, the plan would receive premium payments due during
the interval.
ADVANTAGES OF THE HERITAGE PLAN
A consumer-based plan would have profound and beneficial effects on
America's health care system. Among the most important:
/
Every American family would have access to affordable and adequate
health care.
Under the Heritage plan, all Americans—most important, all Americans now
uninsured—would be enrolled in a health plan or covered by a public program
(chiefly Medicaid or Medicare programs).
�•
Americans no longer would lose coverage when then they changed jobs.
American families would be able to obtain health coverage from any source,
not just their employers, with exacdy the same tax benefits. This means health
insurance would be "portable." So when a worker changed jobs, he or she
would take the family's health plan to the next job, just as they normally keep
the same life insurance protection or mortgage company. For this reason, worries about "pre-existing condition" clauses in a new employer's plan would disappear, and families would keep the same doctor and benefits of their chosen
plan.
•
Americans could choose new kinds of group plans.
The fact that individuals will buy health plans does not mean that individuals
must buy the kind of individual coverage typically sold today. Individual plans
today tend to be more expensive for a number ofreasons.Their administrative
and marketing costs, for instance, are high because the insurer has to collect
premiums from each individual. Group plans, such as those run by employers,
cost less because the insurer is dealing in "bulk" and can negotiate with medical
institutions.
Under the Heritage proposal, families could still gain the financial advantages
of group purchasing. They could still join groups structured around their
employer. More important, families could join plans organized by other groups
and stillreceivetax benefits. Today, of course, if families are not pan of an
employer group plan, typically the families enjoy no tax benefits. Several new
types of group probably would emerge. Among them:
Unions
Under the federal employee system, 35.5 percent of enrollees are covered in
plans organized by a union or other employee organization. In many instances,
these union plans are open to non-union members. Sometimes the union health
plan is much larger than the union itself. There are about 500,000 members of
the Mail Handlers Plan, for instance, but only about 30,000 regular members of
the union.
Union-sponsored plans likely would become a growth industry under the
Heritage proposal. They would possess a marketing advantage because many
workers would trust a union-sponsored plan rather than one from most other
sources, particularly one promoted by management. Unions might also see a
health plan as a goodrecruitingtool for attracting individuals as regular members. Further, many unions already have expert health benefits negotiators who
could easily become the administrators of the union's own plan.
5 Technically, enrollees pay a small fee to become associate members of the union for the purposes of coverage,
but arc in no sense regular union members.
�Churches
In many communities the church easily could sponsor a group health plan.
This is especially true in the black community, where typically the church already functions as a social and economic development agency. Similarly, the
Church of Jesus Christ of Latter Day Saints (that is, the Mormon church) carries
out a sophisticated social welfare function for its members. Sponsoring a health
plan for members would be a natural development.
Farm bureaus
Some state farm bureaus, such as Virginia's, already have a health plan for
farm-based families. But often families receive limited or no tax breaks for joining such plans. With the Heritage proposal as law, farm bureaus and similar organizations would have a natural market niche in rural areas, especially for
seasonal or casual workers.
Sickness groups
In some cases, a family might choose a plan offered by an organization of individuals suffering from a particular ailment. Many such organizations exist and
give advice on obtaining treatment. Making a plan available to members would
be a simple step. These plans, moreover, would structure medical services
around the particular needs of the member, say a diabetic. Today, a diabetic typically has to take a standard company-sponsored plan containing items he or she
does not use and then pay out-of-pocket for additional specialized services.
•
Costs would be controlled effectively and efficiently.
The Heritage plan uses the best device ever found to hold down costs without
sacrificing quality and efficiency: consumer choice within a competitive market.
This works well and simply in the huge Federal Employee Health Benefit System, where cost increases are running at about one-third to one-half less than increases in company-sponsored plans. It also works well in non-company insured markets, such as cosmetic surgery. It also works in every other private sector of the economy.
The Heritage plan would permit it to work in health care. Families would
"shop around," comparing the premium prices and benefits ofrivalplans and
making their choice accordingly, just as they do for life insurance, a car or a
house, or college education for their children—and as federal workers do for
health plans. Premium costs would be reduced by virtue of the tax credit, but
families would still save money by choosing the least expensive plan that met
their needs. In turn, plan organizers would have to compete aggressively for the
family's dollars by developing plans that combined attractive benefits with a
6 See Moffit, op. cit.
�good price—precisely the same imperative that keeps costs under control elsewhere in the economy.
/
The Heritage plan is budget neutral.
The Heritage plan would not increase the federal deficit. This means that it is
budget neutral. This is because the new credit system would cost the same as existing tax breaks for health care. As explained below, the plan also is budget
neutral for states.
Q : Does a system based on the Heritage proposal have to be budget
neutral?
A : No. But the basic plan could be made more generous to, say, the lowerpaid by additional help from a state or the federal government. This, of course,
would mean an extra cost to the budget
DETAILS OF HOW THE HERITAGE CONSUMER CHOICE
HEALTH PLAN WOULD WORK
The Heritage Foundation contracted with Lewin/ICF to construct a model of
the plan within theframeworkof Lewin's econometric model of the health care
economy. Lewin/ICF conducts econometric analysis for government and the
private sector and is among the most highlyrespectedcompanies in thefieldof
health analysis. For purposes of this model, Lewin made small modifications,
some to enhance the basic plan and others to simplify the modelling process.
Thisrequiredvarious assumptions and produced specific results.
•
How the tax credits would be structured
Lewin/ICF modelled three versions of the basic Heritage plan. Other versions
are of course possible. In each version, Lewin calculated the credit percentages
that wouldresultin budget neutrality for the federal government and the states.
These are presented in Table 1. Minor adjustments could be made in the rates to
produce more rounded numbers without departing significantly from budget
neutrality.
Version #1 Is a voucher plus a flat credit for remaining insurance and out-ofpocket costs. Each individual in a family would qualify for a refundable credit
to help buy insurance. This "health insurance voucher" would be equal to a maximum of $220 per individual per year (80 percent of $275) or $880 for a family
of four. In addition, the family could claim a flat 18 percent refundable credit
for all insurance costs and out-of-pocket costs above $275 per year per individual (that is, above the amount subject to the voucher).
Version #2 is a sliding scale credit for all insurance costs and out-of-pocket
COStS. In this version, families wouldreceivea sliding scale credit to help offset
the cost of insurance and out-of-pocket costs. As these costs rise as a proportion
�Table 1
Federal Tax Credit Alternatives
Tax Credit Version #1
•
80 of the cost of premiums up to $275 per family members, plus
•
18 percent of premiums over $275 per member, plus
•
18 percent of umreimbursed medical expenses.
Tax Credit Version #2
Premiums and
Unreimbursed Expenses
as a Percent of Gross
Household Income
Percent Reimbursed
Under the Credit
Below 10%
21%
10%-20%
45%
20% or more
65%
Tax Credit Version #3
•
75 percent of premiums up to $275 per family member, plus
•
14 percent of premiums over $275, plus
" as a PercentS S S S '
Z X S S S of Gross
Household Income
Percent Reimbursed
.,_ . * - „ |
Mt v
K
U n d e r t h e
n
H
4
C r e d , t
Below 10%
21%
10%-20%
45%
20% or more
65%
Note: The credits are refundable.
This structure of credits is budget neutral at the state and federal levels.
Source: Lewin/ICF estimates using the Health Benefits Simulation Model.
�of family income, the percentage
credit also wouldrise.The structure of this sliding scale credit is
much like the child care credit in
today's tax code.
Version #3 is a combination of
the first two. A voucher and flat
rate credit would apply to insurance costs only, and a sliding
scale credit to out-of-pocket
costs. This version would encourage families to buy a basic
plan, but give them a bigger incentive to accept higher deductibles and copayments.
•
The minimum benefits package required by law
Table 2 indicates the minimum
benefits package that would be
required by law under the
Heritage proposal, as chosen by
Heritage analysts and priced by
Lewin/ICF. For a family of four
this plan is estimated to cost
$277.33 per month or $3,327.84
per year, so it is by no means a
"bare bones" plan. It should be
noted that the plan has been
priced on a per capita basis. In
practice family plans cost less
than the total would be if each
member bought a separate plan.
So the cost for a family in the
model is probably an overestimate in some cases. Equivalent
coverage options would be permitted. For instance, instead of
75 percent coverage for
physician services, a plan may
have a higher percentage, but a
Table 2
Basic Plan Required by Law
Minimum standard coverage required for
all Americans.
•
$ 1,000 deductible ($2,000 per family).
•
$5,000 cost-sharing maximum.
Coinsttrance
Inpatient Hospital Sarvlcas
(365-day per stay maximum)
80%
Out pattern Hospital Sarvlcas
80%
Hospital AKsmatlvM
(extended or home health care)
Yes
Physician Services
75%
Prsnatal/Well-Baby/
Well-ChIM Cara
75%
Diagnostic Tests
75%
Prescription Drugs (inpatient)
75%
Emergency Services
100%
Mental Health Care
Not Covered
Dental Care
Not Covered
Vision Care
Not Covered
Average monthly cost of the plan is $69.33
per person.
Actuarial equivalent alternatives are permitted.
Note: Individuals covered by a government heallh program such as Medicare and Medicaid are exempt Irom
those coverage requirements.
Actuarially equivalent plans are ones with different
coverage or benefit levels than those specified here, but
whose total cost is the same for individuals with the
same actuarial characteristics such as age, sex, and
geographic location.
7 A copayment, or coinsurance, is the percentage of an otherwise insured medical bill that must be paid by the
patient
10
�lower percentage for inpatient prescription drugs. A prepaid managed health
plan (such as a Health Maintenance Organization, or HMO) with at least the
same basic coverage would be permitted.
The legally-required basic
plan would limit deductibles for
a family to no more than $2,000
and total unreimbursed costs (including the deductible) to no
more than $5,000, often known
as the "stop loss" amount or
amount above which there is
"catastrophic" protection. A
family could choose a plan with
a lower deductible or
catastrophic protection, but normally that would mean a higher
premium. These unreimbursed
medical costs would be offset
by a credit in each version of
the Heritage plan (they are not
normally given tax relief today)
and so would be less costly to a
family than the same amounts
included in a company-sponsored plan today.
•
The employer's responsibility
Table 3 summarizes the
responsibility of employers. In
essence employers act as bookkeepers for their employees,
handling premium payments
and tax adjustments on the
employee's behalf. One important assumption is made about
Social Security (PICA) tax. If
employer-provided plans become subject to tax (offset, of
course, by the new credit), the
value of those benefits also
would become subject to the
"employer's share" of Social
Security tax. Heritage analysts
instructed Lewin/ICF to assume
in modeling the plan that in con-
11
Table 3
The Employer's Responsibiliy
Employers have the option of:
• Continuing to provide health benefits; or
• Discontinuing the health plan.
For employers who continue to
provide benefits:
• The average amount of the employer's
contribution is counted as taxable
income to the employee.*
• Employees may not take cash in lieu of
coverage.
For employers who discontinue
coverage:
• Employers must maintain their current
level of effort by converting benefits to
income.
•
Employers must deduct premiums for
workers.
Employers will hold workers harmless
for the employer share of increased
RCA tax payments due to taxation
of benefits.
* Separate employer contribution amounts would
be used for persons with single and family coverage.
�verting current benefits to cash during the transition year, employers pay this
extra tax (see below). Other than this small tax, there would be no change in
taxes or total employee compensation costs for an employer.
•
Changes in the insurance market.
Table 4 indicates the proposed reforms of the insurance market under the
Heritage Consumer Choice Plan. The most important of these is that all health
plans henceforth would be required to guarantee annualrenewalfor any enrollee
who wished to do so, with a premium increase no greater than the average for
all enrollees covered by the carrier. This means that insured individuals could
not be dropped, or charged unduly high premiums, if they became
sick. In addition, under the
Table 4
Heritage plan, three underwriting
Insurance Market Reforms
requirements would be placed on
insurance companies—at least
Reform of renewal practices.
during a transitional period while
the insurance market adjusted to
• Guaranteed renewal.
the new financing system.
• Renewal Premium updated by
First Requirement: Uninsurable
Americans (those for whom insurance is impossible in a free
market except at prohibitive
prices) who are currently uninsured would be randomly assigned to insurers and plans doing
business in a state. This would
spread the cost of insuring highrisk families among existing
plans.
Second Requirement: If an insurer now covers a family, say
through a employer-based plan,
that insurer would berequiredto
continue coverage if the
employee wished it This means a
sick person now in a companysponsored plan would not be
dropped if the employer ended
the plan or the employee moved.
The insurer would be required to
convert the group coverage to individual coverage, so the woricer
would not lose coverage if he or
she changed jobs.
12
carrier-wide average increase.
•
Changes in premium due to changes in
health status are prohibited.
Current marketing/underwriting practices
modified during at least the transition
period.
•
Uninsurable individuals who are currendy
uninsured are randomly assigned to
carriers.
•
Insurers must extend portable, individual
coverage to all persons they now cover
through employment-based group plans.
•
In converting from group to individual
coverage, premiums are permitted to vary
by no more than 25 percent on the basis
of age, sex, and geography-adjusted
premiums.
State mandates are preempted by
standard benefit package.
State Laws restricting selective contracting and managed care plans are
preempted.
�Third Requirement: Plans could not charge more than 25 percent above or
below the average charged for new enrollees with similar characteristics. This
means that sick families, who today often find the cost of coverage prohibitive,
could not be charged premiums more than 25 percent above those for similar
families of average health. If a family switched plans, moreover, the new carrier
could not charge them more than
25 percent above the average
premium charged for similar
Table S
families.
Key Assumptions
•
Modelling assumptions made
by Lewin/ICF
Lewin/ICF had to make certain
assumptions about consumer behavior and other features of the
basic Heritage plan to "run the
numbers." Some of these are crucial; others simply were to ease
the process of modelling and
could be changed in any final program. These are contained in
Tables 5 and 6. Among the most
important:
First Assumption: All
employers are presumed to discontinue their existing plans and
convert their value into additional cash income for employees.
This makes the calculations
easier and morereliable,but is
not crucial to the plan. Some
large companies might well continue to provide coverage.
Second Assumption: Healthy
families buy a basic plan and
pocket the savings, while currently insured Americans in poor or
fair health either maintain their
existing coverage or upgrade to
better coverage. The model assumes all the uninsured buy the
basic package, which includes
catastrophic protection (although
some doubtless would buy more
elaborate plans).
13
Employers who now offer insurance:
•
All will discontinue coverage and conven
benefits to wages.
•
Firms with over 1,000 workers establish
employee premium financed cafetena plans,
which will reduce administrative costs.
Workers now covered by
employer Insurance:
•
Those in poor/fair health will select plans
that at least maintain their existing level of
coverage.
•
Those in good/excellent health will
downgrade to the standard package.
n Health services utilization for penons who
downgrade coverage will decline based
upon price elasticities reponed in the
literature (a price elasticity of -0.2 was
selected).
Persons now covered by
non-group insurance:
•
Persons who now have coverage in excess
of the minuimum standard will maintain that
coverage.
•
Others will upgrade to the minimum
standard.
Currently uninsured persons:
•
All will take the minimum standard package.
•
Utilization will adjust to levelsreportedby
insured persons with similar charactoeristics.
No change is assumed in the number of
persons enrolled in Medicaid.
�Third Assumption: Administrative costs are assumed to be lower than for
today's individual health insurance plans. However, Lewin/ICF does not assume
that all employers would make a payroll deduction for employees and send
premiums to the chosen insurer. In fact, Heritage analysts make that a legal requirement. This might mean somewhat lower administrative costs than
Lewin/ICF projects.
Table 6
Administrative Cost Assumptions
Administrative costs would be the same as under current policy for workers in
firms where the employer arranges employee deductions.
Administrative costs for others purchasing individual insurance would be 21.9
percent of claims. This retention rate was estimated as follows:
Administrative Costs for Individual Coverage
as a Percentage of Claims
r.,rr»n» Policy"
Current Drtiiou*
Assumed level Under
t>
9.3%
8.0%
Claims Administration
T a x
C r e d | t
General Administration
12.5
10.0
Interest Credit
-1.5
-1.5
Risk and Profit
8.5
2.7
Commissions
8.4
0.0
Premium Taxes
2.8
2.7
40.0%
21.9%
Total
a: Hay/Huggin estimates of administrative costs for groups with 1 to 4 members under current
policy.
b: Hay/Huggin estimates of administrative costs for groups with 1 to 4 members under a
voluntary risk pooling arrangement adjusted to assume that insurer profits as a percent of
claims correspond to the national average observed in the current system.
Source: Congressional Research Service. "Cost and Effects of Extending Health Insurance
Coverage," Washington, D.C. October 1988.
14
�HOW TOTAL SPENDING WOULD BE AFFECTED
Effect #1:Total U.S. spending on health care would fall immediately by $10.8 billion. Families Initially would save $18.8 billion.
Households would pay direcdy for their own coverage under the Heritage
plan, rather than have their employer paying for it as happens today. As a result,
total household health payments would, in the first instance, go up substantially.
But the cost would be more than offset by two items, as indicated in Table 7: the
tax credit (worth a total of $84.9 billion), and the increase in wages due to firms
cashing out existing benefits (for a total increase in cash wages of $148.7 billion). This would leave families as a whole ahead by $18.8 billion. Private
employers, as well as federal, state and local governments, would save on health
costs, but pay their employees more in cash income. The net effect on total
health spending, concludes Lewin/ICF, would be a reduction of $10.8 billion.
Q : Would this one-time saving be all the cost reduction under the
Heritage plan?
A : No.
T«bt«7
Change in National Health Spending by
Lewin/ICF does
Source of Payment
believe that the pat(billions ol dollars)
tern of spending
after these changes
would continue in
• K-:. :x •
• liwact on Pavort • •J
line with today's
$129.9
Household Payments
$88.2
trend. However,
Premium Payments
62.7
Out-of-Pocket Spending
Heritage analysts
Tax Credits
(84.9)
believe the new in63.9
Eliminate Tax Exclusion
centives for
(112.4)
Private Employers"
families to shop
around for the best
Federal Government"
(5.1)
bargain would hold
(23.2)
State Governments
the annual growth
S K - ; HetCtwruw iii Hetittt Ssendlna
of spending sig(10.8)
Changed In Health Spending
nificandy below
8.9
Utilization for Newly Insured
current trends. If
(21.8)
Utilization for Currently Insured
2.1
the general inInsurer Administrative Costs
crease were to be
Note: Figures indicate Increase in spending. Reductions in spending are in
held to the rate in
parenthesis.
The increases in
recent years of the a wages of $148.7 household health spending will be offset by increased
billion,
consumer-based
b Reflects elimination of employee coverage. Employer savings in health
spending will be offset by Increases in wages not shown here,
Federal Employee
c Reflects elimination of employee coverage and savings to county
Health Benefits
hospitals.
source: Lewin/ICF estimates uslno the Health Benefits Sirnjlatlon Model
Program, for instance, American families would save tens of billions of dollars each year in
health costs, with bigger savings each year compared with current projections.
:
:;::
a
0
15
�Effect #2:The plan would ba budget neutral at the federal and state levels
The Heritage proposal is budget neutral. Tables 8 and 9 indicate the impact in
federal and staterevenues.Significandy, the states would enjoy a windfall of
$13.2 billion by cutting costs at public hospitals that treat the uninsured. These
uninsured would now be covered by insurance partly financed with a tax credit.
States with income taxes also would receive extra taxes since taxable wages
would rise because of the elimination of the tax exclusion for company plans. To
preserve budget neutrality at federal and state levels, the Heritage plan assumes
that the states make a contribution to the federal tax credit equal to their net
savings.
Q : How would the states contribute to the federal credit?
A : One way could be through a reduction in the federal share of funding
for the federal-state Medicaid program, or reductions in other federal
health grants to states. This makes sense because the federal credit would help
lower-paid state residents to afford care, thusrelievingthe health care costs of a
state.The Bush Administration's proposed low-income health credit would be
financed in part in this way. Another method would be to require states to make
a contribution to the credit (such as being responsible for a fixed dollar amount
of the insurance voucher in versions #1 or #3 of the Heritage plan).
Tables
Sources and Uses of Federal Funds
Under the Tax Credit Program In 1991
(in billions of dollars)
Tax Credits
Elimination of Tax Exclusion
Federal Income Tax
OASDI Payroll Tax
HI Payroll Tax
39.7
21.2
5.7
$84.9
Civil Service Plan (FEHB)
$66.6
Health Benefits
Wages
OASDO and HI Taxes
(4.6)
4.6
o.5
0.5
Eliminate Deduction for
Health Expenditures in
Excess of 7.5 percent of AG I
2.5
Contribution from State and
Local Governments
18.8
T©talSour<»*©f Funde
Corporate Income Tax Loss*
2.5
$87.9
Note: Number in parenthesis represent negative amounts.
* We assume that the full amount of the employer share of the increase in OASDl and HI payroll
taxes is absorbed by employers as reduced profits resulting in a change in corporate income tax
payments.
Source: Lewin/ICF estimates using the Health Benefits Simulation Model.
16
�Q : Could states introduce their own health credit?
A: Yes. In fact a credit in a state's tax code would be a logical addition to the
basic federal plan. Several states, including Maryland and Minnesota, already
are considering a state health tax credit.
Q : Could states add funds to the plan to give more help to the low-paid?
A : Yes. In one version of the Heritage proposal, Lewin/ICF was asked to assume that each state would supplement the federal program with a program to
cover the expenses of any family that, despite the federal credit, faced out-ofpocket costs of more than 20 percent of its income. In modeling this version,
states were given discretion in how they would structure such additional assistance. Taking together the various savings to states and local governments,
thanks to the federal credit and tax changes, Lewin/ICF calculated that the new
program would cost state and local governments $6.7 billion more than they
now spend on health care. In this variant of the plan, the states would not contribute to the cost of the federal credit. Thus for federal budget neutrality, the
federal credits would have to be less generous.
TabtoS
Sources and Uses of State Funds
Under the Tax Credit Program in 1991
(billions of dollars)
Elimination of State Income
Tax Exclusion
8
$8.3
($13.2)
State and Local Worker Benefits
Premium Taxes"
Current Revenues
Revenues Under Policy
Public Hospitals
(1.6)
1
5
(0.1)
State Corporate
Income Tax Loss
,
Q
{
Net Change In Revenues
Health Benefits
Wages
OASDI and HI Taxes
Contribution to
' ' Federal Tax Credit
(23 8)
23
8
2
0
2.0
1 R R
0
°
$7.8
Note: Number in parenthesis represent negative amounts.
a The increase in wages under the program will result in an increase in state income tax payments,
b Premium tax revenues decline due to the reduction in the value of health insurance coverage
under the tax credit program.
Source: Lewin/ICF estimates using the Health Benefits Simulation Model.
17
�Effect #3:Wrth all the changes employers would pay less than $10 a month extra
per average employee.
Table 10 shows the bottom line for employers. Employers would be required
to pay the "employer's share" of the Social Security tax payable on "cashed out"
health benefitsreturnedto the employee as extra wages. On the other hand, this
extra tax wouldreduceprofits and thus corporate income taxes. The net effect
would be an annual increase in costs to employers averaging $104.80 per
employee (or just $8.73 per month).
Tab* 10
Change in Employer Health Spending
Under the Tax Credit Program in 1991
(billions ot dollars)
Change In
Spenttlng
Current Employer Expenditures for Health Care
8
$124.3
5
Convert Employee and Dependent Benefits to Wages'
Benefit Payments
(120.2)
wages
2
0.0
1 2 0
OASDI and HI Tex on Benefits (employer share)
10.9
Change in Employer Costs
10.9
Change In Corporate Taxes
6
(3.1)
Net Change In Employer costs
(Change in costs per worker of $104.8 per year)
$7.8
Not*: Number in parenthesis represent negative amounts.
a Includes the employer share of expenditures for workers, dependents, and retirees,
b Employer contributions for worker and dependent benefits are converted to wages.
Retiree coverage is assumed to be retained,
c The entire amount of the Increase In OASDI and HI payroll taxes is assumed to be absorbed by
employers as reduced profits resulting in a change in corporate income taxes.
Source: Lewin/ICF estimates using the Health Benefits Simulation Model.
WHAT THE HERITAGE PLAN MEANS FOR TYPICAL FAMILIES
Impact 1: As a whole, American families would save $18.8 billion in the first
year of the plan, and would not lose coverage if they changed or lost their job.
Table 11 indicates the aggregate impact of the plan on American households
not on Medicaid or Medicare. Families would be affected in several different
ways. Since families would select and pay for their own health plan, typical
workers would pay more in premiums as well as out-of-pocket costs. They also
18
�would lose
Tabl«11
the tax exChange in Household Health Spending
clusion for
Under the Tax Credit Program in 1991
any company(billions of dollars)
provided
benefits. Yet,
they would
$88.2
Premium Payment
Employee Contribution in Employer Plans (45.2)
also receive
Individual Premium Payments
133.4
extra income,
because
62.7
Out-of Pocket Expenses
employers
(84.9)
Tax Credit
would be required to give
Eliminate Tax Expenditures
them cash in61.4
(individual share)
stead of
Federal
53.1
State
8.3
benefits and
they would
Eliminate Health Expense Deduction
2.5
receive a new
(over 7.5% AGI)
tax credit to
129.9
Nat Change In Health Spending
replace the
tax exclusion.
The net effect
Increased Wages
(148.7)
is that work(offset to change in health spending)
ing age
($18.8)
Net Impact on Households
households
would have a
Note: Number in parenthesis represent negative amounts.
total of $18.8
Source: Lewin/ICF estimates using the Health Benefits Simulation Model.
billion more
in their pockets after all these changes. They would also be able to choose their own health
plan and keep it if they changed jobs.
Impact 2: A family with an annual income below $50,000 typically would
receive higher tax breaks for its health care plan.
Table 12 shows how the value of tax breaks for health coverage would be affected for typical households. Today the typical family earning less than
$10,000 gets just $50 a year in taxreliefunder the tax exclusion system. Under
version #1 of the Heritage plan, this family wouldreceive$372 more in (refundable) tax benefits and $684 more under version #2. A family earning over
$50,000, but less than $75,000, would lose just $13 in tax breaks under version
1, or just over $1 a month. Families as a whole wouldreceivemore federal tax
relief under the plan than they do because health cost savings to the states would
be added to the funds tofinancethe new credit.
8
Allfigurescited here from Tables 12 and 13 are averages for all families within income class.
19
�TtW«12
Average Change in Federal Tax Benefits for Families by Income
Under the Tax Credit Plan In 1991
Current Tax
Exclusion
Family Income
less than $10,000
$10,000-$14,999
$15,000-$19,999
$20,000-$29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 • $74,999
$75,000-$99,999
$100,000 or more
All Families
Tax Credit
Version #1
Tax Credit
Version #2
Tax Credit
Version #3
50
207
366
594
857
986
1,373
1,427
1,463
$ 372
462
444
365
365
256
(13)
(32)
47
$ 684
664
612
451
401
182
(232)
(345)
(285)
$ 476
517
487
372
388
248
(84)
(129)
(55)
$ 802
$250
$250
$250
$
a Includes federal Income taxes and the employer and the employee share of the OASDI and HI
payroll taxes.
b The tax credits are structured to be budget neutral
Source: Lewin/ICF estimates using the Health Benefits Simulation Model.
Q : Does the Heritage plan mean, as some have charged, that families
would lose tax relief for their health benefits?
A : No. Only the method of taxreliefwould change—from tax-free company
plans to arefundabletax credit. Indeed, as Table 12 shows, most families would
receive larger tax breaks for health care.
Impact 3: In version #1 of the proposal (voucher with flat 20 percent credit),
typical families with annual incomes between $15,000 and $100,000 would pay
less, after taxes, on health care than they do today. All families could choose
their health plan and it would be portable.
Chart 13 shows the net change in federal taxes broken down by income level.
The top row indicates the value of the current tax break for employer-paid insurance. The next three rows show the change in health costs when the current
tax exclusion is eliminated and the next row computes the increases in wages
when current benefits are converted to cash.
The next threerowsshow the typicalrefundabletax credit for each version of
the Heritage proposal. Thefinalthree rows show the "bottom line" for each family broken down by income. These rows indicate the net change in a family's
health care spending compared with the current system. Figures in parentheses
indicate a reduction in spending compared with today. For this bottom line, the
family now would have at least a basic plan of their choice that they could take
from job to job, with a limit on total out-of-pocket costs.
20
�Tabte13
Average Net Impact of Alternative Tax Credit Options on Families by Income (1991)
IlllijlP^
less than $10,000 $15,000 $20,000 $30,000 $40,000 $50,000 $75,000 $100,000
HousehoWa $10,000 -$14,999 -$19,999 -$29,999 -$39,999 -$49,999 -$74,999 -$99,999 or more
Household Health Spending
Under Current Law
Elimination of State and
Federal Tax Expenditures'
1
$1,223
$1,428
$1,638
$2,106
$1,954
$2,295
$2,400
$3,238
671
930
991
1,100
1.279
1,312
1,459
1.679
1,854
692
Change In Out-of-Pocket
Payments for Care
$887
1.214
Change In Premium
Payments"
$1,841
108
286
367
519
769
990
1.059
1,053
1.176
745
35
154
283
500
736
875
1.330
1,397
1,492
Wage Effects l i l l l i l i l l l l l l l l !
f
Increased Wages (oountad as
an offset to health spending)
(1.767)
(162)
(657)
(1.119)
(1.531)
(2,060)
iiiiiiii t l i l l l i l
(2,313)
(2.681)
(2,754)
(2.770)
ind
Tax Credits (ffederai a State l i i i i
p
Version #1
(1.052)
(422)
(669)
(810)
(959)
(1.222)
(1.242)
(1.360)
(1,395)
(1.510)
Version #2
(1.052)
(734)
(871)
(978)
(1,045)
(1.258)
(1.168)
(1.141)
(1.082)
(1.178)
Version #3
(1.052)
(526)
(724)
(853)
(966)
(1.245)
(1.234)
(1.289)
(1.298)
(1,408)
ige in After
•Tax Health Spending Net < 'ax Change in Income
> After-T
f
Version #1
(168)
210
Version #2
(168)
Version #3
(168)
44
(288)
(371)
(498)
(378)
(193)
(82)
(158)
(456)
(457)
(534)
(304)
(26)
293
574
126
(11)
(331)
(378)
(521)
(370)
(122)
77
344
Note: Figures in parenthesis represent negative numbers.
a
Includes individual premium payments less employee contributions to employer plans eliminated under the tax proposal.
b
Includes the additional taxes paid on employer benefits converted to income including: federal income taxes; the employee share of OASDI
and HI payroll taxes; and state income taxes.
Source. Lewin/ICF estimates using the Health Benefits Simulation Model (HBSM).
(20)
242
�Impact 4: In version #2 of the proposal (a sliding scale credit), typical families
with annual incomes below $75,000 would pay less, after taxes, on health care
than they do today. All families could choose their health plan and it would be
portable.
See Table 13.
Impact 5: In version #3 of the proposal (voucher with sliding scale credit),
typical families with annual incomes between $10,000 and $75,000 would pay
less, after taxes, on health care than they do today. All families could choose
their health plan and it would be portable.
See Table 13.
Impact 6: Case studies of typical families under the Heritage plan are given
below.
SELECTEDCASE STUDIES
Case #1: A young two-parent farm family with one child and has a family income of $25,000 per year. The family has no insurance and average health. In a
typical year pays out $1,500 in essential hospital and doctor bills, but has no
major medical protection.
Under the Heritage plan, this family selects a basic plan offered through
their state farm bureau. The plan costs $2,500 and the family pays $500 in
out-of-pocket expenses.
Todav
T 0 < l a y
Tax relief for health
0
U n d e r
H e r l t a
9
e
Proposal
$1,051
Extra cash Income
0
Net extra taxes paid under Heritage proposal
Change in disposable Income after tax changes
and health spending under Heritage proposal
-1,051
N / A
_
44g
.
Ttie change In disposable income is the additional Income received by the family less the extra direct
payments for health care and the less the net extra taxes paid.
22
�Case #2: A young single blue-collar worker in excellent health currently
works for a major industrial company and earns $21,000. The worker currently
has an employer-paid health plan with no deductible worth $3,000 per year.
Under the Heritage plan, the worker switches to a basic plan sponsored by
his union. For this plan he pays $850 and he pays out $450 in out-of-pocket costs. The employer adds $3,000 to his paychecks over the year and
makes a payroll deduction equal to the premium for his union plan and
sends the money to the union.
'
Today
Tax relief for health
$450
Extra cash Income
Under Heritage
Proposal
$ 404
3,000
Taxes on extra Income
N/A
450
Net extra taxes paid under Heritage proposal
N/A
46
Change In disposable Income after tax changes
and health spending under Heritage proposal
+1,654'
TIM change in disposable income Is the additional income received by the family less the extra direct
payments tor health care and the less the net extra taxes paid.
Case #3: An engineer, aged 50, with a manufacturing company has a nonworking spouse, two children, and a typical history of health problems. Curently he earns $45,000 and has a company-paid plan. The company pays the
premium of $6,000 and the family pays out the full $600 each year in deductibles and copayments. This year, however, the company has decided to lay off
the worker. Although he fortunately has the offer of another job paying the same
total compensation of $51,000 ($45,000 + $6,000) with a small engineering
firm, that firm says it will not give part of the compensation in the form of
health benefits, because it cannot arrange affordable group coverage. So he
faces the prospect of being uninsured.
Under the Heritage proposal, he elects to continue his current plan, converted to individual coverage for his family and paid for by himself. The
plan will cost the same premium with the same deductibles and copayments.
23
�Today
U n d e r
(old job)
Tax relief for health
H e r l t a
fl
Proposal
o a B y
e
(new job)
$1,254
$1,870
Extra cash Income
6,000
Taxes on extra Income
N/A
1,254
Net extra taxes paid under Heritage proposal
-616
Change In disposable Income after tax changes
and health spending under Heritage proposal
+616*
Tbe change In disposable income is the additional income received by the family less the extra direct
payments for health care and the less the net extra taxes paid.
Case #4: A two-eamer professional family, with one child, earns $130,000 per
annum.The family is covered under the father's policy, which is paid by his
employer and is worth $7,000. The family pays a deductible of $600. In addition, the family has mortgage interest payments and other deductions of $30,000
per year.
Under the Heritage plan, the family decides to take the $7,000 value of its
current plan in cash and instead buy a less comprehensive policy with a $3,000
premium and out-of-pocket costs of $1,500.
Todav
T 0 0 a y
Tax relief for health
$2,235
U
n
d
e
r
H
«
r l t a
fl
e
Proposal
$1,321
Extra cash Income
7,000
Taxes on extra Income
2,235
Net extra taxes paid under Heritage proposal
Change In disposable Income after tax changes
and health spending under Heritage proposal
914
N/A
+2,186*
The change in disposable income is the additional income received by the family less the extra direct
payments for health care and the less the net extra taxes paid.
24
�COMMONLY ASKED QUESTIONS ABOUT
THE HERITAGE CONSUMER CHOICE HEALTH PLAN
Q : Are American families capable of choosing health plans?
A : Yes. About 9 million federal workers and federal retirees do so every year
under the Federal Employee Health Benefits Program (FEHBP). These
workers include mail room clerks, janitors, and messengers, as well as professional economists, congressmen and cabinet secretaries. In the Washington,
D.C, area they choose from among over thirty plans. They can make choices because consumer organizations, the local press, their family doctors, employee organizations, and other groups supply them with "userfriendly"information on
which to base their choices. The same kinds of information would quickly mushroom for 100 million American households choosing health plans as exists
today to help these households buy a car, a house, or a mutual fund.
Q : How would costs be controlled?
A In the same way as they are controlled in the automobile or computer market—by cost-conscious consumers buying a product from among
competing suppliers. Critics of consumer-based cost control claim that families
cannot question the cost of specialized medical procedures. But this ignores the
way consumer choice would work. Most Americans know little about carburetors or steering systems in an automobile. If they bought a car by purchasing all the components individually from different firms the car no doubt would
be very expensive, and would not run well. Instead they buy completed cars
from among rival assemblyfirms.In turn thesefirmsbargain for quality and
pricefromcomponent makers.
Essentially the same process would operate in a consumer-based health system
—and does so today in the FEHBP. Families would choose among competing
plans. The plan organizers, not the families, would bargain with doctors and
hospitals to keep costs down. That system of consumer choice and competition
has enabled the FEHBP to keep its premium increases well below those of
private employer-sponsored plans.
Q : How would the obligation to buy insurance be enforced?
A In two ways. Taxpayers would have to attach proof of insurance or enrollment in a public program to their tax return or face afine.In addition,
employees would have to fumish their employers with proof of insurance,
which would be forwarded to the government. Those unable to show they had
9 See Moffit, op. cit.
25
�coverage might be assigned to Medicaid by the state but billed for all or part of
the cost of coverage. To be sure, some individuals still would evade the law, but
the number is likely to be small.
Q : Would the Heritage plan foster lower-cost managed care plans?
A : It probably would, but only because families freely chose managed
care in a competitive market. In the consumer-choice Federal Employee
Health Benefits Program, federal workers choose HMOs (a form of managed
care) at about double the national rate. But managed care would not be artificially encouraged, as some reform plans would do. If a more efficient form of
health care delivery were to emerge and satisfy consumers, it would win customers under the Heritage proposal.
Q : What would happen to the very sick under the Heritage plan?
A They would be able to purchase a plan of their choice at no more
than 25 percent higher premiums than similar families with normal health,
and they would have the right to renew the plan each year without
premium increases any larger than those for healthy individuals in the
plan. They would receive a higher tax credit to offset part of this higher
premium. Today they are often unable to obtain insurance.
Q : What about the very healthy?
A : Typically they would opt for a "lean" basic plan and enjoy higher
after-tax incomes. Today they are typically overinsured and tend to adopt a
"use it or lose it" attitude to health services. Further, the healthy and wealthy
would pay higher taxes, which would pay for the cost of generous credits for the
poor and sick. But this does not mean the healthy and wealthy would object.
They simply would take less of their income in insurance coverage and more in
(taxable) cash income for other uses—much like getting a taxable raise.
Q : Wouldn't some of the working poor pay more for health care under
the Heritage plan?
A: As Table 13 shows, under versions #1 and #3 of the Heritage plan,
lower-paid families typically could pay slightly more than they do today—
although under the least-attractive version that would be an average of no
more than $18 per month. But for this money the family now would have insurance, and insurance it couldrenewautomatically each year and keep from
job to job.
Further, as indicated earlier, states and the federal government could choose
to increase the help given to the lower-paid. The federal government could
change the tax credit formula, in a budget neutral way, to give extra help to the
26
�poor byreducingthe tax relief for middle and upper income families. Or if the
federal government decided to increase net spending (or tax help) for health, it
could make the credit more generous for the lower-paid. States could introduce
their own budget neutral credit, or they could add funds to assist the lower-paid.
Q: What about those families on Medicaid?
A : Medicaid would not be affected directly by the proposal. Today a
head of household on welfare typically has to give up thousands of dollars in
Medicaid health benefits if he or she leaves welfare and takes a job without
health benefits. But under the Heritage Plan, many families now on welfare (and
Medicaid) would choose to take a job because a refundable credit for health care
insurance would be available. This wouldreduceMedicaid and AFDC costs.
Q: What about those now on Medicare?
A : The basic Heritage plan does not change Medicare. However, it would
be quite logical to allow working Americans to keep their health plans when
they retire, with the federal government making a financial contribution to these
plans in place of today's Medicare cumbersomereimbursementsystem. This
"voucherizing" of Medicare would encourageretireesto shop for the best plan
for their needs. The FEHBP operates in much this way for federal retirees.
Q : How does the Heritage plan differ from the Bush Administration's
recent health reform proposal?
A For those now uninsured, both plans are quite similar, except that
the Bush plan gives a refundable credit only for the poor, and a deduction
for non-poor uninsured families. But it would, like the Heritage plan, cover
today's uninsured and enable them to obtain a "portable" plan. The Bush plan,
however, would have litde or no effect on the costs of company-provided plans,
because it makes no changes at all in the tax treatment and so would not encourage employees with company-sponsored plans to seek better value for
money. There is also no explicit mechanism in the Bush plan to pay for its
new credit and deduction.
Q : Does the Heritage plan have to be introduced all at once?
A No. It could be phased in gradually. One first step might be to limit the
tax exclusion for company-sponsored plans to, say, $4,000 per year for a family,
and use the tax revenue to fund a credit for out-of-pocket health expenses ex-
10 See Stuart M. Butler, "What's Right and Wrong with Bush's Health Plan," Heritage Foundation Executive
Memorandum No. 321, February 7,1992.
27
�ceeding 5 percent of family income. In later years the exclusion limit could be
lowered, and more generous credits made available.
CONCLUSION
The Heritage Consumer Choice Health Plan is a comprehensive reform of the
American health care system designed to assure affordable access to health care
for all Americans without an increase in taxes and with an improvement in the
efficiency of the health care system.
Unlike the Canadian system preferred by some lawmakers, the Heritage plan
would not institute government-controlled rationing and waiting lists. And unlike the "play or pay" system, it would not compound the problems of today's
system with new payroll taxes and a huge new public program. Instead it would
change the way government helps Americans to obtain care, making that help
more equitable, and it would trigger in health care the same dynamic forces that
secure quality and efficiency in therestof the economy—consumer choice and
competition.
28
�
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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[A Policy Maker’s Guide to the Health Care Crisis Part II: The Heritage Consumer Choice Health Plan] [loose]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
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Clinton Presidential Records: White House Staff and Office Files
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12092971
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https://clinton.presidentiallibraries.us/files/original/ed931b6d0fc851d678abdee8e978dd18.pdf
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�Clinton Presidential Records
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�CONGRESS OF THE UNITED STATES
CONGRESSIONAL BUDGET OFFICE
Poll
4 CBO STUDY
JUNE 1991
�
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Policy Choices for Long-Term Care] [loose]
Creator
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
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2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-037-014-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/36677ff39b0eb836e2ab82c1f4b3bf98.pdf
0cddbc57aa41ad6394801b56a087b59d
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1978
OA/ID Number:
FolderlD:
Folder Title:
[Policy Alternatives for Occupational Health] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
1
3
�employers is further compounded by the recent passage TLVs, and hence play no important role in Cal/OSHA's
of Senate Bill 198, which mandates injury prevention regulations. (See "Reproductive Health Hazards in the
programs in all worksites.
Workplace: Policy Options for California," CPS Brief
The state and national regulatory framework is also 4(1), February 1992.)
undergoing reexamination. At the national level, ConCalifornia leads the nation in developing innovative
gress is considering the "Comprehensive Occupational controls for toxic substances in the workplace and the
Safety and Health Reform Act" (S 1622, HR 3160). This environment. As the leader it enjoys the benefits of new
legislation would amend the 1970 act in two important policy innovations but also bears the costs of untimely or
ways. First, it would strengthen workers' rights to know ill-considered mistakes. Toil and Toxics provides insights
and to act in response to hazardous exposures. The into past experiences and guidelines for future efforts to
centerpiece of these changes would be requirements that control toxic substances in California and in the United
all workplaces above some minimum size establish joint States as a whole.
worker-management safety and health committees with
the authority to investigate working conditions and James C. Robinson is an associate professor of health
propose improvements. Second, the new legislation policy and economics at the University of California,
would streamline OSHA's process for establishing Berkeley. He teaches at the School of Public Health and
Permissible Exposure Limits for large numbers of toxic is also affiliated with the Institute of Industrial Relations.
substances, completely bypassing the Threshold Limit
Values. Both parts ofthe proposed amendments connote
recognition that the large number and constantly changThis information is being circulated by the Caliing nature of hazards encountered by workers have far
fornia Policy Seminar as a service to state governoutstripped OSHA's capabilities.
ment. Toil and Toxics: Workplace Struggles and
The standard-setting problems besetting OSHA at
Political Strategies for Occupational Health, analyzthe the national level are also evident in California's
es 30 years of efforts to control workplace health
program. Although it is innovative in some ways, Cal/
arid safety hazards, with an eye to identifying the
OSHA generally has been content to follow the lead of
most successful approaches. It traces the history of
federal OSHA. Most of Cal/OSHA's health standards
the right to know movement from the local level, :
are based on Threshold Limit Values, for example, and
through OSHA's Hazard Communication Stanfew confront the health hazards posed by carcinogens,
dard, to the "community right to know" provisions
reproductive toxicants, and neurotoxicants. The failings
of federal law, arid then analyzes the strengths and
of Cal/OSHA health standards are most obvious for
weaknesses of the "right to act" as embodied in
chemicals that threaten reproductive health, causing
labor law, management policies, legislation, and
infertility, sterility, miscarriage, and/or birth defects. A
the proposed requirements for mandatory; training
large number of suspected reproductive hazards do have
arid safety committees. The book then examines
Cal/OSHA PELs, which give the appearance of guaranthe strengths and weaknesses of direct governmenteeing worker safety. In actuality, however, the PELs for
tal regulation of health and safety hazards. ^ ^ :
almost all these substances were adopted from the TLVs,
The book is available through the University
based on their potential for causing acute toxicity at high
of California Press; 2120 Berkeley Way, Berkeley,
exposure levels. The scientific evidence that these
CA 94720. To order from the publisher and obtain
substances may pose chronic health hazards, such as
a 20% discount (discounted price: $23.96) phone
reproductive damage, at lower exposure levels was
1-800-UC-BOOKS.
routinely excluded from the analysis used to establish
' IJHE CALiFofelA'POLICT SEMINAR;.
* 3 % A"JOINXiPROGRAM OF THE , R
v ^UrSIVERSlfY OE CALIFORNIA V
2v AND STATE GOVERNMENT
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POLICY ALTERNATIVES FOR OCCUPATIONAL HEALTH
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tv. y •.:
James C. Robinson
Editor's note: This Brief is based on Robinson's new book, Toil and Toxics:
Workplace Struggles and Political Strategies for Occupational Health, published in 1991
by the University of California Press.
- \ f
-
1
Public policy towards toxic exposures and injury risks in the workplace is at a
crossroads. Emphasis has traditionally been placed on direct workplace regulation by
the federal Occupational Safety and Health Administration and by Cal/OSHA in
California. Interest is now shifting to information-oriented approaches such as the
worker's "right to know" and California's Proposition 65. Both the regulatory and
the information-oriented strategies have important strengths but also important
limitations. In the coming years policy choices need to build on past experiences to
save the best of what has been tried while avoiding the costliest failures.
The debates concerning workplace hazards have direct implications for the larger
concern over environmental and community exposure to toxic substances: Can
Proposition 65, the "community right-to-know" legislation, and other informationoriented strategies, successfully mobilize public concern for environmental and public
health protection? What is the proper role for regulatory bodies such as the air and
water quality control boards and the newly created California Environmental Protection Agency with regard to toxic substances?
-. -
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Worker Responses to Workplace Hazards
As documented in Toil and Toxics, workers are aware of many of the health and
safety hazards they encounter on the job. From 30 to 40% of all workers report facing
at least one serious health or safety hazard; among blue collar occupations, this rises
to 50-60%. Twenty-two percent of workers report serious exposure to risks of illness;
7% report serious exposure to dangerous chemicals.
Worker morale is lower and industrial relations are worse in jobs with unsafe and
unhealthy conditions. Compared to workers in safe jobs, workers in hazardous jobs
are more likely to express dissatisfaction with their jobs; more likely to quit; more
likely to be absent without reason; more likely to be temporarily or permanently laid
off; more likely to go on strike; and more likely to be fired.
Moreover, workers faced with health and safety risks are substantially more likely
to favor union representation than workers in safe jobs. Those in the riskiest jobs are
�twice as likely to be unionized than workers in the safest protesting against unsafe or unhealthy conditions.
jobs. Consistent with thesefindings,nonunion workers in However, union representation has declined rapidly in
hazardous jobs express greater desire for union represen- recent years, to a point where only 12% of private-sector
tation than nonunion workers in safe jobs, and union employees are covered by collective bargaining.
representation elections occur and are won more freWorker advocates are now seeking to recreate
quently in hazardous industries than in safe industries.
through legislative and regulatory means some of the
Labor unions have dramatically increased their health institutional framework that unions traditionally providand safety activities in recent years. They have been ed. Various pieces of proposed legislation would require
bargaining for better information on exposures and employers with more than a specified number of employhealth risks, the worker's right to refuse hazardous ees to form joint labor-management safety committees
tasks, safer working conditions, hazard pay premiums, and/or would provide protections for workers disciplined
employer-paid protective equipment, and joint union- for reporting violations of safety and health regulations.
management health and safety committees. Due to In addition, OSHA's Hazard Communication Standard
increased resistence by management, however, union and California's Proposition 65 require employers to
coverage in hazardous industries has declined in recent provide various types of hazard information, a function
that traditionally fell under the employer's obligation to
years (as has union representation in safe industries).
Worker and labor union responses to information on bargain with the labor union in good faith. It is presently
workplace hazards sometimes generate conflict with unclear what effect these "right to act" efforts will have
management, with adverse impacts on economic perfor- in nonunion workplaces.
mance. For example, labor productivity (and profit rates)
are significantly lower in hazardous manufacturing Regulatory Efforts to Control
industries than in safe manufacturing industries.
Workplace Hazards
Since 1980 there has been a dramatic increase in
The major alternative to the information-oriented
public policies relating to the worker's "right to know" strategies embodied in the "right to know" and the
and "right to act" concerning workplace hazards. While "right to act" is direct control of toxic exposures by
information and worker-oriented strategies for improving governmental regulatory agencies. OSHA and Cal/OSHA
health and safety conditions have great potential, they have devoted a disproportionate share of their resources
also have serious problems. Workers already recognize over the past 20 years to the promulgation and enforcemany of the hazards to which they are exposed. By ment of Permissible Exposure Limits (PELs), which
extension, they can learn from "right to know" efforts define maximum allowable concentrations of hazardous
and will develop new and more innovative strategies. substances for the working environment. The EPA and
However, they are unlikely to ever be able to fully various state regulatory agencies have emphasized emisunderstand the risks they face, especially in an increas- sions limits and allowable pollutant concentrations for
ingly nonunion environment. The most informed and toxic substances in the general environment. Toil and
concerned workers may be the first to quit or be fired, Toxics analyzes the often tortuous history of OSHA's
leaving their less educated and less mobile coworkers controls on cancer-causing chemicals to illuminate the
without leadership.
strengths and weaknesses of the regulatory strategy in
The worker's "right to act" concerning health toxic substances policy.
hazards and other workplace concerns is embodied in the
Shortly after its creation in 1971, OSHA adopted as
framework of U.S. labor law, which relies traditionally on mandatory PELs the voluntary exposure guidelines
labor unions as collective representatives of individual ("Threshold Limit Values") of a private, industryworker interests. Union activities in health and safety oriented organization. These startup standards gave the
have increased substantially over the past three decades, agency something to enforce, but proved a burden to
and include collective bargaining, worker training, and further progress. Instead of developing a strategy for
the establishment of joint union-management safety analyzing and regulating large numbers of toxic subcommittees. Central to labor union activities is the stances, OSHA was content to enforce the TLV-based
grievance and arbitration mechanism, which provides startup standards and focus its efforts on analyzing and
some protection for individual workers disciplined forregulating a small number of additional substances. Thus
the 1970s were consumed by elaborate and expensive
rulemaking procedures for a few carcinogens, such as
asbestos, coke oven emissions, vinyl chloride, acrylonitrile, arsenic, and benzene, and for two other hazards,
lead and cotton dust.
The regulatory proceedings of OSHA's first decade
were important in elucidating many of the important
toxicological, epidemiological, economic, and legal
dimensions of occupational hazards and their control.
However, implicit in OSHA's regulatory strategy was
the untested assumption that the primary problem was
due to a small number of widely prevalent substances. It
is now clear that the risks to occupational and environmental health result from large numbers of substances,
only a few of which are widely prevalent at high exposure levels. OSHA's energies were consumed by its substance-specific regulations, however, leaving it no
resources to grapple with the very large number of other
potential problems. A similar dissipation of energy
occurred at the EPA, especially with respect to toxic air
pollutants regulated under the Clean Air Act.
By the end of the 1970s, OSHA was changing its
regulatory orientation towards a new approach for
chemical carcinogens. The proposed "Generic Carcinogen Policy" of 1980 would have established guidelines
for expeditiously assessing the risks posed by suspected
substances and mandating protective measures for those
found to pose unacceptable dangers. The EPA was
engaged in similar endeavors under the authority of the
clean water and clean air acts. These efforts ended,
however, with the presidential election of Ronald
Reagan in November 1980. Subsequently OSHA abandoned the proposed new policy and began to weaken the
standards it had promulgated during the 1970s.
After several years emphasizing deregulation, OSHA
gingerly began to consider establishing some new regulations for occupational carcinogens. The Hazard Communication Standard, implemented for the manufacturing
sector in 1983, mandated employee training programs in
all worksites using carcinogenic substances. OSHA
developed four substance-specific carcinogen PELs
during the decade, covering benzene, ethylene oxide,
asbestos, and formaldehyde.
The centerpiece of regulatory policy for the 1980s
was the Air Contaminants Standard, which established
new Permissible Exposure Limits for over 400 hazardous
substances. Ironically, however, this new regulation
embodied a reversion to OSHA's first effort. Virtually
all of the new exposure limits were taken from the
Threshold Limit Values. What might have been acceptable public policy in 1971, when there were no realistic
alternatives, constituted clear policy failure in 1989. In
the interim, the TLVs were shown to have been based
often on poor scientific evidence and developed by
corporations that had direct financial interests in the
toxic substances in question. Alternative recommendations were available from the National Institute for
Occupational Safety and Health, the National Toxicology
Program, and the International Agency for Research on
Cancer. OSHA largely ignored these scientifically based
recommendations.
Current Issues in Occupational
Health Policy
California and the nation face important choices in
dealing with toxic substances. Every week new scientific
evidence is available concerning potential adverse health
effects from commonly used materials, many of which
play central roles in the economy. It is impossible to ban
every pesticide, plastic, heavy metal, or artificial fiber
that poses some risk to someone at some time. Rather,
we must develop efficient and equitable means for
prioritizing individual substances for control. As argued
in Toil and Toxics, two basic approaches are available:
indirect control through information and guarantees of
the "right to act," and direct control through governmentally enforced exposure and emissions limits.
Given the long history of ignorance and coverup
concerning toxic substances, it is not surprising to
observe the current widespread emphasis on the worker's and the public's "right to know" and "right to
act." California leads the nation here as elsewhere in
toxics policy, especially since the landslide adoption of
Proposition 65, the Safe Drinking Water and Toxics
Enforcement Act of 1986. Employers were initially
exempted from the warning requirements of Proposition
65, since it partially overlaps with the federal and state
Hazard Communication Standard. After lengthy deliberations, however, the courts have ruled that Proposition 65
applies to occupational exposures to carcinogens and
reproductive hazards and not merely to exposures
through consumer products and the general environment.
It is still not clear, however, how the requirements for
clear and reasonable warnings concerning several hundred officially listed toxic substances will be enforced in
the California workplace. The pressure on California
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Policy Alternatives for Occupational Health] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-037-013-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/0c61773db28fb0b4359a9332dd67f79f.pdf
33ff63e9074dcdc5fd8dd312b480a46e
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1337
OA/ID Number:
FolderlD:
Folder Title:
[Philadelphia Center Letter] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
6
1
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
Patient to Mrs. Clinton and Ira Magaziner [partial] (1 page)
11/3/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
O A / B o x Number:
1337
FOLDER TITLE:
[Philidelphia Center Letter] [loose]
2006-0885-F
wr837
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) o f t h e FOIA)
b(3) Release would violate a Federal statute 1(b)(3) o f t h e FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) o f t h e FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) o f t h e FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) o f t h e FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) o f t h e FOIA]
National Security Classified Information 1(a)(1) o f t h e PRA|
Relating to the appointment to Federal office [(a)(2) o f t h e PRA|
Release would violate a Federal statute [(a)(3) o f t h e PRA]
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) o f t h e PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(5) o f t h e PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) o f t h e PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�PHILADELPHIA CENTER FOR YOUNG ADULT PSYCHIATRY
1 1 1 NORTH 4 9TH STREET
PHILADELPHIA/ PA 1 9 1 3 9
FAX COVER SHBBT
TO:
A//e . tT^ ^
M
4
-Zs/ntt
FACILITY:
ADDRKSS:
PHONE #
FAX #
FROM:
FACILITY:
PHILADELPHIA CENTER FOR YOUNG
ADULT PSYCHIATRY
ADDRESS:
111 NORTH 4 9TH &X&ggT
PH1LADBLPHTA.
PHONE
#
PAX #
(215)
.
PA
19139
471-2128
(215) 471-2B4A.
NUMBER OF PAGES
(NOT INCLUDING COVER SHBBT)
RBMAHKS >
DjrW/4-3-91
10 "d
ZQ\?BBGZ LL,9SPZ2Zl6s
t
01
WOiJd
Wd0f :£:0 £:S6T-£:0-TT
�PHILADELPHIA CENTER FOR YOUNG ADULT PSYCHIATRY
At the Institute of Pennsylvania Hospital
Steven H. Weinstein, M.D.
Medical Director
Beverly N. Hurley
Adminisiralive Coordinator
November 3, 1993
BOARD OF DIRECTORS
Russell £. Phillips. M.D.
President
James L. D. Cox. M.D
Vice President
Ms. H i l l a r y R. Clinton
I r a Magaziner
The White House
Washington D.C. 20500
Elliot Cooperman, M.D.
Secretary
James H. Gilioil. M.D.
Treasurer
Dear Ma. Clinton and Mr. Magaziner:
Robert Gibbon. Jr.. M.D.
As a provider of Mental Health services i n a Partial
Hospital Program, I have witnessed the many benefits
we provide to our patients. Not only do we provide
a more cost-effective level of treatment,
we often
prevent patients from unnecessary hospitalization.
I n addition our services allow the patients to
function independently in their community where they
may continue to hold down employment, continue in
school and maintain their family l i f e . I cannot
stress how strongly I believe that p a r t i a l
hospitalization be made available by individual
accountable health plans, and not be l e f t to the
health plans discretion. I understand that there
was a drafting error that indicated -- p a r t i a l
hospitalization did not have to be made available by
individual accountable health plans, and may be
covered at the health plan's discretion. I urge you
to correct t h i s error before the f i n a l legislation
i s released to Congress
Sincerely,
Camel Devlin, R.N.
C l i n i c a l Coordinator of
Phila. Center for Young Adult Psychiatry
111 North 49th Street
Philadelphia, PA 19139
(215)471-2128
(215) 471-2140
20 • d
£0t78B6£:iA9St>20S T 6 /
•1
UDdd
Ud0t7:£:0 £ 6 6 T - £ 0 - T I
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
Patient to Mrs. Clinton and Ira Magaziner [partial] (1 page)
11/3/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1337
FOLDER TITLE:
[Philidelphia Center Letter] [loose]
2006-0885-F
wr837
RESTRICTION CODES
Presidential Records Act - (44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) ofthe FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA]
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) of the FOIA]
National Security Classified Information 1(a)(1) ofthe PRA)
Relating to the appointment to Federal office 1(a)(2) of the PRA|
Release would violate a Federal statute 1(a)(3) ofthe PRA)
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�PHILADELPHIA CENTER FOR YOUNG ADULT PSYCHIATRY
Al the Insiiiuie of Pennsylvania Hospiial
Sieve,, H. Weinshsm. M.D
M t d i t u l Director
Beverly N, Hurlay
Adreiiiiisii ative Cooidinaior
BOARU OP DIRECTORS
November 3, 1993
Russell E. PMIips. M D
Prfeiadcnt
Jamas L. D Co*. M.D
Vice Piewdeiu
Hs. HUlary B. Clinton
Ira Hatfaslner
Th« White House
Hashinrtoa. P.C. 20500
James H. Gilfoil. M f)
Tteasmet
Dear Hs. Clintoa and Br. Maffasiner-
RoUiti Gibbon. Jr.. M.D
EHioi Cooperman. M.Q
Secretary
Aa a patiant who i s r«oaWins p a r t i a l hospitalisation
sarvices. I want you to know how important i t i s that
partial h o s p i t a l i z a t i o n be nade availabla as part of the
nantal health benefit by a l l accountable health plajxa. I
might now bs unneoeaaarily hospitalized i f i t weren't f o r
the a v a i l a b i l i t y of p a r t i a l hospitalization services.
Instead, p a r t i a l hospitalisation has enabled ne to
fuaotioa independently i n the community. I t I s ay
understaadln* that a drafting error may leave the
a v a i l a b i l i t y of p a r t i a l hospitalisation services to the
discretion of Individual health plana.
I urge you to correct t h i s error before the f i n a l
l e g i s l a t i o n i s released to Consresa.
Slnctf
111 North 19th Sueei
Philadftlphitt. PA 19)39
(2ISM71-2I28
(215)47! 2110
ZQ'd
SBTOBGCiigSf20215/
01
WOad
WdTf:C0 C66T-E0-IT
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Philadelphia Center Letter] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-037-012-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/fc345839cb402b648433c0f9615da2a8.pdf
15c1033f69e722e0d24c92a887d41575
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1337
OA/ID Number:
FolderlD:
Folder Title:
[Partial Hospitalization Letters] [loose]
Stack:
Row:
Section:
Shelf:
s
56
1
6
Position:
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. fax
Betty Gross to Ira Magaziner [partial] (1 page)
11/3/1993
P6/b(6)
002. fax
Form Letters from patients at St. Vincent Stress Center [partial] (4
pages)
11/3/1993
P6/b(6)
003. fax
Uniton Memorial Hospital to Ira Magaziner [partial] (1 page)
11/3/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1337
FOLDER TITLE:
[Partial Hospitalization Letters] [loose]
2006-0885-F
wr836
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) ofthe FOIAj
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA)
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIAj
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIAj
National Security Classified Information |(a)(l) ofthe PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA|
Release would violate a Federal statute 1(a)(3) ofthe PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. fax
SUBJECT/TITLE
DATE
11/3/1993
Betty Gross to Ira Magaziner [partial] (1 page)
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1337
FOLDER TITLE:
[Partial Hospitalization Letters] [loose]
2006-0885-F
wr836
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552<b)|
PI National Security Classified Information 1(a)(1) ofthe PRA)
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA)
b(l) National security classified information 1(b)(1) ofthe FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA)
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�NV 3 9 WD 1 : 2
O- - 3 E 6 2
EEGENHS
VRRE/PC
FX N. 7 7 9 1 1
A O 13082
P0
.1
co0
November 3, 1993
Ira Magaziner
The White House
Washington, DC 20500
Dear Ira Magaziner
I am a psychiatric nurse with over 20 years of experience, much of it on an inpatient unit.
I now work in a partial hospitalization program, and I want you to know how important it
is that partial hospitalization be made available as part of the mental health benefit by all
accountable health plans. Many of my patients might now be unnecessarily hospitalized
if it weren't for the availability of partial hospitalization services. Instead, partial
hospitalization has enabled many of my patients with mental health problems to function
independently in the community. Further as a psychiatric nurse, I can attest to the costeffectiveness of partial hospitalization as an alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
Betty Gross, RNC
�NV 3 9 WD 1 : 2
O- - 3 E 6 2
EEGENHS
VRRE/PC
FX N. 7 7 9 1 1
A O 13082
P 0
. 2
Management & Professional
ServkeS Corporation
(717) 390-0353
PO. Box 10697, Lancaster, PA 17605
November 3, 1993
Ira Magaziner
The White House
Washington, P.C. 20500
Dear Ira Magaziner:
As a psychiatrist to several partial hospitalization services for the past twenty years, I
want you to know how important it is that partial hospitalization be made available as
part of the mental health benefit by all accountable health plans. Many of my patients
might now be unnecessarily hospitalized if it weren't for the availability of partial
hospitalization services. Instead, partial hospitalization has enabled many patients with
serious mental illnesses to function independently in the Qommunity. Further, as a
provider, lean attest to the cost-effectiveness ofpartial hospitalization as an alternative
to inpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
Herbert K. Cooper, III M.D.
Psychiatric Services
•
Psychological Evaluations
Program Development Consultation
•
•
Intensive Outpatient Services
Management Consultation
�NOU-03-1993
St.Vincent
StressCenter
Chemical Dependency
Counseling Services South
5110 Commerce Square
(7800 S. Emerson)
Indianapolis. Indiana
46237
(317) 881-2111
15=20
FROM
S t . Uincent Stress
South
TQ
12024567739
Ira/Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs.
Clinton:
As a provider of partial hospitalization services,
I want you to know how important i t i s that partial
hospitalization be made available as part of the
mental health benefit by a l l accountable health
plans. Many of my patients might now be unnecessari l y hospitalized i f i t weren't for the availability
of partial hospitalization services. Instead, partial
hospitalization has enabled many of my patients with
serious mental illnesses to function independently
in the community. Further, as a provider, I can
attest to the cost-effectiveness of partial hospitalization as an alternative to inpatient psychiatric
care.
I urge you to correct this error before the final
legislation is released to Congress.
Sincerely,
P.01
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002. fax
SUBJECT/TITLE
DATE
Form Letters from patients at St. Vincent Stress Center [partial] (4
pages)
11/3/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1337
FOLDER TITLE:
[Partial Hospitalization Letters] [loose]
2006-0885-F
wr836
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA]
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA]
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) ofthe FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�NOU-03-1993
15:21
St.Vincent
StressCenter
Cheirtcal Dependency
Counseling Services South
5110 Commeroe Square
(7800 S. Emerson)
Indianapolis. Indiana
46237
(317)881-2111
FROM
St. Uincent Stress South
TO
12024567739
I r a Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear I r a Magaziner/Mrs. Clinton:
As a patient who i s receiving partial hospitalization
services, I vant you to know how important i t i s that
partial hospitalization be made available as part of
che mental health benefit by a l l accountable health
plans. I might now be unnecessarily hospitalized i f
i t weren't for the availability of partial hospitalization services. Instead, partial hospitalization
has enabled me to function independently i n the
community. I t i s my understanding that a drafting
error may leave the availability of partial hospitalization services to Che discretion of Individual
health plans.
I urge you to correct this error before the f i n a l
legislation i s released to Congress.
Sincerel)
P.02
�NOU-03-1993
St.Vincent
StressCenter
Chemical Dependency
Counseling Services South
5110 Commerce Square
(7800 S. Emerson)
Indianapolis, Indiana
46237
(317)881-2111
15:21
FO
RM
St. Uincent Stress South
TO
12024567739
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear I r a Magaziner/Mrs. Clinton:
As a patient vho i s receiving partial hospitalization
services, I want you to know how important i t i s that
- partial hospitalization be made available as part of
the mental health benefit by a l l accountable health
plans. I might now be unnecessarily hospitalized i f
i t weren't for the availability of partial hospitalization services. Instead, partial hospitalization
has enabled me to function independently i n the
community. I t i s ay understanding that a drafting
error may leave the availability of partial hospitalization services to the discretion of individual
health plans.
I urge you to correct this error before the f i n a l
legislation i s released to Congress.
P.03
�NOU-03-1993
StVincent
StressCenter
Chemical Dependency
Counseling Servioes South
5110 Commerce Square
(7800 S. Emerson)
Indianapolis. Indiana
46237
(317)881-2111
15:21
FO
RM
St. Uincent Stress South
TO
12024567739
I r a Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear I r a Magaziner/Mrs. Clinton:
As a patient vho i s receiving partial hospitalization
services, I vant you to know hov inportant i t i s that
partial hospitalization be made available as part of
the aental health benefit by a l l accountable health
plans. I might now be unnecessarily hospitalized i f
i t weren't for the availability of partial hospitalization services. Instead, partial hospitalization
has enabled me to function independently i n the
community. I t l a my understanding that a drafting
error may leave the availability of partial hospitalization services to the discretion of individual
health plans.
I urge you to correct this error before the f i n a l
legislation i s released to Congress.
Sincerely,
P.04
�NOU-03-1993
15:21 FROM
St.Vincent
StressCenter
Chemical Dependency
Counseling Services South
5110 Commerce Square
(7800 S.Emerson)
Indianapolis, Indiana
48237
(317)881-2111
St. Uincent Stress South
TO
12024567739
Ira Magaziner/Mrs. Clinton
The White House
Washington, O.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a patient vho i s receiving partial hospitalization
services, I vant you to knov hov important i t i s that
.partial hospitalization be made available as part of
the mental health benefit by a l l accountable health
plans. 1 aight nov be unnecessarily hospitalized i f
i t weren't for the availability of partial hospitalization services. Instead, partial hospitalization
has enabled me to function independently in the
community. I t is my understanding that a drafting
error may leave the availability of partial hospitalization services to the discretion of individual
health plans.
I urge you to correct this error before the final
legislation i s released to Congress.
P. 05
�NOU-03-1993
St.Vincent
StressCenter
Chemical Dependency
Counseling Services South
5110 Commerce Square
(7800 S. Emerson)
Indianapolis. Indiana
46237
(317)881-2111
15:22 FROM
St. Uincent Stress South
TO
12024567739
Ira/Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services,
I want you to know how important i t is that partial
hospitalization be.made available as part of the
mental health benefit by a l l accountable health
plans. Many of my patients might now be unnecessari l y hospitalized i f i t weren't for the availability
of partial hospitalization services. Instead, partial
hospitalization has enabled many of my patients with
serious mental illnesses to function independently
in the community. Further, as a provider, I can
attest to the cost-effectiveness of partial hospitalization as an alternative to inpatient psychiatric
care.
I urge you to correct this error before the final
legislation i s released to Congress.
Siiroerely,
/ ?
\
P.05
�fiYC DRY HOSPITALS
TEL No.602-967-7125
Nov
3.93 13 = 34 No.005 P.01
November 3, 1993
The Valley's
First Day Hospital
tor Troubled Kids
Tempe AYC
1500 South Mill
Tempe, Arizona 85281
(602)764-5592
Phoenix Adolescent AYC
1800 East Van Buren
Phoenix, Arizona 8S006
(602)251-8812
Phoenix Children's AYC
1800 East Van Buren
Phoenix, Arizona 85006
(602)251-8612
AYC Administration
320 East McDowell
Suite #105
Phoenix, Arizona 85004
(602)256-9110
FAX: (602) 256-0138
Ira Magaziner
The White House
Uashington. D.C.
20500
Dear I r a Magaziner,
AS
a provider of partial
hospitalization
services, I want you to know how important i t i s
that partial hospitalization be made available
as part of the mental health benefit by a l l
accountable health plans. Many of my patients
might now be unnecessarily hospitalized
if it
weren't
for the a v a i l a b i l i t y
of
partial
hospitalization
services.
Instead,
partial
hospitalization has enabled many of my patients
with
serious mental i l l n e s s e s to
function
independently in the community. Further, as a
provider, I can attest to the cost-effectiveness
of p a r t i a l hospitalization as a alternative to
inpatient psychiatric care.
I urge you to correct this error before the
f i n a l legislation i s released to Congress.
Sincerely
Chris Dal Pra
Director of C l i n i c a l
Programming & Development
A Division ot
Youth Health
Resources, Inc.
�8537" P01
THE UNIVERSITY OF TENNESSEE
MEMPHIS
The Health Science Center
November 2, 1993
College of Medicine
Division of Child end Adolescent Psychiatry
Day Treatment Program, 711 Jefferson 607W
Memphis, Tennessee 38105, (901) 528-6378
Ira Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know how important it is
that partial hospitalization be made available as part of the mental health benefit by all
accountable health plans. Many of our patients might now be unnecessarily hospitalized
if it weren't for the availability of partial hospitalization services. Instead, partial
hospitalization has enabled many of my patients with serious mental illnesses to function
independently in the community. Further, as a provider, I can attest to the costeffectiveness of partial hospitalization as an alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation is released to Congress.
Sincerely,
Laurel J. Klser, Ph.D.
Executive Director
Day Treatment Programs
LjK/vb
�P
N O V —
— 9
3
1 6
:
1 9
Hunterdon
Medical Center
Community Mental Health Center
November 3, 1993
Ms. H i l l a r y Clinton
I r a Magaziner
The White House
Washington/ D.C. 20500
Dear Ms. Clinton and Mr. Magaziner/
Partial hospitalization should be required as part of the
mental health benefit by a l l accountable health plans. As
a provider of p a r t i a l hospitalization services, I want you
to know how important t h i s i s : many of my patients might
now be unnecessarily hospitalized i x i t weren't f o r the
a v a i l a b i l i t y of p a r t i a l hospitalization services.
Further. I can attest t o the cost-effectiveness of p a r t i a l
hospitalization as an alternative to inpatient psychiatric
care.
Sincerely,
2100 Wescott Drive • Fleminglon, New Jersey 08822-9237 • Tfilonhnno ana.7fia.e>trt<
. 0
1
�P
H O V -
3 - 3 3
W E D
1 6 : 1 9
Hunterdon
Medical Center
Community Mental Health Center
November 3, 1993
Ms. Hillary Clinton
Ira Magaziner
The White House
Washington, D.C. 20500
Dear Ms. Clinton and Mr. Magaziner,
Partial hospitalization should be required as part of the
mental health benefit by a l l accountable health plans. As
a provider of partial hospitalization services, I want you
to know how important this i s : many of my patients might
now be unnecessarily hospitalized i f i t weren't for the
availability of partial hospitalization services.
Further. I can attest to the cost-effectiveness of partial
hospitalization as an alternative to inpatient psychiatric
care.
Sincerely,
2100 Wescott Drive • Flemington, New Jersey 08822-9237 • Teleohone 908.78fl.fidni
. 0
2
�N O V
—
—
3
R
Ul
Hunterdon
Medical Center
Community Mental Health Center
November 3, 1993
Ms. Hillary Clinton
Ira Magaziner
The White House
Washington, D.C. 20500
Dear Ms. Clinton and Mr. Magaziner,
Partial hospitalization should be required as part of the
mental health benefit by a l l accountable health plans. As
a provider of partial hospitalization services, I want you
to Jcnow how important this i s : many of my patients might
now be unnecessarily hospitalized i f i t weren't for the
availability of partial hospitalization services.
Further, I can attest to the cost-effectiveness of partial
hospitalization as an alternative to inpatient psychiatric
care.
Sincerely,
2100 Wescott Drive • Flemington, New Jersey 08822-9237 • Teleohnn* qnfl.7pp.^ni
.
0
3
�N O V
—
— 9
W E D
P
1 6 : 2 0
Hunterdon
Medical Center
Community Mental Health Center
November 3/ 1993
Ms. Hillary Clinton
Ira Magaziner
The White House
Washington, D.C. 20500
Dear Ms. Clinton and Mr. Magaziner,
Partial hospitalization should be reguired as part of the
mental health benefit by a l l accountable health plans. As
a provider of partial hospitalization services, I want you
to know how important this i s : many of my patients might
availability of partial hospitalization services.
Further, I can attest to the cost-effectiveness of partial
hospitalization as an alternative to inpatient psychiatric
Sincerely,
2100 Wescott Drive • Flemington, New Jersey 08822.9237 • Telephone 908-788-64D1
.
0
4
�H O V -
3 - 9 3
W E D
1 6 . 1 2 1
._.
—
—
Hunterdon
Medical Center
Community Mental Health Center
November 3/ 1993
Ms. H i l l a r y Clinton
Ira Magaziner
The White House
Washington/ D.C. 20500
Dear Ms. Clinton and Mr. Magaziner,
Partial hospitalization should be required as part of the
mental health benefit by a l l accountable health plans. As
a provider of p a r t i a l hospitalization services, I want you
to Jcnow how important t h i s i s : many of my patients might
now be unnecessarily hospitalized i f i t weren't f o r the
a v a i l a b i l i t y of p a r t i a l hospitalization services.
Further, I can attest t o the cost-effectiveness of p a r t i a l
hospitalization as an alternative t o inpatient psychiatric
care.
Sincerely,
IWJO,
line wrJ
2100 Wescott Drive • Flemington, New Jersey 08822-9237 • Telephone 908-788-6401
P •
M
0
l
�N O V -
3 - 9 3
W E D
1 6 : 2
1
Hunterdon
Medical Center
Community Mental Health Center
November 3, 1993
Ms. H i l l a r y Clinton
I r a Magaziner
The White House
Washington, D.C. 20500
Dear Ms. Clinton and Mr. Magaziner,
Partial hospitalization should be required as part of the
mental health benefit by a l l accountable health plans. As
a provider of p a r t i a l hospitalization services, I want you
to know how important t h i s i s : many of my patients might
now be unnecessarily hospitalized i f i t weren't f o r the
a v a i l a b i l i t y of p a r t i a l hospitalization services.
Further, I can attest t o the cost-effectiveness of p a r t i a l
hospitalization as an alternative to inpatient psychiatric
care.
2100 Wescott Drive • Flemington, New Jersey 08822-9237 • Teleohone 908-788-6401
•
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�11-03-1993
04:i3PN
U H OUTPT PSYCH
M
410 554 6603
P. 02
THE UNION MEMORIAL HOSPITAL
November 3, 1993
Mr. I r a Magaziner
The White House
Washington, D.C. 20500
Dear Mr. Magaziner,
As the President
of the Maryland Association
of P a r t i a l
Hospitalization and a provider of p a r t i a l hospitalization services,
I want you to know how important i t i s that p a r t i a l h o s p i t a l i z a t i o n
be made available as part of the mental health benefit by a l l
accountable health plans.
Many of my patients might now be
unnecessarily hospitalized i f i t weren't for the a v a i l a b i l i t y of
p a r t i a l hospitalization services. Instead, p a r t i a l h o s p i t a l i z a t i o n
has enabled many of my patients, with serious mental i l l n e s s e s , to
function independently i n the community. Further, as a provider,
I can attest to the cost-effectiveness of p a r t i a l h o s p i t a l i z a t i o n
as an alternative to inpatient psychiatric care.
I urge you to correct t h i s error before the f i n a l l e g i s l a t i o n i s
released to Congress.
Sincerely,
$UUuUL <^r7wc<2
Alice Jonas, R.N., M.S.N., C.P.C.
President, Maryland Association of
P a r t i a l Hospitalization and Program
Director, P a r t i a l Hospitalization
Program, Department of Psychiatry
201 East University Parkway •> Baltimore, Maryland 21218-2895 * (410) 554-2000
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003. fax
SUBJECT/TITLE
DATE
Uniton Memorial Hospital to Ira Magaziner [partial] (1 page)
11/3/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1337
FOLDER TITLE:
[Partial Hospitalization Letters] [loose]
2006-0885-F
wr836
RESTRICTION CODES
Presidential Records Act -144 ll.S.C. 2204(a)|
Freedom of Information Act - |S Ll.S.C. 552(b)l
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office [(a)(2) ofthe PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) ofthe PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA|
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute [(b)(3) ofthe FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) ofthe FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy |(bK6) ofthe FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) ofthe FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�11-03-1993 04:i3Pn
UH O T T P Y H
M UP SC
410 554 6603
P 03
.
THE UNION MEMORIAL HOSPITAL
November 3, 1993
Mr. I r a Magaziner
The White House
Washington, D.c. 20500
Dear Mr. Magaziner,
As a patient who i s receiving partial hospitalization services, I
want you to know how important i t i s that partial hospitalization
be made available as part of the mental health benefit by a l l
accountable health plans.
I might now be unnecessarily
hospitalized i f i t weren't for the a v a i l a b i l i t y of partial
hospitalization services. Instead, partial hospitalization has
enabled me to function independently in the community. I t i s my
understanding that a drafting error may leave the a v a i l a b i l i t y of
p a r t i a l hospitalization services to the discretion of individual
health plans.
I urge you to correct this error before the f i n a l legislation i s
released to Congress.
201 East University Parkway * Baltimore, Maryland 2121S-Z8y:> * (4iu; 5i4-zuw
�11-03-1993 04:i4Pn
U H O T T PSYCH
M UP
410 554 6603
P 04
.
THE UNION MEMORIAL HOSPITAL
November 3, 1993
Mr. I r a Magaziner
The White House
Washington, D.C. 20500
Dear Mr. Magaziner,
As a provider of p a r t i a l hospitalization services, I want you to
know how important i t i s that p a r t i a l hospitalization be made
available as part of the mental health benefit by a l l accountable
health plans.
Many of my patients might now be unnecessarily
hospitalized i f i t weren't for the a v a i l a b i l i t y of p a r t i a l
hospitalization services.
Instead, p a r t i a l hospitalization has
enabled many of my patients, with serious mental i l l n e s s e s , to
function independently i n the community. Further, as a provider,
I can a t t e s t to the cost-effectiveness of p a r t i a l h o s p i t a l i z a t i o n
as an alternative to inpatient psychiatric care.
I urge you to correct t h i s error before the f i n a l l e g i s l a t i o n i s
released to Congress.
Sincerely,
U/faM
mf
u^
CP^
201 East LjhiversityParkway^fr Baltimore, Maryland 21218-2895 •> (410) 554-2000
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
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2006-0885-F
Text
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Title
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[Partial Hospitalization Letters] [loose]
Creator
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
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2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
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42-t-12092971-20060885F-Seg3-037-011-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/73cf6d22a7b0be78dce9185a541f7c5e.pdf
8db47c5e1f40c049addd046434adb25f
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1337
OA/ID Number:
FolderlD:
Folder Title:
[Northridge Letters] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
6
1
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
001. fax
SUBJECT/TITLE
DATE
Form letters from patients to the Ira Magaziner and Hillary Clinton
advocating for mental health benefits [partial] (14 pages)
1/20/2000
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1337
FOLDER TITLE:
[Northridge Letters] [loose]
2006-0885-F
wr835
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information [(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal ofTice 1(a)(2) ofthe PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA|
b(l) National security classified information 1(b)(1) ofthe FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe F01A|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) ofthe FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�jfiN-aa-'aa FRI 01:29
ID:
TEL NO:
ttna pai
M fh k o
ot r J e
KospSiT
Medcaf Center
KORTKRIMC HOSPITAL MIDI CAL CENTER
KEKTAb KZALTB IXSTITVTl
TF.LEf A COVtR ?A01
X
OATt:
TO 1
ra will bf * tot»l V<
.p*g»> to follow.
Xf you 4o not rtcoSvo »n of tho
1
ploftio call
�JPM-20-'00 FRI 01:29
ID:
TEL NO:
ttll0
P02
In M fuim/hln. Clinton
M
The White HOUIB
Wuhington. D.C. 20500
Dear Ira Macaziner/Mn. Clinton:
As a provider of partial hospltaiitation lervicw, I wartt ydu to k o towimpoituit II ii that
nw
panial hospitalization b« m d available is pan of tha mental health benefU by all accountable
a*
health plana. Many of m patienu mifht n w be unneoeisazily hoapltaliaed If It weren't for the
y
o
availability of partial hospitallutlon lervlooi. Instead, partial hospitalization hai enabled miny
of m patients with serious mental illnesses to function independently In the community.
y
Further, aa a provider, I can attest to the oost-efToctiveneu of partial hospitsJiotion as an
alternative to Inpatient psychiatric care.
I urge you to correct this error before thefinallegislation is released to Congraas.
Sincerely,
^
In Magadner/Mr*. Clinton
The White House
Wuhington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
As a provider of panial hospitalisation scrvliai, I w«nt you to k o h w imponant It!» thai
nw o
panial hospitalization b m d availablo is part of the mental health benefit by all accountable
o ae
health plans. M n of m patients might n w be unneeessarily ho^italized if It weren'tforthe
ay
y
o
availability of partial hospiutlicatfon cervices, Instead, p&rtul hoipitalittdon has enabled m n
ay
of m patientt with serious mental illnuwi toftmctlonindipondently in the community.
y
Further, as a piovider, I can attest to the cost-effeetiveneas of partial hospitalization as an
alternative to inpatient psychiatric care.
1 urge you to correct this error befoje the final legislation is released to Congress.
Sincerely, ^ ^ ^ ^ > ^ ^
x
^ ^
s
^
)
/^V?
�JGN^a-'Se FRI 01:30
ID:
TEL NQ:
ttllB
P03
In Mi^jln^r/Mrj. Clinton
Hie White House
Washington. D.C. 20500
Dear In Magaziner/Mrs. Clinton:
As a provider of partial hospitalisation services, I want you to know how important It is that
partial hospitalization be m d available as part of the mental health benefit by all accountable
ae
health plana. Many of m patients might n w be unnecessarily hojpitalited if it weren't for the
y
o
availability of partial hospitalization services. Instead, partial hospitalitation has enabled many
of m patients with serious mental illnesses to function independently in the community.
y
Further, aa a provider, I can attest to the oost-effecdveness of partial hospltaliation as an
alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation isreleasedto Congress.
Sincerely,
Ira Maguintr/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear Ira Magaziner/Mrs. Clinton:
As a provider of partial hospitalisation services, I want you to know h w important il is that
o
partial hospitaluatlon be m d available as part of the mental health benefit by all accountable
ae
health plans. Many of m patients might n w be unnecessarily hospitalixed if it weren't for the
y
o
availability of partial hospitalization services. Instead, partial hospitalization has enabled m n
ay
of m patienu with serious mental illnesses to function independently in the community.
y
Further, as a piovider, I can attest to the cost-effecdveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge you to conect this error before thefinallegislation is released to Congress.
Sincerely,
�— JAN-20- '00 FR I 01:31
ID:
TEL NO:
ttll0
P0/|
In Muadntr/Mrc. Clinton
The White House
Wuhington, D.C. 20500
Dear In Magaziner/Mn. Clinton;
At a provider of partial hospitalization services, I want you to k o h w important tt is that
nw o
panial hospitalization be m d available as part of the mental health benefit by all accountable
ae
health plans. M n of m patients might n w be unneeessaxily hospitalised if it weren't for the
av
y
o
availability of partial hospitalization services. Instead, partial hospitalization ha enabled m n
ay
of m patients with serious mental illnesiai to function independently in the community.
y
Further, as a provider, I can attest to tha eost-effeedveness of panial hospitallndon as an
alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation Is released to Congreu.
Sincerely,
In Magaziner/Mn. Clinton
The White House
Wuhington, D.C. 20500
Dear Jn MegaziWMrs. Clinton:
As a provider of partUl h < ia < H n services, I u/ant you to k o h w important it is that
o pt ? u o
nw o
partial hospitalisation be m d available u pan of tha mental health banetn by all aeeountable
ae
health plans. Many of m patienu might n w be unnecessarily hospitalized if It weren't for the
y
o
availability of panial hospitalization aervices. Instead, panial hospitalisation hu enabled m n
ay
of m patients with serious mental illnesses to Ainctlon independently In the community.
y
Further, as a provider, I can attest to tht cost-effectiveness of partial hospitalization as a
n
alternative to inpatient psychiatric cere.
I urge you to correct this error before thefinallegislation is released to Congress.
Sincerely, —
�JON-23-'00 FRI 01:31
ID:
TEL NO:
ftl 10 P05
In Mapuintr/Mn. Clinton
The White Hbuie
washiniton, D.C. 20500
Deer In Mac«ziner/Mrs. Clinton:
Ai e provider of partial hospitaljM&M lervicat, I w n you to k o h w Imponant It if that
at
nw o
partial hospitaJization he m d available as pan of the mental halth beoeflt by all accountable
ae
health plans. M n of m patientt might n w be unneoewarily hospitalised if it weren't for the
ay
y
o
availability of partial hospitalization aervices. Instead, partial hospitalicadon haa enabled m n
ay
of m patients with serious mental iUnaisas toftmctionindependently In the community.
y
Further, as a provider, I can attest to the oost-efteetiveneu of partial hospitalbatien as an
altcmalire to Inpatient psychiatric can.
I urge you to correct this error befon t j final legislation isreleasedto Congreu.
hp
Sincerely
In Magaziner/Mrs. Clinton
The White House
Wuhington, D.C. 20300
Dear It* Magaziner/Mrs. Clinton:
As a provider ©f partial hospltalieatien servioas, I w n you to k o h w imponant It Is that
at
nw o
paniol hospitalization be m d available u pan of the menial health benefit by all aeoountable
ae
health plans. M n of m patients might n w be unnecessarily hospitalized if It weren'tforthe
ay
y
o
availability of panial hospitalization services, instead, panial hospitalization hu enabled m n
ay
of m patients with serious mental illnuwi to function independently in the community.
y
Further, u a provider, I can attatt to the cost-etfectivenats of panial hospitalization u an
alternative to inpatient psychiatric care.
I urge you to corrca ihh enur before the final legislation is released to Congraas.
Sincerely,
}V.
�JAN-20-'00 FRI 01:32
ID:
TEL NO:
8110 P06
In Miguintr/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear In Magaziner/Mrs. Clinton:
As a provider of partial hospitalitation services, I want you to know how important it is that
panial hospitalization be m d available aa part of the mental health benefit by all aeoountable
ae
health plana. Many of m patients might n w be unnecessarily hospitalized if it weren'tforthe
y
o
availability of partial hospitalization lervices. Instead, partial hospitaiication haa enabled many
of m patients with serious mental illnesses to A oi n independently in the community.
y
m to
Further, as a piovider, I can attest to the cost-effectiveness of panial hospitalization as an
alternative to Inpatient psychiatric care,
I urge you to correct this error before thefinallegislation is released to Congreu.
Sincerely,
In Magaziner/Mn. Clinton
The White House
Washington. D.C. 20500
Dear Ire Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know h w important ll Is that
o
panial hospitalization be m d available as pan of the mental health benefit by ali accountable
ae
health plans. Many of m patienu might n w be unnecessarily hospitalized if it weren'tforthe
y
o
availability of panial hospitalization services, instead, partial hospitalization has enabled m n
ay
of m patients with serious mental illnesies to function independently in the community.
y
Further, as a provider, I can attest to the cost-effeedveneu of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge you to correct this error before thefinallegislation is released to Congreu.
�JPN-^O-'Oa FRI 01:33
ID:
TEL NO:
ttll0 P07
In Mtpudntr/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
As a provider of partial hospitalization servioas, I want you to know how imponant It is that
partial hospitalization be m d available as part of the mental beelth benefit by all aeoountable
ae
health plans. Many of m patientt might n w be unnecessarily hospitalized if it weren't for the
y
o
availability of panial hospitalization services. Instead, partial hospitalization has enabled many
of m patienu with serious mental illnesses to A oi n independently in the oommunlty.
y
m to
Further, as a provider, I can attest to the oost-effecdveness of partial hospitalization as an
alternative to inpatient psychiatric can.
I urge you to correct this error before thefinallegislation is released to Congress.
Sincerely,
In Magazine/Mrs. Clinton
The White House
Wuhington, D.C. 20500
Dear Ire Magaziner/Mrs. Clinton:
As a provider of partial hospitalization services, I want you to know h w important it is that
o
panial hospitalization be m d available as part of the mental health benefit by all accountable
ae
health plans. Many of m patients might n w be unnecessarily hospitalized if it weren'tforthe
y
o
availability of partial hospitalization services. Instead, partial hospitalization hu enabled many
of m patienu with serious mental illnesses to function independently in the community.
y
Further, as a provider, I can attest to the oost-efTectiveneu of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge you to correct this error before thefinallegislation isreleasedto Congreu.
Sincerely,
�jPN-aa-'aa FRI 01:33 ID:
TEL NO:
HUB P08
1 1 Mttuif^r/Mn. Clinton
1
The White Houie
Wuhington, D.C. 20500
Deer lie Maiiztner/Mn. Clinton:
Ai e provider of partial hospitaliiation aerviou, I w n youtok o h w important It ll that
et
nw o
panial hospitilizatlon be m d available a part of the mental bealth benefit by all a o o t be
ae
a
o o na l
holth plana. M n of m patients mg t n w be unnecessarily hospitalised if it weran'l for the
ay
y
ih o
availabiUty of panial hospitalitation lervieei. Instead, partial hoipitaUadoo h a enabled m n
a
ay
of m patients with serious mental illnum toftmctkmindependendy In Ihe community.
y
Further, aa a provider, I can attest to the cost-effectiveneu of partial hospitaUsation 1 an
1
alternative to inpatient psychiatric can.
1 urge y u to correct this error befon thefinaltegirtatlonIs released to Congreu.
o
In Magaziner/Mn. Clinton
The White House
Washington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
As a provider of partial hospitalization services, J w n y u to k o h w important It is that
at o
nw o
partial hospitalization be m d available u part of the m na health benefit by all a o u t be
ae
e tl
e o na l
health plans. M n of m patients mg t n w b unnecesnrily hospitalized if it weren'tforthe
ay
y
ih o e
availability of partial hospitalization services. Instead, partial hospitalization hu enabled m n
ay
of m patients with serious mental illnusu to function Independently in the community.
y
Further, as a provider, I can attest to the cost-effectiveneu of partial hospltaliation at an
alternative to inpatient psychiatric care.
I urge y u to correct this error before t efinallegislation isreleasedto Congreu.
o
h
Sincerely,
�JRN-20-'00 FRI 01:31
ID:
TEL MO:
HI10 P09
ba Matutotr/Mn. Clinton
Ite Whi* Houu
wuhington, D.C. 3 S 0
O0
Dor In Mua»ner/Mrs. Clinton:
At a provider of pvttal hotpiulitetien Mrvieei, 1 wmt yeu to k o h w important U U that
nw o
partial hoapitaliution b m d available u part of the mental health benefit by all a o u a l
o ae
o o m be
heallh plana. M n ef m patient! mg t n w be unneoeaailly ho^iulixed if it werw'tforthe
ay
y
ih o
availability of partial hotpltallzation Mrvioea. Instead, partial hospitaUadon haa enabled m n
ay
of m patienu with serioui mental innassei to fitnetion Independendy in the oommunlty.
y
Further, as a piovider, I can attest to die eost-tftetlveneai ef partial hospltaliation ai aa
alternative to inpatient psychiatric cam.
I urge you to conect this error before the final legislation is released to Congreu.
Siocerely,
Ua Maguiner/Mn. Clinton
The white House
Washington. D.C. 20500
Dear Im Maguiner/Mn. Clinion.'
As a provider of partial hospitaliiation services, I w n you to k o h w important It Is that
at
nw o
partial hospitaliiation b m d available u part of the m na health benefit by all aeeountable
e ae
e tl
health plans. M n of m patientt mg t n w be unneeessarily hospi tallied if it wasen't for the
ay
y
ih o
availability of partial hospltaliution services, instead, partial hospitalisation hu enabled m n
ay
of m petienti with serious mental illnusu to function independendy In the community.
y
Further, u a provider, I can attest to the oost*effectlvanau of panial hospltaliution u an
alternative to inpatient psychiatric care.
! urge you to correct this error before the final legislation isreleasedto Congress.
Sincerely,
�JflH-20-'00 FRI 01:35
ID:
TEL NO:
til 10 P10
In Mieuin«r/Mn. ClimoA
7)tf Whiu Houn
Wuhington, D.C. 20500
Dev In M«|uinor/Mn. Clinton:
As • providsr of putial hospltilitttion servton, I want youtok o hew imponant It is (hat
nw
partial hoipitsliation b m d available as pan of the mental health benefit by all a e u a e
e ae
ee m M
health plans. M n of m patients mg t n w be unnecessarily hospitalised if It werm't far the
ay
y
ih o
availabiUty of panial hospltaliution servioas. liutaad, partial hospitaliiation hu enabled m n
ay
of m patientt with serious mental illnassutofunction independendy in the eommualty.
y
Further, u a provider. I can attest to t o eost<*ff*dveneas ef partial hoipUHlntien as an
h
alternative to inpatient psychiatric can.
I urge you to correct this encr befon thefinallegislation is nleased to Congraas.
Siocerely,
In Magasiner/Mn. Clinion
The White H ue
os
Wuhington, D.C. 20500
Dear In Magasiner/Mn. Clinton:
As a provider of panial hotpitaliutien serriees, I w n youtok o h w imponant It is that
at
nw o
partial hospitalisation be m d available u pan of the m na health benefit by all aeeountable
ae
e tl
health plans. M n of m patients might n w be unnecuartly hospitalized If it weren'tforthe
ay
y
o
aviilabllity of partial hospltaliution tervtaes. Instead, partial hospitaliiation hu enabled m n
ay
of m patients with serioui mental illnusu u ftmcdonindependently in the community.
y
>
Further, u a piovider. I can attest to the coit«efrectiveness of partial hospitalization u an
alternative to inpatient psychiatric cam.
t urge you to correct this error before thefinallegislatien is nleased to Congress.
Sincerely,
�JRN-20-'00 FRI 01:35
ID:
TEL MO:
HI10 P l l _
In Miguiner/Mn. Clinton
The White Houw
Wuhington, D.C. 20500
Dear In Megtzincr/Mn. Clinton:
At e provider of pertiil hospiUHuHon lerviou, 1 want you to k o h w imponant it la thai
nw o
panial hospitalization be m d available u pan of ths mental health benefit by all aeoountable
ae
health plana M n of m patienu might n w be unnecessarily hospitalised if it weren't for the
ay
y
o
availability of panial hospitalization services. Instoid, partial hospitalisation hu enabled m n
ay
of m patienu with serious mental illnuses to function independendy in the community.
y
Further, u a provider. I can attest to the cost-effecdveneu of partial hospitallaiion u an
alternative to inpatient psychiatric can.
I urge you to cornet this error befon thefinallegislation isreleasedto Congreu.
Sincerely,
fy^U
In Magaziner/Mn. Clinton
The White House
Wuhington. D.C, 20300
Dear In Megaziner/Mrs. Clinton:
As a provider of partial hospitalization serricei, I w n you to k o h w imponant It Is that
at
nw o
panial hospitalization be m d available u pan of the mental health benefit by all aeeountable
ae
health plans. M n of m patienu might n w be unnecessarily hospitalized if it weren'tforthe
ay
y
o
availability of partial hoipitaliution serviees. Instead, partial hospitalization hu enabled m n
ay
of m patienu with serious mental illnesses to function independently in the community.
y
Further, as a provider. I can attest to tha coit-effectivaneii of pania] hospitalization u an
alternative to inpatient psychiatric care.
I urge you to comet this error before thefinallegislation is released to Congreu.
�JAN-20-'00 FRI 01:36 ID:
T E L N a
.
8110 P12
InMtgiziner/Mn. Clinton
Hit White Hbuie
Wethington, D.C. 20500
Deer In Migetiner/Mrs. Clinton;
1
h'ta SSJ^J!!?? T l T ^ ^
^'cee, I w n you to k o h w important
at
nw o
it it thatjmtiil hospltaliution bemade available u part of the mental health benefit byy
accountsMe health plan,. 1 mlglit n w be unneoeesarily hospltaliaed if U \ £ S t (u
o
t^Uty o f ^ ^ l ^
wviocs. Instead, partial
ftmction independently in t e community. It is m t dt t n J g that a dnftiBE mwmwtat
h
y m fna d n
the availability of partial hospltaliation services to the discretion of i n ^ S ^ t h ^ W
p
m
I u g you to correct this error befon t efinallegislation is nleased to Congreu.
re
h
Sincerely,
^
In Mag«nner/Mn. Clinton
The White House
Waahington. D.c 20500
Dear In Magaainer/Mrs. Clinton;
�,
JPIN-20- 00 FRI 01:36
ID:
TEL NO:
ttll0
P13
In Magaziner/Mn. Clinton
The White House
Washington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
As e provider of partial hospltaliution services, I w n you to k o h w important It is that
at
nw o
partial hospitalization be m d available as part of the mental health benefit by ell aeoountable
ae
health plans. M n of m patients mg t n w be unnecessarily hospitalized if It weren't for the
ay
y
ih o
availability of partial hospitalization services. Instead, partial hospitalization has enabled m n
ay
of m patients with serious mental illnesses to function independently in the community.
y
Further, aa a provider, I can attest to the cost-effectiveneu of partial hospitalization ts an
alternative to inpatient psychiatric can.
I urge you to correct this error befon the final legislation is released to Congreu.
Sincere^,
In Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
As a provider of partial hospitalization servicae, I w n you to k o h w important it is that
at
nw o
panial hospitalization be m d available as pari of the m na health benefit by all accountable
ae
e tl
health plans. M n of m patients mg t n w b unneeessarily hospitalized if it weren'tforthe
ay
y
ih o e
availability of panial hospitalization services. Instead, partial hospitalization hu enabled m n
ay
of m patients with serioui mental illnesses to funolcm independently in the community.
y
Further, as a provider, I can attest to t e cost-effectiveneu of partial hospitalization as a
h
n
alternative to inpatient psychiatric can.
I urge you to conect this error befon t efinallegislation is nleased to Congreu.
h
�JPN-20-'00 FRI 01:37
ID:
TEL NO:
til 10 P H
In Magaiintr/Mn. Clinien
The White Houte
Waihlnglon, D.C. 20500
Dear In Magaziner/Mn. Clinton:
Ai a provider of partial hoipltalization servtaes, I want you to k o h w important It il that
nw o
panial hospitalization be m d available as part of the mental bealth benefit by all aeoountable
ae
health plans. M n of m patients might n w be unneeessarily hospitalised if It wamn'tfcrthe
ay
y
o
availability of panial hospitalitation services. Instead, panial hospitalisation hu enabled m n
ay
of m patienu with serious mental lUnusei to function independently in the commuoity.
y
Further, aa a provider, I can attest to the cosMffecHveneu of partial hospltaliation u an
alternative to inpatient psychiatric can.
I urge you to correct this error befon thefinallegislation isreleasedto Congress.
In Magaziner/Mn. Clinton
The White House
Wuhington, D.C. 20500
Dear In Magaziner/Mn. Clinion:
As a provider of partial hospitaliiation servioM, I w n you to k o h w important il Is that
at
nw o
partial hospitalisation be m d available u pan of the mental health benefit by all aeoountable
ae
health plans. M n of m patienu might n w be unnecessarily hospiudised if it weren'tfarthe
ay
y
o
availability of partial hospitalization services. Instead, partial hospitalisation hu enabled m n
ay
of m patienu with serioui mtnlal illnesses toftinctlcmIndependently In the community.
y
Further, as a provider, I can attest to the cost-effectiveness of partial hospitalization as an
alternative to inpatient psychiatric care.
I urge you to correct this error befon thefinallegislation is released to Congreu.
�J P N ^ a - ' O a FRI 01:38 ID:
TEL NO:
t t l l B P15
Ifl Micuintf/Mn. Clinton
The Whits Hout*
Washington, D.C. 20500
Dear Ira Magaziner/Mn. Clinton:
Ai a provider of panial hotpitaHaadon servioet. I w n you to k o h w Important It Is that
at
nw o
partial hospitalization be m d available as pan of the mental health benefit by all aeoountable
ae
health plana. M n of m patients might n w be unneoewarily hoapltaliaed if it weren't for the
ay
y
o
availability of partial hoipiialiration services. Instead, partial hoipitaliution hu enabled m n
ay
of m patienu with serious mental illnesses iofonctfonindependendy in the community.
y
Further, u a provider, I can attest to tha wst-effcctivweu of partial hospltslizttion as an
alternative to Inpatient psychiatric care.
I urge you to correct this error before thefinalleglslAtion Isreleasedto Congreu.
')?MaL Grk Qtf^ CTfe
l
In Magaziner/Mn. Clinton
The White House
Wuhington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
As a provider of panial hospitalization senwas, I w n you to k o h w important It is that
at
nw o
partial hoipltalization be m d available a part of the mental health benefit by all accountable
ae
a
health plans. M n of m patients might n w be unnecessarily hospitalized if it weren't for the
ay
y
e
availability of partial hospltaliution serviees. Instead, pirtisl hospitallution hu enabled m n
ay
of m patients with serioui mental illnesses to function independently in the community.
y
Further, u a provider, I can attest to tha cost-effeetlveflftsi of partial hospitallaiion u an
alternative to inpatient psychiatric care.
I urge you to correct this error before thefinallegislation isreleasedto Congress.
Slnordy, / ^ ^ / ^ y * ^ ^ . A/.
�JRN-20-'00 FRI 01:38
ID:
TEL NO:
8110 P16
In Mipzintr/Mn. Clinton
Ute White House
Washington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
As e provider of partial hospltaliution services, I w n youtok o h w imponant it It that
at
nw o
panial hospitalization be m d available as pan of the mental health benefit by all aeoountable
ae
health plans. M n of m patients mg t n w be unneeessarily hospitalized if It weren't for the
ay
y
ih o
availability of panial hospitalization services. Instead, partial hospitalization haa enabled m n
ay
of m patients with serious mental illnuses to function i d p n e d In the community.
y
n e e dn y
Further, as a piovider, I can attest to the cost-effectiveneu of partial hospltaliation is an
alternative to inpatient psychiatric can.
I urge you to correct this error befon t efinallegislation is nleased to Congreu.
h
Sincerely,
In Magaziner/Mn. Clinton
The White House
Washington. D.C. 20500
Dear In Magaziner/Mn. Clinton:
As a provider of panial hospltaliation services, I w n you to k o h w imponant it is that
at
nw o
partial hospitaliadon be m d available as pan of the m na health benefit by ell a o u t be
ae
e tl
e o na l
health plans. M n of m patients mg t n w be unnecessarily hospitalized if it weren'tforthe
ay
y
ih o
availability of panial hospltaliution servioet. Instead, partial hospltaliation hu enabled m n
ay
of m patienu with serious m na illnuses to function i d p n e d in the community.
y
e tl
n e e dn y
Further, u a provider, I can attest to the cost-effectiveneu of partial hospitalization as a
n
alternative to inpatient psychiatric can.
I urge you to correct this error befon t efinallegislation is released to Congreu.
h
�JfiN-20-'00 FRI 01:39
ID:
TEL MO:
til 10 P17
In Mifaziner/Mrs. Clinton
The White Houie
wuhington. D.C. 20500
Dear In Ma*azinor/Mn. Clinton:
As e provider of partial hospitaHution services, I w n you to k o h w imponant It is that
et
nw o
partial hospitalization be m d available u pan of the mental health benefit by all accountable
ae
health plans. M n of m patienu might n w be unneeessarily hospitalised if it wenn'tforthe
ay
y
o
availability of panial hospltalizadon services. Instead, partial hospitalisation has enabled m n
ay
of m patients with serious mental illnesses toftmctionindependendy in the community.
y
Further, u a provider, I can attest to tha cost-effectlveneis of partial hospltallnfien as an
alternative to Inpatient psychiatric can.
I urge you to correct this error befon thefinallegislation isreleasedto Congreu.
Sincerely,
£ Wife Ms>
In Magaziner/Mn. Clinton
The White House
wuhington, D.C. 20500
Dear In Magaziner/Mrs. Clinton:
As a provider of partial hospitalisation servioas, I w n you to know h w important it is that
at
o
partial hospitalization be m d available u part of the mental health baneflt by all accountable
ae
health plans. Many of m patients might n w be unneeessarily hospitalised if it weren'tforthe
y
o
availability of partial hospltaliution services, instead. partUl hospltaliution hu enabled m n
ay
of m patients with serious mental illnuses to function independently In the community.
y
Further, u a provider, I can attest to tha cosNeffectivsneis of partial hospltallzBdon u an
alternative to inpatient psychiatric care.
I urge you to correct this enur before thefinallegislation is nleased to Congress.
Sincerely,
VldAiui
/
/fta
�JRN-20-'00 FRI 01:40
ID:
TEL NO:
HI10 P1B
In M<fuin*/Mn. ClUtten
The White Houie
Weihington, D.C. 20500
Dear In Maguiner/Mn. Clinton:
Ai a provider of partial hospitalization lervica, I want you to k o h w important it U that
nw o
panial hospitalization be m d available as pan of the mental health benefit by all aeoountable
ae
health plans. M n of m patients might n w be unnecessarily hospitalized if it wenn't for the
ay
y
o
availability of partial hospitallution terviou. Instead, panial hospltaliation hu enabled m n
ay
of m patients with serious mental illneisei toftmetlonIndependendy in the oommunlty.
y
Further, u a provider, I can attest to the cost-effecdvenets of partial hospltaliation u an
alternative to inpatient psychiatric cam.
I urge you to comet this error befon thefinallegislation isreleasedto Congreu.
Sincerely,
In Maguintr/Mrc. Clinton
The White House
Wuhington, D.C. 20500
Dear In Maguiner/Mn. Clinton:
As a provider of partial hospltaliution aervices, I w n you to k o h w important it Is that
at
nw o
partial hospitalization be m d available u pan of the mental health benefit by an accountable
ae
health plans. M n of m patienu might n w be unnecessarily hospitalised if it weren't for the
ay
y
o
availability of partial hospludization setvices. Instead, partial hospitallution has enabled m n
ay
of m patienu with serious mental illnesses to function independently In the community.
y
Further, u a provider, I can attest to thf cost-effectiveness of partial hospitalization u an
alternative to inpatient psychiatric care.
I urge you to conect this error before thefinallegislation isreleasedto Congreu.
Sincerely,
�J P M - 2 0 - ' 0 0 FRI 0 1 : 1 0
ID:
TEL NO:
H I 1 0 P19
In Maguiner/Mn. Clinton
The White H u
Ow
Wuhington, D.C. 20500
Dear In Maguiner/Mn. Clinion;
AI a provider of panial hospltaliution setvioei, I want you to k o h w imponant ll it that
nw o
panial hoipltalization be m d available u part of the mental bealth benefU by all aeoountable
ae
health plana. M n of m patienu might n w be unneouiarily hospitalized if it weren't for the
ay
y
o
availability of partial hospltaliution Mrviou. Instead, partial hosphallutlon hu enabled m n
ay
of m patients with serioui mental iUneises to function Independently in the oommunlty.
y
Further, aa a provider, I can attest to the coit-eftetiveneu of partial hospitallaiion u an
alternative to inpatient psychiatnc can.
I urge you to conwt this error befon the final legislation is nleased to Congreu.
Sincerely,
6.
(j
A>
<
In Maeazintr/Mn. Clinton
The White House
Wuhington, D.C. 20500
Dear In Maguiner/Mn. Clinton:
Ai a provider of panial hospitallution services, I w n you to k o h w important tt is that
at
nw o
panial hospitalization be m d available u pan of the mental health benefit by ail aeeountable
ae
health plans. M n of m patients might n w be unneoettarily hospitalised if it weren'tforthe
ay
y
o
availability of partial hospltaliation tervioee. Instead, partial hospitallution hu enabled m n
ay
of m patients with serious mental illnuses to function independently In the oommunlty.
y
Further, a a provider, I can attest to the cost-effectivanau of partial hospitalisation u an
>
alternative to inpatient psychiatric care.
I urge you to correct this error before the final legislation isreleasedto Congreu.
Sincerely,
�JAN-20-'00 FRI 01:41
ID:
TEL NO:
8110 P20
In Maguintr/Mre. Clinton
The White Houie
Wuhington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
Ai a provider of partial hospitalization services, I w n youtok o h w important It is that
at
nw o
panial hoipltalization be m d available as pan of the mental health benefit by all aeoountable
ae
health plans. M n of m patients mg t n w b unneoeisarily hospitalized if it wenn'tforthe
ay
y
ih o e
availability of panial hospitalization lervioes. Instead, partial hospitallution h a enabled m n
a
ay
of m patients with serious m na illnuses to fimctlcm independently in the community.
y
e tl
Further, u a provider, I can attest to the cost-effecdveneu of panial hospitalization as an
alternative to inpatient psychiatric can.
I urge you to correct this error befon the final legislation is nleased to Congreu.
Sincerely,
In Magaziner/Mrs. Clinton
The White House
Washington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
As a provider of partial hospitalization services, I w n you to k o h w important It Is that
at
nw o
panial hospitalization be m d available as pen of the m na health benefit by ail accountable
ae
e tl
health plans. M n of m patients mg t n w be unnecessarily hospitalized if it weren'tforthe
ay
y
ih o
availabiUty of partial hospitalization services. Instead, panial hospitalisation hu enabled m n
ay
of m patients with serious mental illnuses to function i d p n e d in the community.
y
n e e dn y
Further, as a provider, I can attest to t e cost-effectiveness of partial hospitalization as a
h
n
alternative to inpatient psychiatric care.
I urge you to correct this error befon t e final legislation Is nleased to Congress.
h
Sincerely,
'
^
S^S
JT *<, —
�JRN-20-'00 FRI 01:42
ID:
TEL NO:
«110 P21
In M«Euif)*/Mn. Clinton
The White Houie
Wuhington, D.C. 20500
Dear In Magaziner/Mn. Clinton:
Ai a provider of panial hoipltalization lervioet, I w n you to k o h w important It ii that
at
nw o
panial hoipltalization be m d available a part of the mental health benefit by all aeoountable
ae
$
health plana. M n of m patientt mg t n w be unneecuarily hospitalized if It wenn't for the
ay
y
ih o
availability of partial hospitalization aervioei. Instead, panial hospitalization hu enabled m n
ay
of m patients with serious m na illnuus to function independently in the oommunlty.
y
e tl
Further, as a provider, I can attest to the cost-effecdveneu of partial hospitalization as an
alternative to inpatient psychiatric can.
I urge you to correct thii error befon the final legislation isreleasedto Congreu.
In Magaziner/Mn. Clinton
The White House
Wuhington. D.C. 20500
Dear In Magaziner/Mn. Clinton:
As a provider of partial hospitalization lervioes, I w n y u to k o h w i p n n it Is that
at o
nw o m o a t
panial hoipittlizatlon be m d available as pan of the m na health benefit by all accountable
ae
e tl
health plans. M n of m patients mg t n w be unnecessarily hospitalized If it weren't for the
ay
y
ih o
availability of partial hospitalization services. Instead, partial hospitalization hu enabled m n
ay
of m patients with serious m na illnuus to function i d p n e d in the community.
y
e tl
n e e dn y
Further, as a provider, I can attest to t e cost-effectiveneu of partial hospitalization as a
h
n
alternative to inpatient psychiatric can.
I urge you to correct this error befon the Anal legislation isreleasedto Congreu.
Siacrdy, ^
^
^
�JAN-^B-'Ba FRI 01M2
ID:
TEL NO:
ttllB
P22
In M««Mln«r/Mr». Clinton
The White Houie
Woihington, D.C. 20500
Dear In Magaziner/Mn. Clinion:
Ai a provider of partial hoipitaliution lerviwu, I want youtok o h w imponant It It that
nw o
panial hoipitaliution be m d available u part of the meetal bealth benefit by all aeeountable
ae
health plans. M n of m patients might n w be unnecessarily hospitalised ifttweren't fbr the
ay
y
o
availability of partial hospltaliution serviooi. Instead, partial hospitallution hu enabled miny
of m patients with serioui mental illnesses toftmctionindependently in the commuoity.
y
Further, u a provider, I can attest to the coit-rffectlvenau of partial hospitaliiation u an
alternativetoinpatient psychiatric care.
I urge you to correct this error before thefinallegislation Isreleasedto Congreu.
Sincerely, A^uJ^A-^A
\
In Magaziner/Mn. Clinton
The White House
Wuhington, D.C. 20500
Dear In Maguiner/Mn. Clinton:
As a provider of partial hospitaliiation services, I w n you to k o h w imponant it is that
at
nw o
partial hoipitaliution be m d available u pan of tha mental health benefit by all accountable
ae
health plana. M n of m patients might n w be unnecessarily hospitalised if it weren't for the
ay
y
o
availability of panial hospitallution services. Instead, partial hoipilaliation hu enabled m n
ay
of m patienu with serious mental illnwies to function independently In the community.
y
Further, u a provider. I can attest to die cost-effectiveness of partial hospltaliation u a
n
alternative to inpatient psychiatric care.
I urge you to correct this error before thefinallegislation is released to Congreu.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. fax
SUBJECT/TITLE
DATE
Form letters from patients to the Ira Magaziner and Hillary Clinton
advocating for mental health benefits [partial] (14 pages)
1/20/2000
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1337
FOLDER TITLE:
[Northridge Letters] [loose]
2006-0885-F
wr835
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) ofthe PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy ((a)(6) of the PRA)
b(l) National security classified information 1(b)(1) ofthe FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) ofthe FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy ((b)(6) ofthe FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) ofthe FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�JflN-ZB-'BB FRI 01:43 ID:
In Magwiner/Mn. Clinton
ThoWhitoKouM
W W go , D.C. 2 5 0
u nto
00
TEL NO:
W110 P23
r H
^
o 0
J
Dev In Magitiner/Mn. Clinton:
At e petient w o i$ nceiving panial h s ia z to lervieei, I w n you to k o h w i p ra t
h
opt H ai n
at
nw o m ot n
it is t a partial hospitalization b m d available as pert of t e m na health benefU b all
ht
e ae
h e tl
y
a e u t be health plans. I mg t n w be u noaaU hospitalized If It weren't fbr the
e o na l
ih o
n eesr y
availabiUty of partial hospitalization seiviccs. Instead, partial hospltalizadon h a enabled m to
a
e
function i d p n e d In t e c m u iy It Is m u d na dn thata drafting enw m y leave
n e e d n y h o m nt .
y n e tn l g
a
t e availability of partial hospitalisation services to the discretion of individual health plans.
h
I u g you to cornet this error before t e final legleledon 1 released to Congreu.
re
h
*
Sincerl"
In Magaziner/Mrs. Clinton
lhe White H ue
os
W a i go , D.C. 20500
a hn t n
Dear In Magasiner/Mn. Clinton:
I u g y u to oonect this error befon t e final legislation is released to Congress.
re o
h
Sincerely,
�JAN-20-'00 FRI 01:43 ID:
TEL NO:
8110 P24
In Mtfiann/Mn. Clinion
Uw Whit* Houie
WtlWiiftoB, D.C. 20500
Deer In Migaztner/Mn. Clinton:
Ai e petient w o ii nceiving partial hospitalization services, I want you to k o h w important
h
nw o
it is that partial hospitalization be m d available aa pan of the mental haalth benefit by all
ae
aeeountable health plana. I migfit n w be unneoeisarily hospitalized if it weren't for Ihe
o
availability of panial hospitalization lervioes. Instead, partial hospitalization hu enabled m to
e
function independently in the oommunlty. It li m understanding that a drafting error m y leave
y
a
the availabiUty of partial hospitalisation services to the discretioo of Individual haalth punt,
I urge you to conect this error befon the final legislation is released to Congress.
Sincerely,
ta Magaziner/Mn. Clinton
The White House
Waahington, D.C. 20500
Dear In Magasiner/Mn. Clinton:
1 urge you to correct this error before thefinallealsladon la mi
Sincerely,
�JQM-aa-'OS FRI 01 M l
ID:
TEL MO:
t t l l O P25
In MtfiBBti/Miv. Clinton
TluWhiloHouM
Wuhington, D.C. 2S O
0O
Dur In Migulner/Mn. Clinton:
At • patient who Is receiving putfil hospltaliation services. I w n you to k o how important
at
nw
it Is that paniil hospitallution be m d avallablt u part of the mental health benefit by all
e*
acoounnble heallh plant. I ml^t nw be u n o a a ly hesplullxed if it werea't for the
n e e a rl
availabiUty of partial hospitalization services. Instead, partial hospitalisation hu enabled m le
e
function independently in the o m u ly It is m understanding that a drafting enor may leave
o m nt .
y
the availability ef partial hoqrftallsatloe services to tha discretion of individual health puns.
I urge you to correct this error bafan theflnslleglslsdon is released to Congreu.
SiQfiBEte
Ira Magaziner/Mn. Clinton
lhe White House
Washington, D.C. 20500
Dear in Magulner/Mrs. Clinton:
1
f 1
w e r B a l
availability of partial hospltalixaSn teMeu S S T ^ - i E T J
< * to
<
Wion h f p n c ty h i T ^ m u S T h i . m ^ ^ ? . ^ ^ ^ ^ ^ ^ ^
we e d nl
the avaiUbilit, of A
. ^ S J l l ^ r r ^
0
I urge you to correct this error beftm the final leglslatioa is released to Congnes.
Slneemiy
�JON-aa-'OB FRI 01:15 ID:
til 10 P2S
TEL NO:
In Mvgiziiw/Miv. Clintoa
TW White KOUM
l
WuUaftoB, D.C. 20S00
Daw In Migatlner/Mrt. CliAtoa:
At • patient w o it receiving ptrthd hospitaliadon services. I w n you to k o h w important
h
at
nw o
it is that partial hospltaliution b m d available u pen of the mental lieaUh benefit by all
e ae
accountable health plans. I mg t n w be unnecessarily hospliallzad if It weren't for the
ih o
availability of partial hoipitaliution servicos, Instead, partial hospltaliution hu enabled m to
e
ftmctlun i d p n e d In the community. It Is m u d m n i g that a dnftleg error m y laave
n e e dn y
y n e a dn
a
the availability of panial hospitaliadon services to the dieoratlon of Individual health pUas.
I urge youtocomet this error bafcn thefinallegislation Is released to Congreu.
Slner
In Magaziner/Mn. Clintoa
Ths White House
Waahington. D.C. 20300
Dew ire Mafaslncr/Mrs. Clinton:
M S T S ; ^
accountabEThsalth p l i T l ^ j f l
to^LZXSt
^
byaH
availability of i ^ t a ^ S i S t a K T ^ f f i S r , 'I
' ^ *'
ftMKittenWapSwtJyfaTScSSuiSThm ^ ^ ^ T f ^
anabtadTneio
the availability of p a ^ h ^ S ^
1
,f
w a ,
h
Sliteerriy,
u
t
�,
-JfiN-20- 00 FRI 01:45 ID:
TEL NO:
«110 P2?
In Mtfuum/Mn. ainton
Uw White Kouw
WeiUagton, D.C. 2 5 0
00
Deer In Magettoer/Mn. Clinton;
Ai e petient w o Is nceiving partial hospitalization services. I w n you to k o h w i p ra t
h
at
nw o m ot n
it is t a paxtiaJ hospitalization b m d available as pan of the m na health benefit b all
ht
e ae
e tl
y
accountable health plana. 1 mgt n w b u n o e a iy hospitalized if It weren't fbr the
i ft o e n e e s rl
availability of panial hospitalization aervioei. Instead, partial hospitalization hu enabled m to
e
function I d p n e d In t e o m u ly It is m u d rt n i g that a drafting error m y leave
n e e d n y h o m nt .
y n e sa dn
a
the availabiUty of panial hospitalization services t tha discretion of individual heallh plana.
o
I u g you to o r e t thli error before t efinalJcgjslsdon isreleasedto Congreu.
re
oro
h
Si
In Magaziner/Mn. Clinton
The White H ue
os
Washington, D.C. 20500
Dear In Magazlner/Mn. Clinton:
t tiri» yau lo oomct thl, error bsfon Kit AM) l^Wuloa Itreletufto CMfnn.
'ItenlK
�t i i i a P2e
TEL MD:
jpM^a-'aa FRI 01:-IS ID:
In Mifuaner/Mn. Clinton
11M W lo Hooto
bt
WuUaiton, D.C. 20500
Dear Ira Magazlner/Mn. Clinton:
As a patient w o la receiving partial hoipitallzation ie(vicet I w n you to knew hew imponant
h
et
it li that panial hoipitaliiatton b m d avillable ai pan of the mental haalth benefit by all
e ae
a o u a l haalth plani. I m & n w b unneoeasarily hospitalized if it wareaH fbr the
o o m be
l t o e
g
availabiUty of panial hospitalization wrvloes. Initad, panial hospitaliiation hu enabled m to
e
functiui ind^endcntiy in t e o m u ly tt li m undantanding that a dnfthig error m y leave
h o m nt .
y
a
the availabiUty of partial hospitaliiation servioes to the dlaeredoe of individual health puns.
r
T urge youtoooneet this error bofart the final legisladon Is released to Contitss.
Sincerely
ba Magaziner/Mrs. ainton
Uto White H m
o e
Waahington, D.C. 20500
Dear Im Matatiner/Mrs. Clinton:
M
ftmcrtonimlq^y t e wmmunltv. tti mu..•A^W-^-'IT'?" ? ^ •"wndmeto
nincHon-indqjenoejnJyinInfl^WunSTi, m ^ ^ n ^ T r 7 „ *« •»bWme to
h
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a
|d to Congress.
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ID:
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ttllB
P29
In Mnizmer/Mn. Clinton
Hit White Horn
Weihington, D.C. 20500
Dear In Magasiner/Mn. Clinton:
At a patient w o is nceiving panial hospitalization servioet. I w n you to k o h w i p n n
h
at
nw o m o a t
it is t a partial hospltaliation b m d available as part of t e m na health benefit b all
ht
e ae
h e tl
y
accountable health plans. I mg t n w b u n o e a iy hospitalized if It weren'tfort e
i h o e n e e a rl
h
availabiUty of partial hospitalization servioes. Instead, panial hospitalization hai enabled m to
e
function I d p n e ty in t e c m u iy It ii m u d rt n i g that a drafting error m y leave
n e e d nl
h o m nt .
y n e sa dn
a
t e availabiUty of partial hospitalization services t t e disendon of individual health plana.
h
o h
T u g you to comet this error befon t efinallegisladon is nleased to Congress.
re
h
Sincerely,
In Magaziner/Mn. Clinton
Tha While Houie
W a i go , D.C. 20500
a hn t n
Dear In Magasiner/Mn. Clinton:
1 ui* y u to contfA thli wrctteAvtihi AM]togltlidoftU ttleaMd ui Congmt.
o
Sincerely
�JQN-23-'Ba FRI 01M? ID:
TEL MO:
Ira Ma|tziner/Mrv. ainton
HM White Houaa
WaddnitOA, D.C. 20500
Dw In Mi|UiMr/Mn. Clinton:
It It AU pudil hMfimiaitoi
. haplitltod If h wno't (or «•
ba Mifaaner/Mn. Clinton
Hte White H m
o e
Wuhlniton, O.C. 20500
Dear in Magasiner/Mn. Clinton:
Ai a petient w o is neetving partial hospitalization services, I w n you to k o h w impenaat
h
at
nw o
It is that partial hotpitalisaUon b m d available as past of t © mental bealth benefit b all
e ae
h
y
accowiBsble health plant. I mgM n w be unneeessaffly hospitalised if it werea't fbr the
il
e
tv&ilabllity of partial hospitalixadon servioes. Instead, partialfafpitsllTiUowJiunablwImBtp
A ei n independently in the c m u iy it Is m undentuding that a drafting error m y leave
m to
o m nt ,
y
a
the availability of partial hospitalisation servicestothe diserctton ef individual health plans,
I urge youtoconect this error belbn thefinalleglsletion U releasedtoCongress.
�In Mi|iziner/Mn. Clinton
TtoWhitoKouie
Wuhington, D.C. 20300
Dotr In Migasiner/Mn. Clinton;
Ai • patient w o ii nceiving putial hospltaliation services, 1 w t you t k o h w i p ra t
h
m
o n w o m ot n
it ii t a partial hospitallution b m d available es part of t e m na health benefit b all
ht
e ae
h e tl
y
accountable heahh plant. 1 migftt n w b u n o ea iy hospitalised if it weren't fbr the
o e n e e s rl
availability of partial hospitalization servioes. Instead, partial hospitaliiation hu enabled m to
e
ftmction I d p n e ty in t e c m u iy It is m u d na dn thai a drafting error m y leave
n e e d nl
h o m nt .
y n e tn l g
a
t e availability of partial hospitalitation servioa t t e disatdon of individual health puns.
h
o h
I u g you to correct this error befon t efinallegisladon is released to Congreu.
re
h
Sincerely,
ba Mageaner/Mn. ainton
The White Houie
W a i go , D.C. 20500
a hn t n
Dear Ira Magaziner/Mrs. Clinton:
•eeounawefealihpJui J niSl^^^IiImLii^I? K
< ^f"^ li«llh benefit b all
y
Sincerely,
l£d 0TT«
••ON 131
••QI
8t>:18 MJ 00.-02-Nbr
�In Mijiziner/Mn. Clinton
Th» White HOtt*
Wiahtofton. O.C. 20500
Dear Ira Mapitaer/Mri. Clinton:
0
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me sva»«wui»j «• r
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, d
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•
Sincerely
Ira Mafadner/Mrs. Clinton
The White Houie
Wuhin|ton, D.C. 20500
Dear In Magaalner/Mn. Clinton:
At e patient w o Is receiving partial hoipitaliaiion services, I w n you to k o h w i p n n
h
at
nw o m o a t
it is that partial hospitalization b m d available as pan of t e m na health benefit b sll
e ae
h e tl
y
accountable health plans. 1 mg t n w b unncooasaiily hospitalized if it wenn't for t e
ih o e
h
availability of panial hospitalization servioes. Instead, petiial hospitalization has mbteditieio
ftmctiontodepemJcmlyin the c m u iy It Is m u d na dn that a drafting enor m y le
o m nt .
y n e tn l g
a
the availabiUty of panial hospitalization services to t e discretion of Individual health pirn*.
h
legisladon is nleased to Congress.
S£d 0TT»
:ON 131
-.QI
B f - W tad 00.-02-Nyr
�In Mtguiner/Mn. Clinton
Thi White H m
o o
WuWniton, D.C. 20500
Deer In Maftilner/Mn. Clinton:
Ai e petient w o is nceiving partial hospltaliation services, I w n you to k o h w i p n n
h
at
nw o m o a t
it li t a panial hoipitaliution b m d available u pan of t e m na haalth benefit by all
ht
e ae
h e tl
accountable health plans. I mg t n w b u n o aa iy hospltallad If it weren'ttorthe
i h o e n e o s rl
availability of panial hospitalization services. Instead, panial hospitaliadon hu enabled m to
e
function Independently in t e c m u iy It is m u d m n i g that a dnfttng error m y leave
h o m nt .
y n e a dn
a
t e availability of panial hospitalisation services t t e discretion of individual health plani.
h
o h
I u g you to conect this error before t efinallegisladon is nleased to Congnu.
re
h
Sincerelv.
In Magaziner/Mn. Clinton
The White H u e
oa
W a i go , D.C. 20500
a hn t n
Dear In Magasiner/Mn. Clinton:
accountable health plans I mMir ™ kT^ •« P« of the menial health benefit bv a
mmmmmm
Sineenly
^^
:ai
6^:10 I y j 00.-02-Nbr
�bl Maf*ziner/Mn. Clinton
Tht White H u
ow
WuMniton, D.C. 20500
Dev Ire Magadner/Mn. Clinton;
Ai a patient w o Is receiving partial hospitalization services, I w n you to k o h w i p ra t
h
et
n w o m ot n
it is that partial hospltaliution b m d evtllable es part of t e m na henlth benefit b all
e ae
h e tl
y
accountable health plana. I mg t n w b unneeessarily hospitalized if it werea't for the
ih o e
availability of partial hospitalization scrvioea. Instead, partial hospitalization hu nabled m to
e
function independently in t e c m u iy It is m u d na dn that a drafting enor m y leave
h o m nt .
y n e tn l g
a
the availability of partial hospitalization services to t e discretion of Individual health pans,
h
T u g you to correct this error beftm t efinallegislation is nleased to Congnu.
re
h
Sincerel
ba Magaziner/Mn. ainton
lhe White HOuu
W W go . D.C. 20500
u ntn
Dear In Magaziner/Mrs. Clinton:
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Hit White H m
o e
Wuhlniton, D.C. 20500
Dear In Maguiner/Mn. Clinton:
At a patient w o is nceiving panial hospitalization itfvleec, I w n you to k o h w i p ra t
h
et
nw o m ot n
it is t a partial hospltaliution b m d avaflible u pert of t e m na health benefit b ell
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h
ivaibbility of partial hospitalization servioes. Instead, partial hospitalization hu enabled m to
e
flmction Independently in t e c m u iy It is m u d na dn that a drafting enor m y leave
h o m nt .
y n e tn l g
a
the availabiUty of panial hospitalization services to t e discretion of Individual health plana.
h
I u g you to oorreet this error before thefinallegislation is nleased to Congnu.
re
Sincerely
In Magaziner/Mrs. ainton
lhe White House
W a i go , D.C. 20500
a hn t n
Dear In Magaziner/Mn. Clinton:
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y
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Tha White Kduae
Wuhington, D.C. 20500
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At a petient w o is nceiving partial hospltaliation services, I w n you to k o h w i p ra t
h
at
n w o m ot n
it is t a paiHil hoipitaliution b m d available as part of t e m na haalth benefit b all
ht
e ae
h e tl
y
a e u t be health plans. I mg t n w b unneoeisarily hospitalised If It weren't for the
e o na l
ih o e
availability of partial hospitaliadon aervices. Instead, partial hospitallaiion hu enabled m to
e
ftmction independently in t e c m u iy It Is m u d m n i g that a drafting error m y leave
h o m nt .
y n e a dn
a
the availability of partial hospitalization services to the discretion of individual health plans.
I u g you to correct this error before t efinallegisladon is nleased to Congnu.
re
h
Sineenly,
In Magaziner/Mn. Clinton
The White H ue
os
W a i go , O.C. 20500
a hn t n
Dear la Magasiner/Mn. Clinton:
1
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Sincerely
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Northridge Letters] [loose]
Creator
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
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2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Reproduction-Reference
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3/16/2015
Source
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42-t-12092971-20060885F-Seg3-037-010-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/82dd8f4e3e41d65817ca3723e328bbe3.pdf
bc0a7d77f87c673e7b8cb5afacb60bec
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1969
OA/ID Number:
FolderlD:
Folder Title:
[National Health Care Policy] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
9
3
�A
NATIONAL HEALTH CARE POLICY
by
George W Ranta
.
Master o f Public A f f a i r s
A Research Report
Submitted i n P a r t i a l Fulfillment
of the Requirements f o r the Master of Science Degree
Department of Ccmmunity Development
i n the Graduate School
Southern I l l i n o i s University
at Carbondale
May 1992
�Abstract
The purpose of t h i s paper i s to provide an understanding of modem
health care i n the United States so that a comprehensive national policy
can be implemented.
I t seeks to achieve such an understanding by describ-
ing the major participants involved i n health care, namely, physicians,
hospitals, the consuming public, the insurance industry and health
maintenance organizations and health care regulators.
Further, i t reviews serious issues which affect health such as
c h i l d immunizations, infant mortality and morbidity and the AIDS epidemic.
Deterrents to a national policy are reviewed such as the aged Social
Security recipients; the effectivenss of national health insurance on
the poor i n other countries,and the reaction of small businesses t o
health care reform.
Finally, i t reviews recent proposals and makes policy reconmendations
such as using the present Medicare program as a vehicle t o improve the
a v a i l a b i l i t y of health care to a l l the citizens. I t explains the nature
of ccmpetition and the need to research outcomes and seek system s i m p l i f i cation and standarization and to reduce the number of participating
hospitals.
The implementation of a national health care policy w i l l provide
many positive contributions to ccmmunity development programs. At the
present time, many r u r a l and inner-city comnunities and even states
lack health care resources which impede t h e i r growth and cause some
camunities to decline.
these communities.
A good quality of l i f e i s not available i n
By providing improved access through a national
health care system, new avenues f o r r e v i t a l i z a t i o n of many r u r a l ,
i
�medically underserved ccmnunities can occur.
ccmmunity development opportunities.
la
This w i l l present many
�a.
Regional Health Planning Department.
The department shall
prepare a Regional Health Plan which shall define:
�Table of Contents
Introduction
Understanding Health Care Providers
. - 17
2
The Medical Practitioner
2
7
The Hospital
7
11
The Consuming Public
11
13
The Insurance Industry and Health
Maintenance Organizations
13
16
Health Care Regulators
16
Conclusion
17
Serious Health Care Issues
17 - 33
Child Irrmunization
Recomnendation - 1
17 - 20
Infant Mortality and Morbidity
Recommendation - 2
20 - 28
AIDS Epidemic
Recomnendation - 3
29 - 33
34 - 37
Policy Considerations
Social Security
34 - 35
Effectiveness of National Health Insurance
Small Business and Health Care Reform
36
36 - 37
Approaches t o a National Health Policy
37 - 51
Canada's Universal Health Insurance
37 - 41
Medicare Expansion
41 - 44
Universal Health Care Act of 1991
44 - 48
The President's Proposal
48 - 51
l i
�Additional Health Care Policy Recommendations
52 - 81
Reccrrmendation - 4 - Retain Present Medicare
52 - 54
Recui 1 lenda t ion - 5 - Provide Incremental Change
1
54 - 55
Reccmmendation - 6 - Simplification
55 - 56
Recomnendat ion - 7 - Contractual Services
57 - 65
Recarmendation - 8 - Medical Education Policy
66 - 71
Reccmmendat ion - 9 - Regional Structure
72 - 73
73
9a- Research - Medical Outccmes
9b- Fraud and Abuse
73 - 74
9c- Provider Contracts
74 - 75
9d- Legislative Liaison
75
9e- P r i o r i t y f o r Health Fducation
75
9f- Competitiveness
75 - 76
9g- Administrative Simplification
76
9h- Quality Assurance
76
Reccrnmenda t ion -10 - Medicare Reform
77 - 81
10a- Depreciation
77 - 78
10b- Operations
78 - 79
10c- Arbitration
lOd- Fraud and Abuse
lOe- Co-payment and Deductibles
lOf- Skilled Nursing Services
79
79 - 80
80
80 - 81
lOg- Insurance Ccripanies
81
lOh- Rural Support
81
Implementing the National Health Care Policy
Surrmary
82 - 87
88
�Introduction
During the Spring Term, 1990, a three member panel i n the Corrmunity
Development Department at Southern I l l i n o i s University - Carbondale prepared a report t i t l e d "National Health Care Policy" which was submitted
to leading members of Congress, the Department of Health and Human Services,
the Congressional Budget Office and other governmental offices involved
i n health care policy.
Positive reponses to the report were received from Gail R. Wilensky,
Administrator, Health Care Financing Administration (H.C.F.A.), Martin
M. Gerry, Assistant Secretary f o r Planning and Evaluation, Department
of Health and Human Services, and David Nexon, Director, Health Office,
Committee on Labor and Human Resources, United States Senate.
Both Dr. Wilensky and Mr. Gerry referred the report to task forces
studying how to strengthen the health care delivery system and make i t
more respnsive to the needs of the poor.
Several of the recommendations of the Ccmmunity Development panel
are s i m i l i a r to those subsequently adopted administratively by Secretary
Sullivan, Department of Health and Human Services.
The concern of the author of this updated report i s that the leading
policy makers are preparing health care i n i t i a t i v e s which could accelerate
medical care i n f l a t i o n without taking the required steps to standardize,
simplify and reform the present complex and duplicative system.
I t is
for this reason that the author, who has over t h i r t y years of handson administrative experience i n health care, has prepared this report.
�1. Understanding Health Care Providers
Since Medicare was approved f o r the elderly i n 1966, there have
been repeated e f f o r t s by a l l subsequent Administrations to contain cost
increases through various methods. The only p a r t i a l l y successful method
was the Diagnosis Related Groups (D.R.G.s) whichEEduced the access and
the lengths of stay i n hospitals.
However, this method shifted program
costs from in-patient care to out-patient care and increased private
and business health care unit costs due to decreased u t i l i z a t i o n of hospitals.
One of the reasons f o r the f a i l u r e to contain health care cost i n creases was due to a misunderstanding of the health care industry, particul a r l y competition, by the policy-makers and the regulators.
Health care
policy makers equated health care comptetition with the i n d u s t r i a l model
which doesn't exist i n i t s pure form i n the health care industry.
The following sections w i l l describe some of the characteristics
of the health care industry, the consuming public, the insurance industry
and the health care regulators as they relate to cost increases. This
should help to create a better understanding.
The Medical Practitioner
Physicians and specialists receive eleven or more years of s c i e n t i f i c
training i n our colleges, universities and hospitals before they can
s t a r t their professional practice.
This i s not only a very expensive
education to the individual and to society, but i t defers significant
earnings and often leaves the student heavily i n debt. The four year
�costs of sane private medical education i s now as much as $100,000 and
the typical new doctor graduates with an average debt of about $46,000."''
The practical t r a i n i n g for the new physician has been provided by
some of the best hospitals i n the country which have the latest medical
equipment and specialty services. When new physicians assume medical
practice i n other hospital settings including r u r a l areas, they expect
the same level of equipment and the same standarcte of care.
During t r a i n i n g , physicians realize the ccmplexity of medicine and
the consequences of f a i l u r e to assimilate knowledge and apply i t correctly.
They beccme f e a r f u l of consequences which leads them to increased
specialization and to defensive medicine.
as a specialist or a surgeon.
Seme physicians prefer practice
They can eam more than $300,000 a year
2
ccmpared to the average family practitioner's income of $96,000.
"Only
30 percent of the nation's 600,000-plus doctors are i n primary care.
In Great B r i t a i n , by contrast, the figure i s 70 percent.
Perhaps the
disproportionate nunber of U.S. doctors engaged i n high-paying specialties explains i n part why health care soaks up 11 percent of the U.S.
gross national product but only 6 percent of Britain's.""
3
Soon a f t e r graduation, the physician often has to become a businessman whether i t i s i n solo practice, group practice or a large c l i n i c
practice.
I n these practice situations they have to adhere to the patterns
established by t h e i r peers or t h e i r employers.
In these situations they
have to be concerned with personnel, benefit plans, h i r i n g , promotion,
discharge; purchase of medical and other supplies; building maintenance;
depreciation; claim processing; supervision; paying for l i a b i l i t y and
�other insurance; compensation for therselves and a return on t h e i r investment
The physician's own compensation levels can be very f l e x i b l e .
These
can depend on such factors as the affluence of the corrmunity, the degree
of competition, and personal expectations regarding income and social standing.
I f the practice has a high volume of private patients, the physician can
adopt r e s t r i c t i v e policies such as refusing to accept new Medicaid patients;
refusing Medicaid obstetric patients and not accepting Medicare patients.
The physician can supplement his income by providing a variety of
ancillary services such as laboratory, radiology, marrmography, ultrasound,
physical therapy, and respiratory therapy
in competition with local
hospitals, other physician groups and larger c l i n i c s .
He has the advant-
age of being able to direct his patients to these services whether they
are i n his o f f i c e setting or at outside f a c i l i t i e s with whom he has agreements .
In a recent Florida study, i t was reported that doctors owned 93
percent of the diagnostic-imaging centers, 60 percent of the c l i n i c a l
laboratories and 38 percent of the physical therapy and r e h a b i l i t a t i o n
centers. Miami doctors prescribe MRI scans (cost $800) twice as often
as doctors i n Baltimore where few own the equipment. Laboratory charges
4
are more than twice as high at f a c i l i t i e s owned by doctors.
The U.S. Department of Health and Human Services estimates that 1
in 4 medical testing laboratories i s now owned wholly or i n part by doctors
who refer t h e i r own patients.
Unfortunately, surveys show that few con-
sumers w i l l defy t h e i r doctor or shop f o r lower laboratory prices. The
Florida study showed that the average patient paid $46.22 at doctor owned
laboratories ccmpared with $27.85 at independent laboratories.
5
�Doctors have the further advantage over hospitals i n that t h e i r personnel
don't have to have the same qualifications as hospital personnel as they
work under his personal supervision. Additionally, hospital personnel
have to be available 24 hours per day, seven days per week even when the
volume i s low.
The physician's motivation depends on his social conscience rather
than true competition.
Because the t y p i c a l physician offers such a variety
of services,he can maintain, for example, low o f f i c e v i s i t charges and
high ancillary service charges which make comparisons d i f f i c u l t .
An I l l i n o i s example of charges was a requirement by the Cost Containment
Council that a l l hospitals prcminently post t h e i r most common charges
so that prospective patients can see them. This became a subject of local
interest for several months after which i t was ignored.
I f the physician joins a Health Maintenance Organization (H.M.O.)
or a Preferred Provider Organiztion (P.P.O.) which requires a discount
on fees, he can raise his fees to non-participants so as to maintain his
profitability.
At the present time. Health Maintenance Organizations are gaining
members; there are 38.4 m i l l i o n members even though their
i s declining.
profitability
Their income i s expected to f a l l i n 1992 from the $850
6
m i l l i o n i n 1991 to $350 m i l l i o n despite a 14 percent increase i n premiums.
Another concern of the private practice physician i s to maintain
effective credit and collection e f f o r t s i n his office practice. He i s
in a somewhat better position i n this area than the hospital as his t o t a l
charges are less than the hospital's and the patient wants to retain their
personal physician, whereas, the patient doesn't expect to be hospitalized
�in the immediate future.
can't be repossessed.
Good health i s not a tangible cccmiodity, i t
The patient can ignore the b i l l s , change doctors
or go to the hospital emergency room.
Medical practice i s not t r u l y ccmpetitive except i n very limited
circumstances.
Physicians are selected by word-of-mouth, community
reputation, family t r a d i t i o n , a good personality, and good bedside manners.
Likewise, patients change physicians when they move away from the community,
when there i s a perceived lack of good care; lack of personal attention;
perceived lack of knowledge of modem medicine or the failure of the patient
to get well quickly or i f a new physician cones to the corrmunity who
these expectations.
fulfills
Seldom, i f ever, do patients change physicians because
of high charges.
There i s a growing body of research which shows that patient expectations, physician's hunches, and local medical custom are more l i k e l y
to influence a physician's practice pattern than empirical evidence of
a treatment's effectiveness. Landmark research by Dr. John H. Wennberg
of Dartmouth Medical School, for example, found that Boston residents
were twice as l i k e l y as people i n New Haven to undergo caroted endarterectomies, a $9,000 procedure that cuts f a t t y deposits from neck arteries.
Yet there was no difference i n how patients i n the two c i t i e s fared i n
the long term.
7
Exceptions to physician selections are the H M O s and the P.P.O.s
...
where selection i s limited to physicians participating i n the plan.
Physicians employed by governmental units, who do not have administrat i v e responsibilities, do not have to be businessmen. Others are
�physicians employed by the Veterans Administration, the m i l i t a r y , hospitals,
mental health and public health departments and other s i m i l i a r health
organizations.
Their ccmpensation i s generally at a lower level.
According to one study, the mean physician income i n the United States
i s $146,200 while i n Ontario i t i s $115,000 (U.S. dollars).
of people per doctor i n the U.S.
The number
g
i s 488; i n Canada i t i s 463.
Another important responsibility of the physician i s to provide
a high quality of care.
There are many checks and balances on the quality.
Physicians must constantly update t h e i r medical knowledge so as to be
current i n their profession.
This i s required by specialty organizations;
by hospitals with which the physician i s a f f i l i a t e d and sometimes by
governmental organizations.
In addition, their peers expect them to
have current knowledge as their c l i n i c s could be adversely effected by
lawsuits and lack of public confidence i n their professional a b i l i t i e s .
From the above discussion, i t can be seen that the physician i s
an important element i n conventional health care.
The discussion w i l l
now turn to another important element.
The Hospital
The hospital i s a unique i n s t i t u t i o n ; i t i s both a business and
a corrmunity social service.
I t serves both the indigent and those who
are able to pay f o r services.
The majority of the 6,700 hospitals i n the United States are notf o r - p r o f i t i n s t i t u t i o n s govened by local citizens.
They generally have
a very snail administrative s t a f f ccmposed of the chief executive o f f i c e r ,
the assistant administrator, the chief financial o f f i c e r , the personnel
�director; the director of nurses and the purchasing agent. The department heads are usually working supervisors who provide direct patient
care or other d i r e c t services.
They do some administrative work.
The chief executive o f f i c e r usually has a master's degree i n hospital
administration or i n business administration.
Typically, they have worked
for a number of years i n other departments of the hospital or i n other
hospitals before beccming the chief executive o f f i c e r .
Unlike schools,
colleges, universities and other public i n s t i t u t i o n s , the hospital i s
open 24 hours a day, 365 days per year. The chief executive o f f i c e r
is responsible f o r i t s operation.
When the Medicare program started, a number of optimistic f i n a n c i a l
projections were made as to the cost of the program. However, i t soon
became apparent that too much had been promised to the recipients. Cost
reduction programs began a f t e r the Johnson Administration.
These were,
for the most part, largely ineffective as they r e l i e d heavily on paperwork control rather than reduction of benefits or the a v a i l a b i l i t y of
service.
The laws were directed at hospitals rather than physicians.
The hospitals had to become the enforcement agents of the new laws.
I t wasn't u n t i l the Diagnosis Related Groups (D.R.G.s) that the
cost reduction program became effective for the Medicare program. I t s
effect was to s h i f t more of the t o t a l health care cost to the private
sector and the individual patients.
This s h i f t of payment responsibility was traumatic to the hospitals.
I t caused a number of small, r u r a l hospitals to close.
At the same time
that this s h i f t was occurring, the nation was changing from a manufacturing
�and agriculturaleconcmy. to a lower paid service economy.
The Diagnosis Related Groups achieved t h i s s h i f t by establishing
very s t r i c t c r i t e r i a for hospital admission and prescribing average lengths
of stay for each medical condition.
I f the patient exceeded these average
lengths of stay, there were serious financial penalties which effectively
reduced the hospitalization period.
During the 1980s there was an increase i n qu&lity-of-care consciousness.
This was brought on by both the Medicare program and the Joint Comiission
of Health Care Organizations.
expectations.
These programs increased patient outccme
I f patient outcome expectations were not met, then a lawsuit
sometimes occurred.
This was a p a r t i c u l a r l y sad issue i n poor r u r a l
comnunities where physicians discontinued obstetric services because
of the r i s k of a lawsuit.
Lawsuits are d i f f i c u l t for hosptal s t a f f s
many years t o resolve - up t o f i v e years.
because they take so
During this time a great deal
of change occurs with employees moving and health care changing.
Juries
tend to apply current standards and expectations to events which occurred
f i v e years previously.
Hospitals responded byenpJoyLigquality assurance coordinators; s t a f f i n g
entire nursing units with registered nurses compared to the previous
mix of registered nurses, practical nurses and nurses'aides; and adding
sophisticated patient monitoring systems. At the same time that the
demand for professional nurses went up there was a reduction i n federal
funds for nursing education.
The result was a shortage of nurses and
an increase i n t h e i r salaries.
One result of potential malpractice claims was the need f o r detailed
�10
documentation of a l l medical events.
Every test, every medication ordered,
every v i s i t and every physician action was recorded i n minute d e t a i l .
When the emphasis shifted from inpatient to outpatient care, hospitals
had to s h i f t resources and s t a f f i n order to survive.
They sought a f f i l i a -
tions with large hospitals i n major c i t i e s ; expanded specialty services;
started new c l i n i c s ; became involved i n home health; marrmography and
ccmmunity services.
Home health services which include:, medical suppliers has seen exceptional financial growth recently.
Earnings i n the $23 b i l l i o n dollar
industry are expected to rise by 25 percent i n 1992.
9
provide services such as intravenous therapy • • .
These ccmpanies
Since Medicare and Medicaid paid less than the cost of care and
since the 37.4 m i l l i o n Americans without health insurance s t i l l needed
basic health care and couldn't pay f o r i t , the cost of these services
had to be paid by those who were insured or who were private paying
patients.
Charges were increased s i g n i f i c a n t l y to offset these losses.
Insurance and private patients were supporting the uninsured, the underinsured and the governmental patients.
Charges for employer-sponsored
plans rose, f o r example, by 20.4 percent i n 1989 compared to the previous
10
year.
According to a recent study, "People without health or medical insurance
s t i l l receive 60 percent as much health care as everyone else i n the
nation..."
11
A major concern i n many ccrmunities i s the r i s i n g number of uninsured
which threatens treatment for everyone:
demand f o r uncompensated care
is alreadyforeing trauma-care units and emergency rooms to close, leaving
�11
1
the r i c h as well as the poor without service. ^
Another factor Effecting price increases i s the growth of the very
elderly i n t h i s country.
"Almost 30 percent of a l l Medicare expenditures
are devoted to the 6 percent of the enrollees who are i n the last year
of l i f e . "
1 3
The next section discusses the recipient of health care - the patient.
The Consuming Public
During the past several decades, Americans have become increasingly
absorbed i n modem technology.
This applies to automobiles, airplanes,
computers, television sets, camcorders, and health care.
Yet, when modem
technology i s applied to the human body, the results are not always perfect
since medicine i s an a r t rather than an exact science.
Despite the recognition
of i t s l i m i t a t i o n s , the search continues f o r new technology to sustain
life.
Due to medical s t a f f requests, fear of lawsuits, public expectations
and competitive pressures, hospitals frequently replace expensive laboratory and radiological equipment with newer models. Patients equate excellent
health care with the a v a i l a b i l i t y of high technological equipment which
is costly.
At the same time that this revolutaon; i n technology was occurring,
Americans were working i n high paid industries with employer-paid health
care plans which took care of a l l t h e i r health care needs. When the
gradual change occurred frcm a manufacturing economy to a service economy
with i t s lower salaries and lack of health care benefits, the patients,
who were accustomed
to these benefits, continued to expect the same
level of technological care without having to pay for i t d i r e c t l y .
�12
In a very interesting a r t i c l e , "Don't Look f o r Better Health from
National Health Insurance," Victor Fuchs, professor of economics at Stanford
University grouped those without insurance into six categories:
1.
The poor. The largestgroup of the uninsured consists of individuals
and families whose low income makes i t unfeasible for them to acquire
insurance, either on their own or as a condition of employment.
About 20% of the uninsured have no connection with the workforce,
but the rest are either employed or are dependents of employed persons.
The Health Insurance Association of America, the principal association
of private insurers, estimates that 31% of uninsured workers earned
less than $10,000 i n 1989; another estimate puts the figure at 63%.
In any case, i t i s clear that the great majority of uninsured workers
cannot afford to give up a substantial fraction of t h e i r wages i n
order to obtain health insurance.
The frequently heard explanation, "small employers cannot afford
health insurance" i s misleading. Employers do not bear the cost
of insurance; workers do, i n the form of lower wages. Lawyers,
accountants and other highly paid professionals organized i n small
firms usually have health insurance. A more accurate description
of the problem would be, "many workers i n small firms cannot afford
health insurance."
2.
The sick and disabled. Many men and women who are not poor are
s t i l l unable to afford health insurance because they have special
health problems and therefore face very high premiums or are excluded
from coverage e n t i r e l y .
3.
The " d i f f i c u l t . " Some people are neither poor nor sick, but have
d i f f i c u l t y i n obtaining insurance at average premiums. They may
be self-employed or out of the labor force entirely. In order to
reach and service such individuals, insurance companies incur abnormall y high sales and administrative costs.
4.
Low users. Some people do not expect to use much medical care.
They may be i n particularly good health; they may be Christian Scient i s t s . For them, health insurance i s a bad buy unless they can acquire
i t at below-average premiums.
5.
Gamblers. Most people buy health insurance i n part because they
are r i s k averse. They would rather pay a fixed, known premium than
run the r i s k of a huge expense i n event of a serious i l l n e s s . But
not everyone i s r i s k averse: The gambler says, " I ' d rather save
the premium and take my chances."
6.
Free-riders. The f i n a l catergory consists of individuals who remain
uninsured because they believe that i f they do get sick, they w i l l
�13
14
get care anyway, with somebody else picking up the b i l l .
I t i s interesting to note that 75 percent of the 1.3 m i l l i o n who
were added t o the l i s t of uninsured between 1989 and 1990 had $25,000
or more i n family income. Of this pool o f new uninsured nearly onet h i r d had family incomes of more than $50,000. Fewer than 9 percent
lived below the federal poverty l e v e l .
at 40 m i l l i o n .
15
Estimates place the uninsured
,
Based on experience as a hospital administrator i t appears that
a very large percentage of out-patients and emergency room patients do
not pay the small deductible or the co-insurance payments on the balance
due when the patients are under-insured.
There are many who have repeat
v i s i t s by a l l family members who make no e f f o r t to pay even a small portion
of the b i l l .
Moreover, payments f o r services t o automobile accident victims are
d i f f i c u l t to collect even i f the driver has insurance; sometimes i t takes
years before payment i s received. S i m i l i a r l y , many states are months
behind i n t h e i r payment obligations f o r Medicaid patients.
The next section deals with the insurance industry and with health
maintenance organizations as they relate t o cost increases.
The Insurance Industry and Health Maintenance Organizations.
The smaller insurance ccmpanies primarily serve as claim processing
firms.
They pay the hospital and physicians' claim according t o the
policy l i m i t s .
The ccmpanies range frcm those that are highly ethical to
those that are questionable. Sometimes policies are sold with high deductibles, or high payments f o r pre-existing conditions.
The insurance firms
that make very small payments on claims present many collection problems
�14
for
patients who thought they were f u l l y covered by their policies.
nit
The larger insurance companies also provide, simple "indem y"
reimbursement.
fraudulent.
Insurers unquestioningly paid any b i l l that was not
I n the early eighties company health plans began requiring
p r i o r approval of hospital admissions, except f o r emergencies.
coriputerized. systems were developed which screened
claims.
New
hospital and physician
This system of u t i l i z a t i o n review could chop as much as 5 percent
to 8 percent from a company's health costs. This seemed to be a posit i v e factor; however, i t could be only a pause i n medical i n f l a t i o n .
Many of these plans sought to create competition and thus lower
medical i n f l a t i o n .
However, there are many doubters among physicians.
" I t ' s foolish to expect to control health care costs through competition,"
declares Dr. Arnold S. Relman, editor of the New England Journal of
Medicine.
The problem, he says, i s that the suppliers of health services
- doctors - are uniquely able to influence demand. The best way to
get a grip on costs, Relman argues, i s to develop improved "outcomes"
data that t e l l which operations and tests work best and which are wasteful
and risky.
With that kind of information, the medical system w i l l be
able to heal more e f f i c i e n t l y and safely than now."^
Health maintenance organizations have become increasingly popular
as an alternative to t r a d i t i o n a l insurance. Studies indicate, however,
that when insurers use co-payments to discourage unnecessary doctor
v i s i t s , they may be keeping people who need treatment from using health
care especially the poor.
The early objective of the H O was to control expensive claims
Ms
by encouraging treatment i n the early stages of an i l l n e s s .
This objective
�15
changed when medical i n f l a t i o n grew faster than general i n f l a t i o n .
For example, when the cost of an o f f i c e v i s i t was $15.00 or less,
47 percent of those with minor symptoms sought medical help. A national
survey defined "minor symptoms" as an upset stomach for 24 hours, stuffy
nose or sneezing f o r two weeks or more or a sore throat or cold f o r more
than three days.
About one-third did not use a doctor's services when
they suffered "serious symptoms" and the fee for«an o f f i c e v i s i t was
$15.00 or less.
More than one-half refused to see a doctor when the
fee was $30 or more and they suffered such symptoms. The "serious symtoms" included shortness of breath during l i g h t exercise or l i g h t work;
chest pain during exercise; loss of consciousness; abnormal breathing
or weight loss of 10 or more pounds without a change of d i e t .
1 7
The results of managed care systems operated by large insurance
companies are mixed.
For example, only 29 percent of employers surveyed
by A. Foster Higgins and Company, an employee benefits firm, say that
their preferred provider organizations helped to control their health
18
care costs.
Despite t h i s dissatisfaction, managed care plans are be-
ccming increasingly popular with major employers.
Many ccmpanies, seeking to reduce health care costs, participate
i n plans such as a national data bank which was set up by Dr. Paul Ellwood's
Interstudy, a Minneapolis think tank, which tracks the treatments of
millions of patients.
These employers w i l l evaluate these data i n order
19
to choose the best providers.
The problem with such a plan, i f i t i s related to patient charges,
is the economy. I f , for example, hospitals i n Ypsilanti, Michigan
�16
were " e f f i c i e n t " low cost providers before the proposed General Motors
plant closing, they would become "less e f f i c i e n t " hospitals a f t e r the
closing due t o charge s h i f t i n g because there would be thousands of additiona l people without adequate health insurance who would s t i l l require care.
Such scenarious could occur a l l over the United States.
I f i t i s only
related to the quality of care, this could also change due to changing
technology, changing medical s t a f f members and changing patients and
diagnostic mix. For example, i f there were many homeless people or welfare
recipients with multiple health problems. This type of analysis would
only make inner c i t y hospitals and health care f a c i l i t i e s seem worse.
Health Care Regulators
The state and federal regulators have added greatly t o the cost
of medical care through detailed attempts to control costs and the quality
of care.
An example i s the Diagnosis Related Groups (DRGs) which has
been previously described.
This system had specific payments to both
r u r a l and metropolitan hospitals which paid hospitals for 468 illnesses
and conditions. These condition determinations were made following physician study.
The problem with the system f o r those hospitals that had a
high percentage of patients who were the f r a g i l e very elderly and had
multiple health problems which required treatment beside the single diagnosed
disease or condition; the hospitals we're not paid- for the added care.
Another concern was the c r i t e r i a f o r admission which required multiple
measurements of severity before the elderly could be admitted into the
hospital.
This also hurt the very elderly whose resistance t o disease
was very low.
�17
Conclusion
The preceding section dealt with some of the issues which were respnsible for the high medical i n f l a t i o n which has occurred during the years
since Medicare was enacted i n 1966.
The next section w i l l deal with
seme of the major concerns of the 1990s.
2. Serious Health Care Issues
Child Immunization
The United States, according to D.A. Henderson of Johns Hopkins
University, a world irrmunization specialist, i s probably the worst i n
vaccination rates by age 2 i n the Western Hemisphere, save f o r H a i t i
and Bolivia, two impoverished countries.
On c h i l d immunization, we beat
Uganda on a world-wide basis.
The U.S. polio vaccination rate f o r children of color at age 1 i s
behind that of Mongolia and Botswana. According to a recent a r t i c l e :
a decade ago, only 20 percent of children i n developing nations
received vaccinations by age 1 f o r measles, mumps, typhoid, polio,
diphtheria and pertussis. After a massive campaign, the World Health
Organization announced last f a l l i t had reached 80 percent rates
of immunization. As a result, i t said, three m i l l i o n lives were
saved l a s t year.
War-tom E l Salvador had overall coverage of 76 percent. Warravaged Iran had 90 percent coverage of measles. Totalitarian China
is at 95 percent. P o l i t i c a l l y turbulent Chile i s at 98 percent.
In the United States, we wait u n t i l children enter school,
at about age 5, before we immunize them. That has allowed measles
to surge again. I n 1983, there were 1,500 cases of measles. I n
1991, there were nearly 28,000 cases. Nearly half the neasles cases
h i t children under 5. The death t o l l f o r the last two years has
crossed 100.
In Hartord and New Haven, i n Connecticut, only 53 percent of
2-year-olds are irrmunized. Only 43 and 46 percent of early-school-age
children i n Maimi and Houston received measles vaccination by age 2.
�18
A san Diego survey found that only 20 percent of African-American,
35 percent of Latino and 37 percent of Asian-American kindergarten
children were f u l l y immunized by aged 2. In New York state, J e r i
Bunn, iirmunization program manager, has said that only 29 percent
of babies are minimally immunized by age 1.
The problem according to David Smith, head of primary care
at Dallas' Parkland Memorial Hospital is...shortages, lack of health
insurance, long lines and s t a f f shortages at c l i n i c s to complicated
regulations that bar quick, walk-in shots.
Around the world, WHO i s not waiting f o r p i l o t programs such
as proposed by President Bush f o r 6 c i t i e s . , WHO wants 90 percent
coverage by the year 2000. To achieve the goal, the world must
spend $20 b i l l i o n a year. WHO says t t ^ t this i s what the world
spends on the m i l i t a r y every 10 days.
The author of t h i s report believes that childhood immunization should
be one of the top p r i o r i t i e s of the country i n the 1990s.
Reccrrmenda t ion
1.
I t i s reccmmended that early c h i l d inmunizations achieve the 90
percent level recorrmended by the World Health Organization (WHO)
by the year 2000. This i s to be achieved by using the Medicare
payment system f o r services rendered by physicians and health care
personnel.
Rationale
I t i s suggested that Medicare-C applications be prepared f o r infants
at the same time b i r t h certificates are prepared.
An irrmunization schedule
and authorization form shall be part of the process.
A copy of the schedule
and authorization shall be f i l e d with the Medicare intermediary handling
immunization claims. A copy shall be f i l e d with local, county and state
authorities.
The witnessed authorization shall provide f o r permission f o r
�19
for immunization and contain an agreement to accept binding a r b i t r a t i o n
i f there are l i a b i l i t y questions provided, of course, that binding a r b i t r a tion has been enacted into federal law or state law.
Immunizations can be provided at physician's offices, c l i n i c s , schoolbased medical c l i n i c s , corrmunity health centers, schools, health departments, hospital out-patient c l i n i c s , mobile health c l i n i c s , and other
accessible places.
The location and the schedule of the immunization sites shall be
published by l o c a l , county or state authorities.
Shots can also be provided
by family physicians at their offices as requested by the responsible
parents.
Resonsible parents may elect a l l of the series offered, parts or
none for t h e i r children.
They may also withdraw their authorization.
An important part of the application process shall be informed consent.
Educational material shall be provided at the time of the application.
Further material shall be submitted when the new Medicare-C card i s mailed
and annually u n t i l a l l immunization shot have been given. Additional
health education material shall be provided at the irrmunization sites
each time shots are given.
The Medicare-C credit card i s used at the immunization sites i n
order to expedite processing of charges by submitting them electronically
to the Medicare Intermediary who shall also prepare an annual p r o f i l e
on each c h i l d .
A ccmpleted p r o f i l e s h a l l be submitted to local school
authorities at the time of the childs admission to school.
These profiles
shall also be submitted to designated local health authorities f o r follow-
�20
up and public education.
Payments shall be made monthly to providers of services.
Central
purchasing of supplies and materials shall occur whenever possible.
Cost and payment p r o f i l e s shall be developed for the d i f f e r e n t
irrmunization settings. Renewable contracts shall be developed f o r each
type of setting.
There shall be periodic, perhaps annual evaluations,
of each setting.
These a c t i v i t i e s shall be conducted by designated author-
ities .
Congress shall annually appropriate funds for the imnunization program.
Infant Mortality and Morbidity
The well-being of America's children presents a paradox. To-day's
children are less well-off than those of 30 years ago i n important areas
of mental, physical and emotional well-being.
The children's rate of
suicide and homicide have risen and t h e i r school performance has f a l l e n
over the past three decades.
In the decade between 1960 and 1970 there was a f a l l i n test scores;
the doubling of teenage suicide and hcmicide rates; and the doubling
of births to unwed mothers. Yet, during t h i s same decade, "...purchases
of goods and services f o r children by government rose very rapidly, as
did real household income per child and the poverty rates of children
plurrmeted. "
2 1
Despite these econonic improvements i n the 1960's, there are many
preventable conditions such as low infant birthweight, and "shameful
infant and c h i l d mortality rates that place the U.S. behind other industialized countries ."
22
In contrast, Canada's infant mortality rate i s 80 percent o f that
�21
i n the United S t a t e s .
23
The infant mortality i n the U.S. i s 10.4 per
1,000 l i v e births compared to 7.9 per 1,000 i n Canada.
There i s considerable variation i n the a v a i l a b i l i t y of health care
according to Wright Edelman, president of the Children's Defense Fund.
She said that pregnant women i n r u r a l areas are more l i k e l y to go without
prenatal care, and r u r a l areas have one-third as many obstetrical specialists
per capita as other regions.
Another area of concern i s infant morbidity - there are 158,000
severly impaired crack babies being bom every year which adds $1.8
24
b i l l i o n to the health care costs.
Recommendat ion
2.
I t i s recarmended that prenatal and maternity benefits be made available.
This i s to be achieved by using the Medicare payment system
for services rendered by physicians and health care providers.
Rationale
The simple provision of prenatal and maternity benefity w i l l do
very l i t t l e to alleviate deep societal problems within the American family.
An example of the urgency of the problems with American families
cones frcm data frcm the state of I l l i n o i s , a large industrial state,
where the infant mortality rate improved 21 percent from 1980 t o 1989
when the rate dropped to 22.7 per 100,000 births and where the state
s t i l l ranked 46th i n keeping newborns alive at least a year.
S t a t i s t i c s provided i n the 1992 "Kids Count Data Book" prepared
by the Center f o r the Study of Social Policy and the Anne E. Casey
Federation note that i n I l l i n o i s :
�22
1.
Since 1979, the percent of I l l i n o i s children l i v i n g i n poverty
has increased 41 percent;
2.
births to single teens rose 16 percent over the decade. The proportion
of children l i v i n g i n single-parent families also rose 16 percent.
3.
The teen.violent death rate increased 23 percent.
Nationally, the study showed that 12.7 children i n America., or
one i n f i v e , were poor i n 1990.
This represents an increase of
2.7 m i l l i o n children, or 22 percent, since 1979.
"The study, using material from government s t a t i s t i c s , considers
nine factors, including b i r t h weight, violent deaths f o r teen-agers,
poverty rates, b i r t h s to unmarried teens, juvenile arrest rates and
children i n single-parent families.
Conditions continued to worsen i n a l l those areas, the report said.
There were two areas that showed improvement - fewer infant deaths
and fewer deaths among children ages 1-14.
One area was unchanged,
the percentage of children graduating from high school."
2 5
Another major problem i s the a b i l i t y of people to see a doctor,
taking into account such factors as economic status and health s t a t i s t i c s .
According to a study of 1990 s t a t i s t i c s by county, there were 857,146
people i n Mississippi or 33.3 percent of the population who had inadequate
access to outpatient health care. Other states who were close behind
included Louisiana with 1.3 m i l l i o n people, representing 31.8 percent
of the population; and West Virginia with 533,213 people, or 29.7 percent
of the population.
The basis of t h i s ccmparison i s one doctor to 1,800 patients.
Using these data, there are 42.8 million Americans who have inadequate
2
medical care. ^
�23
There i s growing recognition of the accessibility problem i n the
country.
The Advisory Council on Social Security, a panel appointed
in 1989 by Health and Human Services Secretay Louis Sullivan recorrmended:
Creation of school-based medical c l i n i c s and insurance f o r children,
the addition of 250 community health centers, and other access
reforms, a t a t o t a l cost of $3 b i l l i o n .
The President, i n his 1993 budget proposal included: $9,4 b i l l i o n
to combat infant mortality, up 18 percent; $684 m i l l i o n f o r cofimunity
health centers, up 15 percent; and $120 m i l l i o n for the National Health
Service Corp, which places doctors i n r u r a l and inner c i t y areas, up
no
19 percent.
Clearly, the problems of maternal and children's health requires
non-traditional solutions which should focus on restoring family values.
The f i r s t task i s to provide prenatal care.
This should be done
in a number o f settings so as to reach a l l pregnant women. The settings
may include t r a d i t i o n a l areas such as physician's offices and medical
c l i n i c s ; non-traditional areas such as hospital out-patient departments,
r u r a l medical c l i n i c s , canrmunity health centers, health departments,
mobile health vans and other approved settings.
National guidelines
shall be developed to assure uniform standards and quality health care.
The over-riding concern i s to reach the maximum number of pregnant
women.
The payment f o r these services would depend on unit cost at each
type of setting which would include routine laboratory and other tests.
Studies would have to be made f o r the d i f f e r e n t types of settings t o
determine unit cost.
I n n o t - f o r - p r o f i t or governmental settings, the
federal government would purchase the i n i t i a l equipnent and supplies.
�24
These l a t t e r units would have to establish reserve accounts i n order
to purchase replacement equipment and supplies. Nursing personnel and
other professionals without immediate physician direction, w i l l receive
medical direction from physicians at c i t y health departments, county
health departments, regional health departments or state health departments as i s appropriate to a particular state.
(This i s s i m i l i a r t o
the way ambulance services are being operated.). ^
d e v i a t i o n s
f r o m
established nursing c r i t e r i a are to be referred to family practitioners
or obstetricians according to pre-established guidelines and local
protocol.
Assessment guidelines f o r the sites where a physician i s
not t r a d i t i o n a l l y present include dietary assessments; social assessments
and referrals to welfare and wellness resources.
Personnel working
in these settings are to be trained i n a number of disciplines so that
they can function i n settings which have a very small s t a f f .
Contractual arrangements w i l l be made with a defined number of
sites so as to assure s u f f i c i e n t volume i n order to maintain a welltrained s t a f f and expertise i n prenatal care.
The Medicare-C plan w i l l pay the charges, for example, on 9 prenatal
v i s i t s including laboratory work on a normal pregnancy and an unlimited
number of v i s i t s i f i t i s a high r i s k pregnancy. A l l high r i s k pregnancies
w i l l be referred to obstetricians.
Charges w i l l be processed monthly
using the credit card system.
Regional Medicare authorities w i l l develop an obstetric services
regional plan so as to assure that hospital obstetric services are within a reasonable t r a v e l distance for the patient; that they provide a
high quality of care and that they have modem technical equipment and
�25
that they have s u f f i c i e n t patient volume i n order to maintain physician
and s t a f f competency.
The Diagnosis Related Groups w i l l be expanded to include a l l the
hospitalization-related obstetrical conditions.
Hospitals which are included i n the Regional Obstetrics Plan f o r
low-risk pregnancies w i l l be given contracts f o r services.
Hospitals
which have been selected and who have less than J.00 beds, may elect
to be covered by either the DRGs or a budgeted contract f o r obstetric
services.
Hospitals with over 100 beds included i n the Regional Obstetrics
Plan for low r i s k pregnancies w i l l be covered by DRGs.
In analyzing hospital services, i t must be remembered that they
are, for the most part, ccmmunity services.
Hospitals w i l l not voluntarily
give up services i n order to be cooperative with neighboring i n s t i t u t i o n s .
They might give up unprofitable services.
There i s community pride
and other factors involved. Obstetric patients, to a large extent,
are young people with l i t t l e or no insurance.
They are frequently under-
insured, on public aid, unable to pay t h e i r b i l l s or they are e l i g i b l e
to receive uncompensated care.
I f hospitals close these unprofitable
units, the financial burden i s shifted to the surrounding communities.
Obstetric services i n hospitals are supported by other departments and
by higher charges on a l l patients.
Hospitals providing services to high r i s k mothers and babies w i l l
be under contract f o r these services with the Regional Obstetrics Office.
These contracts w i l l provide for reasonable mark-ups for services rendered.
These services and diagnoses w i l l not be included i n the DRGs. These
w i l l be budget-based contracts. The reason i s that there w i l l be l i t t l e
�26
or no cost-shifting possible under the DRG system from other services.
The local ccmmunity can not voluntarily continue to support high
risk
mothers and infants from other counties and the surrounding states.
The plan, as outlined, would probably be very cost-effective.
Currently, the charges for a high r i s k baby exceed $70,000 and the major
portion of the high r i s k infants are bom
to poor mothers who have had
inadequate prenatal care; are drug abusers; have,AIDS or are Medicaid
recipients.
By having Medicare, i t would remove the stigma f o r the
poor. The cost of prenatal care i s a small price in ccmparison to the
benefits to be derived.
The mother would r e t a i n her Medicare-C card during her child-bearing
years.
In the preceding
sections, the author discussed the problems with
our society including prenatal care and the organizational procedures
required to improve the delivery of care to mothers and t h e i r babies.
As pointed out i n the earlier sections, we have provided governmental
funding which exceeded the rate of i n f l a t i o n for maternal and c h i l d health,
and yet the problems with the American family have increased u n t i l at
the present time they are very serious.
These proposed solutions to
the problems with society and the family are bound to be controversial,
but, hopefully, they w i l l serve a useful purpose. The decades of the
1960s and the 1970s were i d e a l i s t i c with a ecumenical s p i r i t .
In the
1980s and the 1990s the s p i r i t of idealism and ecumenicalism became i n creasingly confrontational rather than conciliatory.
I t i s proposed i n this paper that we return to the idealism and
the ecumenicalism of the 1960s and 1970s and declare a 10 year moratorium
on abortion c o n f l i c t s so that we may resolve these conflicts i n a f a i r
�27
manner. This might sound l i k e a radical solution, but i t i s intended
to help resolve some of the serious problems confronting society today.
The author i s proposing that the President of the United States c a l l
for regional womens' congresses to help us understand abortion issues.
These womens' conferences,
with s u f f i c i e n t s t a f f and resources,
1
can represent each region of the country.The womens congresses should
have professional p r o - l i f e and pro-choice representatives; p r o - l i f e and
pro-choice a c t i v i s t s ; wcmen representatives of religious groups; j u r i s t s ;
mothers who have elected to have abortions, both single and married;
mothers who have refused to have abortions, single and married; women
lawyers; congressmen; social workers; women
l i v i n g i n ghettos; r u r a l
women; nurses working i n high r i s k nurseries; women physicians working
i n drug abuse programs involving infants; and women working i n hospital
emergency rooms; i n other words, a cross section of women who have had
children so that there i s a deep understanding of a l l view-points
i n this crises situation.
The author recognizes that i t would take a great deal of statemanship
on the part of the President to appoint such a congress. The stakes
are high, as has been shown i n many parts of this report, and there i s
also the human suffering which results frcm our f a i l u r e t o correct the
problems of our society. A l l other approaches have been t r i e d . The
President i s the only person whose o f f i c e would conmand respect which
would be s u f f i c i e n t to c a l l such a conference.
I t would be hoped that
during the period that the conferences are meeting to seek solutions
to these vast problems, that there would be an abatement i n confrontation
so that a national consensus could develop.
1113(16
Periodic reports could be
�•28
by the congress so that public education could occur.
The answers t o
questions as to why women seek abortions; why they elect not to carry
their child to f u l l term and place them into adoption; and answers t o
other social concerns.
This type of conference would have the advantage of learning f i r s t
hand frcm those who have made the decision; their reasoning and to receive
input from religious leaders. Solutions could h^ve wide impact on our
society and could lead to a r e b i r t h of family values.
�29
AIDS Epidemic
A major health issue i n the United States from both the human and
the
financial perspective i s acquired immune deficiency syndrome (AIDS)
or AIDS virus infection.
AIDS deaths i n 1989 rose by one-third over
the previous year with the disease ranking as the 11th leading cause
of death according to the Department of Health and Human Services.
Two years e a r l i e r , AIDS was ranked as the 15th leading cause of
death according to the National Center f o r Health S t a t i s t i c s .
The report said 22,082 people died from AIDS i n 1989, a 33
percent jump frcm the 16,602 deaths recorded i n 1988. Preliminary
figures f o r 1990 show that number has increased again, r i s i n g to
24,120. The 1990 figures were released last August.
9
According to the U.S. Centers f o r Disease Control, the nation's
AIDS epidemic has reached another grim milestone: 200,000 cases, with
the second coming four times as quickly as the f i r s t .
The U.S. Centers f o r Disease Control reported on January 16, 1992
that the nation's AIDS count now stands at 206,392 cases with 133,232
deaths. I t was August 1989, eight years into the epidemic, when
the 100,000th case was reported; the next 100,000 cases took just
26 months.
The cumulative t o t a l — emphasizes the rapidly increasing
magnitude of the AIDS epidemic.
I f the current trends continue, the next 100,000 cases should
ccme even faster as the epidemic continues to spread, said CDC's
Dr. Larry Slutsker, an AIDS epidemiologist.
The AIDS cases we are seeing now are a reflection of infections
that occurred years ago, he noted.
The second 100,000 cases differed from the f i r s t 100,000:
Seven percent of the newer AIDS cases were traced to heterosexual transmission - s t i l l a minority, but up 44 percent ccmpared
with the f i r s t 100,000, 5 percent of which were heterosexual cases.
More than 11,000 heterosexual AIDS cases have now been reported.
CDC scientists expect that count to double by 1995, Slutsker said.
�30
Twelve percent of the second 100,000 AIDS cases occurred i n
women, ccmpared with 9 percent of the f i r s t 100,000.
Thirty-one percent of the second 100,000 patients were black,
conpared with 27 percent e a r l i e r . Seventeen percent were Hispanic
compared with 15 percent e a r l i e r .
F i f t y - f i v e percent of the l a t e r cases occurred i n gay or bisexual men not using injectable drugs, down from 61 percent e a r l i e r .
Twenty-four percent of the l a t e r cases occurred among heterosexual drug abusers, ccmpared with 20 percent earlier.
The 300,000 mark i n U.S. AIDS cases i s expected i n less than
two years, but could ccme much faster.30
Another recent concern i s about the drug AZT which i s both expensive
and widely used. According to a recent study, directed by Dr. John
D. Hamilton at the Veterans Affairs medical centers, people with AIDS
infection who receive the drug AZT early i n their infections postpone
the development of AIDS, but die j u s t as soon as those who s t a r t the
medicine l a t e r .
However, Dr. Paul Skolnik at the New England Medical Center i n
Boston feels that the results should not deter doctors from s t a r t i n g
early AIDS treatments. By delaying the s t a r t of AIDS, treatment im3
proves the quality - i f not the quantity - of patients' lives. "'"
The cost of AIDS and the AIDS virus i s an expensive addition to
the nation's medical b i l l .
According to Fred Hellinger, director of the division of cost and
financing at the federal Agency f o r Health Care Policy and Research,
the cost w i l l reach $5.8 b i l l i o n i n 1991 and almost double to $10.4
b i l l i o n in 1994.
Projected t o t a l f o r 1992 are $7.2 b i l l i o n and $8.7
b i l l i o n by 1993.
He estimated that the cost of treatment i s $4.4 b i l l i o n t h i s year
based on an annual treatment cost of $32,000 per p a t i e n t .
32
�31
Recommenda t ion
3.
I t i s recommended that a major research program be undertaken on
AIDS patients.
Rationale
AIDS, the f i f t e e n t h leading cause of death i n 1988 moved up to
the eleventh cause of death i n 1989.
babies bom
Now, almost one-third of the 20,000
to AIDS infected mothers inthe United States from 1980 to
1990 were estimated to have the AIDS virus.
the 1990s HIV related diseases w i l l be
i n the 20 - 40 age group.
I t i s estimated that during
among the leading causes of death
I t has been said that since 1988 AIDS has
k i l l e d more 2 5 - 3 4 year old men and women i n New York City than anything
59
else.
The cost of treating HIV could reach $10.4 b i l l i o n by the year
1993. The use of costly drugs and increased life-spans accounts f o r
the increase from $5.8 b i l l i o n estimated to be spent i n the year 1991.
The current average yearly cost of treating an average AIDS patient
is estimated to be $32,000; the cost for someone who i s AIDS positive
costs from $5,000 to $150,000.
33
I t i s estimated by World Health Organization that about one m i l l i o n
people i n the United States have been infected with HIV as of early
this year.
By 1992 an estimated 1.6 m i l l i o n HIV infections may have
occurred i n Australia, North America and Western Europe. Almost two34
t h i r d of these are i n the United States.
Frcm these s t a t i s t i c s i t can be seen that AIDS as part of health
care w i l l be one of the major sources of increase i n the cost of health
care i n the United States. A high percentage of these are the young
�32
people i n t h e i r best earning years.
The AIDS virus can take as long as 10 years before death causing
untold suffering and cost.
Irregardless of the health care plan selected,
this illness alone w i l l drive up medical costs,
tion.
exceeding general i n f l a -
Undoubtedly a large percentage of the AIDS cases are currently
being covered by the Medicaid program. Some are being covered under
the Medicare D i s a b i l i t y program. The acute care'hospitalization of
the AIDS patient should be covered by the diagnosis related groups.
A major research e f f o r t should focus on the most effective treatment
plans from a medical and a cost effective point of view.
Nationally
there i s great variation regarding the most effective plans.
I t is
regretable that the issue has to be reviewed fron the cost effective
prospective, but with the addition of millions of young people i n t h e i r
most productive years to the roles of AIDS patients i t i s imperative
that treatments should be cost effective and reasonably priced as possible.
Hospice care should be used when practical as well as outpatient care.
Medicare program resources should be directed toward HIV education.
Instead of using the t r a d i t i o n a l approaches to education, we should
use grass-roots approaches.
0
Young, college age students should be recruited^" "? ghettos and
comtnunities experiencing serious AIDS problems. These young people
should help prepare educational messages to t h e i r peers and the areas
served.
These messages should be directed at high r i s k populations,
such as blacks which accounted f o r 31 percent of the second wave of
AIDS patients ccmpared to 27 percent e a r l i e r ; Hispanics were 17 percent,
35
compared to 15 percent earlier. The health education messages can use
�33
a l l the resources of the universities to reach people who are at the
highest r i s k of getting AIDS. Also, by using these non-traditional
approaches, we should reach for the young age groups with messages about
AIDS and sexually transmitted diseases.
We can no longer have the luxury
of withholding t h i s information from our very young. School nurses
and health educators working i n schools and neighborhood c l i n i c s as
well as other areas shall provide AIDS information.
can provide payment t o the schooJ
The federal government
t o provide such education d i r e c t l y
through the program. These should be small group sessions which promote
closer relationships so that the facts about this serious illness can
be widely disseminated.
Frequently, i n the past, we have had only one
health education course throughout the school experience..
Clearly,
this i s not enough when the cost of AIDS i s expected to be $10.4 b i l l i o n
i n the near future.
�34
3. Policy Considerations
Before policy makers consider making changes i n the health care
system, they should give consideration t o the dynamics of our society.
Some of these changes portend many future problems.
Several of these
issues w i l l be discussed i n this section.
Social Security
Social Security benefits have always been a highly charged p o l i t i c a l
issue.
During the past decade Social Security taxes have increased
by $170 b i l l i o n which i s used to fund the present retirees and not to
fund today's workers.
Since 1980, spending f o r the elderly, including health and retirement
benefits, has more than t r i p l e d - to nearly $470 b i l l i o n .
That i s 33
percent of the entire federal budget and almost 9 percent of the nation's
t o t a l economic output.
According to an a r t i c l e by Howard Gleckman, "Social Security's
Days as a Sacred Cow are Numbered," the government, i n f i s c a l 1991,
w i l l spend 10 times as much on the elderly as on a l l education and environmental programs ccmbined.
After the Vietnam Warthe "peace dividend" was used to s h i f t b i l l i o n s
of dollars frcm the m i l i t a r y to the aged. Benefits were raised and
an automatic cost-of-living increase was b u i l t into the social security
system.
The result i s that the poverty rate among the elderly has been
cut i n half to about 12 percent, compared with 13.5 percent f o r the
t o t a l population.
The average family income among the elderly has i n -
creased by 15 percent, after i n f l a t i o n , i n the past decade.
�35
At the same time, the poverty rate for children i s nearly 20 percent;
the average income for single mothers with children has declined by 2.3
percent since 1979.
For a l l families, average cash income has increased
3
by 5.6 percent or one-third of the rate f o r the e l d e r l y . ^
Other countries of the world are facing s i m i l i a r problems.
In Japan,
the universal health-insurance and the pension system receives 41 percent
of the national income. This i s expected to increase to 45 percent by
2000 and to j u s t below 50 percent i n 2020, when almost two-thirds of
the t o t a l burden would go to programs f o r the elderly.
In aging welfare
states. Like Norway and Sweden, the costs f o r the elderly services exceed
37
60 percent of the national inccme.
In the United States the number of Americans 65 and older w i l l h i t
65 m i l l i o n by the year 2030, compared with 30 m i l l i o n senior citizens
today.
By 2030 there w i l l be more Americans over the age of 65 than under
the age of 18, according to demographers' estimates.
That reduces the
number of younger working people available to support the growing number
*
4--
of retirees.
3
8
�36
Effectiveness of National Health Insurance
Another dilemma i s the effectiveness of national health insurance.
I t does not eliminate or even substantially reduce d i f f e r e n t i a l s i n health
outcones across socioeconomic groups according to Victor Fuchs, professor
of economics at Stanford University.
"In England, for instance, infant
mortality i n the lowest socioeconomic class i s double the rate of the
highest class, j u s t as i t was before the introduction of national health
insurance i n the late 1940s." Mr. Fuchs further states:
Even i n the r e l a t i v e l y homogeneous population of egalitarian
Scandinavia, l i f e expectancy varies considerably: The age standardized
mortality rate f o r male hotel, restaurant and food service workers
is double that f o r teachers and technical workers. In Sweden, a
study of age-standardized death rates among men 45-64 found substant i a l d i f f e r e n t i a l s across occupations i n 1966-70 and s l i g h t l y greater
d i f f e r e n t i a l s i n 1976-80.
National health insurance does seem to control health costs,
but i t doesn't much improve health outccmes.
An explanation of this dilemma could be a failure by the lowest
socioeconomic class to take advantage of the a v a i l a b i l i t y of medical
care because of subtle social pressures and lack of health education.
Small Businesses and Health Care Reform
In order to reduce the number of people without health insurance
New York state offered to underwrite half of employee health insurance
costs for firms with fewer than 20 workers i n a p i l o t program started
i n 1989.
However, i n one year there was only an increase of 3.5 per-
centage points i n the number of small employers covering t h e i r workers.
Researchers associated with Kenneth E. Thorpe, associate professor
of health policy at the University of North Carolina noted:
"This small
effect seems especially suprising because the price of insurance i s the
�37
most frequently cited reason f o r not offering insurance."
The researchers also noted that 75 percent of uninsured Americans
are employed or are married to or a dependent of someone who i s employed
and that most of these people work f o r companies that don't o f f e r health
insurance.
The lead researcher, Kenneth E. Thorpe also noted that:
Smaller ccmpanies are less l i k e l y to of'fer insurance to workers
than large firms, i n part because they have to pay more f o r insurance according to a survey of 530 small ccmpanies.
Administering health benefits i n a small firm i s often the
big proble - these guys running a garage with four or f i v e people
have to act as benefits o f f i c e r s . They are not benefits managers.
This style of program i s also having disappointing results i n other
40
states which have t r i e d a s i m i l i a r approach.
The next section of t h i s report w i l l discuss several d i f f e r e n t approaches to a national health policy.
4. Approaches to a National Health Policy
Canada's Universal Health Insurance
Canada has the second most expensive health care system i n the
world, but i t i s s t i l l less expensive than the United States system.
In 1990, the United States spent $2,566 per capita on health care while
Canada spent $1,991 i n U.S. dollars.
At the same time, i n a study pub-
lished i n the Journal of the American Medical Association, comparing
post-operative death rates f o r 11 surgical procedures i n U.S. and Canada
found no significant differences.
�38
In t h e i r system each Canadian province manages i t s own health i n surance plan. Quebec's program i s t y p i c a l of the different provinces.
The province covers 100 percent of medically necessary physician and
hospital services. Cosmetic surgery and i n v i t r o f e r t i l i z a t i o n are not
covered.
Quebec also covers certain additional items such as prescrip-
tion drugs f o r the elderly and the poor and dental care for children.
The province has not extended drug and dental covferage t o a l l because
doing so would be too costly.
Canadians can choose any doctor and any hospital they want.
Patients must pay extra for private and semi-private rooms.
( I n the
U.S. there are very few wards available.)
Quebec's population, l i k e that of the United States, i s aging,
and the cost of free drugs for the elderly and the poor i s r i s i n g 15
percent a year.
The bulk of a typical hospital's budget comes from the Quebec Health
ministry, which gets about 40 percent of i t s financing from the federal
treasury.
Revenue from such things as private room charges, parking
fees and the cafeteria provide the remainder. Capital spending budgets
are handled separately.
In a t y p i c a l hospital, the attending physicians are paid d i r e c t l y
by the provincial government. They are not c i v i l servants.
Like most
Quebec doctors, they are i n private practice and get a fixed fee f o r
each medical service performed (a simple examination at a general
practitioner's o f f i c e i s worth $12.15, an annual physical $24.10).
�39
As the only customer, the Quebec government has a l o t more
control over costs than do private insurers, governments and individuals i n the U.S. A typical hospital must stay within i t s annual
budget; the province won't cover any d e f i c i t s . Physicians can't
raise t h e i r fees u n i l a t e r a l l y , and Quebec controls the t o t a l amount
i t pays out. For example, once a general practitioner h i t s $39,474
in quarterly fees, the government pays only 25 percent of each
b i l l submitted over that amount u n t i l the next quarter s t a r t s .
The cost differences between the U.S. and Canada can be s t a r t l i n g .
At the Royal Victoria, a large Canadian hospital, a standard quadruple
coronary artery bypass costs an average $12,236, including physician
fees. At New Elngland Medical Center, a teaching hospital of s i m i l i a r
size i n Boston, the same operation costs $25,439.
In a recent report, the U.S. General Accounting Office, an
investigating arm of Congress, singled out three main reasons Canada's
system i s cheaper: Administrative overhead, physician fees and
hospital costs are a l l sharply lower i n Canada than i n the U.S.
41
Administrative costs are lower because the hospital runs at
f u l l capacity compared t o the U.S. average of 65 Percent.
Typical hospitals
don't need large accounting departments because they don't have to deal
with myriad insurance companies. Patients don't have to f i l l out dozens
of forms; they j u s t flash their health insurance cards.
Canadian physicians are paid less than their American counterparts.
In 1987, the average gross inccme f o r a Canadian doctor was $127, 777,
ccmpared with $256,000 for a U.S. doctor.
Yet Canada has one active
physician per 451 people, almost the same as the U.S.
The following i s a s t a t i s t i c a l comparison between Canada and the
United States:
42
Life expectancy -
U.S. 75.3 years;
Canada, 77.1 years.
Infant mortality U.S. 10.4 ^
100,000);
Canada, 7.9.
Death frcm heart disease
U.S., 434 (per 100,000);
Canada, 348.
Per capital health care expenditures - U.S., $2,354;
Canada, $1,683.
r
�40
Health expenditures as a percent of GNP - U.S., 12.3 percent;
Canada, 8.7 percent.
Number of people per doctor U.S., 488;
Canada, 463.
Short-term hospital beds U.S., 4.05 (per 1,000);
Canada, 4.39.
Open heart surgery units U.S., 790;
Canada, 11.
Average physicians inccme U.S., $146,200;
Ontario, $115,000 (U.S.).
Average annual malpractice premium U.S., $57,000;
Canada, $7,500. '
Critique
In Canada t i g h t cost controls affect patient care.
I f a patient's
case i s not urgent, they have to wait i n l i n e f o r certain expensive
procedures which i s a trade off for a hospital working at f u l l capacity.
The wait f o r cataract /lens replacement operation i s about three months,
for a coronary bypass three to six months. However, i f the need i s
urgent, i t w i l l be done right away.
Tight budgets also mean less high technology equipment such as
is used i n U.S. hospitals.
However, many Canadian physicians think
that many U.S. hospitals have too many pricey machines that U.S. doctors
43
- driven i n part by fear of lawsuits - overuse.
Some of the problems are s i m i l i a r t o those i n the United States
such as delays i n the emergency rooms and delays before a patient can
be admitted t o the hospital.
The tax-funded system i s free to most Canadians, although B r i t i s h
Columbia and Alberta charge $48 a month t o those who can afford to pay.
About 33 cents of every Canadian tax d o l l a r goes to health care.
According t o Don Aitken, president of the Alberta Federation of
Labour, " e each are guaranteed access. We have the right t o receive
W
�41
services close to home. We have the r i g h t to the f u l l range of medical
services. We carry that r i g h t to wherever we may be i n Canada, and
44
we are insured that no one i s p r o f i t i n g from our health needs."
Medicare Expansion
Representative Fortney H. "Pete" Stark (Democrat), chairman of
the House Ways and Means subcommittee on health has introduced a b i l l
«
c a l l i n g for a federal health care system for a l l Americans, targetting
children and pregnant women for additional services.
The basis of the system i s the elimination of insurance company
overhead and controlling health-care prices under a single-paifer system
using Medicare reimbursement rates.
This expansion would provide health
care coverage f o r 35 m i l l i o n Americans who are currently uninsured (and
millions who.are underinsured) at a savings of $26.2 b i l l i o n .
The savings estimate was prepared by the Congressional Budget Office
using 1989 data, when health-care spending nationwide totaled $604.1
b i l l i o n . The $26.2 b i l l i o n projected savings -
the mid-range of three
estimates - would have represented a 4.3 percent reduction . i n healthcare spending that year.
A major portion of the savings are projected to come from the elimination of most private health insurance company overhead,a $22.2 b i l l i o n
reduction.
Insurers s t i l l could provide supplemental insurance as they
now do to Medicare policies.
Approximately $16.5 b i l l i o n more would be saved by reducing the
overhead to doctors and hospitals, who now are faced with f i l l i n g out
forms frcm about 1,500 different insurers.
But the CBO predicted that
expanding Medicare would result i n greater use of doctors and hospitals.
�42
adding $12.5 b i l l i o n i n new costs.
The new result, according to the CBO, would be about $26.2 b i l l i o n
45
i n savings.
B r i e f l y , Representative "Pete" Stark's proposal (H.R. 1300) would
46
provide the following single provider benefits:
1.
universal health care benefits;
2.
mandated basic acute care benefits including physician and
mental health services;
3.
preventive care for children and pregnant women only;
4.
pregnancy related care;
5.
well-child care;
6.
expansion of Medicare to a l l age groups;
7.
replacement of Medicaid;
8.
copayment of 20 percent; home and conmunity-based services
of 20 percent; nursing home a f t e r deductib
9.
;
16
- 20 percent;
:
acute care - -five:.huadred'do}lars; : nursing home - 2 months;
10.
caps on personal out-of-pocket expenses (acute care) - $2,500;
11.
financial protection for low-income - yes;
12.
new revenue needed - $125 b i l l i o n per year;
13.
major financing sources - 4 percent inccme tax $1,000 annual
premium;
14.
cost containment - administrative simplification; single-pay
financing; Medicare payment rules;
15.
quality assurance - Medicare mechanisms;
16.
malpractice reform - no.
�43
-
Critique
The author of this report believes that the Medicare single provider
approach i s the best since i t would build on an existing system which
has been extensively reviewed and revised during the past several decades. However,the savings estimates of the Congressional Budget Office
seem overly optimistic as do the annual costs of the program.
The Medicare program currently pays approximately 90 percent of
the cost of hospital care and 85 percent of the h i s t o r i c a l cost of
depreciation.
New replacement medical equipment i s more expensive than
the o r i g i n a l equipment. Other t h i r d party payors have had to pick-up
the costs which resulted from this cost s h i f t i n g .
The transfer of the Medicaid patients t o the Medicare program could
also prove to be costly.
states.
This i s a shared program with the d i f f e r e n t
However, i n many of the poorer states only a fraction of the
e l i g i b l e recipients receive Medicaid benefits.
have many serious medical problems.
These recipients could
This also applies to the 35 m i l l i o n
who are uninsured and the untold millions who are under insured.
All
of these new program participants would add significant cost t o the program.
Another factor i s the inclusion of pregnant women and younger citizens
in
the program. The cost of l i a b i l i t y insurance should be addressed.
Current Medicare recipients have smaller future earnings than do the
younger population,hence greater insurance cost concerns.
At the present
time, many areas of the country have limited obstetric coverage because
of l i a b i l i t y concerns by physicians and hospitals.
Administrative savings to hospitals and physicians would not be
as
great as anticipated during the f i r s t few years of the t r a n s i t i o n
�44
period.
The reason f o r t h i s i s that dual systems would have to be maintained
for past services.
Also, the Medicare u t i l i z a t i o n review and quality
assurance system and cost systems would have to be expanded. These systems
are more complex than those which currently prevail with other payors.
The c r i t i c i s m which applies to t h i s program would also apply to
a l l health care proposals using s i m i l i a r approaches.
The positive factor i s that 37.2 m i l l i o n people without coverage
would receive quality health care and the astronomical costs of health
care to major American industries would be substantially reduced making
them more ccmpetitive i n the world economy.
Reforms and cost-cutting measures w i l l be discussed i n the proposal
section.
Universal Health Care Act of 1991
Representative Marty Russo (Democrat) introduced the Universal
Health Care Act of 1991 (H.R. 1300) i n order to provide accessible health
care to a l l Americans.
The system would eliminate a l l private health
insurance, making the government the sole payor for medical care.
According to an a r t i c l e in' the Southern I l l i n o i s a n , "Government
Control of Health Care Payments i's Problematic" . the money would be
.
raised through additional taxes on employers and employees that approximately match the b i t e currently going to insurance companies.
"EVery single citizen would be covered and there would be no cc-payment
or deductible.
health c a r e . "
In other words everyone would have access to complete
47
Under the proposed l e g i s l a t i o n , the government would pay providers
an arranged amount every month. The reduction i n paperwork alone
�45
would save an estimated $40 b i l l i o n every year.
The plan would be funded by replacement taxes on individuals and
corporations that would go into a national health care fund.
The federal
government would negotiate a health care budget with each state, which
would i n turn hammer out agreements with medical providers i n the state.
In return f o r being released from personal premiums and deductibles,
middle-incomsAmericans would pay about 2 percent' more i n federal taxes
under the plan, and higher-inccme Americans would pay about 3 percent
more. Corporations would pay 7 percent more i n payroll taxes, which
would release them from paying the health care portion of worker's
compensation and the employer's share of health care premiums.
The plan also provides other changes which could help the health
care system. These are as follows:
Prevention efforts which could save the country "enormous
medical costs.
A restructering of r u r a l health care, so not a l l small hospi t a l s t r y to provide the same level of technology.
Greater use of mid-level health care providers, such as nursemidwives, nurse practitioners and physicians assistants.
Conversionof unused hospital beds into long-term units
or other paying propositions.
Better incentatives t o sweeten e f f o r t s to recruit doctors
and nurses to r u r a l areas.
48
B r i e f l y , Representative Marty Russo's proposal (H.R. 1300) would
49
provide the following single provider benefits:
Eligibility
Universal
Mandated basic benefits (acute care)
Includes hospital, physician and
mental health services.
Yes
�46
Preventive care
Yes
Pregnancy related care
Yes
Well-child care
Yes
Out patient prescription drugs
Yes
Long-term care services (LTC)
Includes nursing home, home health
and conmunity-based services.
Yes
Medicare
Replaced
Medicaid
Replaced
Co-payment (
w h a t
y
o u
a
P y)
No
Deductibles
No
Caps on personal out-of-pocket expenses
(acute care)
Not applicable
Financial protection for low inccme
New Revenue needed
Yes
Plan not specific
Major financing sources
6% payroll tax
$57 month health and
LTC premium i n 1992
Increased taxes on
personal, corporate,
Social Security income
Cost containment
National health expenditure
targets/caps
Negotiated payment rates;
Administrative simplification;
Single-payor financing.
Quality assurance
Small business insurance reform
Malpractice reform
Medicare mechanisms.
Not applicable
No
�47
Critique
This plan. The Universal Health Care Act of 1991, l i k e the preceeding
plan promises large savings i n the administrative area, $40 b i l l i o n
in t h i s case, but there are a number of items of concern.
F i r s t , the payment'of ah arranged;or. budgeted amount each month,
would be problematic i f there were no measures of productivity,
quality or efficiency.
Productivity and efficiency are d i f f i c u l t to
measure i n the health care f i e l d .
Health care i s a v i t a l and changing
f i e l d of endeavor and public perceptions about c l i n i c s , private practices
and hospitals can quickly change i f there i s complacency about the care
rendered. The quality of care i n c l i n i c s and i n physicians'offices i s
d i f f i c u l t to measure. For example, i n order to maximize p r o f i t s , a f a c i l i t y
may s i g n i f i c a n t l y reduce the number of laboratory and radiology tests
and procedures to the detriment of patient care.
Second, the elimination of deductibles and co-payments would be
perceived by many i n the system as lowering the value of health services
and lead to massive over-use and abuse. The addition of 37.2 m i l l i o n
people who presently do not have adequate health care to the system would
cause tremendous medical care i n f l a t i o n .
There is, already a very .
limited supply of physicians, nurses and technicians and i t would become
a bidding war f o r services thus, also pushing costs up.
A t h i r d concern would be the aspect of negotiations with the states
and the providers of medical services.
The neediest hospitals and c l i n i c s
might not have the best and smoothest negotiators. There could also
be fraud and abuse i n awarding contracts i f there were no pre-establihed
measurements of productivity, quality and efficiency.
�4fl
A fourth concern i s the elimination of the Medicare program.
This
would be a tremendous psychological blow to the elderly to whom i t represents
a measure of security even i f i t i s replaced by another health care system.
Issues such as l i a b i l i t y insurance are not addressed and extreme
caution should be used i n offering long term care. The government should
proceed cautiously i n t r y i n g to warehouse the elderly by making i t an
easy option.
The President's Proposal
The health care proposal of the President relies on a package of
health care reform rather than a wholesale overhaul which i s being promoted
by the Democrats.
Basically, the plan provides health care f o r low-income households
and reduces tax breaks f o r the wealthy.
According tothe plan, individuals and families who eam
up to 150
percent of the poverty level ($20,000 a year f o r a family of four) would
get a tax c r e d i t .
Under different alternatives being discussed,
the
credit might be replaced by a voucher or, perhaps, private insurance
policies purchased d i r e c t l y by the government.
Families earning up to
$60,000 a year may f i n d i t easier to deduct part of their medical expenses
on t h e i r income taxes.
This modest proposal would not be inexpensive. Twenty m i l l i o n people
- more than a quarter of them children - might qualify f o r the credit
or the voucher.
over five years.
The President's plan i s expected to cost $100 b i l l i o n
Yet the maximum tax credit i s only around $2,500 which
is below the $3,100-per-employee average premium paid by small businesses.
�49
Likely proposals:
1.
The low-income uninsured would get tax credits. Middle-class
workers would get tax deductions to buy health coverage.
Pro:
Would expand the ranks of the insured.
Con:
Tax breaks may not cover cost o f the insurance.
2.
Require a l l employers to make coverage available, though companies
would not have to pay premiums.
Pro:
Uninsured employees could obtain coverage at lower group rates.
Con:
Enployers would have no incentive
medical plan.
3.
t o find the lowest cost
Reform the small-group insurance market.
Pro:
Insurers would be less l i k e l y to deny coverage or charge high
rates f o r companies with sick employees.
con:
Could mean higher rates f o r employers with healthy workers.
4.
Tax benefits f o r wealthy households.
Pro:
Raises revenue, encourages employers to opt for cheaper health
plans.
Con:
A p o l i t i c a l lead balloon.
5.
Cut federal medicaid payments t o states.
Pro:
�50
Would encourage states to move to managed care.
Con:
Another blow to weak state finances during a recession.
6.
Create incentives
buy insurance.
for small ccmpanies to band together t o
Pro:
Small ccmpanies could get better rates.
Con:
Such pooling schemes have a history of fraud.
5 0
Critique of the President's Proposal
The United States i s a diverse and complex country.
There are millions
of unemployed, unknown numbers of homeless, students. Medicaid recipients
and their children, i l l i t e r a t e citizens, people between jobs and new
inrmigrants who are not familiar with our health care system. A large
percentage of these groups do not pay federal income tax or only pay
a minimal amount. Income tax credits or vouchers would mean very l i t t l e
to these groups.
The current 19 month recession and stagnation - possibly the longest
postwar slump on record - sent 1.5 m i l l i o n people t o the unemployment
l i n e , put 148,000 companies out of business and produced a great deal
51
of economic uneasiness.
Requiring small employers to make decisions regarding cost-effective
plans and explaining benefits to employees i s unrealistic.
Even large
employers have d i f f i c u l t y i n making decis ions and interpreting benefits
to employees with plans which have been prepared by insurance company
attorneys.
This subject was previously discussed i n the case of New
�51
York state where the state offered to underwrite half of employee health
insurance costs f o r firms with fewer than 20 workers.
Only 16 percent
of the e l i g i b l e employers were eipected to participate i n the offered
plan because of the additional paper-work required.
In order to enforce compliance, a major advertising and policing
e f f o r t would have to be i n i t i a t e d .
Many jobs are seasonal and some are
by the hour or by the day with the employees forgetfting whether they
were previously covered and by whom. There would be no administrative
reductions i n claim processing by hospitals or by physicians.
Issues such as effective cost-control, quality assurance, l i a b i l i t y
insurance reform appear to be vague i n t h i s i n i t i a l presentation.
Conclusion
This section has reviewed a few of the more than 30 health care
improvement proposals being considered by congress.
The next section
w i l l deal with health care policy and reform as suggested by the author
of this report.
�52
5. Additional.Health Care Policy Recommendations
Intrbduction .
The policy reccmnendations contained i n t h i s section are the result
of the material presented i n the previous sections and the personal
experience of the author who has over 30 years of administrative, operational and professional experience i n the health care f i e l d .
Reconmendations
4.
Retain Medicare as the basic foundation f o r a national health care
plan.
Rationale
Medicare was started i n 1966 and since that time i t has been the
cornerstone of United States health care policy.
The nation's 600,000
plus practicing physicians and i t s . 6,700 hospitals are familiar with
i t s guiding principles.
These physicians and hospitals have provided
inmense input t o the system. This participation has occurred at the
local, regional, state and federal l e v e l .
Challenges to the system
have occurred and they have been resolved by the courts and by the
Congress. Research and refinements have produced new practices t o
control costs and provide a high quality of care.
Although the Diagnosis Related Groups (DRGs) are not universally
popular because they represent bureaucracy, they have standardized health
care costs t o the federal government f o r specific illnesses and procedures and they have also standardized health care quality among a l l part i c i p a t i n g hospitals as i t relates to Medicare patients.
The following i s an example o f the wide variation i n charges f o r
non-Medicare patients:
cataract surgery charges range from $629 to
�53
$6,552 exclusive of physicians fees according to a survey conducted
by the I l l i n o i s Health Care Cost Containment Council of 1990
charges.
52
This wide variation of charges has occurred despite competition among
hospitals and widespread publicity regarding charges by the Cost Containment Council. I n contrast. Medicare pays standardized nation-wide fees
for the procedure.
There are tens of thousands of professional* nurses, technicians
and support s t a f f working nation-wide on the Diagnosis Related Group
program, on u t i l i z a t i o n review and related quality assurance programs.
Many major managed care programs, insurance ccmpanies and large corporations
have followed the lead of the federal programs by requiring pre-admission
approval f o r non-emergency hospital admissions, u t i l i z a t i o n review and
quality assurance programs.
As a d i r e c t result of these programs, there are many positive results
such as the following:
1.
Americans over 80 have the world's second-longest l i f e expectancy,
j u s t behind Iceland.
2.
The hospitalization period i s very short i n the United States
- an average of 7 days compared to Germany where i t i s 13
days.
Another consideration i s cost. The U.S. General Accounting Office
reported l a s t year that the U.S. could save $67 b i l l i o n i n administrative
costs by s h i f t i n g to a single-payer system "more than enough to finance
54
insurance coverage f o r millions of Americans who are currently uninsured.
A f i n a l consideration i s the psychological impact on the Medicare
recipient i f t h e i r present system was abolished and a new, untried,and
�54
unknown
system substituted.
This action would be almost p o l i t i c a l
suicide.
Recommendat ion
5.
Provide incremental health policy change.
Rationale
Health care i s a $733 b i l l i o n a year industfry which has had
increases of 10 percent annually during the past two years.
For the
Federal Government, medical costs have beccme the fastest growing major
item, increasing at more than 8 percent annually at a time when i n f l a t i o n
55
i s only about 5 percent.
A major reason f o r the recent growth i s the 19 month recession
and stagnation - possibly the longest post-war slump on record - which
sent 1.5 m i l l i o n people to the unemployment l i n e and added 1.3 m i l l i o n
people to the ranks of the uninsured between 1989 and 1990.
Medicaid
expansion required by Congress i n 1990 placed 3.1 m i l l i o n more Americans
i n the health care program that year.
I t i s projected that the number
of people without health insurance w i l l reach 40 m i l l i o n i n 1991.
Health care employment i s a b i g factor i n our economy.
5 6
Health
care employment, added 532,000 jobs i n 1989 or more than 22 percent
of the t o t a l increase i n payroll jobs i n that year.
5 7
Further, i t i s estimated that the uninsured receive 60 percent
of the care that they would receive i f they were f u l l y insured with
the burden, through cost s h i f t i n g , f a l l i n g on the insured,the private
58
patients and the government.
�55
In any t r a n s i t i o n period, industry has to maintain parts of an
existing system as well as parts of the new system, i f the t r a n s i t i o n
would occur too rapidly i n the 733 b i l l i o n dollar health care industry,
massive medical i n f l a t i o n w i l l occur.
At the present time there are
serious shortages i n the professional nursing f i e l d , i n primary medicine,
especially i n r u r a l areas as well as i n technical fields which would
only grow worse i f millions of additional people'required f u l l services.
A step-by-step approach would be a more systematic approach to the health
care problems.
Recommenda t ion
6.
Simplification of medical claims processing.
Rationale
Administrative costs do not contribute to quality health care,
they only reduce the amount of health care that i s available.
Estimates
vary as to the costs of administration including the previously discussed
$67 b i l l i o n which could be saved by having a single payer system.
I t i s proposed that the present Medicare card be replaced by a
plastic card s i m i l i a r to the credit card currently being used f o r millions
of daily business transaction.
The state-of-art card could contain such basic information as the
following:
1.
Name of the insured;
2.
Medicare number;
3.
type of plan;
4.
date of b i r t h ;
5.
sex;
�56
6.
color of eyes;
7.
expiration date of card, i f applicable;
8.
authorization of treatment; etc.
The i n i t i a l cost of the card and the accompanying system i s expensive
but reduced processing costs would offset the i n i t i a l expenses.
�57
Recommenda t ion
7.
I t i s reccnmended that contractual arrangements may be made f o r
various services.
Rationale
Congress should grant each of the regions of the United States author-
i t y to enter into contractual arrangements with hospitals and other health
care providers f o r specialized and routine services.
I t would be d i f f i c u l t to implement such a system with a l l providers
of services, but i t can be done selectively i n high cost areas.
An area
of research i n d i f f e r e n t regions, could be the relationships of surgery
and treatments to medical outcomes. For example, i n the previously discussed ccmparison of Canada and the United States, i t was shown that
death from heart disease i n the United States was 434 per 100,000 population
compared to 348 per 100,000 i n Canada. Yet, i n the same period there
were 790 open heart surgery units i n the United States ccmpared to 11
59
i n Canada. 'Heart disease i s important i n the United States and i s l i s t e d
as the leading cause of death i n 1989 accounting for 34.1 percent of
6Q
a l l deaths that year. Further, based on studies by the Rand Corporation,
there were as many as 44 percent of the coronary bypass surgeries and
64 percent of the carotid endarterectomies were either unnecessary or
1
highly questionable.^ " In a separate review for the Philadelphia professional
Standards Review Organization, Dr. Allan Greenspan found that 25 percent
of heart-pacemaker implants performed i n the Philadelphia region were
. ^
62
inappropriate .
Further data ccmparing hospital and physician outcomes are currently
being developed.
In a recent study of 3,055 coronary artery bypass grafts
�58
at 5 New England hospitals by 18 d i f f e r e n t surgeons found that patients
were twice as l i k e l y to die at certain hospitals and 4 times as l i k e l y
6
3
with certain physicians. ' rhese s t a t i s t i c s i l l u s t r a t e that there are
areas of study to determine effectiveness and also indicate that there
may not be a need f o r 790 open heart . surgery units ^
the United States
when the l i f e expectancy i n the country which has only 11 such units
is greater than that of the United States.
A second area of concern i s cost. Canadian health care expenditures
per capita run 40 percent less than the United States and the financial
burden on large employers i s dramatically lower, too. I n 1990, Ford
Motor Company of Canada spent:?41 m i l l i o n on coverage f o r i t s 22,000
workers, or about $65 per vehicle produced.
In contrast, Ford Motor
64
Company U.S.A. spent $300 per vehicle.
In a study by the Metropolitan
Life Insurance Ccmpany, i t was found that the number of coronary bypasses
nearly doubled from 1981 - 1986, while the charges per procedure rose
65
about 50 percent frcm$21,800 to $30,430. Health care for large corporations
is extremely high, f o r example, the cost to General Electric is-$800 •
m i l l i o n per year which causes them to evaluate outccme data so they can
6&
choose the best providers.
The t h i r d issue i s to ccmpare cost to effectiveness of treatment
and outcome. According to Dr. Richard Moy, Dean of Southern I l l i n o i s
Medical School, tough controls on costs w i l l lead to rationing of health
care.
"Nowhere, and certainly not i n the United States w i l l we control
costs without rationing.
You are going to have to ccme to grips with
67
i t , otherwise i t i s gnoke and mirrors." Ttore reserch should be done
�59
to find out which procedures are the most effective.
I f physicians can be provided with better guidelines about what
works i n treating various ailments, they w i l l feel less pressured to
do things on a just-in-case basis. These standards should be guidelines,
rather than rules that might infringe on a physicians best sense of what
the patient needs. The same type of conclusion i s reached by Dr. Arnold
S. Relman, editor of the New England Journal of Medicine.
The problem,
he says,"is that the suppliers of health services - doctors - are uniquely./
able to influence demand. The best way to get a grip on cost i s to develop
improved outcomes data that w i l l t e l l which operations and tests are
best and which are wasteful and risky."
The author of t h i s report suggests that each of the regions form
medical committees with adequate research s t a f f to make such informed
determinations as to the number of f a c i l i t i e s for which contracts shall
be awarded for coronary surgery and other related surgical procedures.
The surgical outcomes shall be important determining factors f o r the
awards. For example, a l l of the open heart surgical units require' very
expensive surgical equipment, highly trained specialists and well-trained
nursing s t a f f members to monitor the patient during hospitalization..
The i n i t i a l contracts for heart . surgery shall be of staggered duration,
for example, 3, 4, and 5 years . This w i l l give time to the research
s t a f f to prepare comprehensive guidelines by which to determine which
i n s t i t u t i o n s are the best i n each region. The following factors could
be included i n the guidelines:
1.
distance to surrounding f a c i l i t i e s ;
2.
size of the q u a l i f i e d medical and surgical s t a f f ;
3.
size and t r a i n i n g of the nursing support s t a f f ;
�60
4.
the volume of cases handled by the s t a f f ;
5.
a b i l i t y to handle additional cases;
6.
physical f a c i l i t i e s ;
7.
survival rate of the patients;
8.
hospital acquired infections;
9.
number of medical l i a b i l i t y cases based on volume of cases;
10.
age of physical plant and i t s equipment;
11.
size of area served, etc.
A l l the studies should be done methodically as the studies w i l l be challenged
by a l l of the hospitals whose services would be curtailed or eliminated.
Sufficient notice would be given to each of the hospitals whose
coronary surgical units would not be e l i g i b l e to continue to participate
in the Medicare program.
The hospital payment system would be the Diagnosis Related GroupsThe nation w i l l be divided into regions, which w i l l be described l a t e r
in this paper. These regions w i l l develop a master p r o f i l e of a l l the hospi t a l s i n t h e i r region. This p r o f i l e should encompass a l l 6,700 hospitals
in the United States. The p r o f i l e can be prepared by consulting firms such
as the Rand Corporation or other corporations with s i m i l i a r capabilities.
The profiles should be i n i t i a l l y prepared f o r each of the regions and
then submitted to the Department of Health and Human Services which w i l l
then select the proper profiles f o r hospitals of different size
i n the
United.. States.
This type of information gathering i s better than i n i t i a l l y s t a r t i n g
a national standard as i t would allow the plan to r e f l e c t local issues.
The information provided i n the plan would have a pre-determined
�61
effective date so that there would not be major purchases of new equipment.
However, a l l contracts f o r equipment and building changes issued p r i o r
to this date w i l l be considered to be a part of the p r o f i l e .
Planned
purchases or improvements w i l l not be honored, unless contracts have
been signed or purchase orders issued p r i o r to the effective date.
The average percent of occupancy of the 6,700 hospitals i n the United
States i s s l i g h t l y less than 65 percent which contrasts with Canada's
95 percent occupancy level.
This indicates that there are too many hosp-
i t a l s i n the United States.
The 95 percent occupancy level i n Canada
is too high.
Excess capacity should be available for seasonal and week-
end fluctuations.
pancy level.
A r e a l i s t i c target would be an 80 to 85 percent occu-
To reach such a goal, there must be a reduction i n the
number of hospitals. Many hospitals have added a number of new services,
reduced the number of available beds and made these hospitals into f u l l
service hospitals i n order to compensate f o r the loss of income from
in-patients.
While this has raised the level of health care available,
i t i s , also, expensive to have a l l hospitals provide a f u l l range of
services.
The reduction i n the number of hospitals should not be entirely
proportional as many are located i n r u r a l areas where travel distances
are great.
The same type of data would be used as was obtained f o r
the specialized areas.
I t should be very comprehensive and show the
f u l l range of services which are available and the a v a i l a b i l i t y of such
services i n the immediate area.
When the data has been collected and analyzed, then the authorities
in each region shall make determinations as to the types of services that
�62
they w i l l contract f o r i n each hospital within the region. Later i n
this document, the author w i l l discuss changes i n the method of financing
Medicare, so that regions which elect to maintain a high number of hospitals
w i l l have to expect higher payment costs than those that are more E f f i c i e n t .
When the data from each of the 6,700 hospitals have been f u l l y analyzed,
then contracts w i l l be offered to the hospitals within these regions.
Sufficient notice w i l l be given regarding the effective dates of these
contracts, so that i f specific services are eliminated or i f hospitals
are not offered contracts, then they can begin the transition to other
7
services or to becoming long-term care f a c i l i t i e s or to the closure of "the
facility.
The federal government w i l l issue long-term bonds to cover
outstanding debts of the hospitals that are closed and financial assitance to those whose services are being substantially changed. The reason
is to maintain the a b i l i t y of hospitals to obtain reasonable financing
in the future.
I t would be d i f f i c u l t i f the market for hospital bonds
became depressed. As soon as p r a c t i c a l , s i m i l i a r
profiles w i l l be started
for free-standing c l i n i c s , physicians offices, and other s i m i l i a r services.
The i n i t i a l areas to be p r o f i l e d would include radiology departments,
ultrasound, mammography units, kidney dialysis services, MRI scans and
other equipment where the equipnent cost i s high and frequently where
there i s low volume. The same type of standards, namely, the date of
purchase or purchase agreement should apply as applies to the hospital
component. National standards f o r c e r t i f i c a t i o n or registration of the
s t a f f should be enacted which would supercede state regulations i n these
areas. Currently many states have weak or non-existant requirements
for the t r a i n i n g of technicians i i imammography and other areas.
These
�63
are c r i t i c a l areas i n wcmens health care. Many pieces of t h i s type of
equipment are used t o supple'nent physician's inccme and i t reduces the
a b i l i t y of hospitals provide cost effective services. As has been pre-viouly _ discussed, competition i s not effective i n the health care f i e l d ,
as the physician determines the tests to be done and the f a c i l i t i e s t o
be used. These, accumulated data w i l l , again, be used by the regional
authorities to make judgements regarding the retention of particular
facilities.
Great care should be used i n establishing standards as t h i s
could be subject t o fraud and abuse and favoritism.
be used to prepare analysis and reconmendations.
regional authorities should be p u b l i c l y
Outside firms should
Decisions made by the
available and the reasons why
determinations were made. As i n the case of hospital decisions, contract
awards should be effective over a period of time so that proper adjustments
can occur.
F a c i l i t i e s receiving contract awards should have the capacity
to expand t h e i r operations and the services should be available at times
which are convenient t o the public and to related health services
because
there w i l l be some reduction i n the irrmediate a v a i l a b i l i t y of services.
Over the period of the contract there should be specific responsibilities
on those f a c i l i t i e s being awarded the contracts. Out-patient and c l i n i c
services shall have negotiated payments f o r each type of service or procedure to be done. These negotiated payments should be comparable t o other
f a c i l i t i e s i n s i m i l i a r situations.
For example, r u r a l f a c i l i t i e s may
have a low volume each day, but s t i l l require s t a f f i n g 24 hours each
day f o r emergency services.
high costs.
Such s t a f f i n g makes these f a c i l i t i e s have
Payments to these f a c l i l i t i e s would have to be ccmparable
to f a c i l i t i e s located i n s i m i l i a r situations.
�.64
Diagnosis Related Group strategy shall also be used for workers'
compensation health care payments and health care portions of autcmobile
accidents.
I f t h i s i s not done there would be major cost s h i f t i n g t o
those areas by hospitals that were t r y i n g to maintain a l l services that
they formerly provided.
There w i l l be an offset t o the inclusion of
these additions, namely, there should be substantial premium reductions
to individual policy-holders as well as employers. The insurers w i l l
s t i l l have the a b i l i t y to s e l l insurance for pain and suffering and other
compensable damages. Hospitals and physicians and other providers w i l l
be helped by t h i s payment system since, currently, there are long delays
in resolving c o n f l i c t s and many law suits before there i s any payment
for services. This would, of course, be a costly addition t o the taxpayer
but they would be saving i n premiums. Naturally, there w i l l be problems
with the issues discussed i n this section. Physician's patients might
have to go to other f a c i l i t i e s for X-rays, mammograms, etc., i f they
were not provided i n his o f f i c e .
The physician might not be able t o
receive reports as quickly as when they were done i n his own o f f i c e .
However, with the use of FAX machines and other s i m i l i a r equipment these
results could be available within a reasonable period of time.
The credit
card type of system proposed could be used i n some of the settings including
some of the physicians' offices where batch-billing and electronic b i l l i n g
are not i n current use.
Seme of the smaller f a c i l i t i e s , namely, hospitals
with less than 100 beds which are n o t - f o r - p r o f i t could have budget-based
negotiated payemnts. These hospitals would be primarily i n r u r a l locations
where there are few medical f a c i l i t i e s .
Hospitals where medical and
surgical services were discontinued, for example, could retain 24 hour
�65
observation services where determinations could be made f o r admission
to other f a c i l i t i e s .
I n large c i t i e s which have many hospitals there
could be specialization of services.
For example, there could be hospitals
that would specialize i n heart disease, cancer and respiratory illnesses.
The advantage of t h i s specialization i s that these hospitals would
not have to maintain expensive intensive care coronary units, surgical
units and emergency services i f t h e i r specialization did not require
such units.
These "are very expensive units to maintain frcm a s t a f f i n g
point of view as well as requiring modem equipment which i s frequently
underutilized.
Specialization would also improve expertise i n specific
areas. Outccmes could be ccmparable to other s i m i l i a r f a c i l i t i e s .
�66
Recommendat ion
8.
I t i s recommended that a national medical education p o l i c y be developed.
Rationale
One of the reasons f o r the high medical costs i n the United States
ccmpared to other countries of the world may be the medical eductation
system. At the present time only 30 percent of the nation's 600,000plus doctors are i n primary care.
This contrasts with Great B r i t a i n
where 70 percent of the physicians are i n primary care.
As was noted i n our previous discussion, there are many areas of
the country where large segments of the population have l i t t l e or no
access to medical care.
Nationally, there i s a growing awareness of
the need f o r change i n the number of specialists compared t o the number
i n primary care.
For example, the Robert Wood Johnson Foundation i n
Princeton, New Jersey granted $1.8 m i l l i o n to 12 medical schools t o
spur a re-examination of curriculum
This type of re-examination i s
going on at many of the nation's i n s t i t u t i o n s .
Some steps have also been made, especially with the Medicare program,
to increase the financial rewards paid to primary care physicians, namely,
those who practice internal medicine, family medicine and pediatrics.
As noted i n the previous sections, payments to primary care providers
are a small fraction of that paid to many s p e c i a l i s t s .
69
Another area of concern i s the fact that specialists order medical
care at higher costs than family physicians.In an "outcomes" study
which tracked 20,000 patients i n Chicago, Boston and Los.Angeles as published by the American Medical Association, which compared the quality
�67
of care and costs suggests that there could be new avenues f o r cost containment. According t o the a r t i c l e :
In terms of specialities, the new data show that heart doctors
and gland specialists, or endocronologists, order much more expensive
care than general internists or family doctors when treating v i r t u a l l y
identical conditions.
For example, after adjusting f o r differences i n sickness and
other variables, the researchers found that cardiologists hospitalized
10.5 percent of the patients i n 1986, endocrinologists hospitalized
7.1 percent, general internists hospitalize^ 5.6 percent and family
practitioners hospitalized 4.8 percent. These are significant
differences.
While the study noted that HMDs trim costs more than any other
practice arrangement, they also limit patient choices of practitioners w
than any other arrangement according to Dr. Richard L. Cravits o f the
70
U.C.L.A. Department of Medicine.'
I t i s proposed that each region of the new Medicare program begin
a t o t a l re-examination of the goals of medical education with the objective
of reducing the number of students entering specialty f i e l d s to a more
reasonable percentage.
For example, i f only 25 percent of the physicians
went into specialty areas and 75 percent went into primary care consisting
of family practice, internal medicine and pediatrics, t h i s would improve
the overall a v a i l a b i l i t y of health care.
As was shown i n previous examples,
there are many states which have millions of people without the necessary
primary care.
Each region of the United States i s d i f f e r e n t , i n the sense of
emphasis i n t h e i r medical schools.
Some have only a few medical schools;
some provide specialists f o r the nation; some provide medical school
teachers while others have a regional or state emphasis on primary care.
�68
This research, which seeks new goals and mission, would be expensive
but i t should produce change. Governmental grants for research given
to medical schools should also be directed toward outcome i n the medical
field.
The number of scholarships i n specialty fields should be reduced
while the number of scholarships i n primary medicine should be increased.
I t should be noted that this type of re-examination and change
of emphasis w i l l take time and immediate results.should not be expected.
Each i n s t i t u t i o n i n t h i s proposal should prepare 10 year goals
and the steps to be taken annually so that change does not only occur
in the last year of the 10 year plan.
I t has been suggested that the income of the primary care physicians
are r e l a t i v e l y low and that there i s a staggering debt, which at some
private educational i n s t i t u t i o n s i s as much as $100,000 as a reason
why many physicians do not enter primary care.
The typical doctor has
a debt of $46,000. However, the issues are probably deeper than the
amount of debt.
At seme medical schools, primary care i s not considered
to be at the same social level as specialty care.
This and the lower
income expectations deters physicians from entering primary medicine.
Also, as has been discussed, there i s the complexity of medical
care and the p o s s i b i l i t y of medical l i a b i l i t y i n primary care while
specialty care medicine has a narrow focus on specific diseases.
Financial programs which provide forgiveness of debts to medical
students after they work f o r a certain number of years i s one step t o
getting doctors t o these areas. However, the greatest potential f o r
remaining i n a given cctrmunity i s i f you were bom, educated and i f
your family lived i n that area.
�69
The author o f t h i s report feels that the forgiveness o f the physicians'
debt i s probably not the complete solution.
locate a practice are ccmplex.
Decisions as to where t o
Many of the young physicians who enter
a practice are married or expect to be married shortly and the physician's
spouse or fiancee does not wish to go to remote areas or ghettos, however
attractive they may be because of the lack of social and peer opportunities
these ccnmunities may have for the new doctor. This causes the physician
to enter medical practice i n attractive suburban and urban settings.
Merely providing financial rewards and loan foregiveness does not necessari l y mean retention of these physicians i n underserved areas. They may
enter
practice i n these areas and remain f o r three to five years i n
order to repay t h e i r loan and then leave. I n the meantime, the communities
which have set-up c l i n i c s are without a physician particularly i n the
r u r a l areas.
Naturally, i t i s hoped that a f t e r three to f i v e years
in a community, a physician w i l l remain i n that ccmmunity. This.may
not be necessarily true as the physician would probably enter those
practice situations where he planned i n i t i a l l y t o go with his education
and training rather than remain i n the underserved area. The greatest
potential f o r remaining i n a given community i s i f you were bom and
educated and your irrmediate family lived i n that area.
Many r u r a l areas do not have s u f f i c i e n t volume t o support specialists,
so these physicians practice i n larger ccrmunities.
The regional authorities should also work with the medical schools
and the universities i n the f i e l d of technical health education. At
the current time, probably because of the recession, increasing numbers
of young people are entering graduate school rather than finding employment
�70
after their baccalaureate education.
These young people are a major
resource f o r our country i n the health care f i e l d .
Currently there
are very limited opportunities i n the health care f i e l d for students
with graduate degrees. There are thousands of highly motivated young
people who are professional nurses, laboratory technicians and other
specialists who could be trained f o r d i f f e r e n t responsibilities. I t
would seem l o g i c a l that new specialties could be> created to help the
primary care physician working i n underserved areas.
This would help
to bridge the gap with the millions i n t h i s country who do not have
access to health care and who, as a result use the nation's emergency
rooms. This type of proposal would be d i f f i c u l t to implement and would
take time working with vested interests i n the different states.
These graduate programs could be based at local 2 year colleges
with instructors from medical school faculties.
The additional cost
of such programs could be limited t o the instructional area alone.
At the present time, much of the college infrastructure i s i n place
in the country.
Colleges and universities could also be used f o r expanded
coverage of the health program.
A few years ago, the American Medical Association endorsed a concept
of physician's assistants. This concept could be enlarged into a graduate
program into which professional nurses, health educators, laboratory
technicians and other health care workers with baccalaureate degrees
could enter.
With the advent of new technology such as closed c i r c u i t television,
FAX machines, conputers and s a t e l i t e systems, the graduate school trained
technicians could provide services at ccmmunity f a c i l i t i e s and have
�70a
t h e i r assessments reviewed at medical schools or at hospitals or larger
clinics.
Advanced technology could be used by the technicians i n the
f i e l d where patient histories are taken i n great d e t a i l , entered into
conputers and then transmitted to central f a c i l i t i e s .
S i m i l i a r l y X-
rays, laboratory test results and other data could be transmitted t o
other locations. The reccmmendations of the technicians i n the f i e l d
could be v e r i f i e d and treatment authorized.
Such arrangements could
elevate the present limited access to physician care i n underserved
areas.
In some instances, the level of care could actually be improved
because technicians would be available and the histories of patients
could be much more detailed than the present histories taken by the
over-worked primary care physicians.
Outcomes could be better related
to the treatment through the use of computers, also the use of medical
schools and major hospitals could bring the same high level of care
that i s available i n the large metropolitan areas t o the r u r a l communities
because they could be accessed by the specialists i n those areas.
A major obstacle to change i n the regions would be the licensing
authorities.
Sometimes i t takes years to change bureaucratic i n s t i t u t i o n s
to new thinking.
There would be resistance t o such changes from the
medical establishment, but the stakes are very high i n a $699 b i l l i o n
dollar industry which i s threatening our country's econcmic survival.
This resistance could be overcome by working with the state authorities,
using reward systems, grants and other inducements. The medical schools
could adjust t h e i r curriculum to include two year graduate programs
which would include internships i n high volume patient areas.
could be very intensive i n basic health areas.
The training
During the Vietnam War,
�71
we had highly trained corpsmen who could handle b a t t l e - f i e l d trauma
and minor illnesses.
By u t i l i z i n g this type of training which could
serve as a method of illness screening with v e r i f i c a t i o n by medical
practitioners.
This proposal w i l l allow the nation to reach the areas
which lack primary care.
�72
Recomnendation
9.
I t i s recommended that the new Medicare program place emphasis
on the Regions of the country rather than have central federal
control.
Rationale
The federal Medicare program, for the large part, i s centrally
administered with l i t t l e local, state or regional input into i t s administration.
The result often i s that the major concerns of the program
are the payment o f cost t o the providers of service and the publication
of rules and regulations. The consequences are a lack of concern for
the serious problems within the system. This proposal i s t o decentralize
some of the bureaucracy of the system and to make the regions accountable
for medical i n f l a t i o n occurring i n t h e i r region.
The reason t h i s regional method i s being proposed rather than a
state-operated system i s that there would be too much bureaucracy i f
there were f i f t y d i f f e r e n t state systems. Some states have very small
populations and limited health care and administrative resources.
Also,
major decisions w i l l have to be made regarding the closure of hospitals
and other f a c i l i t i e s and the awarding of contracts for services. The
regional concept would probably provide less unwarrented influence by
vested interests i n the decision-making process. The nation has seen
the success that occurred when the American Telephone and Telegraph
Company was broken up.
This type of organization could be very beneficial
to the health care industry. This i s not to say that there wouldn't
be any federal involvement because there would be uniformity of administration and a need f o r consensus among the regions.
I t i s envisioned
�M
0)
U S DEPARTMENT OF COMMERCE
Burt«u Qt the Consul
* The Midwest Regton wes desio^et^d as the
North Central Region until June 1964.
�73
that there would be a number of areas where there would be cost savings.
An example of t h i s are the many states which have planning authorities
whose duty i t i s to approve hospital and nursing home construction.
Some of these planning authorities could undertake planning f o r a number
of area states, thereby reducing duplication of e f f o r t .
Similiarly
there are cost containment councils i n seme of the states which could
be u t i l i z e d by other states. These regional organizations could be
located at some of the major universities thus saving the cost of building
new support f a c i l i t i e s , such as research f a c i l i t i e s .
In the following
section there w i l l be a discussion of some of the major functions of
the proposed regional organization.
9a.
Research into medical outcomes.
Rationale
Major research should be directed into the areas of medical outcomes
as these are necessary f o r the development of quality medicine as well
as for cost effectiveness. The regional organization could issue awards
to researchers.
The idea i s to give prestigious awards t o individual
and organizations that develop good models for use by the region's physicians as well as nation-wide.
Often there are research findings which
are significant, but which are not transmitted t o the providers of care.
One of the goals of the research organization could be to maintain active
cenrmunications with physicians throughout the region as well as with
other regions.
9b.
Fraud and abuse.
Here again, i n the present system there are major issues of fraud
�74
but because of the vastness of the bureaucracy only a few measures are
taken to counteract the fraud. Recent examples are i n the medical supply
and equipment areas where major fraud has occurred.
I t i s suggested
that a fixed percentage of the allocation of the region's expenditures
be devoted to fraud and abuse. This fixed percentage should increase
annually at least at the rate of general i n f l a t i o n and that should be
fixed by law.
A recent example was a reduction of monies allocated
to fraud and abuse'which was reduced f o r budgetary reasons even though
each dollar expended reduced fraud by eleven., dollars.
The Federal Bureau of Investigation could permanently assign s t a f f
to this function who would be working from the regional offices.
These
investigators could be persons familiar with medicine such as professional
nurses, physicians, laboratory technicians and others. Physician profiles
could be prepared and t h e i r income analyzed. Payments due to regional
hospitals could be reviewed by knowledgeable personnel.
This review
could f l a g unusually large payments to physicians or to other providers,
thereby helping to correct problems before serious fraud and abuse occurs.
9c.
Contracts with providers.
These contracts would require a great deal of research i n i t i a l l y .
Each of the providers would be required to submit an inventory of their
equipment. Since Medicare reimburses building and equipment, they should
be allowed to monitor and approve major purchases. The regional o f f i c e
should be knowledgeable regarding the d i f f e r e n t types of equipment that
medical providers use and establish p r i o r i t i e s as to what should be
replaced and how soon. A c r i t i c i s m of the Canadian and some of the
systems i s that the approval time takes too long' f o r . c r i t i c a l '
�75
instrumentation.
The regulations should provide for speedy resolution
of certain problems and slower resolution of others. Specifications
for provider contracts w i l l take time to prepare especially i n certain
areas where extensive studies are required p r i o r t o implementation.
9d.
Legislative l i a i s o n .
In the past there was rapid growth o f expenditures i n some of the
areas of health care which were not noticed or corrected. I t i s proposed
that effective l i a i s o n be maintained by the regional o f f i c e with Congressmen. This would allow the enactment o f laws to curb abuse almost as
soon as i t occurs rather than after a long time has elapsed.
9e.
There should be a high p r i o r i t y f o r health education i n the new
Medicare plan.
There should be a major p r i o r i t y f o r health education. Many of
the country's major health improvements have occurred through l i f e - s t y l e
changes and healthful l i v i n g .
The program should place fixed responsibil-
i t y for growth i n the area of health education expenditures.
A fixed
percentage of the t o t a l health care budget should be devoted to health
education.
This percentage should increase anually at the same rate
as medical i n f l a t i o n .
Health education material should be produced
locally rather than centrally.
Input should be sought from minority
and other groups whose health care s i g n i f i c a n t l y deviates from other
citizens of the country. Specific problems should be addressed which
apply to such groups as AIDS, teenage pregnancy, drug use and abuse, etc.
9f.
Competitiveness.
The regional organization should promote competition among the
different regions. By providing financial rewards to employees f o r
�76
suggestions as well as incentatives to hospitals and other providers
w i l l help competitiveness.
Recent studies have shown that there are vast differences i n charges
among the d i f f e r e n t regions of the country.
Some of this i s due t o
the fact that certain states have placed a great deal of e f f o r t on cost
control during the past decade.
9g.
Administrative simplification and standardization.
There should be task forces working on administrative cost reduction
through s i m p l i f i c a t i o n and standardization... .In.the past, a l l hospitals
developed t h e i r own forms i n response t o federal and state requirements
which i s an expensive way to meet these requirements.
By standardizing
some of the forms and making them available to other hospitals reduces
costs.
Also, there i s much duplication of information which i s of question-
able value.
Standardization and s i m p l i f i c a t i o n w i l l reduce the volume
of paperwork.
9h.
Quality assurance and accreditation.
Regional accreditation systems should be used rather than national
systems. By observing l i t i g a t i o n and responding to the reasons f o r
the suits w i l l enhance the region's a b i l i t y to respond to l i a b i l i t y
concerns. The region could develop survey organizations which help .to
reduce the need f o r each hospital to have i t s own quality assurance
staff.
I f the nation's 6,700 hospitals were to eliminate one-third
or one-half the s t a f f devoted to quality assurance, i t would
substantial savings.
than internal s t a f f s .
provide
Outside s t a f f s might enhance problem solving better
�77
Recomnenda t ion
10.
I t i s recommended that the present Medicare program be reformed.
Rationale
With the present Medicare system as the basis of the new national
health care system, there has to be a certain amount of reform and change
to accomodate a national system.
Seme of the baeic assumptions made
when the program was adopted and written into rules and regulations
might not be applicable to a national system.
The following are re-
commendations f o r the new national Medicare:
10a. Depreciation.
At the present time. Medicare pays approximately 85 percent of
the depreciation cost attributable t o the program.
I f there was a nation-
a l system, t h i s would mean that over a period of time there would be
l i t t l e or no funds available to replace equipment and buildings. The
depreciation i s based on h i s t o r i c a l costs, which i n the inflationary
times-is i n s u f f i c i e n t f o r equipment and building replacement.
The new system would require 100 percent depreciation on equipment
plus medical i n f l a t i o n on the equipment.
The depreciation on the building
could be h i s t o r i c a l cost plus the cost of general i n f l a t i o n .
Even t h i s would not be s u f f i c i e n t f o r replacement. The depreciation
payments could be handled i n several ways, f o r example, the program
could retain the funds and issue vouchers t o the hospitals which would
be used to requisition equipment when i t s purchase has been approved.
This, frcm the hospital point of view would be the least desireable
method; the other method would be to continue to pay the depreciation
�78
to the i n s t i t u t i o n , but require approval before they can expend funds,
and the t h i r d method would be to allow them to purchase equipment as
they have i n the past.
However, the system w i l l have to be reformed
so as to provide s u f f i c i e n t assets to continue as viable i n s t i t u t i o n s .
I f , as has been projected i n this paper, there i s a reduction i n
the number of i n s t i t u t i o n s which are f u l l service hospitals, because
the plan i s to reach 8 0 to 85 percent occupancy .Levels compared t o the
present 65 percent levels.
These lower levels would make i t possible
to maintain the same level of funding as i n the past.
Howver, there
may be a one or two year lag before the down-sizing can occur.
10b. Operations.
At the present time. Medicare pays approximately 90 percent of
the cost of care f o r t h e i r patients.
This would have to be at least
100 percent for the patients who are currently on Medicare. Because
there can no longer be any cost s h i f t i n g of amounts that Medicare Qoesn't
pay to other payors.
The program w i l l have to support i t s share
of the entire hospital operations. This would cause an increase i n
diagnosis related payments for the Medicare-aged patients.
For the
new additional patients there would have to be seme additional compensation
above the diagnosis related groups.
Some of the hospitals i n the Los
Angeles area have much higher charges, than, for example, the New York
state area.
The implementation of this program could have a serious
impact on such high cost i n s t i t u t i o n s .
New York state has had cost
controls f o r a number of years which has been successful i n reducing
their costs. This has not been true i n California.
�79
During the f i r s t year the diagnosis related groups should pay 120
percent above the national average; then i n the following year, reduce
t h i s to 115 percent; then i n the t h i r d year, to 110 percent; then i n
the
fourth year to 105 percent and f i n a l l y to zero percent throughout
the country.
However, a l l of these amounts would increase due to i n f l a t i o n .
This system of support during the t r a n s i t i o n i s s i m i l i a r to the time
when t r a n s i t i o n occurred to r u r a l and metropolitan rates of payment.
The i n i t i a l increase i n costs could be offset i f the regional organizations were able to reduce the number of hospitals i n the country
based on occupancy levels.
10c. A r b i t r a t i o n of medical claims.
Laws should be enacted which require a r b i t r a t i o n by the participants
in the new Medicare program i n case of medical l i a b i l i t y .
Also l i m i t s
should be placed on pain and suffering which can be raised depending
on national
inflation.
The program can not pay large monetary awards
and s t i l l survive as a viable system of care.
lOd. Fraud and abuse.
There should be changes i n the present laws to detect and punish
those who practice fraud. In the area of home health services and durable
medical equipment, there should be physician c e r t i f i c a t i o n or other
professional c e r t i f i c a t i o n for medical equipment used at home. This
c e r t i f i c a t i o n would be the same type that was used by physicians who
treat Medicare patients.
The c e r t i f i c a t i o n would require the dates
of the most recent physician v i s i t or v i s i t s by a
nurse.
The form
should specify the status of the patient; whether the patient i s ambulatory,
�80
bedfast; can walk with a walker or i f he has to use a wheelchair, etc.
C r i t e r i a should be established f o r the need for different types
of equipment depending on their status. The c r i t e r i a should be reviewed
at least annually i f new services are being added. This would stop
some of the automatic approvals by physicians for purchases of durable
medical equipment.
S i m i l i a r l y , i n the case of high-tech equipment therapy,
there should be units of service established
I t should be reasonable.
for services rendered.
Hot lines should be established i n each region
and advertised where citizens can ccmplain about high prices paid for
durable medical equipment and services.
lOe. Co-payment and deductibles.
Prenatal care, maternity services and children up t o the age of
18 w i l l not require a deductible or a co-payment for patient services.
Deductibles and co-payments w i l l be required for a l l adults above the
age of 18.
There should be a limited number of co-insurance plans which
would reduce the amount of paper-work at hospitals and physicians' offices.
10f. Skilled nursing services.
Skilled nursing services should continue i n the same manner as
i n the past.
The author feels that nursing homes should continue to be covered
by the Medicaid program as has occurred i n the past.
To allow participants
who have the resources to pay for the program to receive benefits would
not be included i n the new Medicare program. This applies to custodial
services, not s k i l l e d services.
I f nursing heme care were included
in the program, there would be a tremendous increase i n the number
entering nursing homes which would be t o t a l l y unpredictable and would
�81
place a tremendous burden on the system.
be available f o r these patients.
Medicaid should continue to
I n the case of AIDS patients, they
shall receive the same type of hospitalization as other patients who
have acute conditions when such conditions occur.
Their care i n nursing
homes should continue to be under the Medicaid program u n t i l the system
has had some further experience.
lOg. Insurance ccmpanies.
*
Insurance companies shall continue t o provide insurance f o r deductibles
and co-insurance f o r Medicare-aged patients and the new Medicare patients.
Provisions i n the policies could include additional obstetric benefits
and maternity benefits.
I t was suggested i n the earlier part of this
paper that there would be l i m i t s to the annual number of v i s i t s t o
physician offices based on current nation-wide averages.
Visits i n
access of these goals could be covered by the insurance companies.
lOh. Support of r u r a l hospitals.
Underserved areas could receive support based on t h e i r needs i f
services are d i f f i c u l t to obtain.
�82
6. Implementing the National Health Care Policy
General Principles
1.
A l l federal health care programs w i l l be administered by the Department of Health and Human Services.
This w i l l include the present
Medicare, Medicaid, CHAMPUS, Veterans Administration hospitals.
Bureau o f Indian A f f a i r s health f a c i l i t i e s , m i l i t a r y hospitals
and a l l governmental health care a c t i v i t i e s .
2.
The present Diagnosis Related Groups (DRGs) shall be used f o r a l l
claims
3.
processing.
The present Medicare claims processing centers w i l l be retained
and exp nded t o include a l l governmental providers of health care.
4.
The present Professional Review Organizations
(PPOs) w i l l be region-
alized f o r greater efficiency.
5.
The Department of Health and Human Services w i l l serve as a Regional
coordinator.
6.
An annual incentive and appraisal system w i l l be established.
This w i l l include employees at the national, regional and d i s t r i c t
levels.
The purpose of this section i s t o create competition among
the regions i n areas'of cost effectiveness and the quality of care
provided.
The basic concept would be s i m i l i a r to the break-up
of the telephone system into regional systems.
7.
Regional. Health Administration Centers w i l l be established (ReHacs).
The Centers would be s i m i l i a r t o the present census centers. The
w i l l be organized i n the following manner:
�83
a.
Administrative Structure. A l l the regions shall have an executive
director and a support s t a f f s u f f i c i e n t to maintain responsibilities
assigned under the National Health Care Plan.
Regions such as
Alaska and Hawaii may be combined with the Pacific Region. There
shall be a governing body which i s ccmposed of representatives
of the d i f f e r e n t states i n the Region. The states shall present
a slate of nominees frcm each of t h e i r congressional d i s t r i c t s .
The majority of the governing body shall be consumers of health
services.
The congressional d i s t r i c t s shall be organized i n a
s i m i l i a r manner.
b.
Departments.
Child Irrmunization. The major focus of this department i s health
education and the coordination of a c t i v i t i e s of the d i f f e r e n t
congressional d i s t r i c t s of the region.
The department w i l l help
to prepare health education material for specific groups i n each
region.
Infant Mortality and Morbidity. This department w i l l f i r s t focus
on those areas of the region which have the following characteristics:
i . underserved health areas including wards i n c i t i e s and r u r a l
conrmunities;
ii. high poverty areas including wards i n c i t i e s and r u r a l corrmunities;
i i i . high drug and substance abuse areas;
iv.
high teen-age pregnancy, poor maternal health and poor childhood health areas;
v.
vi.
low population density areas; and
high medical cost areas.
�84
Research i n AIDS. This department w i l l coordinate AIDS research i n
the region.
I t w i l l coordinate and encourage locally-produced
health education material pertaining to AIDS. I t w i l l inform the
regions, through newsletters about progress i n this v i t a l . f i e l d .
Simplification and Standarization Department. This department w i l l
coordinate regional a c t i v i t i e s i n the f i e l d of simplification and
standardization of hospital and other provider forms and claims
processes so "as to reduce administrative expense.
Contractual Services Department. The o r i g i n a l Medicare law had
Conditions of Participation which required hospitals and other
providers to meet certain standards of care; however, t h i s new
concept, requires providers to have contracts for specific services.
This w i l l require a l o t of work i n the beginning to d r a f t model
contracts for the d i f f e r e n t types of services. As the program
progresses there w i l l be a reduction i n the number of hospitals
which w i l l be awarded contracts f o r in-patient and specialized
care.
Medical Education Department. The objective of this department
is to evaluate the need f o r medical specialists as opposed to family
practitioners.
I t w i l l coordinate the a c t i v i t i e s of the medical
schools i n seeking proper relationships i n this area so that long
term objectives can be met i n physician education.
I t w i l l encourage
experimentation i n new education methods and service delivery i n
r u r a l and ghetto areas.
Medical Outccmes. This department w i l l work with other regions
�85
of the country to coordinate research into medical outccmes so
that duplication i s reduced and so that outccme information i s
provided to medical practitioners.
A recent example of the lack of knowledge was the breast implant
issue where spokespersons of the Federal Food and Drug Administration
announced publicly that there i s more knowledge available about
replacement t i r e performance than about breast implants which affect
millions of wtxnen.
The department should provide grants to researchers i n an
organized manner.
Fraud and Abuse Department. This deparament shall review patterns
of care, payments to medical providers, excess budgets f o r services
and other indications of fraud or abuse. I t should review the
d i s t r i c t s so as to prevent problems.
There should be close working
relationships with federal and state law enforcement authorities
so that they w i l l become aware of potential problems i n the health
care delivery system.
Legislative Liason Department. This department w i l l work closely
with the congressional d i s t r i c t s i n each region so that changes
in laws can be made i n a timely manner. The relationship should
be informative as opposed to being a lobbying relationship.
The
same relationship should be encouraged f o r the d i s t r i c t s of the
region who are working with state legislators.
Health Education Department. This department w i l l focus to coordinate
health education a c t i v i t i e s i n hospitals and other health settings
so that the latest information i s available to a l l health care
: ^Kxaders.
'
�86
Competitiveness Department. This department w i l l review the financial
reports of a l l hospitals and other health care providers who are
required t o submit such reports. The review w i l l be based on the
cost of medical services and trends at the different providers
of health care.
S t a t i s t i c a l ananlysis of performance w i l l occur.
Ccmparisons w i l l be made among the d i s t r i c t s as well as against
other regions i n the nation.
Quality Assurance Department. This department w i l l serve to coordinate quality assurance a c t i v i t i e s i n the region.
I t w i l l work with
the d i f f e r e n t d i s t r i c t s so that they can s t a r t cooperative quality
assurance programs among the d i f f e r e n t providers.
Arbitration Department. This department w i l l work with the different
states i n preparing uniform laws regarding medical l i a b i l i t y i f
such laws are not enacted by congress,
c.
Planning Responsibilities.
Each of the d i s t r i c t s w i l l employ community development professionals t o assesss health care resources.
They w i l l survey a l l
the counties and other local sub-divisions to determiner
resources
present and future for new health care providers such as school
health c l i n i c s and irrmunization centers.
They w i l l map d i s t r i c t
resources as well as medical resources i n surrounding areas.
They
w i l l work with the corrmunities i n each region so that there w i l l
be coordination of services and that required services are available,
d.
D i s t r i c t Organizations.
The d i s t r i c t s shall also have an executive director and a
�87
support s t a f f s u f f i c i e n t t o maintain respnsibilities assigned under
the National Health Care Plan.
There shall be a governing body
whose majority i s composed of consumers of health services. The
governing body s h a l l be small, perhaps 9 members. I t shall be
chosen from members representing the congressional d i s t r i c t .
The
membership shall be larger, f o r example, 100 or more so as t o be
representative.
The s t a f f , with board concurrence, shall assess
providers of services and make other recommendations t o the regional
boards.
e.
Facilities.
Whenever possible, both the region and the d i s t r i c t
shall use medical schools, research universities and other educational
f a c i l i t i e s f o r t h e i r administrative f a c i l i t i e s as as to avoid building
costly infrastructures.
�88
Summary
By having a regional organization as opposed to a national organization
would enhance the program's a b i l i t y to act on problems quickly and resolve
these problems i n an e f f i c i e n t manner.
In the area of competition, the Regions could have the t r a d i t i o n a l
areas such as Metropolitan and Non-Metropolitan plus Regional with an
i n i t i a l neutral standing f o r a l l regions and then those Regions with
higher than average cost increases would have higher payments by i t s
citizens f o r health care.
�89
End Notes
"'"Nancy Linnon, "A New Bnphasis on Ccnpassion," U.S. News and World Report,
Washington, D.C., A p r i l 29, 1991, p. 85.
2
E d i t o r i a l s t a f f , "New Rx f o r Doctors," U.S. News and World Report,
Washington, D.C, A p r i l 29, 1991, p. 85.
3
"^Editorial s t a f f , Op.cit., p. 85.
4Janice Castro, "Condition: C r i t i c a l , " Time, N.Y., Nov. 25, 1991, p.
38.
5
E d i t o r i a l s t a f f , "Health" U.S. News and World Report, Washington, D.C,
February 3, 1992 p. 47.
t
6
J u l i a Flynn S i l e r , Susan B. Garland, Paula Dwyer, "An Operation Fraught
With Risks," Business Week, N.Y.,N.Y., p.83.
7
E d i t o r i a l s t a f f , "A P r e s c r i p t i o n f o r Reform," Business Week, N.Y.,N.Y.,
October 7, 1991, p. 60.
i t o r i a l s t a f f , "Medical Care i s on the C r i t i c a l
Evening C a l l , DuQuoin, I I . , Jan. 11-12, 1992, p.
9
J u l i a Flynn S i l e r , Susan B. Garland, Paula Dwyer,
With Risks," Op. c i t . , p. 83.
" ^ E d i t o r i a l s t a f f , "Health Care Keeps Taking Bigger
BusinessWeek, N.Y.,N.Y.,Feb. 19, 1990, p. 3.
L i s t " (NEA), DuQuoin
7.
"An Operation Fraught
Bites o f the Economy,"
"'""'"Nick Mareano, "U.S. Health Care: I s There a Better Way?" American
Weekend, Jan. 4-5, 1992, p. 7.
"^Susan B. Garland, "A P r e s c r i p t i o n f o r Reform," Business Week, N.Y.,N.Y.,
Oct. 7, 1991, p. 6 1 .
" ^ V i c t o r Fuchs, "The Health Sector's Share o f the Gross National Product,"
Science, February 2, 1990, p. 536.
14
V i t o r Fuchs,"Don't Look f o r Better Health from National Health Insurance,"
T h e Wall S t r e e t Journal, December 11, 1991, p. 7.
Dr. David Hinrnelstein, "More and More Americans Don't Have Health Insur- T
ance," Southern I l l i n o i s a n , " Carbondale, I I . , Dec. 19, 1991, Sec. B,
p. 2.
16
E d i t o r i a l s t a f f , "Health Section," Fortune, N.Y.,N.Y., A p r i l 23, 1990,
p. 224.
17
Seymour Sudman, "Studies Find HMO Fees Discourage Doctor Use," DuQuoin
Evening C a l l , DuQuoin, I I . , A p r i l 2, 1990, p. 5.
18
E d i t o r i a l s t a f f , "Health Issues," Business Week, N.Y.,N.Y., February
3, 1992, p. 27.
19
J u l i a Flynn S i l e r , Susan B. Garland, Paula Dwyer, "An Operation Fraught
With Risks," Cp. c i t . , p. 83.
20
Derrick Z. Jackson, "We're Behind: U.S. T r a i l s World on C h i l d Immunization,"
15
�90
Southern I l l i n o i s a n , Carbondale, I I . , Mar. 5, 1992, p. 8.
21
V.R. Fuchs, Diane Ricklis, "Children Wellbeing Falling i n Past 30
Years," Science Magazine, Southern I l l i n o i s a n , Carbondale, I I . , Jan.
4, 1992, p. 7.
22
Daniel R. Hawkins, Jr., "42.8 M i l l i o n Americans Have Inadequate Medical
Care," National Association of Comnunity Health Centers, DuQuoin Evening
Call, Feb. 27, 1992, p. 3.
23
Jim Gallagher, "Canadian Likes His Health Plan," St. Louis Post Dispatch,
Oct. 31, 1991, p. 5.
24
Marian Wright Edelman, "Study: Rural Kids More Likely to be Poor,
Unhealthy,"_ Southern I l l i n o i s a n , Carbondale, 111., Dec. 19, 1991,
Sec. B, p. 2.
25
Staff, "Report: I l l i n o i s Children at Greater Risk Than Most," Kids
Count Data Book, Southern I l l i n o i s a n , Mar. 24, 1992, p. 2.
26
Daniel R. Hawkins, Jr., "42.8 M i l l i o n Americans Have Inadequate Medical
Care," Op. c i t . , p. 10.
27
Staff, "Panel Proposes Plan to Improve Health Care, Advisory Council
on Social Security," Southern I l l i n o i s a n , Carbondale, I I . , Dec. 20,
1991, p. 10.
28
Staff, "Bush"s Budget Increases Social Program Spending," Southern
I l l i n o i s a n , Carbondale, I I . , Jan. 27, 1992, p. 26.
29
Staff, "Aids Deaths Rise By One-Third," Department of Health and Human
Services, Southern I l l i n o i s a n , Carbondale, I I . , Jan. 8, 1992, p. 2.
30
Staff, "AIDS Epidemic Affecting More Heterosexuals," U.S. Center of
Disease Control, Southern I l l i n o i s a n , Carbondale, I I . , Jan. 17, 1992,
p. 7c.
31
Dr. John D. Hamilton, "Study: Early AZT Does Not Prolong AIDS Victims'
Lives," New England Journal of Medicine, Southern I l l i n o i s a n , Carbondale,
I I . , Feb. 13, 1992, p. 5a.
32
Fred Hellinger, "AIDS, HIV Cost to Hit 5 B i l l i o n , " Agency f o r Health
Care Policy," Southern I l l i n o i s a n , Carbondale, I I . , Nov. 29, 1991,
p. 1.
33
Staff Report, "Cost of Treating HIV Could Reach $10.4 B i l l i o n , " RN
Magazine, Southern I l l i n o i s a n , Feb. 24, 1993, p. 3.
34
Staff Report, "Heterosexual Sex Causes 90 Percent of New HIV Cases,"
Op. c i t . , p. 5A.
35
Staff Report, "AIDS Epidemic Affecting More Heterosexuals,Op. c i t . ,
p. 6c.
36
Howard Gleckman, "Social Security's Days as a Sacred Cow are Numbered,"
�91
Business Week, N.Y., N.Y., Apr. 2, 1990, p. 33.
37
Susan Dentzen, "The Graying of Japan," U.S. News and World Report,
Washington, D C , Sept. 30, 1991, p. 69.
..
38
Staff, Population Reference Bureau, "Aging Population Points to Health
Care, Retirement Crunch," DuQuoin Evening Call, DuQuoin, I I . , Jan.
3, 1992, p. 2.
39
Victor Fuchs, "Don't Look f o r Better Health from National Health I n surance," Op. c i t . , p. 18.
40
Kenneth E. Thorpe, "Business Declined Health Insurance Help," Journal
of the American Medical Association, Southern I l l i n o i s a n , Carbondale,
I I . , Feb. 19, 1992, p. 10.
41
Editorial Staff, "Feeling Better: In Canada, Universal Health Care
i s Popular Despite Lack of F r i l l s and Some Delays," Wall Street Journal,
N.Y.,N.Y., Dec. 3, 1991, p. A10.
42
Editorial Staff, "Feeling Better: In Canada, Universal Health Care
is Popular Despite Lack of F r i l l s and Seme Delays," Op. c i t . , p. A10.
43
Editorial Staff, "Feeling Better: I n Canada, Universal Health Care
is Popular Despite Lack of F r i l l s and Some Delays," Op. c i t . , p. A10.
44
Jim Gallagher, "Canadian Likes His Health Care," Op. c i t . , p. 2.
45
Larry Lipman, "Medicare Expansion Urged to Cut Health Care Costs,"
Atlanta Journal/Atlanta Constitution, Jan. 8, 1992, p. 6.
46
Staff, "Confused About Health Reform Plans?
Week, Jan. 1992, p. 12.
Here's a Guide," Business
47
E d i t o r i a l , "Government Control of Health Payments i s Problematic,"
Southern I l l i n o i s a n , Carbondale, I I . , Apr. 12, 1991, p. 17.
48
Cindy Humphreys, "Poshard: Everyone Deserves Health Care," Southern
I l l i n o i s a n , Carbondale, I I . , May 7, 1991, p. 3.
49
Staff/'Confused About Health Reform Plans?
p. 12.
Here's a Guide," Op. c i t . ,
50
Staff, "Bush's Health Care Rx: A Diluted Dose of Market Forces,"
Business Week, N.Y.,N.Y., Feb. 3, 1992, p. 26.
51
Kathleen Madigan, Zachary Schiller, Wendy Zellner, "The Recovery i s
Here at Last," Business Week, N.Y.,N.Y., Mar. 30, 1992, p. 20.
52
Marita Gomez, "Cataract Surgery Costs Range from $629 to $6,552 i n
I l l i n o i s Survey," DuQuoin Evening Call, DuQuoin, I I . , Mar. 5, 1992,
p. 5.
53
Mark Maremont, G. Schares, S. Toy, S. Garland, "Can Europe Help Cure
�92
America's Health Care Mess," Business Week, Mar. 9, 1992, p. 53.
54
William C. Symonds, " I t ' s Not Perfect, But I t Sure Works," Business
Week, Mar. 5, 1992, p. 35.
55
Janice Castro, "Condition C r i t i c a l , " Op. c i t . , p. 34.
56
Staff Analysis, Public Citizens Research Group, Physicians f o r a National
Health Program and the Center f o r Health Program Studies at Harvard
University, DuQuoin Evening Call, DuQuoin, I I . , Dec. 18, 1991, p.
7.
57
Staff, "Economic Analysis," Business Week, N.Y.,N.Y., 1990, p. 45.
58
Nick Mariano, "UrS. Health Care:
p. 7.
I s There a Better Way?" Op. c i t . ,
59
E d i t o r i a l Staff, "Feeling Better: I n Canada, Universal Health Care
is Popular Despite Lack of F r i l l s and Some Delays," Op. c i t . , p. A10.
60
Janice Castro, "Condition C r i t i c a l , " Op. c i t . , p. 40.
61
Janice Castro, "Condition C r i t i c a l , " Op. cot., p. 40.
62
Janice Castro, "Condition C r i t i c a l , " Op. c i t . , p. 40.
63
Susan B. Garland, " Prescription f o r Reform," Op. c i t . , p. 62.
A
64
William C. Symonds, " I t ' s Not Perfect, But I t Sure Works," Op. c i t . ,
p. 54.
65
Susan B. Garland, " Prescription f o r Reform," Op. c i t . , p. 60.
A
66
Julia Flynn S i l e r , Susan Garland, Paula Dwyer, "An Operation Fraught
With Risks," p. 83.
67
Anthony Man, "No Quick Cure Seen f o r 111 Health System," Southern
I l l i n o i s a n , Carbondale, I I . , Jan. 15, 1992, p. 3A.
68
Staff, "Health," Fortune, Apr. 23, 1990, Op. c i t . , p. 224.
69
Staff, "Medicare Fee Schedule Only P a r t i a l Answer," American Association
of Retired People, Modem Health Care, N.Y.,N.Y., Dec, 1991 - Jan.
1992, p. 2.
70
Dr. Stephen Greenfield. "Specialists Order Care at Higher Costs Than
Family Doctors - Study," Medical Outcomes Study, Southern I l l i n o i s a n ,
Carbondale, I I . , Jan. 29, 1991, p. 8.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[National Health Care Policy] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-037-009-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/b63f21f518ef2319453a591729c99ea4.pdf
095cec0c708225f2f763a35ed473a00f
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1985
FolderlD:
Folder Title:
[Methodist Hospital of Houston, Texas] [loose, letter and VHS tape]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
4
1
�Office of tijc ^ttorncp (general
#>tntc of Texas'
DAN MORALES
V n OKNHY III NLK \ l
March 29,1993
Hillary Rodham Clinton, Chair
Health Care Task Force
1600 Pennsylvania
Old Executive Office Building, Room 287
Washington, D. C. 20503
Dear Ms. Clinton:
In fashioning a solution to our current health care crisis, I urge your committee to
examine the charity care duty of tax-exempt, non-profit hospitals. Our
communities provide billions of dollars of subsidies to these hospitals every year.
It is appropriate and necessary that they live up to their responsibilities for the
health care needs of their communities in return for their tax-exempt status.
Texans have recently seen firsthand what happens to people when the directors
of tax-exempt hospitals turn their backs on the uninsured in their communities.
The Methodist Hospital of Houston, Texas, is the largest non-profit hospital in
the United States. This complex is renowned for world-class, state-of-the-art
medical care. But Methodist Hospital offers this care only to those who can pay.
Close by, on tlie other side of the Medical Center, uninsured Houstonians wait 18
hours or more in the overburdened public hospital emergency room where they
may or may not receive care for a wide range of life-threatening illnesses, some
conditions aggravated by lack of primary care. The uninsured people of
Houston, like others in many parts of this country, are caught in the grips of a
desperate health care crisis.
In 1990, this office filed suit against Methodist Hospital in Houston for failure to
provide the charity care required to fulfill its charitable purposes and satisfy its
tax-exempt status. Methodist is one of the richest hospitals in the United States,
with over $600 million in unrestricted cash assets and profits in 1991 alone of $76
million.
512/46V2I00
P.O. BOX 12 54*
AUSTIN. TEXAS 7871 1-2 548
�Ms. Hilkry Rodham Clinton
March 29,1993
Page 2
Yet, Methodist Hospital follows an admission policy designed to exclude the
uninsured: people who have no insurance must pay a deposit equal to the
anticipated costs of their care. Anyone who cannot pay (and is not an emergency
under the stringent definition of that term in anti-dumping laws) is sent on their
way without medical care.
Larry Mathis, President-elect of the American Hospital Association and
Methodist's CEO, denies any responsibility for charity care to the uninsured. He
states, "In my view, it is charitable to serve a rich man or a poor man." He
contends it is the government's responsibility to solve access issues, failing to
recognize any role for his institution as a tax-exempt hospital.
Mr. Mathis points to IRS revenue rulings as one source of his contention that
medical care per se is a charitable purpose and that his hospital can exclude the
poor and uninsured and still be "charitable." The Attorney General's Office is
presently appealing a summary judgment order granted for the hospital in which
a state district court judge surprisingly agreed with this position.
I urge your committee to examine the role of tax-exempt, non-profit hospitals in
providing charity care to their communities as part of your review of this
country's health care system. My office has worked closely with two Texas
legislators. Representative Glen Maxey and Senator Rodney Ellis, who have
introduced state legislation that clearly establishes the responsibility of these
hospitals to provide charity care. Across the country, states are addressing this
issue through court actions and legislation.
However, strong federal action is imperative to address current federal policies
which relieve hospitals of the responsibility to provide any charity care. In 1991,
two congressmen, Brian Donnelly and Ed Roybal, introduced bills to clarify the
requirements of tax-exempt hospitals to provide charity care. My office testified
in favor of that legislation. The legislation failed, however, and to our
knowledge no further action has been taken to change the current position of the
IRS regarding hospitals' tax-exempt status.
This country has long followed a tradition of public/private partnerships in
addressing the nation's problems. Indeed, our system of tax-exemptions is
founded on that principle.
It is not my intention to suggest that non-profit, tax-exempt hospitals should be
expected to burden more than their share of responsibility for solving the current
�Ms. Hillary Rodham Clinton
March 29, 1993
Page 3
health care crisis. These hospitals do play a pivotal role in the health care
delivery system and, in my opinion, must assume a more proactive role in
helping our country address the problem of access to the health care system by
the uninsured.
If we are ever to make health care totally accessible in our communities, control
spiraling health care costs, and solve our health care crisis, then we have both a
legal duty and a compelling need to allocate public tax resources efficiently. As
charitable, tax-exempt institutions, non-profit hospitals are the stewards for
millions of such public dollars. These hospitals cannot both exclude the
uninsured and the poor and fulfill their legal duties as stewards of the
communities' resources.
Enclosed is a video regarding the Methodist Hospital case, which vividly
illustrates the disparity in access to health care in our country. Please feel free to
contact me if you would like to discuss this matter in more detail. You may also
have your staff contact Assistant Attorney General Ann Kitchen at 512/475-4182
for further information.
Thank you for your attention to this matter.
Dan Morales
Attorney General
DCM/hpb
Enclosure
�Clinton Library Transfer Form
| Case #, if applicable
jj2006-0885-F
Collection/Record Group
jjClinton Presidential Records
Subgroup/Office of Origin
[j Health Care Task Force
[Methodist Hospital of Houston, Texas] [loo
Folder Title
!
' i Description
p of ltem(s)
VHS titled, "Rindy Media Methodist Hospital'
I Donor Information
\
> Last Name
Phone (Wk):
| Affiliation: W
Phone (Hm):
| State (or Country): ||
Street:
i Transferred to:
HI
(Audio/Visual Department
mmxmm
|l|
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Methodist Hospital of Houston, Texas] [loose, letters and VHS tape]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-037-008-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/7f123ac9af2e0b5a653c9c82c4c1c027.pdf
b6a16c2715da1429ef1fa7a1b8eca0fb
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1337
OA/ID Number:
FolderlD:
Folder Title:
[Mental Health Letters] [loose]
Stack:
Row:
Section:
Shelf:
Position:
s
56
1
6
1
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. letter
Consituent to Ira Magaziner & Hillary Clinton, re: mental health (1
page)
11/3/1993
P6/b(6)
002. letter
Constituent to Ira Senior, re: mental health [partial] (1 page)
10/25/1993
P6/b(6)
003. letter
Constituent to Ira Magaziner, re: mental health [partial] (2 pages)
9/27/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
O/VBox Number:
1337
FOLDER TITLE:
[Mental Health Letters] [loose]
2006-0885-F
wr834
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA]
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
Financial information 1(a)(4) ofthe PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA]
b(l) National security classified information 1(b)(1) ofthe FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA]
b(3) Release would violate a Federal statute [(b)(3) ofthe FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
Consituent to Ira Magaziner & Hillary Clinton, re: mental health (1
page)
11/3/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1337
FOLDER TITLE:
[Mental Health Letters] [loose]
2006-0885-F
wr834
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA)
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRAJ
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) ofthe PRA)
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA|
b(l) National security classified information 1(b)(1) ofthe FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency |(b)(2) ofthe FOIAJ
b(3) Release would violate a Federal statute [(b)(3) ofthe FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) ofthe FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) ofthe FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002. letter
SUBJECT/TITLE
DATE
Constituent to Ira Senior, re: mental health [partial] (1 page)
10/25/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task. Force
Tarmey
OA/Box Number: 1337
FOLDER TITLE:
[Mental Health Letters] [loose]
2006-0885-F
wr834
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA]
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) ofthe PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA)
b(l) National security classified information 1(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA)
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions |(b)(8) ofthe FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�IM if
October 25, 1993
Mr. I r a Senior
The White House
Old Executive O f f i c e B u i l d i n g B, Room 216
Washington, DC 20500
Dear Mr. I r a Senior:
I have a f a m i l y
member who has a severe and p e r s i s t e n t
mental i l l n e s s . Just a few s h o r t years ago there was very
l i t t l e hope t h a t my f a m i l y member would ever recover enough
t o c o n t i n u e being a c o n t r i b u t i n g member o f s o c i e t y .
Today we know t h a t people w i t h mental i l l n e s s can recover
and be independent. This i s made p o s s i b l e by such necessary
s e r v i c e s as p s y c h i a t r i c r e h a b i l i t a t i o n and case management.
Please do e v e r y t h i n g i n your power t o make sure t h a t these
s e r v i c e s are not dropped from t h e A d m i n i s t r a t i o n ' s Health
Care Reform p r o p o s a l .
V&ry TlrulY
yours.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003. letter
SUBJECT/TITLE
DATE
Constituent to Ira Magaziner, re: mental health [partial] (2 pages)
9/27/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1337
FOLDER TITLE:
[Mental Health Letters] [loose]
2006-0885-F
wr834
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act - [5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(S) ofthe PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA)
b(l) National security classified information 1(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA]
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIAj
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�September 27,
1993
Ira C. Magaziner
Senior Advisor to the President
The White House
Old Executive Office Building
Room 216
Washington DC 20500
oo
0
Dear Mr. Magaziner:
Reccsimendations to eliminate psychiatric rehabilitation from the
Administration's standard mental health benefits package i n health care reform
are devastating for Americans who have a serious and persistent mental
illness. Not only w i l l such a proposal jeopardize the availability of these
efficacious and cost effective treatments, but this proposal w i l l further
erode the quality of care individuals with serious and persistent mental
illnesses now have available i n states through public mental health systems
which are reliant on Federal funds from Medicaid, Medicare and block grants.
Psychiatric rehabilitation services are not "social services". They are
research based treatments for the management of serious and persistent mental
illnesses. Reconmendations by the White House Mental Health Task Force, the
National Advisory Mental Health Council and the Mental Health Liaison Group
representing over 35 national mental health organizations, strongly endorsed
their inclusion i n a comprehensive mental health services plan for a l l
Americans requiring treatment for a mental illness.
I know individuals with serious and persistent mental illnesses are a
population vulnerable to homelessness, victimization, poverty, and unnecessary
and costly institutionalization i n j a i l s and psychiatric hospitals. This
nation can i l l afford to perpetuate these more costly remedies when research
i n outcomes and state-of-the-art practices show conmunity based psychiatric
rehabilitation services do the following: reduce the u t i l i z a t i o n of costly
hospitalizations; develop coping strategies for symptom management; enhance
daily functioning to optimize independence; and represent significant factors
i n the recovery process. One day of treatment for psychiatric rehabilitation
frequently costs less than one hour of psychotherapy.
I am a family member of a person with mental illness. Discriminatory health
care treatment for individuals with the most serious mental illnesses w i l l
send a potent signal to states that the nations should not waste precious
health care dollars on this population. I am urging you to include
psychiatric rehabilitation services i n the mental health benefits package to
afford access to essential health care for these American citizens too.
Sincerelv.
�September 27,
1993
Ira C. Magaziner
Senior Advisor to the President
The White House
Old Executive Office Building B> Room 216
,
Washington DC 20500
Dear Mr. Magaziner:
Reconmendations to eliminate psychiatric rehabilitation from the
Administration's standard mental health benefits package i n health care reform
are devastating for Americans who have a serious and persistent mental
illness. Not only w i l l such a proposal jeopardize the availability of these
efficacious and cost effective treatments, but this proposal w i l l further
erode the quality of care individuals with serious and persistent mental
illnesses now have available i n states through public mental health systems
which are reliant on Federal funds from Medicaid, Medicare and block grants.
Psychiatric rehabilitation services are not "social services". They are
research based treatments for the management of serious and persistent mental
illnesses. Reccrnnendations by the White House Mental Health Task Force, the
National Advisory Mental Health Council and the Mental Health Liaison Group
representing over 35 national mental health organizations, strongly endorsed
their inclusion i n a comprehensive mental health services plan for a l l
Americans requiring treatment for a mental illness.
I know individuals with serious and persistent mental illnesses are a
population vulnerable to homelessness, victimization, poverty, and unnecessary
and costly institutionalization i n j a i l s and psychiatric hospitals. This
nation can i l l afford to perpetuate these more costly remedies when research
in outcomes and state-of-the-art practices show comnunity based psychiatric
rehabilitation services do the following: reduce the u t i l i z a t i o n of costly
hospitalizations; develop coping strategies for symptom management; enhance
daily functioning to optimize independence; and represent significant factors
i n the recovery process. One day of treatment for psychiatric rehabilitation
frequently costs less than one hour of psychotherapy.
I am a family member of a person with mental illness. Discriminatory health
care treatment for individuals with the most serious mental illnesses w i l l
send a potent signal to states that the nations should not waste precious
health care dollars on this population. I am urging you to include
psychiatric rehabilitation services i n the mental health benefits package to
afford access to essential health care for these American citizens too.
Sincerely,
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Mental Health Letters] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-037-007-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/aacca3089ec81e631bd868212d9b73d8.pdf
7c8a5ab5e6ed931d2ebc965532ec873e
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1338
OA/ID Number:
FolderlD:
Folder Title:
[McMaster University Letter] [loose]
Stack:
Row:
Section:
Shelf:
S
56
1
6
Position:
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
George Lewis to President Clinton [partial] (1 page)
9/8/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1338
FOLDER TITLE:
[McMaster University Letter] [loose]
2006-0885-F
wr833
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA]
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA]
National Security Classified Information 1(a)(1) ofthe PR A|
Relating to the appointment to Federal office [(a)(2) ofthe PRA)
Release would violate a Federal statute 1(a)(3) ofthe PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
George Lewis to President Clinton [partial] (1 page)
9/8/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1338
FOLDER TITLE:
[McMaster University Letter] [loose]
2006-0885-F
wr833
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Kreedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA)
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA)
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) ofthe FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) ofthe FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�McMASTER UNIVERSIT
faculty of health/scie/ic
• *.\JK> i v i a i i i ^ C I C C L
TitJ
iaii
Telephone: (416) 525-9140
^
(c 4**6
e
^e*"- ^P* ^7 ^
�By GEORGE LiEWIS
1
its
A-"FUNNY thing happened to me on
my/ "way through^ The Spectator's
splendid four-part series on the
recent McMaster-Southam Health
Care Forum '79.
/•'Funny? Perhaps shocking would
be" better.
-;Suddehly, I realized that either I
Was completely out-of-step'with the
m'any eminent participants in • this
prestigious conference or else (perislj'the thought) these bright people
vyere performing in a consistently,
confused and unbright manner.,
J i A t first, well aware ot my own
iunitations, I was quite willing to.
accept the former, assuming that
the I'.fatter was an impossibility in
such-'a renowned conclave.
; JAt any rate, who am I to question?; But there it was, in black,
w.Kite and color on newsprint,
:
©
<
same as
care
,1 Pennies for
prevention, ^
but dollars I
tor cures |
3
4
enough surely to confirm my slowly
evolving suspicion • that here in
Ontario as in the rest of Canada,
a health
system. A medical
^system, yes. And to the t&oe
ibillioi^ annually
'system
Spectator reported, used the familiar catch terms medical care and
health care over and over again as
though they are synonymous and
freely. interchangeable, which they
are not.
To use them as though they are,
in my opinion, thoroughly confuses
the vital issues involved and renders the; highly stressful conflict
over medical dollars even more
resistant to peaceful resolution.
I do hot believe that it is an idle
exercise in nit-picking to require
the preliminary clarification of
some essential basic terms concerning health and. illness in the
interest of intelligent discussion.
Ill-health
George Lewis
Health, for example, is thoughtfully. defined by the World Health
-Organization (WHO) as "a state of
optimal physical, mental and social
well-being, and not merely the
absence of disease and infirmity".
If we accept this view, we can see
at once that any proposed health
care system for Ontario will be
very different from our present illhealth or medical care system
whose interest in health is, if it
exists at all, only minimal and
marginal.
%s Dr. Fraser Mustard, Dean of
the-Faculty of Health Sciences at
care
McMaster University, put it at
tion to Mr. Timbrell's dilemma is,
Forum '79: "Most of us forget that
not surprisingly, as simple as this.
health care is primarily concerned
Can you imagine what four billion
with supportive care of people who
pennies strategically invested in
are ill or who think they are i l l . "
promoting health awareness would
Read health here to mean illdo toward unclogging our present:
health.
ill-health care system? And can'youi
imagine the challenge of introducDennis Timbrell, Ontario Minising Canadians to the novel concept
ter of Health, recently enunciated
of a health-enhancing care scheme
what we may now call the "Timwhich rewards them with the
brell Principle", namely that if; we
wealth of their own good health?
are to balance our provincial budThe goal of optimal physical,
get, we must cut health care costs.
mental and social well-being for all
Read health here again to mean illCanadians sounds incredibly naive,
health. Begins to make sense when
I admit. But is it truly the impossiput this way, doesn't it?
ble dream, a goal totally beyond
Mr. Timbrell's dilemma peaked
our reach?
some time ago when in a moment
We do have a genuine "crisis in
of frustration he publicly put the
health care" as The Spectator iniquestion , to all Ontarians: "O.K.,"
tially entitled its series. I firmly,
how would you cut health costs?"
believe, however, that .if we start
right now with penny-wise investAt that time, the eminent logic
ment in Ontario's prime resource,,
of simply cutting the amount of illnamely, the good health of its peohealth in this, province did not
ple, the next McMaster-Southam
appear to be among, the. viable solutions offered. Today,' however,' this :. Health Care Forum will be giving
us our first official progress report
is without question the. pre-eminent
on>\OHIP's diminishing cost to the
approach to budget-balancing, both
e\ver-shrinking public purse.,
provincially and federally.
Mr. Lewis is a professor ol anatoPennies for prevention of illmy at McMaster University.
health or dollars for cure. The solu-
HEALTH CARE FORUM 79
First of a four-part scries
A CRISIS SN MEDICAL CARE
Doctors' problems
are only the
symptoms of an
ailjng health system
AS T H E d o c i o r i ift«Tn.
who
mi/ftl
thrlr
n w u n l l n i p r o b l r m i with
^ t n t m r n l i f f onl;
j i m p l o m a/ r h f r r * l
[ h i t It i t r i d i l *
minlni Cinadi'i
H I T i>->iem
"A
�Keeping the healthy out of hospital could^ut costs
m
It seems to me that Betty Lou that sort of thiiig. Sometimes,
• Lee's excellent'series, 'Are our they say. it would take hours to
hospitals healthy?', steers away
pull 10 people from the river, and
from the critical companion ques- even then only a few would surtion: "Are our hospitals interest- :Vive.
•' •
ed in the healthy?"
"Though the number of victims
in the river has increased greatly
She speaks primarily about
in recent years, the good folks of
whether our so-called heallh care
• dollars are well and responsibly Downstream have responded
spent. In general. I would agree . admirably to the challenge. Their
- with her that so far as treatment. rescue system is cleartysecond to
' of the clinically ill is concerned, none: Most people discoyered in
our Hamilton hosptials rate as the swirling waters^re reached
• excellent, given their ever-present (and growing) staffing'and
financing problems.
,r %
*
However, our Ontario health
minister, Dennis Timbrell. hav-/.
ing read the hand-writing on the^,
economic wall, now advises us to
keep people out of hospitals.
As llio administrator of a near
Sfi-billion budget, he now sees our
)rovince on ils merry way to ,
}ankruptcy if it continues bit'ndly '
to finance the multitude of'\p.
tients who quite s
be in hospital. '
A contemporary
illustrates our present thinking in .
regard to the responsible spend-^v
ingofour.money.
i-/';;^\ ~'t;i'
"It was_many years'ago that;-;
;v,villagers in Downstream recall •.
'"• •spotting the first body in the riv-' .
>'.;cr. Some oldtimers remember
.'. how spartan.were the facilities•
^
'and; procedures, for ^managing
:
mm
r
within 20 minutes — many in less volved, and the large number of ,
highly trained and dedicated .
than 10. Only a small number
swimmers always ready to risk '.
drown each day before help artheir lives to save victims from';'
rives — a big improvement from
the raging currents. Sure it costs >
the way it used to be.
a lot but, say the Downstreamers,'^ £
"Talk to the people of Downstream and they'll speak with i what else can decent people do'ii..;
except to provide whatever isi'C
pride about the new hospital by
necessary when human lives are.^
the edge of the waters, the flotilla
at stake?'
• • • ;-:/';/: ' ;'-::
of rescue boats'ready for service
at a moment's notice, the compre"Oh, a few people in Downhensive health plans for co-ordi- / stream have raised the question
nating all the manpower in- I'now 'and again, but most
| | p ! p c | | | | p j s h o w little interest in ' .what's^.
p ^ ^ ^ ^ p j M i a p p e n i n g Upstream.' It seems^A
there's so much to do to help those
in the river that nobody's got time..^
to check how all those bodies are,-:',
getting there in the first place. ,4
That's the way things are some-,j
times." ('High Level Wellness:
An Alternative to Doctors. Drugs
and Disease' — Donald'B. Ar-7
dell). '••^••-^ -•
•In my opinion, Mr. Timbrell's
masterful plan, not yet fully artic-?
ulated. is brilliant. However, its*
success will ultimately hinge
upon just how. many Ontarians he
convinces to work upstrearcrat ,
keeping themselves and others •7
/healthy and-thus well beyond, the^i/downstream need for -medical;^
I nursing and hospital care. >
^
j'M
: ;
:
;
4
:
:
:
, :
George F. Lewis; ^
Associate Professor of Anatomy,.:
•>;./;, McMaster University.* .i
• ^v^-f
;P
�)king area' keeps house unpolluted
By MARILYN DUNLOP
Star staff writer
George and Mary Lewis of Winona have designated one
part of their home as the "smoking area." It is the outside
porch.
"That may be extreme," Lewis says. "But we feel if we are
going to keep our home in first-class condition with a clean,
healthy atmosphere, inside air must be automatically a nosmoking area."
Lewis, professor of anatomy at McMaster University in
Hamilton, thinks a lot of people would like to free their homes
of smoke and dirty ashtrays. "But it is rather tricky with your
friends."
Nevertheless, he says, even friends who are heavy smoker
have accepted the Lewis' stand and still visit
Some of them, he said, say they find it easy not to smoke
because inside the home all the things Lewis calls "external
cues" have been removed. "There are no ashtrays, no lighters
clicking, no smell of smoke in the air, to trigger them into lighting up."
Social gatherings
An ashtray, says Lewis, is an invitation to smoke. Etiquette
books written 30 years ago, he said, called for cigarettes and
ashtrays on well-set tables. "But that is now turning around,"
he says. " I looked at ashtrays fcr years as part of the scenery.
Now I see that as completely out of step."
In fact, he says, "Smoking is so much less welcome than it
used to be that we've attended recently some social gatherings
where smoking would be a real put-down, a sign of not caring
about others."
The professor admits many people won't want to go as far
as telling guests to puff outdoors. In some cases, one of the inhabitants smokes heavily. He recalled one woman, almost in
tears, who complained about the "sticky tarry film on windows
and walls" and the piles of ashtrays she had to clean up each
morning, because her husband was a heavy smoker. She
blamed her own chest disease on living for years in a home
with polluted air.
: Lewis said in these cases people might designate one room
such as a den, as the smoking area. "It should be a room that is
out of sight and out of smell."
An air filter—some can remove up to 90 per cent of smoke
from the air—can also help, he said. "In an apartment, you can
if you have one, designate the balcony as"the smoking area."
. Guests' reactions
But, he warns, an indoor smoking section can become so
smoky, "even the smokers can't stand it"
Most guests, he says, prefer to forego their habit or step
outside. "We had a houseguest from Ottawa last weekend, a
chain smoker, who went out every half-hour or so."
On the other hand, two women visitors on a recent
evening, both heavy smokers, refused to go out, he said. "One
said to the other: 'Do you realize we've been here four hours
and haven't smoked? Do you feel any pain?' The other admitted
she did not"
A lot of smokers, Lewis says, would like to quit. "But they
go to a stop-smoking clinic and get revved up and then crumble
when they are dropped back into a world with so many smdk— Star photo bv Brian King
CUM.
INC GUEST Vinoe Mazza « ,
„ eta with G j ^ a n d Mary Lewis. N.„. /
es nave designated porch as smoking area to keep the air in their home clean. \ them tbat choice."
t
t h c >
ft.J^.&ElS.St&SS&'SSS
�The Toronto Sn
•THE CANADIAN• COLOR COMICS • ST
December paid eireulation
EST.^BLISHED 1S92
Mon.-Fri. 4S:S.401. Sal. T'l.KSS
liin.i
mil
IIIIIIUIIIII
nm
mi
Saturday, January 14, 197S—252 pages
i
Stay in Quebec
to bury Levesque
PM tells English
Today in The Star
By PATiilCK DOYLE
Star staff writer
Reborn Barons
dump Leafs 5-2
STANSTEAD, Que - - Prime Minister
Pierre Trudeau last night urged English Quebeckers "to bury Rene Levesque" who is already
on his political deathbed.
Trudeau's remarks came hours after it was'
revealed that he and Finance Minister Jean
Chretien had met Sun Life Assurance Co. officials Thursday in Ottawa to persuade them to
reconsider their decision to move out of Montreal.
Witii five new players in their line-up.
Cleveland Barons proved they're no longer
an NHL push-over by dropping Toronto
Maple Leafs' 5-2 last night. Barons, who
fired three unanswered goals in the third
periiHt. have knocked off three of (he
Special tlircetors' meeting
A special meeting of Sun Life directors was being
held in Montreal today to discuss arguments presented
by Trudeau and Cliretien.
Addressing a primarily Knglish-speaking audience
of aiiout 7jt) \n the Easfern Toumhips commimify of
PHOTOCOPY
PRESERVATION
�r*remier William Davis, who suggested tlie advisory
umimittce be.set up last July, is un vacation in Florida.
Timbrell said he pUins to review the reconimendalions with the Qnlario Medical Association (OMA) the
Untai-TTTTospiiai Association anu oth^t* he&Hli 'VhOletSee COULD NOT, page A2
'Medical care
is a bad place
to cut costs'
T'uuglily lialf of l") Dersons. interviewed by.^The Star
PHOTOCOPY
PRESERVATION
�f RipAYjiSERTEMBER.S: 1993 •"
• Glinton.agf^UoMnclude:'^ " • AboutSSS biilion'for home
andcornmunily caVeJoFtheiel-"
defly'and chfoniqally.iil.
_
^'••MeSirarei savjiigs ^we. are'..
. golng'lb- resize "as: we slowgrbwthv'ih • T ' oyerall^h'ealUi'- .
Qe
• care. SYHtern wiU^"be'-used' io ;
fma-that;'; said'-lra Magaziner,' •
GUhtbn'sTtop health, adviser,;' :
.V Medicare/prescriptioh
: benefits, with'a$25gideaucjible
and '20Wfcopaymeht-,'costing ,UR'to jraibillidn ^.'tSe'SMne'
be"neJthe'll'offer no"ri*ldeMy:i.
• MedicareisaviEgs and,ppffii;'
,biv.ia'$f.feaeral'cigafette?tax•iin'crfase andlhigher liquo'r'.tax- •
wbiild otfset three COSBM^.
[
1
1
:
:
I
li
i
^T^^/C
/V^/t.77/
/
a ^uj^o d^t-'C t+rthrf •/^M.^a, /:
co g
rr y
�vun tut llt'ctJUl
3.
1
Cuntinued frum page 1
a Is. BJ nail ^seeking
Lazarus~rDEtr^said in an
interview his association
will have no comment
until after its meeting with
•Timbrell in • February.
/Three'"members of the spe/ cial committee are on the
I OMA executive.
The comniittee's-report
said insured healtli spending more tlian doubled,
i
u t New Democratic
r t y ' Leader Stephen
Lewis said the report refleets present government
thinking — to make the
consumer pay.
itients admitted
t h a n three
ir bur sing home'
J:
-';
; l i b s t antial"
charge^— fr4m $25 to ?75
- for t h e ' f i m day of each
hospital admission up to a
maximum of two per year;*
This would .'not apply tojj
those whose' premiums are :
partly or. fully paid by the';'
province.
:
Lewis said the government'slio id d be working to
clean-up waste and duplication, but instead "every,Dr. Iain Todd, chief tir
m a j or recommendation urology at Scarborough
says the consumer V i l l General Hospital. and' a
pay tlirough the teeth." .
past-president of the OMA,
?0
l[ !a b lllonIn i 7 il
T h e committee d i d said in an interview he
was'not sure the surcharge
to
billion, between' charge "a misuse of facilit i e s , duplication a n d would act as a deterrent
to patients or doctors who
is expected to reach $3.8 waste" in the health sys- admit them.
Ontario's healtli care bill
billion In 1977-78. and the tem, but committee chairman Taylor to'ld the news
He suggested, instead..committee said provincial
revenues are not keeping conference the answer is , that .patients be charged
not stronger government for their food in hospital.
up.
control.
. "When you're on t h e
Premiums covered only
"We're certainly n o t outside, you're paying for
26 per c e n t of insured
health services in 1977-78.
endorsing a totalitarian food. Why should we not
be responsible for our food
approach to health." hi
OII1P PREMIUMS
said. Instead, the commit' while in hospital'?"
lee was guided by the con
Committee member Dr.
A DISAPPOINTMENT
"vVilliam Vaii. an O M A viction t h a t "universal
said he was disapvice-president, told a new; welfare is wrong" a n d
leads lo unwarranted esOtmimiUefi Ha*
•efice a F
no comment about
Park yesterday the pubflj
o s s i b i l l i y "oT
has no awareness of
i e r ever reasoi;
i^ontinuing UliiP sup'
costs.
easible, users sll
oft\or "quasi-sctemine"
i S b p f l ^ a significant p;
' ? "!.l : . '.
5
and the poor is not tlie answer."
He predicted the government would m l be bound
l>\the report.
?^
jyvb a d m. n
Ontario ueaiin W u r a n c^e I healtli care," he said.
e
cliiropractors.
.
Plan (OHIPi • pn
Chiropractic and acu- | j
should be reviewed
that would puncture have no proven : .
nuaJly and adjisled to proscieniific value, he sairl, [
(luce a revenue ot :(3 per have users pay more:
— A review of those yet OH1P pays -for the ! ,
cent of insured health
who receive free services former and not the latter. I
costs!
^ , much of the
However, „
At present rales, that or subsidized premiums..
|
would meaji an increase of specifically, Taylor said, \
all those 65 and older who ^
,"
$12 over the present $32
monthly family premium receive free premiums re- better efforts iii looMli^ dt
L heallh care costs," Todd
a ll (I $6 above t li e $IU gardless of income:
— A charge for chronic"nraTTT
premium for single people.
Opposition
Lea d e r
Stuart Smith said raising
OIIIP premiimis is a regressive form of taxation.
He agreed (lie l n ^ h care
svstem
in a mess hut
l
l l v n
r e i t o r l
e
n
s
e
K l
m
a
d
a n U
l i K n
PHOTOCOPY
PRESERVATION
a
s
UL
a w f u l
e
w
y
o n e o f
LI1C
g o o d
{
M
�THE SPECTATOR, FR1
Forum
Target tobacco in war on drug
Hypocritical to keep exporting tobacco while battling less-damagii
By GEORGE F.LEWIS •
ON HIS retirement as U.S. Surgeon
General in 1989, Dr. C. Everett
Koop scored a bull's-eye on his government's complicity in international drug-trafficking.
''It is the height of hypocrisy for
the United States,, in our war"
against drugs, to demand that foreign nations take steps to stop the
export of cocaine to our country
while at the same time we export
nicotine, a drug just as addictive as
cocaine, to the rest of the world."
• For the record, of course,.cocaine in an illegal drug, though at
one time it was legal, as when it
was used.freely .ih.Coca-Cola, net
called Coke fcr nothing: Nicotine,
perhaps better;Icnowh as harcotine,
is a legal driig^Hhough Uoday- we
have a long and lerigthehihg list nf
good reasons for second thoughts in
regard to its status before the law.
We know now that nicotine
addiction is -for-.most-.cigarette
smokers the strongest.- of- all
addictions: and the -hardest to
break. -We know.^that-i mcotine
addiction;'is th"e;ultimate'cause of
all smoking-related illness-disability'and premature death. And that
by comparison, cocaine aCacUon
is a minuscule social problem..
YOUU gE HAPPV TojCMo.W
YOU'RE
WAY
PRESERVING THE
OF LIFE F ^ R
-
COUNTLESS AMERICAM
TOBACCO FfcRKlERS...
•..SN'~ THAT WORTH I T ?
.
1980s
into :
will
year
renct
reach
cer o
nent.
Bu;
entre
this ;
unab;
court
the la
Thi
an ur.
"cut, i
you H
E
urgen
no v
alerte
this s
dailV'
He;
Bush:
alarrr
tion'fi
He h;
with
. war ;
:that t
snugl;
knowi
1
Hundreds of crashes
PHOTOCOPY
PRESERVATION
We Canadians and.oiir.American neighbors are just beginning to
realize-how badly our national
health priority list has been bent,
twisted, skewed and otherwise distorted for us by those we elect to
positiohs'.-of power. The on-going
death coll from playing cigarette
roulette is now over 40,000 Canadians and 400,000 Americans each
year for the foreseeable future.
To put this catastrophic outlook
into perspective, consider that the
expected equivalent toll in lives
snuffed by cigarettes will continue
to exceed that of 100 Canadian and
1,090 Ameriesn faiiv-foadea' jumbo
jets crashing each year
Contrast, if you will, this incredible every-day disaster with the
relatively tinv toll from AIDS
Here in Canada. AIDS has
claimed 3,500 lives to date — and
these spread over the 12-year period since this fatal disease was first
recognized and its victims recorded .• • ' '
Surely no one would dispute the
' importance of the AIDS problem
or of the cocaine problem or of the
urgent need for sustained attention
which each of these generates. Yet
somehow the nicotine problem has
so far failed to gel in the public
mind, certainly not in a way that
The Christian Science Monitor
• Los Angeles Times SyncJicaie —
shouts for appropriate, aggressive,
remedial action now.
Even in this year of American
elections, who among the many
hard-running candidates has dared
to address nicotine addiction as a
public-health problem with no near
equal?-
George Bush, in his bid for reelection, is especially conspicuous
today in his apparent avoidance of
what can be treated as the perfect
political issue of our time For
what other federally-approved
consumer product has ever before
been so clearly and so closely
linked to so many undesirable consequences?
As president of the United
States, Mr. Bush is also a vulnerable target for criticism because of
his government's so-called war on
drugs, directed at illicit drugs only.
But more. When he and Ronald
Reagan were running mates in
1980, the Reagan-Bush Committee
"Ths disease impact of smoking
justifies placing the problem of
tobacco use at the^top ofthe public
health agenda."
— U.S. Surgeon General
C. Everett Koop
promised its unqualified support to
American tobacco farmers, assuring them, that, if elected, the new
cabinet ministers '"'will be far too
busy with-substantive matters to
waste their time. proselytising
againstjthe dangers of cigarette
smoking."
And more. As vice-president in
the Rei.gan administration, he was
also president of the Senate and as
such, received the annual'surgeon
general's report from the secretary of health and human services.
The most significant of these
reports, focusing upon the real culprit, was and is the 1988 -reporfon
nicotine addiction. Mr. Bush could
henceforth in no way plead ignorance of the extent of human dam-
Asl
class'K
ment':
tling t
while
feders
uet W(
and ki
ry belt
Mor
licit di
age caused by nicotine dependence gins \
since the secretary's accompany- drug t
ing letter, included in the report, fore d
begins with "Dear Mr. President" senou
and ends with, "The disease impact stance
of smoking justifies placing the
As (
problem of tobacco use at the top ronev
of the public health agenda. The electic
conclusions of this report provide limiteanother compelling reason for becom
strengthening our efforts to reduce thev u
tobacco use in our socieiy."
the ch
Tlie impact of smoking . on. pandir.
women in particular is now a front- less D;
and-centre matter for attention in will th
anv discussion of corporate abuse otine '.
and .violence. Undoubtedly .the. export
most graphic evidence of the trage- eign la
Thai
dy wrought in our time by chronic
compulsive smoke inhalation is the they c
fast-growing incidence of female plarylung cancer in relation to breast bigges;
cancer.
. In the early 1960s, breast can- Georg.
cer held the tfo. 1 position among sor of
cancers in women and lung cancer versity
held position No. 8. By the early campa
�zal to keep exporting tobacco while battling less-damaging drugs
1980s, lung cancer had moved up
into No. 2 position' The year 1985
will long be remembered as the
year when ihe increasing occurrence of women's lung cancer
-reached and surpassed breast cancer on'the North American continent
But even now that ii is firmly
entrenched in the No 1 position,
this alarming tr-md wili continue
unabated well into the 2lst century
courtesy of teenage girls who form
the largest group of new smokers.
Think-about it If ever there was
an urgent feminist issue, this clearcut, male-orchestrateo attack on
young women is sureiy the most
urgent of all time. And yet to date,
no women's.' rights group has
alerted its i'membership to" treat
this seductive, invasive assault as
daily corporate rape.
Heaven forbid' that President
Bush should be the one io sound the
alarm, but who knows what election fever will force to the surface.
He has recently been more Uken
with waging a pohticaliy-correct
..war against cocaine and putting
. that bad, bad boy.Manuel Noriega
snugly behind bars. But again, who
knows? ..
•geon
•erett
erna-
;y for
war
t forp the
a'ntry
sport
ve as
d."
?. coghat
len it
i. nci.
otine,
otine.
v- we
isl of
htsin
law.
'otine
;rette
all
;t to
otine
se of
sabilI that
•.ction
menng to
.ional
bent,
e dis!Ct to
going
irette
nadieach
tlook
it the
lives
tinue
n and
imbo
credi the
has
- and
penfirst
:ord-
shouts for appropriate, aggressive,
remedial action now.
Even in this year of American
elections, who among the many
hard-running candidates has dared
to address nicotine addiction as a
public-health problem with no near
age caused by nicotine dependence
since the secretary's accompanving letter, mcluded in the report,
begins with "Dear Mr." President"
and ends with "The disease impact
of smoking justifies placing . the
problem of tobacco use at the top
of the public health agenda. The
cbnciusions of this report provide
another compelling reason for
strengthening our efforts to reduce
tobacco use incur society."
Tlie impact of smoking on
wcmei: in particular is now a frontand-centre matter for attention in
any discussion of corporate abuse
.violence. Undoubtedly the
also president of the Senate and as and • graphic evidence of the tragesuch, received the annual'surgeon most
dy wrought in our time by chronic"
general's report from the secre- compulsive smoke inhalation is the
tary of health and human services. fast-growing incidence of female
The most significant of these lung cancer in relation to breast
reports, focusing upon the real cul- cancer.
prit, was and is the 1988'Teporfon
In the early 1960s, breast cannicotine addiction. Mr. Bush could cer held the No. 1 position among
henceforth in no way plead igno- cancers in women and lung cancer
rance ot" the extent of human dam- held position No. 3 By the early
"The disease impact of smoking
justifies placing the problem of
tobacco use at the top ofthe public
equal'George Bush, in his bid for re- health agenda."
election, is especially conspicuous
— U.S. Surgeon General
today in his apparent avoidance of'
what can be treated as the perfect
C. Everett Koop
pohlical issue of our time For
what other federally-approved
consumer product has ever before
been so clearly and so closely
linked to so many undesirable consequences?
As president of the United
ethe
blem States, Mr Bush is also a vulnera• fthe ble target for criticism because of
ntion his government's so-called war on
. Yet drugs, directed at illicit drugs only.
.1 has But more. Wben he and Ronald
ublic Reagan w'ere running mates in
that 1980. the Reagan-BusfTCommittee
promised its unqualified support to
American tobacco farmers, assuring them that, if elected, the new
cabinet ministers ""will be far too
busy with .substantive matters to
waste their time proselytising
against.;the dangers of cigarette
smoking."
And more. As vice-president in
the Reagan administration, he was
:
Confused priorities
As Dr. Koop has implied, this is a
classic case of the S'ish government's inverted priorities — battling the inflow of Colombian snow
while at the same time exporting a
federally-blessed consumer product well-known at home to cripple
and kill. (Details appear in the story below.)
Moreover, we now know that illicit drug use almost invariably begins with and accompanies licit
drug use and that nicotine therefore deserves first place in every
serious altempt to reduce substance.abuse.
As George Bush and Brian Mulroney busily campaign for their reelection this vear and next their
limited choice in this matter will
become clearer day by day.- Wilithey wish to be seen continuing as
the chief accomplices of a fast-expanding empire building on needless oain. grief and suffering? Or
will they at once cut all ties to nicotine interests and terminate all
exports of tobacco products to foreign lands?
'That is, by these, actions, will
they .choose to be seen as exemplary leaders in what-will be the
biggest drug bust in history? . .
x
George F Lewis, retired professor of anatomy at McMaster University, has been a long-time
campaigner against smokina.
PHOTOCOPY
PRESEfflMT/ON
�Chi! (ibfe anil Mail
CANADA'S NATIONAL NEWSPAPER
... • i
Vv
Proprietor — The Globe and Mail Division of Canadian Newspapers Company Limited
• 444 Front St. W., Toronto M5V2S9
The Globe founded 1844
Telephone 416 585-5000
The Mail founded 1872
R. HOWARD WEBSTER, Honorary Chairman
A
..!.:.;i;t;:. -
A. ROY MEGARRY. Publisher
NORMAN WEBSTER, Editor-in-chief
GEOFFREY. STEVENS, Manafling Editor
'•,••3
..
IAN CARMAN, Executive Editor
FRIDAY, JANUARY 10, 1986
Quitting for charity
•v
So, little more than a week
Into the New Year and your
family has found you chewing
ihe living room carpet — an
emotional excess yielding much
the same taste in the mouth as
the cigaret craving that caused
it. Worse, ypu may have fallen
prey to the subversive thought
processes that lurk treacherously at the back of every reforming
smoker's mind, suggesting an
inviting series of rationalizations
for giving up the effort to quit. Maybe, after all, the New
Year's resolution is an unsuitable vehicle to carry as fragile a
commodity as human resolve
through the bumpy weeks of
January — though there is some
reason to believe that giving up
cigarets works better if it is
imbued with significance. Perhaps if it were in double harness
with some other noble cause, it
would stand a better chance.
George Lewis, who teaches
anatomy at McMaster University and is probably the most
implacable foe of smoking in all
of Canada, likes the double harness approach — and he has one
in mind. Although firmly convinced that quitting is the best
•il'-'v.'-'.v-'•
•m W
W
;
t,.'.
•'•'?
;. t
gift anyone can give himself or
his family, Prof. Lewis is quite
willing to work in economic
motivation and the appeal of
other worthy causes.
Noting the ready, generous
response of Canadians to appeals for aid to the hungry in
Africa, it occurred to him that
Canada's 7.4 million smokers, in
the course of giving up the habit,
might consider contributing the
cost of one packet of cigarets a
week to the cause of alleviating
hunger. There is a potential here
for about $17-million a week in
aid, with substantial health
benefits and reduced Canadian
health costs into the bargain.
Together, of course, with the
reinforcing effect of an obligation to help the less fortunate.
This is, of course, pure fantasy. The very notion of all Canadian smokers quitting together
makes far too much sense to be
remotely plausible. Still, there is
a tide in the affairs of men
which, if taken at the flood,
could lead to mass quitting. If
you are in the market, and dates
are still significant. National
Non-Smoking Week runs from
January 16 to 22.'
mmmi
:
�12 The Spectator, Saturday, October 1, 1 11
9
-
By TERRY COLLINS
Spectator Staff
HAMILTON WILL have an armsmoking bylaw like Toronto's if a
McMaster University anatomy
professor has his way.
Prof. George Lewis says ho will
present city council with a motion
~-to-ban smoking in public places.
"People who smoke will have to
accept the social responsibility that
goes with it. Take it out behind the
barn again," Mr. Lewis said.
He says the Toronto bylaw,
which takes effect today, will help
.smokers there kick the habit.
"This is the first time they
(smokers) have a clear-cut choice
between going into a smoking area
and going to a smoke-free area.
"I'm banking on most, smokers
saying: ' "Look, I can do myself a
favor and go to a place, where I
don't have to smoke if I don't need
one or want one; I won't be trig-"
gered inlo it.'
A former .smoker himself, Mr.
Lewis likens smoking to noise pollution.
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" I f you walked into a restaurant
and made vulgar sounds you'd be
ushered out very quickly. But you
walk into a restaurant, light fires,
pollute the air, litter the environment, spread sticky, tarry film all
over everything and annoying everybody around you."
He advocates the diplomatic
approach in protecting non-smok-
ers' rights and disagrees with Toronto shopkeepers who feel the
bylaw will cost them business.
Mr. Lewis suggests proprietors
advertise smoke-free areas, which
is positive, rather than hang negative no-smoking signs.
He also feels the Toronto bylawshould cover more places than it
does. Licensed premises, restau-
rants, lunch counters, barbershops,
hairdressing salons and restrooms
are still places where smokers ran
indulge themselves.
"Those are the very place? you
want to control — they're the places where people are tightly packed
and are absolutely defenceless if
someone lighis tip beside them." he
said.
�McMAS I LK UNIVIikSI'l Y WCDK.'AI. ( ! NI KIi
Dep.n uncnl ul A n j l u n i y
I '20U iVLnn Sircot \Vc$l, Hamilton, Omano, C.:».!da L8S -1)9
Tclcnhoru.'. (.llC) 5 2 > 9 1 4 0
The Spectator, Friday, October 21, 1977 7
THE ENTIRE Canadian medical profession should be charged'
with professional malpractice for its weak position on anti-smoking issues, a McMaster University medical professor •
charged last night.
George Lewis, a professor of anatomy at McMaster University Medical'
Centre, said Canadian doctors have given no support io anti- smoking cru-'
saders and have been "a total cop-out".
Tlie British Medical associations) don't give
going (o
Association and the leadership, they'reespecially
look pretty silly,
American Medical Asso- when the public groups are
ciation have taken doing the job physicians
strong stands against should be doing."
Mr. Lewis also said when
smoking, he said, by
students in
publishing reports and he spies smokinglines at the
the registration
pub 1 i c1y a n n o unci n g medical centre, lie tells
their position on ciga- them they have already
flunked.
rette smoking.
" I tell them point blank
But Ihu Canadian and
Ontario Medical Associations (which Mr. Lewis calls
"COMA") have maintained
a stunning silence on the
issue IK; said.
Mr. Lewis was a member
of (he audience at the .innual meeting of Ihe HamillonVVen t worth
Non-Smokers'
liighls Associaiion.
There is a handful of
doclors who publicly sup.
port anli-.smokiiig groups,
Mr. Lewis said, but they are
ridiculed arid critici/.ed by
their colleagues.
Mr. Lewis commended
doctors who have put tip No
Smoking signs in their offices ni' who have become
involved in anti-smukmg
efforts.
they don't know a thing
about healh care and don'l
defcrve to graduate," he
said.
Guest speaker Or. Mur-'
ra\ Brandstater told Ihe
members the association,
ha; three objectives — to
cortinue present anli-smoking information campaigns,
to iclp people who want to.
qui: smoking, and to establish a non-smoking society.
"But they are actually
ridiculed by other doctors."
he said. "They call (he::i
'busybodics' and 'do-gooders' and I urn off when yoi:
gel on the subject of smoking"
Mr. lewis .said that to his
knowledge the subject o
becoming involved in an
anti-sinokii'ig campaign ha:
never come up al medic, ,
associaiion conferences or
meetings.
"I'd like to think Ihey
never got around to it," he
said, "but sometimes I
think there's an actual conspiracy to ignore it.
" i f Ihey (Ihe medical
:
1
�McMASTER UNIVERSITY
acully of health sciences
Th-:; Spectator, Saturday, Odober 22, J!)77 7
THE PRESIDENTS of the Canadian and Ontario medical associations have rejected charges by a Hamilton anatomist that
their associations have not taken a strong stand against smoking.
Both Dr. Robert Gourdeau of the CMA and Dr. Lazarus Loeb of lhe OMA
called statements by George Lewis, an anatomy professor at McMaster
University, extreme and unfounded.
Mr. Lewis told a
meeting of anti-smokers
Thursday he thought
the Canadian medical
community should be
charged with professional malpractice for
its position on smoking.
Dr. Loeb of Ottawa said
he fell Mr. Lewis' charge
was "extreme and hardly
worthy of cominem."
Tlie OMA has passed
several resolutions against
smoking, he said, including
banning smoking at association meetings. Aud it has
always taken a lead in educational programs on the
dangers involved.
"I'm not saying we are
doing everything right. Hut
we certainly aren't ignoring
the issue and encourage our
members and uur patients
not to smoke. Hut il is a
personal thing, not something we feel we can legislate," said Dr. Loeb.
Dr. Gourdeau of Quebec
City, said the CMA is also
on record against smoking
and similarly helps in' activities designed to discourage
smoking.
"But it is an individua:
decision. We cannot make
people give up smoking, we
can only advise," he said.
"Even if some doctors
who still smoke have to take
(he 'Do as I say, not as 1 do
attitude, I think wc try tc
discourage smoking conlinu
ally."
Dr. Gourdeau s a i c
studies have shown doctors
are less apt to be smoker:
than others, especially those
doctors who see the ravage;
of smoking-related diseases.
Al the latest CMA meeting in Quebec City, the asso
cialion dill not accept a
resolution lo ban the sale ol
tobacco in hospitals because
it did not agree on whether
it was the doctors' business.
!
Dr. William Nicholas,
j president of tlie Hamilton
; and dislrict academy of
medicine, said IK; doesn't
i think doctors should be
! thrown in jail over the
• smoking issue, but he
i agrees with Mr. Lewis (hat
a stronger stand could be
taken by the medical associations.
"1 know George (Mr.
Lewis) personally and I
know he is sincere in his
campaign against smoking.
I think doctors could take a
stronger role in the issue.
The medical profession has
nol shown significant lead-ership and he is fed up."
Me. said the Hamilton
association has about S O
S
members but could not say
how many are non-smokers.
"Bul 1 would imagine
there are fewer smokers in
that group than in another
group of 850 people."
�Thursday'
March 31, 1983
Smoking drivers worse
than drunk drivers: MD
W
hat an incredible waste.
. In less than a week,
beginning with a column here and ending with the entire front page on Saturday, The
Toronto Star used up 2,953,888
pages of valuable newsprint to tell
the uncensored and remarkably
obscene story of the drunk driver.
through an emission control sysAnd we got it wrong.
At least we did if you buy tem and out the tail-pipe while
George Lewis' argument that "the inhaling it directly from a paper
most dangerousT thing ifl { p tube inside the car?"
Such thinking began as part of a
vision he once had in a wrecking
•qnyfir'saffMiafiHwywrif ,. yard, where he went looking for a
tieorge Lewis is an associate replacement for a
tailprofessor of anatomy at McMas- gate and discovered smasheddidn't
that "!
ter University and this is not the realize so many cars were burnt
first time he has walked into this out from the inside." That brought
page — you might recall Frank
a pathologist colJones' account of Lewis' short- back something when performing
league had said
lived refusal to teach students who autopsies
dared to smoke even on their own who had on young, healthy men
died suddenly
no
time. Nor is he new to outrageous apparent reason; instead for the
of
controversy, having once had the usual medical jargon like "myogall to seek the impeachment of cardial infarction," the pathologist
the Pope over a theological issue. had often threatened to write
But this time he comes bearing a nothing other than "Death by cigamajor paper he'll be. presenting rette" on the certificate.
this summer when the fifth World
Two small incidents, but when
Conference on Smoking is conLewis added them up he was ablevened in Winnipeg, July 10-15.
Perhaps a few excerpts are in to conclude that, "The most dan;erous group on the roan tociav
order:
• ". . . smoke-inhaling drivers
are far out in iront as the largest m liilfftuft liMoxido. ami iP
.
, .
ig;
omrua nnvers on our streets .jnd m l n UM - ilk- c'uy'eitrff
u' m ' U.1
i
Mlllllll' DlU IBU on the Molotov
"Smoking in a car can quickly cocktail."
raise the blood carbon-monoxide
Popular, he isn't. Some collevel to well over 50 parts per mil- leagues see him on the lunatic
lion which is the industrial safetv fringe of medical science and
limit."
some others, who will at least lis• ". . . color vision is affected, ten, have sat through his arguespecially the ability to distinguish ments and supporting research,
between green and fed. visual stared him straight in the eye at
acuity or sharpness of vision is the end and said. "George, you're
lowered, while brain functions and absolutely right — but drop dead."
locomotor responses are slowed.
George Lewis thinks that's
All of these are quite apart from funny. He also thinks that, even
the overall mental depression in- though he's 62, he will live to see
volved."
society's attitude to tobacco
It is this man's belief that for change, perhaps even before our
every blurred-vision and missed- attitude to drunk driving. "Next
reflex accident caused by drink to nuclear bombs/' he says in partthere is an all-but-ignored incident ing, "tobacco is tlie loading instruof heart attack brought on hy a ment of violence in our society."
Such arc the words of the true
carbon monoxide hit, coughing l it.
believer. Who might be erazy.
or panic over ashes.
"Why then." he asks, "bother Who might, he rinht. Who doesn't
channelling poisonous carbon plan to .shut, up no m.itter whai
monoxide gas from the motor vou think.
I
if
�THE OTTAWA CITIZEN . WEDNESDAY, MARCH 1, 1989 A'
Where there's smoke,
there's George Lewis
L
itUe wonder Brian Mulroney doesn't appear to
have much interest in
getting back to work.
When he dropped into his office on Monday — in for a
quick • bite with the premiers
and then to chew over the possibility of postponing Parliament for yet another month / - MacGREGOR AT LARGE
there were white-haired men
and women waiting outside in smoke.
Under section 19 (1) (i) and
the cold, just the sort of people
who a few years ago would (ii) of the Immigration Act/
,
have cheered at the sight of George Lewis sees smokers
the head of the pack when he
him.
But this time they were reads that "No person shall be
chanting, "Traitor! Traitor!" at granted admission if he is " .vv :
everyone they saw who hap- likely to be a danger to. public;:,
pened to support the prime min- health or public safety or
might reasonably be expected
ister's vision of their country.
But that wasn't even the to cause excessive demands on
health or social services."
worst of it.
By George Lewis's caustic
If the prime minister picked
up his mail when he was in, he measure, the chemical poisonwould have found a hand-writ- ing of the people of Bhopal will: •
ten, five-page letter from- a re- stand as a tragedy "small in
proportion" compared to what
tired anatomy professor.
But not a letter of congratu- is happening right in our own:
lations. An open letter accusing backyards with lighted cigahim of criminal negligence and rettes.
As he likes to put it: "Next to:
culpable homicide.
Prime Minister Martin Brian nuclear bombs, tobacco is the
Mulroney, George Lewis would leading instrument of violence
like it to be known b ^ everyone in our society."
y
And for all these reasons,:
who voted for the man, is reponsible for around 100 deaths Monday — the day Brian Mul- •
a day — 140,000 Canadian roney sat down to pretend sepacorpses in his first term alone. ration was the greatest danger
"He has been presiding over we face in Canada today —
the literal gassing of 35,000 Ca- was a day of particularly sad, ;,
nadians a year," says Lewis note to George Lewis.
For it was 20 years ago to
from his ancestral home near
Hamilton's McMaster Universi- the day, on Feb. 27, 1969, when,
ty, where he taught until man- the House of Commons Standing'
datory retirement caught up to Committee on Health, Welfare'
him — much to the relief of his and Social Affairs tabled its re-J
port on tobacco.
fellow workers.
George Lewis, - you see, was "The story of the healtli ha*'
the first of the militant non- ard created by cigarette smot
smokers. His "No Smoking" ing represents an unrivalled.,
signs and requests that visitors tale of illness,' disability afttf
butt out date back nearly 40 death," the committee reported.
years, and it would not be an
"The potential benefits to W
exaggeration to say that he derived from the. cessation "of "
may have been the least , popu- smoking," the MPs of 1969 de-;
lar faculty member in McMas- clared, "place it at a level, of
-ter's history.
importance in preventive mediNow that George Lewis is re- cine with pasteurization of milfe,"
tired, however, he has set his the purification and chlorination
fan on the government of Brian' of water, and immunization.""":^'
Mulroney.
.; ' • •
"So what have we got?'''.
That's Brian Mulroney, killer.. George Lewis asks in 1989. "Ill
And his minister, of health — tell you — 20 years of silence!"!'
first Jake Epp, now Perrin
The prime minister may have :
Beatty — who get to share the stopped smoking himself, butjtntitle "Most Dangerous Man in Lewis's mind that makes the
the Country."
prime minister no less guilty of
Coming up with legislation to .the,murder of 100 Canadians.;a,
v •
^
cramp tobacco advertising is a day. '•' •
poor excuse for really doing
And that's why he wants Casomething, George Lewis says.
nadians fo gettogetherand sue'.'
"Who the heck cares about the Mulroney government for.
advertising? You don't need ad- all the pain and grief and sufvertising to sell marijuana or fering they have caused.
cocaine, do you?"
And still, some of us have the.
He is even planning to start nerve to wonder why Briatf
hounding the government about Mulroney is avoiding the offic^
letting in immigrants who these days...
o
1
r
L
�:: L :i'-.-fL
Tobacco kills,! no ifs, ands or butts about it, says anti-smoking crusader
F
or George Lewis, 40 years of being Canada's No. 1 Pain in the
Butt finally paid off this past
week.
• And it all happened, he suspects, by
accident.
The way George Lewis sees it, Minister of Health Perrin Beatty got caught
in a political pinch this past summer
when he suddenly announced that the
Royal Society of Canada would be
asked to decide, once and for all, if
smoking is truly addictive.
The study cost $30,000 - the best
$30,000 this country ever spent, Lewis'
says, because the scientists came out ;
last week with virtually the same opinion King James I first offered back in
1604 on the new social fad of smoking:
\*"A custom loathsome to the eye,
hateful to the nose, harmful to the <
brain, dangerous to the lungs, and in
ihe tyadc, stinking fume thereof,
nearest resembling the horrible Styg-.
ian smoke of the pit that is bottomless."
' George Lewis, who is in his late 60s,;',
has been claiming that and worse for
the 40 years since he became the first .
. known Canadian to hang a "No Smoking" sign in his workplace.
A Workplace that happened, more
He called for a royal commission on
smoking.
He argued that smokers were as
guilty of "impaired driving" as drinkers.
He argued that immigrants who
smoke should*be refused admission to
October 20,1989; Canada on the basis that they violate
the Immigration Act that prohibit those
who "might reasonably be expected to
MacGREGOR AT LARGE
cause excessive demands pn health or
social services."
often than not, to contain cadavers '
Less than a year ago, he called for
whose lungs and hearts had been dePrime Minister Brian Mulroney to be :
stroyed by the habit.
charged with the murder of 100 CanadiWhen George Lewis cut open his first ans a day.
corpse and saw what the tobacco he
By refusing to outlaw smoking, he arhimself then enjoyed could do, he quit
gued, the Canadian government was
cold turkey and set out on a life that
condemning 35,000 citizens a year to
has, to a large extent, been devoted to
death from smoking.
being the biggest Pain in the Butt any
But now he thinks, thanks to Perrin
smoker ever met.
Beatty, anti-smokers have the ammuniIn 1976, when he was a professor of
tion they need to put an end, once and
anatomy at Hamilton's McMaster Unifor all, to the sale of tobacco products.
versity, he declared that no one who
Only he doesn't call it "selling,'; of
smoked should be permitted to study
course — he calls it ''trafficking."
medicine or nursing.
And he doesn't talk anymore about
His unpopularity grew in leaps and
big tobacco companies and governbounds.
ments. He talks about the "Canadian
He went on strike, refusing to teach
and American drug cartel."
students who dared to smoke even on ^ That's right, drug cartels — and *
their own time.
headed up by those well-known drug
ROY
MacGREGOR
Citizen '
staff I
!
fp
'
' '•'' "
.1'!
//
i i A custom loathsome to the eye, hateful to
the nose, harmful to the brain and dangerous
to the lungs. JJ
— King James I
Commenting on new fad-in 1604
lords, Brian Mulroney and George
a clear cut picture of accountability
Bush.
and liability.
"So the government's new tobacco
. You wonder how George Lewis can
arrive at such wild thinking? Listen up: . legislation is really a bill that ends up
"What they're saying," he says from defending drug trafficking in Canada.
"What does that do for Brian Mulhis home near Hamilton, "is that this
roney's and George Bush's credibility
study will allow them to put a proper
when they talk about Colombia?
warning on a pack of cigarettes. You
"What the Colombians should be sayknow the kind of thing — 'This product
ing is 'We'll torch our cocrfa fields if
is highly addictive.'
you'll torch your tobacco fields.'
"But that's nothing short of absurd.
"After all, I would bet AmericanHow can they be allowed to get away
made Marlboros are killing more Cowith a simple warning on something
lombians than Colombian cocaine is
that is now proven to be highly addickilling Americans."
tive?
As you can see, you don't become the
"And don't forget, we are talking
biggest Pain in the Butt in the country
here about a federally-approved conby shying away from controversy.
sumer product. An addictive drug, sold
"I'm used to it by now," he says.
under license, with the government rak' "Besides, I wouldn't have, it any other
ing in most of the profits.
way.""What Perrin Beatty has given us is
•)
�Anti-smoking gains gratify, but don't sa
dal notification or letter ci rec
distinguished himself across Canada into effect this month. Under the hew
tion 6r appreciation from
and beyond for the role he has bylaw, an employer isrequiredto
' university or the hospitalforhis conplayed m what might be called the provide a smoke-free workplace If
bibutioa
littlefight(hat grew. For him, this smoking istobe permitted, it must
was the campaign that became an be carried out in specially desigGeorge Lewis is not a mantorest
obsession. And most of the time, he nated, ventilated rooms which comoh Ins laurela however sparse
willtellyou, George Lewis felt vay prise no more than 25 percent of the
Advances have been made, be says,
much alone.
' "
total area.
but the war is a kmc way fran WOT.
He notes that the VS. Surgeon
Vindication is not a word he likes.
Gerage Lewis may not be a vin; General's latestreport,outlining25
George Lewis is tut a vindictive dictive man but he has not always
, years of progress calculates that in
man.
stood as a pillar of gradousnesg
the mid-l960EJ, 35a000 Americans a
. But
waited for the
Tami Paikin Nolan guardedhe does admittoa certain/ while be hascome aroundtorestof
year were dying of smoke-related illsatisfaction and feeling of the worldto
his way
ness. Ibe number has risento390,000
accomplishmenttodayas the federal of thinking.
up against"
a year today.
government considers new reguIn 1973, Mr. Lewis sent around a
No interest
for
"ItafS!
note inviting peopletocome togeth- lationss Parktobaccoadvertisers and
and local municipaliTbe federal government's adverHe has been unrelenting in his
er to talk about making Mac a Queen' in withtighterlawstocurb
ties kick
tisn* bans are not enough, he says,
healthful smoke-free environment smoking in public and in the work- criticism of the medical profession
v - ,fmo cares about advertisiiig?
which, he says, still has no interest in
Not a soul replied
You dont need advertising to sell
In the years that have come be- place. City of Hamilton's bylaw oh preventive medidne a«L lifestyle George Lewis: still fuming
, The
; marijuanaOTcocaine, do you?
tween, George Lewis, now 69, has smoking in the workplace comes disorders such as alcoholism and nic' -And Hamilton's new anttsmoking
otine addiction.
aga pale by comparison.
y
Tlie doctors dont care about it,
Tve never been onetosay I told bylaw misses the boat if it is nc*
r goingto
he says; and the medical schools you so,"reflectsMr. Lewis.
^ -indeed, itindude restaurants; which
is not (Restaurants will
wonttouchit One respected admin"But when people tome uptome
istrator fold him years ago: "Come now and say: 'Goodforyou, George;'' continuetocome under a 1960 bylaw
on, George you know that good med- I am sometimestemptedtoade ^whieh merely;requires. separate
idne is bad business."
them' where they were when; I s sectionsforsmoking and nonflmokGeorge Lewis believes doctors needed them."
and medical schools are guilty df
McMaster hospital , became V'^^he^rar on drugs, he says, is
complicity in a wanton disregard of smoke free in July 1907, by coin- ' absurd unless you. are goingtoin-dude the legal drugs. He describes
the tacts. An ounce of prevention is
worth a pound of chemotherapy any cidence the very month of the vay 'Vv nicotine as toe most powerful and
year George Lewisretiredafter 17
ngly-addictive drug oh the
SATURDAY, MARCH 3,1990
the status q o
uL
He befieves Brian Mulroney is years of disturbing rathersurprises .KfaceoftheE^rth.
To this dayTh
Patience has never been one (rf the
guilty of culpable homkadeforpresiding over the gassing of about 39,- bini tftftt despite tils interest and virtues of George Lewis. We will
000 Canadians a year due to smoke- obviouis expertise on the subject, he have a truly anoke-free environwas new consulted or asked for ment by the year 2000; somebody
related illness.
. He believes George Bush is input when the dedskn wasfinaltyi said,
%
To which
i Lewis replies,
bossman of a drug cartel that makes made:
Nor did he ever receive any afO- ' ' ."Why not 1
the deathly dealings of Manuel Nori-
GEORGE LEWIS is the Jules Verne
of the anti-smoking set a man ahead
of his time
George Lewis tried to get
McMaster to declare its medical
centre smoke-free nearly 20 years
ago.
"ITiey told me they understood
what I was saying but I should drop
dead," the retired professor of anatomy says today.
One member of the board of governors told Mr. Lewis back in the
early 1 7 s that the crusading pro90
fessor had his sympathy and support
but that was as far as it would go —
because the companyfor which he
worked was owned by a company
that was owned by a company that
was owned by R J. Reynolds Tobacco.
"Riat's when I knew what I was
;
1
�
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Health Care Task Force Records
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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Box 37
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[Maryland Policy Choices: 1993] [loose, spiral]
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56
2
4
3
�MARYLAND POLICY CHOICES: 1993
Schaefer Center for Public Policy
Principal Researchers:
Dr. Patricia Florcstaino
ll|ipiilll||ij!
Dr. Larry Thomas
Dr. Herbert C.Smith
�SCHAEFER CENTER
15011
P U B L I C P O L I C Y at the University of Baltimore was established in April 1985.
The Center's mission is to serve the public, non-profit, and quasi-governmental sectors by
engaging in research on pubic policy issues, providing management consulting and computer
consulting, conducting management training and professional development programs,
collecting and analyzing data, and organizing educational conferences.
As a university-wide center, the Schaefer Center is able to draw upon the expertise of the
entire university community to carry out its mission of applying academic knowledge to realworld problems to produce tangible, useable results. The activities of the Schaefer Center
are supported by the University of Baltimore, by grants and contracts, and by private
endowment funds.
SCHAEFER CENTER ACTIVITIES
The Schaefer Center has eight main areas of activity:
Program evaluation and policy implementation assessment
Organizational, program, and policy analysis
Survey research
Management consulting
Computer consulting
Management training and professional development workshops
Computer training workshops
Educational seminars and conferences
ADVISORY BOARD
Mr. Jacques Schlenger, Esquire
Advisory Board Chairman
The Honorable Clarence Blount
Mr. Hal Donofrio
Mr. Philip D. English
Mr. Arnold J. Kleiner
Mr. Thomas T. Koch
Mr. Milton H. Miller
Mr. J. Stevenson Peck
Mr. Bishop Robinson
Mr. Henry A. Rosenburg, Jr.
The Honorable Edgar P. Silver
Mr. Walter Sondheim
Mr. Bailey Thomas
Mr. Bernard C. Trueschler
Dr. H. Mebane Turner (Ex Officio)
SCHAEFER CENTER STAFF
Dr. Larry W. Thomas - Director
Ms. Ann Winogrodzki - Assistant Director
Dr. Don Haynes - Project Director,
Survey Research
Dr. Robert Durant - Research Chair
Dr. Patricia Florestano - Senior
Research Fellow
Dr. Lenneal Henderson - Senior Research
Fellow & Distinguished Professor
Dr. George Rawson - Research Associate
Ms. Diane M. Aull - Administrative Assistant
�MARYLAND POLICY CHOICES: 1993
The Maryland Policy Choices 1993 survey is an on-going project in the Schaefer Center
for Public Policy at the University of Baltimore. The purpose ofthe survey is to provide citizens
and public officials with systematic and representative information on citizen attitudes toward
policy issues facing Maryland state government. The 1993 survey, which took place from
December 12 to 20, 1992, asked 1022 Marylanders over the age of eighteen a series of questions
on topics such as spending preferences, economic outlook, health care, crime, welfare reform,
environment, state lottery, and term limitations. To conduct this random survey, telephone
numbers were selected from computer generated lists of all possible phone numbers in the state.
The margin of error for this survey is approximately +1-3%.
Several items in this report are based on results from a survey conducted in early
December, 1992 in conjunction with the Maryland Department ofthe Environment. These items
are noted in the graphic presentation. The project was a cooperative effort between the Schaefer
Center and the Maryland Department of the Environment. The environmental survey used the
same sampling strategy as above and targeted the same respondents. The only differences
between the two surveys are in the number of respondents-1032 rather than 1022-and the
timing ofthe survey. Weighting factors, margins of error, and reporting practices are the same.
In addition, several items in the 1993 survey were asked in the 1992 survey. Where
applicable, comparisons between the 1993 and the 1992 data are presented A note of caution
in making comparisons between the two surveys is in order. The sample used for the 1992
survey was 844 Maryland registered voters who had voted in recent elections. The 1993 study
is a survey of the general population. Comparing the two surveys can pose problems in
interpreting differences from one year to the next since the two populations are different.
However, we feel that registered voters are not so different from the general population that
limited comparisons and inferences about change can not be made as long as those differences
are kept in mind.
A complete description of the sampling strategy as well the demographic characteristics
ofthe sample can be found in Appendix A. To simplify reporting, survey results described in this
document have been rounded to the nearest whole percentage. All percentages are based on an
N of 1022 from Fall Survey. The environmental survey has an N of 1032 and the 1992 Fall
Survey has an N of 844. In some cases, where missing data and refusals are presented, the
figures reported will not sum to 100%. In effect, this results in a relatively more conservative
interpretation of the data.
�The 1993 Policy Choices survey was designed by the staff of the Schaefer Center for
Public Policy. Principals included Dr. Don Haynes, Dr. Larry Thomas, and Dr. Patricia
Florestano ofthe University of Baltimore and Dr. Herb Smith of Western Maryland College. A
great deal of gratitude is extended to the interviewers who spent numerous hours talking with the
citizens of Maryland and recording their conversations. A special thanks is accorded Ms. Ann
Cotten, Assistant Director, the Schaefer Center, who created the data files and contributed to the
analysis as well as to Ms. Diane Aull, Administrative Assistant in the Schaefer Center, who
created the graphics and managed the final production of the report.
The survey was paid for out of the Schaefer Center's private endowment funds and
through financial contributions made by the Maryland Health Resources Planning Commission.
The Schaefer Center for Public Policy at the University of Baltimore conducts the
Maryland Policy Choices Survey annually. The poll is open to public agencies, public interest
groups, not-for-profit agencies, and the media which want to purchase questions to put on the
survey. Interested parties can purchase single questions or blocks of questions. For more
information on scheduling and prices, please contact Dr. Don Haynes at the Schaefer Center for
Public Policy (410)-333-2657.
�TABLE OF CONTENTS
PAGE
Executive Summary
Perceptions of Maryland's Problems
1
Evaluation Government Performance
6
Public Spending Priorities
6
Health Care Issues
12
Environmental Issues
23
Welfare Reform
32
Crime and Gun Control
34
Education: Public Service
40
Maryland Lottery
42
Term Limits
44
Appendix A: Methodology
46
�EXECUTIVE SUMMARY
The following summarizes the majorfindingsof the survey.
1.
A variety of economic issues are the most important problems facing the state.
Approximately 38% of the respondents identified the state budget as the most
important problem facing the state. Unemployment was noted by 11% of the
respondents as the most important problem and taxes by 6%, for a total of 55%.
Health care was noted by 11% of the respondents to this question.
2.
Respondents are moderately optimistic about the future of the state's economy.
Thirty-nine percent (39%) of those surveyed felt that Maryland's economy would get
better next year, while 19% thought it would be worse. In terms of personal
economic fortunes, 43% said that they were about the same as last year. Forty-three
percent (43%) believe that they will be better off economically next year.
3.
Approximately 82% of the respondents said government efforts to solve problems in
Maryland were either "only fair" (54%) or "poor" (28%).
4.
More than 70% of the respondents believe that more money should be spent on
public education and public safety.
5.
Rising health insurance costs was the health care issue of most concern to the
respondents (78%), followed closely by higher out-of-pocket costs for health care
(68%), and cuts in benefits due to high costs (67%).
6.
Fifty-five percent (55%) of the respondents believe that the state should go ahead
and develop its own health care plan rather than waiting for the adoption of a
national plan (34%).
7.
Fifty-six percent (56%) of the respondents would prefer to pay more for health care
if they could retain their choice of doctors, while 30% supported the idea of lower
costs and less choice.
8.
Close to three-quarters of the respondents (28% "strongly support" and 44%
"support") say that they are willing to pay higher taxers in order to insure that all
people have access to health care.
9.
Each of three proposals on ways the state government could make health insurance
available to everyone in the state received approximately 30% of the respondents'
support.
10.
Suggestions to place limits on health care availability in order to control costs were
opposed by the respondents. Sixty-six percent (66%) oppose restrictions on care for
patients with costly illnesses, and 58% oppose restrictions on care given to people
who might not be expected to survive long after the treatment is received.
11.
A majority of respondents oppose a government requirement that immediate families
of elderly medicare and medicaid recipients pay a larger share of the costs of care.
Forty-six percent (46%) "disagree" and 11% "strongly disagree." However, this leaves
a sizable minority (44%) who support the idea.
�12.
Over 80% of respondents approve of "right-to-die" legislation.
13.
When asked to judge the seriousness of various environmental concerns, 80% of the
respondents ranked hazardous and toxic wastes as the item of greatest concern.
Other highly ranked concerns were threats to drinking water (74%), pollution in
rivers and streams (72%), and cleaning up the Chesapeake Bay (72%).
14.
When asked to think about environmental priorities from the point of view of the
state as a whole, cleaning up the Chesapeake Bay ranked as the most pressing
environmental concern with 20% mentioning that item. When asked about their own
communities, responses differed. The two biggest problems for communities were
seen to be pollution from automobile (20%) and solid waste disposal (19%).
15.
Seventy-four percent (74%) of the respondents believe that Maryland state
government programs do not do enough to solve environmental problems. Similarly,
58% of the respondents said that environmental regulations in Maryland were not
strict enough.
16.
Sixty-eight percent (68%) of the respondents would support stricter environmental
regulations even if product costs were raised as a result. Fifty-seven percent (57%)
would approve of stricter regulations even if they increased taxes. Only 45% approve
when stricter regulations would be a threat to the competitiveness of state businesses.
Only 31% approve if stricter regulations would cost jobs or discourage business
location in Maryland.
17.
Sixty-four percent (64%) of the respondents agree that supporting clean air is worth
potential sacrifices.
18.
Seventy-six percent (76%) of the respondents approve of stricter state regulations to
control the air pollution caused by automobile exhausts. Eight-three percent (83%)
of those approving continued their support even if the cost of a new car went up by
$200.
19.
Fifty-three percent (53%) of the respondents believe that welfare benefits make poor
people dependent on the government, while 36% felt that welfare benefits allow
individuals a change to stand on their own.
20.
Marylanders support placing requirements on the receipt of welfare benefits. Eightynine percent (89%) support mandatory work for those receiving welfare benefits.
Seventy-three percent (73%) support limiting payments after a specified number of
children. Seventy percent would support cutting welfare benefits to families whose
children did not attend school regularly.
21.
Seventy-eight percent (78%) of the respondents said that the laws regulating the sale
of handguns should be made more strict. Eighty-four percent (84%) would support
the ban of the sale of military style assault weapons and 82% would support a law
requiring a police permit before an individual could purchase a handgun. Fifty-nine
percent (59%) oppose banning the sale of all handguns in the state.
�22.
Sixty-four percent (64%) of the respondents would approve of using the National
Guard to patrol high crime areas in the state.
23.
Eighty-nine percent (89%) of the respondents would approve of a law mandating a
minimum prison sentence for car-jacking.
24.
Legalizing some drugs as a way of reducing crime was opposed by 66% of the
respondents.
25.
Community service as a requirement for high school graduation was supported by
60% of the respondents.
26.
The operation of the Maryland lottery was generally supported by Marylanders.
Thirty-three percent (33%) gave a "favorable" evaluation of the lottery's management,
and 10% gave a "very favorable". Over one quarter of the respondents had "no
opinion."
27.
Forty-six percent (46%) of the respondents said that keno was not the right way for
the state to raise revenues. However, the majority of Marylanders either thought
KENO was the right way to raise revenues (24%) or had no opinion (30%) on the
topic.
28.
Seventy-one percent (71%) of the respondents favored limitations on both the
amount of time someone could serve in the Maryland legislature and the amount of
time someone could serve in Congress.
�MARYLAND POLICY CHOICES
SECTION 1:
Perceptions of
Maryland's
Problems
1993
Maryland state government is facing a number policy choices in
1993 that are of critical importance to the citizens of this state.
Policy choices influence economic activities, determine eligibility
for social benefits, establish norms of legal behavior, regulate
business operations, and provide for job opportunities. Policy
choices also affect the quality-of-life of the citizenry as well as
influence matters pertaining to the environment, education,
taxes, and other issues.
To determine which of the policy issues facing the General
Assembly during the 1993 session the citizenry considers to be
the most important, respondents were asked, without prompting,
to express what was uppermost in their minds.
Question: What would you consider to be the single most
important problem facing the state legislature in the next
year?
Responses tended to be geared toward economic issues (see
Figure 1.A). Concern about the state's budget was the most
frequently mentioned item. Approximately 38% of respondents
noted that this was the single most important issue facing the
General Assembly in 1993. Unquestionably, these perceptions
are the result of another year in which the economy was flat,
tax revenue was below projections, and massive cuts had to be
made in the state's budget. Last year, a majority (51%) of
registered voters sampled stated that the budget crisis was the
major problem facing the state.
Respondents also indicated that other economic issues are of a
major concern as well. Unemployment was mentioned by 11%
of the respondents as the single most important issue facing the
General Assembly in 1993, and another 6% mentioned taxes.
All told, 56% of the respondents indicated that economic issues-i.e. the budget, taxes, and unemployment-are the biggest
problems facing Maryland.
Maryland Policy Choices: 1993
Schaefer Center for Public Policy
�Figure 1.A
Biggest Problem Facing Maryland
Budget
38%
Taxes
Health Care
6%
•
11%
Growth Management
1%
Higher Education
3%
Welfare
4%
Unemployment
^
11%
P u b l i c Education
6%
Crime
7%
Drug
Environment
n
4%
t
Other
er
^ 1 %
^ ^ ^ H
Don't k n o w J ^
0%
& 1 1
2%
10%
20*/.
Percent Mentioning
30%
40%
Problem
Figure 1.B
Biggest Problems Facing Maryland
Comparison of 1992 and 1991 S u r v e y s
Budget
Taxes
Health Care
G r o w t h Management
Higher Education
Welfare
Unemployment
P u b l i c Education
Crl me
Drugs
Environment
Other
6 0 % 6 0 % 4 0 % 3 0 % 20% 1 0 % 0% 10% 2 0 % 3 0 % 4 0 % 6 0 % 6 0 %
Percent M e n t i o n i n g
1992
Percent M e n t i o n i n g 1991
1
I
�Health care was mentioned as a primary concern by 11% of the
respondents. This likely reflects the soaring cost of health care
to citizens of the state as well as the problems associated with
access to quality health care. Last year, only 3% of the
respondents indicated that health care was a major problem.
Clearly, many feel that cost containment, access to health care,
Medicaid and Medicare are issues which the state legislature
must address.
With these exceptions noted, the pattern of concerns has shifted
remarkably little from last year. Although issues such as the
environment, public education, crime, welfare, and drugs are
extremely important, the public perceives that the budget,
health care, and unemployment, in that order, are the top three
issues the General Assembly should deal with during its 1993
session.
Perceptions of Economic Conditions
To gauge the extent of economic optimism or pessimism on the
part of the state electorate, we asked a series of questions
concerning respondents' perceptions of the future of the
Maryland economy and their own economic fortunes.
Question: In terms ofthe overall Maryland economy, do you think
things in the next year will get better, will get worse, or do
you think things will stay about the same?
Question: What about your own personal economic situation, are
you better off today than you were a year ago, are you
worse o f f , or do you think you are about the same as four
years ago?
Question: Again, thinking about your own personal economic
situation, do you think you will be better off a year from
now, worse o f f , or do you think you will be about the
same?
Maryland Policy Choices: 1993
Schaefer Center for Public Policy
�The results of this series of questions are presented in the
accompanying Figure l.C. In terms of the Maryland economy,
only 19% of the respondents thought Maryland would be worse
off next year. Thirty nine percent (39%) felt Maryland would be
better off and another 39% felt Maryland would be about the
same.
In terms of personal economic fortunes, about 30% said they
were worse off than last year, but about 43% said they were
about the same and 27% said they were better off. Higher
income groups were more likely to see themselves as better off.
For those with family incomes over $100 thousand, 52% said
"better off' compared to 18% of those making between 15 and
20 thousand dollars and 27% making between 25 and 50
thousand dollars.
The most important of these questions is the last since it is a
closer measure of economic optimism or pessimism. The good
news is that only about 10% of the respondents were truly
pessimistic saying they would be worse off next year. About
equal numbers of people say they will be better off
economically (43%) or about the same (42%) next year. Again,
higher income groups were more optimistic about the future.
A clearer picture of the state's shift in mood is obtained by
comparing the results of this question with last year's responses,
(see Figure 1.D) Two items clearly show a pattern of increased
optimism. Thirty-nine percent (39%) of respondents to the 1992
survey indicated that they thought Maryland's economy would
be better next year compared to last year. In contrast, only
19% of the respondents to the 1991 survey felt that the
economy would be better in the following year. In addition,
Marylander's personal economic expectations are much more
positive (43%) this year than last (25%).
Maryland Policy Choices: 1993
Schaefer Center for Public Policy
�Figure 1 . C
E v a l u a t i o n s of E c o n o m i c Situation
MARYLAND ECONOMY
BETTER NEXT YEAR
Better
Worae
About same
39%
19%
39%
YOU'RE BETTER OFF
TODAY T H A N LAST Y E A R ?
Better
Worae
About same
S 27%
••Q 3 %
0
51 43%
Y O U ' L L B E BETTER OFF
NEXT Y E A R ?
Better
Worae
A b o u t same ^
fi 43%
10%
fi 42%
0%.
10%
20%
30%
40%
60%
Figure 1.D
E c o n o m i c E v a l u a t i o n s C o m p a r e d to L a s t Y e a r
MARYLAND ECONOMY
BETTER NEXT YEAR
Better
Worae
About same
/
^
39%'
19%'
y
39%'
YOU'RE BETTER OFF
TODAY T H A N LAST Y E A R ?
Better
Worae
About same
^119%
S /
^ s>
^ ^
AieeL
•27%
30%
43% I
^
43%
Y O U ' L L B E BETTER OFF
NEXT Y E A R ?
Better
Worae
About same
^
/ \ 32%
^ \ 29^
y ^
37%
/
/
y
60%
42%
40%
/
^
^
20%
11992 S u r v e y Q l S S I
Note differences In survey populations,
see page 2.
/
0%
Survey
25%
20%
,
^ ^
20%
40%
^iRtmc.
60%
�SECTION 2:
Evaluating
Government
Performance
The 1992 survey asked respondents to evaluate state
government's performance in solving Maryland's problems.
Question: In general, how would you rate the performance of state
government in solving problems in Maryland? Would you
say excellent, good, only fair, or poor?
Fifteen percent (15%) felt that state government had done a
good job and 1 an excellent job. Fifty-four percent (54%)
%
indicated that the state's performance was only fair and 28%
maintained that state government had done a poor job of
solving Maryland's problems. However, the evaluations are
slightly more positive this year than last.
SECTION 3:
Public Spending
Priorities
Despite the state's budgetary crisis, Maryland citizens voice
preferences for increasing government spending in several policy
areas. This is reflected in Marylander's responses to the
following question.
Question: For each of these services funded by state or local
government, tell me whether you think we should spend
more money, spend less money, or whether there should be
no change in the amount of money spent. Please keep in
mind that spending increases come out of tax money paid
by you.
a. Elementary and secondary schools
b. State universities and colleges
c. Parks and recreation
d Public assistance to the poor
e. Arts and cultural activities
f . Aid to local governments
g. Aid to Baltimore City
h. Public transportation
L Environmental protection
j. Police and public safety
k Prisons and corrections
I. Roads and highways
m. Programs for the elderly
n. Medical assistance to the poor
Maryland Polity Choices: 1993
Schaefer Center for Public Policy
�Figure 2A
.
G v r m n P rom n e in Solving M r l n ' Po l m
o en e t ef r a c
aya ds r be s
Excellent -
Go
od
4
Only Fair- 5 %
Poor
i
i
i
i
i
i
J
I
L
J
L
7 % 6 % 5 % 4 % 3 % 2 % 1% 0 1 % 2 % 3 % 4 % 5 % 6 % 7 %
0 0 0 0 0 0 0 % 0 0 0 0 0 0 0
11992 S r e B 9 1 S r e
uvy 1 9 uvy
Note differences in survey populations,
see note p.2.
�The data for public spending priorities are presented in the
Figure 3.A. The figures to the left of the center axis on the
chart are the percentages of respondents who said "more money
ought to be spent in this area," while thefigureson the right of
the axis combine the percentages of those who said that there
should be "less money" or "no change" in the amount of money
spent on specific programs. The distinction between the latter
two is identified by the different bar patterns.
The programs which Marylanders feel should have more money
allocated to them include public education, public safety, and
medical assistance to the poor. For each of these programs,
more than 65% of respondents agreed that "more money" ought
to be given to these areas. Following closely were programs for
the elderly, public assistance to the poor, environmental
protection, and support for state colleges and universities.
It is interesting to note the similarities between the patterns of
public priorities of the 1991 survey and the 1992 survey (See
Figure 3.B). In terms of relative ranking, the spending priorities
this year are virtually the same as last year. The primary
difference is the general higher percentage of people who say
"spend more" this year than last. The accompanying graphic
compares only those who said "spend more" for each category.
The results seem to reflect the shift to a more optimistic view
of the future. Respondents generally were less frugal with the
public purse this year than last.
A ranking of public priorities can be based on adding the
percentages of respondents who indicated that there should
more spending or the same amount of spending in specific
policy areas. As in Table 3.A the top five areas in which
Marylander's support the same or additional amounts of
spending are public education (96%), public safety (96%),
programs that assist the elderly (95%), medical assistance to the
poor (94%), and public universities (90%). The next level of
spending priorities include the areas of environmental
protection, assistance to the poor, public transportation,
highways, prisons, aid to Baltimore City, parks, and aid to local
government. The lowest ranked spending priority was for the
arts and cultural activities (63%).
Maryland Policy Choices: 1993
Schaefer Center for Public Policy
�F i g u r e 3.A
S p e n d i n g Priorities
Public Education h 74%
CollegeAJnivoraltlea
Parks and Recreation
Assistance to Poor
Arts and Culture
Local Government
B a l t i m o r e City
Public Transport
Environmental Prot.
Public Safety
Corrections
Roads and Highways
Elderly Programs
Medical Assistance
100% 80% 6 0 % 4 0 % 20%
0%
20% 40% 60% 80% 100%
H S p e n d M o r e E S p e n d L e s s HD S p e n d Same
N o t e : p e r c e n t a g e s d o n o t s u m t o 100 b e c a u s e o f " D o n t K n o w s " a n d r e f u s a l s .
Figure S . B
C o m p a r i s o n of S p e n d i n g Priorities 1992 v s . 1991
ISpend
More
in 1 9 9 2
P u b l i c E d u c a t i o n ) - 74%
College/Universities
Parks and Recreation
A s s i s t a n c e to Poor
Arts and Culture
Local Government
Baltimore City
Public Transport
Environmental Prot.
E
Spend
More
In
^
^
^
1991
67%
48%
54%
51%
P u b l i c S a f e t y ) - 75%
Corrections
Roads and Highways
Elderly Programs)Medical Assistance
63%
Q6%
100% 80% 60% 4 0 % 20%
Note differences In survey populations.
See page 2 for explanation.
/
0%
S
S
/ \ 51%
20% 4 0 % 60% 80% 100%
�Table 3A
Ranking of Priorities
Spend More and Spend Some Combined
Spend More
Public Education
Public Safety
Elderly Programs
Medical Assistance
Colleges/Universities
Assistance to Poor
Environmental Protection
Roads & Highways
Public Transportation
Corrections
Parks < Recreation
&
Local Government
Baltimore City
Arts & Culture
Spend Some
Spend Less
Spend More
Spend Same
Combined
Ranking
74
75
63
66
48
54
51
34
35
37
21
28
35
11
21
19
29
25
38
31
34
48
43
40
54
43
34
49
4
4
4
6
9
12
11
16
16
17
22
23
21
34
95
94
92
91
86
85
85
82
78
77
75
71
69
60
1
2
3
4
5
65
65
8
9
10
11
12
13
14
10
�Table 3.B
SPENDING PRIORITIES BY REGION
% Say "Spend More"
Baltimore
Baltimore
Metro
itiiiiiii:!!
Maryland
Southern
Maryland
Eastern
Shore
Elementary/Public Schools
81
67
82
72
74
Maryland University/
Colleges
50
43
65
41
50
48
Parks Recreation
39
22
17
18
19
17
Public Assistance to Poor
68
51
54
54
49
53
Arts/Cultural Activities
18
11
14
8
9
9
Aid to Local Government
34
30
29
31
31
29
Aid to Baltimore City
65
45
29
18
23
22
Public Transport
45
30
43
35
44
36
Environment Protection
65
49
52
54
59
58
Police/Public Safety
83
78
74
68
65
73
Prisons Corrections
38
41
38
33
42
36
Roads Highways
49
32
35
32
27
28
Programs for Elderly
69
64
63
63
64
64
78
64
69
65
62
63
|| Med Assist, to Poor
11
�Table S.B shows spending priorities by Maryland's geographic
region's. Percentages are for those who say spend more. In
general, Baltimore City respondents are somewhat more likely
to say "spend more" across all programs. Geographic
differences are evident on aid to Baltimore City. The question
shows a 30 to 40 percent shift from Baltimore City respondents
to those in the D.C. area. Western Maryland, and Southern
Maryland.
SECTION 4:
Health Care Issues
in Maryland.
As in the rest of the nation, health care is a major issue
confronting policy makers. Health care issues span questions of
availability, cost containment, unequal distribution, and access.
In addition, the state will have to deal with the very difficult
issues of providing coverage to persons below the poverty line
who do not receive Medicaid, providing insurance to workers
who are not covered under employer-provided insurance, and
financing the long-term health care of the state's increasingly
elderly population. To gauge Marylander's views on health care
issues, we asked a series of questions designed to tap various
dimensions of the health care crisis.
Questions: For each of the following items, please tell me if this is
something you are concerned about a great deal, concerned
about somewhat, not very concerned about, or not at all
concerned about.
a. Rising health insurance costs
b. Your ability to pay for catastrophic illnesses
c. Loss of health insurance coverage
d Cuts in your health insurance benefits because of high costs
e. Limits on wages because of health costs
f . Higher out-of-pocket costs for health care
g. Inability to obtain insurance because of an existing
illness or condition
Maryland Policy Choices: 1993
12
Schaefer Center for Public Policy
�This question asked respondents to voice their concern about
situations in which health care insurance might be more costly
or more difficult to obtain. Figure 4.A shows the percentage of
those saying they were concerned a "great deal". Across the
board, respondents found each of the items to be things that
greatly concerned them. Seventy-seven percent (78%) of the
respondents were concerned about the rising costs of health
insurance, 67% were concerned with cuts in benefits due to high
costs of insurance, and 65% were concerned with the potential
loss of health insurance coverage. Unquestionably, the issue of
most concern was the threat of rising health insurance costs-an
issue that touches virtually everyone regardless of income or
other demographic criteria. Indeed, examination of demographic
breakdowns show this to be a consensus issue across virtually all
categories with only minor variation by age: young people are
slightly less likely than older respondents to be greatly
concerned with this issue, and wealthier respondents were less
concerned.
The two least threatening items were "limits on wages due to
high insurance costs" and the "inability to get insurance because
of pre-existing illness". But even for these, a majority of the
population saw a threat to their health care.
Question: There has been a lot of talk about a national health
care plan but so far no plan has been adopted. Do you
think the state of Maryland should go ahead and develop
its own health care plan, or do you think Maryland should
wait until a national plan is adopted?
A major issue in the recent national election was the rising cost
of health care. The outcome ofthe election signaled that health
care would be high on the new administration's policy agenda.
Heath carefinancinggained national prominence at the same
time that state governments, including Maryland, were wrestling
with the problem. For states, a basic issue is whether to take a
"wait-and-see" strategy with regard to federal action or to be
proactive on the issue. This question attempts to gauge public
sentiment on this question.
Maryland Policy Choices: 1993
13
Schaefer Center for Public Policy
�Figure 4A
.
Patterns o H at Care Concerns
f e lh
Rising Health
Insurance Costs
Ability of Pay for
Catastrophic Illness
Loss of Health
Insurance Coverage|
Cuts in Benefits Due
to High Costs |
Limits on Wages Due
to High Ins. Costs|
Higher Out-of-Pocket
Costs for Care |
Inability to Get
Insurance Because of
Pre-Existing Illness |
0
%
20%
40%
60%
80%
100%
Pre t s yn c nend " g e t da"
e c n a i g o cr e a r a e l
14
�As Figure 4.B shows, about 55% of the respondents felt that
Maryland ought to move ahead with its own plans and not wait
for the federal government. Thirty-four percent (34%), on the
other hand, felt the state should adopt the wait-and-see strategy.
Ten percent (10%) had no opinion or voiced "don't know".
Question: Ifyou had to make a choice, would you rather lower the
amount of money you pay for health care but give up some
of your freedom to choose your own doctors, or would you
rather pay more for health care and maintain complete
freedom to choose your own doctors?
One issue that has structured the health care debate has been
the issue of freedom of medical choice. As the argument has
been framed, the alternatives are: (1) to pay lower costs but lose
freedom to choose doctors, as is the case in some nationalized
health care plans in other countries; or (2) to pay higher costs
and retain complete freedom to choose doctors, as is currently
the case in the United States.
As shown in Figure 4.C, in general respondents were more
inclined toward the freedom of choice of doctors even if costs
remained high. Some 55% of respondents preferred to pay a
higher price and retainfreedomto choose their own doctors:
Adding to this the 9% who volunteered a qualification -some
of each -produces a picture of a public that values traditional
freedom of choice of doctors. This is in line with national
opinion favoring private-based systems.
Question: If it meant an increase in your taxes, would you strongly
support, support, oppose, or strongly oppose an increase in
government spending to ensure that all people have access
to medical care?
Combining the "strongly support" and "support" categories for
this question shows that close to three-quarters (72%) of
respondents say they are willing to pay higher taxes in order to
insure that all people have access to health care. (See Figure
4.D) Twenty-eight percent (28%) "strongly support" and fortyfour percent (44%) support the increases. A national survey
conducted in 1991 for the AMA by Gallup Associates shows
most Marylanders tend to be somewhat more conservative than
the nation on this issue. That survey using a similar question
Maryland Policy Choices: 1993
IS
Schaefer Center for Public Policy
�Figure 4 . B
S h o u l d Maryland Develop Its O w n
Health P l a n or Wait for F e d e r a l G o v e r n m e n t
55%
Go Ahead. Develop
Dont Know
Wait for Feda.
Figure 4 . C
F r e e d o m to C h o o s e D o c t o r s v s .
L o w e r C o s t s of Health C a r e
Lower costs, give up
some choice
Pay m o r e a n d retain
c h o i c e of d o c t o r s
Some Combination
Don't k n o w
0%
10%
20%
16
30%
40%
50%
60%
�Figure 4D
.
Wilingness t P y for H at Care
o a
e lh
S e dn Increases
pn i g
Strongly Support
Support
Oppose
Strongly Oppose
Don't Know
1 % 20% 30% 40% 50%
0
17
�found that 45% said "strongly support" and 24% said "support"
increased spending even if it meant an increase in taxes.
Question: There are several different proposals being discussed
about how state government should go about making sure
health insurance is available to everyone in the state.
Please tell me which of the following you think is the best
way for the state to proceed
1. Should the state pass laws requiring employers to offer
health insurance to employees.
- or -2. Should the state create and administer its own health
insurance plan.
- or -3. Should the state use state funds to help people who
cannot afford insurance.
This question attempts to describe basic state strategies for
ensuring that everyone has access to affordable health care.
Results are shown in Figure 4.E. The results are interesting in
that no consensus on a preferred strategy emerges. Virtually
identical numbers of respondents (approximately 30% in each
case) prefer each of the strategies with about 9% saying they
"don't know" which strategy is best.
In some ways, the responses to this question exemplify the
dissonance that exists in the public's mind about this issue.
Delivery and affordability of health care are complex issues that
the publicfindsdifficult to sort out.
Question: Some health plans that have been discussed in other
places would place limits on the treatment available to
people with diseases that are costly to treat, others have
proposed putting limits on the treatments available to
people who would not be expected to live long even if they
receive the treatment.
Would you favor or oppose a plan in Maryland that would
limit the treatment available for costly illnesses?
Would you favor or oppose a plan in Maryland to limit
treatment available to those who would not be expected to
live long even if they received the treatment.
Maryland Policy Choices: 1993
18
Schaefer Center for Public Policy
�Fg r 4.E
i ue
Preferences f r At r ai e Strategies
o len tv
f r Po i i g H at I s r n e
o r vdn e lh n ua c
-Require employers to
offer insurance!
-State create a d
n
administer plan
• s state funds for
Ue
those unable to p y
a
•Donl k o
nw
0 5 1% 1% 2% 2% 3% 3%
% % 0 5 0 5 0
5
19
�As Figure 4.F shows, neither of these questions received
majority support in Maryland. Indeed, clear majorities in both
cases oppose plans that would ration health care based on the
nature of the disease or on the survivability prognosis for the
patient. Sixty-six percent (66%) oppose restrictions on care for
patients with costly illnesses, and 58% oppose restrictions on
care given to people who might not be expected to survive long
after the treatment is received.
Question: Currently, a high percentage of Medicare and Medicaid
payments go to care for elderly people who are unable to
care for themselves. Some people argue that the families of
those people ought to be required to pay a greater share for
this care. Would you strongly agree, agree, disagree, or
strongly disagree with the government requinng immediate
families to pay a larger share of care of these costs?
A majority of respondents disagree with the government
requiring immediate families of elderly medicare and medicaid
recipients to pay a larger share of the costs of care. (Refer to
Figure 4.G) Adding together "disagree" and "strongly disagree"
shows that some 57% of respondents reject this strategy. Only
a minority (34%) agree with the state requiring families to
shoulder a larger share of the burden. As with other health
questions, there were a sizable number of "don't know" (8%)
responses to this question.
Question: Some states have laws that are called right-to-die laws.
That is, people are allowed to appoint someone who has
the right to say if the patient should continue to receive life
support in the event that they are unable to decide for
themselves. Would you approve or disapprove of such a law
in Maryland?
In the past, several bills calling for "right-to-die" legislation have
failed in the state legislature. Public approval of this type of
legislation appears to be very high. About 80% of the
respondents approve of legislation of this type and only 14%
disapprove. Data is shown in Figure 4.H.
Maryland Policy Choices: 1993
20
Schaefer Center for Public Policy
�Figure 4.F
Approval of Placing Limits on
Health Care Availability
Favor
25%
Favor
32%
Don't Know
8%
Oppose
66%
For Costly Illnesses
Don't Know
9%
Oppose
58%
For Those Not Expected
to Live Long
�Figure 4.G
S h o u l d F a m i l i e s of E l d e r l y P a y a L a r g e r
S h a r e for Health C a r e C o s t s ?
23%
46%
0%
10%
20%
30%
40%
50%
Figure 4.H
Approval of Right-to-Die L a w s
100%
—ao% -
80%
60%
40%
20%
Approve
Disapprove
22
Don't
know
60%
�SECTION 5:
Environmental
Issues
Public opinion polls have consistently indicated that
Marylanders' commitment to a cleaner environment, particularly
as it relates to the Chesapeake Bay, is stronger than ever.
Despite this commitment, the state still suffers from problems
of air and water pollution, solid-waste pollution, toxic and
hazardous-waste pollution, and changing land use patterns.
Respondents were asked to indicate how serious they thought
various environmental problems are in the state.
Question: For each of the following problems, please tell me if it
is a very serious concern, a somewhat serious concern, or
not a serious concern to you personally?
a. Pollution of Maryland'sriversand streams.
b. Air pollution from automobiles
c. Air pollution from industrial sources
d Disposal of solid waste and garbage
e. Disposal of hazardous and toxic wastes.
f . Cleaning up the Chesapeake Bay.
g. Protecting forests and natural areas.
h. Pollution of drinking water
L Lead poisoning
j. Radon in your home
Results showing the percentage of respondents that said each
item was a "serious concern" to them personally are portrayed
in Figure 5.A. Attention should be given not only to the
absolute percentages for each item, but also to the relative
ranking of each. Ranking tends to produce a portrait of the
public's perception of risk of various environmental threats.
The item of greatest concern was hazardous and toxic wastes
with 80% of respondents voicing a great deal of concern. This
was followed by threats to drinking water with 74%, and with
pollution to rivers and streams (72%) and threats to the
Chesapeake Bay (72%).
Interestingly, air pollution, which has received a great deal of
attention both nationally and in Maryland was ranked relatively
low with only 55% saying they were concerned a great deal with
automobile air pollution and 64% saying the same about
industrial air pollution. Lead poisoning (53%) and radon in the
home (32%) ranked relatively low as well.
Maryland Policy Choices: 1993
23
Schaefer Center for Public Policy
�Fg r 5
i ue .
A
P ten o E vr n e t l C n en
at r s f n io m na o c r s
Percent saying 'A Serious Concern"
Rivers and Streams
Auto Air Pollution
Industrial Air Pol.
Solid Waste Disposal
Hazardous Waste
Chesapeake B y
a
Forest/Natural Areas
Drinking Water
Lead Poisoning
Radon
0
%
2%
0
40%
Note: data from environmental survey.
See note page 1
24
6%
0
8%
0
100%
�Question: Thinking about the state as a whole, which of these
things do you think is the most pressing environmental
problem facing Maryland?
Question: Now, thinking about the community where you live,
which of these things do you think is the most pressing
environmental problem facing your community?
A slightly different way of getting at environmental priorities is
represented in these two questions. After asking respondents to
consider the environmental issues from a list read to them,
respondents were asked to indicate what they felt was the most
pressing issue for the state as a whole, on the one hand, and for
the community where they lived, on the other. Interviewers were
instructed to mark the first item mentioned by respondents.
Some interesting differences emerge from comparison of the
questions. Figure 5.B shows these patterns of concern.
For the state as a whole, cleaning up the Chesapeake Bay
ranked as the most pressing environmental problem with 20%
mentioning that item. Pollution of rivers and streams was
second with about 16% of the respondents mentioning this
issue. Various kinds of air pollution and waste received about
10% each. However, adding together automobile and industrial
sources of air pollution produces a slightly higher ranking than
the Chesapeake Bay with 22% of the respondents mentioning
one or the other. Similarly, adding both solid and hazardous
waste produces a level of concern similar to the Bay's level.
Lead poisoning, radon, and forests and natural areas each
received 2% or less of the responses.
When asked about their own community, responses differed.
The two biggest problems for communities were seen to be
pollution from automobiles (20%) and solid waste disposal
(19%). Water pollution of various sorts also received about 20%
when added together.
In terms of environmental threats, Marylanders make sharp
distinctions between the threats to the state as a whole and the
kinds of environmental threats they face on a day to day basis.
Maryland Policy Choices: 1993
25
Schaefer Center for Public Policy
�Fg r 5B
i ue .
M s Pressing E vr n e t l C n en
ot
n io m na o c r s
in Sae a d C m u i
t t n o mn
t
y
lln M r l n Bin y u c m u iy
aya d
o r o mn
t
Rivers a d Sr a s n te m
A t Air Pollution
uo
Industrial Air Pol.
Solid W se Disposal
at
H z r o s W se
a ad u a t
C e a e k By
hspae a
Forest/Natural Areas
Di kn W t r
rn i g ae
Lead Poisoning
Rd n
ao
Donl K o
nw
2 % 2 % 1% 1% 5
5 0 5 0 %
N t : d t fo e vr n e t l survey.
oe aa r m n io m na
See n t p g 2.
oe a e
26
5 1% 1 % 2% 2 %
% 0 5 0
5
�Question: Thinking about the things you just mentioned, do you
think state government programs go far enough to help
solve the problems, or don't they go far enough?
When asked to evaluate Maryland's efforts to solve
environmental problems, almost three quarters of the
respondents felt that Maryland was not doing enough. (Figure
S.C) Seventy-four percent (74%) said "don't go far enough" and
only 15% said state government programs do "go far enough".
Eleven percent (11%) volunteered that they did not know.
Question: Do you think Maryland's environmental laws and
regulations are too strict, or not strict enough, or have
struck the right balance?
A companion question to the one above asked respondents
about environmental regulations in Maryland. (Figure S.D) A
majority of respondents (58%) said they felt environmental
regulations in Maryland were not strict enough. Twenty-six
percent (26%) said they thought legislation had struck the right
balance. Only 3% of the respondents said existing
environmental regulations were too strict, and 12% said they
did not know.
Question: Would you support or oppose stricter environmental
regulations by the state of Maryland if these regulations ...
a. Raised the costs of products purchased by consumers
b. Increased the taxes that you pay
c. Made it more difficult for Maryland companies to
compete against other companies
d Cost some workers their jobs
e. Discouraged businesses from moving to Maryland
With this question, we attempted to qualify high support for
existing environmental regulations by attaching support for
regulations to real costs to consumers and to the Maryland
economy. Results of the series of questions are shown in Figure
5.E. What is interesting about thefigureis that a majority of
Marylanders continue to support stricter environmental
regulations when the additional costs are being bom by
themselves in the form of higher product costs and higher taxes.
However, support falls off when the costs are generalized to the
Maryland economy or to the general public. Sixty-eight percent
Maryland Policy Choices: 1993
27
Schaefer Center for Public Policy
�Figure S . C
Environmental Programs
G o F a r E n o u g h To S o l v e P r o b l e m s ?
G o far e n o u g h
15%
D o n t g o far e n o u g h
74%
Dont know
11%
D a t a from e n v i r o n m e n t a l s u r v e y .
F i g u r e S.D
P e r c e p t i o n s of E n v i r o n m e n t R e g u l a t i o n s
Too Strict
Not Strict Enough
$6%
Struck Right Balance I
Don't K n o w
0%
10% 20% 30% 40% 50% 60% 70%
Data from environmental survey.
See n o t e p a g e 2.
28
�(68%) approve of stricter regulations if product costs were
raised and 57% approve if taxes were increased. Only 45%
approve when the possibility of threats to competitiveness is
included, and support falls rapidly to 31% if stricter regulations
cost jobs or if relocation of industry is hurt. Note also that the
more abstract threats produce a higher volume of "don't know"
responses.
Question: As you may know, the national Clean Air act obligates
states like Maryland to pass tougher clean air laws. Some
people argue that the Clean Air act is too tough and that
it will cost Maryland jobs and economic growth. Others
argue that obtaining cleaner air is worth the sacrifice.
Which of these comes closest to your views on the issue?
In general, the public supports clean air legislation embodied in
the federal Clean Air Act. Figure S.F shows that (64%) of
respondents said that obtaining clean air was worth the
potential sacrifices. Only about 21% said that the clean air
requirements would be too tough. However, 14% said they had
no opinion on the question.
Question: Would you approve or disapprove of stricter Maryland
regulations to control the air pollution caused by
automobile exhausts?
Question: Would you still approve if the cost of a new car went up
by $200?
This question asks specifically about restrictions on automobile
emissions. Fully three-quarters (76%) of respondents approved
of stricter regulations while only 21% disapproved. To qualify
this support, we asked those who approved of stricter
regulations if their approval would be the same even if the
regulations raised the price of a new car by $200. Even with
the specter of higher costs, 83% of those approving continued
with their approval of the stricter regulations and only 14%
declined (see Figure 5.G).
Maryland Policy Choices: 1993
29
Schaefer Center for Public Policy
�Figure 5.E
S u p p o r t for Stricter E n v i r o n m e n t a l R e g u l a t i o n s
If They Raised Costs -
68%
I f Taxes I n c r e a s e d
57%
If C o m p e t i t i o n Hurt
I f They Cost J obs
If Relocation Hurt
80%
60%
40%
20%
0%
20%
40%
60%
I Pet Approving H P c L Disapproving
Note: data from environmental survey.
"Dont knows- omitted.
Figure S . F
C l e a n Air A c t in Maryland
64%
70%
Too T o u g h / C o s t J o b s
W o r t h t h e S t srllice
Data from Environmental Survey
30
Dont Know
80%
�Figure 5.G
Support for Stricter Automobile Exhaust Standards
Yes 83%
Disapprove
21%
Don't Know
3%
No 14%
Don't know 3%
Approval of Stricter
Laws and Regulations
Data from Environmental Survey
Approve Even if Cost of
Cars Increased $200
�SECTION 6:
Welfare Reform
As noted in an earlier section, Marylander's generally exhibit
positive attitudes toward spending on social programs for the
poor. Yet many of these same citizens have negative feelings
about the effects of social welfare programs on the poor.
Certain segments of the population argue that social welfare
programs have the unintended consequence of encouraging
people to become dependent on the government by
guaranteeing a minimum standard of living.
Question: Which of the following statements do you agree with the
most: welfare benefits give poor people a chance to stand
on their own two feet and get started again, or welfare
benefits make poor people dependent and encourage them
to stay poor?
A majority of Marylander's (53%) felt that welfare benefits
make poor people dependent on the government and encourage
them to remain poor. Only 36% felt that welfare benefits give
poor individuals a chance to stand on their own two feet and
get started again. (See Figure 6.A)
Question: Would you support or oppose a state plan that required
people on welfare to work for the money they receive?
Question: Would you support or oppose a plan that would limit
welfare payments after a women had a certain number of
children?
Question: Would you support or oppose a plan that would cut
welfare payments to families whose children did not attend
school regularly?
Marylander's also support placing requirements on the receipt
of welfare payments (see Figure 6.B). Eighty-nine percent
(89%) of the respondents would support a state plan which
would require mandatory work for those receiving welfare
benefits. Seventy-three percent (73%) stated that they would
support a plan limiting welfare payments after a woman had a
certain number of children and seventy percent (70%) declared
that they would support a plan cutting welfare payments to
families whose children did not attend school regularly. Clearly,
Marylander's favor some kinds of welfare reform.
Maryland Policy Choices: 1993
32
Schaefer Center for Public Policy
�Figure 6.A
B e l i e f s About the E f f e c t s of the Welfare S y s t e m
-Helps People
Stand
On Own |
36%
-Encourages People to
Stay on Welfare)
53%
-Don't Agree With
Either
9%
-Don't
Know
2%
0%
_L
J_
10%
20%
30%
40%
50%
60%
Figure 6 . B
S u p p o r t for Limitations o n Welfare P a y m e n t s
R E Q U I R I N G PEOPLE T O
W O R K FOR WELFARE
Support
Oppose
D o n t Know
89%
7%
4%
L I M I T I N G PAYMENTS
AFTER # CHILDREN
Support
Oppose
D o n t Know
73^
22%
5%
CUT PAYMENTS IF
C H I L D R E N N O T IN S C H O O L
Support
Oppose
D o n t know
70%.
24%
0%
20%
40%
33
60%
80%
100%
�SECTION 7:
Crime and
Gun Control
Crime in Maryland has increased at an alarming rate in recent
decades. In particular, the rise in violent crime against random
victims-e.g. carjackings and drive-by shootings-has intensified
the widespread fear of so-called street crime.
One obvious goal of public policy is to reduce the incidence of
crime as well as individual's widespread fear of crime by limiting
access to weapons which can be used in the commission of
illegal acts and by increasing the costs of engaging in illegal
behavior. A number of questions on the survey dealt
specifically with these two approaches to limiting criminal
conduct.
The first question asked respondents to voice their support or
opposition to additional restrictions on the sale of handguns.
Question: In general, do you feel the laws covering the sale of
handguns should be made more strict, less strict, or kept as
they are now?
Responses to this question can be found in Figure 7.A.
Seventy-eight percent (78%) stated that the laws regulating the
sale of handguns should be made more strict. Seventeen
percent (17%) felt the laws regulating the sale of handguns
should be kept as they are now and only two percent (2%) felt
that they should be made less strict.
Question: There have been a number of proposals to deal with the
problems of guns and violence. Please tell me if you would
support or oppose each of the following.
a. A law requiring a seven day waiting period for the
purchase of handguns.
b. A law that would ban the sale of military style assault
weapons.
c. A law that would ban the sale of all handguns.
d A law that would require a police permit before the
purchase of a handgun.
Maryland Policy Choices: 1993
34
Schaefer Center for Public Policy
�Fg r 7
i ue .
A
Strictness o Hn g n L w
f adu a s
M d Mote Strict
ae
K p as T e Ae Nw
et
hy t o
M d Less Strict
ae
Donl K o
nw
1%
7
2
%
3
%
0
%
2%
0
4%
0
35
6%
0
8% 10
0
0%
�The types of firearms restrictions that Marylander's would be
willing to support are indicated in Figure 7.B. An overwhelming
92% favor the current seven day waiting period for the purchase
of handguns. In addition, eighty-four percent (84%) would
support a law that would ban the sale of military style assault
weapons and eighty-two percent (82%) would support a law
that would require a police permit before an individual could
purchase a handgun. By the same token, only thirty-eight
percent (38%) of the respondents would support a law that
would ban the sale of all handguns in Maryland. Clearly, the
citizenry is willing to place restrictions on the type of weapons
that can be purchased and toughen the procedures for
purchasing those weapons.
However, a majority of
Marylander's would oppose efforts to ban the sale of all
handguns in the state.
Question: Some people have proposed that the National Guard be
used to patrol communities where there is a high crime
rate. Would you approve or disapprove of using the
National Guard in high crime areas?
In an effort to reduce the incidence of crime in certain
communities of Baltimore City, proposals have been put forth
which call for the mobilization of the National Guard to patrol
high crime areas. We asked Marylander's whether they would
approve or disapprove of using the National Guard in high
crime areas?
Responses to this question are presented in Figure 7.C. A
substantial majority of citizens (64%) would approve of using
the National Guard to patrol high crime areas in the state.
Thirty percent (30%) disapproved of this proposal and 5%
stated that they did not know or that they did not have an
opinion on the topic.
Question: Some states have enacted tough penalties for the crime
of car-jacfdng. Would you approve or disapprove of a
Maryland law that would require a minimum sentence of
ten-years in prison for people convicted of car-jacking?
Maryland Policy Choices: 1993
36
Schaefer Center for Public Policy
�Figure 7.B
Support for F i r e a r m s Legislation
W a i t P e r i o d F o r S a l e - .92%
Ban Assault W e a p o n s - • 84%
Ban All Handgun Sale
59%
Police Permit to Buy - '
82%
_1
120%
80%
40%
0%
40%
L-
80%
120%
H Support Q Oppose
N o t e : P e r c e n t a g e s w i l l n o t sum t o 1 0 0 % b e c a u s e " D o n t K n o w s * are o m i t t e d .
Figure 7 . C
U s e National G u a r d in High C r i m e A r e a s
Approve
Disapprove
37
Don't Know
�Mandatory sentencing is another mechanism that states have
employed to help reduce the crime rate. The assumption
underlying determinate sentencing is that it will limit judges'
discretion in deciding punishment for particular crimes.
Offenders are required to serve minimum prison terms for
certain crimes-i.e. murder, rape, etc. During the past year, carjacking has become a major problem in Maryland. Marylander's
were asked their opinion about requiring a mandatory sentence
of ten-years for individuals convicted of car-jacking.
As shown in Figure 7.D eighty-nine percent (89%) of
Marylander's indicated that they would approve of a law which
would mandate that an individual convicted of car-jacking would
have to serve a minimum of ten years in prison. Only 7% of
the respondents disapproved of this mandatory sentence
measure.
Question: As you may know, some people have said some illegal
drugs should be legalized as a way to reduce drug addiction
and crime. Other people believe that this would not really
help the drug problem and would only make matters worse.
Do you think legalizing some drugs would make the drug
problem better or worse, or is this something you don't have
an opinion on?
An overwhelming majority of respondents (66%) felt that
legalizing some drugs would only make the problems of drug
addiction and crime worse. Twenty four percent (24%)
indicated that such a public policy effort would make the
problem better and 10% did not have an opinion on the issue.
Clearly, most Marylander's do not support the legalization of
drugs. (See Figure 7.E.)
Maryland Policy Choices: 1993
38
Schaefer Center for Public Policy
�F i g u r e 7.D
A p p r o v a l of C a r - J a c k i n g S e n t e n c e s
0%
Approve
Disapprove
Don't
Know
Figure 7 . E
Would L e g a l i z i n g D r u g s
Make the Problem Better or W o r s e ?
66%
60%
40%
20%
0%
Make Problem Better
Make Problem Worae
39
Have N o O p i n i o n
�SECTION 8:
Education: Public
Service
Requirements
for Graduation
Education policy in Maryland has been marked by significant
changes, and some of these changes have created a public
controversy. Recently, the Maryland Department of Education-an agency responsible for specifying curriculum, establishing
teacher certification standards, and providing funding to local
school districts-passed a controversial regulation which requires
high school students to perform 75 hours of community service
in order to graduate. The following question was asked of the
respondents in order to elicit Marylander's attitudes toward this
requirement.
Question: Recently, the state Department of Education began
requiring high school students to perform 75 hours of
community service as a requirement for graduation. Doyou
approve or disapprove of this requirement, or is this
something you don't have an opinion on?
Figure 8.A shows the distribution of opinion on this question.
In general, some 60% of think community service for
graduation is a good idea. About 34% of the respondents do
not approve of the requirement. Five percent (5%) had no
opinion on this issue.
Maryland Policy Choices: 1993
40
Schaefer Center for Public Policy
�Figure 8A
.
A po a o C m u iy Service
p r vl f o mn
t
for Hg School Ga u to
ih
r d ai n
A po e
p rv
6%
0
D nt K o
o ' nw
5
%
Ds p r v
ia p o e
3%
4
41
�SECTION 9:
The Maryland
Lottery
Recently, the Maryland Lottery Agency has been criticized for
the introduction of certain new games and for the conditions
surrounding the letting of contracts to manage the new games.
The survey asked several questions related to the lottery.
Question: What is your overall opinion of the way the Maryland
lottery is currently run? Would you say it is very favorable,
somewhat favorable, somewhat unfavorable, very
unfavorable, or is this something you realty don't have an
opinion on?
The interesting point about the results shown in Figure 9A. is
the extremely large number of people who responded that they
had "no opinion" on the management of the Maryland Lottery.
Fully a quarter (26%) gave this as their response. For those
who voiced an opinion on the issue, the opinion of the
management was generally favorable: 10% said "very favorable"
and another 33% said "somewhat favorable". For those with
more negative views, 15% said "somewhat unfavorable" and
13% said "very unfavorable".
Question: Recently the state added a new game called KENO to
the state lottery in order to raise state revenues. Some
people say that this is not the right way for the state to raise
revue. Do you think raising revenue through the use of the
KENO game is the right way for the state to raise revenue,
or not, or is this something you have no opinion on?
Club KENO is the new lottery game that has sparked the most
controversy during the past few months. Adopted with little fanfare, the game has since run afoul of opponents who question
the game on ethical grounds. Our question asked only about
this dimension and not about alternatives to KENO for raising
revenue. Forty-seven percent (47%) say KENO is "not the right
way" for the State to raise revenue. However, 24% agreed that
it was the "right way" for the state to proceed, and another 30%
of those responding had no opinion on KENO. While a large
minority do voice ethical concerns about KENO, a majority of
Marylanders either support KENO or have no opinion on the
issue. (See Figure 9.B)
Maryland Policy Choices: 1993
42
Schaefer Center for Public Policy
�Figure 9.A
Overall Evaluation of Management
of the Maryland Lottery
Very Favorable
Somewhat
Somewhat
Favorable
33%
Unfavorable
Very Unfavorable
Have No Opinion
0%
10%
20%
30%
40%
Figure 9.6
Is Keno the "Right Way"
for Maryland to Raise Revenue
Yes-Right Way
24%
No-Not the Right Way
46%
Have No Opinion
30%
43
50%
�SECTION 10:
Term Limits
Proposed limitations on the amount of time that any individual
can serve in either local, state, or national legislative bodies
have become major issues in states across the country in the
past several elections. In the 1992 elections, voters in 14 states
and 3 counties in Maryland approved proposed limits on the
terms of legislators. Since three counties approved limits on
local legislative bodies, we asked how Marylanders felt on the
issue with regard to the state legislature and Congress.
Question: In some states, citizens have called for limitations on the
amount of time a person can serve in Congress or in the
state legislature. Would you favor or not favor legislation to
limit the amount of time a person can serve in the
Maryland State legislature?
Question: How about for Maryland's delegation to Congress.
Would you favor or not favor limiting the amount of time
Maryland's representatives to Washington can serve in
Congress?
Results are shown in Figure 10.A. Responses to the two
questions were virtually identical. Seventy-one percent (71%)
favored limitations on both the amount of time a person could
serve in the Maryland legislature and the amount of time that
a person could serve in Congress. Only 21% disapproved of
each question and 6 had no opinion on the issue.
%
Maryland Policy Choices: 1993
44
Schaefer Center for Public Policy
�Figure 1 .
0A
F v r T r Limits for Legislators
a o em
S A E LEGISLATORS
TT
Not Favor]
No Opinion I
C N R S I N L DELEGATEO G E SO A
0
%
20%
40% 60%
Note: Percentages do not s m to 10 b c u e 'Donl Know' omitted.
u
0% e a s
45
�Appendix A
Sampling Strategy: The sample was stratified to account for regional differences in
Maryland. For those interested in exploring regional variation via survey research, the
distribution of population poses something of a problem. In Maryland, according to 1990
census data, some 81% of residents live in the Baltimore-Washington Corridor. The core,
as we define it, comprises the counties of Montgomery, Prince George's, Howard, Anne
Arundel, Baltimore, Carroll, and Harford, as well as Baltimore City. A typical random
household survey would contain only about 20% of its final respondents from outside this
core area. Once these are broken into Western Maryland or the Eastern Shore, for example,
there are far too few respondents for reasonable comparison. The solution is to stratify the
sample by core or non-core status. We interviewed approximately 505 respondents from the
core counties and another 517 respondents from the non-core areas. This provides a larger
number of people from outlying areas for comparison.
Weighting the Sample: For aggregate snapshots of Maryland as a whole, the stratified
sample needs to be weighted in order to eliminate the effects of overcounting respondents
outside of the core counties. Weighting factors were calculated on two dimensions:
geographic area and gender. The following weighting factors were used: for males in the
core area 1.36 and for females in the core area, 1.94; for males in non-core areas, .43 was
used, and for females in non-core areas, .38 was used. This produces response patterns in
line with geographic distribution of inhabitants. Throughout this report, the weighted
distribution is used unless regional comparisons are being made.
Maryland Policy Choices: 1993
46
Schaefer Center for Public Policy
�Demographic Characteristics
UNWEIGHTED mm
Gender
Male
Female
49
50
500
513
46
54
469
543
83
13
2
845
136
25
78
17
3
517
172
33
46
12
29
11
472
126
298
111
51
12
25
10
517
124
257
104
32
43
23
330
434
235
35
42
21
348
423
214
9
22
18
21
11
17
94
226
179
216
116
174
15
36
28
9
5
7
151
365
288
86
46
69
Race
White
Black
Other
Registration
Democrat
Independent
Republican
Not Registered
Age
18-34
35-53
Over 55
Region
Baltimore City
Baltimore Metro
D.C. Metro
Western Maryland
Southern Maryland
Eastern Shore
Maryland Policy Choices: 1993
47
Schaefer Center for Public Policy
�i
UNIVERSITY OP BALTIMORE
The University of Baltimore, founded in 1925, is a public, upper-divisionuniversity offering
the third and fourth years of undergraduate study and graduate and professional programs.
Through it career-oriented curricula, faculty research and consulting, and service activities,
the University of Baltimore contributes to the social and economic development of the
region.
The University of Baltimore is a member of the University of Maryland System. Academic
Programs at the University of Baltimore are administered through three academic divisions:
Robert G. Merrick School of Business, Yale Gordon College of Liberal Arts, and the School
of Law.
The University is accredited by the Middle States Association of Colleges and Secondary
Schools, the Maryland State Board of Education, and The American Bar Association and
, holds membership in the Association of American Law Schools. The University's graduate
^ and undergraduate business programs are accredited by the American Assembly of
Collegiate Schools of Business (AACSB). The University's Master of Public Administration
(MPA) is accredited by the National Association of Schools of Public Affairs and
Administration (NASPAA).
MarjlMd Policy Choices: 1993
48
Scha^ftr Center for Public Policy
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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[Maryland Policy Choices: 1993] [loose, spiral]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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Box 37
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Clinton Presidential Records: White House Staff and Office Files
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2006-0885-F
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administrative marker by the William J. Clinton
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Clinton Presidential Records
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Health Care Task Force
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Tarmey
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1985
FolderlD:
Folder Title:
[Maryland Health Care Bill] [loose, letter and bill]
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�COMMITTEES:
PAUUV C . HOLLINGER
ECONOMIC AND ENVIRONMENTAL AFFAIRS
1 1 DISTRICT
CHAIR-HEALTH SUBCOMMITTEE
BALTIMORE COUNTY
SENATE CHAIR
55 RAISIN TREE CIRCLE
ADMINISTRATIVE, EXECL'TIVE. LEGISLATIVE
BALTIMORE, MD 21208-1364
REVIEW COMMITTEE
(410)484-4888
HOME ADDRESS:
JOINT OVERSIGHT COMMITTEE
SENATE OF M A R Y L A N D
HEALTH CARE COST CONTAINMENT
A N N A P O L I S , M A R Y L A N D 2 1401 -1 991
DISTRICT OFFICE:
SENATE OFFICE BUILDING
ROOM 206
ANNAPOLIS, MARYLAND 21401-1991
TELEPHONE: ( 4 1 0 ) 841-3131
NATIONAL CONFERENCE OF
STATE LEGISLATURES
February 2, 1993
Ms. H i l l a r y Rodham C l i n t o n
White House
Washington, D.C. 20004
Dear Ms. C l i n t o n :
I t i s a r e a l pleasure t o s t a r t t h i s l e t t e r w i t h t h e "White
House" address. For those of us who have been w a i t i n g twelve long
years f o r a change i n a d m i n i s t r a t i o n i t i s e x c i t i n g and gives us
renewed purpose as we f i g h t a t the s t a t e l e v e l , many of t h e same
b a t t l e s you and t h e President are f a c i n g n a t i o n a l l y .
As t h e Chairman o f t h e Women's NETWORK o f t h e National
Conference o f State L e g i s l a t u r e s , I am d e l i g h t e d t o extend t o you
an i n v i t a t i o n t o speak t o the NETWORK a t t h e annual meeting of t h e
N a t i o n a l Conference o f State L e g i s l a t u r e s i n San Diego, C a l i f o r n i a ,
J u l y 26, 1993. You have already received an i n v i t a t i o n from our
Executive D i r e c t o r , Sue M u l l i n s on December 29, 1992, but as Chair
I wanted t o p e r s o n a l l y o f f e r the i n v i t a t i o n . You are t h e woman of
the hour and t h e one we have a l l waited f o r t o provide t h e example
of t h e p r o f e s s i o n a l woman who manages t h e d i f f i c u l t task o f
combining work and f a m i l y .
My other h a t i s t h a t o f State Senator i n Maryland. I am a
r e g i s t e r e d nurse who has been involved i n h e a l t h care l e g i s l a t i o n
and h e a l t h care reform f o r the past f o u r t e e n years - e i g h t as a
member o f t h e House o f Delegates and s i x i n t h e Maryland Senate.
I know from f i r s t hand experience the j o b you have f a c i n g you as
Chairman o f t h e Task Force on Health Care Reform, but am d e l i g h t e d
t h a t a person of your s t a t u r e i s leading t h e charge. I understand
you are l o o k i n g f o r examples of l e g i s l a t i o n and f o r t h a t reason, I
am enclosing a copy of t h e b i l l I have introduced f o r c o n s i d e r a t i o n
i n t h i s year's session of the Maryland General Assembly.
�Ms. C l i n t o n
Page 2
February 2, 1993
I n c l o s i n g , please accept n o t only my c o n g r a t u l a t i o n s , but my
sincere best wishes as you s t r u g g l e t o change America's h e a l t h care
policy.
Sincerely,
PCH/lt
/
Paula C. Hollinger
U
�C3
31r0806
Drafted by: imhoff
Typed by: ms
Stored - 01/28/93
Proofread by
Checked by
^/
By: Senator Hollinger
S^>r\e
(
QloUirV
A BILL ENTITLED
X j ^ - t ? ^ \lJ • f i x J i ' ^ 7
' ^ j ^ ^
^
V'
of
AN ACT concerning
1
Maryland Health Insurance Purchasing Cooperative
2
FOR the purpose of creating a new regulatory program governing certain health benefit
3
plans; establishing a Maryland Health Insurance
Purchasing Cooperative;
4
establishing certain regional advisory boards; providing for the establishment of
5
rules and procedures for contracting with participating carriers; allowing each
6
defined region in the State to be serviced by only one participating carrier that is
7
chosen in accordance with a certain bidding process; limiting the plans and types of
8
coverage that may be offered; requiring the Cooperative to determine benefits that
9
may be offered in a health benefits plan; delineating factors to be considered in
10
determining benefits; prohibiting exclusions or limitations on preexisting conditions;
11
allowing assistance in payment of premiums for certain individuals and families;
12
establishing the Maryland Health Insurance Premium Assistance Fund; establishing
13
a health care data base and requiring certain information to be submitted to the
14
data base for certain purposes; defining certain terms; and generally relating to
15
health insurance availability and purchasing.
16
BY adding
17
New Article 48C - Health Insurance
18
Annotated Code of Maryland
19
(1991 Replacement Volume and 1992 Supplement)
EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
20
�'31rOS06
SECTION
1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF
MARYLAND, That the Laws of Maryland read as follows:
21
22
ARTICLE 48C - HEALTH INSURANCE
23
TITLE 1. MARYLAND HEALTH INSURANCE PURCHASING ACT
24
SUBTITLE 1. DEFINITIONS
25
1-101.
26
(A)
IN THIS TITLE THE FOLLOWING WORDS HAVE THE MEANINGS INDICATED.
27
(B)
"CARRIER" MEANS AN INSURER THAT HOLDS A CERTIFICATE OF
28
AUTHORITY IN THIS STATE.
(C)
"COOPERATIVE"
29
MEANS
THE
MARYLAND
HEALTH
INSURANCE
PURCHASING COOPERATIVE.
(D)
31
"DEPENDENT" MEANS THE SPOUSE OR NATURAL OR LEGALLY ADOPTED
MINOR CHILD OF AN ELIGIBLE EMPLOYEE.
(E)
"ENROLLEE" MEANS A PERSON WHO RECEIVES HEALTH COVERAGE
THROUGH THE PROGRAM FROM A PARTICIPATING CARRIER
(F)
30
32
33
34
35
"HEALTH BENEFIT PLAN" DOES NOT INCLUDE:
36
(1)
ACCIDENT-ONLY INSURANCE;
37
(2)
FIXED INDEMNITY INSURANCE;
38
(3)
CREDIT HEALTH INSURANCE;
39
(4)
DENTAL INSURANCE;
40
(5)
VISION INSURANCE;
41
(6)
MEDICARE SUPPLEMENT POLICIES;
42
(7)
LONG-TERM CARE INSURANCE;
43
-2-
�'31r0806
(8)
DISABILITY INCOME INSURANCE;
44
(9)
COVERAGE ISSUED AS A SUPPLEMENT TO LIABILITY INSURANCE;
45
(10) WORKERS'COMPENSATION OR SIMILAR INSURANCE;
46
(11) DISEASE-SPECIFIC INSURANCE;
47
(12) AUTOMOBILE MEDICAL PAYMENT INSURANCE; OR
48
(13) ANY OTHER INSURANCE PLAN EXCLUDED BY THE COMMISSIONER
49
OF INSURANCE.
(G)
50
"MEMBER EMPLOYER" MEANS AN EMPLOYER WHO PARTICIPATES IN THE
PROGRAM.
(H)
51
52
"PARTICIPATING CARRIER" MEANS A CARRIER THAT HAS ENTERED INTO
53
A CONTRACT WITH THE COOPERATIVE TO PROVIDE HEALTH BENEFIT PLANS
54
UNDER THIS TITLE.
55
(I)
"PROGRAM" MEANS THE PROGRAM ESTABLISHED BY THE COOPERATIVE
UNDER THIS TITLE.
(J)
56
57
"REGIONAL ADVISORY BOARD" MEANS A BOARD COMPOSED OF
RESIDENTS OF A REGIONAL AREA
58
59
SUBTITLE 2. HEALTH INSURANCE PURCHASING COOPERATIVE
1-201.
60
61
(A)
THERE
IS
A
MARYLAND
HEALTH
INSURANCE
PURCHASING
COOPERATIVE.
(B)
(1)
63
THE COOPERATIVE CONSISTS OF TEN MEMBERS APPOINTED BY THE
GOVERNOR AND SIX EX OFFICIO MEMBERS.
(2)
62
64
65
THE APPOINTED MEMBERS SHALL INCLUDE:
66
(I)
67
ONE REPRESENTATIVE OF A HOSPITAL IN THE STATE;
-3-
�'31rOS06
(II)
ONE PHYSICIAN;
68
(III) ONE NURSE;
69
(IV) ONE REPRESENTATIVE OF LABOR ORGANIZATIONS;
70
(V)
71
ONE REPRESENTATIVE OF A BUSINESS THAT EMPLOYS LESS
THAN 25 PERSONS;
72
(VI) ONE REPRESENTATIVE OF A BUSINESS THAT EMPLOYS MORE
THAN 25 PERSONS;
73
74
(VII) THE CHAIR OF EACH REGIONAL ADVISORY BOARD; AND
75
(VIII) SIX EX OFFICIO MEMBERS INCLUDING:
76
1.
ONE REPRESENTATIVE OF THE HEALTH SERVICES COST
REVIEW COOPERATIVE;
2.
78
ONE REPRESENTATIVE OF THE HEALTH RESOURCES
PLANNING COOPERATIVE;
3.
THE SECRETARY OF HEALTH AND MENTAL HYGIENE OR
THE MARYLAND INSURANCE COMMISSIONER OR A
THE SECRETARY OF ECONOMIC AND EMPLOYMENT
THE SECRETARY OF THE OFFICE ON AGING OR A
DESIGNEE OF THE SECRETARY.
(C)
83
84
DEVELOPMENT OR A DESIGNEE OF THE SECRETARY; AND
6.
81
82
DESIGNEE OF THE COMMISSIONER;
5.
79
80
A DESIGNEE OF THE SECRETARY;
4.
77
85
86
87
88
(1)
THE TERM OF A MEMBER IS 4 YEARS.
89
(2)
AT THE END OF A TERM A MEMBER CONTINUES TO SERVE UNTIL A
90
SUCCESSOR IS APPOINTED AND QUALIFIES.
-4-
91
�31r()S06
(3)
A MEMBER WHO IS APPOINTED AFTER A TERM HAS BEGUN SERVES
92
ONLY FOR THE REST OF THE TERM AND UNTIL A SUCCESSOR IS APPOINTED AND
93
QUALIFIES.
94
(4)
A MEMBER WHO SERVES TWO CONSECUTIVE FULL 4-YEAR TERMS
95
MAY NOT BE REAPPOINTED DURING THE 4-YEAR PERIOD FOLLOWING COMPLETION
96
OF THOSE TERMS.
97
(D)
ANNUALLY, FROM AMONG THE MEMBERS OF THE COOPERATIVE:
98
(1)
THE GOVERNOR SHALL APPOINT A CHAIRMAN; AND
99
(2)
THE CHAIRMAN SHALL APPOINT A VICE CHAIRMAN.
100
(1)
WITH THE APPROVAL OF THE GOVERNOR AND WITH ADVICE AND
101
CONSENT OF THE SENATE, THE COOPERATIVE MAY APPOINT AN EXECUTIVE
102
DIRECTOR, WHO IS THE CHIEF ADMINISTRATIVE OFFICER OF THE COOPERATIVE.
103
(E)
(2)
THE EXECUTIVE DIRECTOR SERVES AT THE PLEASURE OF THE
COOPERATIVE.
(3)
104
105
UNDER THE DIRECTION OF THE COOPERATIVE, THE EXECUTIVE
106
DIRECTOR SHALL PERFORM ANY DUTY OR FUNCTION THAT THE COOPERATIVE
107
REQUIRES.
108
(F)
(1)
A MAJORITY OF THE FULL AUTHORIZED MEMBERSHIP OF THE
109
COOPERATIVE IS A QUORUM. HOWEVER, THE COOPERATIVE MAY NOT ACT ON ANY
110
MATTER UNLESS AT LEAST NINE MEMBERS IN ATTENDANCE CONCUR.
111
(2)
THE COOPERATIVE SHALL MEET AS NEEDED AT THE TIMES AND
PLACES THAT IT DETERMINES.
(3)
EACH
REIMBURSEMENT FOR
MEMBER
113
OF
THE
COOPERATIVE
IS
ENTITLED TO
114
EXPENSES UNDER THE STANDARD STATE TRAVEL
115
REGULATIONS, AS PROVIDED IN THE STATE BUDGET.
(4)
112
THE COOPERATIVE MAY EMPLOY A STAFF IN ACCORDANCE WITH
-5 -
116
117
�31r()S06
THE STATE BUDGET.
(G)
118
IN ADDITION TO THE DUTIES SET FORTH ELSEWHERE IN THIS SUBTITLE.
THE COOPERATIVE SHALL:
(1)
119
120
ADOPT REGULATIONS THAT RELATE TO ITS MEETINGS, MINUTES,
AND TRANSACTIONS;
121
122
(2)
KEEP MINUTES OF EACH MEETING;
123
(3)
ANNUALLY PREPARE A BUDGET PROPOSAL THAT INCLUDES THE
124
ESTIMATED INCOME OF THE COOPERATIVE AND PROPOSED EXPENSES FOR ITS
125
ADMINISTRATION AND OPERATION;
126
(4)
ON OR BEFORE OCTOBER 1 OF EACH YEAR, SUBMIT TO THE
127
GOVERNOR, TO THE SECRETARY, AND TO THE GENERAL ASSEMBLY AN ANNUAL
128
REPORT ON THE OPERATIONS AND ACTIVITIES OF THE COOPERATIVE DURING THE
129
PRECEDING FISCAL YEAR, INCLUDING:
130
(I)
A
COPY
OF
EACH
SUMMARY,
COMPILATION,
AND
SUPPLEMENTARY REPORT REQUIRED BY THIS SUBTITLE; AND
(II)
ANY
OTHER
FACT,
SUGGESTION,
131
132
OR
POLICY
133
RECOMMENDATION THAT THE COOPERATIVE CONSIDERS NECESSARY.
134
1-20Z
135
THE COOPERATIVE SHALL:
136
(1)
DEVELOP STANDARD ENROLLMENT PROCEDURES;
137
(2)
CONTRACT WITH THE LOWEST RESPONSIBLE BIDDER WHO MEETS
138
THE SPECIFICATIONS SET OUT BY THE COOPERATIVE;
(3)
DEVELOP GRIEVANCE PROCEDURES FOR RESOLVING DISPUTES
BETWEEN THE COOPERATIVE AND PARTICIPATING CARRIERS;
(4)
DEVELOP GRIEVANCE PROCEDURES THAT ENROLLEES WHO MAY
-6-
139
140
141
142
�31r0806
HAVE A DISPUTE WITH A PARTICIPATING CARRIER MAY USE UPON EXHAUSTION OF
143
THE GRIEVANCE PROCEDURE MECHANISM OR OTHER ADMINISTRATIVE REMEDIES
144
AS MAY BE ESTABLISHED UNDER THE ENROLLEES' HEALTH BENEFIT PLAN;
145
(5)
ADOPT REGULATIONS AS NECESSARY
TO ADMINISTER THE
PROGRAM;
146
147
(6)
APPOINT COMMITTEES AS NECESSARY TO PROVIDE TECHNICAL
ASSISTANCE IN THE OPERATION OF THE PROGRAM; AND
(7)
EXERCISE ANY OTHER POWER REASONABLY NECESSARY TO CARRY
148
149
150
OUT THIS TITLE.
151
1-203.
152
(A)
(1)
THE COOPERATIVE SHALL SET DEADLINES FOR PARTICIPATING
CARRIERS FOR THE FILING OF REPORTS REQUIRED UNDER THIS TITLE.
(2)
153
154
THE COOPERATIVE MAY ADOPT REGULATIONS THAT IMPOSE
155
PENALTIES ON PARTICIPATING CARRIERS FOR FAILURE TO FILE A REPORT AS
156
REQUIRED.
157
(B)
EXCEPT FOR PRIVILEGED MEDICAL INFORMATION, THE COOPERATIVE
SHALL:
158
159
(1)
MAKE AVAILABLE FOR PUBLIC INSPECTION AT THE OFFICE OF THE
160
COOPERATIVE DURING REGULAR BUSINESS HOURS EACH REPORT FILED AND EACH
161
SUMMARY, COMPILATION, AND REPORT REQUIRED UNDER THIS TITLE; AND
162
(2)
MAKE AVAILABLE TO ANY STATE AGENCY ON REQUEST EACH
SUMMARY, COMPILATION, AND REPORT.
(C)
163
164
NOTWITHSTANDING SUBSECTION (B) OF THIS SECTION, PROPRIETARY
165
INFORMATION, ACTUARIAL CERTIFICATION, OR OTHER PRIVILEGED INFORMATION
166
MARKED CON FI DENTIAL THAT IS SUBMITTED BY A PARTICIPATING CARRIER MAY
167
NOT BE MADE AVAILABLE TO THE PUBLIC BY THE COOPERATIVE OR ANY STATE
168
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AGENCY. CONFIDENTIAL INFORMATION IS SUBJECT TO THE PROVISIONS OF TITLE 4,
169
SUBTITLE 1 OF THE HEALTH - GENERAL ARTICLE.
170
1-204.
171
(A)
(1)
IN ACCORDANCE WITH DIVISION I I OF THE STATE FINANCE AND
172
PROCUREMENT ARTICLE, THE COOPERATIVE MAY CONTRACT WITH A QUALIFIED,
173
INDEPENDENT THIRD PARTY FOR ANY SERVICE NECESSARY TO CARRY OUT THE
174
POWERS AND DUTIES OF THE COOPERATIVE.
175
(2)
UNLESS
PERMISSION
IS
GRANTED
SPECIFICALLY
BY THE
176
COOPERATIVE, A THIRD PARTY HIRED BY THE COOPERATIVE MAY NOT RELEASE,
177
PUBLISH, OR OTHERWISE USE ANY INFORMATION TO WHICH THE THIRD PARTY HAS
178
ACCESS UNDER ITS CONTRACT.
179
(B)
THE COOPERATIVE MAY NOT DIRECTLY PURCHASE HEALTH CARE
180
SERVICES, ASSUME THE RISK FOR COST OR PROVISION OF HEALTH CARE SERVICES,
181
OR OTHERWISE CONTRACT WITH HEALTH CARE PROVIDERS FOR THE PROVISION
182
OF HEALTH CARE SERVICES.
183
1-205.
184
(A)
THE COOPERATIVE
SHALL
ESTABLISH
THE FOLLOWING
FOUR
CONTIGUOUS REGIONAL AREAS IN THIS STATE:
185
186
(1)
187
(2)
THE DISTRICT OF COLUMBIA METROPOLITAN AREA;
188
(3)
WESTERN MARYLAND; AND
189
(4)
(B)
BALTIMORE METROPOLITAN AREA;
EASTERN MARYLAND.
190
CONTRACTS WITH PARTICIPATING CARRIERS SHALL BE ENTERED INTO
191
SEPARATELY FOR EACH REGIONAL AREA.
192
1-206.
193
-8-
�3lr()S06
(A)
(1)
THE COOPERATIVE SHALL ESTABUSH A REGIONAL ADVISORY
194
BOARD FOR EACH REGIONAL AREA A REGIONAL ADVISORY BOARD SHALL
195
CONSIST OF NOT LESS THAN FIVE NOR MORE THAN 15 MEMBERS SERVING TERMS AS
196
ESTABLISHED BY THE COOPERATIVE.
197
(2)
(I)
EXCEPT FOR THE CHAIRMAN OF A REGIONAL ADVISORY
198
BOARD, WHO IS APPOINTED BY THE GOVERNOR, THE OTHER MEMBERS SHALL BE
199
SELECTED AS PROVIDED IN THIS PARAGRAPH.
200
(II)
ALL MEMBERS OF A REGIONAL ADVISORY BOARD SHALL BE
CONSUMERS AND RESIDENTS OF THE REGION.
201
202
(III) TO SELECT THE INITIAL REGIONAL ADVISORY BOARDS, THE
203
COOPERATIVE SHALL APPOINT ONE HALF OF THE INITIAL MEMBERS FOR 2-YEAR
204
TERMS AND THE OTHER HALF FOR 4-YEAR TERMS.
205
(IV) THEREAFTER, THE REGIONAL ADVISORY BOARDS SHALL BE
ELECTED BY MEMBER EMPLOYERS
206
FOR 4-YEAR TERMS. VACANCIES ON A
207
REGIONAL ADVISORY BOARD SHALL BE FILLED FOR THE REMAINING PERIOD OF
208
THE TERM BY A MAJORITY VOTE OF THE REMAINING ADVISORY BOARD MEMBERS
209
IN THAT REGIONAL AREA
210
(V)
ALL APPOINTMENTS AND ELECTIONS OF REGIONAL ADVISORY
BOARD MEMBERS SHALL BE SUBJECT TO THE APPROVAL OF THE COOPERATIVE.
(VI) A MEMBER MAY NOT SERVE FOR
MORE THAN TWO
CONSECUTIVE TERMS.
(B)
213
ACTIVITIES
NECESSARY
215
THE
216
PROGRAM, INCLUDING MARKETING AND PUBLICIZING THE PROGRAM, AND TO
217
ENSURE COMPUANCE WITH THE PROGRAM BY PARTICIPATING CARRIERS; AND
218
(2)
UNDERTAKE
212
214
THE REGIONAL ADVISORY BOARD SHALL:
(1)
211
TO
ADMINISTER
ENSURE FAIR AND AFFIRMATIVE MARKETING OF THE PROGRAM.
-9-
219
�31rOS()6
(C)
THE REGIONAL ADVISORY BOARDS SHALL PROVIDE COMMENT AND
220
ADVICE TO THE COOPERATIVE AND ACCEPT ASSIGNMENTS AND ADDITIONAL
221
RESPONSIBILITIES AS DELEGATED BY THE COOPERATIVE.
222
SUBTITLE 3. HEALTH INSURANCE ACQUISITION
1-301.
223
224
(A)
EACH REGION IN THE STATE SHALL BE SERVICED BY ONE PARTICIPATING
CARRIER IN ACCORDANCE WITH THIS SECTION.
(B)
225
226
THE COOPERATIVE SHALL ENTER INTO A CONTRACT FOR A REGION
227
AFTER SELECTING THE PARTICIPATING CARRIER FOR THAT REGION ON THE BASIS
228
OF COMPETITIVE SEALED BIDS UNDER § 13-103 OF THE STATE FINANCE AND
229
PROCUREMENT ARTICLE.
230
(C)
EACH CARRIER THAT SUBMITS A BID SHALL:
231
(1)
BE AUTHORIZED TO DO BUSINESS IN THIS STATE;
232
(2)
HAVE DEMONSTRATED THE CAPACITY TO ADMINISTER THE
233
HEALTH BENEFIT PLAN, INCLUDING ADEQUATE NUMBERS AND TYPES OF
234
ADMINISTRATIVE STAFF;
235
(3)
236
HAVE THE ABILITY, EXPERIENCE, AND STRUCTURE TO ENSURE THE
DELIVERY OF THE APPROPRIATE LEVEL AND TYPE OF HEALTH CARE SERVICE;
(4)
HAVE THE ABILITY, POLICIES, AND PROCEDURES TO CONDUCT
UTILIZATION MANAGEMENT;
(5)
238
239
HAVE THE ABILITY AND PROCEDURES TO MONITOR AND
EVALUATE THE QUALITY AND COST EFFECTIVENESS OF CARE;
(6)
237
240
241
HAVE THE ABILITY TO ENSURE THAT ENROLLEES HAVE ADEQUATE
242
ACCESS TO PROVIDERS OF HEALTH CARE, INCLUDING GEOGRAPHIC AVAILABILITY
243
AND ADEQUATE NUMBERS AND TYPES;
244
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�31rl)806
(7)
HAVE THE ABILITY AND PROCEDURES TO MONITOR ACCESS
INCLUDING APPOINTMENT WAITING TIMES;
(8)
246
HAVE A SATISFACTORY GRIEVANCE PROCEDURE AND ABILITY TO
RESPOND TO ENROLLEES' CALLS, QUESTIONS, AND COMPLAINTS: AND
(9)
247
248
BE FINANCIALLY SOLVENT, INCLUDING THE ABILITY TO ASSUME
THE RISK OF PROVIDING AND PAYING FOR COVERED SERVICES, AS APPUCABLE.
(D)
245
A CONTRACT TO SERVICE A REGIONAL AREA SHALL BE EFFECTIVE FOR 3
249
250
251
YEARS.
252
1-302.
253
(A)
A PARTICIPATING CARRIER SHALL USE REINSURANCE, PROVIDER RISK
254
SHARING, AND OTHER APPROPRIATE MECHANISMS TO SHARE A PORTION OF THE
255
RISK.
256
(B)
PARTICIPATING CARRIERS SHALL OFFER ONLY THE HEALTH BENEFIT
257
PLANS APPROVED BY THE COOPERATIVE IN ACCORDANCE WITH § 1-303 OF THIS
258
SUBTITLE.
259
(C)
PARTICIPATING CARRIERS SHALL PARTICIPATE IN CONTINUOUS OPEN
260
ENROLLMENT FOR THE BENEFIT OF ENROLLEES COVERED BY THE PROGRAM.
261
1-303.
262
THE PARTICIPATING CARRIER SHALL REQUIRE THAT ANY POLICY ISSUED
UNDER THIS TITLE IS:
(1)
TRANSFERABLE
263
264
WITHIN
THE
STATE
PROVIDED
THAT THE
POUCYHOLDER:
265
266
(I)
RESIDES IN THE REGION WHERE THE POLICY IS ISSUED; AND
267
(II)
AGREES TO PAY THE GREATER OF THE DIFFERENCE IN
268
PREMIUMS BETWEEN REGIONS.
269
- 11 -
�31rOS06
(2)
REFUNDABLE FOR THE UNUSED PORTION OF THE CONTRACT
270
PROVIDED THAT THE POUCYHOLDER PROVIDES EVIDENCE OF A CHANGE OF
271
RESIDENCY TO A LOCATION OUTSIDE OF THE STATE.
272
1-304.
273
(A)
(1)
A PARTICIPATING CARRIER
SHALL OFFER,
IN ORDER
OF
INCREASING COST:
274
275
(I)
A MANAGED CARE PLAN;
276
(II)
A PREFERRED PROVIDER NETWORK; AND
277
(III) A TRADITIONAL HEALTH INSURANCE PLAN.
278
BENEFITS
PLAN SHALL BE
279
DETERMINED BY THE COOPERATIVE IN ACCORDANCE WITH SUBSECTION (B) OF
280
THIS SECTION. BENEFITS FOR THE PREFERRED PROVIDER NETWORK AND THE
281
TRADITIONAL PLAN SHALL BE APPROVED BY THE COOPERATIVE
282
(2)
(B)
(1)
UNDER
THE
MANAGED CARE
THE COOPERATIVE SHALL DETERMINE BENEFITS TO BE OFFERED
IN A MANAGED CARE PLAN AS PROVIDED UNDER THIS SUBSECTION.
(2)
(I)
283
284
BENEFITS SHALL INCLUDE THE FULL RANGE OF LEGALLY
285
AUTHORIZED TREATMENT FOR ANY HEALTH CONDITION FOR WHICH THE
286
COOPERATIVE DETERMINES A TREATMENT HAS BEEN SHOWN TO REASONABLY
287
IMPROVE OR SIGNIFICANTLY AMELIORATE THE CONDITION.
288
(II)
THE COOPERATIVE MAY EXCLUDE HEALTH CONDITIONS THE
289
TREATMENT OF WHICH DO NOT IMPACT ON CLINICAL HEALTH OR FUNCTIONAL
290
STATUS OF INDIVIDUALS.
291
(3)
CLINICAL
BENEFITS SHALL INCLUDE THE FULL RANGE OF EFFECTIVE
PREVENTIVE
SERVICES,
INCLUDING
SCREENING,
293
COUNSELING, AND IMMUNIZATION AND CHEMOPROPHYLAXIS, SPECIFIED BY THE
294
COOPERATIVE, APPROPRIATE TO AGE AND OTHER RISK FACTORS.
295
- 12-
APPROPRIATE
292
�3lrOS06
(4)
ANY
296
TREATMENTS THAT IT DETERMINES, BASED ON CLINICAL INFORMATION, HAVE NOT
297
BEEN REASONABLY SHOWN TO IMPROVE A HEALTH CONDITION OR SIGNIFICANTLY
298
AMELIORATE A HEALTH CONDITION. EXCEPT AS SPECIFICALLY EXCLUDED, THE
299
ACTUAL SPECIFIC TREATMENTS, PROCEDURES, AND CARE SUCH AS THE USE OF
300
PARTICULAR PROVIDERS OR SERVICES THAT MAY BE USED UNDER A PLAN OR BE
301
USED WITH RESPECT TO HEALTH CONDITIONS SHALL BE DETERMINED BY THE
302
PARTICIPATING CARRIER.
303
(5)
THE
COOPERATIVE
MAY EXCLUDE
FROM
BENEFITS
IN DETERMINING BENEFITS, THE COOPERATIVE SHALL JUDGE
304
MEDICAL TREATMENTS, PROCEDURES, AND RELATED HEALTH SERVICES BASED ON:
305
(I)
THEIR EFFECTIVENESS IN IMPROVING THE HEALTH STATUS OF
INDIVIDUALS; AND
(II)
306
307
AND
308
IMPROVING HEALTH AND PRODUCTIVITY AND ON REDUCING THE CONSUMPTION
309
OF HEALTH CARE SERVICES.
310
(C)
(1)
THEIR
EACH
LONG-TERM
HEALTH
BENEFITS
IMPACT
PLAN
ON
MAINTAINING
SHALL INCLUDE UNIFORM
DEDUCTIBLES AND COST-SHARING ASSOCIATED WITH BENEFITS.
(2)
311
312
IN ESTABLISHING COST-SHARING, THE COOPERATIVE SHALL:
313
(I)
314
INCLUDE ONLY SUCH COST-SHARING AS WILL RESTRAIN
CONSUMERS FROM SEEKING UNNECESSARY SERVICES;
(II)
NOT
IMPOSE
COST-SHARING
315
FOR
COVERED
CLINICAL
PREVENTIVE SERVICES;
316
317
(IH) BALANCE THE EFFECT OF THE COST-SHARING IN REDUCING
PREMIUMS AND IN AFFECTING UTILIZATION OF APPROPRIATE SERVICES; AND
(IV) LIMIT THE TOTAL COST-SHARING THAT MAY BE INCURRED BY
AN INDIVIDUAL IN A YEAR.
318
319
320
321
- 13 -
�31rOm
(3)
THE COOPERATIVE MAY NOT ALLOW PROVI DERS PARTICIPATING IN
322
THE PLAN TO CHARGE FOR COVERED SERVICES AMOUNTS IN EXCESS OF THE
323
COST-SHARING.
324
(D)
EACH HEALTH BENEFITS PLAN SHALL OFFER FOUR KINDS OF COVERAGE:
325
(1)
COVERAGE ONLY OF AN INDIVIDUAL;
326
(2)
COVERAGE OF AN INDIVIDUAL AND THE INDIVIDUAL'S SPOUSE;
327
(3)
COVERAGE OF AN INDIVIDUAL AND ONE CHILD; AND
328
(4)
COVERAGE OF AN INDIVIDUAL AND MORE THAN ONE ELIGIBLE
329
FAMILY MEMBER.
(E)
330
A HEALTH BENEFITS PLAN MAY NOT IMPOSE ANY EXCLUSION OR
331
LIMITATION ON ANY PREEXISTING CONDITION.
332
1-305.
333
(A)
EACH PLAN SHALL BE COMMUNITY RATED. THE RATE SHALL BE THE
334
SAME FOR EACH INDIVIDUAL COVERED UNDER THE CONTRACT WITHOUT REGARD
335
TO AGE, SEX, HEALTH STATUS, OR OCCUPATION. RATES MAY VARY BASED ON
336
FAMILY COMPOSITION.
337
(B)
THE COOPERATIVE SHALL DETERMINE THE ADMINISTRATIVE EXPENSE
338
RATIO FOR EACH PLAN.
339
1-306.
340
(A)
A CONSUMER ELECTING TO PURCHASE INSURANCE THROUGH THE
341
COOPERATIVE SHALL PAY THE STANDARD PREMIUM SET BY THE REGIONAL
342
CARRIER DIRECTLY TO THE CARRIER.
343
(B)
CONTRIBUTIONS BY ALL EMPLOYEES AND THEIR DEPENDENTS SHALL BE
SET BY THE COOPERATIVE
(C)
344
345
BY REGULATION, THE COOPERATIVE SHALL ESTABUSH STANDARDS FOR
- 14-
346
�31r0806
DETERMINATION OF ELIGIBILITY FOR STATE-FUNDED ASSISTANCE FOR PREMIUM
347
PAYMENTS FOR INDIVIDUALS AND FAMILIES WHOSE ADJUSTED GROSS INCOME IS
348
AT OR BELOW 200% OF THE POVERTY LINE AS DEFINED BY THE FEDERAL OFFICE OF
349
MANAGEMENT AND BUDGET AND REVISED ANNUALLY IN ACCORDANCE WITH
350
SECTION 673(2) OF THE OMNIBUS BUDGET RECONCILIATION ACT OF 1981.
351
1-307.
352
(A)
THERE IS A MARYLAND HEALTH INSURANCE PREMIUM ASSISTANCE
FUND.
353
354
(B)
EXCEPT AS PROVIDED IN SUBSECTION (F)(2) OF THIS SECTION, THE
355
MARYLAND HEALTH INSURANCE PREMIUM ASSISTANCE FUND SHALL BE USED
356
EXCLUSIVELY TO PROVIDE DIRECT PAYMENT TO PARTICIPATING CARRIERS FOR
357
PREMIUM PAYMENTS ON BEHALF OF INDIVIDUALS AND FAMILIES WHO QUALIFY
358
FOR ASSISTANCE UNDER § 1-305 OF THIS SUBTITLE.
359
(C)
THE MARYLAND HEALTH INSURANCE PREMIUM ASSISTANCE FUND
SHALL CONSIST OF:
360
361
(1)
STATE AND FEDERAL FINANCIAL PARTICIPATION IN MEDICAID;
362
(2)
CONTRIBUTIONS BY ALL CONSUMERS AND THEIR DEPENDENTS
363
WHO MEET THE CRITERIA UNDER § 1-306 OF THIS SUBTITLE IN THE AMOUNT OF A
364
UNIVERSAL SLIDING SCALE PREMIUM TO BE SET BY THE COOPERATIVE; AND
(3)
(D)
THE PROCEEDS FROM ANY OTHER SOURCES OF FUNDS.
AN EMPLOYER MAY PAY ALL OR ANY PART OF THE UNIVERSAL SLIDING
365
366
367
SCALE PREMIUM ESTABLISHED UNDER SUBSECTION (C)(2) OF THIS SECTION FOR AN
368
EMPLOYEE OF THE EMPLOYER.
369
(E)
(1)
THE FUND IS A CONTINUING, NONLAPSING FUND AND IS NOT
SUBJECT TO § 7-302 OF THE STATE FINANCE AND PROCUREMENT ARTICLE.
(2)
ANY UNSPENT PORTIONS OF THE FUND MAY NOT BE TRANSFERRED
- 15-
370
371
372
�31r0806
OR REVERT TO THE GENERAL FUND OF THE STATE, BUT SHALL REMAIN IN THE
373
FUND TO BE USED FOR THE PURPOSES SPECIFIED IN § 1-305 OF THIS SUBTITLE.
374
(F)
(1)
THE CHAIRMAN OF THE COOPERATIVE OR THE DESIGNEE OF THE
375
CHAIRMAN SHALL ADMINISTER THE MARYLAND HEALTH INSURANCE PREMIUM
376
ASSISTANCE FUND.
377
(2)
A PERCENTAGE OF THE FUND TO BE SET BY THE COOPERATIVE
SHALL BE USED FOR ADMINISTRATIVE COSTS.
(G)
378
379
THE LEGISLATIVE AUDITOR SHALL AUDIT THE ACCOUNTS AND
380
TRANSACTIONS OF THE FUND AS PROVIDED IN § 2-1215 OF THE STATE GOVERNMENT
381
ARTICLE.
382
1-308.
383
A HEALTH BENEFITS PLAN MAY NOT BE OFFERED BY ANY CARRIER EXCEPT AS
PROVIDED UNDER THIS SUBTITLE.
1
ft-fr -^
-frPP^^i l
0
>
t - W - ^ j ^ f f i t E 4. HEALTH CARE DATA
_ . ,,
r
A
co op B k ^ - r W & ,
1^01.
384
_ 385
386
387
(A)
THE COOPERATIVE SHALL ESTABLISH AND MAINTAIN A UNIFIED HEALTH
CARE DATA BASE TO ENABLE IT TO:
(1)
389
DETERMINE THE CAPACITY AND DISTRIBUTION OF EXISTING
RESOURCES;
(2)
388
390
391
IDENTIFY HEALTH CARE NEEDS AND DIRECT HEALTH CARE
POLICY;
392
393
(3)
EVALUATE EFFECTIVENESS
OF INTERVENTION PROGRAMS ON
IMPROVING PATIENT OUTCOMES;
(4)
394
395
COMPARE COSTS BETWEEN VARIOUS TREATMENT SETTINGS AND
APPROACHES; AND
396
397
- 16-
�31rOS06
(5)
PROVIDE INFORMATION TO CONSUMERS AND PURCHASERS OF
HEALTH CARE.
(B)
398
399
THE DATA BASE SHALL CONTAIN UNIQUE PATIENT AND PROVIDER
400
IDENTIFIERS AND A UNIFORM CODING SYSTEM, SHALL REFLECT ALL HEALTH CARE
401
UTILIZATION, COSTS, AND RESOURCES IN THIS STATE, AND SHALL INCLUDE HEALTH
402
CARE UTILIZATION AND COSTS FOR
403
SERVICES PROVIDED
TO MARYLAND
RESIDENTS IN ANOTHER STATE.
404
1-402.
405
(A)
PARTICIPATING CARRIERS, HEALTH CARE PROVIDERS, HEALTH CARE
406
FACILITIES, AND GOVERNMENTAL AGENCIES SHALL FILE REPORTS, DATA
407
SCHEDULES, STATISTICS,
BY THE
408
COOPERATIVE TO BE NECESSARY TO CARRY OUT THE PURPOSES OF THIS SUBTITLE.
409
THE INFORMATION MAY INCLUDE:
410
(1)
OR
OTHER
INFORMATION
DETERMINED
HEALTH INSURANCE CLAIMS AND ENROLLMENT INFORMATION
USED BY HEALTH INSURERS;
(2)
412
INFORMATION RELATING TO HOSPITALS FILED WITH THE HEALTH
SERVICES COST REVIEW COOPERATIVE; AND
(3)
ANY OTHER INFORMATION RELATING TO HEALTH CARE COSTS,
UTILIZATION, OR RESOURCES REQUIRED TO BE FILED BY THE COOPERATIVE.
(B)
411
413
414
415
416
THE COOPERATIVE, AFTER CONSULTATION WITH THE COMMISSIONERS
417
OF BANKING, INSURANCE, AND SECURITIES, BY REGULATION MAY ESTABUSH THE
418
TYPES OF INFORMATION TO BE FILED UNDER THIS SECTION AND THE UME AND
419
PLACE AND THE MANNER IN WHICH SUCH INFORMATION SHALL BE FILED.
420
(C)
RECORDS OR INFORMATION PROTECTED BY THE PROVISIONS OF THE
421
PHYSICIAN-PATIENT PRIVILEGE OR OTHERWISE REQUIRED BY LAW TO BE HELD
422
CONFIDENTIAL SHALL BE FILED IN A MANNER THAT DOES NOT DISCLOSE THE
423
IDENTITY OF THE PROTECTED PERSON.
424
- 17-
�31r0806
(D) THE COOPERATIVE SHALL ADOPT A CONFIDENTIALITY CODE TO ENSURE
425
THAT INFORMATION OBTAINED UNDER THIS SECTION IS HANDLED IN AN ETHICAL
426
MANNER.
427
1-403.
428
ANY PERSON WHO KNOWINGLY FAILS TO COMPLY WITH THE FILING
429
REQUIREMENTS OF THIS SUBTITLE OR REGULATIONS ADOPTED UNDER THIS
430
SUBTITLE SHALL BE FINED NOT MORE THAN $1,000.
431
SECTION 2. AND BE IT FURTHER ENACTED, That the terms of the initial
432
members of the Maryland Health Insurance Purchasing Cooperative shall expire as
433
follows:
434
(1)
Three members in 1995;
435
(2)
Three members in 1996;
436
(3)
Three members in 1997; and
437
(4)
One member in 1998.
438
SECTION 3. AND BE IT FURTHER ENACTED, That, not later than October
439
1, 1994, the Department of Health and Mental Hygiene shall apply to the Secretary of
440
Health and Human Services for all waivers of requirements under health care programs
441
established under Title XIX of the Social Security Act, as amended, that are necessary to
442
enable the State to deposit federal payments under those programs in the State treasury
443
to the credit of the Maryland Universal Health Insurance Fund.
444
SECTION 4. AND BE IT FURTHER ENACTED, That, not later than October
445
1, 1994, the Maryland Health Insurance Purchasing Cooperative shall seek waiver from
446
the provisions of the Employment Retirement Income Security Act, as amended, in order
447
to ensure total participation of all residents of the State in the Plan.
448
SECTION 5. AND BE IT FURTHER ENACTED, That Subtitles 1 and 2 of
449
Article 48C - Health Insurance, as enacted by this Act, shall take effect October 1, 1993.
450
- 18-
�31rOS06
SECTION 6. AND BE IT FURTHER ENACTED, That Subtitles 3 and 4 of
451
Article 48C - Health Insurance, as enacted by this Act, shall take effect January 1, 1995.
452
-19-
�TITLE PAGE
C3
31r0806
By: Senator Hollinger
A BILL ENTITLED
AN ACT concerning
Maryland Health Insurance Purchasing Cooperative
FOR the purpose of creating a new regulatory program governing certain health benefit
plans; establishing a Maryland Health Insurance Purchasing Cooperative;
establishing certain regional advisory boards; providing for the establishment of
rules and procedures for contracting with participating carriers; allowing each
defined region in the State to be serviced by only one participating carrier that is
chosen in accordance with a certain bidding process; limiting the plans and types of
coverage that may be offered; requiring the Cooperative to determine benefits that
may be offered in a health benefits plan; delineating factors to be considered in
determining benefits; prohibiting exclusions or limitations on preexisting conditions;
allowing assistance in payment of premiums for certain individuals and families;
establishing the Maryland Health Insurance Premium Assistance Fund; establishing
a health care data base and requiring certain information to be submitted to the
data base for certain purposes; defining certain terms; and generally relating to
health insurance availability and purchasing.
BY adding
New Article 48C - Health Insurance
Annotated Code of Maryland
(1991 Replacement Volume and 1992 Supplement)
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Maryland Health Care Bill] [loose, letter and bill]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-037-004-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/e458a6b9efdd5eaf64fadf5cc2a3cd18.pdf
10036331a505783a62813400f9985c9f
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1972
FolderlD:
Folder Title:
[Life of a Group]
Stack:
Row:
S
56
Section:
1
Shelf:
Position:
10
3
�Life
Of
A
Group
OX CHASE
CANCER
CENTER
Philadelphia. Pennsylvania 19111
�1
L i / e Of A Group is a clramarization of a support group tor cancer patients. The group is composed of
social workers from Fox Chase Cancer Center who portray patients receiving treatment for a diversity
ofcancer diagnoses. Three meetings of the group are presented: the first meeting, the middle phase
and the termination session. As the group evolves, the "patients" reveal the complex range of
psychosocial issues with which they are confronted.
"Those who attended are still
talking about it, those who didn't
are wishing they had!"
- Social Worker
"I'd like all of our residents and
Conceived and directed by Jerry Carter, L.S.W., Assistant Director ot Social Work Services at Fox
Chase, Life Of A Group has been acclaimed by professional oncology audiences throughout the
United States. In addition to Philadelphia area presentations, it has been performed for the National
Institutes of Health, American Cancer Society, National Association of Oncology Social Workers,
and the American Group Psychotherapy Association.
students to see this. "
- Attending
Physician
" I had lost touch with all of the
feelings inside."
Life Of A Group is compelling and successful as it moves into its 10th year of presentation because it
offers a unique way of considering the cancer experience. The audience is engaged both intellectually
and emotionally by the powerful dramatization.
- Oncology Nurse
" H o w did you know how it was
;
for us. "
Audience Benefits:
- Cancer Survivor
Tw s presentation can be appreciated from several perspectives. For those unfamiliar with cancer, it
is a powerful portrayal of how patients experience the illness and address its human consequences. For
oncology professionals, it demonstrates clinical issues along with group facilitation skills useful to those
responsible for support group program development. For all audiences, it presents an opportunity to
reflect on the meaning of life and the universal struggle to find fulfillment.
"Powerful, poignant, moving
and w o n d e r f u l . "
- Hospital
Administrator
"It made me laugh and cry."
- Business
Requirements for Effective Presentation at Your Facility:
• Auditorium or large conference room with capacity tor amplification ot taped music,
controlled lighting and slide projection
• Room easily accessible to stage
• Map of route to facility and directions to parking
• Contact person available to meet with Jerry Carter for planning/coordination
• Scheduling of presentation subject to prior commitments and availability of presenters
• Evaluation to be distributed and returned to Jerry Carter
• Agreement that Life Of A Group will not be video or audiotaped.
Executive
A . n adapted version of Life Of A Group, in which Jerry Carter engages you and your group in
presenting the drama at your facility, is also available. Mr. Carter can explain how this modality may
best be utilized.
I f you are interested in bringing Life Of A Group to yc
Jen-y Carter, L.S.W.
Fox Chase Cancer Center
Philadelphia, PA 191 1 1
215.728.2669
The brochure is made possible through the generosity of Mr. L;
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
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Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
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Clinton Presidential Records: White House Staff and Office Files
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42-t-12092971-20060885F-Seg3-037-003-2015
12092971
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https://clinton.presidentiallibraries.us/files/original/f27c0ae194421b04036716f4232add49.pdf
687c3adb0cffcb1a65bb09c56f7a04fd
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1985
FolderlD:
Folder Title:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [3]
Stack:
Row:
s
56
Section:
Shelf:
4
Position:
�KJ
/
s
�METROPOLITAN DADE COU NTY-FLORIDA
METRO•DADE
111 N . W. FIRST
ALEXANDER PENELAS
MIAMI.
FLORIDA
(305)
CENTER
STREET. S U I T E
220
331281963
375-5071
Febuary 3, 1993
Mrs. H i l l a r y Rodham C l i n t o n
Chairperson
P r e s i d e n t ' s Task Force on N a t i o n a l
H e a l t h Reform
The White House
Washington, D.C.
20500
Dear Mrs. C l i n t o n :
C o n g r a t u l a t i o n s a g a i n t o you and P r e s i d e n t C l i n t o n on
t h e e l e c t i o n and f a b u l o u s I n a u g u r a t i o n ceremonies.
I am p l e a s e d t o be w r i t i n g t o you i n your c a p a c i t y as
C h a i r p e r s o n o f t h e P r e s i d e n t ' s Task Force on N a t i o n a l H e a l t h
Reform. Dade County has been s t r u g g l i n g w i t h t h e i s s u e o f
h e a l t h c a r e f o r many y e a r s .
Accordingly, I wish t o i n f o r m
you o f some o f o u r e x p e r i e n c e s .
I a l s o want t o commit t o
a s s i s t i n g you, t h e Task Force and t h e P r e s i d e n t i n t h e
development and passage o f a u n i v e r s a l access h e a l t h p l a n .
A t t a c h e d f o r your r e v i e w i s a package o f i n f o r m a t i o n
c o n c e r n i n g a p r o p o s a l I sponsored c a l l e d "Health-Net."
This
p r o p o s a l i s a m u l t i - f a c e t e d approach t o s e c u r i n g u n i v e r s a l
access t o needed h e a l t h c a r e on a r e g i o n a l b a s i s . K i n d l y
review
t h e package and c o n t a c t me d i r e c t l y
a t (305)
375-5071, s h o u l d you w i s h t o d i s c u s s t h i s m a t t e r f u r t h e r .
C o n g r a t u l a t i o n s and best wishes.
Sincerely,
Alexander Penelas
County Commissioner
AP/st/clint
Attachments
�A Public-Private Health Care
Universal Access Initiative
January 16, 1992
Alexander Penelas
Dade County Commissioner
�For Release: January 16, 1992
PENELAS INTRODUCES HEALTH CARE REFORM PLAN
Metro-Dade Commissioner Alexander Penelas held a press
conference today, i n t h e Mayor's Conference Room a t t h e
Government Center, 111 N.W. 1 St., where he introduced a
comprehensive health care reform plan f o r Dade County.
Penelas"
"Health-Net" strategy provides "universal access"
to health care f o r a l l Dade residents.
The plan also c a l l s f o r reforming the Dade County
h e a l t h care d e l i v e r y and financing system i n order t o create
a basic package o f services f o r a l l Dade residents,
regardless o f a b i l i t y t o pay.
"Health care i s a r i g h t , not a p r i v i l e g e , " said
Commissioner Penelas. "My Health-Net strategy seeks t o
provide access t o a f f o r d a b l e health care coverage f o r a l l
Dade residents through a combination o f p u b l i c / p r i v a t e
sponsored programs and a f f o r d a b l e employer-based insurance
coverage."
The Board o f County Commissioners w i l l review t h i s
proposal at i t s Jan. 21 meeting.
Contact: Jackie R. Menendez
375-2830
COMMUNICATIONS
METRO-DADE CENTER • 111 NW 1st STREET* SUITE 2510 • MIAMI. FLORIDA 33128-1986 • 375-2836 • FAX 375-3968
�Agenda Item No.
RESOLUTION NO.
RESOLUTION ESTABLISHING GUIDELINES FOR THE
PUBLIC HEALTH TRUST TO REVIEW AND ADDRESS
IN DEVELOPING A LONG RANGE FIVE-YEAR PLAN
FOR MEETING THE HEALTH CARE NEEDS OF ALL
DADE COUNTY RESIDENTS; ESTABLISHING PRINCIPLES
AND PRIORITIES; RECOMMENDING PROGRAMS; AND
SPECIFYING PROCEDURES FOR PUBLIC INPUT
WHEREAS, the Board of County Commissioners recognizes that
access to basic health care should be available to a l l c i t i z e n s
of Dade County as a right, and not a privilege solely for those
who can afford i t , and that our community w i l l be judged i n part
by how we provide for the health care needs of our most
vulnerable and disadvantaged c i t i z e n s ; and
WHEREAS, the current health care delivery system and
supporting f i n a n c i a l mechanisms in Dade County contain many
deficiencies and are in c r i s i s because of spiraling costs and the
i n a b i l i t y to provide basic health care for many of those i n need;
and
WHEREAS, the number of uninsured individuals without access
to basic health care services continues to grow at an alarming
rate, and more than seventy-five percent (75%) of those uninsured
are employed or are dependents of those who are employed; and
WHEREAS, increasing health care costs have p a r t i c u l a r l y
�Agenda Item No.
Page No. 2
affected small businesses, resulting i n the i n a b i l i t y of many of
those employers to provide health care coverage for t h e i r
employees and dependents; and
WHEREAS, many middle c l a s s and poor families are finding i t
d i f f i c u l t i f not impossible to keep up with spiraling health care
insurance premiums; and
WHEREAS, the Dade County Public Health Trust (PHT) i s
currently in the process of developing a long range five-year
plan for the delivery of county-wide health care services.
N W THEREFORE, BE IT RESOLVED THAT:
O,
Section 1. As the PHT develops i t s long range five-year plan for
the delivery of county-wide health care services, t h i s Board
recommends that the PHT consider and address the following
p r i n c i p l e s and p r i o r i t i e s :
(a) the most effective means of reducing the medically
indigent population and thereby reducing uncompensated
health care i s by increasing the number of patients who
have health insurance coverage;
(b) individuals should be responsible for t h e i r own health
and are expected to contribute to the cost of their
own health care needs to the extent that they are
f i n a n c i a l l y able;
�Agenda Item No.
Page No. 3
(c)
the establishment of preventative, early intervention,
and primary health care programs and the most cost
e f f i c i e n t method to implement them in the long term;
(d) access to affordable and comprehensive primary care
which i s conveniently located and c u l t u r a l l y
sensitive to the community served;
(e)
implementation of system-wide a d m i n i s t r a t i v e and
operational cost e f f i c i e n c y measures which w i l l
contain the cost of health care services f o r Dade County
residents;
( f ) those p r i v i l e g e d t o p r a c t i c e medicine or operate a
h e a l t h care f a c i l i t y i n Dade County have a
r e s p o n s i b i l i t y t o provide at l e a s t a minimum l e v e l of
c h a r i t y care or f i n a n c i a l c o n t r i b u t i o n i n l i e u of such
care;
(g) the consideration to be given to the amount of indigent
care which a medical provider i s giving or f i n a n c i a l
contribution made in l i e u of such care;
(h) Metro-Dade has a responsibility in assisting employees
and employers in accessing affordable basic health care
coverage; and
(i) the manner and means of establishing a comprehensive
and systematic change in the delivery and financing of
health care services that w i l l provide effective cost
containment and universal access to basic health care
�Agenda Item No.
Page No. 4
services for ALL Dade County residents.
Section 2.
The PHT s h a l l also consider the f e a s i b i l i t y of
establishing the following programs in the long range five-year
plan:
(a) a comprehensive program for universal access to prepaid
basic health care services for ALL Dade County
residents, especially the medically indigent, through
public-private sponsored programs and affordable
employer-based insurance coverage funded through a
combination of the following:
(1)
income-based s l i d i n g scale premiums paid by
enrollees;
(2)
a contribution of private dollars currently i n the
health care system allocated on an equitable basis
(e.g., a voluntary "set aside" of payments by a l l
private sector purchasers and payors to hospitals,
physicians, home health agencies, laboratories, and
pharmacies);
(3)
to the extent permitted by law, a portion of the
county general revenue of eighty percent
(80%)
maintenance of effort to the PHT to defray cost
of services and supplies provided to medically
indigent persons;
(4)
private charitable contributions; and
�Agenda Item No.
Page No. 5
(5)
(b)
other p u b l i c ( l o c a l , s t a t e and f e d e r a l ) funding.
establishment of a regional purchasing
cooperative to consolidate the purchasing power of
public and private e n t i t i e s ;
(c)
establishment of a p u b l i c - p r i v a t e program t o
encourage and a s s i s t small businesses i n securing
a f f o r d a b l e group insurance coverage f o r t h e i r
employees and
(d)
dependents;
expansion of operational hours a t those primary
care centers and p u b l i c health u n i t s which are most
overburdened;
(e)
development of primary health care centers i n
geographic areas of growing need, i n c l u d i n g but not
l i m i t e d t o Overtown, West Perrine, L i t t l e H a i t i ,
and L i t t l e Havana;
(f)
expansion of the JMH Health Plan network t o make
i t more marketable and competitive.
Section 3.
The PHT s h a l l include the f o l l o w i n g components i n the
long range plan:
(a) an inventory and description of a l l health care
services available in Dade County;
(b) recommendations on which services can best be
coordinated t o achieve maximum b e n e f i t s t o the
medically indigent i n Dade County;
(c) an inventory of existing and potential Federal,
�Agenda Item
Page No. 6
No.
State, and Local funding sources f o r indigent h e a l t h
care services, i n c l u d i n g funding a v a i l a b i l i t y by
revenue source, p o t e n t i a l funding r e s t r i c t i o n s and
u n c e r t a i n t i e s , and p o t e n t i a l p r i v a t e funding sources;
and
(d) recommendations on governmental l e g i s l a t i v e
initiatives.
Section 4.
The PHT
s h a l l include the f o l l o w i n g as p a r t of the
planning process leading t o the s u b m i t t a l of a long range plan t o
the Board of County Commissioners not l a t e r than July 31,
1992:
(a) establish a timetable for public input and conduct
public hearings including:
(1) identification of
and
meetings with interested community groups and
organizations, (2) consultation with various County
sponsored Committees and Councils,
including but
limited to the Health Council of South Florida
not
and
the Indigent Health Care Task Force, (3) review by
. County Departments for planning purposes, and
(4)
closing of the public input period;
(b) make a v a i l a b l e the proposed d r a f t f o r the long range
plan t o the community i n a v a r i e t y of "accessible"
formats, e.g.,
audio cassette, large p r i n t , and word
processing f i l e , as w e l l as standard paper copies f o r
c i t i z e n s requesting them;
�Agenda Item No.
Page No. 7
(c) hold, at minimum, one televised public hearing in the
Commission Chambers on the proposed long range plan.
The foregoing resolution was offered by Commissioner
, who moved i t s adoption.
was seconded by Commissioner
The motion
, and upon being
put t o vote, the vote was as f o l l o w s :
Mary C o l l i n s
Charles Dusseau
Joseph M. Gersten
Larry Hawkins
Alexander Penelas
Harvey Ruvin
Arthur E. Teele, J r .
Sherman S. Winn
Stephen P. Clark
The Mayor thereupon declared the r e s o l u t i o n duly passed and
adopted t h i s
DADE COUNTY, FLORIDA
BY ITS BOARD OF
COUNTY COMMISSIONERS
MARSHALL ADER, CLERK
Approved by County Attorney as ^ - By:
to form and legal sufficiency.
Deputy Clerk
�HEALTH-NET
A Public-Private Health Care Universal Access I n i t i a t i v e
White Paper
The
first
step t o s o l v i n g the complexity of problems
t h a t encompass the health care d e l i v e r y and finance c r i s i s
i n Dade County was taken t h i s past July when the membership
of
the Public Health Trust
scope of r e s p o n s i b i l i t y
("PHT") was expanded and i t s
broadened beyond Jackson
Memorial
Hospital t o include the d e l i v e r y of county-wide health care
services.
The next step i s a systematic review of Dade's
health care finance and d e l i v e r y system,
i n c l u d i n g primary
care services, emergency medical services, and acute care:
secondary and t e r t i a r y care services.
The
Initiative
care
Public-Private
("Health-Net")
delivery
system
Health
calls
Care
Universal
Access
f o r reform of our h e a l t h
and funding mechanisms i n order t o
create a basic package of services t o ALL Dade r e s i d e n t s ,
regardless
of a b i l i t y
t o pay.
In effect,
Health-Net
increases the number of Dade residents who have access t o
a f f o r d a b l e health care coverage
and thereby p r o p o r t i o n a l l y
reducing the medically indigent population and c o n t r o l l i n g
uncompensated health care costs.
(1)
�Introduction
Public support for a state and/or national solution to
our health care c r i s i s i s now at an a l l time high.
Surveys
reveal that the great majority of Americans favor reforming
the health care system.
Support for reform now crosses many
boundaries, including business,
doctors
and
consumer groups.
labor, insurance, hospital,
In fact, for the f i r s t time
the American Medical Association has called for a complete
overhaul of our system of health-care financing.
I t appears that the concerns with
the current
system
are not based on d i s s a t i s f a c t i o n with the quality of health
care services.
regarding
Rather, discontent i s based on uncertainties
the a v a i l a b i l i t y and timeliness of such care
and
the future of health benefits in our largely employer-based
system of insurance.
increased
For example, r i s i n g costs have led to
out-of-pocket
expenditures
for
individuals
and
decreased benefits provided by the government and employers.
In March 1991,
the Florida Task Force
Financed Health Care issued
i t s final
on Government
recommendations to
Governor Chiles setting out a policy framework.
Force's
stated goal was
mandate
Task
universal access to primary health
care for a l l Floridians by 1996.
recommendations
The
that
by
S p e c i f i c a l l y , the formal
1996,
state
and
local
governments, in cooperation with the private sector, s h a l l
(2)
�ensure t h a t at least 95 percent of unemployed,
persons
have
access
Similarly,
by
dependents
must
to
1996,
95
primary
health
low
care
care
services.
employees
primary health
have
percent of
income
and
their
coverage
or
employers s h a l l be mandated t o provide such coverage.
To
t h i s end, the Task Force set as a p r i o r i t y the development
of
community
based
model
delivery
systems
to
provide
innovative primary health care coverage t o i n d i v i d u a l s
are
i n e l i g i b l e f o r Medicaid.
In Dade County,
care
who
is directly
health
care
the issue of access t o basic
related
delivery
to deficiencies
system
and
of our
supporting
health
current
financing
mechanisms.
F i r s t , there are increasing numbers of persons in Dade
County without access to basic health care, in part due to
the fact that health care costs continue to r i s e at a rate
well
above
that
of
inflation.
Statewide,
there
are
an
estimated 2.2 million uninsured Floridians; 34 percent are
Hispanic, while 26 percent are African-American.
In Dade,
there are an estimated 145,000 individuals under the age of
65 who
are uninsured, and
minorities.
Another
44,000
the percentages
Dade
residents
insured, bringing the combined total
uninsured
to approximately
189,000.
(3)
are worse for
are
partly
of underinsured
The
total
and
number i s
�projected
to
substantially
increase within
the
next
few
years.
Second, r i s i n g
costs have had
an
small businesses' a b i l i t y to provide
for t h e i r employees.
less bargaining
adverse impact
on
health care coverage
Smaller businesses t r a d i t i o n a l l y have
power with health care coverage
providers
and cannot afford the group health plans that are available
in today's world of r i s i n g health care costs.
small
businesses
choose
not
to
coverage for their employees.
offer
In turn, many
health
insurance
Consequently, 75 percent
of
uninsured Floridians are workers or dependents of workers.
Although
reform, there
there
i s no
agree that there are
may
be
a
consensus
agreement on
for
health-care
the 'approach.
Experts
four major approaches for extending
health insurance coverage to the
uninsured:
I.
The government requires that every employer
provide health insurance to i t s employees, and the
government insures a l l nonworkers and poor people;
II.
The government gives employers the choice of
either providing insurance to their employees or
paying a tax for the government to provide those
employees insurance, and, again, the government
insures a l l nonworkers and poor people;
I I I . Individuals are given income-related tax credits
to purchase their own health insurance,
independent of their employers or the government;
or
IV.
The government provides health insurance for
everyone, similar to the Medicare program for the
elderly.
(4)
�These
approaches
containing
differ
cost,
primarily
redistributing
in
ensuring
income
and
access,
methods
of
financing.
Certainly,
the ever-increasing
concern
health care coverage i s well-founded.
social,
cultural,
economic,
and
f o r adequate
Unfortunately, due t o
regional
differences,
n a t i o n a l s o l u t i o n may be unattainable and/or
State and l o c a l governments, i n cooperation
a
impracticable.
w i t h the p r i v a t e
sector, must now act responsibly and e f f e c t i v e l y i n order t o
adequately address our current health care c r i s i s .
At minimum, a long range strategy must be developed t o
address our current
system d e f i c i e n c i e s i n a manner t h a t
reviews a l l major components of our health
system
and
financing mechanisms.
The
care d e l i v e r y
r e s u l t must be
an
i n t e g r a t e d strategy t o ensure a f f o r d a b l e basic health care
coverage f o r ALL Dade residents t h a t promotes q u a l i t y care
and f a c i l i t a t e s e f f e c t i v e cost c o n t r o l s .
A d d i t i o n a l l y , the
s t r a t e g y must feature i n t e g r a t e d a d m i n i s t r a t i o n i n order t o
reduce o v e r a l l costs, coordinate
provider
participation,
payment
to
instituted
providers.
f o r providers
and
a v a i l a b l e funding, manage
ensure
Finally,
e f f e c t i v e and
incentives
prompt
should
be
t o p a r t i c i p a t e i n cost e f f e c t i v e
and managed health service s e t t i n g s .
(5)
�Health-Net Strategy
Health-Net
i s an
innovative
universal
health
care
access model t h a t promotes c o s t - e f f e c t i v e a l t e r n a t i v e s t o
traditional
methods of health
care d e l i v e r y
and funding.
The p r i n c i p a l element of the strategy i s the c r e a t i o n of a
Dade County universal access program, which along w i t h the
JMH health complex, w i l l serve as a health care safety net
f o r ALL Dade residents.
Health-Net would ensure affordable health care services
to ALL Dade residents and would provide access t o a broad
range
of health care services f o r the medically i n d i g e n t ,
including,
but not l i m i t e d
care, and h o s p i t a l care.
a continuity
t o , primary
care, preventive
Great emphasis has been placed on
of care i n the most c o s t - e f f e c t i v e
setting,
t a k i n g i n t o consideration both a high q u a l i t y of care and
geographic access ( d e c e n t r a l i z a t i o n ) .
For
the
purpose
of
this
discussion,
"medically
indigent" i s defined as persons having i n s u f f i c i e n t income,
resources, and assets to pay for needed health care without
using resources
required to meet basic needs for shelter,
food, clothing, and personal expenses; or not being e l i g i b l e
(6)
�f o r government sponsored coverage (Medicare
and
Medicaid),
or s u f f i c i e n t t h i r d - p a r t y insurance coverage.
In formulating a long term universal health care access
solution,
the
Health-Net
strategy
adopts
the
following
policy pre-requisites articulated by the Health Council
South Florida's study of local financing of indigent
of
care:
1.
Health care i s a r i g h t , not a p r i v i l e g e ;
2.
I n d i v i d u a l s are responsible f o r t h e i r health and
are expected t o c o n t r i b u t e t o the cost of t h e i r own
health care t o the extent t h a t they are f i n a n c i a l l y
able;
3.
Access t o a f f o r d a b l e and comprehensive primary care
i s paramount. I t should be provided at various
p r i c e l e v e l s , conveniently located, and c u l t u r a l l y
sensitive;
4.
R e s p o n s i b i l i t y f o r f i n a n c i n g indigent care must be
shared by f e d e r a l , s t a t e and l o c a l government.
Every e f f o r t t o coordinate b e n e f i t s must be
pursued;
5.
The number, v a r i e t y and l o c a t i o n of professionals
and f a c i l i t i e s serving the indigent must be
expanded;
6.
Professional associations of physicians, dentists,
and other health professionals and hospitals should
provide leadership necessary to assure greater
participation in the provision of services on both
voluntary and s l i d i n g fee bases; and
7.
Services should be provided a t the l e a s t i n t e n s i v e ,
l e a s t expensive and most appropriate l e v e l t o
assure most cost e f f e c t i v e use of a v a i l a b l e
resources.
Consistent
without
into
limitation, reimbursement methodologies that
account
patients,
with these objectives, Health-Net promotes,
the
cost
recognizes
of
services
hospitals
(7)
rendered
that
to
take
eligible
render
a
�disproportionate
incentives
share of indigent
care,
t o promote the d e l i v e r y
requires cost
of c h a r i t y
containment i n c l u d i n g ,
case management.
provides
other
care, and
but not l i m i t e d t o ,
I t also promotes t h a t a l l h o s p i t a l s and
other health f a c i l i t i e s i n Dade County a f f o r d p u b l i c access
t o a l l q u a l i f i e d residents of Dade County.
Health-Net Universal Access Program
Health-Net would reform Dade's health care delivery and
financing
system
health care
health
to provide universal
for ALL Dade residents
care
services,
including
access
to prepaid
in the form of basic
but
not
limited
to,
physician care, hospital inpatient and outpatient services,
prescription medications, and laboratory and x-ray services.
The program would provide a low cost, accessible, managed
care, prepaid health coverage plan to be contracted on a
competitive basis with regional providers and administered
by the PHT.
Every resident
receive
program.
basic
health
of Dade County would be e l i g i b l e t o
care
services
under
the Health-Net
Enrollees would be required t o pay premiums on an
income-based s l i d i n g scale.
Premiums w i l l be set by the PHT
based on a market analysis,
negotiations w i t h
providers and sound a c t u a r i a l methods.
interested
Employers would be
permitted t o p a r t i c i p a t e i n the payment of a l l or a p o r t i o n
of
their
employee's
premiums.
(8)
A
separate
component of
�Health-Net would provide an affordable group plan for small
businesses,
including
premium
subsidies
for
medically
indigent employees and dependents.
The Health-Net universal access program could be funded
through a combination of the following sources:
(1)
income-based sliding scale premiums paid by
enrollees;
(2)
a contribution of private dollars currently in the
health care system allocated on an equitable
basis; (e.g., a voluntary "set aside" of payments
by a l l private sector purchasers and payors to
hospitals, physicians, home health agencies,
laboratories, and pharmacies);
(3)
to the extent permitted by law, a portion of the
county general revenue eighty percent (80%)
maintenance of effort to the PHT to defray cost of
services and supplies provided to medically
indigent persons;
(4)
private charitable contributions; and
(5)
other public ( l o c a l , state and federal) funding.
The
PHT
following:
and
would
(a)
subsidies;
administration,
be
responsible
for
establishing
the
budget and policy guidelines; (b) premiums
(c)
covered
services
monitoring, and
other
offered;
related
and
(d)
operational
and management duties of the plan.
The PHT
s h a l l also define operational requirements for
contracting the prepaid
health plan(s),
limited to the following:
(9)
including but
not
�(a)
service area of the plan
(b)
marketing program
(c)
enrollment and disenrollment procedures
(d)
case management system
(e)
out of plan use provisions
(f)
a v a i l a b i l i t y and a c c e s s i b i l i t y of services
(primary care, emergency, etc.)
(g)
grievance procedures
(h)
q u a l i t y assurance programs
( c l i n i c a l & administrative)
(i)
f i n a n c i a l r i s k and insolvency p r o t e c t i o n
(j)
r e p o r t i n g requirements
The PHT s h a l l determine which prepaid services w i l l be
required under the plan, s p e c i f i c a l l y :
I n p a t i e n t Hospital Services
Outpatient Hospital and Emergency Services
Physician Services
Independent Laboratory and X-Ray Services
Prescribed Drug Services
Family Planning Services
Home Health Services
Early and Periodic Screening, Diagnosis and
Treatment Services
Transportation Services
Visual Services
(10)
�Hearing
Services
Dental Services
Plans should not be l i m i t e d t o the b e n e f i t l e v e l s o r d i n a r i l y
applied t o services provided under other government
fee-for-service
programs
(e.g.. Medicaid).
funded
However, the
service b e n e f i t s o f f e r e d by the PHT plan should not be more
restrictive
than
those
f e e - f o r - s e r v i c e program.
whether
expansion
responsive
offered
i n the F l o r i d a
I n f a c t , the PHT should
i s necessary
t o make
t o the community needs.
Medicaid
consider
the plan
more
Moreover, c o n t r a c t o r s
should be encouraged t o expand covered services and provide
services
not covered
under the program i n order
t o make
plans more a t t r a c t i v e t o p o t e n t i a l e n r o l l e e s .
Cost Analysis
Assuming
approximately
a
first
10,000
year
target
enrollment
of Dade County's medically
population, the Health-Net universal access
cost approximately $15 million.
a basic prepaid
$109.71
prepaid program.
$13 million.
indigent
program would
The projection assumes that
health care plan could
per month rate
of
contracted
be secured
at the
by the Medicaid AFDC
At that rate, total premium costs would be
Approximately $2 million would be budgeted for
administration, monitoring, and marketing of the program.
(U)
�The Health-Net program could be funded by three major
sources employing a 2:2:1 matching r a t i o .
enrollee portion
could
represent, on
S p e c i f i c a l l y , the
average,
$25.00 per
month per enrollee contribution (actual premiums would
be
based on an income s l i d i n g scale with a minimum of $10.00
per month).
Another 40 percent of the total cost, equalling
$6 million, could be absorbed through a variety of
sources,
including a reallocation
industry
dollars,
state
charitable contributions.
remaining
and
of private health care
federal grants,
The PHT
funding
and
private
could contribute in the
$6 million through a reallocation of a portion of
the general revenue 80 percent maintenance of effort.
Small Business Access Program
The number of workers and families in the United States
without
adequate health care coverage continues to grow at
an alarming rate.
The "working uninsured" r e f l e c t a c r i s i s
in health care financing, particularly in the nation's small
business
community.
Currently,
over
50
percent
of
the
"working uninsured" are employed by small businesses.
Although many small businesses
health
insurance
expensive
coverage
premiums,
to
surveys
choose not
their
indicate
to offer
employees
that
most
due
to
small
business employees would obtain health coverage at work i f
it
were available.
A recent Gallup Poll reveals that
(12)
57
�percent of U.S.
availability
small businesses l i s t health care costs and
as
their
primary
concern.
There
are
approximately 50,000 small businesses with between 1 and
19
employees in Dade County which could be targeted for this
program.
The existence of an accessible, low cost, managed care,
health group plan f o r small businesses i s a key component of
the Health-Net strategy.
The program i s designed t o reduce
high small group premiums by pooling groups and absorbing
the a d m i n i s t r a t i v e and marketing costs.
The
Health-Net small business access program
will
be
based upon p u b l i c - p r i v a t e cooperation, whereby the County
w i l l market, coordinate and administer the program, as w e l l
as
provide
limited
income c r i t e r i a .
contribute
a
subsidies t o
individuals
based
upon
Small businesses accessing the plan w i l l
nominal
sum
to
assist
the
County
in
administering the program (e.g., $1 per employee).
Eligibility
determined
by
negotiations
requirements for small businesses w i l l
the
with
PHT
be
based upon a market analysis and
interested providers.
A
precise group
should be targeted in order to more effectively market the
program.
(13)
�Total premium costs are p a r t i c u l a r l y important t o the
successful
marketing
of the plan,
premiums may prevent
because
some businesses
from
unreasonable
participating.
Employers w i l l be required t o pay 50 percent of the premiums
of
a l l their
employees
covering 100 percent.
but w i l l
not be precluded
from
Employers w i l l be encourage but not
required t o pay a p o r t i o n of dependent coverage.
A County
subsidy f o r such coverage s h a l l be established by the PHT,
based on market analysis and income c r i t e r i a .
This access mechanism has proven
t o be an e f f e c t i v e
measure of p r o v i d i n g a f f o r d a b l e group health coverage t o
uninsured
individuals
proportionally
and t h e i r
dependents; and thereby,
reducing
the medically i n d i g e n t population
and uncompensated care.
A d d i t i o n a l l y , t h i s mechanism.is a
model of p u b l i c - p r i v a t e cooperation whereby the b a r r i e r s t o
uninsured i n d i v i d u a l s t o access a f f o r d a b l e basic h e a l t h care
services,
and consequently
eliminated
by spreading
a
better
health s t a t u s , are
responsibility
t o the r e c i p i e n t ,
employer, government and h e a l t h care providers.
Regional Purchasing Cooperative Program
The other feature element of the Health-Net strategy i s
the development of a regional purchasing cooperative
to pool
the purchasing power of public and private e n t i t i e s within
the
region.
local
This
governmental
"pooled" purchasing power should
and private
(14)
entities
to offer
allow
better
�health coverage to employees.
for
participants.
participating
initial
The program would be optional
Funding
entities,
would
although
term may be obtained
start
be
provided
up costs
by
for an
through the PHT (or even the
State).
A state cooperative
was organized
this past year to
pool state employees, prison inmates, e t c . This existing
program w i l l
serve as a useful guide i n developing Dade's
regional concept.
Conclusion
It
care
i s no secret that our current
delivery i s i n c r i s i s .
health
care
spending
from
Despite
"system" of health
large increases i n
individuals,
employers,
government, access to basic health care i s declining.
and
more families are discovering that they
and
More
are becoming
members of the growing class of medically indigent -- those
who are uninsured or underinsured.
There are no easy solutions to the complexity of health
care access problems.
Solutions w i l l
require
cooperation
between individuals, employers, government, and health care
providers to ensure access to basic health care services for
ALL Dade residents.
cooperation
Health-Net i s a model of public-private
whereby the barriers to the medically
(15)
indigent
�to
access
spreading
basic
health
responsibility
care
services
are eliminated
t o a l l involved.
I f we
by
truly
believe t h a t access t o basic health care i s a r i g h t f o r a l l
our r e s i d e n t s , then Dade County must take r e s p o n s i b i l i t y and
act now.
(16)
�UNIVERSAL ACCESS PROGRAM
ELIGIBILITY:
— ALL Dade County residents.
PROGRAM SUMMARY:
— provide the medically indigent, as well as ALL Dade residents, access to low cost,
managed care and prepaid health care services;
— contracted on a competitive basis with regional providers and administered by the PHT;
— enrollees will be required to contribute to the payment of premiums on an income-based
sliding scale;
— employers may participate in the payment of all or a portion of premiums for their
employees; and
— government subsidies will be provided to individuals based on income criteria.
NEEDS ANALYSIS:
— poor uninsured: The number of individuals who are economically disadvantaged when it
comes to affording adequate health care coverage continues to rise at an alarming rate.
— these are unemployed individuals without access to health care coverage and working
individuals whose income cannot withstand premium payments for coverage and cannot
qualify for government sponsored programs (Medicare or Medicaid).
— in Dade County, 189,000 individuals are uninsured or partially insured; and
— the uninsured generally suffer from lower health status.
PROGRAM IMPACT AND OBJECTIVES:
— increase in the number of Dade residents with health coverage resulting in transparency
of their medically indigent status;
— cost containment through the benefits of prepaid managed care;
— better access to preventative and early intervention care;
— reduction of uncompensated care;
— "cost shifting" opportunities for JMH and other facilities for uncompensated care; and
— decentralization of health care delivery and decompression of JMH.
FUNDING:
— income-based sliding scale premiums paid by program enrollees;
•
— private industry contribution thru a variety of options, e.g., voluntary set-a-side of private
dollars currently in the health care system allocated on an equitable basis;
— a portion of the county general revenue eighty percent maintenance of effort to the PHT
to defray the cost of services and supplies provided to medically indigent persons;
— other public (local, state and federal) funding; and
— private charitable contributions.
�SMALL BUSINESS ACCESS PROGRAM
ELIGIBILITY:
— small businesses in Dade County with between 1'and 25 employees.
PROGRAM SUMMARY:
— pooling small businesses to consolidate purchasing power and increase access to
affordable group insurance coverage;'
— reduce the high escalating insurance premiums for small businesses;
— County absorbing administrative and marketing costs;
— employers contribute minimum of 50% of premiums (cover all employees);
— the PHT will administer, coordinate, and market the program; and
— subsidies to individuals and dependents based on income criteria.
NEEDS ANALYSIS:
— over 75% of the uninsured are families with at least one working adult ("working
uninsured");
— over half of the "working uninsured" are employed by small businesses;
— Dade County has approximately 59,000 businesses with an estimated 53,000 being
small businesses with less than 20 employees, and over 45,000 having less than 10
employees; and
— small businesses employ over 250,000 individuals in Dade County, accounting for
approximately 33% of the workforce.
PROGRAM
—
—
—
—
IMPACT AND OBJECTIVES:
access for small businesses to affordable group insurance coverage;
reduction of "working uninsured" population;
containment of overall health care costs; and
other advantages resulting from universal access, e.g., decentralization and
decompression of health care delivery, cost shifting, preventative care emphasis, better
health status and cost containment.
FUNDING:
— income-based sliding scale premiums from program enrollees;
— small business fee for administrative costs;
— State contribution for administrative costs, e.g., the State currently funds a similar
program through the State of Florida Health Access Corporation; and
— County subsidy to employees and dependents on an income-based criteria.
�PURCHASING COOPERATIVE PROGRAM
ELIGIBILITY:
— all public entities, primarily municipal, county, school system, state and federal
employees; and
— medium to large size private entities.
PROGRAM SUMMARY:
— pooling purchasing power of public and medium to large private entities within the region;
— offer participants cost effective and expanded health benefits for employees; and
— voluntary participation with a specified minimum enrollment period requirement.
NEEDS ANALYSIS:
— increasing numbers of businesses are reporting changing benefit plans to reduce costs;
— many medium sized businesses have been eliminating benefit plans altogether;
— higher out-of-pocket expenses (co-payments, deductibles, and dependent coverage) due
to businesses changing benefit plans; and
— health care costs are rising at a rate nearly twice that of inflation.
PROGRAM IMPACT AND OBJECTIVES:
— increased and more cost effective health care coverage for participating entities and their
employees;
— overall health care cost containment; and
— other advantages resulting from expanded access.
FUNDING:
— start-up grants from participating public entities; and
— fees from participating entities.
�State of Florida
PR E T
E CN
UNU E
NS RD
I
I EC
N AH
R C EH C
A ET N
/ I
GOP 19
R U 90
Source:
Florida Task Force on
Government Financed
Health Care:
Final Report March 1991
34.3%
30
26.5%
/--
20
17.9%
10
White
Non-White
Hispanic
All Floridians
�•
PROJECTED COSTS
National Average Family Health Costs
10/^
$9,397
8
$6,163
T
0
6
u
s
$4,296
A
N 4
D
S
$2,731
$1,742
• • M M * IMSSSI
n 1 ••HHB mma
m
wmummmmmmi wmmmi mmm\
^•••••••III
mmmm' mmm
nviMiBBBBiiiB imms immm 0
irjaniiavniiB, mm nwmm
•'I'nr'iivjiBiri ^fii" Hiwmm
1980
1985
nmmimmmmaaik " isssidivrj
m dmmmm^ Maaun^i jimmmm
i wmmm-**, 'mmmm* ^mmm
•k. ^ISk aaBBHk BBI Source: Families USA Foundation
•BBM
J B ^ ^ B B B B I BBI
1990
1995
2000
!/
�NATIONAL HEALTH CARE SPENDING
Average Family Spent $4,296 in 1990
General taxes
39%
($1,675)
Out-of-pocket
32%
($1,375)
Medicare premiums
3%
($129)
Medicare payroll tax
9%
($387)
��HEALTH CARE TASK FORCE SORTING SHEET
CODER:
TYPE OF MATERIAL:
General mail
Personal stories
Letterhead
.Offers to help
Letter Campaign
.Policy
Casework
Employment
.Advocacy
_Re quests:
-speech
-meeting
Other
Explanation:.
ADVISORY PANEL?
physician
.large employers
.other health provider
small business
seniors
other consumers
Explanation:.
PRIMARY INTEREST:
COST ISSUES
Drug Prices
Physician Fees
Hospital Fees
Unnecessary Procedures
Medical Equipment
Fraud and Abuse
.PUBLIC HEALTH/SPECIAL POPULATIONS
Prevention
AIDS
Women's Health
Immunizations
Rural
Urban
COVERAGE
Working Families
Unemployed/Low Income
Benefits
Providers
GOVERNMENT PROGRAMS
Medicare
Medicaid
Veterans
DoD
ORGANIZATION
Insurance Premiums
Insurance Reform
Insurance Pools
Boards and Oversight
INFRASTRUCTURE/WORKFORCE
Quality Assurance (Guidelines)
Administration, Reimbursement
& Patient Information Systems
Malpractice & Tort Reform
Manpower Issues (Training)
LONG-TERM CAKE
MENTAL HEALTH
FINANCING
OTHER
Explanation:.
PTAN P R E F E R E N C E : (Support = +; Oppose = - )
CP
SP
OP
Clinton Plan
Single Payer
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits, Vouchers,
Medical Savings Accts.
CA
BR
GE
Canadian
British
German
�STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
1016 Ens! First St. B5-1
1
I'ort Aimelcs. II asliin-'ton <)Ho62-li)9 .'
January 26, 1993
Hillary Clinton, F i r s t Lady
The White House
1600 Pennsylvania Ave. N W
..
Washington, D.C. 20500
Re:
HEALTH CARE ACCESS FOR LOW-INCOME PEOPLE
Dear Mrs. Clinton;
Thank you for your s o l i c i t a t i o n of input concerning the health
care c r i s i s in our country. I would like to share some of our
experiences and solutions that we have developed at a local
level.
BACKGROUNP
Clallam County i s located on the Olympic Peninsula in Washington
State.
The economy i s timber-based with fishing and tourism
adding some. We are a rural county with a population of 55,000.
Approximately 17000 people have no medical coverage nor do they
qualify for Medicaid.
Approximately 4000 people are receiving
some sort of public assistance.
Approximately 5000 people are
retirees from out-of-State are clustered in the Sequim area.
The are two public hospitals and three Tribal c l i n i c s . There are
f i v e Tribes located on the Peninsula. There are approximately
110 physicians of a l l s p e c i a l t i e s in the area. Approximately 900
children are e l i g i b l e for EPSDT but are not u t i l i z i n g the
program. W are a conservative Democrat County where people tend
e
to vote for their pocketbooks and jobs rather then for larger
issues.
THE ISSUES
The people in Clallam County either have money or they don't.
Despite the high number of physicians in the County, none of
them are taking new Medicaid r e f e r r a l s and those who are s t i l l
carrying Medicaid c l i e n t s on their caseloads, are incredibly
overloaded. There are only 8 physicians who are currently seeing
Medicaid recipients.
People are often forced to use the
emergency room to receive primary care,
Pregnant women and
children are able to receive care however, the problem i s adult
care.
EFFORTS
The Clallam County Medical Care C r i s i s Task Force was convened 18
months ago to address these issues as a community. Providers,
p o l i t i c i a n s , and consumers were invited to a workshop to devise
local solutions. (see attached)
The Clallam County Medical
Society has j u s t begun a process of addressing members who choose
�HEALTH CARE ACCESS PAGE TWO
not t o see poor people v i a sanctions. We at the local Community
Services O f f i c e met w i t h an HMO i n order t o coax them over t o the
Peninsula from the urban areas. They chose t o put o f f making a
decision f o r two years.
We also approached two T r i b a l c l i n i c s
and asked them t o consider expanding
services t o non-Native
c l i e n t s . We, the CSO, have had an ongoing VISTA program in-house
addressing various needs such as teen pregnancy and low-income
housing so l a s t year,
we asked ACTION t o give us a one year
p o s i t i o n t o expand the Healthy Kids Program (EPSDT) and they
approved one VISTA volunteer t o work on expanding
capacity f o r
Healthy Kids beginning l a s t August.
The H O decided not expand services in our area as previously
M
stated but....the Lower Elwha S'Klallam Tribe and the Quileute
Tribe have decided to contract with the State of Washington
d i r e c t l y and w i l l be seeing non-Native Medicaid c l i e n t s beginning
t h i s Spring
. W w i l l be paying them on an "encounter rate"
e
basis which i s $86.00 per v i s i t .
Unfortunately we can only do
t h i s with 638 Status c l i n i c s which are mostly located on
Reservations. W
e are hoping that the Tribes can serve the nonemergent needs of Medicaid c l i e n t s since the medical community
chooses not to.
SUGGESTIONS
The descriptions of the President's proposals in the press are
good but I also r e a l i z e that not everyone f e e l s positive about
s o c i a l i z i n g medicine and that you are in for a f i g h t .
Capping
costs,
u t i l i z i n g a s i n tax to raise revenue, taxing employers,
etc. are good approaches in theory however,
the consumers
t y p i c a l l y don't
have advocates nor do they advocate for
themselves; insurance companies and medical corporations do.
What works are local i n i t i a t i v e s coupled with National and State
leadership.
A two-pronged approach
towards education and
l e g i s l a t i o n j u s t might move us into the 21st Century with a
health care system s i m i l a r to what the rest of the i n d u s t r i a l i z e d
nations have.
M suggestions
y
are;
A)
Start with county task forces that represent providers,
consumers, and governmental personnel to create a local plan
that would be incorporated into a State-wide plan.
B)
Facilitate
the implementation
of State-wide
plans,
eg;establish timelines that need to be adhered to, give the
States the framework of Federal
laws and regulations and
allow them to f i l l in the missing pieces, build in
�HEALTH CARE ACCESS PAGE THREE
f l e x i b i l i t y t o meet regional needs.
C)
Force the issue w i t h the medical industry
and sanctions i f needed.
via legislation
D)
Provide i n c e n t i v e s t o State and l o c a l agencies develop new
preventative programs and enhance e x i s t i n g ones over a f i v e
to ten year period as opposed t o a year or two year period.
The real cost savings w i l l be r e a l i z e d down the l i n e .
E)
Downsize the m i l i t a r y .
The c u r r e n t cost of one B-1 bomber
w i l l found Children's Services i n a l l f i f t y States at double
t h e i r e x i s t i n g budgets.
F)
Expand the provider base t o n o n - t r a d i t i o n a l
practitioners.
IE nurse p r a c t i t i o n e r s , midwives,
e t c . i n order t o reduce
o v e r a l l costs.
G)
Don't give up.
Grassroots o r g a n i z a t i o n w i t h Federal backing w i l l be the key t o
success. Call me a t (206) 457-2640 M-F 8-5 P a c i f i c time i f I can
be of f u r t h e r help. Good luck.
»spectfully submitted,
Roger Lern&ferbm, Supervisor
Social Services DSHS Port Angeles
�MEDICAL CARE CRISIS TASK FORCE
MEETING AGENDA
November 21, 1991
9-9:50 a.m. - I n t r o d u c t i o n and Overview
- A c t u a l Numbers
- County Resources
10-11 a.m.
-
Focus Group D i s c u s s i o n
Problem I d e n t i f i c a t i o n
Solutions
Next Steps
Synthesis
11-12 a.m.
-
Solution I d e n t i f i c a t i o n
Group P r e s e n t a t i o n s
Next Steps
Close
�STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND
HEALTH SERVICES
1016 Last Fir.il St. B5-I • Port A nonius. Washin/rton 98362-1099 - (206) 4 ~ 2. . H
> -y> I
MEDICAL CARE C R I S I S TASK FORCE
I N I T I A L FINDINGS
NOVEMBER 2 1 .
1991
The f i r s t meeting of the Medical Care C r i s i s Task
attended by 28 community members who spent t h r e e very
hours d i s c u s s i n g problems i n access t o h e a l t h care by
people.
Force
was
productive
low-income
The a t t e n d e e s broke down i n t o t h r e e working groups t o i d e n t i f y
b a r r i e r s , purpose s o l u t i o n s , and prepare a p r e s e n t a t i o n i n order
t o determine d i r e c t i o n s the Task Force needed t o go t o address the
problems.
The
b a r r i e r s t o h e a l t h care access were i d e n t i f i e d
as:
1.
Reimbursement r a t e s f o r Medicare do not a c c u r a t e l y
r e f l e c t the a c t u a l c o s t s of p r o v i d i n g s e r v i c e s ,
2.
The paperwork r e q u i r e d f o r reimbursement i s
s t a g g e r i n g and o f t e n incomprehensible. Changes i n
procedure occur too f r e q u e n t l y and the t o l l - f r e e
p r o v i d e r h o t - l i n e i s o f t e n l e s s than h e l p f u l ,
3.
P a t i e n t s o f t e n lack basic h e a l t h care e d u c a t i o n
p r e v e n t i o n and s e l f - c a r e . This o f t e n leads t o
"premature" or overuse o f Medicare s e r v i c e s ,
4.
in
Non-physician medical p r a c t i o n e r s (nurse p r a c t i o n e r s ,
e t c . ) are unable t o be reasonably reimbursed or not
a t a l l , f o r the p r o v i s i o n of s e r v i c e s ,
5.
The h i g h cost of m a l p r a c t i c e insurance causes some
OB-GYN's t o t h i n k t w i c e about t a k i n g on w e l f a r e c l i e n t s ,
6.
The lack of c o n s u l t a n t s
confirming diagnosis,
7.
P h y s i c i a n s and c l i n i c s cannot b i l l f o r "no shows".
P a t i e n t s using Medicaid miss a l o t of appointments
t o the p o i n t t o where i t i s n o t i c e d county-wide,
8.
I n a p p r o p r i a t e use of the emergency rooms a t our
l o c a l h o s p i t a l s . H o s p i t a l s w i l l not t u r n away c l i e n t s ,
and t h i s d r i v e s c o s t s up,
9.
Burnout. Several p h y s i c i a n s f e e l an o b l i g a t i o n t o
see a l l p a t i e n t s and end up s h u t t i n g out w e l f a r e
p a t i e n t s c o m p l e t e l y when they see t h e i r c o l l e a g u e s not
p i c k i n g up a " f a i r share" of the w e l f a r e caseload,
i n t h i s area i s a b a r r i e r t o
�TASK FORCE - PAGE TWO
10.
Misuse o f resources. Many Medicaid r e c i p i e n t s are
viewed as a b l e - b o d i e d and are " m i l k i n g " t h e system,
11.
A t t i t u d e s i n the community towards w e l f a r e r e c i p i e n t s
range from i n d i f f e r e n c e t o o u t r i g h t h o s t i l i t y ,
12.
P h y s i c i a n s f e e l an o b l i g a t i o n t o see i n i t i a l GA-U
e v a l u a t i o n c l i e n t s may s p i l l over i n t o the i n c a p a c i t y
d e t e r m i n a t i o n process,
13.
DSHS i s t o o slow i n responding t o the needs o f s e r v i c e
provi ders,
14.
Community as a whole f e e l s powerless and unable t o do
a n y t h i n g about t h e d e t e r i o r a t i n g economy and the h i g h
c o s t o f h e a l t h care.
The s o l u t i o n s t h a t were proposed i n c l u d e :
1.
The e s t a b l i s h m e n t o f a w a l k - i n c l i n i c w i t h r o t a t i n g
p h y s i c i a n s t h a t would serve low-income o r Medicaid
clients.
The best e x i s t i n g s i t e c u r r e n t l y i s a t the
Olympic Memorial H o s p i t a l ,
2.
Medicare c l i e n t s be r e q u i r e d t o p r o v i d e a small copayment f o r each v i s i t ,
3.
Expansion o f the Basic H e a l t h Care Plan,
4.
Increase paternal r e s p o n s i b i l i t y .
Ensure absent
f a t h e r s are i n c l u d e d i n t h e h e a l t h care process,
5.
B r i n g back the Medical C l e r k p o s i t i o n i n the l o c a l
CSO t h a t would be funded by DMA,
6.
E s t a b l i s h case management s e r v i c e s f o r h i g h r i s k
medical cases,
7.
I n c r e a s e e d u c a t i o n a l and v o c a t i o n a l s o c i a l
s e r v i c e s t o GA-U and SSI r e c i p i e n t s ,
8.
I n c r e a s e communication between emergency room
p h y s i c i a n s and primary care p h y s i c i a n s ,
9.
Ongoing t r a i n i n g and e d u c a t i o n f o r medical
clerks,
work
billing
�TASK FORCE - PAGE THREE
10.
S i m p l i f y r e p e t i t i o u s paperwork i n regards t o b i l l i n g ,
11.
Process medical
12.
Subsidize malpractice insurance,
13.
Create a l o c a l t o l l - f r e e number f o r r e f e r r a l s ,
14.
E s t a b l i s h a " d r o p - i n " , no o r l o w - c o s t , daycare i n a
c e n t r a l i z e d l o c a t i o n f o r p a t i e n t s needing t o v i s i t
a physician,
15.
utilize
16.
Develop an e d u c a t i o n a l program f o r c l i e n t s t h a t would
emphasize p r e v e n t i o n and s e l f - c a r e ,
17.
Create an a c t i v e pool o f r e t i r e d p h y s i c i a n s t o a c t
as a c o n s u l t i n g resource.
claims
locally,
a DSHS p h y s i c i a n f o r GA-U e v a l u a t i o n s ,
Several o f t h e suggested s o l u t i o n s are "do-able" a t a l o c a l l e v e l .
DSHS can begin a t r a i n i n g c y c l e f o r b i l l i n g c l e r k s and OMH i s
a c t i v e l y p u r s u i n g the e s t a b l i s h m e n t o f a w a l k - i n c l i n i c .
The next Task Force meeting i s t e n t a t i v e l y s e t f o r Tuesday n i g h t
between 7 and 9 on January 14, 1992, a t the County Courthouse.
RL:cfa
�- <y
ACT/oNS
t^cehS
a check-up have been made easier for children up
those from the Adult Action Center reported such
to age eighteen with Medicaid coverage through a
changes preceded their entry into the programs.
Again, shortfalls in services which would allow federal program providing extended reimbursepeople to sustain themselves in a home setting will ment for physicians. Adult dental care has been
precipitate their premature use of more expensive returned as a benefit of Medicaid coverage. Comservices outside the home in hospitals and nursing munity Action Council has established a Health
homes. Recent state lids on numbers of new nurs- Care Access Program to provide funding for uring home beds are likely to exacerbate this prob- gently needed medical and dental services not
lem, putting an even greater emphasis on adequate covered under some other program. The program
home care options. With difficulties in attracting includes a voluntary referral network of providers
available to give no-cost care on a limited basis.
and keeping staff for these services already a
problem because of low pay, increasing demands
That's the good news. The bad news is that the
for home care services are likely to result in some low-income population of Clallam and Jefferson
forms of service cutbacks or additional
Counties continue to report a number of signifiprioritization. Emphases on the critical needs of cant health care service needs. Clients identified
children and the elderly may mean
needs for help in the health services area
that other family membersfindlittle
which were comparable to those reassistance for their needs: there are
ported for housing and subsistence needs.
we still
really no services directed specifiThere have been improvements in gethave a considcally to adults. The situation deting health care services to the poor; as
erable way io
scribed by arespondent to the Client
dismal figures on infant mortality and
go before being
Survey is all too typical:
the poor health status of poor children
poor does not
and adults illustrate, we still have a
also mean
considerable way to go before being
"The programs for kids are
poor does not also mean being sicker
being sicker
great,"
and dying younger.
she writes, but "my husband
and dying
ff
and I are falling apart at the
younger..
seams."
Among the most notable continuing
problems pointed out by providers is the
Finally, there are shortages of services for lowdifficulty, even with a source of payment, in
income families where dissolution is the aim.
finding a dentist or physician to provide care. With
Legal services for contested divorces or those with Medicaid reimbursement policies covering a
child custody issues are a low priority for legal aid shrinking proportion of the costs of care, estimated
providers. Poor women trying to escape a domes- at forty to fifty percent of the usual fee level, more
tic violence situation may find themselves unable
and more providers are limiting the numbers of
to pay the costs required to terminate the relation- such patients they serve, refusing to add new
ship and keep their children.
patients with Medicaid coverage to their caseload,
or refusing altogether to accept Medicaid coupons.
The problem is particularly acute for dental and
HEALTH CARE SERVICE NEEDS
obstetric care. There is some early indication that
Needs for assistance with the high cost of medi- problems may be developing in pediatric care as
well.
cal and dental care dominated the conclusions of
Community Action's previous needs assessment.
Other shortcomings in the health care system
In the intervening four years, there has been a good result from the differing restrictions and limitadeal of progress in meeting these needs. Washing- tions placed on what is actually covered under the
ton State has implemented a Basic Health Plan
various programs available. The Basic Health
which enables low-income families who do not
Plan, for example, does not provide coverage for
qualify for Medicaid to purchase health insurance mental health services. At the community mental
on a sliding fee scale. Still in its early stages of health centers, state funding dictates that clients
implementation, this program is available in Clal- with chronic and emergency problems be served
lam County: Jefferson County residents do not
first: low-income persons who need mental health
have access to the program. Visits to a doctor for care for other reasons cannot readily receive ser-
�vice. Few services are available for those suffering
from both mental illness and substance abuse.
There are no alternatives to Medicaid or donated
care for low-income families needing dental work
and here too the emphasis is on providing emergency or critically needed services rather than
preventative care.
Some clients who would otherwise qualify for
Medicaid coverage find themselves caught in
Department of Social and Health Services requirements for documenting a particular level of medical services expenses: without coupons, they cannot get treatment; without showing treatment expenditures, they cannot qualify for coupons. Some
persons with insurance coverage cannot readily
cover the required deductible, and so avoid going
for care. Others need medications or medical
supplements not covered under any program. In
this regard, Community Action's Health Care
Access Program, which is directed to urgent need,
cannot well meet these requirements for an ongoing expense. Finally, patients and providers are not
always well informed about the often confusing
array of programs and regulations for their use.
Some newer programs improving coverage for
children are not being used as fully as needs
indicate, apparently due to lack of knowledge
about their availability. Many of these difficulties
are evident in the responses to client surveys.
SURVEY RESULTS
• Thirty-five percent of the respondents to the
Client Survey reported they had no assistance with
medical bills; forty-eight percent no assistance
with dental bills. Medicaid or Medicare provided
help paying medical costs for thirty-nine percent
and dental costs for thirty-six percent; nine percent
held private or employer provided medical insurance and eight percent private or employer dental
coverage.
ment option.
• Respondents who held full-time employment
were most likely to have private or employer
medical insurance (forty percent) or to participate
in the Basic Health Plan (thirty percent). Those
who had been unemployed for less than six months
were most likely to have no health care assistance
(sixty-one percent); thirty-five percent of those
unemployed for more than six months also reported no assistance with medical coverage.
• Respondents to the Re-Employment Support
Center (RSC) Survey were asked if health insurance expenses were a current or a likely future
problem for their households: thirty-five percent
indicated this was a current problem; another
twenty-one percent expected it would become a
problem.
• Most Client Survey respondents were unaware
that Community Action provided any medical or
dental assistance services: fifty-two percent said
they did not know these services were available
when asked if they had used them during the past
year; thirty percent indicated they did not need
these services; fourteen percent had used the program.
• Given the above, it is understandable that thirtynine percent of the Client Survey respondents
indicated they needed insurance or help to pay
medical bills; thirty-four percent needed assistance with dental bills; thirty-three percent needed
assistance paying for prescription drugs. Unemployed respondents were most likely to indicate
they needed help.
• Care needs were greatest for immediate needs:
thirty-four percent for a current dental problem;
thirty-two percent for vision or hearing care; and
thirty-one percent for routine medical needs. Respondents also needed preventative dental care,
•
Just eleven percent of the Client Survey
respondents were participants in the Washington checked as a need by thirty-three percent. Larger
Basic Health Plan, a program whose minimal costs households were most likely to report needs for
may have been too much for these low-income routine medical assistance.
families to afford: seventy-two percent indicated
they could afford to pay no more than $8.00 a
• Clients were less forthcoming about their needs
month for health insurance coverage. Capacity to for mental health assistance: nineteen percent
pay for health insurance was significantly related indicated they needed stress management; eighto income, with those in the lowest income brack- teen percent checked a need for improved selfets most likely to select the least expensive payesteem; thirteen percent (twenty-four clients) noted
�a need for mental health counseling. Respondents
with more education as well as respondents aged
thirty-one to forty-five were more likely to identify mental health needs than other groups.
• Among respondents to the Senior Survey, those
receiving Home Care services were most equivocal about their "emotional well-being," with
sixty-nine percent indicating it was "okay, and
eighteen percent that it was "not good." RSC
Survey respondents tended to be up-beat, but
twenty-five percent did report that they felt more
depressed than excited about their future.
• Older respondents to the Client Survey were the
least likely age group to identify needs for help
payingmedical billsbut most likely to report needs
for care for a chronic condition and needs for care
for vision or hearing problems.
health care supplies or equipment; other seniors
sampled were considerably below these levels of
reported need. Some senior respondents labeled
their physical health as "not good," particularly
those in the Home Care program: sixty-two percent of the sixty-one respondentsfromHome Care
said their health status was not good, considerably
more than other sample participants.
• Change in health status was, however, a significant factor in generating the need for the services
Senior Survey participants were involved in: either an acute medical condition or deterioration of
a chronic medical condition were the precipitating
events leading to service use for some seventy
percent of the respondents receiving Home Delivered Nutrition and Home Care services.
Table 4 gives responses from the Client Survey
for health care needs:
• Senior Survey respondents typically did not
identify themselves as having any health care
needs. One-fourth of the twenty persons included
in the sample from the Adult Action program
indicated they needed medical or dental care, or
TABLE 4
HEALTH CARE NEEDS
Insurance or help to pay medical bills
Insurance or help to pay dental bills
Care for a current dental problem
Yearly visits for preventative dental care
Assistance paying for prescription drugs
Vision and hearing care
Care for routine medical needs
Essential Orthodontic services
Assistance paying for restorations/dentures
Care for a chronic medical problem
Specialist care
Transportation to medical care
Other
None of the above
Source: 1991 Community Action Client Survey
39%
34%
34%
33%
33%
32%
31%
19%
15%
14%
11%
10%
2%
21%
�in Clallam County has been capped since April of
1991: 1,074 persons were covered by the program
as of July of this year. This limitation in program
Community Action Council's Health Care Ac- availability is another factor, besides cost, which
cess Program served 1,277 persons in 1990 with a restricts access to health care coverage through
this program. The modest costs for coverage still
broad range of financial help for medical needs:
two hundred seventy-eight people received assis- exceed thefinancialcapacity of the county's poortance with dental care costs, one hundred ninety- est residents, leading one provider to describe it as
seven help for medical care expenses, three hun- "helping the upper level of low-income level
people."
dred sixteen were assisted with transportation to
medical services, three hundred thirty-seven obFor Jefferson County residents, who cannot be
tained help for medication costs, eighty-three
covered by the Basic Health Plan, prospects for
needed medical equipment, and fifty received
assistance with medical bills are even more limsupport to pay laboratory expenses.
ited: there are no immediate plans for extending
Fifty-one percent of those assisted came to the coverage to Jefferson.
A waiting list has been established
Port Angeles office, three percent were
for new applicants to the Clallam
in the Forks area, and the remaining
County program but no enrollment
forty-six percent sought assistance in
by previously uncovered families
Port Townsend.
... Health
has been allowed: statewide the
Clients in the Health Care Access
Care Access is
waiting list for Basic Health is about
Program make up the majority of those
needed to fill
19,000. The 1991 Legislature alloserved through Community Action's
gaps of critical
cated some additional funding for
Community Resource and Referral
importance...
the program in the new state budget;
Division. Sixty-seven percent of these
this is less than needed to meet
clients are single heads of their houseexisting demand and is unlikely to
hold; thirty-four percent obtain some of
resolve the above issues. With comtheir household income from employpetitionfromother counties for limment; twenty-seven percent obtain
assistance from welfare payments; and forty-four ited funds, Clallam County is likely to add little to
its current program level despite its designation as
percent receive food stamps. These clients typically have multiple needs, and are represented in a high need area because of timber industry cutstatistics for a variety of Community Action ser- backs. It is particularly unfortunate that residents
vices as well as those delivered by other agencies. of the Forks area were not included in the program
until recently and thus did not begin program sign
Community Action staff assist clients directly
with support for urgently needed medical or dental up until shortly before it reached capacity.
services, and indirectly by helping them maximize
In another approach to improving health care
the benefits from other services for which they
services for the poor, a program to improve access
may be qualified. Sometimes medical costs can be to care for Medicaid recipients was implemented
covered by finding support for another expense,
in Clallam County in the fall of 1989. Following
thereby reallocating some of the client's own
a health maintenance model, patients would sign
scarce resources. Like many other Community
up with a specified provider who would have
Action programs. Health Care Access is often
overall management of the patient's medical care,
needed to fill in the gaps not covered by other
and who would be paid a set fee, regardless of
services, gaps which can be of critical importance whether or not services were delivered. Participatwhen the need is for health care services. Also like ing physicians in this program felt that they were
other programs, restricted availability of funds
losing money, in part because they could not
means that non-emergent needs cannot be adcontrol patients' high use of emergency room
equately addressed.
services. All doctors who had signed up as providThe Basic Health Plan promises to provide a way ers had discontinued participation as of January of
1991. Ironically, this same programmatic idea
for low-income families to self-pay their own
implemented in another state was recently highhealth insurance and thus maintain their own
health care safety net. Unfortunately, enrollment lighted by a national news show as an effective and
Service Indicators
�and its resulting social distress.
Clallam County's west end surrounding the city
of Forks is likely to be hardest hit by timber
industry dislocations. Residents in Jefferson
PROVIDING FOR THE FUTURE
County's west end will be similarly affected, as
will those still engaged in timber-related work in
An assessment of this sort should do more
than pinpoint needs at a given point; it also should the Quilcene area. Port Angeles has a substantial
make projections for the future status of the popu- population of timber-dependent workers, but the
lation under consideration. This attention to what greater economic diversity of that community is
will be as well as what is seems particularly expected to reduce the severity of the effects of
important when the community is in the process of dislocations, but county services dependent on
major changes. Such is the case in Jefferson and timber tax revenues may not fare so well.
Clallam Counties, and by extension, changes will
There are, as discussed previously, a number of
come for their low-income residents as well. A
consequences in these economic shifts for the lowmajor thrust of this needs assessment has been to income residents of the North Olympic Peninsula.
collect informationfromclients and
Loss of timber-dependent jobs will inservice providers which will concrease the competition for the jobs that
tribute to projections about the shape
remain. A cumulative effect throughout
and consequences of these changes
...the
bulk of
the job market, culminating in more
for the counties' poorest residents.
hardships for those most marginally
employment
employed, is likely. Some of these people
Two groups are singled out for
dislocation is
are already Community Action clients
particular attention here: dislocated
expected to
and will have expanded service needs;
workers and senior citizens needing
take place
others, who were previously able to
supportive services. Both represent
within the next
manage without assistance, are likely to
distinctive segments of the populayear or two.
now need Community Action's and
tion, both are likely to experience
other low-income services.
increases in service needs in the
The workers who will be losing timnext four years, and neither will be
ber-related jobs will probably present a broad
adequately served by the existing service strucrange of service needs. Some will take other jobs
ture.
here or elsewhere and need no services, others will
use employment-related services but not require
Population Indicators:
social or emergency services, and still others are
likely to require the full complement of available
Those parts of the North Olympic Peninsula
social and economic services.
economically dependent on the timber industry
have experienced restrictions for the past several
Clallam-Jefferson Community Action Council
years as a result of both market and environmental was granted a program in July of 1989 to provide
factors. Technological changes also have contrib- support and referral services to dislocated workers
uted to a reduction in the timber-related workforce. and other unemployed and under-employed perThe federal mandate to preserve habitat for the
sons. The Re-employment Support Center (RSC)
spotted owl has recently added dramatically to
service was intended to fill the needs of these
these other forces causing industry declines and is workers for information about support and other
expected to contribute to overall job losses in this services, to provide referral and help with access
area, estimated to be in excess of2,000jobs. Some to such services where available, and to give
of this employment dislocation has already oclimited direct assistance when other services were
curred; the bulk of it is expected to take place
not available. By the end of 1990, the program was
within the next year or two. Precise estimates of in contact with an average of eighty clients a
when and how many jobs will be lost are depen- month, a number that has continued to expand.
dent on court and governmental decisions not yet Most of these clients were served through the RSC
made. What is known, and what is already evident, office in Forks; others were assisted by a RSC staff
is that timber-dependent communities and their
person in Port Angeles.
residents are entering a period of economic stress
A total of four hundred twenty-five clients were
creative solution to health needs of low-income
families.
�Medical Care C r i s i s in Clallam County
by
Roger Lemstrom, Social Services Supervisor
Division of Social and Health Services
Port Angeles, Washington
November 6, 1991
Adequate health care for the low income c i t i z e n s in Clallam
County i s becoming harder to find as State resources for Medicare
become scarcer.
55 cents of every State assistance dollar
currently goes to providing medical services to people who
receive
Medical coupons and the reimbursement rates for those coupons does
not r e f l e c t the actual cost of services. Many physicians and
c l i n i c s often find themselves in a dilemma when a Medicare c l i e n t
walks into their waiting room and often find themselves needing
to choose between keeping their doors open for business or turning
a c l i e n t away.
The c l i e n t needing help often contacts several
physicians attempting to receive care and often winds up in an
emergency room of a hospital which has no choice but to accept
them. The hospital often absorbs the costs or b i l l s the State at
an extremely high cost to the taxpayers for something that should
have been handled by a family doctor.
Over 2200 people in Clallam County alone, receive some sort of
medical help from the State.
DSHS served over 650 pregnant women
alone in the l a s t 18 months.
Feelings over t h i s c r i s i s run high. Clients are angry about not
�being able t o locate medical care f o r themselves or t h e i r f a m i l i e s .
The medical community i s upset about the low rates of reimbursement
and the seemingly uncomprehensible g l u t of paperwork required f o r
reimbursement.
C l i e n t advocates are f r u s t r a t e d by the bureacracy
and perceived unresponsiveness of State social workers.
The State
l e g i s l a t u r e i s seen by a l l p a r t i e s as being unconcerned w i t h the
p l i g h t of the low income f a m i l i e s of the county.
The business
community f e e l s pinched by taxes t h a t seem t o disappear down a
black hole w i t h no a c c o u n t a b i l i t y f o r the spending.
Every community i n the United States i s f a c i n g the same
challenge i n the decreasing accessabi1ity i n health care.
Solutions t o these challenges work best when developed
locally.
The Port Angeles o f f i c e o f the D i v i s i o n of Social and Health
Services has asked the medical community and other s e r v i c e
providers t o meet t o form the Medical Care C r i s i s Task Force of
Clallam t o examine the problems and develop workable local
solutions.
The L e g i s l a t u r e , local government, and the c i t i z e n s of
Clallam County w i l l be working c o l l a b o r a t i v e l y i n a series of
working meetings over the next year t o create a f r i e n d l i e r
of health care.
system
�HEALTH CARE
REFORM
Except where noted (*) these provisions are based on the pending recomniendations of the
Washington State Health Care Commission (Redmond Commission).
Basic to this proposal is the concept that individuals, employers and the public sector must
accept more responsibility for controlling costs, promoting health andfinancinghealth care.
I.
COST CONTROL
An independent state agency, the Health Care Services Commission is created with
responsibilities and authorities over both the public and private health care systems.
A.
Governance
Five members; fulJ time; Chair the chief administrator of the agency and
serving at the pleasure of the governor.
B.
Powers
1.
Establish a core benefit plan, including individual cost sharing
standards.
2.
Determines a maximum premium for the core benefit plan.
3.
Develops standards to simplify billing, claims and utilization
management.
4.
Approves provider payment methods.
5.
Develops methods to control unnecessary technology and capital.
6.
Cenifies insurers or plans.
7.
Prioritizes new funds for community based public health and preventive
services.
8.
Sets policy for an improved and more closely integrated health
information system. •
9.
Promotes and oversees quality of care and provider accountability. *
�10.
11.
II.
Designated as the lead agency to seek waivers with the federal
governnaent for inclusion of federal programs in any cost containment
and access improvement efforts of the state. •
Recommend to the legislature improvements in the health care
system.*
INSURANCE REFORM
More equitable standards must be adopted for the health insurance industry,
especially as they apply to small business and their employees. Firms with fewer than
100 employees:
A.
B.
Community Rating would be required.
C.
Guaranteed issue and renewability for groups.
D.
III.
Pre-existing conditions would be eliminated.
Participating individuals or families would be guaranteed the right to
continuation if they terminate their employment.*
ACCESS
This proposal provides a schedule to achieve universal access. There will be a phasein period of four years.
A.
Individual Role: Every individual has a personal responsibility to maintain
their own health and to contribute to the cost of an affordable system based
on their ability to pay.
1.
2.
Other cost sharing as determined by the Commission.
3.
B.
Individuals responsible for a portion of the premium.
Incentives for healthy lifestyles developed by the Commission.
Employer Role: All employers must assume primary responsibility for a
healthy workplace andfinancingaffordable health care for their employees.
1.
Establish a mechanism so employers either direaly or indirectly finance
care for employees. *
2.
Provide assistance to smallfirmsthat are affected by this policy.
�C.
Public Role: State government will take responsibility for more of the
uninsured.
1.
Basic Health Plan: The BHP is expanded and re-located.*
a.
Allow small businesses the option to buy-in their employees at
no cost to the state.
b.
Increase subsidized enrollment in an orderly manner.
c.
Enroll employees of firms that opt to pay rather than provide
health insurance.
d.
Allow individual enrollees to continue their panicipation - at no
cost to the state - when gross family income exceeds 200 per
cent of poverty.
e.
Move the BHP into the Health Care Authority to achieve
administrative savings.
f.
Sunset is repealed and the program is expanded statewide.
Medicaid:
a.
Explore the possibility of decreasing cost shifting by increasing
the Medicaid payments more in line with Commission
determined premium levels.
b.
Give serious consideration, pending federal waivers, to the
de-linking of Medicaid from Welfare.* This should be done
only if:
possible expansion can be done less expensively than
providing Basic Health to the expanded population, and
if the change improves the health care system for the
poor and near poor.
�IV.
Tax: To accomplish these changes tax increases will be necessary. The proposal
requires tax mechanisms to accomplish the following goals.*
A.
Fund the activities of the Commission.
B.
Expand enrollment in the Basic Health Plan for low income unemployed and
part time employed people.
C.
Pay or play mechanism.
Office of the Governor
Olympia Washington 98504
(206) 753-6780
(FAX) (206) 753-1488
12 November 91
�Group Health Clinic
For Port Angeles Is
'Touch And Go'
By Martha Ireland
Group Health Corporation
(GHC) is studying the feasibility
of extending its medical care service to eastern Clallam and Jefferson Counties.
"From a financial point, it's
touch and go whether the present
Group Health population and
general population can support a
clinic," Dr. Phil Nudelman, president of GHC, told an eight-member delegation from the North
Olympic Peninsula during a meeting in Port Ludlow, March 20.
"We have an interest in the
Jefferson/Clallam area largely
because we have members and
enrollees who have asked us to,"
he said, "but we have an obligation to our other half-million
members to be solvent."
To assure that the proposed
clinic would not lose money,
"something else is going to have
to be added," he said, "maybe an
alliance with thestate—if thcstate
will be creative."
He offered to have two GHC
Continued on page 33.
Peninsula Business Journal
Group Health
Continued from page 1.
representatives sit down with two people
from the state to "see what kind of collaboration can take place and see if thatchanges
our perception."
"It's got to make, sense," Nudelman said.
"If it doesn't make sense financially, it
doesn't make sense for Group Health."
In areas it serves, GHC contracts with
the state Basic Health program and is one of
several medical care options for state
employees. Once they are members, state
employees can continue with Group Heallh
even if they transfer to posts outside the
GHC service area.
"I'm a Group Health member and I love
it,"said Man Jo Olson, Departmentof Social
and Heallh Services (DSHS) administrator
in Port Angeles. She is one of 60 state
employees in the area who are GHC
members and have petitioned to bring in
Group Health.
Doctors in "two of the three larger
communities" in the area are interested in
working for or with GHC to serve its
members, reponed Dr. Gary Feldbau, GHC
Chief of Staff. "A Group Health physician
presence may not be welcomed," he said.
"An opportunity does exist to deliver service through existing physicians, but that
might adversely affect your problem."
Crisis Or No
Roger Lemstrom, supervisor of the Port
Angeles DSHS office organized the NOP
delegation which urged GHC to help alleviate "a medical access crisis" by bringing
more primary care physicians to the area.
Group Health's eight representatives at
the meeting, and four people from the
Olympia DSHS office, were unsure that a
crisis exists. The peninsula's healthy physician-to-populaiion ratio led them to suggest that more doctors are not needed, but
rather that more of the doctors who are
already here should open their doors to
Medicaid patients.
"A significant number of our primary
care physicians are not seeing assistance
clients," admitted Dr. Thomas Locke, Clal-
April
lam County Heallh Officer. 'Their practices are near capacity so it's unlikely they
will.Weareapproaching capacity and need
to expand in some way," he concluded.
"A large percentage of our physicians
are specialists," added Clallam County
Commissioner Doroihy Duncan.
There is no problem with referrals to
specialists,Lemstrom indicated,but"Ican't
find a doctor who will see me," is a complaint his office hears twice daily, and
hospital emergency room (ER) costs are
rising as people use the ERs for basic care.
"At our office, we determine who's eligible for medical coupons," said Olson,
"butproviders are pulling lids on the number
of Medicaid people they will see." Neither
the Port Angeles DSHS office nor the
Olympia hotline know of any doctors in the
area who will take new Medicaid patients
at this time, she reported.
Economic Block
"It's primarily an economic block" that
causes doctors to refuse assistance patients,
Locke said, "people are looking at the
economic health of their practices."
Educating doctors not to think in terms
of "fee for service" could open their doors
to Medicaid clients, suggested Gaylan
Gaither of the DSHS agency which administers medical assistance. He oversees
a program under which doctors take assistance patients on a "capitation basis."
The program failed when tried earlier
in Clallam County because local physicians did not grasp the concept, he said.
Capitation means that a medical practice enrolls 100 or more Medicaid patients
and is paid a fiat amount—say S20—per
person per month wheiher they see a doctor
or not. Only a few of lhe 100 need care
during any given month, so the money
received for the whole group—$2,000 in
this example—profitably covers theircare.
If doctors lake too few enrollees—say
25—"it doesn't work," Gaither said, "one
bad case can wipe them out for the entire
year." The ideal is to have a group of physicians sign up for the plan, but the state
offers alternatives for individual doctors.
Those interested in the capitation plan can
contact Gaither at (206) 586-5339.
�Health care crisis symptom of more serious illness
BY JOHN A. BENNETT
on to the consumer. Organizations like
The crisis in medical care in this
Housekeeping, Consumer's Union
Reader commentary Goodthe medical specialty organizations
country is one of many symptoms of the
and
disease that has progressed in our society
could place an advisory warning, or "seal
during this century. At the same time that look forward, and imagine how a truly of approval" on new or established
we hear that the U.S. medical system free market medical care system could products.
provides the best care in the world, we exist with, and benefit from, the scientific
Individuals would discuss drugs with
wonder how long we can continue lo pay progress that has occurred in this century.
for it. Many individuals are unable to pay
As a Libertarian, I have been in- their physicians, pharmacists and even
for insurance, let alone the cost of serious fluenced by the writings of Murray Roth- with each other in order to make decisions
illness. The slates and federal gQyernment bard and ' Milton Priedman, both free- based on their personal needs and situaare also:-Jfj^i^'-the;(m^i^|j^phg tliwrv|j|ldec6n0ffii«»:
'j^^***®^- tionsi^ai^^ttha^^jiave the decision made
in Wa^hipglgp. f^ised on the "public
socialist programs increasingly difficult."
In ^ d e r tO'allow the free market, to good."' With the elimination of regulaWhat should be done about-all of this? function; we have to eliminate, the tions and restrictions, the Drug EnforceSuggestions have been made that we restraints that we have placed on it over ment Agency would not be necessary.
move to a nationalized health care sys- the years. This is radical stuff, but bear
tem- Other plans involve increasing con- with me. We need to eliminate the Food
The functions of the boards of phartrol over the professions by the govern- and Drug Administration, the Drug En- macy: and licensure and disciplinary
ment, requiring employers to provide in- forcement Agency, the Department of boards would be assumed by the professurance, government-controlled rationing, Health and Human Services, the Public sionals. Personal and group reputations
and — of course — increasing taxes to Health Service and its surgeon general, would be at stake, and the press and
pay for extra programs and bureaucracy. the Department of Health and boards of private watchdog organizations would
It has been concluded that the free market pharmacy, medical licensure and discipli- oversee the professions. Graduation from
has failed us, and that we need the nary boards in every state. I have already professional school and passing of apgovernment to save us and protect us in lost the hard-core socialists by now, so I propriate board exams would allow one to
will continue with the need to eliminate enter the profession of choice.
the future.
Medicare and Medicaid.
There would be a natural competition
I object! The government is the
problem, not the solution. The free market
These changes will not occur in a between professions, so that if one profeshas not been allowed to function since the vacuum, but would be part of a major sion was too restrictive or too lenient,
turn of the century. The older members of change in government in general to allow public opinion would apply pressure to
our society were but children when the individual choice, and empower the the individual practitioners of that profesgovernment began to interfere in the free government to protect us from violence, sion, and new professions would naturally
market, placing handcuffs on the "in- theft, fraud and breach of contract. It evolve to replace them. Midwives,
visible hands" described by Adam Smith. would not protect us from ourselves or naturopaths, chiropractors, D.O.s, M.D.s,
It is difficult for us to visualize what our our bad decisions, so we would look to nurses, Christian Scientists and any other
system would be like in the absence of the free market as individuals for that group would naturally want lo protect
their collective reputations by policing
government intervention in medical care. protection if we wanted it.
each other. We don't need the governThe free market didn't fail; it was
Private organizations would replace ment to do it.
crushed.
these departments, agencies, boards and
If we try to think back to the way that it programs, and individual choice would
Drugs would be available in a pharwas with the free market, medical care replace the rules and regulations. The macy or any retail outlet. If a person was
system, we have to look to the 1890s and FDA would no longer prevent the intro- ill and needed a drug, then a physician
• 1900s, an era that preceded present medi- duction of new drugs, and the cost would be consulted for a diagnosis and
cal technology. Rather, I will attempt to savings of development would be passed recommended treatment, including
1
recommended follow-up. The person
would then take that advice and obtain the
recommended drugs, without prescription
or restriction. If the lady next door was
knowledgeable, one could choose to ask
for her advice or help.
Medical insurance would continue to
be available and, without governmental
restrictions, would be less expensive. The
individual would tend to use insurance
with a deductible,' and so would'search•
out cost effective'medical "care. Private
watchdog organizationswould observe
and certify insurance companies, as they
do now. The courts and government
would become involved only in the case
of fraud or breach of contract.
Over the years, people have paid in to
Medicare and Social Security, and the
government has to fulfill the implied contract that it has with all of us. The system
is bankrupt, and can continue to function
only with continued taxation. The federal
government does have significant assets,
however, which could be sold to allow the
establishment of personal annuities
through private insurance to fulfill the social promises made to us, without placing
the burden of overwhelming taxation
upon our children and their children.
Obviously the free market has not
failed to provide medical care — it has
not been allowed to do so. Either we insist
that the government get out of our lives
now, or it will continue to m;ike our
decisions for us, stifle our progress, and
cause/us to be even more dependent on it
than we are now. It's frightening, but we
must retake control of our own lives.
:
• John A. Bennett - ix ci Sequim
physician and member uf the Washinglun
State Board of Osteopathic Medicine nnd
Surgery in Olympia.
�PENINSULA WOMEN'S CLINIC
923 Georgiana Street
Port Angeles, WA 98362-3911
457-8840 1-800-628-1296
Practice Limited to
Gynecology and Obstetrics
Robert H. Palmer, Jr., M.D.
Charles T. Haley, M.D.
Carole S. Kalahar, A.R.N.P.
t - " 1 . ;
November 15,
:
1991
Roger W. Lemstrom, M.P.A.
Social Services Supervisor
DSHS-PA
1016 E. F i r s t S t r e e t B5-1
P o r t A n g e l e s , WA
98362-4099
Dear Mr. Lemstrom:
I r e c e i v e d your l e t t e r d a t e d 10-28-91 d e s c r i b i n g a m e e t i n g on
November 21 f r o m 9 a.m. t o noon a t t h e DSHS o f f i c e r e g a r d i n g a c c e s s
t o c a r e . I am q u i t e i n t e r e s t e d i n t h i s i s s u e and w o u l d l i k e t o be
p a r t o f the
s o l u t i o n , h o w e v e r , I p e r f o r m s u r g e r y on Tuesday and
T h u r s d a y m o r n i n g s and have o f f i c e h o u r s t h e r e s t o f t h e week
between 9 and 5.
Evening
meetings
are c e r t a i n l y easierf o r
physicians
t o attend although
committee
meetings
and o t h e r
community r e s p o n s i b i l i t i e s can make even t h o s e d i f f i c u l t .
I know
t h a t you c a n n o t s c h e d u l e your m e e t i n g a r o u n d me and I w i l l be
u n a b l e t o a t t e n d t h i s m e e t i n g , h o w e v e r , I c o u l d p e r h a p s a t t e n d an
e v e n i n g s e s s i o n were one a v a i l a b l e .
As s p e c i a l i s t s , we t y p i c a l l y see p a t i e n t s on r e f e r r a l f r o m o t h e r
physicians.
These p a t i e n t s a r e g e n e r a l l y seen by p r i m a r y c a r e
p h y s i c i a n s who a t t e m p t e d t o work up t h e i r b a s i c p r o b l e m and when
t h e y r e a c h an i m p a s s e , r e f e r t o u s . Our C l i n i c has n e v e r ceased
t o t a k e any GYN p a t i e n t on r e f e r r a l r e g a r d l e s s o f i n s u r a n c e s t a t u s .
We d i d t a k e an 18 month h i a t u s ( J a n u a r y 1 , 1990 - June 3 0 , 1 9 9 1 )
i n n o t a c c e p t i n g O b s t e t r i c a l p a t i e n t s who were i n s u r e d w i t h DSHS
f o r p e r s o n a l and economic r e a s o n s w h i c h have now been r e s o l v e d .
B e g i n n i n g J u l y 1 , 1 9 9 1 , we began a c c e p t i n g o b s t e t r i c a l p a t i e n t s
c o v e r e d by DSHS on p h y s i c i a n r e f e r r a l .
Because o f a number o f
f a c t o r s , many p a t i e n t s a r e u n a b l e t o g e t a r e f e r r a l b u t s t i l l want
t o have c a r e by a b o a r d - c e r t i f i e d s p e c i a l i s t i n OB-GYN. F o r t h i s
p u r p o s e and a g a i n w i t h i n o u r g o a l s o f p r o v i d i n g s p e c i a l t y c a r e , we
a r e now a c c e p t i n g o b s t e t r i c a l p a t i e n t s w i t h DSHS c o v e r a g e w i t h o u t
referral.
We do r e q u i r e t h e s e p a t i e n t s , as we r e q u i r e a l l o f o u r
o b s t e t r i c a l p a t i e n t s , t o have a p r i m a r y c a r e p h y s i c i a n by t h e end
of t h e p r e g n a n c y so t h a t f o l l o w i n g t h e i r s i x week p o s t
partum
c h e c k , t h e y c a n be r e t u r n e d t o a p r i m a r y c a r e p r o v i d e r . We s i m p l y
do n o t p r o v i d e p r i m a r y c a r e and c a n n o t a t t e n d t o t h e b a s i c m e d i c a l
needs o f a p a t i e n t , i . e . c o l d s , f l u s , e t c . Each p a t i e n t w i l l need
t o u n d e r s t a n d t h a t l i m i t a t i o n and t h a t we a r e n o t t h e i r r e g u l a r
d o c t o r b u t a r e s i m p l y t a k i n g c a r e o f one c o n d i t i o n w i t h i n o u r
specialty training.
�Page 2
November 15,
1991
I would be pleased t o d i s c u s s t h i s w i t h you p e r s o n a l l y or i n a
meeting, and as I s a i d , am i n t e r e s t e d i n working on community
s o l u t i o n s t o t h i s problem.
Again, I am s o r r y t h a t I w i l l not be a b l e t o a t t e n d the scheduled
meeting but l o o k f o r w a r d to being of help i n o t h e r ways.
Sincerely,
2r&-
Robert H. Palmer, J r . , M.D.,
RHP/co
F.A.C.O.G.
�mmmm
January) ;8j ,1992-,;,...
- ".< v.'_/ '•• '"' *•
•
' •'
:
POR
ANGELES
CLINIC
433 EAST 8TH STREET
PORT ANGELES
WASHINGTON 98362
TELEPHONE
(206) 452-3373
FAMILY PRACTICE
Quentin Kinlner, M.D.
John L. Siemens, M.D.
E.A. Hoplner, Sr., M.D.
Richard J. Van Calcar, M.D.
Roger M. Oakes, M.D.
William R. Kintner, M.D.
Peter J. Erickson, M.D.
Mark S. Redlin, M.D.
DERMATOLOGY
Michael W. Piepkorn, M.D.
SURGERY
Robert M Allman. M.D.
INTERNAL MEDICINE
Robert S. Crist. M.D.
Mark D. Fischer. M.D
Arthur L. Tbrdmi. M.D.
RADIOLOGY CONSULTANTS
E. Rand Apgood, M.D.
Benjamin Pisciotta. M.D.
D. Bork, M.D.
Eric Schreiber, M.D.
ADMINISTRATOR
Leonard J. Borchers
Roger W. Lemstrom
Social Services Supervisor
Dept. of Social & Health Services
1016 East 1st St, B5-1
Port Angeles, WA 98362-4020
Dear Roger:
I appreciate the opportunity to attend the meeting yesterday, January
7, 1992, regarding healthcare access issues for DSHS clients. Although
we are aware that there continue to be access problems for certain types
of patients, it appears that pregnant women and children are well-covered
at the present time. I would like to offer a few additional comments
regarding a number of items which were discussed.
We believe the fundamental problem in this community is one of maldistribution of case loads. The current access problems are exacerbated
by the Port Angeles Clinic's decision to begin limiting new DSHS clients.
We believe that the high percentage of DSHS clients that we presently
serve, puts us at a competitive disadvantage in the marketplace. We
believe that longterm, lasting solutions must address this fact. We are
encouarged by DSHS willingness to provide data to the local community,
which will indicate the exact nature and extent of the problem. It may
be helpful to encourage a greater participation by other community
physicians. I think that the idea of a referral system which could be
established to allocate new DSHS clients to various providers throughout
the community in an equitable fashion might also be workable. Any such
system, of course, would depend upon the level of commitment made by
individual physicians to accept new patients.
I personally am encouraged by DSHS willingness to investigate and
implement managed care systems. It is possible that the Port Angeles
Clinic would be willing to enter into significant discussions concerning
such an approach for our existing DSHS patients. We would have very
limited interest in any approach which would link our success or failure
to the participation or actions of any other providers in the community.
In other words, if DSHS would be willing to enter into a relationship
for some of its clients and not require that the entire community population enter into the program, there is ample room for some very
productive discussions to occur.
The idea which was presented suggesting a medical case manager to assist
the client and providers also has merit. As I know you are aware, many
clients have multiple needs and a case management approach can be very
effective in coordinating and achieving proper utilization of resources.
We will be very willing to consider a pilot project in this area.
�Finally, as I have stated previously, we continue to remain opposed to the idea
of a specialized low income clinic within the community. As a last resort, it may
prove necessary. However, a universal access and delivery system which is truly
"seamless" should not and cannot differentiate service delivery on the basis of
economic status.
One additional way in which the State and DSHS could effectively encourage
greater participation by physicians, would be to create incentives within their own
healthcare benefits package which encourages State employees to utilize providers
who are making a significant effort to meet the needs of DSHS clients. Some
type of a preferred provider network comprised of physicians meeting or exceeding
local market standards for DSHS participation levels would provide a direct and
significant benefit to providers. I suspect that there may be legal and/or administrative problems which would undoubtedly make such a system difficult to
implement, but is a rather simple and straightforward concept which may merit
consideration, given the State's rather bleak financial forecast.
Again, thank you for your efforts to provide leadership in this troublesome area.
I am encouraged by the range of possibilities which have been presented. The Port
Angeles Clinic remains willing to work with you concerning potential solutions.
.en Borchers
Administrator
cc:
Jeff Graham, M.D.
Roger M. Oakes, M.D.
Ed A. Hopfner, M.D.
LB/la
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r Social anJ Heaiv»
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financial f S
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$6.50 an hour.
$6 50
a
c
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Lcmsuom. social
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.,
b e n c
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n
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^
years, after,. lhe
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^rt\i
"Onder Fire,.- a j
book ^"tten °yHl
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North
T h
rivahnfr \
f
a
i
* £ North
e 446-oaRC booK.
�pouring of the ashes.
. .....^ t ui t c u
nuii being nearly too "tec-hee,"
as the naive tccn giggling through
her first love. But functioning as
pure symbol, she pulled it off,
teetering between sappy and sympathetic. Finally, it was a happy
ending when she waxed serious to
deliver a poignant "They Were
You." So we forgave everything;
believed, at last, that she was real.
The flat-out show stealers were
Dave Bendell as the Old Actor
with his fractured Shakespeare,
his tattered bombast and sagging
underwear, and newcomer Jeff
Howard as The Man Who Dies,
and never does. Jeff had the audience howling, doubled over at
his delight and contortions —
winks, leers, sniffs, wiggles, knee
jerks and collapses. Flipping cotton Indian braids as the first
caricature, and raising a crooked
eyebrow and sneering lip under a
flopping pirate hat, he maintained
an evil pact with the audience as
they cheered him on.
Crucial to maintaining the
spell of fantasy, Justin Barrett
was a flawless mime as The Mute,
with impassive chalk-white face. .
With sensitive hands and highly
trained body language, he created
;very scene -'change" — the
kVall, the Rain, the Fire, the
jeasons.
The good.neighbors on either
ide of the wall were Bill Anabel
s the stocky and sarcastic fatherf-the-boy, and Lew Barlolomew, confused and handringing keeper-of-the-girl. The .
>ntrast between the two worked,
cir dance routines clipped and
rfected, their voices sure and
;y. Shawn Dawson was tender
young Matt — his voice, like
rson's, not showcased until the
: two duos: "Round and
und" and "They Were You."
tut the red badge of profeslal courage and performance,
my money, goes to the two
icians (that's all, folks) who
d the theater with enough fine
id for a full orchestra. Sitting
t
Continued from A l
doctors that accept Medicaid. They
said there were no openings from
Port Townsend to Clallam Bay.
Situations like that occur every
day, Lemstrom said, as his social
workers find it harder and harder to
convince a doctor to take a patient.
Often, they are sent all over Western
Washington to find a doctor, and
the state buys the gas, he said.
More often, patients go to the
Olympic Memorial and Jefferson
General hospital emergency rooms,
which costs the state twice what an
office visit would cost.
Medicaid paid Olympic Memorial
$21,000 for emergency room doctors in the first half of this year,
hospitalfinanceofficer Chuck Karst
said. That paid 20 percent of the
emergency room doctors' bills, he
said, and did not include the equal
amount of hospital overhead, which
is footed by the hospital district
taxpayers.
If the.state,Legislature,paid doctors more for Medicaid, the state
would .save money on emergency
rooms and sending, people around
the state to find doctor^,'.many
physicians and officials say.
However, some officials say a few
doctors are partly to blame. •
" I believe there is bias .against
poor people," said Dr. Tom Locke,
Clallam County public health officer. "There are physicians who
would rather not take care of poor
people."
Some doctors think that if they
accept Medicaid they will Ijave
drunk, dirty patients who disrupt
the waiting room.
"We don't agree with that point
of view," said Dr. Roger Oakes of
the Port Angeles Clinic, which
Lemstrom and Locke said carries
the bulk of the welfare patients in
Clallam County. "By and large that
group of patients is not any more
difficult than any other," Oakes,
said.
While he agreed that it would help
if some doctors on the Peninsula,
especially obstetricians, would open
their doors to Medicaid patients,
Oakes said the state must pay doc-
tors more. • .
>
.. ••:
The clinic stopped taking new
Medicaid patients because of the
money, he said. " I t has gotten to
the point where it is affecting our
business."
The 40 cents on the dollar does
not even cover a doctor's operating
costs, Oakes said, adding if a doctor
accepted all welfare patients, he
would be out of business.
The head of the Washington State
Medical Association agreed.
"The problem with Medicaid is
the under payment," said Dr. Jim
Kildoff, a urologist in Bremerton
and association president.
While the association's credo is to
not turn anyone away because of
how they pay, doctors have financial obligations as well, and can be
altruistic only to a point.
"You do have an obligation to
your own family, your children," he
said.
The final solution, he and others
said, is a revamping of the state
health care system, with universal
health insurance for everyone.
However, he said, that will be a long
time coming.
"This noise'is like standing n
to a jet plane," said Barbara Off
mann. "And we're more than oi
half mile away."'
• i ...
Others complained about a den:
white cloud that was released wh<
the plant was .running. There w.
even speculation that thc-'cloi
caused leaves to turn brown. Whi
said the claim was unfounded.
Other gripes included fuel odo,
and frustration that there wasn
more publicity about the company'
plans, Benson Road residents said.
Fields Shotwell manager Miki
Davidson acknowledged tht
neighborhood's concerns.
"They're well-founded, and
they're taken care of," Davidson
said. "Anybody that asks us questions has been fairly impressed with
our answers."
The burn plant is designed to
clean fuel-tainted soil by pouring it
into a large, rotating oven capable
of being heated to temperatures as
high as 750 degrees, Davidson said.
Such high temperatures cause the
hydrocarbon molecules in gasoline
IIKHK'S TIIE.STOHK
WIIEHt VOUH *. BUY MOHK
0°°'
Continued from A l
The project was kept so secret
that North and Novak registered at
hotels under assumed names and
was referred to by publisher HarperCollins only as "Mr. Smith Goes to
Washington."
As he has throughout his
testimony to Congress and in court,
the former Marine officer insisted
he had full authority for the sale of
U.S. weapons to Iran and the diversion of the profits to the Contra
rebels in Nicaragua.
Reagan conceded he approved the
sale of weapons to Iran in the hope
of winning freedom for Americans
held by pro-Iranian radicals in
Lebanon. But he has denied knowing of the diversion to the Contras,
which violated a congressional ban
on U.S. aid to the rebels.
" I have no doubt that he was told
about the use of the residuals for the
Contras and that he approved it.
Enthusiastically," North wrote.
North concedes, however, that he
never spoke to Reagan about the
diversion and that it was possible the
president's top aides, sought to
shield him and the office of the
presidency from the scandal, i
North.said one Reagan confidant
who was clearly in on the diversion
was William Casey, the CIA director who died of cancer in 1987.
North said Casey tutored him in the
secrets of codes and off-shore bank
;
accounts when he sought Casey's
help to arrange private contributions for the Contras from wealthy
A m e r i c a n s and f o r e i g n
governments.
. There was no answer Saturday at
the office of Reagan's spokesman.
Despite efforts to keep the U.S.
involvement in the Contra resupply
network a secret, at some point well
over 100 people in various government agencies knew about it, North
said.
"Offering me up as a political
scapegoat was part , of the plan —
although Casey believed there would
be others," North wrote.
" North was convicted in 1988 of
destroying documents, accepting an
illegal gratuity and aiding the
obstruction of Congress.
1
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114 East Front • 457-7484
�HEALTH CAKE TASK FORCE SORTING SHEET
CODEfti
TYPE OF MATERIAL:
General mail
^Letterhead
Letter Campaign
Casework
.Personal stories
.Offers to help
^Employment
.Policy
.Advocacy
_Re quests:
-speech
-meeting
Other
Explanation:
ADVISORY PANEL?
physician
large employers
small business
y*^other health provider
seniors
other consumers
Explanation:
PRIMARY INTEREST:
COST ISSUES
Drug Prices
Physician Fees
Hospital Fees
Unnecessary Procedures
Medical Equipment
Fraud and Abuse
COVERAGE
Working Families
Unemployed/Low Income
Benefits
Providers
PUBgiC
HEALTH/SPECIAL POPULATIONS
Prevention
AIDS
Women s Health
TmiriiiTiiyjttinTia
Rural
Urban
GOVERNMENT PROGRAMS
.Medicare
Medicaid
Veterans
DoD
ORGANIZATION
Insurance Premiums
Insurance Reform
X Insurance Pools
1 Boards and Oversight
INFRASTRUCTURE/WORKFORCE
Quality Assurance (Guidelines)
Administration, Reimbursement
& Patient Information Systems
Malpractice & Tort Reform
Manpower Issues (Training)
LONG-TERM CARE
MENTAL HEALTH
FINANCING
OTHER
Explanation:.
PLANT PRBFBHENCB: (Support = +; Oppose = - )
CP
SP
OP
Clinton Plan
Single Payer
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits, Vouchers,
Medical Savings Accts.
CA
BR
GE
Canadian
British
German
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [3]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-037-002-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/67bb7dbb0258d80cb98855646a50b86f.pdf
b711aae0fec8af83c469c2cb6c148c90
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1985
OA/ID Number:
FolderlD:
Folder Title:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [2]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
4
1
�State of
Vermont
AGENCY OF HUMAN SERVICES
DEPARTMENT OF HEALTH
DIVISION FOR CHILDREN WITH
SPECIAL HEALTH NEEDS
P.O. Box 70
Burlington, Vermont 05402
Telephone: (802) 863-7338
1-800-660-4427
H i l l a r y Clinton
Task Force on National
Care Refonn
The White House
Washington, DC 20510
January 29,
Health
1993
Dear H i l l a r y ,
Congratulations on your appointment to head up the e f f o r t to
refonn health care in the United States. I place my f u l l e s t
t r u s t i n your a b i l i t y and determination to see t h i s c r u c i a l
project through.
While my i n t e r e s t i n health care reform encompasses a l l age
groups, my deepest concern r e s t s with children with special
health needs and t h e i r f a m i l i e s .
Compared to other constituencies, children with d i s a b i l i t i e s and
chronic i l l n e s s are a small voice, indeed. Lacking the lobbying
power of, say, older Americans, children and t h e i r families often
find themselves l e f t off the agenda when issues of long term
care, insurance coverage, or health care policy are being d i s cussed.
1
Your background with the Childrens Defense Fund and your work on
educational refonn in Arkansas assure me that children w i l l not
be overlooked in your new endeavor. That said, though, I would
be negligent i f I did not write you today.
Over the past three years I have served on a number of task
groups at the state and regional level to address the f u l l gamut
of health care for children with special needs. Access to care
and funding of care have been the central i s s u e s . I am sending
you copies of the product of two regional projects and a small
handful of other pertinent items.
The two booklets. Ensuring Access and Paying the B i l l s , came out
of a task group sponsored by New England Serve. This task group,
comprised of parents, health care providers, s t a t e - l e v e l policy
makers and representatives of the insurance industry, attempted
to evaluate present health care financing r e a l i t i e s , assess true
need, and develop c r i t e r i a against which proposed reform might be
measured.
�We are honored that Ensuring Access has been recognized by congressional and other designers of health care a l t e r n a t i v e s . I am
proud to share i t with you. Paving the B i l l s was created by the
parents on the task group and resulted, i n large part, from t h e i r
sharing of frustrations and successes over lunch and during
breaks in the proceedings of the larger group. I am doubly proud
to share t h i s document with you. I t has become a best s e l l e r , i f
that term may be applied to an item we gladly give away to f a milies and advocates.
Please, i f i t would help you in any way, c a l l upon me or any of
the eminently qualified (and far more eloquent) individuals
l i s t e d in either booklet. Any of us, I am sure, could marshal
testimony, documentation, and case history to help you and your
group put the needs of children and t h e i r families into i t s
proper context within the larger tapestry of universal
care...universal coverage.
Thank you for the opportunity to share these thoughts with you
and my very best wishes and prayers to you as you begin your
work.
Yours very t r u l y ,
Stephen Brooks
Administrator, Division for
Children with Special Health Needs
(CSHN)
Enclosures
�5
or
Children with Special Health Needs
o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o
Special Help for Special Kids
We recognize that parents are experts
about their child, and CSHN staff are
committed to answering parents' questions, listening to their recommendations and including them at every stage
of treatment.
Children with complex health conditions
and their families may need assistance
in getting the medical care needed to
allow them to reach their full potential.
The Vermont Department of Health has
long recognized this need. Since 1914,
Vermont has offered medical, social and
financial support to families with a child
who has special health needs.
Clinics and Services
Children with Special Health Needs
(CSHN) has previously been known as
Handicapped Children's Services.
Children receive specialty medical care
either within a clinic setting or through
consultation. Many CSHN clinics and
support services are located in towns
and cities around the state, bringing
care as close to home as possible.
Eligibility
CSHN Services include:
To qualify for services, an individual
must be a Vermont resident, have a
medically eligible condition (see list on
reverse), and be under 21 years of age.
• specialty clinics • medical and
developmental diagnosis and treatment
• referrals and assistance in obtaining
services from other medical, educational and community agencies • care
coordination • referral to parent-toparent support • assistance in finding
financial resources to help pay for care
• limited financial assistance for:
specialized medical care, equipment
and supplies, medications and tests,
respite care, lodging and transportation,
inpatient and outpatient care
The CSHN Team
To ensure coordinated care, CSHN
brings together the parents, local health
care providers and Health Department
specialists to work as a team. This team
develops and carries out a plan of care
for each child.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
n
j
Pot* more,
inforrr\aY\oi>\,
af to apply
fat" services—
contact
tke C S f I A ) Specialist
a t the V e r m o n t D e p a r t m e n t of - H e a l t k o f f i c e n e a r e s t y o u (listed o n r e v e r s e ) o r u s e
tke toll-free n ^ e r — i-800-660-4427 (TDD equipped).
Y.
.
j v, j
' •'A
•7
\y
, ,,
�Contact the Vermont Dept.
of Health office with a
CHSN Specialist nearest
you, or call toll-free—
1-800-660-4427.
In addition to local health care providers,
other CSHN specialists may include:
•
•
•
•
•
•
•
•
pediatric physician specialists
nurses
medical social workers
psychologists
physical therapists
nutritionists
orthotists
other consultants
BARRE
255 North Main St.
Barre, VT 05641
479-4200
RUTLAND
9 Merchants Row
Rutland, VT 05701
773-5852
Services are provided for children
with chronic conditions such as:
• orthopedic • complex hearing loss
• cystic fibrosis • spina bifida
• epilepsy/ other neurological conditions
• heart conditions • PKU/ other metabolic
disorders • cleft palate/ craniofacial
needs • muscular dystrophy • juvenile
rheumatoid arthritis • hemophilia
• genetic disorders • cerebral palsy
• congenital disorders
BRATTLEBORO
232 Main St.
Brattleboro, VT 05301
257-2884
BURLINGTON
PO Box 70
Burlington, VT 05402
863-7338 (TDD equipped)
• The Child Development Clinic serves
children up to age 8 who may have
developmental delays.
CHILD DEVELOPMENT
CLINIC
56 Colchester Ave.
Burlington, VT 05401
863-7315 or toll-free
1-800-640-4232
Please contact us if you have a question
about coverage of any unusual medical
conditions not listed.
yNpril 1 9 9 2
�.
i
OCT 1992 • CENTER FOR CHILDREN WITH CHRONIC ILLNESS AND DISABILITY • VOL. 1 NO. 1
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High Cost Children:
The Unknown Liability
1
INSIDE
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Few employers can identify how much their employees'
children cost to insure—until a catastrophic case arises.
By Margaret McManus, Paul Newacheck, Rebecca Kelly and Marie Macklin
Outside of occasional
references to children with
special needs, high-risk
infants, technology-dependent children, or adolescents
with mental health and
substance abuse problems,
most employers design their
cost management programs
without paying particular
attention to the unique
nature of children.
An employer can't predict
how many children will be
enrolled as dependents and
what their health may be.
Nevertheless, one child bom
with a serious birth defect
can cause enormous increases
RESEARCHERS
in insurance premiums and
threaten the coverage of the
whole group.
Consider, for example, the
situation experienced two
years ago by Sid Spencer,
Director of Employee Benefits at Cadmus Communications Corp. in Richmond,
Virginia. Cadmus had
acquired the 65-employee
Garamond/Pridemark Press
in Baltimore, Maryland, and
Spencer was seeking health
care benefits for the printing
plant. It had been insured
under an indemnity plan
through a trade association,
Printing Industries of Maryland. Spencer says the
premiums were high and
subject to increases every six
months. Workers' contributions were also rising. "We
were looking at potential 10%
to 15% increases twice a year
and wanted a managed care
option," says Spencer.
Deal Falls Through
Spencer thought he had
found an ideal solution at an
HMO, but the deal fell
through when the HMO
refused to cover the teenage
son of one pressman. The
teen, who lived at home,
required a respirator and
daily nursing care. "But his
doctor said he would hospitalize the teen if he was not
treated by RNs," Spencer
says.
Spencer called a meeting
of his employees and told
them the situation: Cadmus
wanted to reduce its health
care expenditures and the
premiums its employees
were paying, but the designated HMO plan refused to
cover the teen. " I just laid it
out and-told them the situaAccording to the Health
tion, and everyone in the
Insurance Association of
plant—everyone—supported
America, New York, 61.5% of
our decision." The HMO
children under age 16 were
subsequently retracted its
covered by private health
offer to cover the group.
insurance plans through
An alternative solution
employers in 1989. Most are
was ultimately worked out
healthy. However, 5% of
by the Coordinating Center
privately insured children
for Home and Community
were reported by their
Care, a case management
families to have a chronic
firm in Millersville, Marydisease or impairment that
land, which was already
limited their usual activities,
handling the case under the
according to Paul
previous benefit plan. A new
Newacheck, Associate
plan was offered by the
Professor of Health Policy at
Printing Industries of Marythe Institute of Health Policy
land: Cadmus switched to an
Studies at the University of
HMO offered through The
.California, San Francisco.
Johns Hopkins Medical
National data collected in
Institutions in Baltimore:
the early 1980's indicate that
The teen's case, however,
total medical charges for
was carved out of this HMO
children under age 21 with
and case managed through
chronic disabling conditions
Maryland's Coordinating
were nearly three times
Center for Home and Comhigher than those for children
munity Care, which handles
without such cqriditions. In
the care of many high-cost
1989 dollars, this averages
children covered by the
$1,514 per disabled child and
state's program for children
$513 for each nondisabled
with special health care
child, according to
needs. The results were
Newacheck. Most chronically
reduced medical costs to
ill children accumulate
Cadmus and its employees
without changing the care the comparatively modest bills,
primarily for ambulatory
teen had been receiving.
�C3ID
services, but a small segment
of the chronically ill population—principally those who
have been hospitalized—
accrue high charges.
Last year, Margaret
McManus, President of
McManus Health Policy, Inc.,
MANAGING EDITOR
in Washington, and
Peggy Mann Rinehart
Newacheck, with the support
of the National Institute of
PRODUCTION/
Disability and Rehabilitation
EDITORIAL ASSISTANT
Research of the U.S. DepartLinda Pratt
ment of Education, and the
Maternal and Child Health
•
•
•
Bureau of the U.S. Department of Health and Human
STAFF:
Services, interviewed 50
Center for Children with
employers with 500 or more
Chronic Illness and Disability
employees to determine how
Robert Wm. Blum, M.D., Ph.D.,
they identify high-cost
Director; Joan Patterson, Ph.D.,
children, manage costs, and
Director of Research; Peter
evaluate cost management
Blasco, M.D., Director of
Education; Harriet Kohen,
strategies after they're
M.A., Center Coordinator; Pat
implemented. They found
Faulkner, Field Coordinator;
that few companies design
Peggy Mann Rinehart, Director
separate strategies for
of Communications; Nancy
children. Failure to recognize
Okinow, M.S.W., Parent
the unknown liability,
Liaison; Karen Stutelberg,
Administrator; Clara Wolman,
however, can lead to disasPh.D., Research Coordinator;
trous insurance conseSandra Kothe, Center Secretary.
quences, especially for small
employers.
Daniel Gresek, who owns
•
•
•
and operates a restaurant in
North Reading, MassachuChildrm't Health Brief* is
setts, is one example. He
published periodically and is made
insured his family and
possible through Grant
H133B900J2 from the National employees—a group of nine
Institute on Disability and
people—through an indemRehabilitation Research. The nity plan. The monthly
opinions expressed do not
charges for the insurance
necessarily reflect the views of the
were about $198 per family
Center, the University of
and $98 per individual.
Minnesota, or their funding
Gresek picked up most of the
cost, although employees
paid a small percentage.
Postmaster Send address
changes to Harriet Kohen,
When his son, Daniel, Jr., was
Box 721,420 Delaware St. SE,
bom five years ago with a
Minneapolis, MN 55455.
rare heart defect, an insurance nightmare began. In his
•
first three months, Daniel, Jr.
raryup $150,000 in medical
Children's Health Briefs
bills and another $150,000 in
Box 721
the next two years.
420 Delaware St. S
E
Minneapolis, MN 55455
Coverage Lost
(612) 626-1032 V
(612) 624-3939 TDD
According to Daniel Jr.'s
mother, Cheryl Gresek, the
insurer first raised the
restaurant's premiums to
$766 per month per family
and $300 per month for
single employees. Then,
premiums rose to $1375 per
month per family and $500
ChUdren*
ftealth briefr
per month for single employees. "That's when we became
uninsured," Gresek says.
Although the Greseks
have found another insurer,
the solution left the underlying problems unresolved.
Another company now
insures the group but Daniel,
Jr. is not covered by it.
44
The Greseks
had to sign a
waiver that
their son's
medical
expenses
would be
excluded from
their insurer's
plan.
Alden's coverage costs $298
per month per family and
$125 per month for single
employees. Single employees
contribute $12 per month to
the plan. Cheryl Gresek, now
an advocate for the Common
Health Support Network in
Boston, notes, however, that
if another high-cost situation
hits any member of the
group, the same spiraling
premium syndrome could
recur with the insurer forcing
the group off its books.
As for Daniel, Jr., the
Greseks were required to
sign a waiver that his medical
expenses would be excluded
from the plan. Daniel, Jr.,
now five years old, will
require at least two more
surgeries in the next several
years costing about $150,000
each. He is enrolled in
Massachusetts' Common
Health Program—a state
program covering
uninsurable individuals. Fees
are based on the parents'
income and availability of
partial insurance, among
other factors. The Greseks
pay $68 a month.
Identifying
High-Cost Cases
The first step in managing
high-cost illness is identification. Depending on the size
of the firm, employers use
one or more of the following
approaches:
•
Employ medical
underwriting practices to
evaluate an applicant's
expected health risks;
•
Set dollar limits per
claim or per year to isolate
the cases that use most of the
plan expenditures;
•
Employ diagnostic
screens to detect specific
conditions or disabilities
associated with higher costs;
or
•
Monitor utilization to
identify repeat or extended
hospitalizations or the use of
multiple providers.
In the McManus/
Newacheck survey, only one
firm completely excluded
coverage for preexisting
conditions. However, 40% of
the respondents imposed
waiting periods between
three months to 12 months.
During this waiting period,
another 18% of the companies reported that coverage
for a preexisting condition
was limited to a certain dollar
amount—for example,
$2,000. Altogether, 60% of
respondents used some form
of underwriting to reduce
their financial risk.
In addition, annual dollar
thresholds, ranging from
$20,000 to $200,000, were
used by one out of five
survey respondents to flag
high-cost cases. Some 56%
used dollar amounts per
episode of care. These ranged
from $2,500 to $100,000 per
episode with an average of
$30,357 per episode and a
median of $20,000. Some 12%
of employers said they
screened claims on both an
episodic and annual basis. In
all, 64% of survey participants used annual or epi- •
sodic dollar thresholds.
�•f
Diagnostic Screens
Some 70% of respondents
identified high-cost cases by
flagging cases historically
associated with costly claims.
Conditions frequently
flagged for intervention
include high-risk pregnancies, premature births, AIDS,
multiple injuries, cancer,
psychiatric and substance
abuse diagnoses, bums, and
transplants.
The survey authors asked
directly whether any of five
childhood chronic conditions—hemophilia, cystic
fibrosis, juvenile diabetes,
asthma, and chronic otitis
media (ear infections)—were
used to identify high-cost
cases. In most instances, it
appeared unlikely that a
child with any of these
conditions would be identified solely on the basis of
these diagnoses.
However, detailed
information on specific
diagnoses used was difficult
to obtain because many
companies considered their
strategies proprietary and
others were unfamiliar with
the details of how these
diagnoses were screened.
Utilization reviews are
also used to signal potential
high-cost cases. Half of the
survey respondents monitored the type or amount of
services used—especially
mental health and substance
abuse services (80% of
respondents), hospital
intensive care units (60%),
and rehabilitation services
(40%).
Some 44% of survey
respondents mentioned other
methods for identifying highcost cases. Employees would
come forward when they
reached their out-of-pocket
limits, for example. Or the
company could easily
identify when an employee
had reached his or her limit.
Employers also reported
learning of high-cost cases by
reviewing the use of sick and
personal leave or via the
company grapevine. Several
employers commented.
More than two-thirds of
the survey participants,
however, said they had
encountered barriers to
implementing case management programs. The most
common included resistance
from patients and providers
(47%), scarcity of cost effective alternatives (12%), and
lack of information about
alternatives (8%).
Although case management programs often incorporate some benefits restructuring, redesign of benefits is
however, that although these generally used only when it
provides a less costly alternainformal methods are costtive to hospitalization. The
effective in identifying highsurvey revealed that almost
cost illness among employ75% of employers paid for
ees, they don't ferret out
potentially high-cost children. benefits not otherwise
available under their plans
Employers are experion a case-by-case basis.
menting with many apAlmost half of these
proaches to manage high-cost
cases. Some of these methods respondents that said they
would alter their benefit
include prior authorization
programs also said, however,
and utilization review; case
that these benefits would be
management; benefit redeprovided only instead of
sign options; employee
existing benefits. For inassistance, preventive care,
stance, companies would opt
health education, and selfto pay for parents to be
care training programs;
trained to care for their
preferred provider arrangechildren at home or for
ments; and benefit restricmodifications to be made to
tions.
the home, as well as extenAll but five employer/
sion of long-term rehabilitarespondents required prior
tion services, in place of
authorization before certain
hospitalization.
services would be reimbursed. Ninety-one percent of
the employers required prior
Restricting Benefits
authorization for hospitalizaBenefits restrictions are
tion, 33% for surgery, 13% for another strategy for controlmental health and substance
ling high costs. Use of this
abuse services, and 14% for
approach has fluctuated over
home care.
the past several years,
suggesting that employers
The survey showed that
86% of respondents used case are struggling to identify the
managers to ensure appropri- appropriate mix of benefits
ate and efficient medical care. restrictions to encourage the
most cost-effective alternaCas6 managers typically
become involved once a high- tives. Almost half of the
survey respondents have
cost case has been identified
recently introduced new
or when a specific condition
benefits restrictions. Most
was diagnosed. More than
often, they've cut back on
half of the respondents used
mental health and substance
registered nurses as case
managers. Another 16% used abuse coverage while increasing employee cost sharing.
a team of registered nurses,
physicians, or social workers. Other benefits restrictions
A few employers replied that included reducing benefits
for chiropractic services and
physicians handle a 1 their
eliminating well-baby care.
case management functions.
Employers are
experimenting
with many
approaches to
manage highcost cases.
44
More than one-third of
the employers responding to
the survey offered guidance
about alternative insurance
options to families that were
likely to exceed their benefit
maximums. Employers that
didn't offer this benefit cited
their lack of knowledge about
other options and expressed
skepticism that anyone
would ever come close to
exceeding his or her maximum. One-fourth of responding companies had unlimited
benefits.
The survey also revealed
that only one out of 10
companies had accessed
programs in their states for
children with special needs,
the state Medicaid agency, or
voluntary associations
serving special needs children. Generally, employers
had not established linkages
with organizations serving
chronically ill children, but
rather relied on the insurers
or case managers to do this.
"This is a step that needs to
be taken—some formalized
or semiformalized arrangement between employers and
state programs for children
with special needs," says
Peter van Dyck, M.D.,
director of Utah's Family
Health Services Program, Salt
Lake City.
Utah has worked out
innovative contracts with
several HMOs in what van
Dyck refers to as a "preventive referral" program. The
HMOs are encouraged to
refer special needs cases to
the state which may, in turn,
refer patients to specialized
medical institutions. In some
cases, the state agency may
be able to put together a
more efficient, higher quality
medical package by combining Medicaid funds—for as
much as 33% of the total
cost—with HMO coverage.
However, van Dyck notes his
agency does not work
directly with employers.
"None have come to us," he
laments.
�1...
CENTER FOR CHILDREN WITH CHRONIC ILLNESS AND DISABILITY
What preventive programs do
employers offer?
(Percentage of employers offering programs.)
Source: McManus M, Kelly, R, Newacheck P. Private Sector Efforts
to Manage High Cost Care Among Children with Chronic Illness and
Disability: Survey Results. Fall 1991.
Judson Force, M.D.,
director of Maryland's
Children's Medical Services,
agrees. "Linking up with
employers is a great idea
although we haven't done it,"
he says. Maryland's Title V
program funds more than 20
specialty clinics for children
with sickle cell anemia,
hemophilia, and other
diseases using hospitals such
as Johns Hopkins and the
University of Maryland.
Maryland's program primarily serves families whose
incomes are below 200% of
the poverty level. For families
with higher incomes, sliding
fee scales are available.
An Example
From Indiana
Indiana, however, does
not allow a waiver of parental income for those not
eligible for Medicaid. (Such a
waiver would not take the
parents' income into consideration in determining
Medicaid eligibility; therefore, the child would become
Medicaid eligible.) This
forced Jeff Larison, vice
president of Hoosier Spline
Broach, a cutting-tool firm in
Kokomo, Indiana, to seek
help directly from the federal
government five years ago
when an employee's son was
bom without a lung or
diaphragm. Larison says the
child had $750,000 in medical
bills in his first 18 months.
At the time, Hoosier
Spline Broach's policy was a
100% employer-paid indemnity plan that covered 32
fami ies—approximately 128
people. It cost the employer
$7,000 to $8,000 per month.
After the birth of the child,
Larison claims the insurer
began raising its premiums
every six months: first 20%,
then 35%. The company
could no longer afford
coverage.
"It was a madhouse
around here," Larison says.
"We were scared to death
that we would all end up
uninsured." As a stopgap
measure, Larison called the
employees together, explained the situation, and
offered them two options: to
continue the same coverage
which was now costing
$16,000 per month, but with
employees contributing to
the plan, or to switch to a less
comprehensive policy which
cost $12,000 a month, with
the employer paying 100%.
The employees voted for the
less comprehensive coverage.
The company then
received a cancellation letter
from its insurance company.
It was also notified that the
insurer wanted a 50% increase to renew the less
comprehensive policy. That
threatened to put the company out of business. "We
didn't know what to do. No
one would insure us. We
didn't know whether to pay
individuals to go and find
their own insurance or to
drop our employee or his
child," Larison says.
Meanwhile, the employee
and his employer began
petitioning U.S. Sen. Dan R.
Coats (R.-Ind.) and Congressman James Jontz (D.-Ind.) for
a federal Medicaid waiver of
parental income. Even the
Office of Vice President Dan
Quayle got involved. At the
11th hour, three days before
the company's insurance
policy was finally slated to
cancel, the federal waiver
was approved and written
into a piece of legislation; it
was the second waiver ever
granted in the country.
Measuring
Effectiveness
Only about half of the
survey's respondents have
formally evaluated the costs
and effectiveness of their
interventions. Among this
group, most relied on data
provided by their case
management or utilization
review vendors. Measurement was limited to comparing current and prior years'
experience in paid claims
with and without the intervention. Some companies
also conducted consumer
satisfaction surveys to assess
the effects of a given program
but few were satisfied with
their measurement of effectiveness or outcomes, especially for chronically ill
children.
Most of the respondents
evaluated cost savings by
comparing actual outlays
with projected costs if there
had been no intervention.
Some limited cost comparisons to inpatient hospital
versus outpatient care while
others compared their overall
cost trends with national
averages.
44
Generally, employers had not
established linkages with organizations
serving chronically ill children, but
rather relied on the insurers or case
managers to do this.
�CENTER FOR CHILDREN WITH CHRONIC ILLNESS AND DISABILITY
44
Partnerships between parents
and employers can be enhanced by
subcontracting with a Title V agency
that has expertise caring for special
needs children.
Several employers said
that making appropriate cost
comparisons is problematic
because it's difficult to
estimate what costs would
have been without intervention. Moreover, increased
out-of-pocket expenses or
other burdens on families are
seldom taken into account in
evaluating cost-savings.
As the chart "Are Management Interventions
Successful?" shows, despite
widespread efforts to manage
high-cost care, many employers are frustrated and concerned about the success of
cost-management interventions. More than 40% of the
employers said that no
intervention strategy had
succeeded in controlling
costs and no single intervention was deemed an overwhelming success. Rather,
there was a general sense that
hospital utilization review.
Are management
interventions
successful?
(Percentage of employers reporting success.)
Source: McManus M, Kelly, R, Newacheck P. Private Sector Efforts
to Manage High Cost Care Among Children with Chronic Illness a n d
Disability: Survey Results. Fall 1991.
mental health and substance
abuse management programs, and case management
had succeeded to some extent
in managing costs.
Working With Parents
More attention should be
paid to programs that expand
preventive care benefits, case
management programs,
employee assistance programs^ self-care training, and
preferred provider arrangements that enable families to
maintain their role as the
central caregivers, the survey
authors conclude.
Unfortunately for many
families and employers, a
partnership has not developed because of a shared
reluctance. In some instances,
parents perceive cost management efforts as an attempt
to drop their child or the
family from coverage.
Partnerships between
employers and parents might
be enhanced by assuring the
most appropriate provider
arrangement, say the survey
authors. In some instances,
this may entail (as the
Cadmus case shows) hiring a
case management firm or
subcontracting with a Title V
agency whose expertise is in
caring for children with
special needs. They could, for
example, be hired for case
management services or as
partial or full care providers.
FOR MORE INFO
^Please send;
^ i ^ e s t a n d ' $ i p . M j t o . -' .>.;•
EditoreWMreSSs'l;j.'-v. •;. s • ••
^Health B r ^ e S l D ^ v V v ;
^iBox:721^|)^Vyare;^<i:
St. SE, M ^ S p 6 1 i s ,
' M N 55455." t / f
�PflQE ?-A/EWS RPM THE NEMOtji
NATIONAL PERSPECTIVE ON HEALTH CARE REFORM
Sarah S. Brown, MPH, Study Director, National Forum on the Future of
Children and Families ofthe National Academy of Sciences
"My worst fantasy is that a
comprehensive health care reform bill will be passed which
does accomplish some changes,
but which does not address some
of the major concerns of families
and children. Simply giving
someone access to health insurance is not enough. It is not
enough because the benefits of a
basic insurance plan may not be
sufficient; there may not be
people to provide the needed
services; and the issues of administrative complexity and the bureaucratic morass
may not be addressed."
Five critical issues that should be addressed in
any bill:
1. Universal Access: Every bill claims to provide
this until you read the fine print. Does it include
illegal immigrants? Does it prohibit waiting periods? Does it cover adolescents who no longer live
at home?
2. Benefits: What services are covered? Many ofthe
current bills omit coverage for family planning
services, well-child care, care coordination, mental health services, dental care, social work services. Long term care has been eliminated from all
of the current bills. Is there a minimum standard
of benefits that must be provided?
3. Resource Development:
Does a bill directly address
whether there are services and
people available to care for all
these newly insured persons?
Does the bill address issues of
professional training, particularly
mid-level practitioners such as
pediatric nurses, and certified
nurse midwives? Does the bill
address provider maldistribution,
or encourage school-based clinics, birthing centers and home. based health services? A related
issue to provider availability is the medical liability problem. Does the bill offer comprehensive
resolution of liability issues?
4. M a n a g e d Care: Everyone is pinning his/her
hopes on managed care to contain costs despite
the fact that there are no conclusive data to confirm this. Managed care can, in fact, create barriers between people and needed care and is often
ill-suited for high-risk populations.
5. A d m i n i s t r a t i v e C o m p l e x i t y : Does the bill
simplify enrollment, claims and grievance procedures? Are we still going to have multiple programs that have different claim forms and a system that is so complicated we have to hire case
managers to explain it to people?
A£ S
|W
NEWOZK
For health policy makers, parents and providers serving
children with special health care needs in New England
New England SERVE: A Planning Network for Children with Special Health Care Needs
WE WANT TO STAY IN TOUCH...
This is our second edition of News From the Network. New England SERVE is continuing to build and support
a network of parents of children with special health needs and the advocates, providers and public agency professionals who serve them. This newsletter is not an ongoing publication — it is published on an "as needed" basis
to share information and resources across the six New England states, and to let you know about recent and upcoming New England SERVE activities. The focus of this edition of News From the Network is on health care financing. Inside, you will find news on "Ensuring Access: A New England Symposium on Health Care Financing
for Children with Special Needs," a regional meeting held on May 1, 1992, at the John F. Kennedy Library in
Boston. We also have two new publications in the health care financing area to share with you. Remember... there
are many ways to get involved in your state on behalf of children with special health care needs. For more information about New England SERVE activities, state contact persons are listed with each state report.
PLEASE READ ON FOR INFORMATION ABOUT...
Payine the Bills
Ensuring
Access
NEW ENGLAND
SERVE
Fall 1992
Paying the Bills: Tips f o r Families on Financing H e a l t h Care f o r Children w i t h
Special Needs: This is a recent New England SERVE publication written by and for parents of children with special health needs. What strategies do families use to get payment
for their children's health care? See page 2.
Executive Summary of Ensuring Access: What are the 14 criteria proposed by New
England SERVE forjudging health care reform proposals? A new Executive Summary of
our Fall 1991 publication, E n s u r i n g Access, is now available for distribution. This
shorter version is more accessible and easier to duplicate and share. See page 2.
101 TREMONT STREET, SUITE 812
BOSTON, MASSACHUSETTS 02108
(617) 574-9493 FAX (617) 574-9608
Susan Epstein, Co-Director
Ann Taylor, Co-Director
Alexa Halberg, Projecr Manager
Nora Wells, Family Collaboration Consultant
Co-Principal Investigators:
Allen Crocker
Developmental Evaluation Center
Children's Hospital
Jane Gardner
Department of Maternal & Child Health
Harvard School of Public Health
Deborah Klein Walker
Bureau of Family & Community Health
Massachusetts Department of Public Health
Reports f r o m each o f the New England states on recent New England SERVE activities
and announcements of upcoming events. See page 3.
May 1st Symposium: We heard some excellent speakers on May 1st. While it is never
possible to reproduce the excitement of a really good speech, we do want to share some of
the tips and current information on health care financing reform that were presented at the
symposium. See page 6.
The preparation of this newsletter was made possible through a grant from the Maternal and Child Health Bureau, Health Resources and
Services Administration, Department of Health and Human Services. This grant #MCJ-255043, through Title V of the Social Security Act,
has supported New England SERVE as a Special Project of Regional and National Significance (SPRANS).
�Pf\qe 2-A/EWS RDM THE NEMOtK
NEW PUBLICATIONS
Paying the Bills
HELPING FAMILIES NEGOTIATE THE
HEALTH CARE FINANCING MAZE
Paying the Bills: Tips for Families on
Health Care Financing for Children with Special Needs
A new booklet published by New England SERVE
was developed by.parents who have children with
special needs. The parent authors have tapped their own
experiences, as well as those of other families and professionals, in order to share information and strategies
for getting payment for children's health care. The
purpose of Paying the Bills is to assist families as they
work their way through the maze
that is our current health care f i nancing system.
The initial ideas and the energy
for developing this booklet came
from the parent members of the
New England SERVE Regional Task
Force on Health Care Financing.
The task force had conducted a
year-long study on health care financing, which resulted in the
publication of Ensuring
Access:
Family-Centered
Health
Care
Financing
Systems for Chil-
Ensuring
Access
d r e n w i t h Special H e a l t h Needs. (See below for
information on new Executive Summary.) The parent
members of the task force felt that while E n s u r i n g
Access is of great interest to families as they advocate
for change in the financing system, it does not address
their immediate needs in negotiating the existing system. Paying the Bills provides specific suggestions for
working with private insurance, accessing public programs, appealing
decisions and connecting with other
families.
New England SERVE will be
working in all six states this year to
get Paying the Bills out to families and professionals and to provide
training to families on health care
financing issues. Paying the Bills
is available at no cost from your
state health departments. To obtain
a copy, call your state contact person
(listed with state reports).
ENSURING ACCESS: EXECUTIVE
SUMMARY NOW AVAILABLE
As we all know, a
significant policy debate
has begun on how to reform health care financing so that rising costs can be
contained and health care coverage provided to all
Americans. Children with special health care needs
are a vulnerable group in this debate.
E n s u r i n g Access is a 27-page booklet that
provides a set of criteria for judging health care reform proposals as well as for critiquing existing financing systems on behalf of children with special
health needs. The criteria are organized into five
major areas: Access, Benefits, Quality, Family Participation, and Cost Containment, and reflect a com-
mitment to family-centered care.
E n s u r i n g Access has been very well received
and has been disseminated widely both nationally and
within the New England region. In order to keep up
with the demand and to stay within our printing
budget, New England SERVE has developed a shorter
version of the booklet. E n s u r i n g Access: Executive S u m m a r y is both easier to share and more
accessible in terms of readability. Copies of Ensuring
Access: Executive S u m m a r y and further information on how you can get involved in health care
reform activities within your own state can be obtained from your state contact persons or the New
England SERVE office.
THE POWER OF STATE-LEVEL REFORM
Susan T. Sherry, Director of State Health Issues, Families USA Foundation
tion, age or gender. It is important to keep track of
these proposals in your state.
"The main message I have for people is that there
are at least four fronts you are going to have to fight
on at once if you are going to be successful in reforming the health care system in this country. These
fronts include coalition building, i n s u r a n c e
reform, cost containment, and long-term
care."
3. Cost Containment: Advocacy groups must address how reforms can be financed. Any successful
reform strategy has to include strategies for containing costs. There are good and bad ways to
contain costs. Bad ways to contain costs put the
burden on the patient. These include restricting
1. Coalition Building: It is critical that families join
benefits, either by bare bones coverage or through
existing networks in their states. The constituency
managed care. This is not real cost containment, it
of parents of children with special health needs is
is cost shifting. It does save costs for the insurance
an important element in building any consumerindustry, but it does not save costs for those who
based coalition for health care refonn. There is a
continue to need the care. Advocacy groups should
new found appreciation on the part of the general
have a position on how resources are spent now public of how "at risk" any of us could be in the
what the system currently pays for and what cost
current health care system.
containment strategies are acceptable.
2. Insurance R e f o r m : The battle to reform cur- 4. Long Term Care: It is still unclear how long term
care will fit into health care reform. Some state
rent insurance laws is being fought most effectively
coalitions have decided, for strategic and political
at the state level. The kinds of reforms that are
reasons, not to tackle long term care. This may be
being considered include: guaranteed renewabila separate battle, but it is one that is important to
ity, continuity of coverage from public programs
this population of children. Do not forget about
and from one private program to another, and no
long term care issues.
allowed rate difference for health status, occupa-
derstand that there are costs involved in building
a coalition. All will need to contribute.
BUILDING A COALITION from page 6
health care reform for children with special health
needs, broaden that concern to health care for all
people. By broadening the issue, more people are
brought in to work on the campaign.
4.
Have a Simple Message. Be able to explain
your issue in three sentences. The message must
have a positive aspect. You have to have an affirmative agenda and not just oppose rotten ideas.
5.
The Messenger is I m p o r t a n t . The people who
speak for your cause and for your organization
have to be people with backgrounds, histories, and
names that people trust.
6.
7.
8.
9.
Have Fun! People are tired of being beaten over
the head and coming to endless meetings. Do some
things from time to time that allow people to have
fun together.
10. Create a Sense o f Belonging. Why is it that
60,000 people will go to a football game when you
cannot get 60 to a critical rally at the state house?
It is because they feel comfortable at the football
game. Build your coalition in a way that people
feel that "this is a place for me to belong."
In closing, even when you do everything right, follow all the rules and work like dogs, it is still incredibly
Have Victories A l o n g the Way. Small, tan- hard. It is the ideals that you have and the concerns you
gible victories are important. If you only have long have for children that keep you going.
term goals, people will get discouraged. These
small victories can be anything — a letter to the
STAYTI/JVED
editor campaign, a successful conference.
New England SERVE will be offering a one-day
Treat Everything as a Campaign. It is crititraining in the Spring of 1993 on E n h a n c i n g
cal that something be done all the time in order to
Quality: Stardards a n d Indicators o f Quality
keep up the momentum. Do not just plan big
Care f o r Children w i t h Special H e a l t h Care
events with months of lag time in between.
Needs. Call your state contact person for further
Coalitions Cost Money. It is important for the
information.
organizations that belong to your coalition to un-
�PflQE k-Nm RPM we Nmjm
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NEW HAMPSHIRE
RHODE ISLAND
• Department of Health - Lead Agency for P.L. 99-457
• Division of Family Health Expands Collaboration with
Parents
• "Putting Family Back Into Family Health" June 30, 1992
to the Surgeon General's "Healthy Children Ready to
Learn" conference in Washington, D.C. On June 30,
1992, we held a day-long conference entitled, "Putting
Family Back Into Family Health" in Warwick, Rhode
Island. This program presented a range of topics exploring parent-professional relationships and included
The Rhode Island Department of Health became the a parent panel on nutritional needs of disabled children,
lead agency for the Individuals with Disabilities Edu- an overview of parent networks and support groups, a
cation Act (P.L. 99-457), as well as the agency respon- primer on early intervention/family inclusion, specialsible for administering early intervention services in ized foster families and other options for home care, and
1992. These changes have brought increasing collabo- families' SSI rights.
ration with parents, including new funds with which to
Planned activities for the year beginning October
engage parents as consultants to programs for children 1992 include quality assurance activities for specialty
with special health care needs. Four parent consultants clinical services and extensive use of the New England
have been working on the state level and program level SERVE booklet, Paying the B i l l s . Another familywith early intervention staff to make Individual Family oriented statewide conference, with New England
Service Plans more "family-friendly." These consultants SERVE support, will be slated for the Spring of 1993.
also facilitate staff/family workshops, and are assisting
in the development of Parent Advisory Committees and Contact persons:
preparation of a central directory of children's services.
Richard Bolig, Health Program Administrator
Work is underway on a standard policy and procedure
Division of Family Health
for parent consultation, necessitated by the plan to inRhode Island Department of Health
volve parents in each of the Division of Family Health's
(401) 277-2312
major program units: Special Needs, Maternal and Child
Dawn Wardyga, Parent
Health, and WIC.
(401) 245-5241
In February 1992, the Department sent five parents
NEW HAMPSHIRE
• Third Parent-Professional Conference Held
April 1992
• Parent Policy Guide Expected Spring 1993
• Recommended Priorities Identified
The New Hampshire Bureau of Special Medical
Services held its third Parent-Professional Conference in
April 1992. This conference, entided "Working Together
on Behalf of Children with Special Health Care Needs,"
brought together thirty-eight parents of children with
special health care needs, eight primary and specialty
care physicians, seventeen allied health specialty care
providers and nineteen Division of Public Health Services staff. This conference provided information about
changes in the health care service system nationwide
designed to meet the needs of children with special
health care needs and their families. It also created a
forum for parent and professionals to discuss how to
achieve coordinated community based care for children
and to identify ways to promote improved collaboration
among parents and providers. Another outcome of the
conference was the review and critique of a proposed
Parent Policy Guide for Bureau services. This Guide will
be available in the Spring of 1993.
Recommendations for the Bureau that emerged
from the conference included the following priorities:
1. Care C o o r d i n a t i o n : There is a need to increase
access to service coordinators, develop better community links and pay local physicians for care management.
2. H e a l t h Care Plans: Develop long-range health
care plans for children in conjunction with families
and pediatricians.
3. Flexibility in the Service Delivery System:
There should be more choices in the system and
more flexibility in clinic times and days (Saturdays,
evenings).
4. Family Support Services: Increase family support services such as parent-to-parent, respite, and
opportunities for involving fathers.
5. F i n a n c i a l Assistance: Families need more information on available resources and increased
flexibility in allowable expenditures.
6. P a r e n t Resource B o o k : Publicize Bureau services more effectively by developing a parent resource book.
7. Promote Parent-Professional Collaboration:
Provide training and other opportunities to promote
parent-professional collaboration.
Continued on page 5
from page 7
Feedback from both parents and professional participants was overwhelmingly positive. Parents appreciated learning about additional resources and networking and meeting with other parents. The medical
and other providers also valued hearing about Bureau
programs as well as learning about parents' perceptions
about the services they receive. Both service providers
and parents recommended that the Bureau continue to
sponsor events such as this conference.
Contact persons:
Jane Hybsch, Chief
Bureau of Special Medical Services
NH Division of Public Health Services
(603) 271-4596
Martha-Jean Madison, Parent
w: (603) 271-4525, h: (603) 942-5540
VERMONT
• Advisory Council Continues to be Significant Partner
• Partners in Care Conference - December 4, 1992
• Implementation of Part-H
The Children with Special Health Needs (CSHN)
Advisory Council, has worked hand-in-hand with state
staff to address the many issues that confront us. Together, we have worked on CSHN reimbursement
policies, a new cost-sharing plan, a program for f i nancing prescription medications, the issue of confidentiality in the age of automation, and countless other
issues. The Advisory Council grew out of the enthusiasm
generated by the New England SERVE regional conference in Newport, Rhode Island, in 1988, and has
been nurtured with invaluable assistance, both technical
and financial, from New England SERVE.
CSHN will co-sponsor, with Parent to Parent of
Vermont and the Vermont Chapter of the American
Academy of Pediatrics, the fourth annual "Partners in
Care Conference," to be held on Friday, December 4,
1992, in Burlington, Vermont. New England SERVE
funds will be used to subsidize family registrations. This
year's conference will include a workshop on Paying
the Bills, which will be based on the recent booklet
developed by parents on the New England SERVE Regional Task Force on Health Care Financing.
CSHN and Parent to Parent of Vermont continue to
work together in the design and implementation of
birth-to-three/early intervention programs in the state.
The Agency of Human Services, of which the Department of Health is a part, is co-lead agency with the
Department of Education for Part H of P.L. 99-457.
Parent to Parent of Vermont will be involved in training
parents who will be hired to serve on the 12 core teams
that cover the state.
Contact persons:
Stephen Brooks, Administrator
Division for ChUdren with Special Health Needs
Vermont Department of Health
(802) 863-7338
Maureen Mitchell, Parent
(802) 823-5256
CONNECTICUT
•
•
Connecticut SERVE Group Continues
Collaboration with The Family Center, Newington
Children's Hospital
• Public Awareness Campaign
Connecticut SERVE is an interagency, parent/professional network that has continued to meet on a
bi-monthly basis since 1987. As a result of activities and
interests generated at regional New England SERVE
meetings, state-level plans are formulated by this group.
Co-chaired by Nancy Orsi and Tony Mascia, Connecticut
SERVE is the vehicle for supporting New England
SERVE objectives and improving systems of care in
Connecticut.
Plans for the coming year include the following two
priority areas:
1. Statewide distribution of the booklet, Paying the
B i l l s . In conjunction with The Family Center at
Newington Children's Hospital, technical assistance
workshops will be planned in Connecticut to assist
parents and others in utilizing this resource.
2. Statewide Task Force on Marketing Campaign. A new
task force is planned to address the feasibility and
implementation of a public awareness campaign in
Connecticut to heighten awareness of the gifts,
rights, needs and plight of children with special
health care needs. Such a campaign would provide
the backbone for future advocacy and education.
Contact persons:
Tony Mascia, Nurse Consultant
Child and Adolescent Health Division
Connecticut Department of Health Services
(203) 566-3767
Nancy Orsi, Parent
(203) 747-8841
�PftQE 6-/VEWS ftpM THE NEMOZK
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FINANCING FOR CHILDREN WITH
SPECIAL NEEDS
On May 1,1992, 130 people joined together to hear
new ideas on how to build coalitions to effect health
care reform and improve access for children
with special health care needs. The day
began with a powerful panel of three parents describing "Today's Realities" for their
children and their families. These parents
reminded us of the real issues they have to
deal with on a daily basis in accessing care
for their children. Their stories of an unresponsive and
confusing health care financing system set the tone for
the day and provided a reality base for the discussions
that followed.
MEMORABLE QUOTES
Cheryl Gresek: Mother of a five year old boy born with
a heart defect requiring extensive surgery and hospitalization.
"What amazes me is that I hear so much about getting uninsured people insured. We were insured and
willing and able to pay a reasonable amount for insurance, yet we were forced off our plan (by increased
premiums) and left uninsured. Our only fault was
having had a sick child."
Edith Lagomarsini: Mother of a six year old son with a
severe hearing impairment. (Speaking through a
translator, Jose Centeno, Connecticut Office
of Protection and Advocacy.)
"By the time I was able to get services for my
son, our family situation had been so effected
that I ended up going into a shelter. I'm sure
that one of the reasons I was not able to get
services was the language barrier. I feel that
hospitals should be more aware and have personnel
within the hospital that are bilingual to assist parents
like myself."
Mary Zupkas: Mother of a ten year old son who contracted Eastern Equine Encephalitis at eight months old,
who has multiple disabilities: visual impairment,
hearing problems, seizures, quadripariasis, lung problems.
"/ think that it is totally unfair that you need to be an
Ivy League-educated bully in order to make it through
this system."
Symposium participants then had the chance to
hear three keynote speakers whose remarks are summarized below.
BUILDING A COALITION FOR HEALTH CARE REFORM
James Braude, Executive Director, T.E.A.M. (Tax Equity Alliance for Massachusetts)
Ten rules for coalition building:
1. Start w i t h E n v i r o n m e n t a l W o r k . It is critical to create an
atmosphere in which there can be a debate. This debate should be
on the merits and must be as participatory as possible. Talk honestly, stick to the facts and trust people to make the right decisions.
2. Recognize the I m p o r t a n c e o f Coalitions. A broad group of
organizations that have common goals working together send a
powerful message. If you are talking to a labor forum, have a
health advocate talk about the impact of your issue on public
employees and have a labor leader talk about the impact on
children.
3. Build a B r o a d Coalition. In developing a coalition around
Continued on page 7
STATE REPORTS
MAINE
an eye opener at "professional" gatherings.
Coordinated Care Services is joining a consortium
through the University of New England, College of Osteopathic Medicine called the Literacy and Health
Maine's Coordinated Care Services Program (CCS) Promotion Project. Through this affiliation, new eduin the Bureau of Health is pleased to welcome Susan cational and information brochures will be developed
Wiley as Family Care Coordinator. The creation of this and present publications will be revised. The aim is to
position has been in the works for almost two years! It make all handouts readable and understandable for the
will be Susan's job to promote family-centered care. general public. Families should not have to learn a
Susan says, "My goal is to help families, health care whole new language to get necessary information on
providers, CCS and other government agencies to work available services.
together as a Team to ensure that a workable, realistic
Finally, sometimes CCS cannot provide funding to
plan of care is developed and implemented for each a family for their child's health care needs. Whenever we
child." As the parent of a child with multiple handicaps, cannot provide the service, we always enclose a copy of
Susan is well acquainted with the problems that are Paying the Bills and the parent coordinator's busiencountered daily by families dealing with special care ness card with the denial letter. If CCS cannot directly
needs. Susan will also be our State Contact for New help the family, we want to help find an agency that
England SERVE activities.
can.
The Access Guide for Statewide Services for Maine's
Children with Special Health Care Needs and Their Contact persons:
Susan M. Wiley, Family Care Coordinator
Families, mentioned in last year's newsletter, is nearing
Coordinated Care Services for CSHN
completion. Once the Access Guide is finalized, the
Maine Department of Human Services
Parent Advisory Committee plans to put together a short
(207) 287-5139
theatrical production or "skit" as a tool to illustrate the
Margaret Squires, Parent
need for family-centered care and to show how families
(207) 582-2504
feel in the maze of health care services. This production
could be used both at family-targeted conventions or as
• Family Care Coordinator Realized
• Access Guide in Final Stages/Parent Training
• Literacy and Health Promotion Project
MASSACHUSETTS
• Division for Children with Special Health
Care Needs Expands
• Parent Networking Conference: September 19, 1992
The Division for Children with Special Health Care
Needs of the Massachusetts Department of Public
Health expanded in 1992 to encompass the state's Early
Intervention Program, a statewide, system of Growth
and Nutrition Clinics to serve families of children experiencing failure to thrive, and a new pediatric AIDS
demonstration project called MassCARE: Massachusetts
Community AIDS Resource Enhancement. This expansion brings with it challenges and opportunities for
1993.
Our second annual Parent Networking Conference
was held on September 19, 1992. Planned by a committee of parents and professionals, the conference
featured a presentation by five parents who have developed a proposal for a statewide family-to-family
support network.
We are continuing to expand parent involvement in
planning and policy-making for services for children
with special health care needs. The Division currently
employs a parent consultant who works in the DPH
Western Regional Office and a parent who works with
the MassCARE project. Parents play an active role in the
Interagency Coordinating Council of the Early Intervention Program. The MassCARE News, a newsletter
written and edited by parents of children with HIV
infection, is currently circulated to over 700 families
through clinics, hospitals and agencies serving families
living with HIV. Copies of the newsletter are available
in English, Spanish and Haitian Creole from the Division.
Contact persons:
Deborah Allen, Director
Division for CSHCN
Massachusetts Depanment of Public Health
(617) 727-6941
Linea Pearson, Parent
(508) 835-2051
�EXECUTIVE SUMMARY
Ensuring Access:
Family-Centered Health Care
Financing Systems for Children
with Special Health Needs
Jt>*
New England SERVE
101 Tremont Street, Suite 812
Boston, MA 02108
November 1992
�New England SERVE
EXECUTIVE SUMMARY
Ensuring Access: Family^Centered Health
Care Financing Systems for Children with
Special Health Needs
Proposals for reforming the financing and delivery of health care in the United States are being discussed in
many forums at the national as well as the state level. A significant policy debate has begun on how to reform
health care financing so that rising costs can be contained and health care coverage provided to all Americans.
Children with special health needs are a vulnerable group in this debate. Characterized by health needs
that are broader (more comprehensive) and deeper (longer in duration) than the population as a whole, these
children require health care financing that can cover a wide range of benefits and services. In order to assess
both the adequacy of existing health financing systems as well as new proposals for reform to meet the needs of
this population, New England SERVE has developed a set of criteria which is described in a publication entitled, Ensuring Access: Family-Centered Health Care Financing Systems for Children with Special
Health Needs.
The 14 criteria included in Ensuring Access reflect what is needed in a family-centered, comprehensive
health care financing system in order to implement care for this population of children. The criteria are organized into 5 main headings: Access, Benefits, Quality, Family Participation, and Cost Containment. In the
complete version of Ensuring Access, each criterion is briefly defined and then followed by a list of indicators,
in question format, to facilitate the application of the criteria to a specific proposal or program. The indicators
are presented on two levels, "Individual Child and Family Indicators" and "System-level Indicators." The
"Individual Child and Family Indicators" include measures that relate to how individuals experience the health
care financing system, while the "System-level Indicators" address how the health financing system supports the
availability and delivery of appropriate services to all children and families.
This Executive Summary of Ensuring Access includes a brief definition of each of the 14 criteria. For
further information regarding Ensuring Access, contact New England SERVE, 101 Tremont Street, Suite 812,
Boston, Massachusetts, 02108.
ACCESS
1. Universal Coverage
Universal coverage guarantees that every family has access to affordable adequate health care, including both
primary and specialty care as needed.
Access to health care should be maintained regardless of changes in child's age, health status, family
income, employment status, geographic location, prior utilization of services or changes in health insurance.
Universal coverage will eliminate current barriers to care such as: discrimination in service delivery, preexisting condition exclusions, waiting periods for coverage or financial hardships. Implementation of universal
access will require public mandates and policies to assure that all children have access to public or private
insurance.
�New England SERVE
2. Provider and Service Availability
Children with special health needs require timely and affordable access to appropriate specialists, providers and
services.
The health care financing system should create incentives and provisions for supporting services in medically underserved areas. Families of children with special health needs are especially vulnerable when they live
in geographically isolated communities or urban areas that are medically underserved. System-level policies that
can assure the availability of needed services include: incentives for licensed providers to accept public reimbursement as well as all other third party payments, and mechanisms to support equitable distribution of providers or health care resources.
3. Consumer Choice
Consumer choice honors family preference in selecting primary and specialty care providers, health care facilities,
and other services for children with chronic health conditions.
The ability to choose providers and benefit plans is especially critical because children with special needs
require sub-specialty medical services as well as pediatric care. As managed care options expand, such skilled
providers may not be available in all settings. The maintenance of long-term relationships with providers
contributes positively to continuity of care and secondary prevention of disability. A t the system-level, this
requires policies to ensure that all insurers provide access to providers, specialists and facilities with appropriate
pediatric expertise.
4. Family Coverage
Family coverage guarantees that children with special health needs are not excluded from their own family's insurance plan because of pre-existing conditions or because they have exceeded annual or lifetime benefit caps.
The financing system should facilitate access to coverage and financing for the family as a unit. Parents
should not be forced to use extraordinary measures such as dissolving the family unit in order to access health
coverage for their child. The achievement of this criterion will require mandates for coverage ofthe family as a
unit, regardless of pre-existing conditions or cost of care.
BENEFITS
5. Prevention
An appropriate range of effective prevention services, including screening and /amily and child education, is supported by the financing system.
Children with special health needs require the usual range of primary care and prevention services needed
by all children. In addition, they may be at particular risk for secondary disabilities or injuries due to lack of
timely or appropriate medical interventions. Financing prevention services can be cost-effective. The financing
system should provide reimbursement for the delivery of primary prevention services and promote strategies for
community-based prevention programs.
6. Comprehensive Benefits
Comprehensive benefits are supported when the financing system covers the full range of health and health-related
services required by children with special health needs for as long as necessary.
Children with chronic illness or disability have broader and deeper needs for health services than the
overall population of children. These needs are often of extended duration and may continue for their entire
�New England SERVE
lives. When the health care financing system supports a comprehensive benefits package for children with
special health needs, it will include a broad range of personal health services, family support services and
specialized services such as housing adaptations, nutrition and access to long-term care.
7. Community-Based Care
Community-based care requires that the financing system facilitate integration of health care services with other
aspects of community living by allowing for the provision 0/services as close to home as possible and in communitybased settings.
Family-centered care for children with special health needs includes the goal of community integration.
This is greatly enhanced when health care financing systems support the delivery of care in community settings.
The financing system should provide incentives for the delivery of health services in the child's home and
community, training for community-based providers and needs assessment and planning at the community
level.
8. Care Coordination
Coordination of care for children with special health needs occurs when cooperative planning and communication is
supported across multiple, specialized providers and between health care and education systems.
Children with chronic health conditions frequently receive services from multiple providers and the coordination of these services is essential. It may be necessary to access services from both public and private sources
as well as across agencies such as health, education, and social services. Effective coordination of services
requires access to information on available resources as well as a mandate for ongoing communication among
diverse providers. The health financing system must support/pay for this level of communication between and
among providers in order to effectively coordinate care and maximize resources.
QUALITY
9. Quality Assurance
Quality assurance requires that the financing system build in mechanisms that can eliminate underutilization,
unnecessary utilisation, and maximize best practices.
Children with special health needs are especially vulnerable to poor quality services due to their high
demand and utilization of health care services. The financing system should utilize standards of care specially
designed for children when approving services for reimbursement. In addition, the quality assurance system
should be designed to include indicators for family and provider satisfaction as well as health status outcomes.
FAMILY PARTICIPATION
10. Family Role in Decision-Making
The roles of families as primary decision-makers as ivell as caregivers to children with chronic health conditions are
acknowledged and supported when the health financing system pays for services that support these roles.
The health care system should provide support and education to families to assist them in exercising their
roles as primary decision-makers as well as caregivers. This support is especially critical when decisions are of a
technical or complicated nature and involve the relative efficacy of different medical procedures. Educational
services and training for families as caregivers should be supported by the system that finances health care.
�New England SERVE
11. Family Role in Resource Allocation
V^hen families participate in the allocation of health resources there is recognition of the family's role as primary
decision-maker. The development of individual plans of care requires active participation of family members.
Families should be involved in decision-making regarding the utilization and deployment of all health care
benefits to which their child is entitled. Parents and advocates must also be included in the planning, authorization, and development of programs that finance care. A t the system-level, there should be mechanisms to
guarantee consumer involvement in public policy development and the allocation of public and private resources.
COST CONTAINMENT
12. Flexible Benefits
When benefits are flexible, the financing system is able to pay for the most efficient and effective services that meet a
child's needs and contain the costs of care.
Medical tequirements for children with special health needs often do not match standard insurance benefit
packages. It is incumbent upon the system to provide effective and flexible solutions, such as an extended
benefits package, to assure that a child's required health care needs are met. Because of heavy reliance on
medical services, children with special health needs are best served by a financing system that can reassess the
effectiveness of tteatment services on a regular basis to take advantage of emerging technology. This may also
include mechanisms such as public subsidies or tax credits to families who have substantial on-going health care
needs that are not covered by health insurance.
13. Coordination of Benefits
When a child is entitled to health care financing from multiple sources, coordination is required in order to maximize
access to services and use resources efficiently.
Children with special health needs often are eligible for multiple programs. Some services may be covered
by private health insurance, others may be provided through public funding. Duplication of effort can be
avoided and resources efficiently applied when such benefits are coordinated. The financing system should
require coordination among service providers and third party payors to prevent duplication of payment and
increase the efficient use of resources.
14. Administrative Efficiency
Administrative efficiency is enhanced when the financing system includes incentives for and places a high priority on
avoiding duplication and unnecessary services.
Because the needs of children with chronic illness and disability are both costly and extensive, it is especially important that their care be delivered in the most efficacious and cost effective manner and that the
financing system does not create additional administrative burdens for the family in accessing care. The financing system should encourage mechanisms such as common forms, streamlined claims processing and limits on
administrative costs.
�About New England SERVE
New England SERVE is a planning and advocacy network for children with special health care needs. The project is funded hy a
grant from the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services as a National Center for
Children with Special Health Care Needs (#MCJ 255043). The project aims to establish a collaborative network of families, the six
New England state health departments, advocates, and community-based providers in order to implement family-centered, communitybased care in New England.
In April 1990, New England SERVE established a Regional Task Force on Health Care Financing. This working group consists of
35 parents and professionals who are concerned about improving health care financing for children with special health care needs. The
Task Force includes public health professionals, physicians, state legislators, insurance industry representatives, parents, and staff from
state insurance commissions and state Medicaid programs. Ensuring Access is a product of this Regional Task Force on Health Care
Financing, whose membership is listed below.
Further information regarding New England SERVE may be obtained from Susan Epstein or A n n Taylor, Project Co-Directors or
Alexa Halberg, Project Manager at (617) 574-9493.
New England SERVE Regional Task Force on Health Care Financing
T J sk Force Chairperson: Deborah Klein Walker, Ed.D.
Co-Principal Investigator, New England SERVE & Massachusetts Department of Public Health
Stephen Brooks
Vermont Department of Health
Jane Hybsch, B.S., R . N .
New Hampshire Department of Health &.
Human Services
* Molly Cole
The Family Center, Newington Children's
Hospital (Connecticut)
Ruth Ikler
Massachusetts Department of Public Welfare
Allen C. Crocker, M . D .
Co-Principal Investigator,
New England SERVE &
Children's Hospital (Massachusetts)
Susan G. Epstein, M.S.W.
Co-Director, New England SERVE
Francis Finnegan, M.P.A.
Lawrence Kaplan, M . D .
Newington Children's Hospital (Connecticut)
Robert Kramer, M . D .
Newington Children's Hospital (Connecticut)
Amelia Lissor, R . N .
Formerly of Vermont Department of
Social Welfate
Representative Pamela P. Resor
Massachusetts House of Representatives
Anne Roach, R . N .
Rhode Island Department of Health
Neil Rolde
Former Maine State Representative
* Linda Ross, R . N .
Parent Advisory Committee, Maine
Coordinated Care Program
* Mary Sapienza
Parent to Parent of Vermont
ConnectiCate, Inc. (Connecticut)
Roger Taillefer, M.Ed.
New Hampshire Department of Health &.
Human Setvices
Jane Gardner, R . N . , Sc.D.
Katherine P. Messenger
Massachusetts Department of Public Health
Ann B. Taylor, Ed.D.
Co-Director, New England SERVE
Co-Principal Investigator,
New England SERVE &
Harvard School of Public Health
Emily Meyer, Ph.D.
Blue Cross/Blue Shield of Massachusetts
Anne Tetrick, M.S.W.
Formerly of New England Hemophilia Centet
(Massachusetts)
Maine Deparrment of Human Services
F. Taylor Mauck, M . D .
A n n Franke
Massachusetts Division of Insurance
* Cheryl Gresek
Health Care for A l l (Massachusetts)
* Maureen Mitchell
Alexa S. Halberg
Project Manager, New England SERVE
* Terry Ohlson
New Hampshire Parent Information Center
Michael H i l l
New Hampshire House of Representatives
Elaine Pegolo, R . N .
Formerly of Connecricut Department of Health
Services
William Hollinshead, M . D .
Rhode Island Department of Health
James Perrin, M . D .
Patent to Parent of Vermont
Massachusetts General Hospital
* Parents of cliildreii ivhh special heakh care needs
Sharyn Tukey, CCC-slp
Maine Department of Human Services
* Marion Wachtenheim, M.S.W.
Parents Reaching Out of Rhode Island
Paul Wallace-Brodeur, M.S.W.
Vermont Health Policy Council
* Nora Wells
Family Collaboration Consultant,
New England SERVE
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�PI
^
| , i ' ^ ? ' ' \*
>
4 V 'Sf:
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�Paying the Bills
Tips for Families on
Financing Health Care for
Children with Special Needs
New England SERVE
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [2]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Reproduction-Reference
Date Created
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3/16/2015
Source
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42-t-12092971-20060885F-Seg3-037-001-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/a28f91fb376380e29c118c03ede10869.pdf
128b0d29fe5abc7fc90becd0b08d4d84
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1985
FolderlD:
Folder Title:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [1]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
4
1
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. resume
Jay Okun Yedvab [partial] (1 page)
n.d.
P6/b(6)
002. letter
Donna Gentile O'Donnell to Hillary Clinton [partial] (1 page)
2/18/1993
P6/b(6)
003a. letter
John Mark Windle to Hillary Clinton [partial] (1 page)
3/9/1993
P6/b(6)
003b. letter
Constituent to John Mark Windle [partial] (1 page)
3/1/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [1]
2006-0885-F
wr824
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. S52(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA]
P2 Relating to the appointment to Federal office [(a)(2) ofthe PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA|
b(l) National security classified information 1(b)(1) of the FOIAj
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIAj
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIAj
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIAj
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�V
NEW J E R S E Y G E N E R A L A S S E M B L Y
ASSEMBLYWOMAN
COMMITTEES:
LORETTA W E I N B E R G
LABOR
37TH DISTRICT
HEALTH & HUMAN
BERGEN C O U N T Y
SERVICES
545
CEDAR L A N E
COMMISSIONS:
TEANECK, N J 07666
(201)928-0100
FAX (201) 928-0406
911
February 2, 1993
COMMISSION
ADVISORY COMMISSION
ON W O M E N
H i l l a r y Rodham Clinton
White House
Washington, DC 20500
Dear Ms. Clinton:
We met along the campaign t r a i l several times while I was
running i n a special l e g i s l a t i v e election in New Jersey. I'm
sure your t a l e n t , energy and commitment are p e r f e c t l y suited
for the task you have undertaken.
I am forwarding the resume of Jay Okun Yedvab for your
consideration to j o i n the task force which w i l l be developing
health care policy. Mr Yedvab not only has years of
experience i n health administration i n the metropolitan area,
but i s presently l i v i n g i n Canada and i s very f a m i l i a r with
t h e i r system.
Not only could he provide invaluable input into the newly
created task force, but he i s w i l l i n g to become involved even
on a pro bono basis.
My best wishes as you embark on one of the most formidable
missions facing our country.
Sincerely,
Loretta Weinberg / /
Assemblywoman, D i s t r i c t 37
LW/jl
end.
c: Jay Okun Yedvab
Printed
on Recycled
Paper
�Jay Okun Yedvab
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. resume
DATE
SUBJECT/TITLE
n.d.
Jay Okun Yedvab [partial] (1 page)
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [1]
2006-0885-F
wr824
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act - |S U.S.C. 5S2(b)l
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA)
P3 Release would violate a Federal statute [(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA|
b(l) National security classified information 1(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) ofthe FOIA]
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIAj
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) ofthe FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) ofthe FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIAj
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Jay Okun Yedvab
Residence:
Office: (416) 368-8800
Fax: (416) 368-0502
CURRICULUM VITAE
U.S. Citizen. Permanent Resident (Landed) of Canada
Current Status:
Retired
EDUCATION:
Cornell University. Sloan Institute of Hospital
Administration. Graduate School of Business and Public
Administration, Ithaca. New York. (1962). M.P.A. with
High Distinction.
Western Reserve University School of Medicine.
Cleveland, Ohio (1959). Research Fellow in Pharmacology.
Major: Sciences and Education.
Alfred University. Alfred. New York, (1956). B.A. Cum
Laude. Major: Biology and Sociology.
King Edward's Hospital Fund for London, guest of the
Hospital Administrative Staff College (summer 1962),
studying hospitals and health programs in England and
Scotland
Health Executives' Development Program
Sloan Program in Health Services Administration
Cornell University, 1986
PROFESSIONAL EXPERIENCE:
1987 - 1992
Baycrest Hospital
Baycrest Centre for Geriatric Care
Toronto, Ontario
�Page 2
Jay Okun Yedvab
Administrator
Member of the Senior Management of a geriatric centre
with multiple facilities, including a hospital, a 370 bed
home for the aged and a 250 unit senior's apartment
complex. Directly responsible for the operation of the 300
bed chronic and geriatric care, teaching and research
hospital, affiliated with the University of Toronto, with
specialty programs in intensive care, palliative care,
geriatric assessment, rehabilitation, geriatric psychiatry
and behavioral neurology. The hospital has an ambulatory
and clinic service, and geriatric and psychiatric day
hospitals.
Lecturer and Preceptor at Baycrest for the Department of
Health Administration, University of Toronto.
1984 - 1987
CONSULTANT AND TEACHER
Independent Management Consultant and Faculty Member,
specializing in health care. Clients included:
Baptist Medical Centre of New York, Brooklyn N.Y.
Retained by the operating trustee, appointed by the
Federal Bankruptcy judge, for this 240 bed hospital and
160 bed nursing home. As part of a consulting team, a
final attempt was made to obtain re-accreditation and recertification by the Medicare and Medicaid programs.
When this attempt was unsuccessful, assigned the position
of Chief Operating Officer to manage the orderly closure of
the hospital, including the transfer of 200 patients,
termination of 350 employees, and surrender of the
operating certificate to the New York State Department of
Health.
The Long Island Lighting Company (ULCO)
Developed hospital portions of the Emergency
Preparedness Plan for the Shoreham Nuclear Power
Station.
The Boulevard Hospital, Queens, N.Y.
Advisor to the Board on hospital operations during the
period that the hospital did not have an administrator.
Recruited a Chief Executive Officer.
The Hackensack Medical Center, Hackensack, N.J.
Ongoing consulting to the President of the Medical Center.
�Page 3
The Jersey City Medical Center, Jersey City, N.J.
Review of the activities of the Emergency Service and
preparation for the Joint Commission on Accreditation of
Hospitals Survey Inspection.
The New York City Health and Hospitals Corporation
Full-time consultant to the President of the Corporation to
improve the health care delivery activities of several longterm care facilities, and to work with the Corporation,
State and Communities concerning the admission of AIDS
patients.
FACULTY
Jersey City State College, Jersey City, N. J .
Member of the adjunct faculty in the graduate program in
Health Sciences, teaching courses in Health Care Fiscal
Management, Epidemiology and Medical Care
Organization.
New York University, New York, N. Y., Graduate School of
Public Administration
Member of the adjunct faculty In the program in Health
Policy and Management, teaching courses in Management
and Planning in Health Care Organizations.
St. Francis College. Brooklyn, N. Y.
Member of the adjunct faculty i n the Undergraduate
Health Care Program for Nurses, teaching the basic course
in Health Care Management and Organization of Health
Care Delivery.
The New School for Social Research, New York, N. Y.
Member of the adjunct faculty in the graduate program in
health care, teaching a course in Planning for Health Care
Facilities and Services.
Montclair State College, Montclair, N. J .
Member of the adjunct faculty in the Undergraduate
School of Management, teaching courses i n Business Policy
and Planning, and Human Resources.
1979 - 1984
Bergen Pines County Hospital
Paramus, N. J . 07652
Executive Director and Secretary to the Board of Managers
Reported to the Board of Managers and its President, with
full executive management responsibility for the public
hospital in Bergen County (population 845,000).
�Okun Yedvab
e 4
Bergen Pines total of 1,233 beds was composed of 209
acute medical-surgical, 333 psychiatric and 691 long-term
care; emergency room, ambulatory services, physical
rehabilitation and substance abuse programs. The hospital
is affiliated with the University of Medicine and Dentistry
of New Jersey, New Jersey Medical School
Supervised an administrative staff of 12 with six direct
reports: Senior Assistant Executive Director, Chief
Financial Officer, Director of Planning, Director of
Community Affairs, Director of Nursing, and Director of
Manpower and Materials. The hospital employs
approximately 2,000 people.
The first goal, as the fourth administrator within a threeyear period, was to develop management and professional
teams capable of handling the activities of a large, public
hospital. This goal was achieved and full accreditation of
all programs by the Joint Commission on Accreditation of
Hospitals occurred in 1980 for the first time i n the
institution's 60 year history. Full accreditation was
renewed in 1983.
A $40 million building program included a psychiatric
pavilion, emergency room and partial replacement of longterm care beds, was planned and constructed.
In a program of national significance, Bergen Pines was
selected as the clinical site for the development of a
"teaching nursing home", to enhance education of health
professionals and the quality of care for long-term care
patients as part of a grant from the Robert Wood Johnson
Foundation to the Rutgers University School of Nursing.
1976 - 1979
Jewish Hospital and Medical Center of Brooklyn,
Brooklyn, N. Y., 11283 (now part of Interfaith Medical
Center)
Executive Vice President
Chief Executive Officer of a 636-bed urban teaching
hospital, a major clinical site for the Downstate Medical
Center, with an affiliated 320-bed skilled nursing facility
(JGMCB Nursing Home Company, Inc.). Reported to the
President of the Board and had full administrative
responsibility for the institution. Recruited by Brooklyn
Jewish with a mandate to determine whether the hospital
could survive. During the next three years, many
organizational changes were made. During the last year,
the hospital operated in Chapter 11 of the U.S. Bankruptcy
Code.
�Jay Okun Yedvab
Page 5
Among significant accomplishments were the creation and
implementation of a plan to save the largest health care
provider, educator and employer in Bedford-Stuyvesant.
Board, employee, union and community support was
mobilized to convince city, state and federal officials to
provide special grants and operations. Adjustments were
made in the management, fiscal and professional
programs, which allowed the hospital to continue to
function under the conditions imposed by governmental
agencies as part of a rescue program.
1970 - 1976
Mount Zion Hospital and Medical Centre
San Francisco, California, 94116
Executive Director
Reporting to the Board of Trustees, functioned as Chief
Executive Officer of a 500 bed community service,
teaching and research center with substantial clinic and
private ambulatory programs.
Declining utilization of the hospital was reversed by
reorganizing and revitalizing the medical staff,
administration and physical plant. A capital improvement
program was begun by purchasing and adjacent 125-bed
proprietary hospital to be used as a facility for psychiatry,
pediatrics, obstetrics and professional support
departments.
As part of the upgrading of the medical services, a major
affiliation with the University of Califomia-San Francisco
Medical School was consummated for the Departments of
Psychiatry, Medicine and the Tumor Institute, and a fulltime Chief of Medicine was recruited.
1967 - 1970
The Woman's Medical College of Pennsylvania
Philadelphia, Pennsylvania, 19129 (now the Medical
College of Pennsylvania & Hospital)
Administrator of the Hospital (1968 - 1970)
Member of the President's staff: responsible for daily
administration of the medical school's 300-bed primary
teaching hospital and extensive ambulatory services.
�Jay Okun Yedvab
Page
Assistant Administrator ofthe Hospital (1967 - 1968)
General administrative duties: served as Administrator of
the Comprehensive Child Care program (C & Y) and
Maternal and Infant Care program (W.I.C), and ambulatory
services. Responsible for coordinating the occupancy of a
new clinical teaching wing.
Clinical Assistant Professor of Preventive Medicine
(Hospital Administration) 1970
Lecturer in Preventive Medicine (1967 - 1970)
1965 - 1966
MONTEFIORE HOSPITAL AND MEDICAL CENTER BRONX,
NEW YORK 10467
Assistant to the Director
Staff position; program planning and review. Medicare
affairs and community health planning activities.
1962 - 1965
LONG ISLAND JEWISH HOSPITAL
NEW HYDE PARK, NEW YORK 11042
(now Long Island Jewish-Hillside Medical Center)
Assistant Director (1964 - 1965)
General administrative duties and line responsibility for
communications, dietary, house staff, housekeeping,
insurance, print shop, purchasing, receiving and stores,
record retention, religious practices, volunteer services
and Women's Services Guild. Involved in planning and
equipping a new building.
Administrative Assistant (1962 - 1964)
General administrative duties and line responsibility for
purchasing, receiving and storeroom.
1961
MOUNT ZION HOSPITAL AND MEDICAL CENTER
SAN FRANCISCO. CALIFORNIA 94115
Administrative Resident
1959 - 1960
STATE UNIVERSITY OF NEW YORK. UPSTATE MEDICAL
CENTER, SYRACUSE. NEW YORK 13210
Senior Technician - Cardio-Vascular Laboratory,
Medical Department
�Jay Okun Yedvab
1956/57/58
Pope 7
NATIONAL INSTITUTES OF HEALTH
BETHESDA, MARYLAND 20014
Administrative Trainee, Grants and Training Branch,
National Heart Institute
1957 - 1965
U.S. ARMY RESERVE, MEDICAL SERVICE CORPS
First Lieutenant
Current Memberships and activities
Lecturer, Department of Health Administration,
University of Toronto
Member of the Board of Directors
St. Alban's Boys and Girls Club, Toronto
Executive Member, Canadian College of Health Service
Executives. CerUfied Health ExecuUve (CHE)
Member, American College of Health Care Executives
(Recertified 1991)
Fellow, American Public Health Association
(Medical Care Section)
Member, The Sloan Institute Alumni Association
(President. 1970 - 1971)
Member. Hospital Administrators Club of New York
Member, Health Executive Forum, Toronto
Preceptorships
Preceptor for Residents in Hospital Administration:
Cornell University, 1968 - 1975, 1977 - 1983, 1990
University of California, Berkeley, 1971 - 1975
University of California, Los Angeles, 1989
University of Toronto. 1990
Licenses:
Nursing Home Administrator, State of New York, License
No. 02834 (inacUve) Nursing Home Administrator, State of New Jersey, License
No. 0632 (inactive)
Publications
"Consumer's Role in Defining Goals, Structures and
Services", Hospital Progress. April 1974. Reprinted in
P.D. Cooper, Health Care Marketing: Current Issues and
Cases. Aspen. Spring 1979.
�Jay Okun Yedvab
Page 8
'The Crisis in Health Care", Alumnae News. The Woman's
Medical College of Pennsylvania, November 1969.
"How to Measure Malpractice Coverage", with S.B.
Ackerman, Professor Emeritus of Insurance, New York
University, The Modern Hospital. December 1965.
"Bolstering the Budget with Bulk Purchasing", with M.
Pike. Hospitals. March 1. 1964
PREVIOUS MEMBERSHIP ACTIVITIES AND AWARDS (Selected)
1989 - 1991
Council of Chronic Hospitals of Ontario
Founding Board Member and Executive Committee
Member-at-Large
1967 - 1984
1960 - 1985
Member. Association of American Colleges. C.O.T.H.
- Council of Teaching Hospitals Representative,
Association of American Medical Colleges Assembly (1973
- 1976)
Member, American Hospital Association
1966 - 1985
Member, The International Hospital Federation
1988 - 1991
Regional Geriatric Program of Metropolitan Toronto. ( A
Ministry of Health Funded Multi-Provider Geriatric
Specialty Program).
Member, Management Council (1988 - 1990)
Member, Evaluation Committee (1988 - 1991)
1982 - 1983
Member, New Jersey Hospital Association Committee on
Aging and Long Term Care
1983
Chairman, Bergen-Passaic Hospital
Administrators' Council
1981 - 1984
Member of the Board. Bergen-Passaic Hospital and
Physician Council
1979 - 1983
Member, Policy Advisory Committee, Hartford
Foundation Geriatric Project, Department of Community
Medicine, UMDNJ. Rutgers Medical School
1975 - 1981
Consultant, Robert Wood Johnson Foundation, Community
Hospital - Medical Staff Group Practice Program
1978 - 1979
Member, Board of Directors, Health Systems
Agency of New York City
�1978
New York City Policemen's Benevolent Association, Special
Service award
1973 - 1976
Member, State of California Building Safety Board
- Chairman Hospital Operations Sub-Committee.
1974 - 1976
- Member, Statute of Intent Sub-Committee, 1973 - 1975
1975 - 1976
Councillor (American Hospital Association Representative),
Accreditation Council for Ambulatory Health Care of the
Joint Commission on Accreditation of Hospitals
1970 - 1976
Member, California Hospital Association
- Chairman, Patient Care Services Committee
(Member from 1971), 1973 - 1975
- Member, Medical Staff and Trustees Committee, 1975
- Member, Emergency Health Services Committee,
1971 - 1972
1967 - 1970
Consultant, Philadelphia County Medical Society
Committees on Community Medicine and Emergency
Health Services
- Sub-Committee on Emergency House calls, 1969 - 1970
1969
Distinguished Service Award. Simon Gratz High School,
Philadelphia
PRESENTATIONS
"Long Term Care Reform: Dream or Nightmare?" Ontario Hospital
Association Annual Convention. Toronto, November 27, 1990.
"Care of the Elderly: New Developments in Long-Term Care", Panel member
at Ontario Hospital Association Conference, Toronto. November 14. 1989.
"Health Care Scoops of 1984", New Jersey Hospital Public Relations
Association Fall Conference. McAfee. New Jersey, September 29, 1983.
'The Role of the Users in Defining Goals, Structures and Services", Leader of
discussion session at Estes Park Institute, Hospital Medical Staff
Conference. Pacific Grove, California. November 19. 1975.
"FORUM: Administrative / Trustee / Medical Staff Relationships", Panelist at
American Hospital Association / Tri-State Hospital Assembly, Chicago,
Illinois. August 20. 1975.
"Hospital Costs and Public Expectations", Institute of Cost Containment and
Budgeting, Association of Western Hospitals, Anchorage. Alaska, November
19, 1974.
�Jay Okun Yedvab
"Hospitals Can Influence Change". 44th Annual Convention. Association of
Western Hospitals. Seattle, Washington. April 23. 1974.
"Federation Planning for Health Services", Council of Jewish Federation and
Welfare Funds, New York City, March 15. 1974.
'The Role of the Users in Defining Goals, Structures and Services",
American Health Congress, Chicago, Illinois. August 21. 1973.
"Hospitals in Today's Changing World", Institute on Labour Relations and
Personnel Practices. Association of Western Hospitals, Albuquerque, New
Mexico. March 12. 1973.
"Implications of the Admission of Alcoholics to the General Hospital".
101st Annual Session of the California Medical Society, San Francisco,
February 13. 1972.
"Community and Environmental Aspects of Security",
American Hospital Association Institute on Hospital Security, Los Angeles.
California, January 11, 1972.
1992
�Attorney General
Lee Fisher
February 2, 1993
Hillary
Rodham
First
Lady
The White
House
Washington,
D.C.
RE:
Clinton
20500
Appointment
Health
Care
of Farah Af. Walters
Task
Force
to
the
* I •»/
Dear
Hi
First
heartfelt
add foremost,
congratulations
Peggy and
to
you.
I
send
our
enthusiastic
and
I am writing
to bring
a great
opportunity
to your attentionthe opportunity
to appoint
perhaps
the most accomplished
female
Health
Care professional
in the country
to your Health
Care
Task
Force.
Farah M. Walters,
the President
and Chief Executive
Officer
of
University
Hospitals
Health
System,
Inc.
and
University
Hospitals
of Cleveland,
is,
to my knowledge,
the
only
female
president
of a major teaching
hospital
in the United
States.
She
would
bring
to your
task
force
degrees
of
skill,
training
experience
and respect
that few other professionals
in the
field
can o f f e r .
Farah Walters'
Masters
Degree in business
administration
and
expertise
in financing
issues
sets
her apart
from others
in
the
health
care area.
She has pioneered
new plans
for the provision
of
health
care that have helped
to improve
the quality
and reduce
the
cost
of health
care
in Ohio.
Under her guidance,
University
Hospitals
of
Cleveland
was recognized
in
1990
as
the
most
innovative
hospital
system
in the
country.
Enclosed
is Ms. Walters'
curriculum
vitae.
I thiiik you
will
find,
as have I , that i t paints
a picture
of an extraordinary
woman
whose talents
would be invaluable
to any administration
e f f o r t to
examine and improve
the nation's
health
care system.
I urge you to
take this opportunity
to appoint
Farah Walters
to your task
force.
Ver^truly
J ours,
LEE FISHER
rac
State Office Tower / 30 East Broad Street / Columbus, Ohio 43266-0410
An Equal Opporturiiiv employer
^Printed
on Recycled Paper
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UniversityHospitals
ofCleveland
January 26, 1993
Attorney General Lee I . Fisher
30 E. Broad Street
Columbus, OH 43215
Re:
Appointment of Farah M. Walters to Hillary Rodham Clinton's
Healthcare Task Force
Dear Lee:
Pursuant to a recent conversation I had with Kate O'Malley, I am enclosing a copy
of the most recent C V . of Farah M. Walters, President and Chief Executive Officer
of University Hospitals Health System, Inc. and University Hospitals of Cleveland.
I think that Farah would be a fabulous choice for Hillary Rodham Clinton's Healthcare
Task Force in that she is well-skilled because of her training and experience in the
development of healthcare delivery systems.
As far as I know, Farah is the only female president of a major teaching hospital in
the United States. She has a Masters Degree in Business Administration from the
Weatherhead School of Management and her area of expertise is the development of
a healthcare system and also the financing of healthcare.
I think that i f she were to be appointed to this committee, not only would her
education, training and experience be of a great benefit to the development of the
healthcare policy in this country, but also the appointment would be widely
recognized as evidence of good judgement on behalf of the administration.
If I can be of any help to further this appointment, please call me and I wll do
whatever is necessary. I am also enclosing copies of several newspaper articles
which further define Farah's achievements.
ely yours,
mes J. McMonagle, J.D.
eneral Counsel
JJM:ls
enclosures
ec: Kate O'Malley
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UniversityHospitals
ofCleveland
Farah M. Walters
Biograpfiical Sketch
Farah M. Walters is President and Chief Executive Officer of University Hospitals Health System, Inc.,
and University Hospitals of Cleveland. The health system comprises University Hospitals, a 947-bcd
academic medical center; QualChoice, Inc., a managed care company; and University MEDNET, a
multi-specialty group of 130 physicians. University Hospitals operates five hospitals — University
MacDonald Womens Hospital, Rainbow Babies and Childrens Hospital, two hospitals for adult medical
and surgical care, and one for psychiatric treatment — and is Case Western Reserve University's primary
research and teaching affiliate.
Mrs. Walters joined University Hospitals of Cleveland in 1986. A year later she was named Senior Vice
President and General Manager oflntcgrated Health Systems. In 1988 she became Executive Vice
President of University Hospitals Health System, Inc., and the academic medical center. Beginning in
1989, she served as Senior Executive Vice President of University Hospitals Health System, Inc. and
Executive Director of University Hospitals of Cleveland, until her current appointment in 1992.
Mrs. Wallers' career in health care began in 1968 as a clinical nutritionist at Peter Bent Brigham Hospital in Boston, a Harvard Medical School teaching hospital. She served The MetroHealth System of
Cleveland from 1971 to 1985 in various roles in nutrition, education, research and management.
She has consulted and lectured for major health organizations such as the Pan American Health Organization, American Hospital Association, National Institutes of Health, the U.S. Army and various
hospitals and universities.
Among her honors, Mrs. Walters received the YWCA Career Woman of Achievement Award in 1988.
Early in her career, she was named the Young Dietitian of the Year by the American Dietetic Association.
She is a member of Beta Sigma Gamma, the national honorary society for business administration. She
has been featured or quoted in The Wail Street Journal, Modem Healthcare, The Plain Dealer, Crain's
Cleveland Business, Cleveland magazine, and on ABC "Nightly News" and CBS "48 Hours," among others.
Mrs. Walters serves on a number of boards. She is on the visiting committee of Case Western Reserve
University's Weatherhead School of Management. She serves on the executive committees of the
University Hospitals Consortium of Chicago, Greater Cleveland Roundtable, American Red Cross,
Greater Cleveland Hospital Association, United Way, University Circle, Inc., Society Bank, Shelby
Insurance and other institutions. She also serves as a delegate to the Council of Teaching Hospitals and
the Associaiion of American Medical Colleges Assembly.
Mrs. Walters holds two Master's degrees, in business administration and in nutrition, from Case Western
Reserve University. She received her Bachelor's degree in medical dietetics from The Ohio State
University School of Medicine.
She resides in Shaker I (eights, Ohio, with her husband, Stephen, a partner in the law firm of Weston
Hurd Fallon Paisley 8c Howley, and her daughter, Stephanie. 16, a student at Hawken School.
�j N 2 - 3 .D 1 : 8
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Corporate Communications
UniversityHospitals
ofCleveland
CAREER HIGHLIGHTS OF FARAH M. WALTERS
PRESIDENT AND CEO OF UNIVERSITY HOSPITALS HEALTH SYSTEM, INC. AND
UNIVERSITY HOSPITALS OF CLEVELAND
After a national search, the Board of Trustees of University Hospitals Health System, Inc. selected Farah
M. Walters as President and Chief Executive Officer. She has brought outstanding leadership to the
academic medical center during her tenure. More importantly, she has the vision to lead the institution
to the forefront of health care in the next century.
Among her most significant achievements, Mrs. Walters developed the concept and strategic plan for
QualChoice, a new managed care company. It has been hailed nationally as one of the most innovative
models of managed care in an academic medical center. In its first year, QualChoice has built a
provider network of 1,200 physicians and 14 community hospitals, and an enrollment of 21,000
subscribers.
A successful expense reduction program under her direction resulted in cutting costs by S O million over
S
the past four years, allowing University Hospitals tofreezeprices and respond to the business
community's need for more affordable health care for employees. The cutbacks occurred without major
layoffs or compromise to high-quality care.
Mrs. Walters has worked in close partnership with the clinical leadership of University Hospitals to build
new centers of clinical excellence, such as the University Musculoskeletal Institute. These centers
integrate multiple specialties to give patients comprehensive, state-of-the-art diagnosis and treatment.
For these and other achievements, University Hospitals received the prestigious gold medal award in
1990 from 3M and the Healthcare Forum as the most innovative hospital system in the United States.
Mrs. Walters has continued to further a commitment to excellence in patient care. University Hopitals'
patient satisfaction rating of 98 percent is testimony to its high-quality, personal care.
During her tenure as Executive Director, University Hospitals captured for the first time in 1990 and
again in 1991 the highest number of admissions and the highest percentage of market share in the fivecounty metropolitan area of northeast Ohio.
P 0
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CLEVELAND, OHIO 44115
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flUG-27-92
CO
the best' better
goal of UH network chief
By HOLLY SHERIDAN
791
'StaflWWter
When a new leader stepped to the
forefront of University Hospitals.
she brought with her a wealth of
knowledge and experience, as well
as a vision for establishing and extending the institution's leadership
in health care Into the future.
"I'm very committed to establishing stronger ties" to hospitals in the
University Hospitals network, said
Farah M. Walters, new president
and chief executive officer of University Hospitals Health System
Inc. and University Hospitals of
Cleveland.
• "I am really fortunate to lead a
Sjospital system known for the best
1
physicians, nurses and faculty,"
Walters said. "Everyone's goal is to
provide the highest quality of care."
A 98-percent patient satisfaction
rating at University Hospitals is a
confirmation of its high-quality,
personal care, she feels.
"One of my biggest priorities is to
recruit to University Hospitals
some of the real stars in various
medicalfields,"both clinical and research, said Walters.
"I believe University Hospitals
has the opportunity and responsibility to assume leadership," she
continued "We have to lead tbe
way in defining health care needs In
this country."
Walters joined University Hospitals in 1986 as director of nutrition
;
and has since held various positions, including senior executive
vice president of University Hospitals Health System and executive director of University Hospitals of
Cleveland.
Among her many honors, Walters
received the YWCA "Career Wom- Farah M. Walters, new president
an of Achievement Award" in 1988. and chief executive officer of
She is an honorary ambassador University Hospitals Health
for the dty of Shaker Heights and a System Inc., is set on bringing top
member of Beta Sigma Gamma, the medical talent to the group.
national honorary society for business administration. Her board her "wonderful and very, supportmemberships include the American ive husband (Stephan) and daughRed Cross, United Way and Univer ter (Stephanie, IS)."
sify Circle Inc.
In her spare time, Walters likes
Walters' role at University Hospi- music, traveling, entertaining and
tals alone is "almost a life." Howev- reading. "I love toread,"she said.
er, she is able to handle it because of "That's the way I relax."
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I>iMcATisTo7uM(>nNGruMAKDP>on«fWN*u]MlMHiAinKAU INNOIITKIAITOWO
P.06
SOTOOQlWl
No mi gtUli the tap without aiming undortcnthy. Everyfouryon, In tha
Ipmidenilal mi Oh/mpk »wm man tnated lo rmlaltm Inttndei to convinct,
: dluuade, shock, tilllkt, or, If tht bat of all worlds mn true, tbnply to infernand
.idvaU. Ctttlngto the top In httlthcsrt end anting Hit opportunity to lad a
'jiatlontfty-nsptcteA torn ofphyuoans, mtardm, end tuimiebns mtam
cmini under semUny. When Dr. Jmts Block mntunad hi} plans to moot to
\Joh,ni HooHtu, Tank M. Yfaltert. uamd in (hatft, aunt undo the careful • •
lemlliiy ofher colltagua, the community, i nd, of course, fht prta.
t lunioed tht xnilinv, and It now tht pretident and chief extcutiv*
officer of Univtnity Hospital Health Syitemt, Inc and Unioenit]/
[HoipltaU ofCleotUni. When Medical Digest ititcrvtctoed Wttn artier this
' mmlh. tht wet gredma with her Ume, honttt in her tntum, ani made no
atlmpt lo keep the paulon ihe fats for Unfoenify HMpitalsofCtevcknd
'out of heryoke.
"One IndhrlAial does not mtke or break a hoipltal lyjlem sudi at thli. No
mauer how good Ihe CtO It, If the CEO It not becked by itrong phy1 htvt intlnly loo much low ind t«- Ai much at Wtlten It commuted to ticlent and a itrona minegement staff, nothing the CEO doei wilt
tpMt for ttvll org«nlullon lo ever do Unlvenity Hoepitalt end the Cleveland
metter.'
-ferahM.Walten
anythingtoundermine ll." WaJtm Mid, community, to too It the hospital and
• "and 1 wei lorry to tee Hut torn* of my community committed lo her. There elder a ptiytidan. particularly dnce thia woman president of Unlvenity Hospithe
•entlirwnts, when expressed by the me- It no better evidence than the tupport la an acadunlc medical center."
tals of Cleveland. With Walters' apdli, iuggeelsd I would ImmedUtely the received during the hotpltat'e
Waltert had three emwen lo thle pointment, a woman, for tbe tint dme,
leave OeveUnd If I were not appointed teardtfora new pfeildenl
question. Pint, the Hid. of the 36 mem- will lead an independent hospital tytpresident end CEO. Wh«n Dr. Block Walter, received from 700 lo 800 let ben of the University Hotpttalt Consor- temlntheUnltodtatei.
nude his mnouneemeit. I made a com- ten of lupporl during the e^erch end tium, repretendng the top eeademle
mitmenttoIhe dwlnnan o/the bovd of over 100 bouquetj of Jtewere a/ier her medical centert In the United Statet, Creating the vision
d I ret ton that no matter who, finally, appointment Tlie tupport came from only tlx are headtd by physicians. Sec- But aU that Is put. Tlie specula don It
wu appointed, 1 would help tho orgui-cfirjaJ chairmen. dlvUlon chlelt, the w ond, the believed the cllnlctl leader- over; the scrutiny, now, willfocuson
aation m»Ve a smooth Wnsldon.*
nlor management team and Unlvenity ship, the phyjldint, and the board of WaJlerf efforts to take Unlvenity HoeWaJltn added that there were only Hotpltalt employeet, it well aa many truateee of university Hoteltalt of pitalt all the wey to the top u an acaCleveland could best determine if the demic medical cenlar.
two other offen (he vres eonitdering at community kadert.
Ihe time, both outllde of Cleveland. "There were rumora that becaute I were ouallfled to deal with the MD/ "One individual does not mtke or
'Had I not been appointed, 1 would wit not * phyddin, 1 wat not a leading non-MD Usue, should II ever arlte. And break a hospital system weh u thia. No
have left UnlvenftyHoapllsU-1 heve candidate for the potlHon. Theie were third, the believed the quesdon wu re- matter how cood the CEO la, V Ihe OBO
been very nicceeiful In the number two totally unfounded. Bul I appreciate lhal ally a dlsgulted wey of laying "bui Is nol backed by Strang phvildans and a
•pot, ana I (ell for my carter It wu dme tome very well-meaning people atkad If you're a woman."
itrong management staff, nothing the
It would nol have been better to eon- For 125 yean, there hu never been a CEO does will matter.
(ormtolrythenumberoneipat." '
Tm not a physidan. but typically lhe
CBO !e not expected lo perform open
heart surgery or diagnose e patient. I
need lo understand healthure, how the
delivery system works, how you punue
exceUence and quality, how you provide compassionate and cost-e/fectlve
can, Different stages of my career have
raqulied that I address these luuee.
T have been given the opportunity to
build on a Wonderful foundation. The
best 1 can do Is help to create a vision
and a value system. Hopefully, despite
the lough economic times we are ell
now experiencing, theu will help ns develop an absolute commlbnent to quilIty patient core, research and education.
That type of commitment means we can
doenythlng,"
Condnutd
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v
»
Dr. Robert
Kltegman, viceWtlten Mid the tignlng o/ lhe a/fll!i-"
chairman end
Hon tgreement between Unlverllt/
Kosplltlt of develend ind Ctte Wejlsjioclate
em Reserve Unlvenity three monlht
director of
teo .wu • moat memorable moment.
pedletrfafor •
•^Vhat a tranendout feeling to toe two:
Rainbow Babies
greet Initltullont, who have In every
and Childrens
tente of the word been an academic,.
medical canterfar96 yeaft. Anally have
Hospital, talks
a written affUlttlon.with a father In
., Thajdea for eatebllihlng a formal
RB&C's neonatal
written a/flllation between the two endIntensive cere
Uei came flntfromthe chalVman of the
unit.
Board of Unlvenity Kowltali of Qeveland, K. William Xeyaolda, and the;
chairman of Ihe Board df Gate Western' Reserve University, Allen Ford. vcrslty to form a joint trustee committee Ume, Waltere said, the Cleveland Foun- listed u one of the top five pediatric
Reynoldi and Ford Wt the afflUaUon Is-to coordinate the strategic developmenl daiion put a moratorium on funding re- hospitals In the country. "I went to
;
sue wu best handled al the board level that will move this academic medical search to the Cleveland Clink, Univer- make jure that Rainbow is a name truly
so that future changes In CEOs and center Into further collaboration. The si^ Hospitals, MetroHealth, and CWRU. recognized u the best in pediatric care
presidents would not influence the (olnt trustee committee will also recom- "Thii wae done lo encourage all the both nationally and Interna dons Ily"
agreement. Ihey formed a Jotnt-tnutee mend a proceta for bringing In Metro- partnen to go along with the Idea of a About e yeir ago, Wolten developed
.committal composed of six bidlviduala. Health. At Slnal Hospital, and the V.A. single ecadsmic medical centw."
who tat on Ihe boards of both organUa- Hospital at other memben of this aca- Having tn tcademk medical center In a committee with broad represenlellon
from Rainbow, theroedMschool, the
dens. The Jofnl-lrusles committee began derric med leal cenler.
The
in eamett to study Ihe reladonshlp be- Acting independently of the affilia-Clevelind wasn't e new Idea, Wellen board, and referring physldant.strate•aid, since CWRU and Unlvenity Hos- committee's fob wu to develop a
tween the hosplla! and the univenlly tion InlHattve being planned by Cate
pitals had been one since 1896. ^Vhat gic plan that would assure tha strength
and ask what Ihe crtdcal points of tha Western anil University Hospitals. Ihe new end innovative andvery excit- ancl future cl Rainbow Into the next ctnand ask what Ihe critical points of tha
wu
new aflUUtionapeaneil should be.
commlllee on technology and new eco- and promising wu Ihe Idea I bring
ing
O
nd beyond. 11nformally referred
ti "I have spent my entire career in nomic development ofaeveland To- other hospitals Into the alfllladon.'
stnleglcplanu "Rainbow 2000."
healthcare, in teaching hospitals and in morrow atked Booz.Allen and Ham- Unfortunately, In mid-July, a report WhOe Ihe Strategic plan was In Its finacademic medical centen," Walters ilton lo Investigate how Cleveland from the Qevelend Foundation Com- ishing stages, the chairman of the Desaid, *»nd ihis is one of the strongest re- might strengthfnlls eeonomle base. The
mission tht l surprised and shocked partment of PedlStrics, William Speck,
lationships I have ever seen between a study concluded that one possible ana
many In the healthcare community out- MD, accepted an administrative posihospital system end a medical schooL* ' would be biomedical technology, pro'
lined two academic medical centen, one tion In New York. "And Just about Ihis
) Unlvenity Hospitals and the School. vided there wet e greater crillcal mauwith tha Cleveland Clinic ind Ohio lima we heard ebout our new ranking.
of Medicine of Case Western Reserve of tdendstt. -Other ciHes have become
State University, end one in which Mt Then 1 went to the search commillce.
University are Independent corpora- •
leadere In biomedical technology by Slnal, the V.A, and MetroHealth would Tosupport our commitmenttoRainUons with their own boards of trustees building on a strong base of id en lists.
affiliate with CWRU end University bow 2000,1 Ield ihe search committee I
and their own governance. This model •
Examples would be San Diego, San Hospitals. "I don't know all the facts be- did not want them to go after one of Ihe
Is similar to John* HopWnt, the Univer-Francisco, Boston, and the trl-slaiea,
•
hind this decision, and speculation top 10 or top 19 stan in the country. I
sity of Chicago, and Yale-New Haven. which Includes New York, New Jersey
doesn't accomplish anything. I do fsei, wanted them lo recruit one of the top
. in other academic medical centers, mostand the BaJUmora area:.. .^f.Miii, personally, that the Cleveland Founda- five to be the new chairman of the Deof which are owned by the s«a tc the uni- "One way to get this critical man tion Commission lost sight of what It partmenl of Pediatrics. We want to
ver Jlty actually owns the system.':- . would be through greater collaboration originally set out to do. The concept of a make sure thai Clevelind becomes e
• "Unfortunately, many people felled and coordination of nsaarch activities, strategic alliance dM not happen el the city known for the bast center Ir. pediato dlstlngulth our academic medical especially In the areas of basic sdence, level ef the Commiislon's report."
ric care In the country."
centerfromthose In which the univer- '
medical research, end medical educa- The concept of Ihe sinlegic alllana; Is Waller's commitment tb recruitment
ally owns the hospital system. People :
tion. A single eudemlc center could sc- that there an orgsnUatlone that can ws* reflected In e Joint search, with the
perceived that somehow Case Western eomplishtWs.
:•.':.•> .
compete on soma things and can col- Dean of the School of Medidne, Nell
was going to acqidra Unlvenity Hospi- Walters said that as a result of the la borate on others for the mutual benefit
Chemlak, MD, for a geneddst. " e are
W
tals and the oiher hospitals we hope willstudy completitd forOeveland Tomor. of both. IBM and Apple, Wellen said. It all thrilled that Huntington Wlllard,
affiliate with tut* .,
. raw, thedeveltnd Foundation formed an example of such e sinlegic tltlancc PhD, Joined U U Ihe chairman of tha
S
fI h the afflUadon agreement there Is ka national commission to look at how to In the business sector.
Department of Genetics.'
commitment between Unlvenity Hos- strengthen medical research and medi- "Hospitals In the affiliation, though Too often people assume that recruitpitals and;Case Western Reserve UnK cal education In Cleveland. Itwatal thia competing In the provision of pallenl ing "stars" to chair a clinical/academic
care, could collaborate and nlntly plan department Is all thif s needed to take
and develop research end education cf- an organization to the very top. "You
fcris." Waltsn believed this synergistic can't buy people. If ws did not already
relationship would have given Cleve- have a foundation of excellence in paland the critical mass of sdentlsli need- tient care, research, and academics, no
ed to become a major center for bio- star would come here. No slat wants to
medical techno.logy.
be associated with an organization that
is kpown for Its mediocrity. We sre
Rainbow 2000
building on our strength.
But spending time on what might . *We simply don't believe Ir buying
havs been doesn't get yau te the top. people If you have to ardildally prop up
Wallen slays focused on what will haj* a prognn, then It Is Inherently not good.
pen tomorrow. And tomorrow looks Money alone can bean uUfldll prop.
great for all areas of University Hospi- There are many otdtlng things going
tals Health Systems. Inc Walters felt on. New programs are being planned In
that Rainbow Bablei and Childrens dlnlcsl areas, We plan to piesent the
Hospital, the pediatric hospital of the board with s proposal for t new pillent
university hospitals system, exemplifies bed towel, We alresdy have one of the
, the enthustisdc planning underway.
_
,
absolute best pediatric hospitals in the
Making it offfaal
X
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Gilbert end Brian Smith it Unlvenity KoTp^Uli of CIeVelihti!-
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July 1992, Healthcare News.
Profile
Farah Walters hits
the top of the ladder
Oy Eiltrn flnt/
ThniiRh she's Invwlpd IP vein in
C'lCvcUiMTi ho»lthcnTt induslry »«tl
i>icr»lly built hsrearcer hert—14 ycart
with MclrpMnjIdi Synem nnd six wiih
UnivfrallV hji>.«plt<ll» of Clcvcliwc-Tjnh Wiihcr» ny» iiot n »n» linon't
txMn wilted president nnd eliief cxceitMve officer M University Hospitals
llc.iiih System Inc nnd University
11rupilnls she would have left town
Kitliout n backward glance.
Several fallback oltcrs, "nil v«ry «!•
tractive," were pending right up in tlie
mwi«:nt lost month * hc-.i the bwru <
M
tntflccs n.imed Woltcre. who has been
running Ihe hospitnl since February, In
SMCftnl l>. jtinw* Oliick, who iy hi-mlcil
fur Jonns Hopkins in IJMtimnrc.
C(;inmcnling on the ixijrd's exliaustivc. naliniiwiJu jcareli by tin:
ini«iivi<, IVnlli'rs inlmlts she prtihnbly
hrd an cdjie on the other cnndlilnto
Kfnux* whe wns n itnt.tvn quAllly. "In
every nspsct—my prolcm lonal enrccr.
putonrllty, how I deal wllli pnpls
.iiidslluatli'ns, how (conduct myself—
I was an open book."
Born in Iron, WaKera, 47, began her
career in Boston ro a nutritionist. In
IWl she came inOcveland.jolnlng tha
Metro) lunlth System in that field. Site
can>cd mnslsr's degrees tn huniiuus
adoilnlMrntlonnnd nutrition Iron One
Western Reserve Univenlly. Aflcr a
scries ol promotions nnd "climbing up
the indtlif," at Mctrollenllli, alv wns
offered lliojx»l of DircclorolNiilrillim
«t Univvrsity Hoapilnls «1« ycar»<ii;a, n
job "too Rood to pens up."
She continued her movcuptln Inddorrt University, branching Into areas
wh<,»rc rUc hcM ndminlnrrnlivc ptwtt,
mul two years SRO wnj nnmad tu t!ie
number two post behind Dr. Ul.icit.
While she in noi n nicillcfli dcKior,
Wnller knowf Unlvcrsily Mtwpltnfc
(rout tint nttk to tlw bnni-mcnt. Sho
knows v.-licro nuiRt ot Ihc fikcL'tom* arc
V
Fsrak Hsltsrs. rrssKsnl ia< RS,OnlvsnKT IHtpltsIs si Cltitlwi*.
Tltisncw focus lathe reasonwtmiKh
puhlidty tvns given to Ihe sinning of
the afflllntlon ngrremenl Knveon llnhojpltnlandlhrschnoleiirllcrlhuycar,
Wallrr< says. While th* two orj;rnlrnlinos litte had a relallonflup lor "7
yesra, she points oul lltal Ihc ngreemenl WAS more important nf a tool lhal
"mitiiitcs a vision for GcMilnnd's lurure." In show llii.. tvnrkl llinl ChfviIn'Hl l> developing an noulcniic medicine communily lhal will help bring
AKHII a scientific crilkai ttinssthnl "e.in
ertMlc a l.it.-tevlHioloji'cal Ini.siiieii!. cu-
hidden, r.nd, ninny say. actually has
been running the hospltnl's divlslnna
for the past cuupli of ye.int.
Propnnis that she had personnlly
initiated, such as QunlChokc, which
lier prwlecr.sor crediled with helnn
one of ihc hospital'» miat innovaiive
programs, will continue to get her
unsliniinq support ^« will the phyricnl
expansion pr(i(.n<in (Mssicr Fildllly
rmsrnni) bcRun by Block.
Prnprflrtw midt ns the Muflcviloakclotfll liulitutc. ihc C.irdlovssci!|,-,r I'rngrnm and lite tietv r-.irhill InsliUile for
tllk'UlilerlynlH.willuol W.illent'cnreful
scrutiny nnd sirppo,-! tuTnuw ll.cy "nil
(t>ois nn prevention and u-tninle^ttce
as u'cllasnirc," Wol!cr«c« plains. Tltey
will help us move aivoy fnim ihe acute
enre hiisinnw Inm llw prevention nml
vnainlpnnwe Inwinw." TlteyftUowill
serve a^fiMKiijl* for vclopiiiAi lie sante
kintlcorcarlvinlcrvrtthon/pn-vcniion.
r.-.jhcrifc.vt ilmalic 111^, pntgnim^ "for
alviiwl every illwase prncew."
W.ilhTS. hownvcr, d^-s plan mnie
t'lian^i-s, A ftifljor ,me .vill be in Ihe
clir.icaMe^arlnu-nt^.ivlicrt'.incoiiiiiiiclion wii'i, Cas*' Wrsleni Itescrvc
Uiiii'onilysMcclienlSt'l'iKtl.Univcrsitv
Hospitals will jpi.ift<-r clinicnl and ri'se.ircll •'nuperstarf ' ivho will hrini; llv
"Vntd f.( ospvrli'c i.t.d clout lo Ciwe1
Inml lhal wil!pulllu-cilyon lltemnp" as
faraf biti.iv.oviicalsodbio-iixhnoii^ical
research Ificoo^criK-il. il-.c 'avs.
vtrnnitu-nl iierv."
Wallns litdicale? ih.11 Uiii'eri.Hy
IlLvpltais will he Iwinchlng oul in its
relaiioniiiip^ with other hofprlols, 1^.
ptrlnlly Itmse tluu serve lhe heAlllKan
needs of Clev.tanil. ^We nre tooklug In
briii); the Iixisely-Jvfiwl it^wments
tve h.-.ve .vllh olhei lnwpil.tls Isueh .is
Mt Sinai, 'Alerans I lospiial.
MetrnlliMllli. The Clevel.i.nl fllnie
Fottn^l.thoitl lo the nest state in order
Ir Ji'i elop hi(;li.i|u,illtyfari'optiiiiis •'
Wliili-WalU-ni'plate iaoverflini'iiiK.
shi: .ulmiis she Aite^ tvitat siv iv.ts
ge'-tiiij; ntlo \. l'.i.n vlte took ihi- top j|tl\
Tllis is a Iili! Ctiif nliloient. not jusl .i
fih. I'm puillnj; a h>roii hnlc' totiolhis,
,
-
,
htlt Ci ecome t(s» f.ir. Jtiiie lis. muv-ll. to
torn tvu-V itow. '
1
Thankfully, tier l.ostwnJ,
l.nvyer.
nnd thnr dnogliter ondersian.i oiul
••Sack m» 1(1(1 percent." Wallers «avs.
�3>
ro
— j
i
co
CO
A R N B A O JOURNAL
KO ECN
JUNE 9, 1992
—5
CLEVELAND .
•3
—
University Hospitals '
picks woman as chief
Farah M. Walters, who began
hercareer at University
Hospitals of Cleveland in 1986,
has been named the first woman
president and chief executive
officer of the 947-bed hospital.
Walters replaces Dr. James
A. Block, who is leaving
University Hospitals to head The
Johns Hopkins Health System
and. Johns Hopkins Hospital in
Baltimore.
Walters has been acting
president since the search for
Block's replacement began in
February.
.«! to mp,Z e a ^ S ^ % ^
n
B i
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oft-
-
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CD
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�CODER:
HEALTH CARE TASK FORCE SORTING SHEET
TYPE QF MATERIAL:
General mail
Personal stories
Letterhead
Offers to help
Letter Campaign
Casework
.Employment
_Re quests:
-speech
-meeting
_Advocacy
_Policy
Other
Explanation:
ADVISORY PANEL?
physician
large employers
_other health provider
seniors
small business
r.n.
other consumers
Explanation:.
PRIMARY TNTBREST:
COST ISSUES
Drug Prices
Physician Fees
Hospital Fees
Unnecessary Procedures
Medical Equipment
Fraud and Abuse
COVERAGE
Working Families
Unemployed/Low Income
Benefits
Providers
PUBLIC HEALTH/SPECIAL POPULATIONS
Prevention
AIDS
Women's Health
Immunizations
Rural
Urban
GOVERNMENT PROGRAMS
Medicare
Medicaid
Veterans
DoD
ORGANIZATION
Insurance Premiums
Insurance Reform
Insurance Pools
Boards and Oversight
INFRASTRUCTURE/WORKFORCE
Quality Assurance (Guidelines)
Administration. Reimbursement
& Patient Information Systems
Malpractice & Tort Reform
Manpower Issues (Training)
LONG-TERM CARE
MENTAL HEALTH
OTHER
Explanation:
PliAN PREFERENCE: (Support = +; Oppose = -)
CP
SP
OP
Clinton Plan
Single Payer
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits, Vouchers,
Medical Savings Accts.
CA
BR
GE
Canadian
British
German
�HIE SENATE
STATE OF MICHIGAN
COMMITTEES:
CHAIRMAN:
SENATE SELECT COMMITTEE
ON FOREIGN RELATIONS
FIRST DISTRICT
VICE-CHAIRMAN:
GOVERNMENT OPERATIONS COMMITTEE
P.O. BOX 3 0 0 3 6
LANSING. MICHIGAN 48909-7536
(5171 373 7346
FAX 15171 3 7 3 - 9 3 2 0
HEALTH POUCY COMMITTEE
THE OFFICE OF
SENATOR JOHN F. KELLY
JUDICIARY COMMITTEE
MEMBER
SENATE SELECT COMMITTEE
ON EXPORT AND TRADE
SENATE SELECT COMMITTEE
ON ETHICS
February 2, 1993
Ms. Hillary Clinton
PERSONAL AND €QNFIBENTIAfc
The White House
President's Task Force on National Health Reform
1600 Pennsylvania Ave.
Washington, DC 20500
Dear Hillary:
As a progressive Democratic health care reformer, I would like to assist you in your
quest to build consensus and initiate national universal health care legislation. The
enclosed proposal would permit state flexibility and I submit it in the form of
legislation which I introduced during Michigan's 1989-90 legislative session.
Look to the Federal Unemployment Tax Act which establishes a uniform tax structure
for all the states with locally designed implementation as your model. Like the
recently adopted National Association of Governors health care reform proposal, my
universal health care legislation would use a standardized claim form, estabhsh
purchasing cooperatives and expand primary and preventive care. It is based on a
tripartite 3% tax on employers, employees and a matching 3% state contribution to
county or multi-county insurance funds. These funds would be governed, and
participating insurers selected by, a small board of directors which includes
contributing employers, employees, and local government appointees, chaired by a
gubernatorial appointee. Each state would be able to design its own catchment areas
and health care priorities to suit local population needs.
I beheve this legislation provides a workable framework for national legislation and
provides the flexibility to address the varying needs within each state. Please feel
free to contact me if you have any questions, I am more than glad to help you with
your laudable quest.
KELLY
ator
JFKjfk/jh
Enclosures
j Recvded
' Paper
DETERMINED TO BE AN ADMINISTRATIVE
MARKING Per E.0.12958 as amended, Sec. 3.3 (e)
Initials: J£i*=
Date:.
�Article 1
Sec. 1 Title: Universal Health Care Insurance and Safety Net Act
Sec. 2. Definitions: 20 definitions including various definitions of employer, applying
to increased number of small employers as the program is phased in over 5 years.
Indemnity plan definition would require nondifferentiation in payment among eligible
providers (covered type and not excluded because of past history of fraud, abuse, or
incompetence), even with a lack of contractual arrangement with indemnity plan.
Sec. 3. Requires employer to provide the health benefit plan required by this act, to
employees and their famihes. Act does not apply to employers providing actuarial
equivalent plan (determined by state insurance commissioner). Employers already
providing insurance may opt to participate in the plan, but provide additional add-on
coverage.
Sec. 4. Employer Requirements: (if not providing equivalent plan) Contribute 3% of
each employees taxable income to universal health insurance fund, withhold and
forward 3% of employees taxable income to universal health insurance fund.
Sec. 5. The state will also contribute 3% of an employee's taxable income to that
region's insurance fund.
Sec. 6. For each medicaid recipient, the state shall pay an amount equal to 9 of an
%
average taxable income in the county of recipient, to that region's insurance fund.
Sec. 7. Penalty: Employers who violate act are subject to fine of not more than 10%
of total expenditures for wages in that year, in addition to assessment to cover all
back contributions due insurance fund from employee, state and employer. Notice
must be given. Speed of compliance after notification of noncompliance will be used
to determinefine.Possibility for employer liability for damages from health care costs
if employer does not comply after notice. Individuals adversely affected by violations
of act can bring judicial action to compel compliance.
Sec. 8. Employees may waive enrollment in health benefit plan if show proof that
covered under spouse's or parent's health benefit plan, or if covered under plan by
another employer. Employers may not discriminate against any individual who has a
spouse or a child because employer must comply with this act.
Article 2
Sec. 20. Health benefit plans are required to: provide benefits of sec 22, coverage to
enrolled listed in sec. 24, provide for deductibles and co-payments listed in sec. 27.
�Sec. 21. Establish an advisory board (4 employers, 2 labor organization
representatives, 2 insurance industry representatives, & 2 actuaries) to determine 3
model actuarial equivalent plans, establish procedures to certify actuarial standards
for employers opting out of required plan, and review proposed changes in minimum
plan options and make recommendations to legislature.
Sec. 22. Health benefit plan required by this act will cover: inpatient and outpatient
hospital care, inpatient and outpatient physician services, diagnostic and screening
tests, prenatal care and well baby care up to age 12 months. Optional mental health
care of 45 days inpatient, not less than 20 outpatient visits. Plan is not required to
cover experimental or medically unnecessary services or procedures.
Sec. 23. Director of Public Health will annually prescribe and revise required well
baby care.
Sec. 24. Coverage for employees will begin not later than 30 days after initial hour of
employment or first day of legal requirement.
Sec. 25. No individual or preexisting condition exclusions, but states that preexisting
conditions of 6 months or more are covered under standards & guidelines of medicaid
reinsurance fund.
Sec. 26. Temporary employees become eligible under temporary service firm's health
benefit plan at beginning of month following completion of 320 hours of service during
six consecutive months. Continued coverage if employee completes 70 hours of service
in immediately preceding calendar month.
Sec. 27. Health Benefit plans may require employee enrolled to pay for premiums (for
not more than 1 month or more than 3% of employee's hourly wage), deductibles and
coinsurance amounts.
Sec. 28. Optional benefit insurance costs may be computed based on cost of single
employee, employee with spouse, employee with spouse & children, or employee with
children.
Sec. 29. Limitations on basic insurance plan deductibles: single employees - $150 or
an amount that does not exceeds 1 of the total wages paid to employee in plan year;
%
employees with family members - $250 per year, or an amount that does not exceeds
2% of the total wages paid to employee in plan year. No deductibles can be applied to
prenatal or well baby care. Fixed deductible increases indexed to previous year's
Detroit consumer price index. Deductibles cannot be applied until 1 year after
enactment.
Sec. 30. Limitations on basic insurance plan copayment or coinsurance: if provided by
participating provider in compliance with reasonable procedures to ensure efficient
and appropriate utilization of covered services, copayment cannot exceed 10% of the
�cost of the item or service, cannot be applied after employee has reached calendar
year out-of-pocket limits, and cannot be applied to prenatal or well baby care. Mental
health care benefit copayments cannot exceed 50% of the cost of the item or service.
Maximum annual out-of-pocket limit is $1,000 per year, with increases indexed to
previous year's Detroit consumer price index or an amount that does not exceed 10%
of the total wages paid to the employee.
Article 3
Sec. 40. Creation of a universal health insurance fund with in each health insurance
zone. This fund will receive employer and employee contributions, state contributions
for medicaid recipients. Fund may accept grants and gifts.
Sec. 41. Each fund will be operated by 9 member Board: 3 members elected by
contributing employers, 3 members elected by contributing employees and medicaid
recipients, 2 members appointed by county board of commissioners or county
executive. The chair shall be appointed by the governor, with the advice and consent
of the senate.
Sec. 43. Counties with less than 500,000 could join with other county or counties for
an insurance fund. If 2 counties: the 13 member Board would consist of 2 elected
contributing employers from each county, 2 elected contributing employees or
medicaid recipients from each county, 2 appointed by county commissions from each
county. If 3 or more counties: each county will have 1 elected by contributing
employers, 1 elected by contributing employees and medicaid recipients, 1 appointed
by county commission.
Sec. 44. Each Board would select, monitor and oversee insurance providers
participating in providing service for their fund; designate hospitals, clinics and
providers eligible to participate in providing care for the fund; evaluate and make
recommendations concerning coverage and programs.
Sec. 45. The commissioner of insurance shall establish procedures for periodic
certification of insurers participating in insurance funds. Apphcants shall meet
standards offinancialstabihty; standards for quality and type of services; agree to
provide 2 indemnity plans, 2 managed care plans and some optional benefits; agree to
enroll any eligible group; and agree to only offer plans and plan options approved by
the commission to organizations required to enroll.
Sec. 46. Applicants for participating insurer will submit specific plans and other
required information. When determining certification, the commissioner will consider
price of the plans, quality and type of services in the plan, applicant's experience and
financial stability. Commissioner will certify plans within 1 year of act's effective date
and publish list of participating insurers. Commissioner will periodically evaluate
performance and may terminate certification.
�Sec. 47. Participating insurers will offer 2 (1 minimum & 1 comprehensive benefit
package) indemnity plans and managed care plans, plus additional optional benefits
available at additional premiums.
Sec. 48. Optional premiums shall be fixed under a statewide community rating system
for all employers.
Sec. 49. Participating insurers may enter into subcontracts with other entities. They
are encouraged to enter into arrangements with entities representing business groups
for provision of administrative services, with premium reduction for plans to reflect
the value of the administrative services. Technical assistance and enrollment forms
to be provided by commissioner.
�HEALTH CARE TASK FORCE SORTING SHEET
CODER-
TYPE QF MATERIAL:
General mail
Personal stories
Casework
Letterhead
Offers to help
Employment
Letter Campaign
_Policy
.Requests:
-speech
-meeting
Other
.Advocacy
Explanation:
ADVISORY PANEL?
physician
large employers
other health provider
seniors
small business
r.n.
other consumers
Explanation:.
PRIMARY INTEREST:
COST ISSUES
Drug Prices
Physician Fees
Hospital Fees
Unnecessary Procedures
Medical Equipment
Fraud and Abuse
.PUBLIC HEALTH/SPECIAL POPULATIONS
Prevention
AIDS
Women's Health
Immunizations
Rural
Urban
COVERAGE
Working Families
Unemployed/Low Income
Benefits
Providers
GOVERNMENT PROGRAMS
Medicare
Medicaid
Veterans
DoD
ORGANIZATION
Insurance Premiums
Insurance Reform
Insurance Pools
Boards and Oversight
INFRASTRUCTURE/WORKFORCE
Quality Assurance (Guidelines)
Administration, Reimbursement
& Patient Infonnation Systems
Malpractice & Tort Reform
Manpower Issues (Training)
LONG-TERM CARE
MENTAL HEALTH
FINANCING
OTHER
Explanation;.
PliAN PREFERENCE: (Support = +; Oppose = -)
CP
SP
OP
Clinton Plan
Single Payer
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits, Vouchers,
Medical Savings Accts.
CA
BR
GE
Canadian
British
German
�I
THE UNITED STATES CONFERENCE OF MAYORS
1620 EYE STREET. NORTHWEST
WASHINGTON, D.C. 20006
TELEPHONE (202) 29^-7330
RAX. (202) 293-2? =12
President:
WILLIAM J. ALTHAUS
Mayor of York
Vice President:
JERRY ABRAMSON
Mayor of Louisville
Past Presidents:
RAYMOND L. FLYNN
Mayor of Boston
ROBERT M. ISAAC
Mayor of Colorado Springs
JOSEPH P RILEY. JR.
Mayor of Charlesion. SC
COLEMAN A YOUNG
Mayor of Detroir
Ttustecs:
VICTOR ASHE
Mayor ol'KnoxviIle
JOAN W. BARR
Mayor of Evansion
JUANITA CRABB
Mayor of Binghamton
RICHARD M. DALEY
Mayor of Chicago
DAVID DINKINS
Mayor of New York City
SHARPE JAMES
Mayor of Newark. NJ
THEODORE MANN
Mayor of Newton
JAMES PERRON
Mayor of Elkhan
ELIZABETH D RHEA
Mayor of Rock Hill
NORMAN RICE
Mayor of Seattle
GREG SPARROW
Mayor of DeKilb
Advisory Board:
Chair
MAYNARD JACKSON
Mavor of Atlanta
HECTOR LUIS ACEVEDO
Mayor of San Juan
RICHARD ARRINGTON
Mayor of Birmingham
SIDNEY BARTHELEMY
Mayor of New Orleans
CHARLES E. BOX
Mayor of Rtxkford
TOM BRADLEY
Mayor of Los Angeles
ELIZABETH S. BRATER
Mayor of Ann Arbor
CARDELI. COOPER
Mayor of East Orange
JOSEPH R DADDONA
Mayor of Allentown
RICHARD CLAY DIXON
Mayor of Davton
DONALD PHASER
Mayor of Minneapolis
PAUL HELMKE
Mayor of Fort Wayne
DAVE KAKP
Mayor of San Leandro
JIMMY KEMP
Mayor of Meridian
SHEILA LODGE
Mayor of Santa Barbara
EVELYN M. LORD
Mayor of Beaumont
RITA MULLINS
Mayor of Palatine
JOHN O NORQUIST
Mayor of Milwaukee
PETESFERRAZZA
Mavor of Reno
DAVID SMITH
Mayor of Newark, CA
PAUL SOGLIN
Mayor of Madison
MICHAEL R WHITE
Mayor of Cleveland
Executive Director:
J. THOMAS COCHRAN
February 3, 199 3
H i l l a r y Rodham C l i n t o n , Chair
P r e s i d e n t ' s Task Force on
N a t i o n a l H e a l t h Reforin
The White House
1600 Pennsylvania Avenue, N
W
Washington, DC
20500
Dear Ms. C l i n t o n :
C o n g r a t u l a t i o n s on your appointment as Chair o f t h e
P r e s i d e n t ' s Task Force on N a t i o n a l H e a l t h Care Reform.
As you know, t h i s issue i s o f p r i m a r y importance t o a l l
Americans. I am c o n f i d e n t t h a t w i t h your appointment t o
t h i s c r i t i c a l p o s i t i o n , t h e P r e s i d e n t ' s p r o p o s a l w i l l be
one t h a t recognizes t h e myriad o f r o l e s i n both p r i v a t e
and p u b l i c h e a l t h care t h a t must be reformed t o b r i n g
c o s t s under c o n t r o l , y e t p r o t e c t s t h e h e a l t h o f
vulnerable populations.
As t h e e x i t i n g e r a o f h e a l t h care r e f o r m e n f o l d s ,
mayors a r e concerned t h a t t h e debate n o t be l i m i t e d t o
f i n a n c i n g and access o f p e r s o n a l s e r v i c e s alone.
Beyond
the necessity of the i n c l u s i o n of preventive services
w i t h i n a n a t i o n a l "basic b e n e f i t s " package, our
e x p e r i e n c e s w i t h managed care systems f o r M e d i c a i d e l i g i b l e populations — already i n operation i n several
c i t i e s — has shown a g r e a t need f o r a t t e n t i o n t o t h e
p r o v i s i o n o f p o p u l a t i o n based s e r v i c e s .
I have enclosed f o r your c o n s i d e r a t i o n a sevenp o i n t summary o f t h e Conference o f Mayors p o l i c y on
h e a l t h r e f o r m , as w e l l as a copy o f parameters o f h e a l t h
care r e f o r m agreed t o by USCM, t h e N a t i o n a l Governors'
A s s o c i a t i o n , t h e N a t i o n a l Conference o f S t a t e
L e g i s l a t u r e s and o t h e r s .
I read w i t h i n t e r e s t of your plans t o h o l d "town
h a l l " meetings on h e a l t h reform i s s u e s .
Please c o n s i d e r
Cleveland as one o f t h e s i t e s f o r these meetings. I
b e l i e v e t h e r e i s much t o be learned i n my c i t y o f t h e
e x p e r i e n c e s we have gained over t h e years and t h e
innovations' c u r r e n t l y t a k i n g place.
On b e h a l f o f t h e mayors across t h e c o u n t r y , we look
f o r w a r d t o working w i t h you and t h e C l i n t o n
�H i l l a r y Rodham C l i n t o n
-2-
February
3,
1993
A d m i n i s t r a t i o n i n the coming year and wish you t h e
g r e a t e s t of success.
I f you or your s t a f f should have
any q u e s t i o n s r e g a r d i n g the Conference of Mayors' h e a l t h
p o l i c y , please do not h e s i t a t e t o c o n t a c t me d i r e c t l y at
(216) 664-3990 or c a l l Byron J. H a r r i s of the Conference
S t a f f a t 202-293-7330.
Sincerely,
/
M i c h a e l R. White, Chair
H e a l t h Committee
Mayor of Cleveland
�THE UNITED STATES CONFERENCE OF MAYORS
1620 EYE STREET. NORTHWEST
WASHINGTON. D C 20006
TELEPHONE i202) 2 9 } - } } 0
RAX 1202) 29V23S2
Health Care Reform
Summary Points
Health carefinancingreform alone will not create the system changes necessary
to ensure that people and communities receive essential health services. In addition to
the availability of personal health services, population based health services -- those
addressing communicable and infectious diseases and environmental health - are a
necessary component of the health system.
The seven points listed below constitute the United States Conference of
Mayors policy with regard to health reform. They are not intended to reflect an entire
program of reform. Rather, these seven points form a basic parameter under which
mayors believe true health reform must occur to be successful.
The current health care system costs too much and pays for too little. It must
be reformed. Despite the highest per capita spending among industrialized
nations, some 35-37 million of our people remain uninsured.
The issue of health care cost containment must be addressed simultaneously
with universal access for all residents. Without universal access those lacking
regular preventive and primary care will continue to postpone seeking care until
more seriously ill and will be forced to seek care in an inappropriately
expensive setting. Local government bears the cost of much of this
uncompensated care.
Health reform should be national in scope. Basic parameters of health reform
must be set by the federal government to ensure a basic set of health care
insurance availability and access. Lack of federal leadership in this area would
result in a myriad of coverage and basic benefit levels which, collectively,
would be unable to reduce costs as effectively as national enforced reform.
Examples which require federal leadership include:
�a.
the design of a basic benefits package available to every U.S. resident
through either private or public insurance;
b.
the development of a uniform base of information on which consumers
can compare competing health insurance policies;
c.
reform ofthe tort system for medical malpractice suits;
d.
the development, in consultation with states and private insurers, of
standardized claims forms and electronic billing systems;
e.
amendments to the federal tax code to limit the deductibility of health
insurance for both employers and employees.
f.
encouaging the training and placement of culturally competent health
professionals in areas of local need.
4.
A basic benefits package must include a set of preventive services. Steps must
be taken to ensure that these services are not only offered, but delivered by the
care provider agency itself or through reimbursement to local health
departments for providing such services to insurance enrolled patients.
5.
// must be recognized that, even in a system of universal coverage, there will
always be persons who "fall through the cracks" and do not receive the
benefits ofthe system. These individuals are those whose care is and will
continue to be provided by local government through hospitals and clinics. A
national reform system must includefinancialrecognition of the "safety net"
role played by local governments.
6.
Pre-existing health conditions should not be grounds for denial of health
insurance. Currendy insurance companies may refuse persons with prior
conditions, thus making their care the responsibility of personalfinancingor
government. Creation of larger insurance risk pools would allow for coverage
of those with such conditions.
7.
Population based health services and personal health carried out by local
health departments must be continued under a reformed system of health
care. Population based services such as HIV prevention, health promotion,
surveillance and data collection are necessary components for disease control
which cannot be carried out by a personal care insurance system. Personal
health services conducted by local health departments — such as tuberculosis
treatment and control, sexually transmitted disease treatment — not only treat
the disease of individuals, but protect the communityfromsubsequent infection.
�Meeting on Health Care Cost Containment
Statement of Representatives
ofthe
United States Conference of Mayors
National Governors' Association
National Conference of State Legislatures
Council of State Governments
National Association of Counties
National League of Cities
International City/County Management Association
American Business Conference
Committee for Economic Development
National Federation of Independent Businesses
The Business Roundtable
December 15,1992
Washington, D.C.
�On December 1 and 15, in Washington, D.C, representatives of many organizations met on the
critical issue of health care cost containment. These unprecedented meetings were held in recognition ofthe need and public demand for fundamental change in the health care system. The
individuals reached consensus on a number of key national policy issues.
The United States spends more on health care than any other industrialized
nations even though fewer of our citizens have insured access to health care system.
Growth in the health care industry has exceeded growth in the overall economy
for almost every one of the last thirty years. As a result, health care expenditures represent an increasing share of the economy as measured by the gross domestic product
(GDP). In 1980 health care was approximately 9.1 percent of GDP; in 1992 it represented 13.4 percent; and it is projected to represent about 17 percent of GDP by the turn
of the century if current trends continue.
This phenomenal growth in costs has negatively impacted government at every
level and has seriously eroded the competitive edge of our businesses attempting to
compete in a global marketplace.
Clearly the nation cannot sustain the current rate of growth in health care costs.
If the system is expanded to include universal coverage without reform, the cost problems will be greatly exacerbated. While people may argue about the final target for an
acceptable rate of growth in costs, the nation must develop a health care system which,
over the next several years, will move growth in costs toward a long term sustainable
level.
The kinds of structural changes that must occur in the health care system to
control costs cannot be effective unless and until every legal resident has health insurance. Universal access to health care is both a moral imperative and an invaluable cost
containment tool.
�Basic Federal
Framework
We support a managed competitive approach to health care with the caveat that
attention must be paid to ensuring that the approach will work kin both rural and inner
city areas. Toward that end, the federal government should establish a national health
care board that includes state and local representation. Much of the framework necessary to allow the establishment of managed competition could be developed and administered by the national board.
The basic and fundamental federal framework for a restructured health care
system that both controls costs and provides access and coverage, must include, at a
minimum:
•
The federal government should organize a standardized information base for
consumers that would include price and quality information for all providers of
health care services in a given geographic area.
•
The federal government should organize national outcomes research. One component of such research should focus on primary and preventive care. Among
other uses, this research could be used as a base for clinical practice models.
•
In consultation with states, the federal government should develop minimum
standards for the regulation of health insurance, which would include limitations
on the variation in rates that different individuals and groups would be charged,
limitations on medical underwriting, and guaranteed renewability, portability
and availability of insurance products. States can exceed these minimum standards. Once reforms are implemented individuals bear a personal responsibility
to obtain coverage either though public or private programs. The cost of coverage should be supplemented for low-income individuals.
•
The federal government should work with states to develop purchasing cooperatives through which affordable insurance products will be made available.
•
The federal government should develop minimum standards for medical tort
reform, which states may exceed. States must develop systems within those
parameters.
•
The federal government should develop a single claims form and support the
development of electronic billing as a means to reduce administrative costs.
•
The federal government, in consultation with states, localities, businesses, and
labor, shall develop a basic benefit package comparable to that now provided by
the most efficient and cost-effective health maintenance organizations. There
may be some state or regional variations in the basic benefit package, but such
�variations must be certified by a national health care board. Individuals would
be free to purchase additional insurance with after-tax dollars.
The federal tax code should be amended to limit the tax deduction/exemption of
health insurance for both employers and employees. Employer-paid insurance
above the limit would be taxable to either the employer or employee. The selfemployed would be eligible to purchase fully deductible health insurance, exempt from taxation as personal income, within the federal limit and/or tied to a
percentage of an income level. This limit may be tied to the local cost of a basic
benefit package, set at a specific dollar amount. Additional coverage or care can
be purchased with after-tax dollars.
The federal government should greatly expand its support for primary and
preventive care, including, but not limited to, childhood immunizations and
prenatal and well-baby care.
Specific
Cost Containment
Strategies
Even if a federal framework is established which adheres to the principles described above, there is still a real possibility that the federal government will attempt
cost control by capping the federal medical entitlement programs. A cap only on federal
health care entitlement programs will most certainly continue to shift costs to the private sector and local governments and reduce real benefits to real people. A more
effective strategy is to control costs throughout the health care system through the
development of health care expenditure targets.
At this time, it may be unrealistic to set a strict national health care expenditure
budget because adequate objective data do not exist. We propose a goal for growth in
health care costs that represents the sum of the general inflation rate, a population
factor, and a factor that accounts for changes in service intensity and cost-effective new
technologies. Extending the latest Congressional Budget Office estimates, health care
costs should increase by no more than 9 percent in 1994. By 1995 growth should not
exceed 7 percent, and in future years, growth should not exceed 5 percent annually. We
recognize that in the early years, the lack of standardized data will result in a certain
degree of imprecision in the measure of national health care expenditures. We recommend:
•
The goals for growth of national health care expenditures should be established
for expenditures that are publicly supported either directly or through the tax
code. These goals should be used to estimate expenditure targets for each state.
Health care expenditures made by individuals with after-tax dollars would not
be included in the targets.
�Data systems necessary to measure objectively national and state health care
expenditures must be established.
As data become available there should be a review of the progress the federal
and state governments have made toward achieving the national expenditure
goals. Any decisions about the need for statutory enforcement mechanisms and
incentives would be made at that time.
The federal government should issue an annual report to the states which addresses:
1)
The effectiveness of our health care expenditures toward producing and
maintaining health for all of our citizens. The data shall be presented in at
least the following categories: populations, state-by-state, urban and rural,
fee-for-service, various types of managed care, and comparative therapies;
2)
The status of data system improvements, including the development of
data categories, sample sizes, and timeliness;! and
3)
the progress or failure of each state toward any state for per capita expenditure goals.
State and Local
Management
Within the context of a managed competitive approach to health care reform,
which ensures universal access and controls costs, we support the principle of state and
local management. States and local government will need a set of tools to manage a
cost effective health care system.
•
Assuming that there is still a public program, even if that public program is
modeled after Medicaid, states and local government will need stable financing
and a common definition of eligibility. Beyond that, however, states and local
government must be given the flexibility and authority to integrate fully the
public program into a service delivery system that reflects the national movement towards managed care. The federal government must not impose mandates and beyond the basic benefits or service delivery restrictions on the public
program. A streamlined and efficient public program will obviate the need for
the complex and costly waiver process.
•
If Medicare continues to exist as a separate program, states and local government
will need the flexibility to integrate Medicare fully into their health care systems.
�States must have the ability to include the current self-insured market (ERISA
plans) in their state design.
States must have additional authority now precluded by federal anti-trust statutes.
The federal government must participate in a discussion about how to deal with
the access issues of rural areas, inner cities, and populations currently financed
by federal programs including Native Americans, veterans, and CHAMPUS.
The federal government must also participate in discussions about the provision
of care to undocumented aliens.
The federal government, states, and local government must agree on the structure and role of public health financing and delivery systems.
The federal government and states and local government must work toward
agreement on a long-term care program that would "demedicalize' and uncouple
it from the health care system.
While our individual organizations have not yet reviewed or approved these
recommendations , we, as individual members and leaders, believe that they reflect a
reasonable and workable approach to this critical issue. However, the National Conference of State Legislatures has certain formal positions at variance with some aspects of
the statement. We are prepared to work with our organizations, with other interested
organizations, and with the President and the Congress first to flesh out the details of
specific proposals and then to secure formal; support and enactment.
�HEALTH CARE TASK FORCE SORTING SHEET
TYPE OF MATERIAL:
General mail
Casework/personal stories
Letterhead
Resumes/offers to help
Phone call
_Re quests:
-speech
-meeting
_Policy papers
Other
.non-physician health provider
seniors
ADVISORY PANEL?
physician
small business
other consumers
PRIMARY INTEREST:
budgets and caps
_ benefits
HIPC organization
_ employer participation
_ administration, reimbursement,
& patient information systems
organization, boards,
federal and state oversight
_ unemployed/low income
_ medicare
_ insurance reform
_ quality assurance
_DOD
_ Veterans
_ federal employees
malpractice & tort reform
_ prep of health care workers
_ ethical foundations
_ short-term cost controls
_ public financing
_ long-term care
_ mental health
_ economic impacts
_ AIDS
_ women's health
_ immunization programs
other
_ rural, inner city regions
GEOGRAPHY:
Region(NW,SE?):_
Rural, Urban, Suburban?:,
PLAN PREFERENCE;
CP
SP
OP
OT
Endorsed Clinton Plan
Single Payer
Own Plan
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits or Vouchers
�2-11* IH
HEALTH CARE TASK FORCE
EN-TAKE ROOM ROUTING SUP
OFFICE:
Public Liaison
V Intergovernmental
Congressional Relations
First Lady
Other:_
BEQUEST:
Meeting
Speech
Letter
Phone Call
Other:
REQUIRES ACTION:
Immediately
By:
^ Soon, butrmrtqpriority:
(Date)
�4,
STATE OF WYOMING
OFFICE OF THE GOVERNOR
MIKE SULLIVAN
CHEYENNE 8 2 0 0 2
GOVERNOR
February 19, 1993
H i l l a r y Clinton
Chair, Health Refonn Committee
The White House
Washington, D.C. 20501
Dear H i l l a r y :
As you examine options to increase access to health care for
mothers and children and at the same time achieve cost containment, I wanted to bring to your attention a promising concept we
are exploring at the Western Governors' Association through our
Health Passport Project. Five western states are partnering with
several federal agencies (HSS/MCH and we expect USDA/FNS,
HFCA/ORD) to t e s t the use of smartcard technology to combine
electronic benefits transfer with a portable health record. We
believe the Health Passport to be an important experiment,
p a r t i c u l a r l y well suited to delivering health care i n
r u r a l / f r o n t i e r environments. An abstract of the project i s
attached.
I f you want additional information, please contact me, or
Thomas Singer, WGA Director of Research at (303)623-9378 or Terry
Williams on my s t a f f a t (307)7777494.
Sincerel
Sullivan
Governor of Wyoming
/mas
Enclosure
�HEALTH PASSPORT PROJECT
- ABSTRACT The Western Governors' Association (WGA) Health Passport Project
proposes to improve access to and delivery of Maternal and Child
Health (MCH), the Women, Infants and Children Program (WIC),
Medicaid, and related health services by u t i l i z i n g smartcard
technology to combine e l e c t r o n i c benefits transfer with a portable
health data base. The governors of f i v e western s t a t e s — I d a h o ,
Montana, Nevada, North Dakota and Wyoming—have joined i n a
regional e f f o r t to conduct a f e a s i b i l i t y study and then demonstrate
the phased addition of such services as Medicaid, Children with
Special Health Care Needs, Immunization, Prenatal Care and Head
Start to the WIC EBT system that has been s u c c e s s f u l l y demonstrated
in Wyoming.
Recognizing that the project w i l l require a public/private
partnership, the governors have established a WGA Health Passport
Task Force representing state and federal agencies and regional
health care, r e t a i l , banking, insurance, and computer services
i n t e r e s t s to provide stakeholder input and support for the project.
The goal of the f e a s i b i l i t y study and demonstration i s to y i e l d a
national partnership model for regional public/private delivery of
MCH, WIC, and other health care benefits for high r i s k populations,
including Native Americans and migrant a g r i c u l t u r a l workers. The
project also seeks to y i e l d program e f f i c i e n c i e s and to leverage
resources.
�DEPARTMENT OF PUBLIC HEALT
1600 Arch Street, 7th Floor
Philadelphia, PA 19103
CITY O F PHILADELPHIA
February
H i l l a r y Rodham C l i n t o n
The W h i t e House
1600 P e n n s y l v a n i a Avenue,
W a s h i n g t o n , D.C.
20500
Dear
18,
ROBERT K. ROSS, M.D.
Commissioner
1993
N.W.
Hillary:
As y o u b e g i n t o t u r n y o u r a t t e n t i o n s t o t h e i s s u e o f
i m m u n i z a t i o n s f o r c h i l d r e n as a m a t t e r o f n a t i o n a l h e a l t h c a r e
p o l i c y , I t h o u g h t i t m i g h t be u s e f u l f o r y o u t o have some
b a c k g r o u n d on a r e c e n t e x p e r i e n c e we had i n P h i l a d e l p h i a w i t h a
f e d e r a l i n i t i a t i v e t h a t went awry.
Enclosed i s a copy o f t h e I n f a n t I m m u n i z a t i o n
Initiative
(known as 1-3) p r o p o s a l s u b m i t t e d by a c o n s o r t i u m o f p r o v i d e r s ,
n e i g h b o r h o o d and community groups, and under t h e a e g i s o f t h e
P h i l a d e l p h i a Department o f P u b l i c H e a l t h .
T h i s was i n r e s p o n s e
t o a r e q u e s t b y h e a l t h a d m i n i s t r a t o r s a n d a p p o i n t e e s o f t h e Bush
a d m i n i s t r a t i o n , i n c l u d i n g former S e c r e t a r y S u l l i v a n , Surgeon
G e n e r a l N o v e l l o , and D r . Roper, head o f t h e C e n t e r s f o r D i s e a s e
C o n t r o l (CDC).
T h i s f e d e r a l i n i t i a t i v e was begun a f t e r
P h i l a d e l p h i a c h i l d r e n s u f f e r e d a s e r i o u s measles o u t b r e a k .
S e v e r a l c h i l d r e n d i e d , and t h e o u t b r e a k became a n a t i o n a l s t o r y ,
and s e r v e d as a l i n c h p i n f o r t h e f e d e r a l i n i t i a t i v e .
The i n i t i a t i v e was o r i g i n a l l y i n t e n d e d t o i n c l u d e t h e
s e l e c t i o n o f s i x c i t i e s based o n t h e m e r i t s o f t h e i r p r o p o s a l .
The i n t e n t was t o e s t a b l i s h b e n c h m a r k p r o g r a m s t h a t w o u l d
c o m p r e h e n s i v e l y a d d r e s s t h e i d e n t i f i e d i s s u e s as t h e y r e l a t e t o
t h e d e v e l o p m e n t and i m p l e m e n t a t i o n o f e f f e c t i v e i m m u n i z a t i o n
programs.
H a l l m a r k s i n c l u d e d community and n e i g h b o r h o o d
support
and c o n t r i b u t i o n , e f f e c t i v e and s y s t e m i c d a t a management,
o u t r e a c h , e d u c a t i o n , and f o l l o w - u p .
The i n i t i a t i v e was p r e s e n t e d w i t h much f a n f a r e and many
p h o t o o p s i n F e b r u a r y o f 1992.
Following t h e submission o f t h e
p r o p o s a l , we were a s s u r e d by CDC t h a t t h e P h i l a d e l p h i a p r o p o s a l
was " t h e b e s t " , and t h e y a n t i c i p a t e d f u l l f u n d i n g , w h i c h was
a p p r o x i m a t e l y $4,000,000 d o l l a r s .
We w a i t e d p a t i e n t l y as " t h e
process" continued.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002. letter
DATE
SUBJECT/TITLE
Donna Gentile O'Donnell to Hillary Clinton [partial] (1 page)
2/18/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [1]
2006-0885-F
wr824
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIAj
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions ((b)(8) ofthe FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA)
National Security Classified Information 1(a)(1) ofthe PRA|
Relating to the appointment to Federal office Ka)(2) ofthe PRA|
Release would violate a Federal statute 1(a)(3) ofthe PRA)
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) ofthe PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�H i l l a r y Rodham C l i n t o n
F e b r u a r y 18, 1993
Page 2
B u t , we f o r g o t i t was an e l e c t i o n y e a r . The p o l i t i c a l
p r o c e s s r o l l e d i n t o t h e s u b s t a n t i v e i s s u e a r e n a . The o r i g i n a l
f e d e r a l i n i t i a t i v e was s c r a p p e d i n f a v o r o f d o l i n g o u t a few
d o l l a r s t o many s i t e s i n o r d e r t o c r e a t e more f a n f a r e and p h o t o
ops.
As you know, P h i l a d e l p h i a i s a h e a v i l y D e m o c r a t i c c i t y . I t
made no p o l i t i c a l sense t o f o l l o w t h r o u g h w i t h t h e i n i t i a l p l a n ,
s i n c e t h e r e w o u l d be l i t t l e s u p p o r t f o r George Bush h e r e .
U l t i m a t e l y , we r e c e i v e d $430,000, w h i c h made i t i m p o s s i b l e t o
f u l f i l l the objectives of the i n i t i a t i v e .
T h i s c o m m u n i c a t i o n i s n o t i n t e n d e d t o be a l o b b y i n g e f f o r t
t o f u n d t h i s p a r t i c u l a r p l a n o f a c t i o n . We do l o o k f o r w a r d t o
o p p o r t u n i t i e s t o work w i t h y o u and t h e a d m i n i s t r a t i o n t o w a r d
t h e s e g o a l s as p a r t o f a c o m p r e h e n s i v e h e a l t h agenda. R a t h e r , I
t h o u g h t t h i s w o u l d be u s e f u l t o you i n u n d e r s t a n d i n g where we a r e
i n P h i l a d e l p h i a on t h i s i s s u e .
Good l u c k t o you-as y o u c o n t i n u e t o move i n t o t h i s " t h o r n y
b r u s h " w h i c h r e q u i r e s b o t h p r u n i n g and c u l t i v a t i o n .
I am
a v a i l a b l e t o you t o be h e l p f u l i n any way I c a n .
Sincerely
yours,
Donna G e n t i l e O ' D o n n e l l , MSN, RN
Deputy H e a l t h Commissioner
f o r P o l i c y and P l a n n i n g
DGO'D/pah
Enclosure
�Stale Representative
PHIL PANKEY
5763 Shasta Circle
Littleton, Colorado 80123
Home: 798-5873
Capitol: 866-2953
Chairman.
Health, Environment.
Welfare and
Institutions Committee
Member:
State Affairs Committee
C O L O R A D O
H O U S E
O F
R E P R E S E N T A T I V E S
STATE CAPITOL
DENVER
SO203
January
29,
1993
The White
House
Mrs. Hillary
Clinton
1600 Pennsylvania
Avenue,
Washington,
D.C.
20500
Dear
Mrs.
N.W.
Clinton:
As Chairman
of the Colorado
Health,
Environment,
Institutions
Committee
I know that
smoking
budget
millions
of
dollars.
It is my recommendations
to eliminate
farmers.
This will
encourage
citizens
the same time help to cut government
Thank you for your consideration.
do to help you in Colorado
please
me.
Sincerely,
Phil
State
Pankey J
Representative
PP/cam
all
Welfare
increases
and
our
subsidies
to
to stop smoking
spending.
tobacco
and at
If there
is anything
do not hesitate
to
I can
contact
�^North daraliua (General Asscmblo
House uf Ivcprcacutatiurs
Xrgialatiur ©fficr lluilbiug
Kalrigh 27601-1096
REP.
LYONS GRAY
3 9 T H DISTRICT
R O O M 5 I 2. L E G I S L A T I V E O F F I C E B U I L D I N G
LEGISLATIVE OFFICE T E L E P H O N E : (919)
HOME ADDRESS.
733-5907
March 26, 1993
P. O. BOX 1 1 8 6 3
WINSTON-SALEM
N C.
2761
1-1863
1919) 7 5 9 - 2 O 3 0
Mrs. H i l l a r y Rodham C l i n t o n
P r e s i d e n t ' s Task Force on H e a l t h Care Reform
The White House
Washington, DC 20500
Dear Mrs. C l i n t o n :
I am w r i t i n g as a member o f t h e Board o f T r u s t e e s o f
AIDS Care S e r v i c e , I n c . , Winston-Salem, N o r t h C a r o l i n a , t o
suggest a way t h a t people w i t h HIV disease can r e c e i v e
b e t t e r care a t less cost than p r e s e n t l y .
A t g r e a t expense, h o s p i t a l s keep some persons w i t h HIV
d i s e a s e l o n g a f t e r h o s p i t a l i z a t i o n i s r e g u i r e d by t h e i r
m e d i c a l c o n d i t i o n , s i m p l y because many homeless o r i n d i g e n t
HIV+ p e o p l e have nowhere t o go. AIDS Care S e r v i c e p l a n s t o
b u i l d a group home f a c i l i t y where such people can r e c e i v e
f a m i l y - s t y l e c a r e d u r i n g t h e end stages o f t h e d i s e a s e .
The c o s t o f care i n t h i s f a c i l i t y , e s t i m a t e d a t
$90-100 p e r bed per day, w i l l be a f r a c t i o n o f t h e c o s t o f
h o s p i t a l i z a t i o n . F a c i l i t y r e s i d e n t s w i l l r e c e i v e more
p e r s o n a l a t t e n t i o n and s u p p o r t t h a n p u r e l y m e d i c a l
f a c i l i t i e s can a f f o r d t o p r o v i d e .
Group homes, such as t h e one we p l a n , f a c e a g r e a t
o b s t a c l e i n r a i s i n g o p e r a t i n g budgets. The amounts r e g u i r e d
f o r AIDS c a r e seem d a u n t i n g u n t i l comparison w i t h t h e c o s t
of t h e h o s p i t a l a l t e r n a t i v e p l a c e s them i n p r o p e r
perspective.
D e s p i t e t h e g r e a t and g r o w i n g need f o r f a m i l y c a r e
f a c i l i t i e s , t h e d i f f i c u l t y o f f i n d i n g ongoing sources o f
o p e r a t i n g funds d i s c o u r a g e s p o t e n t i a l funders and v o l u n t e e r s
from c o l l a b o r a t i n g t o e s t a b l i s h them. Few e x i s t now.
V
�Mrs. H i l l a r y Rodham C l i n t o n
P r e s i d e n t ' s Task Force on H e a l t h Care Reform
March 26, 1993
Page Two
AIDS Care S e r v i c e suggests t h a t a mechanism o r program
be e s t a b l i s h e d f o r t r a n s l a t i n g t h e funds now spent on
needless h o s p i t a l i z a t i o n o f HIV+ people t o t h e o p e r a t i n g
budgets o f l e s s c o s t l y , more a p p r o p r i a t e care f a c i l i t i e s .
This s h i f t i n
f i n a n c i a l and o t h e r
f a c i l i t i e s and t e n s
c o u l d save m i l l i o n s
funding could r e l i e v e s i g n i f i c a n t
burdens o f thousands o f medical
o f thousands o f a f f e c t e d people. I t
of d o l l a r s annually.
I and o t h e r AIDS Care S e r v i c e board members would be
p l e a s e d t o work w i t h t h e Task Force s t a f f t o e x p l o r e t h e
ways i t m i g h t b e s t be r e a l i z e d .
Please l e t me know t h e b e s t
way t o f o l l o w up t h i s i d e a .
Sincerely,
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003a. letter
SUBJECT/TITLE
DATE
John Mark Windle to Hillary Clinton [partial] (1 page)
3/9/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [1]
2006-0885-F
VVT824
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 5S2(b)|
PI National Security Classified Information |(a)(l) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) ofthe PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information |(b)(l) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes |(b)(7) of Ihe KOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
KR. Document will be reviewed upon request.
�MEMBER OP COMMITTEES
JOHN MARK WINDLE
STATE AEPnESEWTATIVE
FEHTOESS, MORGAN
AND OVERTON COUNTIES
110 WAN MEMORIAL BUILDING
NASHVILLE. TENNESSEE S 7 2 4 M U 1
(615) 741.1290
%ous(e ot fteprettntattoe*
&tate of QLmnztim
JUDICIARY
SUB COMMITTEES
CRIMINAL PRACTICE » PROCEDURE
PERSONAL INJURY S TORT REFORM
TRANSPORTATION
SUBCOMMITTEE
NAPIER
NASHVILLE
March 9 , 1993
Mrs. H i l l a r y Rodham Clinton
Chairperson
P r e s i d e n t i a l Task Force on Health Care
The Wiite House
1600 Pennsylvania Avenue
Washington, D.C. 20500
I'd)
Dear Mrs. Clinton:
Attached i s a copy of a l e t t e r from Mr. ffj
—
^
—
•• - • - • [ , - ; w K ^
•
:;.r^AQ
i n regard as
r e c i p i e n t s , such t o the Medicaid Program about transplanto r
who cannot afford to pay f
t h e i r expensive a n t i - r e j e c t i o n medicine on t h e i r own.
Fortunately, they have medicaid and are very appreciative,
In t h i s case, as well as so many others i t i s a l i f e
threatening s i t u a t i o n .
This i s one area where the health and g u a l i t y of
l i f e i s much improved and more cost e f f e c t i v e t o provide
medicine instead of allowing r e j e c t i o n and the costly
complications that f o l l o w .
I wanted t o share t h e i r l e t t e r and express my
concern f o r the people who need and depend on t h i s very
kind of program. I know you are giving much thought and
consideration t o t h i s issue and I wanted t o give you the
benefit of reading t h e i r l e t t e r .
I f I can ever be of assistance t o you please l e t
me know.
Respectfully,
John Mark Windle
Is
Attachment
cc:
Tennessee Governor Ned R. McWherter
Senator Jim Sasser
Senator Harlan Mathews
• Hea 1 jhh rnrnTTn rrjgaa^-^aiafet 11 Wiite
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003b. letter
SUBJECT/TITLE
DATE
Constituent to John Mark Windle [partial] (1 page)
3/1/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [1]
2006-0885-F
wr824
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information |(a)(l) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) ofthe PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy ((a)(6) ofthe PRA|
b(I) National security classified information [(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�1, /TO
'^Mii 4. ^aivA - 0 ^ JKM jkvK -jw^
|
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;
in visuJ^i
fr-.
�NEW YORK STATE
OFFICE OF ALCOHOLISM
AND
SUBSTANCE ABUSE SERVICES
Mario M. Cuomo
Governor
Marguerite T. Saunders
Commissioner
March 8, 1993
Mrs. Tipper Gore
President's Task Force on National
Health Care Reform
Old Executive Office Building
Room 273
rrjl
»Q • "
1
Washington, D.C. 20501
Dear Mrs. Gore:
As Commissioner of the nation's largest alcohol and drug treatment system, I am ..
writing to extend my office's perspective and assistance to you in your deliberations on
national health care reform.
My principal issue is that national health care reform must address substance
abuse, as the cost of untreated alcoholism and drug abuse is staggering. It is estimated
that the cost of substance abuse to our nation will exceed $300 billion this year.
Currently in this country there are hundreds of thousands of persons with alcohol
and other drug dependencies who cannot access treatment. In 1990 the Institute of
Medicine reported that each year, two to three million people with alcohol and other
drug problems need but cannot obtain treatment. Accordingly, we believe that a
minimum benefit package must include comprehensive coverage for alcohol and other
drug treatment services provided by qualified, licensed, or otherwise certified health care
professionals with expertise in addictions.
Drug users historically have experienced serious difficulty accessing adequate health
care. We are finding that our clients are utilizing inpatient hospitalizations and emergency
rooms in substantial ways, such that substance abuse and alcoholism clients appear to be
one of the largest subset populations who are incurring high risks with repeated episodes.
Even when substance abusers are participating in alcohol or drug treatment, there is
limited access to basic primary care services. This problem is now compounded by the
HIV/AIDS epidemic, the tuberculosis epidemic, and a remarkable increase in sexuallytransmitted diseases; all with significant public health ramifications. In a soon to be
published study conducted by The Montefiore Hospital (NYC) substance abuse program's
primary care unit, 40% of the cases seen were for HIV related illness. Significantly, 60%
of the cases were for other health problems including hypertension, diabetes, heart
disease, asthma, pregnancy and other common conditions of young adults.
PLEASE REPLY TO OFFICE AT:
194 Washington Avenue • Albany, New York 12210
•
•
Executive Park South • Albany, New York 12203
An Equal Opportunity/Aflirmative Action Employer
£j
printed on recycled paper
�Nationally, alcoholism and substance abuse treatment are funded in part by public
and private health insurance reimbursement. In New York State, Insurance Law
stipulates that group health insurance policies must provide coverage for at least 60
outpatient visits per year for treatment for alcoholism and substance abuse, of which up
to 20 may be for family members. The law also requires that such policies make
coverage for inpatient services available. Medicaid is also available for most alcoholism
and substance abuse treatment.
Reform at the federal level will preempt state action; therefore, for the benefit of
100,000 clients and patients in treatment in certified programs in New York State, it is
critical that a continuum of care for alcoholism and substance abuse be included in the
basic benefit package that would be provided to all persons. The benefit must be
flexible enough to accommodate persons with diverse needs. In all instances treatment
should be provided in the setting most appropriate for each individual.
I understand that you have several substance abuse experts on loan from the
Substance Abuse and Mental Health Services Administration (SAMHSA) and the
National Institutes of Health (NIH) participating in your working group on mental health.
As you consider the role of substance abuse treatment within national health care reform,
you may also want to involve professionals from the field ~ those working on "the front
lines" of services for the addicted. Their insights should assist you to formulate
recommendations that will incorporate the needs of those who require services for
alcoholism and drug dependency into the national health care reform initiative. Finally,
if you or your staff is interested in coming to New York State to get afirst-handlook
at some of the heath care issues with which we are contending, I would be pleased to
arrange substance abuse facility visits. Thank you for your attention.
Sincerely,
Marguerite Tl Saunders
MTS:mbm
cc:
Lisa Scheckel
Peter Brock
Bernie Arons, M.D.
0
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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Paper
Dublin Core
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Title
A name given to the resource
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 3] [1]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 36
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Reproduction-Reference
Date Created
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3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-036-008-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/72edc78c6431c35aa4bff1a983a6aed5.pdf
8e79d91ba3fca745427611feeddd7ce5
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1985
FolderlD:
Folder Title:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
4
1
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECIYTITLE
DATE
RESTRICTION
001. letter
To Members ofthe Senate, re: SB 188 [partial] (1 page)
3/2/1993
P6/b(6)
002. letter
W. Straus to Hillary Clinton [partial] (1 page)
3/16/1993
P6/b(6)
003. letter
M. Parsons to Hillary Clinton [partial] (1 page)
2/24/1993
P6/b(6)
004a. letter
Benny Dykes to Mack Parson, re: Medicare Benefits for constituent
(2 pages)
2/19/1993
P6/b(6)
004b. letter
Benny Dykes to Robert Gafford, re: Medicare Benefits for constituent
(1 page)
12/14/1992
P6/b(6)
004c. paper
"Explanation of Your Medicare Part B Benefits" (1 page)
2/17/1993
P6/b(6)
005a. letter
Benny Dykes to Mack Parson, re: Medicare Benefits for constituent
(2 pages)
2/19/1992
P6/b(6)
005b. paper
"Explanation of Your Medicare Part B Benefits" (3 pages)
2/17/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
2006-0885-F
wr823
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA]
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA)
P4 Release would disclose trade secrets or confidential commercial or
financial information |(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA|
b(l) National security classified information [(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency |(b)(2) ofthe FOIA)
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) ofthe FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) ofthe FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) ofthe FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�STATE OF COLORADO
EXECUTIVE CHAMBERS
1 i b Slate C d p i t o l
n c n v t w . C o l o r a d o HO203-1 792
Phijiii- U O i l abfa-24 71
March 12, 1993
Roy Romer
Governor
H i l l a r y Rodham Clinton
Chairwoman
National Health Care Task Force
1600 Pennsylvania Avenue
Washington, D.C. 20500
RE:
HEALTH CARE/CATASTROPHIC
ISSUES
Dear Ms. Clinton,
I am writing during a two-day s t i n t as Acting Governor of
the
State
of Colorado,
(Assistant Minority
Leader
(Democrat) i n real l i f e ) .
The purpose of my l e t t e r i s to bring to your attention a
philosophy/method of care for a very serious i l l n e s s .
For
example, autologous
ABMT and i t s new
hybrid
treatments for cancer may see t h e i r costs cut i n h a l f ,
but
only
through c l i n i c a l
trials
involving c a r e f u l
research protocols.
I am f e a r f u l we may be creating a "healthy" insurance
system rather than a "health" insurance system i f we do
not look at cost/benefit i n such serious i l l n e s s e s as
cancer and others.
A b i l l I am sponsoring would require health insurers to
pay for c l i n i c a l t r i a l s for cancer.
We know that i n
70-90% of c l i n i c a l t r i a l s (which i n 90% of the cases
compare the accepted treatments and compare costs and
outcomes) insurers already pay. Court cases have found
in favor of the insureds 90% of the time. S t i l l , c e r t a i n
companies spend money, time and e f f o r t s i n fighting
payment.
(Please see attached a r t i c l e s for analysis of
t h i s p a r t i c u l a r proposal).
I hope you w i l l factor this approach to catastrophic care
into your health insurance work.
I'm proud to think of
your t a c k l i n g this gargantuan task.
Please l e t me know i f I might become more involved
t h i s issue.
, -laincerely,
J.elna Wells Mendez
f e t i n g Governor
on
�First Regular bession
Fifty-ninth General Assembly
LLS NO. 93-0360.01D JIB
STATE OF COLORADO
.
SENATE BILL 93-
A BILL F R A A T
O N C
102
C N E N N M D C L C S S F R CERTAIN CLINICAL TRIALS F R T E
OCRIG EIA OT O
O H
TETET O CNE.
RAMN F ACR
Bill Summary
(Note: This summary applies to this bill as introduced
and does not necessarily reflect any amendments which m y b
a e
subsequently adopted.)
Requires that insurers, health maintenance organizations,
and nonprofit hospital, medical-surgical, and health service
corporations cover the cost of physician fees and hospital
costs, but not research-related costs, whenever a insured,
n
enrollee, or subscriber participates in a cancer treatment
clinical t r i a l , after referral by his or her primary care
physician, that meets certain requirements. Requires that such
coverage b provided in the s m manner as other covered
e
ae
diseases a d conditions under the policy or contract.
n
Requirements for a clinical trial program include: The
treatment must have therapeutic intent and must b provided
e
pursuant to a national cancer institute approved clinical t r i a l ;
the therapy must be approved by an institutional review board
and the Colorado clinical trial review advisory board; the
providers of the treatment must be qualified by experience or
training; available data must provide a reasonable expectation
that the treatment will b at least as effective as the
e
alternative; and there must be no superior, noninvestigational
alternative.
Creates the Colorado clinical trial review advisory board
in the division of administration in the department of health
to review proposed therapies for the treatment of cancer and
recommend that patient care costs for clinical protocol
therapies be reimbursed.
1
2
Q
Q
0 0
BUSINESS AFFAtPSftL B R
AO
B S N T R Mendez, W a , and Wallenberg;
Y EAOS
hm
also R P E E T T V Fleming.
ERSNAIE
101
1
Be it enacted by the General Assembly of the State of Colorado:
S C I N 1. 10-16-104, Colorado Revised Statutes, 1987
ETO
Capital letters indicate new material to be added to existing statute.
Dashes through the words indicate deletions from existing statute.
�1
Repl. Vol., as amended, is a e d d B T E ADDITION O A NW
mne Y H
F
E
2
SUBSECTION to read:
3
10-16-104. Mandatory coverage provisions. (10) Cancer
4
treatment - clinical trials, (a) A U E I THIS SUBSECTION
S SD N
5
(10), UNLESS T E C N E T OTHERWISE REQUIRES:
H OTX
6
(I) "CLINICAL P O O O " M A S A P A O A SCIENTIFIC
RTCL EN
LN F
7
T E T E T T A INCLUDES G A S A RATIONALE, A D B C G O N F R
RAMN HT
OL,
N AKRUD O
8
T E P A , CRITERIA F R PATIENT SELECTION, SPECIFIC DIRECTIONS
H LN
O
9
F R ADMINISTERING T E A Y A D M N T R N PATIENTS, A DEFINITION
O
HRP N OIOIG
10
O QUANTITATIVE M A U E F R DETERMINING T E T E T R S O S , A D
F
ESRS O
RAMN EPNE N
11
M T O S F R D C M N I G A D TREATING ADVERSE REACTIONS.
EHD O OUETN N
12
(II) "CLINICAL TRIAL" M A S A Y SCIENTIFIC S U Y OF A NW
EN N
TD
E
13
T E A Y IN H M N BEINGS F R T E T E T E T O C N E A D INCLUDES
HRP
UA
O H RAMN F ACR N
1
4
A FULLY DEVELOPED CLINICAL P O O O .
RTCL
15
(III) "INSTITUTIONAL R V E B A D M A S A Y B A D
EIW OR" EN N
OR,
16
C M I T E O O H R G O P F R A L DESIGNATED B A INSTITUTION
O M T E , R TE RU OMLY
Y N
17
A D A P O E B T E F O A D D U ADMINISTRATION T REVIEW,
N P R V D Y H OD N RG
O
18
A P O E T E INITIATION O , A D C N U T PERIODIC R V E O
PRV H
F N ODC
EIW F
19
BIOMEDICAL RESEARCH INVOLVING H M N SUBJECTS. T E P I A Y
UA
H
RMR
20
P R O E O S C REVIEW IS T ASSURE THE PROTECTION O T E RIGHTS
UPS F UH
O
F H
21
A D W L A E O T E H M N SUBJECTS. T E T R H S T E S M
N E F R F H UA
H EM A H
AE
22
M A I G AS THE P R S "INSTITUTIONAL REVIEW C M I T E AS U E
ENN
HAE
OMTE"
SD
23
I SECTION 520 (g) O T E "FEDERAL F O , D U , A D COSMETIC
N
F H
OD RG N
24
ACT", 52 STAT. 1040 ET SEQ., A A E D D
S MNE.
25
26
(IV) "PATIENT CARE COSTS" M A S PHYSICIAN FEES A D
EN
N
HOSPITAL EXPENSES INCURRED W E E E A Y ENROLLEE, SUBSCRIBER,
HNVR N
188
-2-
�1
O I S R D PARTICIPATES I A CLINICAL TRIAL. " A I N C R
R NUE
N
PTET AE
2
C S S D E NT I C U E R S A C - E A E C S S
OT" OS O NLD EERHRLTD O T .
3
(b) A Y O H R P O I I N O LW T T E C N R R
N
TE
R V S O F A O H OTAY
4
N T I H T N I G A L SICKNESS A D A C D N POLICIES A D
OWTSADN, L
N CIET
N
5
C N R C S T A P O I E C V R G W T I T E S A E FR H S I A
OTAT HT R V D OEAE I H N H T T O O P T L
6
C R , M D C L S R I A C R , A D O H R H A T SERVICES A D T A
A E E I A - U G C L A E N TE E L H
N HT
7
A E ISSUED B A ENTITY S B E T T T E P O I I N O P R 2 O
R
Y N
U J C O H R V S O S F AT
F
8
THIS ARTICLE, A N N R F T ENTITY S B E T T T E P O I I N O
OPOI
UJC O H RVSOS F
9
P R 3 O THIS ARTICLE, O A H A T M I T N N E O G N Z T O
AT F
R
ELH ANEAC RAIAIN
1
0
S B E T T T E P O I I N O P R 4 O THIS ARTICLE S A L I S R
U J C O H R V S O S F AT
F
HL NUE
1
1
A A N T P T E T C R C S S I C R E IN A S C A I N W T CLINICAL
GIS A I N AE OT NURD
S O I T O IH
1
2
TRIALS F R T E T E T E T O C N E IN T E S M M N E A Y O H R
O H RAMN F ACR
H A E ANR N T E
1
3
SICKNESS, I J R , DISEASE, O C N I I N IS C V R D U D R T E
NUY
R ODTO
O E E NE H
1
4
POLICY O C N R C , IF T E I S R D E R L E , O S B C I E H S
R OTAT
H NUE, NOLE R USRBR A
1
5
B E R F R E F R S C T E T E T B HIS O H R P I A Y C R
E N E E R D O UH R A M N Y
R E RMR AE
1
6
PHYSICIAN A D S C CLINICAL TRIALS M E T E R Q I E E T O
N UH
ET H EURMNS F
1
7
P R G A H (c) O THIS S B E T O (10).
AARP
F
USCIN
1
8
^
(c) P T E T C R C S S F R CLINICAL TRIALS F R C N E
A I N AE OT O
O ACR
1
9
T E T E T S A L B R I B R E WE A L O T E F L O I G A E
R A M N H L E E M U S D HN L F H O L W N R
2
0
2
1
DMNTAE:
EOSRTD
(I) T E T E T E T IS P O I E W T A T E A E T C I T N
H RAMN
RVDD IH
HRPUI NET
22
A D IS B I G P O I E P R U N T A CLINICAL TRIAL T A H S B E
N
E N RVDD USAT O
HT A EN
2
3
A P O E B T E N T O A C N E INSTITUTE, A Y O ITS CLINICAL
PRVD Y H AINL ACR
N F
2
4
C N E C N E S C O E A I E G O P , O C M U I Y CLINICAL
A C R E T R , O P R T V R U S R OMNT
25
O C L G P O R M ; T E U I E S A E F O AD D U
NOOY R G A S H
N T D T T S OD N RG
2
6
A M N S R T O IN T E F R O A INVESTIGATIONAL NW D U (IND)
DIITAIN
H OM F N
E RG
188
-3-
�1
E E P I N T E UNITED S A E D P R M N O V T R N AFFAIRS; O
XMTO; H
T T S EATET F EEAS
R
2
A QUALIFIED N N O E N E T L R S A C ENTITY AS IDENTIFIED IN T E
OGVRMNA EERH
H
3
GUIDELINES F R NATIONAL C N E INSTITUTE C N E C N E S P O T
O
ACR
ACR ETR UPR
4
GAT;
RNS
5
(II) T E P O O E T E A Y H S B E R V E E A D A P O E
H RPSD HRP A EN EIWD N PRVD
6
B A QUALIFIED INSTITUTIONAL R V E B A D (IRB), A D F N D IN
Y
EIW OR
S EIE
7
S B A A R P (III) O P R G A H (a) O THIS S B E T O (10), A D
UPRGAH
F AARP
F
USCIN
N
8
T E C L R D CLINICAL TRIAL R V E A V S R B A D C E T D
H OOAO
EIW DIOY OR, RAE
9
P R U N T S C I N 25-1-123, C R S ;
USAT O E T O
...
10
(III) T E FACILITY A D P R O N L P O I I G T E T E T E T
H
N ESNE R V D N H RAMN
A E C P B E O D I G S B VIRTUE O THEIR E P R E C O
R AAL F ON O Y
F
XEINE R
TRAINING;
(IV)
T E E IS N S P R O , NONINVESTIGATIONAL ALTERNATIVE
HR
O UEIR
T TE POOO T E T E T AD
O H RTCL R A M N ; N
(V) T E AVAILABLE CLINICAL O PRECLINICAL D T P O I E
H
R
AA RVD
A R A O A L E P C A I N T A T E P O O O T E T E T WILL B A
ESNBE X E T T O H T H RTCL RAMN
E T
L A T A EFFECTIVE A T E ALTERNATIVE.
ES S
S H
S C I N 2. Part 1 of article 1 of t i t l e 25, Colorado
ETO
Revised Statutes, 1989 Repl. Vol., as amended, is amended B T E
Y H
ADDITION O A N W S C I N to read:
F E ETO
25-1-123. Colorado clinical trial review advisory board
- creation - powers. (1) (a) T E E IS H R B C E T D IN T E
HR
EEY RAE
H
DIVISION O ADMINISTRATION IN T E D P R M N O H A T T E
F
H EATET F ELH H
C L R D CLINICAL TRIAL R V E A V S R B A D T E B A D S A L
OOAO
E I W D I O Y O R . H OR H L
C N I T O NINE M M E S A P I T D A F L O S O E M M E S A L
OSS F
EBR P O N E S O L W : N EBR H L
B A PHYSICIAN LICENSED T P A T C MEDICINE IN THIS S A E W O
E
O RCIE
TT H
188
-4-
�1
SPECIALIZES I O C L G A D WO IS N T O T E STAFF O A
N NOOY N H
O N H
F
2
N T O A C N E INSTITUTE DESIGNATED CLINICAL C N E CENTER; O E
AINL ACR
ACR
N
3
M M E SHALL BE A PHYSICIAN LICENSED T PRACTICE MEDICINE I
EBR
O
N
4
THIS STATE WO IS O T E STAFF O A N T O A C N E INSTITUTE
H
N H
F
AINL ACR
5
DESIGNATED CLINICAL C N E CENTER; O E M M E S A L BE A L Y
ACR
N EBR H L
A
6
P R O WO SPECIALIZES I ETHICS; T O M M E S S A L B
ESN H
N
W EBR HL E
7
REPRESENTATIVES O T E C L R D MULTIPLE INSTITUTIONAL R V E
F H OOAO
EIW
8
B A D O E M M E S A L BE A REPRESENTATIVE O A C N E SURVIVOR
OR; N EBR H L
F
ACR
9
G O P O E M M E S A L BE A REPRESENTATIVE O A INSURER; O E
RU; N EBR H L
F N
N
10
M M E SHALL BE A REPRESENTATIVE O A N N R F T H A T C R
EBR
F
OPOI ELH AE
11
SERVICE PLAN; A D O E M M E SHALL B A REPRESENTATIVE O A
N N EBR
E
F
12
H A T M I T N N E ORGANIZATION. T E EXECUTIVE DIRECTOR O T E
ELH ANEAC
H
F H
13
D P R M N O H A T SHALL APPOINT THE M M E S O T E B A D
EATET F ELH
EBR F H OR.
1
4
M M E S SHALL BE APPOINTED F R F U - E R T R S A Y V C N Y
EBR
O ORYA E M . N AAC
15
O C R I G IN T E M M E S I O T E B A D SHALL BE FILLED B A
CURN
H EBRHP F H OR
Y
16
QUALIFIED P R O APPOINTED B T E EXECUTIVE DIRECTOR O T E
ESN
Y H
F H
17
D P R M N O H A T F R T E UNEXPIRED T R O S C M M E .
EATET F ELH O H
EM F UH EBR
18
(b) T E B A D IS A T O I E A D E P W R D T REVIEW
H OR
U H R Z D N MOEE O
19
P O O E THERAPIES F R THE T E T E T O C N E A D R C M E D
RPSD
O
R A M N F A C R N EOMN
20
T A PATIENT C R COSTS F R THESE CLINICAL P O O O THERAPIES
HT
AE
O
RTCL
21
B REIMBURSED.
E
22
R I B R E E T T E B A D SHALL ASSURE T A THE P O O E CLINICAL
E M U S M N H OR
HT
RPSD
23
P O O O T E A Y WILL LIKELY CONSTITUTE A I P O E E T IN EITHER
RTCL HRP
N MRVMN
2
4
COST-EFFECTIVENESS O THERAPEUTIC EFFECTIVENESS F R T E T E T
R
O RAMN
25
O T E DISEASE IN QUESTION.
F H
26
I O D R T CERTIFY ELIGIBILITY F R
N RE
O
O
(c) M M E S O THE B A D SHALL RECEIVE N C M E S T O
EBR F
OR
O OPNAIN
188
-5-
�1
F R THEIR S R I E A D N R I B R E E T F R THEIR E P N E . T E
O
EVCS N O EMUSMN O
XESS
H
2
BAD S A L HV TE A T O I Y T ACP D N T O S AD MNTR
OR H L AE H U H R T O CET O A I N N OEAY
3
GIFTS T A A E D V T D T T E R S A C A D P O O I N O N W O
HT R EOE O H EERH N RMTO F E R
4
ALTERNATIVE MEDICINE O P O E U E .
R RCDRS
5
(2) (a) THIS S C I N IS R P A E , EFFECTIVE JULY 1, 1999.
ETO
EELD
6
(b) P I R T S C R P A , T E C L R D CLINICAL TRIAL
R O O UH E E L H OOAO
7
R V E A V S R B A D S A L B R V E E A P O I E F R IN
EIW D I O Y OR H L E EIWD S R V D D O
8
S C I N 2-3-1203, C R S
ETO
...
9
S C I N 3. 24-1-119 (6), Colorado Revised Statutes, 1988
ETO
10
Repl. Vol., is amended B T E ADDITION O A N W P R G A H to
Y H
F
E AARP
11
read:
12
13
14
15
16
17
18
24-1-119. Department of health - creation. (6) The
division of administration shall include the following:
(e) T E C L R D CLINICAL TRIAL R V E A V S R B A D
H OOAO
EIW DIOY OR,
C E T D B S C I N 25-1-123, C R S
RAE Y E T O
...
S C I N 4. 2-3-1203 (3) (1), Colorado Revised Statutes,
ETO
1980 Repl. Vol., as amended, is amended to read:
2-3-1203. Sunset review of advisory committees. (3) The
19
following dates are the dates for which the
20
authorization for the designated advisory
21
statutory
scheduled for repeal:
committees is
22
(1) July 1, 1999: Tho Colorado natural aroas council> an
23
advisory council to tho board of parks and outdoor rocroationj
24
appointed pursuant to section 33 33-106} C R S
...
25
26
(I) T E C L R D N T R L A E S C U C L A A V S R
H OOAO AUA RA O N I , N DIOY
C U C L T T E BAD O P R S AD OTOR R C E T O , A P I T D
O N I O H OR F A K N UDO E R A I N P O N E
188
-6-
�1
2
3
P R U N T S C I N 33-33-106, C R S '
USAT O ETO
...
(II) T E C L R D CLINICAL TRIAL R V E A V S R B A D
H OOAO
EIW DIOY OR,
A P I T D P R U N T S C I N 25-1-123, C R S
P O N E USAT O E T O
...
4
S C I N 5. Safety clause. The general assembly hereby
ETO
5
finds, determines, and declares that this act is necessary for
6
the immediate preservation of the public peace, health, and
7
safety.
188
-7-
�IE
Reimbursement Issues in Cancer Clinical Trials
[ Robert J. McKenna, MD
S
UPPORT of clinical cancer research has been traditionally borne by various groups—the federal government, the pharmaceutical industry, private institutions,
and third-party insurance carriers. This collaborative research effort is increasingly threatened by various economic pressures—a shortage of federal dollars from the
National Cancer Institute (NCI) and other branches of
the National Institute of Health (NIH), competition for
the research dollar by the acquired immune deficiency
syndrome effort, progressive cutbacks in health care delivery costs by such containment procedures as diagnosisrelated groups, and health care rationing by limiting access
by "expenditure targets," clinical guidelines, preadmission
review, mandatory assignment, to name a few.
Rising Cost of Medical Care
Since Medicare began in 1965. health care costs have
risen faster than the inflation rate, in part due to advances
in medical technology and in part due to consumer demand for services for which they usually do not directly
pay. In 1988, for example, Medicare beneficiaries paid
premiums which covered roughly 25% of the medical
program necessitating a $20 billion contribution from
general revenues. This budget deficit will be further compounded by the growing numbers in the Medicare population which are expected to double over the 60-year
period since 1965. Is there any wonder that there is a
Medicare health care crisis? These economic pressures
have an impact on payment for all types of medical care
and for cancer in particular.
The cost of private health care insurance has also risen
dramatically. The number of Americans who are uninsured continues to grow. Few seem to be willing to subsidize health care for the uninsured further. The catastrophic burden to care for uninsured trauma patients has
resulted in a significant reduction in cancer care for the
socially economically disadvantaged. Perhaps neither
Presented at the American Cancer Society Workshop on Dinical Trials,
The Riu-Carlton, Naples, Florida, September 14-15, 1989.
From the USC Medical Center, Los Angeles, California.
Address for reprints: Robert J. McKenna, MD, President, Wilshire
Oncology Medical Group, 201 South Alvarado Street, Los Angeles, CA
190057.
f
Accepted for publication November 24, 1989.
business nor government will ever be able to pay for unlimited health care despite societal expectations.
Cancer care cost will continue to increase and this despite fewer days of hospitalization and other cost containment measures. It is not surprising that current and
future health care expenditures will be constantly reviewed
with increasing scrutiny. Many current cancer therapies
are reviewed as to need, less costly alternatives, patient
benefit, and quality of care.
State-of-the-Art Cancer Care
Progress in this century in cancer care has been rewarding with more than 50% cures and, for those who
are not cured, significant palliation and extended life spans
with good quality of life. How is the state-of-the-art care
arrived at? Experience, experimentation, review of treatment outcomes, reports in peer-reviewed journals, and
presentations at medical meetings contribute to a body
of knowledge which provides the data base used to establish state-of-the-art therapy. As new knowledge accumulates, newer therapies will be developed.
Research and development is accepted in industry as
essential to progress and considered an investment in the
future. Likewise in medical care, it is only through research
that we can improve current treatments of cancer in humans. Some of these efforts involve randomized clinical
trials (RCT) which compare state-of-art therapy with what
may be better treatment for the future. All arms of the
RCT should be reimbursable treatment costs in our health
care system. Each arm can benefit the patient entered
into the trial and future cancer patients.
Current Reimbursement Policies
Most third-party payers consider research protocols, -^-^C
which have passed review and found to have scientific
'
merit and safety, appropriate for reimbursement. It is reasonable to expect that drugs not yet having Food and
Drug Administration (FDA) approval should be supplied
eS
at no cost by the pharmaceutical manufacturer or by the
NCI. Similarly the cost of data collection and analysis
should not be charged to the patient or the insurance carrier. These studies include medical care which is and
should be reimbursable. Significant variations exist in
what is considered "appropriate" research or investiga-
2405
Y
�2406
CANCER
A/ay 15 Supplement 1990
tional therapy from region to region, both at the State
and the Federal level.
Who Should Determine the Appropriateness
of a Clinical Trial?
If appropriateness is to be used to determine which
trial is reimbursable, guidelines need to be established for
this purpose. Protocols approved by NCI, NIH, nationally
funded cooperative groups, comprehensive and other
cancer centers, and by peer-reviewed clinical and research
cancer facilities and institutes are appropriate for insurance coverage. Many approved protocols may be carried
out in community hospitals with Community Clinical
Oncology Program status or cooperative group affiliated
status CGOP.
The Division of Cancer Treatment (NCI) is willing to
assist governmental and private insurance companies in
the designation of a treatment protocol as appropriate
and therefore reimbursable. Many professional organizations can also assist with this task.
Advocacy
The American Cancer Society advocates the use of
clinical trials and is now encouraging the public and the
bealth professionals to consider protocol studies as appropriate. The NCI has long endorsed clinical trials and
will continue to do so. Most oncologic societies are extremely supportive. The American Association of Cancer
Institutes and the Association of Community Cancer
Centers endorse the expansion of clinical trials.
Perhaps the only opponents of clinical trials are those
who are concerned with the cost of medical care. The
strongest argument for RCT is that it offers state-of-theart treatment for the patient with a life-threatening illness.
The bottom line is the potential to advance medical
knowledge and prevent death from cancer.
Off-Label Drug Use
Off-label use of chemotherapy drugs is the use of an
agent or a dose schedule, alone or in combination, which
has not been specifically listed by the FDA as treatment
of a specific cancer. It is common practice to use best
dinical judgment based on peer-reviewed investigational
studies. A time lag of 1 to 4 years or longer may occur
before new indications for an established drug may be
added to the FDA label insert. Under no circumstances
should the lack of listing in the FDA be used to declare
therapy inappropriate. Likewise, the United States Pharmacopoeia should not be used for determining eligibility.
An NCI consensus statement regarding off-label use would
help clarify the confusion which seems to exist in this
matter.
Voi.v
Discussion
The success with RCT in children's cancer treatmen
is well known in acute lymphoblastic leukemia, Wilmj
tumor, rhabdomyosarcoma, non-Hodgkin's lymphoma
and neuroblastoma. Adult cancer progress has been les
successful in large part because a much smaller percen
of adult cancer patients are entered in clinical trials. Lega
issues provide some obstacles to carrying out clinical trial
and, in some cases, may only be solved by doing the stud
ies abroad.
Access to health care can complicate the eligibility o
availability of clinical trials for those who have no healtl
insurance, for minorities, and for the socially oreconom
ically disadvantaged. Hospitals such as city and th<
county-run facilities may be unequipped to carry out th*
complexities of health care in a RCT setting.
^""Clinical trials are not indicated for those whose cance
/ problem is not suited to investigation. It is likewise in
appropriate when the patient does not wish to participau
or when medical contraindications exist.
More physicians agree that continued research is nec
essary to reach the NCI goal of a 50% reduction in cancci
mortality by the year 2000. At present onlv 3% of aduli
cancer patients are entered into clinical trials._Expansior
of this effort rpnnm hp rarrieri put without continued
reimbursement bv all interested parties. Denial of reimbursement for medical care ofcancer patients entered into
RCT is counterproductive to the national cancer effort
and should be opposed strongly as discriminaton.
In the future we may expect to see legal action when
reimbursement is denied the patient on an "investigation"
protocol. Such an effort was successful in a recent New
Jersey case involving bone marrow transplantation ("Dozar vs. a self-insured company"). Lobbying at the State
and Federal levels where insurance is regulated will be
necessary to educate legislators. Oncologists need to play
a major role in this education effort, but the most potent
force will be the patient with cancer and their advocate
such as the American Cancer Society.
Media attention will garner public support when reimbursement delays and denials occur. Perhaps the news
that reimbursement denial has occurred can be described
best as threatening the cancer patient's access to the stateof-the-art cancer therapy.
Health maintenance organizations seem to be more
critical of RCT than either Medicare or fee-for-service
insurance plans. If quality medical care is provided, one
cannot deny access to clinical trials for those who are
enrolled in a health maintenance organization.
A future goal might be to enroll all patients in a clinical
trial. This seems unrealistic in the immediate future but
might be a long-range goal. Trials at reduced cost with
less red tape could be more economic in the long run by
reducing the burden of premature death, lost productivity,
and indirect societal costs of cancer.
�2380
CANCER
May 15 Supplement 1990
Vol.
TABLE 3. Cooperative Qinical Group Studies in Selected Disease Areas—Protocols Active in 1988—Accraal to Phase II and 111 Studies
Organ system
New cases
in 1988
Alive
(Syr)
Cancer
deaths
(5 yr)
Studies
open to
accrual
Toul
accrual
1988
Breast
Cervix
Colon/rectum
Esophagus
Lung
Mseloma
Pancreas
Prostate
Stomach
Toul
131,619
14,425
141.053
9.616
137.837
11.010
25,229
90,532
14,897
576,218
86.899
8,784
58.023
400
14,817
2,640
535
44.358
3.131
219.587
33,540
5.002
66.570
9,122
119,769
8,007
24,539
27,321
10,791
304,661
39
23
22
6
43
11
9
II
10
174
4374
405
1891
73
1492
405
200
420
159
9419
workers, and relevant physicians (surgeons, radiation oncologists, and medical oncologists). They need to be provided with the appropriate resources necessary to participate meaningfully in clinical research. Additionally, it is
crucial to educate the lay population to the advantages,
both personal and societal, of participating in important,
well-designed clinical research studies. Toward these ends
the Office of Cancer Communication has produced effec- *
tive educational and promotional materials which may
be obtained from the NCI, Office of Cancer Communications, Building 31, Room 10A-29, Bethesda, MD 20892.
New NCI Efforts to Enhance Qinical Trials Accrual
There is a need for accelerated accrual in clinical research. One attempt to engage new investigators to increase clinical trials participation has been the establishment ofthe High Priority Trials mechanism. This effort
is aimed at investigators who either are not participating
in the Cooperative Group system or do not have access
to studies of selected diseases. To identify crucial clinical
studies worthy of special attention and funding, CTEP
regularly holds strategy meetings with both Group and
cancer centers representatives. The most relevant and
pressing scientific hypotheses associated with a certain
disease are highlighted. After selecting candidate protocols,
the Cooperative Group Chairpersons review and approve
the choices. These are then reviewed and confirmed by
the Board of Scientific Counselors of the Division of Cancer Treatment. The general considerations used in making
the High Priority Trial designation included the following:
(1) prevalence of disease, (2) perceived clinical opportunity, (3) the urgency of the scientific question, and (4) the
presumed biologic importance of anticipated findings.
Table 5 describes the initial five High Priority Trials, including the diseases to be studied and a brief outline of
each study design. In addition to meeting these criteria,
there is a special emphasis on studies with curative intent.
Figure 5 shows graphically the accrual to thesefivestudies.
Percent
accrued
3.3
2.8
1.3
0.8
1.1
3.7
0.8
0.5
1.1
Advanced
disease
studies
Advanced
disease
patients
Adjuvant
studio
24
808
228
636
28
1440
405
200
252
142
4139
15
5
10
2
2
0
0
4
1
39
I*
12
4
41
11
9
7
9
135
Adjuva
siudic
patient
3566
177
1255
45
52
0
0
168
17
5280
The NSABP study C03 completed its accrual ahead i
schedule and is closed. Intergroup Study 0067 is now ai
cruing faster than the expected rate and should be com
pleted soon. The other studies are progressing as expecte
although some initial delays were apparent. The costs (
accruing to High Priority Clinical Trials have been modes
Additionally, from an educational point of view, the Hig
Priority Trials Program may engage many new invest!
gators who then become familiar with and interested i
the entire research portfolio of the Clinical Cooperate
Group system.
There are, however, certain concerns which must tx
considered for the High Priority Clinical Trials. There i
uncertainty as to the new investigators' commitment ti
the research, especially in relation to follow-up. Will th
data be of acceptable quality in these studies? Will th
lack of organizational experience impair the generatio
of good quality clinical data? Will the additional costs o
this system be too expensive? How will the scientific di
rection of High Priority Trials be maintained? These po
tentially important questions do not seem to be an issui
yet, but they await ongoing evaluation. Recently, baset
on this preliminary positive experience, a series of fiv
new High Priority Clinical Trials has been designated
They are listed in Table 6. Obviously, there are man;
clinica] trials which could qualify as High Priority Trial.'
and this designation does not necessarily imply that othe;
TABU 4. Qinical Trials Cooperative Group Program
(1985 Versus 1988)
Fiscal year
1985
Total budget (thousands)
Major groups funded
Annual accrual (treatment trials)
Studies open to accrual
1988
50,789
18
18,187*
586
58.08!
11
21,122
495
* Includes some nontherapeutic study accrual.
�NCI COOPERATIVE CLINICAL TRIALS
No. 10
Friedman and Cain
2381
TABLE 5. High Priority Trials
Study
Study design
InterKrouf^0067
Intergroup4X)80
NCCTG-864751
NSABP-C03
NSABP-R02
|
Disease
High-grade lymphoma
Bladder (adjuvant)
Rectal (adjuvant)
Colon (adjuvant)
Rectal (adjuvant)
CHOP vx. M-BACOP, ProMACE-Cytabom vj. MACOP-B
Cystectomy vs. M-VAC + cystectomy
S-FU (CI or bolus) + RT vs. 5-FU (CI or bolus) + methyl-CCNU + RT
5-FU/leucovorin vs. MOF
MOF ± RT vs. 5-FU/1eucovorin ± RT
NCCTG: North Central Cancer Treatment Group; NSABP: National
Surgical Adjuvant Breast and Bowel Project; MVAC: methotrexate, vel-
ban, doxorubicin, cisplatin; 5-FU: fluorouracil; Cl: continuous infusion;
RT: radiotherapy, MOF: methyl-CCNU, Oncovin, 5-FU.
active studies are of lesser interest or value. This is a convenient mechanism for identifying, funding, and accelerating selected research topics. Initially $1.4 million was
\ directed toward this eflbrt, and we hope that additional
monies will be forthcoming.
Another challenge to the clinical research community
concerns the inadequate number of patients of minority
racial groups who are currently being evaluated in clinical
studies. Some Groups collect racial data only incompletely. Nonetheless, there appears to be between 9% and
26% minority accrual to selected Group protocols. A
comparison of the relative incidence, annual mortality,
and 5-year survival for selected diseases for black and
white populations is displayed in Table 7. Also shown is
the total accrual to Cooperative Group Phase II-III studies
for ten cancer public health problems of special relevance
to the black community. Overall efforts are inadequate,
and there is generally underrepresentation of minorities
in NCI-sponsored clinical trials. This is especially important in cervical cancer, esophageal cancer, and myeloma
where there is a substantial epidemiologic and clinical
difference between black and white people in this country.
Moreover, it is not known whether these diseases behave
in different biologic ways in diverse populations. To address these problems, the Minority Satellite Supplement
Program was initiated. The purpose of this program was
to increase accrual of minority patients to the Division
of Cancer Treatment sponsored protocols. The program
was funded through the Comprehensive Biomedical Minority Program of the Division of Extramural Activities
i
PATIENTS
INT-0067
INT-008O
NCCTG-864751
NSABP-R02
NSABP-C03"
PROTOCOL NUMBER
X FIG. 5. Accrual to high priority trials." NSABP-C03 closed 4 * 89. • : 1 * 88; B 4 * 88; • : 7 * 88; B: 10 * 88; a 1 + 89; • : 4 # 89; fit
•7 # 89; • : target.
�SOCIAL AND FINANCIAL IMPACT STATEMENT
BILL: CONCERNING CERTAIN MEDICAL COSTS FOR CERTAIN CLINICAL TRIALS
FOR THE TREATMENT OF CANCER
Sen. Mendez
Prepared By;
Roy B. Jones PhD MD
Director, Bone Marrow Transplant Program
University of Colorado Health Sciences Center
Denver, CO 80262
Phone: 372-9000
Fax:
372-9003
Definitions:
clinical trials -
Any s c i e n t i f i c study of a new therapy i n
human beings for the treatment of cancer and
includes a f u l l y developed c l i n i c a l protocol.
This i s meant to include research programs
where new treatments are tested i n patients,
where established treatments modified i n an
attempt to improve them, or where established
treatments are compared to e s t a b l i s h which
treatment i s superior.
I n s t i t u t i o n a l Review A board, committee or other group designated
Boardby an i n s t i t u t i o n and approved by the US Food
and Drug Administration to review, approve
the i n i t i a t i o n of, and conduct periodic
review of biomedical research involving human
subjects.
protocol treatment -
a plan of s c i e n t i f i c treatment that includes
goals, a rationale, background for the plan,
c r i t e r i a for patient selection, s p e c i f i c
directions for administering therapy and
monitoring patients, a d e f i n i t i o n for
quantitative measures for determining
treatment response, and methods for
documenting and treating adverse reactions.A
treatment studied within a c l i n i c a l t r i a l .
relapse-free survival-when the patient i s a l i v e at a specified
period of time following treatment without
evidence of tumor. The period of 5-years i s
often used to indicate an increased
probability that the patient i s cured.
�I,
INTRODUCTION:
This b i l l requires that sickness and accident insurance c a r r i e r s ,
health maintainance organizations, and health service corporations
cover the cost of physician fees and hospital costs, but not
research-related costs of cancer treatment c l i n i c a l t r i a l s which
have been approved by the Colorado c l i n i c a l T r i a l Review Advisory
Board.
This nine member board w i l l contain physicians, a lay
e t h i c i s t . I n s t i t u t i o n a l Review Board members, a cancer survivor,
and insurers. C r i t e r i a for protocol approval include:
1)
There i s no superior available conventional cancer
treatment.
2) The protocol has been approved by a National Cancer
I n s t i t u t e C l i n i c a l Cancer Center, other arm of the
National Cancer I n s t i t u t e , or the US Food and Drug
Administration
3) The protocol has been approved by the relevant FDAapproved I n s t i t u t i o n a l Review Board
4) The treating f a c i l i t y i s properly qualified to
administer the research treatment.
THE PRESENT SITUATION
In the case of new treatments, The National cancer i n s t i t u t e or
other agencies pay for the costs of any investigational therapies
and a n a l y s i s of protocol r e s u l t s . The other costs of patient care
(blood t e s t s , x/rays, physician fees, hospitalizations for side
e f f e c t s , etc.) are, paid by various insurers in approximately 90% ofcases.
In the remaining cases insurers dispute payment based on
various grounds and the patient or the hospital and i t s s t a f f
absorb the costs.
5
In the case of PDA approved treatments, patients p a r t i c i p a t i n g in
protocol treatments or t h e i r insurer are asked to pay the ooet of
the therapy (drugs, radiation, etc.) as well as other patient care
costs. The research costs are paid through the National Cancer
I n s t i t u t e or other agencies. For lower cost treatments, more than
90%^. of these costs are reimbursed.
For c e r t a i n high-cost treatments (such as many bone marrow
transplant procedures), insurers reimburse on a variable basis
depending upon policy language and interpretation. This presents
a major problem for patients and insurers a l i k e , for insurance
denj^alj^are. -often made at variance with current expert medical
opinion, and r e s u l t in frequent l i t i g a t i o n .
�A. Social and Financial Impact of Higher Cost Protocol Therapies
Cancer Protocol Treatments are commonly u t i l i z e d by Colorado
c i t i z e n s . Cancer Protocol treatments provide a dual benefit to
patients:
l) access to newer, more promising treatments not
routinely available i n the community, and
2) the a b i l i t y to
p a r t i c i p a t e in protocols which define more e f f e c t i v e and coste f f e c t i v e therapies for the future.
Participation in theseprotocols thus benefits not only the patient BUT a l l c i t i z e n s and
insurers in the state.
A v a i l a b i l i t y of Protocol Therapies i s primarily determined by
f i n a n c i a l constraints imposed by insurers and the National Cancer
I n s t i t u t e . Insurance coverage varies widely from ••never," to
s p e c i f i c exclusions irrespective of treatment cost-effectiveness,
to frequent reimbursement. Insurers often deny reimbursement on
grounds that the therapy i s "experimental / i n v e s t i g a t i o n a l " while
ignoring a large majority of expert medical opinion to the
contrary. The budget of the National Cancer I n s t i t u t e to support
the research component of these Protocol Therapies i s limited, but
|hey~orrother agencies always; pay the cost of experimental drugs or"
;6ther-therapies. Colorado c i t i z e n s suffer when patient care costs
(not research costs) are paid on an irregular basis by insurers,
and denials of coverage lack s c i e n t i f i c or c l i n i c a l j u s t i f i c a t i o n .
As described below, the patient care costs of lower cost Protocol
Therapies are generally reimbursed by insurers and are presently
u t i l i z e d to 80% of available National Cancer I n s t i t u t e sponsoring
capacity.
Some patients are deterred from entering these t r i a l s
because of concerns over reimbursement. This b i l l would remove the
capricious denial of coverage for 30-50 patients .per year in t h i s
category (or the category of those who are denied reimbursement on
a retrospective basis) and insure f u l l u t i l i z a t i o n of protocol
therapies.
Most patients who do not receive lower cost Protocol Therapies
receive treatments of equivalent or lesser effectiveness and equal
cost from community physicians.
In the case of higher cost Protocol Therapies, denials of
reimbursement are more frequent.
The example of bone marrow
transplant for breast cancer w i l l be used to i l l u s t r a t e the impact
of t h i s b i l l .
Approximately 2000 patients/yr develop breast cancer in Colorado.
Using presently established c r i t e r i a , approximately 25 patients per
year would be appropriate for bone marrow transplant immediately
following mastectomy. For these patients, the 5 yr relapse free
s u r v i v a l for standard therapy i s 25%; for bone marrow transplant i t
i s 75%.
�Approximately soo patients/year w i l l develop widespread breast
cancer. Patients receiving standard chemotherapy have a five-year
disease-free survival of less than 1%. The comparable figure for
patients treated with bone marrow transplant i s approximately 25%.
TheimaTjorit^cf patients with widespread breast cancer are eithertoo. ,old (40%) or too i l l (20%) to undergo marrow transplant,
leaving 320 patients per year who might be eligible for marrow
transplant treatment. The^ma-joi^y^f^hese
on
the risks involved, leaving afcmp.st-17J5^^p^/yr-vrihfcm-i-ghtctake"-the^
:
A
x
1
lliatel
PP^?- ^
y ^Q.%ziofL:Ratients^wishing-.marrow transplant -obtain
insurance ~.reimbursemeht. Thus, a maximum of 30 additional
patients/yr might obtain insurance coverage as a result of this
b i l l . This number assumes that the Federal ERISA statute exempting
self-insured companies from regulation will be modified or
repealed.
The average cost of a bone marrow transplant for breast cancer in
1992 was $140^00. Thus, $4,200,000 might be added to insurers
cost.
There are j f e a l ^ s a v ^
gSM^CrAn^Mnt ---£6^- breast_-cancer^were—1 imitea—to" approved:
'^"search-cenjters?. A for-profit company i s presently opening a
marrow transplant f a c i l i t y in Colorado, and another non-National
Cancer Institute endorsed marrow transplant program i s in operation
in a Denver hospital. These f a c i l i t i e s might treat the remaining
breast cancer patients in programs lacking the same level of
quality oversight and research output as National Cancer Institutesponsored programs. The cost of these treatments would be 175 pts
(70% reimbursed)- 12 2 insured patients - 70 pts. treated in NCIsponsored programs= 52 patients who might be treated in other
programs = $7,280,000.
I f these non-research treatments were curtailed, the net saving
produced by this b i l l in this area could be $3,080,000.
:
Since virtually ioo% of patients with widespread cancer will die of
their tumor, there are costs associated with the terminal care,
usually estimated at $40,000-60,ooo/pt. For patients who avoid
this cost through successful marrow transplant treatment, further
savings w i l l be realized.
During this terminal care period,
practitioners frequently administer treatments which do not prolong
survival and have never been shown to improve quality of l i f e .
They are used primarily to "give some hope" to dying patients, i f
reimbursement for Protocol Treatments were assured, some of these
patients might participate in cancer Protocol Treatments where both
hope and benefit to society are obtained.
Administrative expenses for insurers would decrease under this
proposal.
Rather than costly dialogs with physicians about
�i n s u r a b i l i t y and frequent
Advisory Board protocol
assurance.
B.
l i t i g a t i o n , Colorado C l i n i c a l T r i a l s
approval would constitute quality
F i n a n c i a l Cost of Lower-cost Protocol Therapies
Protocol Patients/year treated with lower cost therapies:
350
Maximal capacity/year:
420
% unreimbursed treatment costs;
10%
Present unreimbursed patients/yr:
35
Maximal increased reimbursed patients/yr
under t h i s b i l l :
42
There i s l i t t l e cost d i f f e r e n t i a l between lower-cost standard
therapy (usually approximately $15,000-2 0,000/yr) and comparable
lower cost Protocol Therapy. Thus, the cost of t h i s b i l l for these
patients w i l l be negligible.
Summary Statement
In the f i n a l a n a l y s i s , insurers often ask "who should pay the cost
of c l i n i c a l research?", implying that they should have no
obligation to do so.
I t i s i n s t r u c t i v e to turn t h i s question around and ask: "Who
benefits from c l i n i c a l research?" Do not insurers benefit i f more
c o s t - e f f e c t i v e therapies for cancer are developed? Of course they
do. Such developments improve health outcomes and reduce costs.
Since a l l of society potentially benefits from these e f f o r t s , we
a l l (including insurers) should share the cost.
Where insurers do not benefit i s when there i s premature
dissemination
of expensive "halfway" technology outside the
research setting, and high cost research Protocol Treatments such
as bone marrow transplantation are prematurely disseminated to the
non-research setting.
This r e s u l t s i n many patients receiving
lower quality treatment, often for suboptimal indications.
Coronary artery bypass surgery i s a case in point. This technology
was prematurely disseminated to the non-research setting, with the
�result that 50% of these procedures are today performed in
hospitals not meeting the minimal quality criteria of the American
College of Cardiothoracic Society, and 50% of patients are operated
upon for unclear indications as described by the American Society
of Cardiology. 1.5% of a l l US health care expenditures go for this
single procedure. For this procedure alone, 1% of a l l US health
care expenditures are outlaid in inappropriate circumstances.
In contrast, i t i s estimated that the patient care costs of a l l
Protocol Treatments (for a l l diseases, not just cancerl) i s less
than 1% of US health care expenditures.
This b i l l seeks to broaden assess to Cancer Protocol Treatments
while simultaneously controlling dissemination of cancer research
technology to settings where there may be suboptimal benefit to the
patient and no benefit to society. In the case of cancer patients,
this can be done with minimal cost and actual savings to insurers.
�am
"151*1a o "
S
3 1B «
p
n O n
^
I ? ? g. e
24
CAMPUS - COLORADO DAILY
WEEKEND, MARCH 5-7,1993
...Women tell of breast-cancer battles in CU appearance
[FROM PAGE 1]
vivors and terminally i l l patients, beginning an
the group of her outrage at
odyssey of "actively participating" in her own
It's outrageous for a
being patronized by physiconfrontation with the disease.
cians who felt she was person to have to die of
Shaughnessy of Boulder went through a
overreacting to her diag- something that's curable
similar ordeal beginning this past summer, when
nosis.
because of an insurance
she, too, was diagnosed with breast cancer, and
"Two hours after my
quickly afterward encountered physicians who
company.
ultrasound, I wanted a
felt no urgency in helping to confirm the diagbiopsy. My doctor thought
—Juliet Wittman, nosis.
I was being hysterical. I
Boulder writer
was being assertive and
" I encountered one roadblock after anothtaking control of my life.
er. We have to be active participants in our own
He didn't even bother to acknowledge my fear," Weiher health care. I eventually parted ways with that physidan,
said.
because it was such a negative experience," she said.
So negative, in fact, that after she elected to undergo a
Both of the lumps in Weiher's breast were malignant,
and she opted for a mastectomy and chemotherapy after lumpectomy and radiation treatment, she went into a period of isolation, refusing even to discuss the disease.
consulting four other doctors.
But after the actual surgical and treatment ordeals, she
found herself joining support groups that included sur-
" I was literally sleepwalking — it was a void in time.
Then I realized that my life had changed, and I had better
deal with it," die said.
For her, that meant getting involved with the Breast
Cancer Coalition, a national organization devoted to helping women come to grips with the disease, and which also
organizes political action to raise awareness about the disease and the roadblocks to defeating i t
" I realized I can help make a difference — wake up
our government, our doctors and our insurance companies
that this is real," she said.
Wittman agreed emphatically with that notion. Her
experience with the disease five years ago? moved her to
write about the disease in "Breast Cancer Journal: A
Century of Petals" and to raise awareness abbut it that goes
beyond urging mammographies for womeni
" I have all kinds of dark suspicions afibut pesticides,
chemicals. I'm tired of being told we're getting this
because we're deficient in some way. We didn't give it to
ourselves," she said.
�14.
Wittman urged ongoing activism to "shake loose" more
federal money for research and treatment, not just for
mammographies and preventive measures.
She also urged the group to support Senate bill 188,
sponsored by Boulder State Sen. Jana Mendez, that would
require insurance companies to pay for experimental medical treatments if they are deemed by the state's Qinical
Trial Review board to be the best available treatment for
the patient.
Citing the case of CU student Ismael Alvarado, who is
trying to raise money for a bone-marrow transplant,
Wittman said: "It's outrageous for a person to have to die
of something that's curable because of an insurance company."
^
Robinson, who holds a degree in biochemistry as well
as being a general surgeon, answered questions from the
audience about breast cancer and painted a picture of the
disease as one of medical science's most elusive foes.
She described in general terms cases she'd treated in
which patients "with small, localized lumps with no spreading to the lymphnodes" had nonetheless died "within nine
months," as well as cases in which "we thought the patient
would be dead in weeks and is still living afterfiveor six
years."
"In breast cancer, the cards are dealt early on. Some
women will die early, some will survive the rest of their
lives without arecurrence,and then there's a gray area in
the middle — women who may benefit to varying degrees
with treatment," she said.
"So as physicians, we don't really know which group
you'll fit into," Robinson said. "We have to say the same
thing to all of you."
�MEMQBAMDliM
S B. 93-188
TO:
Members of the Colorado Senate
FROM:
Cathy Walsh and Jerry Johnson, for the American Cancer Society
SUBJECT:
SUPPORT for S.B.93-188, "Concerning Medical Costs for Certain Clinical Trials for
the Treatment of Cancer"
Sponsors: Senator Jana Mendez and Representative Faye Fleming
DATE:
February 25, 1993
What thg bill do??;
The bill requires that insurance companies and health maintenance organizations cover physician and
hospital costs for patients being treated for cancer in clinical trials. The clinical trial must meet several
criteria. First, it must be approved by the National Cancer Institute, the Food and Drug Administration
or related entities outlined in the bill. The therapy must be approved by an institutional review board and
by the newly created Colorado Clinical Trial Review Advisory Board. There must be no superior
"standard" alternative for treating the patient. Finally, the available medical data must provide a
reasonable expectation that the clinical trial will be at least as effective as the alternative.
Background;
Although most patients (about 70 percent of bone marrow transplant patients) whose doctors have enrolled
them in clinical trials have had their care paid for, some insurance companies have denied coverage for
this best available treatment because they classify it as "experimental". This has most often happened
to breast cancer victims whose doctors have advised them that high-dose chemotherapy using bone
marrow transplant is their best hope. Medical experts testified in the Business Affairs and Labor
Committee that this treatment is NOT experimental, but rather has been proven effective for well-chosen
candidates for the procedure.
The majority of clinical trials compare two accepted therapies to determine whether one has an advantage
over the other. The remaining clinical trials evaluate the effectiveness of a new therapy, particularly
when there exists no effective standard therapy. Clinical trials also help medical professionals learn more
cost-effective methods of providing various treatments. For example, the bone marrow transplant
program may eventually be provided on a partial outpatient basis, thanks to what is being learned in the
clinical trials.
Why the bill is necessary:
S.B. 188 addresses the minority of insurance companies which are denying coverage that most companies
pay for. This bill has the potential to reduce insurance costs by providing the most effective treatment
for cancer patients. Millions of dollars are paid today for "standard" therapies, even when these have
little chance of extending a patient's life. S.B. 188 establishes a clear process for evaluating, after a
doctor's referral, whether a patient is an appropriate candidate for a clinical trial.
S.B. 188 also may help relieve some of the human agony that has followed denial by insurance companies
of coverage for this treatment. Patients with advanced cancer have been forced to sue their insurance
companies, winning the vast majority of their cases, but after valuable lost time.
Action needed:
SUPPORT for Senate Bill 93-188. which was approved by the Senate Business Affairs and Labor
Committee.
�?3
COL
MlBlBMillilBSiil
Cancer patient wins court battle
to make insurer cover treatment
Associated Press
DENVER — An Aurora public
school teacher battling cancer
won a legal victory Tuesday that
could save her life and the lives
of thousands of Colorado women.
Denver District Court Judge
Morris Hoffman Tuesday ruled
in favor of Cynthia Snow, 41, allowing her to obtain a type of
chemotherapy treatment that
her insurance provider, Comprecare Insurance Co., had refused
to cover.
Hoffman granted a preliminary injunction that requires
Comprecare to pay for the treatment. Comprecare had argued
that the treatment was experimental and not covered under
Snow's policy.
"There is ... no doubt that the
equities in this case favor the
granting of the injunction," Hoffman wrote. "Plaintiff (Comprecare) risks the loss of several
hundred thousand dollars. ... Defendant (Snow) risks the loss of
her life."
Hoffman added: "Defendant is
alive now, and, in the absence of
injunctive relief, the evidence is
uncontroverted that defendant
will die, most likely before this
case reaches the merits (trial)."
Snow," a .third•wade teacher,
was diagnosed with breast cancer in 1989. Doctors were unable
to contain the disease which
spread despite wiS}K»tion$, including mastectomiefptend moderate chemotherapy.'
Doctors said Snow had little
chance to survive without a
:
high-dose chemotherapy treatment, which involves bone marrow cells taken from the patient's blood which are frozen
and used later to replace bone
marrow cells destroyed by potent chemotherapy.
Comprecare, one of the state's
largest health insurance firms,
said the procedure involves a
type of bone-marrow transplant
that is excluded by the policy.
Snow countersued and hearings
were held last week.
In his decision Tuesday, Hoffman noted testimony from cancer doctors treating Snow, saying she has a significant chance
of remission with the treatment
and that the procedure is no
longer experimental.
Snow's policy covers chemotherapy, Hoffman said, and because the procedure involves
harvesting and re-injecting bone
marrow cells "does not at all
mean that the procedure someh^v loses its fundamental chemotherapeutic character."
Hoffman added that the policy's wording was ambiguous,
and cited several federal cases
that have held that "autologous
bone marrow transplants simply
are not 'true transplants,' and
are, therefore, not excluded."
�M R O TRANS.
ARU
TEL : 303-372-9003
Feb 23 93
12=38 No.005 P.02
University olColnrado Health Sciences C enter
Pone Marruw limnpl.inl I'lojiriiiii
C.niipu'. ll*.* RI'XI
J.^Oii I a si NMHII Av.-nuf
Dcii".'. CulDr.uln HW(i2
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I-AX i.M).<) M? y(K)A
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SCMDOI of McdkinC
SchiK.I yf Niiivnn
Scliiv>l of r^illiury
February 22,
sdiw) ol riiurimicr
(imduitlf School
1993
Senate Business Affairs and Labor Committee
Hon. Jana Mendez
Dear Senator Mendez and Members of the Cominittee:
I apologize for being unable to attend the hearing
legislation concerning cancer patients and c l i n i c a l
I w i l l be in transit at that time to a conference
National Institutes of Health. I did wish to express
my thoughts regarding this legislation.
on your
trials.
at the
some of
As you know, I am the Clinical Director of the Bone Marrow
Transplant Program at the University of Colorado Health
Sciences center. Our patient population i s comprised largely
of women with advanced or high-risk breast cancer.
in
addition, we treat patients with lymphoma, ovarian cancer,
and leukemia. Patients are referred to us because they and
their physicians believe that our treatment programs offer
the best chances of cure. I t i s as simple as that. They are
surprised and angry when their insurance company denies
payment for treatment which their physicians recommend. In
an effort to obtain that therapy, they sometimes have to sue
their insurance carrier, an effort which i s expensive in both
financial and emotional terms.
In many cases, when an insurance company sees that a proposed
treatment for a patient in on a c l i n i c a l t r i a l , they
immediately assume that the therapy i s experimental or
investigational and deny coverage. Enrollment onto c l i n i c a l
t r i a l s does not imply that therapy i s experimental or
investigational. In fact, the majority of c l i n i c a l t r i a l s
compare two accepted therapies to determine whether one hasan
advantage over the other.
The remaining c l i n i c a l t r i a l s
evaluate the effectiveness of a new therapy, particularly
when there exists no effective conventional therapy.
The
irony of this i s that treatment i s usually deemed
experimental or investigational based upon where i t i s
administered, ie. private setting ve. university, rather than
what i s administered.
Ttr—TTnTrr—~f—fr"*~rfTtntiti—hnrnifrt
rrnnnnri t rnnitiimp''* ^j^u
-
pa I l l a t i v e '-onlyr^-^^rhe^
chemotherapy with bone marrow or stem cell - eupporty-can-- -
�, N \ M R O TRANS.
.E A R U
TEL : 303-372-9003
Feb 23 93
12 = 38 No.005 P.03
produce long periods of remission in' appfBXlftiatel^^BV^of *
these patients.- While i t may be too early to say whether
this i s equivalent to a cure, i t i s clearly a disease-free
period which results in a meaningful prolongation of l i f e .
For women whose breast cancer i s limited to the breast, but
who, because of involvement of large numbers of lymph nodes,
are at very high risk for recurrence in the subsequent 5
years, the therapy we provide appears to result »injz:long-tera-T
disease-free periods in approximately 70% of--patients'. This
can be compared with less than 40% of patients enjoying that
response
when
treated
with
conventional
doses of
chemotherapy. The treatments we offer are not simple or
inexpensive. High-dose chemotherapy has a very real risk of
fatal complications, which occur in roughly 6% of patients.
The cost i s considerable, approximately $140,000. Patients
who are treated in this manner are exhaustively informed
regarding the risks and potential benefits and sign consent
forms attesting to that. Obviously, patients who decide to
undergo this therapy do so because they perceive the
potential for benefit exceeds the risk.
All patients who are treated by our group are treated on a
University of Colorado Cancer Centar^nd Institutional-Reviaw*.Board approved c l i n i c a l t r i a l .
This i s done for several
reasons.
First, by treating our patients in a uniform
manner, we can evaluate our results and report them in the
medical literature.
Because of this, patients treated by
other physicians benefit from the results of our work.
Second, t h a ^ g & t t & J ^ ^ o i ^
groups <neana^tha.t^they<**iiave^
neoe«»ity;^Bcientific*ratlonal**»aiK^
for the patientr
Thus7*^atlents--ara^not«tr«ated^i*«««ord*
ef f ect ive ther apy^ ire a ay "exists r-'Nor-ar«»rth*y«troatod«4irua
'facilitv^which^haa^Jiot^vbaen.,damongtrAtP.d ntft^Pwff*?**^-**
providing "that-l«veiM>f^edicar carSr
r
I t should be made clear that physicians at the University of
Colorado do not benefit from patients being enrolled on
c l i n i c a l t r i a l s . Physicians such as myself are salaried. We
do not receive pay for service. Therefore, no financial
incentive exists for us to enroll more patients on c l i n i c a l
trials.
The only incentive for enrolling patients on
c l i n i c a l t r i a l s when effective therapy i s lacking i s to
provide state of the art therapy which may benefit the
patient directly, and may benefit future patients based on
information collected.
I t makes sense to a l l of us that insurance companies should
pay for the most effective therapy.
However, when no
effective therapy exists, they should pay for the c l i n i c a l
but not research costs of therapy which has the promise of
being effective. This i s what your proposed legislation
seeks to mandate. Unfortunately, the goals of treatment are
often overlooked by the insurance industry. Less expensive
�JNE MflRROU TRANS.
TEL:303-372-9003
Feb 23 93
12:39 No.005 P.04
cancer treatments totally lacking in efficacy are often paid
for while expensive treatments with great promise of
efficacy, such as bone marrow transplants for breast cancer,
are not paid for. Insurance companies also frequently pay
for treatments which have never been evaluated in randomized
clinical trials.
An example of this i s high-dose
chemotherapy with bone marrow transplantation for lymphoma.
There has never been a c l i n i c a l t r i a l comparing this approach
with that of conventional therapy.
Therefore, denying
coverage because efficacy has not been proven i s an hollow
argument.
I applaud your efforts to assist cancer patients in Colorado
in obtaining the most advanced treatments available. This
legislation, i f passed, w i l l benefit a l l Colorado residents.;
Information wa learn today w i l l help patients^W^treat
tomorrow. In the long run . i t w i l l assist-the^insu^ancaoa*
* industry as well*/- By paying for treatments provided on
c l i n i c a l t r i a l s , they-will^leam^hat i s *ffeotivft-aMxHbftif, isn't.: Their support for the" treatment of- canoer^patier^s^
enrolled on c l i n i c a l t r i a l s w i l l .also help uaxto jwk^tKerapy^>
less expensive _with^the same jcLegree of benefit,
examplevf'
is our treatment program where selected marrow ^4agplfl»*^
patients receive their therapy largely in the eufcpa&Xeofeh
«settin^.
The financial impact today of the insurance
industry paying for treatment on c l i n i c a l t r i a l s in Colorado
w i l l be small, as you have read in the Social and Financial
Impact Statement prepared by Dr. Roy Jones. I t w i l l result
in cost savings and better care for patients tomorrow.
s
Sincerely,
Scott I. Bearman, M.D.
Associate Professor of Medicine
Clinical Director, Bone Marrow Transplant Program
University of Colorado Health Sciences Center
�Transplants extend lives
B n iriarrow transplantation: A speedier
oe
recovery for a life-giving procedure
Too often, breast cancer spreads to
lymph nodes and other parts of the
body. For the last several years, a few
cancer centers have been able to treat
this metastasized cancer using autologous bone marrow transplants. In the
procedure, a patient's bone marrow is
removed, after which the patient is
able to receive a much larger dose —
perhaps five to 10 times a normal
dose — of chemotherapy, which
increases the likelihood of destroying
cancer ceils. After chemotherapy, the
marrow is then injected back into the
patient, and, within three to four
weeks, the marrow
returns to the bones.
During these weeks,
until their bone marrow
is restored, patients are
at risk for life-threatening infections. This, then,
places a premium on the
speed with which their
cell svstems can be
returned to normal.
Recovery in half
the time
Today, CU researchers
directing University
Hospital's bone marrow
transplant unit have now
been able to reduce their
oatients' recovery time
They do this by transplanting only
certain types of cells needed for marrow recovery and by using a growth
factor.
The husband-and-wife team, Roy
B. Jones, MD and Elizabeth Shpall,
MD, with their partner Scott Bearman,
MD, have developed a technique that
allows them to select positive stem
cells — instrumental in producing all
the blood elements needed by the
body — from harvested bone marrow. Using monoclonal antibody
technology, they are able to collect
stem cells while leaving behind un-
wanted marrow and tumor cells. The
monoclonal antibody attaches to the
surface of the stem cells so the cells
can be culled from the marrow by a
computerized filtering device.
By using only a high concentration of stem cells, Doctors Shpall and
Jones are able to reduce the amount
of bone marrow infusion. By using
this "positive selection" method,
normal bone marrow cells return to
the bones more quickly, with reduced
risk of infection, bleeding, and infusion of tumor.
The experimental
technique has now
been performed on
60 advanced breast
cancer patients
between the ages of
30 to 56 who received bone marrow
transplants at University Hospital in
the past year.
Husband-and-wife
bone marrow
transplant doctors
Shpall and Jones
�JC.IE MARROU TRANS.
TEL : 303-572-9003
Mar Ol 93
10:50
No.005 P.02
3/1/93
CLINICAL TRIALS
A c l i n i c a l t r i a l i s any organized research program studying patient
outcomes following a defined treatment. The intent i s to collect
outcome and cost-effectiveness data.
The t r i a l may involve testing therapies which are totally proven to
determine which treatment i s superior or testing a modification of
a proven treatment.
These programs usually comprise 90% of
c l i n i c a l t r i a l s , and involve regimens similar or identical to those
used by community practitioners as part of standard care.
10% of t r i a l s involve testing treatments which are undergoing
i n i t i a l studies in humans, or i n i t i a l studies in humans with a
particular type of disease.
These are usually considered
experimental because there i s no firm idea about benefit. In these
t r i a l s , the therapeutic agent (drug, biologic, irradiation source)
i s always given to the patient free of charge and research costs
are paid by the government or other agencies. Patient care costs
are usually paid by insurers but some refuse, ignoring the fact
that other ineffective treatments would be given with similar
patient care costs i f patients do not participate in these
programs.
THE N M E OF PATIENTS IN THIS CATEGORY IS 35-50
UBR
PATIENTS PER YEAR MAXIMUM.
H W M N NCI TRIALS ARE APPROVED?
O AY
My reading of the b i l l i s that the c l i n i c a l t r i a l can either be
NCI-approved or approved by an NCI-designated c l i n i c a l cancer
center.
Using that criteria, 137 c l i n i c a l t r i a l protocols are
active now. Approximately 450 patients/yr enroll in these studies,
80% of the available capacity limited by research funding.
The above figures do not include Children's Hospital, for which I
do not have data. The number of patients enrolled there/yr i s
small.
,
,
,
H W M N COLORADO HOSPITALS ARE • NCI-APPROVED ?
O AY
The following hospitals or groups within c i t i e s are approved to
carry out NCI or cancer center protocols:
University Hospital
Denver VA Hospital
�I?L\-;E MHRRDU
TRANS.
TEL:303-372-900O
M r Ol 93
a
10 = 50 No.005 P.03
Denver General Hospital
Fitzsimraons Army Medical Center
Grand Junction
Penrose Hosp. (Colorado Spgs)
Laramie, W
Y
Greeloy
Memorial Hosp. (Colorado Spgs)
Boulder
Lutheran Hosp. (Denver)
St. Anthony (Denver)
presbyterian-St. Lukes (Denver)
Porter (Denver)
Swedish (Denver)
Rose (Denver)
St. Josephs (Denver)
This l i s t may have omitted 1-2 hospitals treating adult patients.
The last six hospitals participate through protocols sponsored by
the Univ. of Wisconsin, the Eastern Cooperative Oncology Group, or
the National^ surgical Adjuvant Breast/Bowel Project, a l l NCI
approved. ThlP^patients enrolled through these centers are small
compared to the other programs and almost no "experimental"
protocols are conducted there.
Children's Hospital performs NCI-approved studies but i s not listed
with the adult programs cited above.
SUMMARY
NCI-approved Protocol Studies conducted outside University, VA, and
Denver General Hospitals are small in number and size.
The accrual of patients in Protocol Studies i s limited by research
funding so that large expansion of these programs (and insurance
l i a b i l i t y ) is_impossibIeT
I f the Clinical Trials Advisory Board limits new t r i a l s in the area
of marrow transplantation for breast cancer to those approved by a
NCI-approved c l i n i c a l cancer center or the NCI i t s e l f , this will
result in an actual decrease in procedures done.
�Victim wins
treatment
for cancer
By Howard Panfcratz
Denver Post Legal Affairs Writer
California cancer victim Barbara Tepe
will begin potentially life-saving chtemotherapy at University Hospital on Friday
after a judge ruled yesterday that a Colorado insurance company must pay for her
treatment.
'
The high-dose chemotherapy for Tepe,
who has breast cancer, is expected to cost
about $130,000. Tepe said seven doctors
have told her the treatment is her only
chance.
Tepe, 51, sued Blue Cross and Blue
Shield of Colorado in Denver District
Court, four months after learning that
Blue Cross and Blue Shield of CaUfornia
wouldn't pay. An expert said Tepe had the
option of suing in California, wherfe she
lives, or Colorado, where she sought treatment.
Tepe claimed she was entitled to the
high-dose treatment under the Blue Cross
Federal Employees Plan held by her husband, Les, a 29-year employee of the federal government.
Blue Cross claimed that the federal employees' policy specifically excluded highdose chemotherapy for breast cancer.
But Chief District Judge Connie Peterson found there was coverage and* that
Please see CANCER on 4B
Wednesday, March 3, 1993
Cancer victim wins
high-dose treatment
CANCER from Page "IB
changes in the policy were ambiguous.
Peterson said any ambiguities
must be construed against the insurance company and where there
was more than one reasonable interpretation a judge must rule in
favor of providing coverage.
Tepe's attorney, Arlene Gilbert
Groch of New Jersey, said yesterday's ruling is important for thousands of federal employees and
their spouses who hold Blue Cross
policies.
"Judge Peterson's ruling was so
persuasive and clearly articulated
that I believe courts (around the
country) will look to it," she said.
In an affidavit filed with the
lawsuit, Tepe told Peterson she
and her husband could not believe
that "the insurance company ta
which we faithfully paid our premiums for seven years was denying my only chance for life. . . .
"I cannot begin to convey the
additional stress that this battle
with my insurance company has
added to the already unbearable
stress of my disease and my treatment," she wrote.
Tepe said she was beside herself
Monday, the day before Peterson's
ruling. "I cried all day."
But early yesterday
her
brother, Denver lawyer
Morris Hecox
Jr., called with
the good news.
"It was like
this
huge
weight was
taken off me,"
said Tepe, the
mother of two
Peterson
adult children.
Tepe's breast cancer was diagnosed in August 1992. She underwent a mastectomy and chemotherapy, but the cancer returned
and spread through her chest.
Blue Cross lawyer Rich Caschette, said the company will appeal but Tepe will receive the
complete high-dose treatment in
the meantime. ;
Carl Miller, a spokesman for
Blue Cross and Blue Shield of Colorado, said the company normally
covers high-dose chemotherapy
for its policyholders. But he said
the Tepes belonged to a self-insured federal health plan administered by Blue Cross. The government excluded high-dose chemotherapy from coverage and Blue
Cross, as administrator, complied
with those wishes, Miller said.
:
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
DATE
SUBJECT/TITLE
To Members of the Senate, re: SB 188 [partial] (1 page)
3/2/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
2006-0885-F
wr823
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
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PI
P2
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P4
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an agency 1(b)(2) ofthe FOIA)
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PRM. Personal record misfile defined in accordance with 44 U.S.C.
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RR. Document will be reviewed upon request.
�P6/(b)(6)
March 2.1993
Members of the Senate:
I am writing in support of SB 188, which would require insurers to pay for the costs of
treatment in certain cancer clinical trials. Cancer clinical trials can be the best treatment, and in
some cases can be the only hope of survival. I know, because Tve been there. I was diagnosed
with terminal kidney cancer in late 1989. My prognosis gave me only a 4 chance of being
%
alive three years after diagnosis, yet 40 months later I am not only alive, but healthy. I owe this
entirely to my participation in a clinical trial of a drug called interleukin D. As a result of my
experience, I teach a course on cancer clinical trials to other patients. In the process of
developing this course, I have devoted hundreds of hours to studying cancer clinical trials.
The term "clinical trial" brings to mind radically new treatments being given to humans
for thefirsttime, and opponents of SB 188 are capitalizing on this image of clinical trials to
argue that a clinical trial is necessarily a shot in the dark for which they should not berequiredto
pay, yet this is far from the truth. All clinical trials are experiments in the sense that they are
trying to ask a scientific question, but this does not mean that the treatments are cither new or
untested. Many clinical trials compare two completely standard treatments to see which gives
better results. An excellent example is early stage breast cancer where clinical trials were
conducted to compare mastectomy to the less disfiguring lumpectomy plus radiation. Both
treatments were and are standard treatments that involve no unapproved new drugs, but
questions can remain about treatments even after ihey have become standard.
Some clinical trials, including the one I participated in, do involve unapproved new drugs, but
even then, there are often years of experience with the new drug and an abundance of results
suggesting that the new drug is superior to standard treatment Consider the drug I received,
interleukin II. IL-2 wasfirstgiven to patients back in 1984, and the first dramaticresponsesin
terminal patients with advanced kidney cancer and melanoma happened in 1985. By the time I
received my treatment in 1989, there were formerly terminal patients out more than four years
with no sign ofrecurrentcancer. Yet, IL-2 was not approved by the FDA until May 1992, more
than seven years after thefirstdramatic response was observed. During this time, IL-2 was
available only through a clinical trial. This seven year delay is actually typical of the slowness of
the FDA's drug approval process, and is one very good reason why clinical trials are often the
best treatment for cancer patients. Patients are often denied reimbursement for treatment in even
the most promising trials; I was turned down by one insurance company, but I was lucky enough
to have two policies and to be reimbursed by the second, and so I lived.
Vote yes on SB 188 and give other patients have the same chance at life that I had!
. . H i . - .
•i' ?.
�20
nocKy Moumain wews
i njjrs., i-eo. ^o,
«•/ • i < i r i . - >• . ^.1 ,;•
- ^ r - r — — —
Cancer patients win a round in Senate committee
was bitterly opposed by insurance
industry spokesmen.
But cancer victims such as
Steve Dunn of Boulder, who received an extremely toxic drug
treatment for kidney cancer in
1989, argued the legislation was a
By John Sanko
life-or-death decision for many
people like himself.
Rocky Mountain News Capitol Bureau
"For me, the alternative to a
Cancer victims could force their
clinical trial was certain death,"
insurance companies to pay for
some "clinical trial" treatments said Dunn, who was rejected by
such as bone-marrow transplants one insurance company but apunder legislation approved by a 5- proved by another for his treat3 vote in the Senate Business Af- ment. "It was the only hope I had
fairs Conunittee Wednesday.
of saving my life.
The bill, which could result in 30
"Three years later, I'm healthy,
to 40 additional bone-marrow I'm married, and I'm back to work.
transplants annually in Colorado at When we get sick, we expect our
a cost topping $100,000 apiece, insurance companies to pay for the
Insurance would cover
treatments such as
marrow transplants
under bill approved
best medical treatment available."
Another witness, Lupe AyalaVallez, a 41-yearold Brighton high
school teacher and
mother of two, was
shocked to discover her insurer
would not pay the
$150,000 cost of a bone-marrow
transplant, even though doctors
told her it provided the greatest
chance of survival.
"Hopefully, there are not going
to be that many of us that need it,"
she said of the treatments provided by the bill. She received her
transplant last year after family
and friends raised $150,000
through garage sales, dances and
other events.
Under SB 188 by Sen. Jana
Mendez, D-Boulder, a nine-member board would determine which
cancer patients should receive
"clinical trial" treatment approved
by the National Cancer Institute.
The treatment would have to provide improved chances for longerterm survival and be carried out at
an NCI-approved hospital.
Mendez said 70% of those receiving the bone-marrow transplant now are covered by insurance, but 30% are rejected. "I'm
not asking for all cancer treatment
in all cases," Mendez said.
Dr. William R. Nelson, a Den-
ver-area surgeon, added, "There
are patients who really need this
method of therapy and can't get
it." Insurance and health-maintenance organization representatives opposed the bill as unnecessary, ineffective and potentially
very expensive.
Kyle Brennan of the Colorado
Group Insurance Association
warned the" bill would open the
door to others seeking coverage
for everything from diabetes to
AIDS. He suggested placing the
issue in a referendum to see if
voters are willing to pay the costs
rather than raising premium rates.
"We're worried about an opendoor policy for clinical trials," he
said.
READERS FORUM
A doctor comments on Senate Bill 188 and cancer treatment
Monday's editorial headlined "State research costs are paid by the National
shouldn't dictate how cancers get
Cancer Institute or other agencies), evtreated" contains a series of misrepresen- eryone benefits. The patient receives optations and errors of fact about Senate timal therapy and society benefits as suBill 188, which will be heard in the Senate perior cost-effectiveness is established
Business Affairs and Labor committee to- and inferior therapies are discarded.
day at 1:30 p.m. (The bill mandates health
High-dose multi-drug chemotherapy
insurance coverage for treatments under- for breast cancer has been deemed effecgoing clinical trials).
tive by the vast majority of breast cancer
Only a small minority of clinical trials experts, the National Cancer Institute,
"test new medical theories."
and the courts. The Food and Drug Administration does not approve any multiAt the University of Colorado Cancer
Center, over 70 percent of clinical trials drug treatment for cancer, nor has it ever
done so — it is not part of their mission.
compare proven therapies of established
effectiveness to determine which is the High-dose chemotherapy for breast cancer is neither experimental nor investigamost cost-effective. Another 20 percent
tional. That is why, as discussed in your
test refinements of these established
treatments. In virtually all cases, these front-page article recently, Comprecare
treatments are also given by community was unable to obtain expert testimony to
practitioners outside the research setting. prove in court that this therapy is experimental.
When the identical treatments are given
as part of a clinical trial (in which the
Blue Cross/Blue Shield will not be ex-
empt from Senator Mendez's bill as written, although large corporate self-insurance plans, including but not limited to
those administered by Blue Cross/Blue
Shield, would be exempt.
We are glad that you support "treatments with encouraging odds of success."
In the case of high-dose chemotherapy for
breast cancer, many research trials document between a 15 and 50 percent fiveyear tumor-free survival benefit compared to the best available conventional
treatment.
The state shouldn't dictate how cancers get treated, but should insurers be
allowed to deprive breast cancer patients
of highly proven and effective treatments
without their consent or knowledge?
ROY B. JONES, Ph.D., M.D.
University of Colorado
Health Sciences Center
�Lupe Ayala-Vallez ABMT Committee
Be a part of the cure:
Dear Policy Makers:
For the most of last year we were in the unfortunate position of having to
raise over $100,000 to pay for a medical procedure -Autologous Bone
Marrow Transplant for breast cancer-that is considered to be
experimental by some insurances -Comprecare being one of them. We
always thought ourselves to properly insured and adequately covered in
cases of extreme emergencies. However due to a wording on our insurance
policy we were excluded from a procedure that 99% of the courts have
ruled is not experimental. (Recent Colorado Court has ruled against
Comprecare and in favor of the patient in the case of the autologous bone
marrow transplant for breast cancer.)
We were very fortunate to have many-many friends and caring people who
helped us raise the needed money in less than 60 days. Many of these
people, by donating money to help pay for the transplant, were indicating
their frustrations with Comprecare and other insurances insensitiveties
to the needs of the consumer. Public opinion is to have insurances be held
accountable to their subscribers. Women across Colorado and the country
are frustrated with policies that discriminate against them, in particular
when dealing with the best treatment for breast cancer. Hispanics in
particular are frustrated with insurance companies such as Comprecare
and other insurance companies that show total disregard for the care of
woman with breast cancer. We Urge your to vote for Senate bill #93-188.
There can only be so many garage sales in Colorado to support what
insurances will not. Help stop Breast Cancer. Support the cure.
•_
The Lupe Ayala-Vailez ABMT Committee.
Post-It™ brand fax transmittal memo 7671 | # of pages *
"smr* sen*™
Dept.
m
Co.
PhOM#
Fax*
�KEY VOTE 8B93-188
3/03/93
Last year the l e g i s l a t u r e supported SB92-4 t o study a proposed h e a l t h care system
c a l l e d "Colorado Care." The l e g i s l a t u r e also passed SB92-114 c r e a t i n g a cost
containment and access commission t o study and recommend a c t i o n t o vou on
stemming the i n c r e a s i n g cost of h e a l t h care, recommending a minimum b e n e f i t plan-Tx
f o r Colorado and assessing the e f f i c a c y of a "guaranteed issue model" f o r the^S
s t a t e . I t seems very premature and c o n t r a d i c t o r y f o r t h i s body t o mandate a new,
very expensive b e n e f i t at the same time you have d i r e c t e d t h i s commission t o
provide you w i t h t h e i r recommendations on vhat the minimum benefit-package should
be f o r Colorado.
/^Q
This b i l l , w i l l i n i t s mandate of a new b e n e f i t :
(^D * Increase o v e r a l l h e a l t h care costs ( a c t u a r i a l s t u d i e s of t h i s
proposal show premiums w i l l go up) which are the very f a c t o r why
fewer f i r m s o f f e r h e a l t h insurance and our uninsured r o l l s are
increasing;
/JTN * Place the burden of t h i s mandate and subsequent cost increases almost
[7/
s o l e l y on small and medium sized employers. Why? Because the state
cannot f o r c e those e n t i t i e s t h a t are s e l f - i n s u r e d under ERISA t o
comply. Only large businesses and governmental e n t i t i e s s e l f - i n s u r e ;
* D i s c r i m i n a t e against the 60 percent of the p o p u l a t i o n not covered due
t o the ERISA exemption; and
* Apply t o funding c l i n i c a l t r i a l s t h a t i n v o l v e experimental thera
pies—meaning 40 percent of the insured p o p u l a t i o n i n Colfefado w i l l
be funding c l i n i c a l researjsh. .
(5ur 15,500 members ana t h e i r over 155,000 employees who want a f f o r d a b l e riedith
insurance ask you t o VOTE NO on t h i s b i l l .
T h i s i s NOT new coverage. Depending on the procedure, 70-90% of i n s u r e r s
are ALREADY p a y i n g f o r cancer t r i a l s . (INCLUDING s e l f - i n s u r e d s . . . they pay, though
not a l l o w e d t o be covered by s t a t e laws....as i s the case i n a l l i n s . r e q u i r e m e n t s . )
/(2y
A h e a l t h care p l a n t h a t DOESN'T address these s e r i o u s i l l n e s s issues i s not
(
a h e a l t h p l a n , i t ' s a HEALTHY p l a n . THIS BILL GETS ONLY THE PROPER PATIENTS
\
TO THESE TRIALS, CAN CUT COSTS BY BYPASSING LESS EFFECTIVE, COSTLY, BUT OUTDATED
PROCEDURES. A h e a l t h p l a n t h a t channels p a t i e n t s t o t r e a t m e n t t h a t r e s u l t s i n
i n f o r m a t i o n on cost s a v i n g s , p l u s best method of t r e a t m e n t i s of b e n e f i t t o ALL i n s u r a n c e companies as w e l l as p a t i e n t s .
/Qs
I l l i n o i s Blue Cross study showed i f ALL a p p l i c a n t s deemed a p p r o p r i a t e (and
/
t h i s was broader than NCI t r i a l s would a l l o w ) were p a i d , premiums COULD i n c r e a s e
V
7c a month. We are now l o o k i n g a t - t h r o u g h t r i a l s - bone marrow t r a n s p l a n t
(by f a r the most expensive of a l l procedures done) - done on an o u t - p a t i e n t b a s i s ^
CUTTING THE COSTS IN H A L F / ^ e t t h i s w i l l be slow i n coming unless people get i n t o
the t r i a l s .
The chance t h e i r i n s u r a n c e company w i l l deny keeps many people from
even c o n s i d e r i n g i t . (That Blue Cross study d i d n ' t deduct r e g u l a r t r e a t m e n t g i v e n
as an a l t e r n a t i v e , nor t e r m i n a l care c o s t s
)
A n
Most i n s u r a n c e companies ALREADY pay f o r t h i s t r e a t m e n t . . . . i n c l u d i n g s e l f m s u r e d s . Though we can't cover by law, they DO u s u a l l y pay.
I f they d o n ' t , they
LOSE IN COURT 90% of the t i m e ! ! ! What i s the b e n e f i t of NOT p a s s i n g t h i s b i l l ?
They take up so much i n a d m i n i s t r a t i v e w r a n g l i n g w i t h d o c t o r s , paperwork... c o u r t
and a t t o r n e y costs....and then s t i l l u s u a l l y have t o pay.
I n t h i s b i l l , they
s i t on a board l o o k i n g a t which t r i a l s w i l l be done
f o r the f i r s t time
SITTING D W AT THE TABLE WITH DOCTORS, ETHICS PERSONS, AND OTHERS TO MAKE
ON
LOGICAL, LIFE AND COST-SAVING DECISIONS.
V—^
THERE IS A TREMENDOUS COST AND LIFE SAVINGS ISSUE HERE BEFORE YOU.
And what say
y o u . . . . i f t h i s were your w i f e , d a u g h t e r , mother whose chance of s u r v i v a l c o u l d
zoom from a 5-year out 30% chance t o a 5-year-out 70% chance????
t2S
�I>aite^dmieni
THURSDAY
March 4, 1993
BODY AMD SOUL
JULIET WITTMAN
Health care
Larnm-ent
I recenUy attended a health care
conference that provided some clues about
the kind pi: system in store for us.
"Coloradlp Health Care Reform: Options
and Ethics,'' organized by the University of
Colorado ih'Penver, purported to bring
together a'diverse group of people to
discuss the vitfues underlying the healthcare debate:-Y' v 'ri •>••;;
r^n.
In fact, almost the entire discussion was
shaped by the narrow worldview of ex-Gov.
Richard Lamm, and the spectrum of •
speakers was even narrower. There were
ho doctors or nurses. No patients. No
working class or poor people. No people of
color. The only proposals on the table were
ColoradoCare and another put forward by
the insurance companies. No one
mentioned the plan for a Canadian-style .
system that has twice been introduced into
the state legislature, though one panelist
did promote a single-payer approach.
: This group clearly has the ear of Gov.
Roy Romer. It became equally clear as the
day wore on that the structure of the state's
system has already been decided. Having
informed us that managed competition was
the only framework being considered, one
participant urged us all to get involved. If
we didn't, he said, we'd have only ourselves
to blame if We disliked the outcome.
Managed competition is also President
Clinton's favored solution; ColoradoCare —
like the plans being floated in several other
states — is intended to jibe tidily, with
Whatever iormat he comes up with.
It's as though our health care system
were a man who had entered the hospital
with a huge spear in his back. Instantly the
doctors fall to arguing. Is his heart weak?
Are his kidneys functioning? Does he need
painkillers? Should he be chastised for not
having avoided his attacker? Perhaps
someone should rub his feet?
i
�, i.iauageu compeution is also" President
Clinton's favored solution; ColoradoCare —
like the plans beingfloatedin several other
states — is intended to jibe tidily with.
Whatever format he comes up with.
'.: It's as though our health care system
were a man who had entered the hospital
-with a huge spear in his back. Instantly the
'doctors fall to arguing. Is his heart weak?
Are his kidneys functioning? Does he need
painkillers? Should he be chastised for not
having avoided his attacker? Perhaps
someone should rub his feet? .
"Do you think we might take the spear
out?" suggests an intern timidly.
The doctors regard him with scorn, then
turn back to their debate. " " '
Almost all Americans except for the
experts can identify that spear. They know
it's created by the greed of insurance^
'
companies that siphon off a large chunk of
the health care dollar without adding :
anything but paperwork to the system. It's
created by hospitals proliferating like
mushrooms, duplicating services, and then
vying frantically for patients tofilltheir
beds. It's caused by the greed of drug
companies and of doctors; >
-. 1
But that's not how experts like Lamm:
see it. Though he has some cogent things
to say about the overuse of technology, ••
Lamm insists that, in thefinalanalysis, the
problem is your and my outrageous
r
expectation that when we're sick we should
receive care — in fact, the best care ~
possible.
The solution? First, government takes'it . ,
token dab at limiting the amount of money
Insurers arid suppliers drain from the- ac ^system. Then everyone is given a meager
package of health benefits. Insurance
companies dictate which doctor we may
see: It saves money if the doctor works for
the insurer because then he'll focus more
on cutting costs than on serving patients —
as many people currently enjoying the
services of HMOs have discovered.
The victim-blaming tenor of the
conference intensified. A businessman
spoke of "our insatiable demand for health
care." An attorney, ignoring the realities of
unemployment, depressed wages and
skyrocketing insurance costs, came up with
the brilliant formulation that failure to . \
acquire health care coverage was simply a
failure of individual responsibility, ife^;^
During a question and answer period, the
topic of bone marrow transplants arose. It
has been in the hews lately. A breastV.^V™,
cancer patient just won payment in the
courts for a transplantfromComprecare; a
21-year-old college student is trying to raise
funds for a transplant that gives him a 90
percent chance of beating his leukemia.-/
The thought of Coloradans dying for want
:of a procedure readily available to any: .. .
Canadian who needs it did not cause so
much as a wrinkled brow among the
i speakers. "You have to die sometime," they
Jsaid blandly.
Gov. Lamm's wife has had breast cancer.
After the session, I confronted him.
"If your wife had a metastasis," I asked,
"would you agree to her having a bone
marrow transplant or other experimental
treatment?"
Lamm thought a moment, then said in a
low voice: "I would move heaven and earth
to get Dottie anything that might help her."
I was charmed. Later, the implication of
!
s
;
f }
h i s ariSWPr hit m o
ii
•
TJ
3JT3
m i
C o
O
mH
�insurers and suppliers drainfromthe ^ i ""
system. Theii everyone is given a meager
package of health benefits. Insurance
companies dictate which doctor we may
see: It saves money if the doctor works for
the insurer because then he'll focus more
on cutting costs than on serving patients —
as many people currently enjoying the
services of HMOs have discovered.
The victim-blaming tenor of the
conference intensified. A businessman
spoke of "our insatiable demand for health
care." An attorney, ignoring the realities of
unemployment, depressed wages and
skyrocketing insurance costs, came up with
the brilliant formulation that failure to . \
acquire health care coverage was simply a
failure of individual responsibility.
During a question and answer period, the
topic of bone marrow transplants arose. It
has been in the news lately. A breast/ /r
cancer patient just won payment in the '
courts for a transplantfromComprecare; a
21-year-old college student is trying to raise
funds for a transplant that gives him a 90
percent chance of beating his leukemia.^
The thought of Coloradans dying for want
of a procedure readily available to any-. * .
Canadian who needs it did not cause so
much as a wrinkled brow among the
speakers. "You have to die sometime," they
said blandly.
Gov. Lamm's wife has had breast cancer.
After the session, I confronted him.
"If your wife had a metastasis," I asked,
"would you agree to her having a bone
marrow transplant or other experimental
treatment?"
Lamm thought a moment, then said in a
low voice: "I would move heaven and earth :
to get Dottie anything that might help her."
I was charmed. Later, the implication of
his answer hit me. Under the new rules, if
Dottie Lamm — or anyone else rich and
highly placed — needs a transplant or
experimental treatment, she will receive it
But you and I would not only be turned
away in similar circumstances, we'd be
scolded for our greed in wanting to live.
This is the Brave New World of health
care that Lamm and his counterparts in
Washington are bringing you.;
•
Body and Soul appears every second
week.
• <-\
•
v
i
U
332
mi
to o
8
o-<
�COUNTY OF BERGEN
DEPARTMENT OF HUMAN SERVICES
DIVISION ON AGING
Administration Building • Court Plaza South • 21 Main St. • Hackensack, N.J. 07601-7000
(201)646-2625
William P. Schuber
County Executive
Gina M. Plotlno, Director
Department of Human Services
Gloria Layne
Division Director
March 11, 1993
Ms. H i l l a r y Rodham Clinton
and Members of the Task Force
on Health Care Reform
White House
Washington, D. C.
Dear Ms. Clinton and
Members of the Task Force:
On behalf of County Executive William "Pat" Schuber and the Bergen
County Division on Aging Advisory Council and s t a f f , we enclose the
t r a n s c r i p t of our Public Hearing on Health Care Reform conducted
Thursday, February 25, 1993.
As you can see from the copy of the announcement f l y e r , the hearing
was open to a l l residents of Bergen County (845,000; 173,000 are
age 60+) .
There was standing room only and many of those in
attendance made a special e f f o r t to t e l l us that they appreciated
the opportunity to share t h e i r concerns and/or suggestions on t h i s
v i t a l issue. The enclosed t r a n s c r i p t i s sent to you and the Task
Force with ideas and i s t r u l y a dialogue of what people are
thinking.
We hope t h i s information w i l l be of interest and value to you as
you work on the health care plan.
Best wishes.
Gloria Layne
Director
g/hilrclin
�{--^ii
f ^i-t"?*^":
~.~j7'
County of Bergen
William P. Schuber
County Executive
Board of Chosen Freeholders
J. William Van Dyke
Chairman
Richard A. Mola
Vice Chairman
Todd R. Caliguire
Anthony J. Cassano
Barbara H. Chadwick
Richard H. Kelly
James J. Sheehan
Department of Human Services
Gina M. Plotino
Director
Division on Aging
Gloria Layne
Director
�Public Notice
The Advisory Council
ofthe
Bergen County Division on Aging
together
with
William Pat" Schuber
County
Executive
in an effort to bring together a l l residents,
invites your participation i n a special Public Hearing
to share your thoughts on the issue of
Health Care Reform
Date:
Thursday, February 25, 1993
Time:
11:45 a.m. - 3 p.m.
Place:
The Meeting Place
Riverside Square Mall, Hackensack
First Lady H i l l a r y Clinton has been charged w i t h the responsibility of
leading a Task Force to study the subject of health care r e f o r m and to
present recommendations to President Clinton w i t h i n the f i r s t 100 days of
this new administration.
Health care is a major concern not only f o r
older adults but f o r children, youth, and those i n their middle years. I t is
an issue that effects a l l individuals!
Testimony can be w r i t t e n or oral and w i l l be recorded by a court
stenographer. The transcript w i l l then be forwarded to Mrs. Clinton f o r
inclusion i n her study.
Also invited to share their thoughts and listen to the concerns of our
residents are
Congresswoman Marge Roukema, Congressman Robert Torricelli,
Senator B i l l Bradley and Senator Frank Lautenberg
as well as members of our State Legislature who represent Bergen
County.
For more information,
please contact Gerry Drummond at 646-3413
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002. letter
SUBJECT/TITLE
DATE
W. Straus to Hillary Clinton [partial] (1 page)
3/16/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
2006-0885-F
wr823
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act - |S U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) o f t h e FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) o f t h e FOIA)
b(3) Release would violate a Federal statute 1(b)(3) o f t h e F O I A j
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) o f t h e FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) o f t h e FOIA)
b(S) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) o f t h e FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) o f t h e FOIA|
National Security Classified Information 1(a)(1) o f t h e PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA|
Release would violate a Federal statute [(a)(3) o f t h e PRA)
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) o f t h e PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA)
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�(HommonfrjcaltJ] of ^Htassadiusetts
House of ^epresentatftjea
March 1 6 ,
1993
Mrs. H i l l a r y Rodham C l i n t o n
The White House
Washington, D.C. 20201
Re:
H e a l t h Care
Dear Mrs. C l i n t o n :
I am w r i t i n g w i t h regard t o your c u r r e n t d u t i e s i n r e v i e w i n g h e a l t h
care o p t i o n s i n t h e n a t i o n .
-i—tiaye been contacted by one o f my c o n s t i t u e n t s w i t h regard t o her
idea ifor r e d u c i n g t h e c o s t o f a d m i n i s t r a t i o n o f h e a l t h c l a i m s .
M
suggests t h a t t h e r e
,
—
^m^m^,^..^,^... - „
.
•
.
.
.
be u n i t o r m n a t i o n a l c l a i m torms wmcn wouia be used i n processing
claims no m a t t e r whether we keep t h e same p r i v a t e insurance and
government c l a i m system, o r have a system o f a reduced number o f
payers.
I hope t h a t you w i l l consider t h i s suggestion i n t h e aspects o f
h e a l t h care reform.
Very t r u l y yours,
W i l l i a m M. Straus
State Representative
cc:
�DON BALFOUR
District 9
2889 Carrousel Court
Stone Mountain, Georgia 30087
COMMITTEES:
Banking and Financial Institutions
Governmental Operations, Secretary
Health and Human Services
Higher Education
SUBCOMMITTEES:
Merit System
Health Care Facilities and Professions
W t & t t Senate
h >at
Atlanta, Georgia 30334
February 25, 1993
Mrs. Hillary Rodham Clinton
The White House
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mrs. Clinton:
Recently, a constituent, Ms. Bonnie Lambert, came to me during Georgia Senior Day.
She asked that I forward these articles to you.
Mrs. Lambert is concerned about the apparent inefficiency of the Medicare department
charged with collection of overpaid hospital charges. She believed you should be
made aware of these newspaper articles and their allegations.
Thank you for your attention to this matter. If I can be of further assistance, I can be
reached at (404)656-0095.
Sincerely,
DON BALFOUR
DB/gw
Enclosure
�.
rth^Ji,
/Z''??^
_
....
Auditor says Medicare
too busy for paybacks
• It is estimated that
the program is owed
$265 million by
hospitals.
Knight- Ruldi r Newspapers
WASHINGTON - Hospitals that
have overcharged the Medicare program are having a hard time paying
the money back because the program's paper handlers are too busy to
accept the money, a federal auditor
testified Wednesday.
The audit of randomly selected
hospitals estimated that the Medicare program is owed, at this point,
$265 million in repayments for overcharges, double-billing or medical
services paid for but not performed,
"The significant thing is that twothirds (ofthe 76 hospitals) tried to pay
Medicare back, and the intermediaries said they were too busy to take it,"
Health and Human Services Inspector General Richard Kusserow told a
House subcommittee Wednesday.
The audits covered the last year to
18 months of Medicare reconis, according to Judy Holta. a spokeswoman for the inspector general's office.
Intermediaries are the 58 private
companies that handle Medicare paperwork and payments. The nine intermediaries included in the audit Blue Cross and Blue Shield affiliates
in Pennsylvania, New Jersey, South
Carolina, Michigan, California, Connecticut, Oklahoma and Wisconsin Please see MEDICARE, page 8A
'Medicare owed
$265 million,
( (I
audit shows
r>
From page IA
place no emphasis on recovering
Medicare overpayments, Kusserow
said.
"They weren't even looking. It.
wasn't on their to-do list," Kusserow
told the House Energy^ and Commerce
subcomminee
on
investigations.
Officials of Blue Cross and Blue
Shield and hospitals cited in
Wednesday's hearing said they had
not attended the hearing and could
not comment on the audit
Subcommittee Chairman John
Dingell, D-Mich., said the audit
showed that "hospitals throughout
the country are sitting on bulging
slush funds. ... Even more disturbing, some hospitals apparently have
just simply pocketed these Medicare
monies with little more than the
stroke ofthe pen - when regulations
and propriety demanded their return
to the taxpayer."
Kusserow said that a similar audit
in 1986 had resulted in repayments tu
the Medicare trust fund
�Seniors
assail
Medicare
• Lack of refund procedure for
overcharges is absurd, advocates tell Congress.
The Associated Press
WASHINGTON - Many Medicare beneficiaries
are being overcharged by doctors, and the federal
government refuses to require refunds, advocates for
the elderly told Congress Tuesday.
"This interpretation of the law is absurd," Carol
J imenez ofthe Med icare Advocacy Project, Los Angeles, told the Senate Aging Committee. "It makes no
sense that although a
charge is illegal, a refund
Senior citizen:
need not be issued."
"You don't have to have 'You dont have to
a ski mask — you can have have a ski mask
a scalpel and do the same
thing," said Stanley Lip- — you can have a
son, a 68-year-old piano scalpel and do the
tuner from Bayside, N.Y. same thing."
He told the committee he
was overcharged more
than $1,000 for surgery butgot so tired of fighting the
government, the medical profession and the insurance industry that he eventually paid the bill.
"I'd have to tune a hell of a lot of pianos for that
money," he said.
Eventually, an advocacy group got Lipson a refund.
But other Medicare beneficiaries are not so fortunate, said Sen. William Cohen, R-Maine, who presided over the hearing.
As Cohen explained it, the problem involves "nonparticipating" doctors - those who do not agree to
accept Medicare-approved amounts as full payment
for services.
Medicare generally pays 80 percent of a doctor's
fees and the patient is responsible for the remainder.
Doctors who do not accept those restrictions are prohibited by law from charging more than 120 percent
of the Medicare fee. This is known as the limiting
charge, or billing limit
Cohen accused the federal Health Care Financing
Administration, which runs Medicare, of being extremely lax in enforcing the limit and of failing to
inform beneficiaries of the law. Despite the law, he
and witnesses said, many Medicare patients are notified they are liable for amounts far in excess of the
Medicare limits.
Cohen noted that until recently, the "Explanation
of Medicare Benefits" form, which is sent to anyone
who files a Medicare claim, failed to mention any
limit on what a doctor may charge or what a beneficiary must pay. Why did it take HCFA two years after
Congress passed the limit law to have it refiected on
Medicare forms? Cohen demanded.
"We just missed it," replied Carol Walton, deputy
director of HCFA " I apologize for that"
Ms. Walton said insurance companies, which handle Medicare claims and checks, are developing a
better benefits form.
�FEBRUARY
1993
NEWSBREAK
Billions lost to Medicare
fraud, says G O report
A
tems to prevent waste.
GAO says HCFA has routinely failed to investigate reports of fraud and abuse, and that HCFA's
The General Accounting Office (GAO) says that,
payment policies encourage abuse and excessive
"in recent years, the Medicare program has lost bil- charges by doctors, hospitals and clinics.
lions of dollars to waste, fraud and abuse." And it ac- GAO recommends that HCFA "exercise stronger
cuses the Health Care Financing
leadership in managing the Medicare program."
Administration (HCFA), which
William Toby Jr., acting administrator of HCFA,
runs Medicare, of doing a poor job told reporters he was not surprised tofindMedirooting out these problems.
care listed among the highriskprograms but said
he was surprised that the report did not credit the
In a report to Congress, GAO
agency for its "enormously aggressive efforts" at
chief Charles A. Bowsher cites
combating waste and fraud. "If s the size of our prothis example: "We found that congram that makes us vulnerable," he said.
Bowsher: critical tractors [insurance carriers servicing Medicare claims] paid an estiA few days later a joint "action team" formed by
mated $2 billion in claims that should have been
the Department of Health and Human Services, the
paid by other health insurers [in 1991]."
Justice Department and the Office of Management
"We also found that hospitals owed Medicare
and Budget reported on the administration's own
[more than] $170 million in over-payments, but
investigation of abuses in the health-care system.
[HCFA] contractors had done little to recover the
"While there has been progress in eliminating
money," he says.
fraud and abuse in health-care programs, additional
To make things worse, Bowsher says, HCFA was
attention is needed to curb health-care fraud and
unaware of the lack of effort to recover the money
waste," the group reported.
"because it had no system to monitor" the contracThe interdepartmental group recommended sevtors who are letting the money get away.
eral steps including expansion of federal anti-kickMedicare provides health insurance for 35 million
back laws to cover all public and private payers, exmostly elderly beneficiaries.
tending the ban on self-referrals to physician-owned
Medicare was among 17 federal programs cited by facilities, strengthening monetary penalties and
the GAO as having a "high risk" of fraud because
sanctions against waiver of Part B copayments by
they are deficient in procedures to guard against
providers and establishing databases of fraud invesfraud and abuse and infinancialmanagement systigations and actions.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003. letter
SUBJECT/TITLE
DATE
M. Parsons to Hillary Clinton [partial] (1 page)
2/24/1993
RESTRICTION
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COLLECTION:
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Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
2006-0885-F
wr823
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C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�ALABAMA STATE SENATE
ALABAMA STATE HOUSE
MONTGOMERY, ALABAMA 36130-4600
ALABAMA
MAC PARSONS
February 24, 1993
COMMITTEES:
CHAIRMAN. JUDICIARY/CIVIL
PUBLIC WELFARE
CONSTITUTION AND ELECTIONS
LOCAL LEGISLATION NO 2
STATE SENATOR 17TH DISTRICT
1724 THIRD AVENUE. NORTH
BESSEMER. ALABAMA
35020
(205) 425-7671
MONTGOMERY (205| 242-7877
Ms. Hillary Rodham Clinton, Chairman
Task Force on Nation's Health Care System
The White House
1600 Pennsylvania Avenue
Washington, D. C. 20006
Dear Ms. Clinton:
I am sending you the enclosed because of your
assignment by the President. I t would seem to me that
the cost of treatment for Mrs. ^^^|^|||^^^| bed sores
was very high. I don't know why cn6?6 etiulan*t be a
cheaper way to buy bandages and ointment.
ij"} s ancillary
Mr. Robert C. Gafford, Mrs.
conservator, t e l l s me that previous to the nursing home
contracting with MEDPRO PLUS under the incontinent
patient's plan. the jpa r r1ngton gel and gauze pads used
to treat Mrs.
in the nursing home cost between
$45 and $75 per mont which was paid for out of Mrs.
p m m M s limited funds.
Mr. Gafford t e l l s me that the nursing home
continually apprised him of Mrs.
's condition
concerning her bed sore, and told him oh numerous
occasions that the size of the decubitus was no more
than the size of a pencil point. I t i s far fetched and
beyond my imagination that treatment of a decubitus
costing month in and month out no more than $45 to $75
would suddenly demand a treatment as costly as the
treatment provided by the nursing home under MEDPRO's
contract amounting to $3,726.45.
�Mrs. H i l l a r y Rodham Clinton
February 24, 1993
Page Two
I f incontinent care programs such as the one
provided by MEDPRO are prevalent throughout the United
States then i t ' s no wonder that the cost of Medicare and
other government programs are so rampant, costly and out
of hand.
I laud you in your efforts to control spending i n
this area and i f you are successful in bringing costs
such as these in l i n e , which in my opinion are very
excessive, you w i l l have done an exemplary job.
Sincerely,
Mac Parsons, Member
State Senate, D i s t r i c t 17, Hueytown
MP/mt
Enclosures
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
004a. letter
DATE
SUBJECT/TITLE
Benny Dykes to Mack Parson, re: Medicare Benefits for constituent
(2 pages)
2/19/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
2006-0885-F
wr823
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information [(a)(1) ofthe PRA]
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PS Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(5) ofthe PRA)
P6 Release would constitute a clearly unwarranted invasion of
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b(l) National security classified information [(b)(1) of the FOIA|
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b(3) Release would violate a Federal statute [(b)(3) ofthe FOIAj
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information [(b)(4) ofthe FOIA)
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purposes 1(b)(7) ofthe FOIA|
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financial institutions 1(b)(8) ofthe FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) of the F01A|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
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DOCUMENT NO.
AND TYPE
004b. letter
SUBJECT/TITLE
DATE
Benny Dykes to Robert Gafford, re: Medicare Benefits for constituent
(1 page)
12/14/1992
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
2006-0885-F
wr823
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P2
P3
P4
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b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) ofthe FOIA]
b(3) Release would violate a Federal statute [(b)(3) ofthe FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIAj
National Security Classified Information 1(a)(1) ofthe PRA|
Relating to the appointment to Federal oflice [(a)(2) ofthe PRA]
Release would violate a Federal statute [(a)(3) ofthe PRA|
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financial information 1(a)(4) of the PRA]
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and his advisors, or between such advisors [a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�SKIN CARE SUPPLIES FURNISHED:
1 EA-
PROTECTIVE BARRIER
1 EA-
IRRIGATION SOLUTION
1 EA-
IRRIGATION SYRINGE
2 PK-
CASTILE SOAP
1 PR-
LATEX GLOVES
1 EA-
DISPOSABLE UNDERP AD
1 EA-
DISPOSABLE WASHCLOTHS
1 EA-
PLASTIC WASTE DISPOSAL BAG
PROCEDURE
1) Assemble equipment at resident beside.
2) Wash hands and explain procedure to resident.
3) Pull Cubicle curtain around resident to provide privacy, close door and drape resident.
4) Place underpad under buttocks.
5) Remove soiled clothing.
6) Assist resident in turning to expose buttocks area and put on gloves.
7) Remove fecal material from resident buttock using toilet tissue.
8) Mix castile soap with warm water and wash buattock and genitalia. ( 1 pkg of soap for each quart of
water used.)
9) Open sterile water and mix with warm water. Fill syringe and rinse involved areas throughly.
VERY IMPORTANT! BE SURE WHEN RINSING TO REMOVE ALL SOAP COMPLETELY.
10) Dry area on resident with towel.
11) Apply skin barrier generously to involved areas.
12) When completed, fold up underpad with all items in kit and place in the zip-lock bag provided and
dispose of bag as per the facility instructions for handling waste.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
004c. paper
DATE
SUBJECT/TITLE
"Explanation of Your Medicare Part B Benefits" (1 page)
2/17/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
2006-0885-F
WT823
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. SS2(b)|
PI National Security Classified Information |(a)(l) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA)
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA]
b(l) National security classified information 1(b)(1) ofthe FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA]
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
005a. letter
DATE
SUBJECT/TITLE
Benny Dykes to Mack Parson, re: Medicare Benefits for constituent
(2 pages)
2/19/1992
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
2006-0885-F
wr823
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)|
Freedom of Information Act - [5 U.S.C. 552(b)|
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P2 Relating to the appointment to Federal office 1(a)(2) of the PRA)
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA|
b(l) National security classified information 1(b)(1) ofthe FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency |(b)(2) ofthe FOIA)
b(3) Release would violate a Federal statute |(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information |(bX4) ofthe FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
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�Withdrawal/Redaction Marker
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DOCUMENT NO.
AND TYPE
005b. paper
SUBJECT/TITLE
DATE
"Explanation of Your Medicare Part B Benefits" (3 pages)
2/17/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1985
FOLDER TITLE:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
2006-0885-F
vvr823
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an agency [(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) ofthe FOIA|
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personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
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�6. CMN's: Pa. Medical Supply will send the CMN to the patient's
physician for completion and signature.
7. Please have a representative of your facility call Pa. Medical
Supply at 1-800-227-8850 at any time to discuss program particulars or to address any special needs you may have.
NEW
Pa. Medical Supply
WOUND C A R E PROGRAM
MEDICARE PART B REIMBURSED
For more information, please contact the
local Independent Marketing Representative.
Available for patients with
surgically debrided decubitus
ulcers or any surgically created
opening.
Reduces the cost of providing
quality wound care treatment
for your patients.
Independent Marketing Representative for:
Improves infection control:
Sterile Kits
Gloves Provided
PA. MEDICAL SUPPLY
780-C PINE VALLEY DRIVE
PITTSBURGH, PA 15239
TEL: 1-800-227-8850
FAX: 1-800-331-2210
Hi-tech specialty dressings
available.
�Products Available:
Patient Eligibility:
Wound care supplies are available in two different sterile kits.
Kit *1 contains:
Kit 2 contains:
12 Sterile 4x4"s
1 Carrington Hydrogel 4x4
1 Micropore Tape 36"
12 Sterile 4x4"s
1 3" Stretch Gauze
1 Micropore Tape 36"
#
1 Waste Disposal Bag with Tie
1 Sterile Basin
2 Pair Sterile Gloves
2 ABD Pad 5x9
1 3" Stretch Gauze
1
1
2
2
Waste Disposal Bag
Sterile Basin
Pair Sterile Gloves
ABD Pad 5x9
The Hi-Tech specialty dressings and sizes currently available are:
Adaptic 3x3
Adaptic 3x8
Bard Absorptive dsg.
Bioclusive 2x3
Comfeel 4x4
Duoderm 4x4
Epilock 4x4
Hydra Gran
Me-Salt
Vigilon 4x4
Intrasite 4x4 dsg. Xeroform 4x4
Tegaderm 2x2
Sween-a- peel 4x4 Sorbsan 2x2
Kaltostat 7.5x12
Sorbsan 4x4
Opsite 572x4
Mitraflex
Dermagran Wet Saline Dsg.
Multidex
Kaltostat 5 gm. packing
Kaltostat 5x5
Applications:
Supplies are available for up to 3 dressing changes daily
per wound site or as per physician orders.
Billing for Product:
We will bill Medicare and the patient's supplemental
insurance directly on behalf of the patient.
There is no cost to your facility for these supplies.
Eligibility for this program is extended to any Medicare
Pan B eligible patient with a surgically created opening
or a surgically debrided decubitus ulcer of Stage I I , III, or IV.
Procedure for Ordering:
1. TO START PROGRAM: Complete the New Home/Physician
worksheet, the Patient Evaluation form, and the Wound Care
order form. Your Pa. Medical Supply Marketing Representative
will be happy to assist you.
2. INITIAL ORDERS: Fax at 1-800-331-2210 or mail the completed forms to Pa. Medical Supply. Upon receipt of orders, a
Pa. Medical Supply phone representative will phone to verify the
orders and answer any questions you may have.
3. REORDERS: A Pa. Medical Supply representative will contact
your facility twice monthly to confirm reorders, verify receipt
of shipments, and troubleshoot any problems you may be
experiencing.
4. SHIPMENTS: Products for a new patient will be shipped
within 3 to 4 days of receipt of orders.
5. NEW PATIENTS: As new patients qualify for the wound care
program, complete the required forms and forward to Pa. Medical Supply. You will be called by a Pa. Medical Supply repre
sentative to confirm the order and sufficient product will be
shipped to provide treatment until the next regular reorder cycle.
�SCOTT HARSHBARGER
ATTOHNEY GENERAL
(617) 727-2200
March 4,
1993
H i l l a r y Rodham C l i n t o n
D i r e c t o r of the Task Force
on N a t i o n a l Health Care Refonn
The White House
1600 Pennsylvania Avenue, N W
..
Washington, D.C. 20500
Dear Mrs.
Clinton:
When I saw you b r i e f l y i n Boston on February 22, you asked
me t o send you d i r e c t l y any proposals my o f f i c e has been
developing i n h e a l t h care reform. We do have a t t h i s p o i n t a
working document which I have enclosed f o r your review . We are
also p r o v i d i n g a copy t o John Hart who met w i t h my s t a f f and
NAAG r e p r e s e n t a t i v e s l a s t week. As I i n d i c a t e d , I c h a i r the
NAAG Health Care Task Force.
The approach o u t l i n e d i n t h i s document combines the
market s t r u c t u r i n g concepts of the Jackson Hole group w i t h
u n i v e r s a l access and global cost c o n t r o l s .
The main elements of the p l a n are as f o l l o w s :
Health care f i n a n c i n g i s reformed and s i m p l i f i e d :
Health insurance i s not t i e d t o employment. The
f e d e r a l government funds the m a j o r i t y of h e a l t h care
costs. The states c o n t r i b u t e the balance.
Federal-state funds are disbursed t o Health Insurance
Purchasing Cooperatives who, based on the annual
choices of t h e i r members, disburse funds t o
Accountable Health Partnerships. HIPCs and AHPs
f u n c t i o n according t o n a t i o n a l l y defined standards as
i n the Jackson Hole model. Medicare and Medicaid are
included i n the same framework.
�Consumers a r e r e q u i r e d t o c o n t r i b u t e t h e i n c r e m e n t a l
c o s t s o f any p l a n they s e l e c t i n excess o f t h e c o s t o f
t h e l e a s t expensive s t a n d a r d p l a n o f f e r e d by t h e i r
HIPC. AHPs compete a g g r e s s i v e l y on t h e b a s i s o f c o s t
and q u a l i t y .
The f e d e r a l c o n t r i b u t i o n i s l i m i t e d by f o r m u l a based
on t h e Gross N a t i o n a l Product.
Ongoing e f f o r t s t o
c o n t r o l c o s t s a r e focussed a t t h e s t a t e l e v e l .
S t a t e s a r e f r e e t o choose t h e i r own approaches t o cost
c o n t r o l . We a n t i c i p a t e t h a t many may l i m i t o v e r a l l
p e r s u b s c r i b e r AHP charges r a t h e r t h a n e n t e r i n g i n t o
more d e t a i l e d p r i c e - s e t t i n g e x e r c i s e s .
The p l a n i s i n t e n d e d t o s t r e n g t h e n consumer c h o i c e , p r o v i d e
u n i v e r s a l access and c o n c e n t r a t e l e v e r a g e f o r c o s t c o n t r o l a t
t h e s t a t e l e v e l . A t t h e same t i m e , i t i s i n t e n d e d t o m i n i m i z e
b u r e a u c r a t i c and p o l i t i c a l i n t e r v e n t i o n i n t h e m a r k e t p l a c e .
The p l a n a l s o c o n t a i n s an o u t l i n e o f a c t i o n s t e p s f o r
i n i t i a t i n g f e a s i b l e reform a t the state l e v e l i n
Massachusetts. S i m i l a r s t a t e e f f o r t s c o u l d be u n d e r t a k e n i n
other states.
Needless t o say, I would be v e r y happy t o s u p p o r t y o u r
e f f o r t s i n whatever way I can, whether o r n o t r e l a t e d t o t h e
enclosed document. We a r e a v a i l a b l e t o c o n s u l t and meet as
a p p r o p r i a t e t o f u r t h e r t h e e f f o r t s o f t h e w o r k i n g groups.
One area n o t developed a t any l e n g t h i n t h e e n c l o s e d
document i s t h e area o f h o s p i t a l a n t i t r u s t enforcement. We a r e
d e v e l o p i n g a p o s i t i o n statement on t h i s i s s u e which we w i l l
f o r w a r d t o you i n A p r i l .
I n summary, o u r v i e w i s t h a t w h i l e
t r u e v e r t i c a l i n t e g r a t i o n i n t h e h e a l t h care i n d u s t r y i s
d e s i r a b l e , e f f o r t s t o weaken t h e a n t i t r u s t laws g e n e r a l l y may
not r e s u l t i n a p r o - c o m p e t i t i v e r e s t r u c t u r i n g .
Thank you v e r y much f o r e x p r e s s i n g an ijafgrfest i n my v i e w s .
Harshbarger
Attorney General
BL1/47
�ATTORNEY GENERAL HARSHBARGER'S
HEALTH POLICY OUTLOOK
CONPIDENTIAL DRAFT —
3/1/93
DETERMINED TO BE AN ADMINISTRATIVE
MARKING Per E.0.12958 as amended, Sec. 3.3 (c)
Initials:
Date: ,1/^
�TABLE OF CONTENTS
I.
Summary o f our Outlook
II.
The Role o f t h e A t t o r n e y General i n H e a l t h Care
III.
T h i s Document
IV.
A.
B.
C.
The F a i l u r e s o f t h e H e a l t h Care Svstem
Access
Lack o f Standards f o r Major Care D e c i s i o n s
S p i r a l l i n g Cost
A.
B.
C.
D.
Causes o f F a i l u r e i n t h e H e a l t h Care System
Fragmented O v e r s i g h t
Distorted Incentives
A d m i n i s t r a t i v e Confusion
S t a t e and Regional V a r i a t i o n i n H e a l t h Care Markets
A.
B.
C.
Management o f C o m p e t i t i o n
S i m p l i f i c a t i o n o f Consumer Choice — S t a n d a r d i z a t i o n
A c c o u n t a b i l i t y f o r Q u a l i t y and Costs
Oversight
A.
B.
Reform o f H e a l t h Care F i n a n c i n g
S i m p l i f i e d U n i v e r s a l Coverage
D i s t r i b u t i o n Mechanism
A.
B.
C.
Cost C o n t r o l and t h e Role o f t h e S t a t e s
Role o f t h e S t a t e s
Basic Approach t o Cost C o n t r o l
I m p l e m e n t a t i o n Issues i n Cost C o n t r o l
A.
B.
C.
A l t e r n a t i v e Approaches t o Reform
The N o n - C o n t r o v e r s i a l Elements o f Our Approach
The C o n t r o v e r s i a l Elements o f Our Approach
The Focussed A c c o u n t a b i l i t y Created by Our Approach
V.
VI.
VII.
VIII.
IX.
X.
Massachusetts A c t i o n Agenda
�I.
Summary of our Outlook
The current condition of our nation's health care system
represents one of the greatest challenges we face as c i t i z e n s .
Daily we encounter new and more convincing factual evidence of
the f a i l u r e s of the system.
As detailed in the discussion that follows, the key
dimensions of f a i l u r e are:
The health care system i s f a i l i n g to reach important
segments of the population with both preventive and
remedial care.
Day-to-day health care decision-making i s chaotic (in
the sense that there are no standards) and often
wasteful or unfair.
The overall level of health care spending i n the United
States i s unacceptably high and s t i l l growing much too
fast.
The key factors leading to f a i l u r e are:
The oversight of the health care system has been
fragmented and ineffective — purchasing of health care
needs to be concentrated.
Consumer decision-making i n the purchasing of health
care needs to be strengthened through standardization
and dissemination of information.
The health care system i t s e l f i s fragmented and
controlled by inappropriate incentives — hospitals,
physicians and insurers work at cross-purposes.
The fundamental values guiding our approach to reform are
the following:
Government's role i n solving the complex problems of
health care delivery must be to provide structure,
f i n a n c i a l support and directional leadership, but not
bureaucratic control.
While i n the f i r s t instance, health i s the
I
�r e s p o n s i b i l i t y of i n d i v i d u a l s and f a m i l i e s , i t i s also
a common good. Universal access i s c r i t i c a l — we
cannot a f f o r d t o allow the basic care needs o f any
c i t i z e n t o go unmet.
Health care i s a fundamentally l o c a l i n d u s t r y , and
s t a t e s should have wide l a t i t u d e t o experiment.
Our approach t o reform has three main t h r u s t s :
S t r u c t u r i n g of competition among providers through
standards, performance measurement and o r g a n i z a t i o n a l
c o n s o l i d a t i o n . I n t h i s , we endorse many elements o f
the Jackson Hole "managed competition" approach.
Movement away from employer-based funding o f h e a l t h
care t o a s i m p l i f i e d approach i n which government
assumes r e s p o n s i b i l i t y f o r f i n a n c i n g (but not
administering) basic h e a l t h care.
State c o n t r o l of costs i n r e g i o n a l h e a l t h care markets
which are too small t o support competition or i n which
the dynamics of competition are not operating
e f f e c t i v e l y t o c o n t r o l cost.
II.
The Role of the Attorney General i n Health Care
The Massachusetts Attorney General has broad law enforcement
and r e g u l a t o r y i n t e r v e n t i o n powers i n many problem areas o f t h e
health care insurance and d e l i v e r y systems.
C r i t i c a l areas
include h e a l t h insurance ratemaking, monitoring p u b l i c c h a r i t i e s
( i n c l u d i n g h o s p i t a l s ) , a n t i t r u s t enforcement, consumer
p r o t e c t i o n , and Medicaid
fraud prosecution.
I n every area of r e s p o n s i b i l i t y , the Attorney General i s
confronted by and c o l l i d e s w i t h the s t r u c t u r a l defects o f t h e
health care system.
The defects o f t e n make i t impossible f o r t h e
Attorney General t o achieve adequate s o l u t i o n s t o h e a l t h care
problems —
i n p a r t i c u l a r , excessive and o u t - o f - c o n t r o l costs and
lack of u n i v e r s a l access — w i t h i n h i s t r a d i t i o n a l law
�enforcement role.
Representing consumers in the rate setting process for
Blue-Cross non-group health insurance, the Attorney General
confronts the problem of providing insurance for those not
covered by t h e i r employers. Rising health insurance costs
have forced many consumers into uninsured status in
Massachusetts.
The rapidly r i s i n g costs of health care
i t s e l f make i t very d i f f i c u l t for insurers to control the
costs of insurance. The problem i s rendered more acute as
less vulnerable individuals drop insurance coverage, leaving
only the most vulnerable (and costly) to be insured. The
Attorney General encounters similar problems in h i s
representation of Medex consumers.
Monitoring public c h a r i t i e s , the Attorney General i s
confronted by non-profit hospitals who use their tax exempt
status to pay high s a l a r i e s , accumulate large cash reserves
and build attractive new high technology f a c i l i t i e s — a l l
at a time when the crying need in most urban areas i s for
wider a v a i l a b i l i t y of low technology primary care. Often,
hospitals are building f a c i l i t i e s which can only attract
patients away from and destroy the economics of older
hospitals which serve community needs perfectly well today.
Enforcing the antitrust laws, the Attorney General i s
presented with very d i f f i c u l t questions about how to respond
to the structural changes that the health care industry i s
undergoing. Hospitals seeking to merge claim that
e f f i c i e n c i e s w i l l be achieved for the consumer. Yet merging
hospitals w i l l enhance their bargaining power in the new
competitive environment created by Chapter 495, which may
allow them to charge higher prices.
Protecting consumers (using the unfair trade laws), the
Attorney General encounters case after case where providers
of health care services or products take advantage of
consumers, who are unable to defend themselves because they
lack information that would allow them to evaluate the
claims of health care providers.
In the consumer context and also in the c i v i l rights
context, the Attorney General frequently encounters
consumers who thought they were insured against serious
i l l n e s s , but find that their insurers have the power to deny
coverage for the i l l n e s s or completely drop them from
insurance coverage.
Protecting nursing home patients from abuse, the Attorney
General sees the vulnerability of the elderly to
unscrupulous long term care providers, and the c r i t i c a l
�importance of high quality long term care.
Prosecuting health care providers who would make fraudulent
claims against Medicaid and other insurers, the Attorney
General sees how the fee-for-service approach to financing
health care creates endless opportunities for abuse.
In h i s other areas of enforcement responsibility —
environmental and general criminal (including urban
violence) the Attorney General encounters problems which are
not necessarily f a i l i n g s of the health care system per se.
Even in many of these contexts, a better structured health
care system would be able contribute to solutions.
In h i s role representing the Commonwealth defensively, the
Attorney General finds himself defending the state when the
i t f a i l s to adequately meet the needs of i t s Medicaid,
public mental health and other c l i e n t s . These f a i l u r e s are
sometimes unavoidable, but are often the r e s u l t of
short-sighted cost-saving measures.
Narrow legal measures in each of these isolated contexts are
of c r i t i c a l immediate importance but of limited long term value.
In order to contribute to lasting solutions for the public, the
Attorney General needs to participate in the structural reform of
the health care system.
For t h i s reason, Attorney General
Harshbarger created and serves as Chairman of the National
Association of Attorneys General Task Force on Health Care.
I l l . This Document
In May of 1992, Attorney General Harshbarger, working with
the Commissioner of Insurance created a prestigious Commission to
address the problems of non-group insurance —
Blue Cross/Blue
Shield had requested a 40% rate hike at a time of declining
enrollment i n i t s non-group program.
The Commission had some
success i n developing a consensus recommendation, but i t was not
a recommendation that attracted the strong and active support of
�a large constituency.
The charter of the Commission prevented i t
from t a c k l i n g the l a r g e r issues of cost-containment and u n i v e r s a l
coverage.
The l i m i t a t i o n s of the s o l u t i o n developed emphasized
the need f o r a more comprehensive approach t o reform.
This document represents an e f f o r t by the Attorney General
to develop an o v e r a l l " b l u e p r i n t " which w i l l guide h i s
p a r t i c i p a t i o n both i n the n a t i o n a l debate about o v e r a l l reform
and i n the many more narrowly focused debates i n Massachusetts.
I t summarizes the Attorney General's views about the health care
system today and o u t l i n e s an o v e r a l l approach t o reform. I t
concludes w i t h a discussion of areas f o r p o t e n t i a l near term
focus i n Massachusetts.
As d i r e c t i o n from Washington becomes c l e a r e r , the Attorney
General plans t o use t h i s " b l u e p r i n t " t o develop a concrete set
of long-term recommendations
IV.
f o r change i n Massachusetts.
The F a i l u r e s of the Health Care Svstem
A.
Access
Nationwide, the absolute number of those w i t h p r i v a t e
insurance i s a c t u a l l y d e c l i n i n g , as the ranks of the uninsured
grow.
1
Massachusetts does a l i t t l e b e t t e r than the nation as
whole i n p r o v i d i n g insurance t o i t s c i t i z e n s —
13.2% of the non-
e l d e r l y are uninsured i n Massachusetts, as opposed t o 16.6%
nationally.
2
I n Washington, D.C,
population i s uninsured.
f u l l y 30.3% of the non-elderly
3
The f a c t remains t h a t 700,000 people i n Massachusetts have
no h e a l t h insurance.
4
Twenty percent of these are c h i l d r e n .
5
�Fourteen percent have incomes below the poverty l i n e , and roughly
h a l f have income below 200% of the poverty l i n e .
6
Medicaid
provides coverage f o r only h a l f of the non-elderly w i t h incomes
below the poverty l i n e .
7
The uninsured, e s p e c i a l l y the poor uninsured, skimp on
preventive c a r e
8
and defer needed treatment f o r major problems.
9
Among those u l t i m a t e l y h o s p i t a l i z e d , those who defer treatment
tend t o stay h o s p i t a l i z e d longer and face a higher p r o b a b i l i t y of
death.
10
Other f a c t o r s , such as lack of education and lack of a
regular physician, also tend t o lead people t o delay c a r e .
1 1
Poor f a m i l i e s w i t h dependent c h i l d r e n who are e l i g i b l e f o r
Medicaid face second class care.
The reimbursement from Medicaid
to providers i s so low t h a t many providers seek t o avoid c a r i n g
f o r Medicaid p a t i e n t s , or do not invest the same resources i n
them t h a t they invest i n p a t i e n t s who are f u l l y paid f o r .
Those who purchase t h e i r own insurance i n the non-group
market have faced sharp r a t e increases.
For example. Blue Cross
non-group Major Medical subscribers i n Massachusetts saw a
doubling of r a t e s from 1988 t o 1991 and an a d d i t i o n a l increase o f
22.6% f o r the c u r r e n t period.
The number of consumers purchasing
coverage through Blue-Cross declined 37.5% over the same p e r i o d ,
12
adding t o the uninsured.
Those who have employer-based insurance are also f e e l i n g
changes.
Prospective u t i l i z a t i o n review has become a much more
prominent element i n employer group p o l i c i e s .
1 3
Recently, more
and more employers have begun t o cut p o l i c y costs d i r e c t l y
�for example, through increasing copayments or increasing employee
14
premium c o n t r i b u t i o n s .
Even those w i t h the most desirable insurance p o l i c i e s today
have begun t o f e e l a c h i l l o f i n s e c u r i t y .
Employers and insurers
have exercised t h e i r r i g h t s t o refuse t o renew p o l i c i e s f o r
i n d i v i d u a l s w i t h AIDS and other serious i l l n e s s e s .
Recent l e g a l
decisions have supported these unconscionable
1 5
acts.
These
decisions v i t i a t e the very n o t i o n of h e a l t h insurance — what
p r o t e c t i o n does one have i f coverage can be l e g a l l y withdrawn t h e
moment costs get too high?
And, of course, many people w i t h
health problems (or w i t h health problems i n t h e i r family) are
locked i n t o employment s i t u a t i o n s because o f the p r o b a b i l i t y t h a t
they would be unable t o procure a new insurance p o l i c y i f they
changed j o b s .
1 6
In some urban and some r u r a l areas, lack o f f a c i l i t i e s
creates a s u b t l e r form o f access problem.
L o g i s t i c a l hurdles i n
t r a v e l l i n g t o physicians or h o s p i t a l s make i t d i f f i c u l t t o get
care, even f o r those w i t h the necessary insurance.
Language
b a r r i e r s create s i m i l a r problems.
In summary, while some of our population i s g e t t i n g
e x c e l l e n t care, much of t h e r e s t i s g e t t i n g inadequate care.
The
share o f the population d e f e r r i n g care because o f cost (36%) i s
more than twice the share of the population a c t u a l l y u n i n s u r e d .
B.
Lack o f Standards f o r Major Care Decisions
Physicians, h o s p i t a l s and insurers dominate fundamental
p a t i e n t care decisions.
Patients must r e l y on the advice they
17
�are given by t h e i r physicians.
They are ultimately dependent on
the willingness of their insurer to reimburse for the care
(and/or the willingness of the hospital to provide p a r t i a l l y or
f u l l y unreimbursed care).
Often patients are incapacitated a t
the time c r i t i c a l decisions are made.
be emotionally
Relatives, i f present, may
unable to think c l e a r l y about care options.
Yet, even for the most common procedures, there are few
clear guidelines and no binding protocols governing decisions.
In fact, generally, different physicians do counsel t h e i r
patients very differently. Studies have shown dramatically
varying rates for common procedures among physicians even i n
neighboring towns (greater than 10 to 1 variation i n
tonsillectomy rate from highest area to lowest area i n one
study).
18
There i s a growing body of troubling evidence, some
s t a t i s t i c a l and some merely anecdotal, which suggests that, i n
the absence of standards, care decisions are being made badly i n
several different ways.
In some settings, care decisions may be influenced by the
race of the patient, with African-Americans getting l e s s
care. This has been demonstrated s t a t i s t i c a l l y for some
cardiac procedures. The influence of a b i l i t y to pay was
controlled for, isolating race as a factor.
For the desperately i l l and suffering elderly, heroic l i f e saving measures and uncomfortable life-preserving measures
are often undertaken against the wishes of the patient.
Recent research has shown a strong sense among care
providers that the patient's wishes are inadequately
reflected i n care decisions.
Since the few very sick
patients account for a large fraction of t o t a l costs, these
decisions may be a s i g n i f i c a n t factor contributing to high
costs, i n addition to being detrimental to the patient.
Similar problems may a r i s e i n decisions i n the care of
8
�t e r r i b l y disadvantaged newborns.
The s u r f e i t of high technology capacity i n some areas may
r e s u l t i n excessive rates of unnecessary and r i s k y
procedures. One study of coronary a r t e r y bypass g r a f t s
showed t h a t l i t t l e more than h a l f were c l e a r l y i n d i c a t e d .
And, as noted above, f o r p a t i e n t s w i t h o u t insurance or w i t h
inadequate insurance, c l e a r l y necessary care may be
i n a p p r o p r i a t e l y deferred).
There i s a c r y i n g need i n the medical p r o f e s s i o n f o r a
recognized standard s e t t i n g e n t i t y —
a d e l i b e r a t i v e body which
would s i f t competing views and develop consensus protocols f o r
common procedures.
Some insurers may have invested i n
development of standards governing t h e i r u t i l i z a t i o n review
decisions.
However, insurers generally refuse t o disclose these
standards f o r fear t h a t physicians and h o s p i t a l s w i l l then be
able t o "game" the decisions.
Absent p u b l i c s c r u t i n y and debate,
these standards are u n l i k e l y t o be of the q u a l i t y and i n t e g r i t y
appropriate t o standards governing l i f e and death decisions.
C.
S p i r a l l i n g Cost
The United States spends over fourteen percent of i t s gross
n a t i o n a l product on health care, w h i l e comparably
prosperous
European countries and Canada spend from twenty t o f i f t y percent
.
.
less. 23 Americans are much less s a t i s f i e d. w i t h t h e i r h e a l t h care
system than are c i t i z e n s of these c o u n t r i e s .
2 4
Health status
i n d i c a t o r s such as l i f e expectancy and i n f a n t m o r t a l i t y are no
25
b e t t e r i n the U.S.
than i n these countries.
Health care costs have been r i s i n g f a s t e r than the Gross
National Product f o r s i x decades i n the United S t a t e s .
2 6
They
�have been t a k i n g a l a r g e r and l a r g e r share o f b u s i n e s s
p e r s o n a l budgets —
2 7
and
t h e number o f hours worked a t t h e average
wage t o pay f o r h e a l t h care has r i s e n from t h r e e weeks i n 1965 t o
28
c l o s e t o f i v e weeks today.
Many businesses now f e e l t h a t t h e h i g h c o s t s o f U n i t e d
S t a t e s h e a l t h c a r e a r e p l a c i n g them a t a d i s a d v a n t a g e i n
international competition.
R i s i n g h e a l t h c a r e c o s t s have been a
29
f a c t o r i n two t h i r d s o f r e c e n t l a b o r d i s p u t e s
, including the
h i g h l y v i s i b l e Boston Gas s t r i k e .
Our sense t h a t h e a l t h care c o s t s a r e much t o o h i g h i s
r e i n f o r c e d by t h e evidence o f redundancy and w a s t e f u l d e c i s i o n making t h a t we see i n t h e system.
"Lack o f Standards
(See d i s c u s s i o n above under
f o r Major Care D e c i s i o n s , " and below under
" D i s t o r t e d I n c e n t i v e s " . ) We need t o address t h e o r g a n i z a t i o n a l
and c u l t u r a l dynamics o f t h e h e a l t h care system which a r e
p r o p e l l i n g i t t o excessive c o s t s .
V.
3 0
Causes o f F a i l u r e i n t h e H e a l t h Care Svstem
A.
Fragmented O v e r s i g h t
Employers buy h e a l t h c a r e f o r two t h i r d s o f t h e
population.
3 1
A l t h o u g h t h e r e a r e some e x t r e m e l y competent
b e n e f i t s manager w i t h i n U.S. i n d u s t r y , employers a r e
f u n d a m e n t a l l y unequipped
t o manage h e a l t h c a r e p u r c h a s i n g .
The
need t o focus on what one does b e s t i s a commonplace o f
management t h i n k i n g .
H e a l t h care i s a good o f h i g h c o m p l e x i t y
demanding s p e c i a l i z e d e x p e r t i s e .
W i t h h e a l t h c a r e c o s t s now
c o n s t i t u t i n g a l a r g e share o f business e x p e n d i t u r e s , we a r e
10
�forcing employers to do precisely what they should not do —
take
their eyes off the b a l l in their main f i e l d of competition.
In a very few areas of the country —
for example —
Rochester, New
32
York ,
the business community has been able to pull
together and exert a significant influence on health care costs.
However, in most areas, the business community has failed to
control health care costs, and i s only now beginning to explore
cooperative approaches to controlling costs.
This f a i l u r e i s
inevitable, given that most senior business managers have l i t t l e
hands-on experience in health care, lack real management
information on health care costs and, in any case, need to focus
primarily on producing their own core products.
In some areas,
real or perceived legal barriers to cooperation may have been a
factor.
The federal and state governments constitute 42% of health
33
care purchases , and with their concentrated c r i t i c a l mass, have
been able to develop the necessary expertise and exert
significant downward pressure on costs.
However, this has often
resulted in cost-shifting to private p a y e r s .
34
Further, in the
past, they have often not squeezed as tightly as they could
35
have , possibly as a result of countervailing pressures from
providers.
Consumers, the ultimate source of d i s c i p l i n e in most
markets, have not generally been an effective force in health
care.
3 6
Most consumers experience significant health problems
only a few times in their l i v e s and are unable to develop a
ii
�personal basis f o r evaluation o f the cost and q u a l i t y o f care.
Nor are services l i k e Consumer Reports a v a i l a b l e f o r l o c a l
h o s p i t a l s or physicians which could give consumers an a l t e r n a t i v e
basis f o r making care decisions.
I n some choices o f p r o v i d e r ,
the consumer may not have a r e a l s e l e c t i o n , because o f time
c o n s t r a i n t s or temporary lack o f competence.
And o f course, many
f e e l t h a t consumer decision-making i s f u r t h e r weakened as a
r a t i o n a l i z i n g force by lack o f copayment provisions —
health
care consumers are often not considering cost i n t h e i r d e c i s i o n making.
Insurers ( i n c l u d i n g HMOs) have become an i n c r e a s i n g l y
powerful d i s c i p l i n a r y force on providers i n many s t a t e s .
3 7
Many
of them have the bargaining power and the necessary management
information t o influence providers' investment and operating
budget decisions.
I n Massachusetts, the power o f insurers has
been s i g n i f i c a n t l y increased by the passage o f Chapter 495 which
allows Blue-Cross t o bargain f r e e l y w i t h h o s p i t a l s .
However,
there i s anecdotal evidence t h a t not a l l insurers are as
aggressive as they could be i n attempting t o negotiate costsaving contracts f o r consumers.
Insurers and HMOs are themselves b e t t e r d i s c i p l i n e d by
consumers than are free-standing providers, because consumers
have repeated contact w i t h them and can form rough judgements
about q u a l i t y of service from the insurer. I n a d d i t i o n , i n t h e
HMO and PPO s e t t i n g s , s t a t i s t i c a l q u a l i t y o f care comparisons are
easier t o generate and more l i k e l y t o be s o u g h t .
12
39
However,
�cost-comparisons between health plans remain d i f f i c u l t because of
the variety of benefit, l i m i t and copyament r u l e s . Similarly,
comparisons of the actual quality of care remain d i f f i c u l t given
the lack of s o l i d public result reporting.
And,
of course,
choices about which insurer to use are often made by employers,
not by consumers.
Summarizing, h i s t o r i c a l l y , the absence of effective market
d i s c i p l i n e (generally, fragmentation of oversight) has to be
viewed as a fundamental underlying cause of f a i l u r e (high costs
and misallocation of resources) in the health care system.
Increased concentration of buying power in the hands of insurers
could be a positive development overall, but real market
d i s c i p l i n e w i l l probably not be f e l t u n t i l consumers have the
necessary information
and incentives to exercise effective
choice.
B.
Distorted Incentives
1.
Phvsicians
The ethic of research and specialization which produced t h i s
century's great s t r i d e s in medical technology i s also a cause of
higher costs in the health care system today.
Young physicians
face a strong set of incentives pulling them into high technology
f i e l d s which are highly lucrative and prestigious.
Once
established in those f i e l d s , the physicians generate volume
—
performing the specialized procedures that they have been trained
to perform, often when the procedures are not necessary.
specialized f i e l d s , the United States has an excess of
13
In most
�p h y s i c i a n s , while
i t i s l a c k i n g i n primary c a r e p h y s i c i a n s .
4 0
in
some i n s t a n c e s , the e f f e c t s of the c u l t u r e of s p e c i a l i z a t i o n are
exacerbated by the p r o f i t motive —
physician f i n a n c i a l i n t e r e s t s
i n t e s t i n g and other f a c i l i t i e s may
generate more
inappropriate
procedures.
2.
Hospitals
Hospitals h i s t o r i c a l l y have competed with each other by
attracting physicians
(who
i n turn generate p a t i e n t volume).
Physicians are a t t r a c t e d by s e r v i c e , a v a i l a b i l i t y of s p e c i a l i z e d
equipment and by short waits for h o s p i t a l i z a t i o n .
dynamic has pushed U.S.
4 1
This basic
h o s p i t a l s , e s p e c i a l l y i n competitive
markets, to s t a f f at high l e v e l s , and to i n v e s t i n a s u r f e i t of
42
beds and/or s p e c i a l i z e d equipment.
regulatory
Federal and
regimes have allowed s i g n i f i c a n t accumulation of
c a p i t a l i n h o s p i t a l s even while squeezing nominal
margins.
The
state
operating
43
i n c r e a s i n g strength of i n s u r e r s (and HMOs) i n
competitive bargaining
may
be making c o s t more of a f a c t o r i n
competition, as h o s p i t a l s s h i f t the focus of t h e i r competition
away from a t t r a c t i n g p h y s i c i a n s and volume towards winning
c o n t r a c t s with i n s u r e r s .
4 4
(This s h i f t w i l l be e s p e c i a l l y
b e n e f i c i a l to the extent t h a t i n s u r e r s seek and are able to
negotiate
c a p i t a t e d agreements.)
However, the e f f e c t s of
competition on c a p i t a l investment are unclear and excess
capacity
i n the i n s t a l l e d base i s so large t h a t consumers w i l l be
carrying
the burden of t h a t excess for many y e a r s .
14
4 5
H o s p i t a l s w i l l seek
�to find ways to have that capacity used by physicians,
revenues.
generating
In some instances, the hospitals w i l l make further
unnecessary investments to attract patients who w i l l use t h e i r
existing excess capacity.
Recent Boston hospital investments i n
redundant obstetrical capacity appear to be i n t h i s category
—
the hospitals hope that obstetrical patients w i l l become long
term patients.
3.
Insurers
Many insurers seek to achieve good financial results by
"cherry-picking" —
insuring a population with low and
predictable care needs.
In general, this means people who are
young and without known medical problems.
The costs of insuring
people in their early s i x t i e s i s roughly four times the cost of
insuring people in their twenties (even including maternity
costs).
4 6
People with known medical problems generally have a
s t i l l higher cost l e v e l .
The mechanisms of "cherry-picking" by
insurers include public marketing to young people, generous
maternity benefits to attract young families, s o l i c i t a t i o n of
employers with young employee groups, and medical underwriting
screening of health r i s k s .
—
A related problem i s cost-avoidance
after the fact, through denial of coverage or termination of
benefits.
To the extent insurers are focussing on r i s k and cost
avoidance, as opposed to health r i s k management (changing health
habits) and the creative management of care, they are not
contributing to control of health care costs or improving health
15
�care q u a l i t y .
They a r e a l s o f a i l i n g t o serve t h e i r b a s i c s o c i a l
function of sharing the r i s k of misfortune.
C.
A d m i n i s t r a t i v e Confusion
As argued above, p h y s i c i a n s , h o s p i t a l s and i n s u r e r s a r e each
s u b j e c t t o t h e i r own s e t o f i n c e n t i v e s which, t o some e x t e n t ,
work c o n t r a r y t o t h e l a r g e r i n t e r e s t s o f consumers.
The f a c t
t h a t they a r e a l l w o r k i n g w i t h d i f f e r e n t i n c e n t i v e s i s a problem
in i t s e l f —
a g r e a t deal o f energy i s consumed as p h y s i c i a n s ,
h o s p i t a l s and i n s u r e r s s t r u g g l e over reimbursement and r e s o u r c e
a l l o c a t i o n issues.
The l a r g e number o f i n s u r e r s aggravates t h e
burden o f paperwork on h o s p i t a l s and p h y s i c i a n s , because o f t h e
v a r y i n g u t i l i z a t i o n review and b i l l i n g p r o t o c o l s o f i n s u r e r s .
Anecdotal evidence i n d i c a t e s t h a t i n d i v i d u a l h o s p i t a l s i n
Massachusetts may deal w i t h w e l l over 100 p a y o r s .
D.
4 7
S t a t e and Regional V a r i a t i o n i n H e a l t h Care Markets
N a t i o n a l debate about s o l u t i o n s t o t h e h e a l t h c a r e c r i s i s
o f t e n i g n o r e s t h e wide s t a t e and r e g i o n a l v a r i a t i o n s i n t h e
n a t u r e o f t h e problem.
populations
a r e uninsured
and a n e t i n c r e a s e
probably
I n some s t a t e s —
—
t h o s e where t h e l a r g e s t
h e a l t h c a r e spending may be t o o low,
i n r e a l r e s o u r c e s may be r e q u i r e d .
I n others,
i n c l u d i n g Massachusetts, a n e t decrease i n r e a l h e a l t h
resources can be combined w i t h a r e s o u r c e r e a l l o c a t i o n t o p r o v i d e
q u a l i t y primary
care f o r t h o s e now l a c k i n g
it.
S i m i l a r l y , competitive structures are d i f f e r e n t .
I n the
Boston area, we have an arms race among major t e a c h i n g h o s p i t a l s ,
w h i l e i n w e s t e r n Massachusetts, many areas a r e served by o n l y one
16
�or two hospitals.
Maryland has a state hospital system dominated
by one major teaching center.
In some areas of the Western
United States, one must travel great distances to reach any
medical f a c i l i t y .
Variations in history, medical infrastructure and physical
layout dictate wide variations in needs and competitive dynamics,
which in turn indicate the need for a f l e x i b l e approach to
regulation of the health care system.
VI.
Management of Competition
To remedy the chaos in medical decision-making and to create
a basis for well-defined head-to-head competition in health care,
we endorse the consumer choice and industry restructuring
elements of the Jackson Hole approach.
48
As developed below, the
principle differences between our approach and the Jackson Hole
approach are in the areas of financing (Jackson Hole r e l i e s i n
part on an employer mandate) and cost control (we emphasize the
state-level use of budget setting as appropriate).
Under the Jackson Hole approach, certain new regulatory
structures are created which are designed to make competition
work more effectively.
In t h i s section, we use with l i t t l e
modification the terminology and concepts developed by the
Jackson Hole group.
Readers encountering t h i s terminology for
the f i r s t time may take away a sense of bureaucratic complexity.
The plan as a whole w i l l dramatically reduce government and
private bureaucracy.
A.
Simplification of Consumer Choice — Standardization
12
�1.
Standardization o f Benefits
We favor the c r e a t i o n of a Uniform E f f e c t i v e Health Benefits
("UEHB") package by a n a t i o n a l Health Standards Board ("HSB")
t h a t would be composed of provider, insurance, employer and
consumer representatives.
The d e f i n i t i o n of b e n e f i t s should include s p e c i f i c a t i o n o f
medical c r i t e r i a f o r reimbursement f o r common procedures.
These
s p e c i f i c a t i o n s should be very d e t a i l e d and based on e v a l u a t i o n o f
medical technologies, medical p r a c t i c e e f f e c t i v e n e s s and consumer
values.
Inadequately s p e c i f i e d standards w i l l leave too much
room f o r providers t o c o n t r o l costs by l i m i t i n g b e n e f i t s r a t h e r
than through e f f i c i e n c y (and, conversely, may permit wasteful or
even counterproductive spending).
Clear standards w i l l also
reduce r a c i a l and other d i s c r i m i n a t i o n against p a t i e n t s .
We advocate a n a t i o n a l standards board as opposed t o
m u l t i p l e s t a t e boards because a n a t i o n a l board i s more l i k e l y t o
have the resources a v a i l a b l e t o make the necessary d e t a i l e d
assessments.
I t may, however, be necessary t o permit some s t a t e
v a r i a t i o n s from the n a t i o n a l standards.
The d e f i n i t i o n of the Uniform E f f e c t i v e Health Benefits
package would include d e f i n i t i o n o f a s t r u c t u r e o f copayments
designed t o discourage unnecessary use of care w i t h o u t
discouraging preventive care v i s i t s .
2.
Outcomes Analysis
Data regarding the outcomes of medical treatment should be
c o l l e c t e d i n a n a t i o n a l r e p o r t i n g system.
18
This system should be
�managed by a board with the same diverse representation as the
Health Standards Board.
purposes:
The reporting system would serve three
(1) I t would help physicians develop better
s t a t i s t i c a l evaluations of different types of treatment. (2) I t
would help the Health Standards Board to evolve the definition of
Uniform Effective Health Benefits.
evaluate health care providers.
(3) I t would help consumers
Health care providers and
insurers would be required to contribute data to t h i s system as a
condition of t h e i r participation in the national health care
funding mechanism defined below.
3.
Health Insurance Standards
Even i n simple indemnity insurance, but especially in the
managed care context, responsiveness of the health insurer or
managed care provider i s a c r i t i c a l element of quality.
Definition of service and operational standards i s as important
to structured competition as the definition of standard covered
benefits.
Accordingly, we support the creation of a Health
Insurance Standards Board ("HISB", not to be confused with the
HSB above) for t h i s purpose.
The HISB would also define standards for the operation of
Health Insurance Purchasing Cooperatives (see below).
In
addition, to the extent fee-for-service b i l l i n g continues i n some
areas, the HISB would define standardized b i l l i n g and claim
forms.
B.
Accountability for Quality and Costs
Accountability can be strengthened by pulling insurers and
�health care providers together i n t o i n t e g r a t e d care d e l i v e r y
networks.
These e n t i t i e s would be accountable f o r the cost and
q u a l i t y of a l l t h e care d e l i v e r e d t o the p a t i e n t .
for p a t i e n t s would be among these e n t i t i e s .
document, t h e term
Competition
I n the r e s t o f t h i s
"Accountable Health Partnership" (AHP) w i l l
be used t o mean an e n t i t y accepting c a p i t a t i o n payments i n r e t u r n
for p r o v i d i n g (or arranging f o r the p r o v i s i o n of) t o t a l h e a l t h
care meeting the b e n e f i t and service standards defined by t h e HSB
and HISB.
Many independent players i n h e a l t h care d e l i v e r y are already
working towards d i f f e r e n t types of a f f i l i a t i o n .
Government
should not seek t o d i c t a t e the actual s t r u c t u r e of i n t e g r a t e d
care d e l i v e r y .
Some AHPs w i l l be formed by i n s u r e r s ; others w i l l
coalesce around h o s p i t a l s and t h e i r panels o f physicians.
There
are undoubtedly a number of models t h a t work and should be
allowed t o compete w i t h each other.
Nor i s i t appropriate f o r
government t o d i r e c t l y mandate t h a t providers f i t themselves i n t o
i n t e g r a t e d care d e l i v e r y networks.
However, government can create a powerful trend towards
a c c o u n t a b i l i t y i n t h e system by channelling i t s f i n a n c i n g of
health care through AHPs.
The sharply defined competitive
pressures on these e n t i t i e s w i l l , over the long term, force t h e
e v o l u t i o n of models i n which insurers (care managers) and
providers work e f f e c t i v e l y together i n the service o f both t h e
economic i n t e r e s t s and the medical needs of p a t i e n t s .
C.
Oversight
20
�We support the creation of a National Health Board modelled
on the Securities and Exchange Commission, an independent federal
agency whose members are appointed by the President and confirmed
by the Senate.
Like the SEC, the NHB w i l l , as a matter of
policy, apply the regulatory standards recommended by the private
sector advisory boards defined under Simplification of Consumer
Choice above.
(The Financial Accounting Standards Board acts i n
such a relationship to the SEC.)
The primary administrative
function of the Board w i l l be to c e r t i f y AHP's —
organizations
meeting the defined benefit and service standards —
and HIPCs,
which are defined below in Section VII.B.
VII. Reform of Health Care Financing
Today, financing of health care i s fragmented among
employers, individuals and public programs, a system that leaves
17% of the population uncovered.
The complexity of the system
directly increases administrative costs and indirectly
defeats
cost control measures.
A.
Simplified Universal Coverage
We favor a simpler approach which provides health coverage
for a l l , but increases consumer choice and incentives for cost
control:
The federal government (with a contribution from the
states —
see below, Role of the States) should, for each c i t i z e n
and regardless of employment status, pay the cost of the l e a s t
expensive health plan offering the standard benefits at the
standard service levels, that i s , the cost of enrollment i n the
least expensive AHP as defined above.
21
This cost would vary by
�region within state.
Every c i t i z e n would be completely free to
choose among available plans, but i f they choose a more expensive
plan, would pay the incremental cost of that plan from t h e i r own
pocket.
( I f an employer subsidizes that incremental cost, the
incremental subsidy could become taxable income for the
employee).
There would be no reason for Medicare or Medicaid or
other government programs purchasing health care to continue to
separately e x i s t .
Funding for health care should be raised i n a way that does
not radically change the current distribution of the burden,
although a s h i f t towards greater progressivity might be
appropriate.
A payroll levy (possibly on a l l forms of
compensation above a defined floor, e.g., $15,000) would be a
l i k e l y candidate given that employers who would pay the levy
would be losing the burden of directly paying for health care.
Another element which i s c r i t i c a l i s that the revenues be
separately identified and dedicated to health care funding; the
funding mechanism should insulate health care funding from annual
l e g i s l a t i v e decision-making.
B.
Distribution Mechanism
Government health funding would be channelled through
non-profit Health Insurance Purchasing Cooperatives
(HIPCs) to
AHPs (organizations meeting the benefit and service standards).
HIPCs would be e n t i t i e s designed to group individual consumers
together to create bargaining power and to enhance the
sophistication of purchasing decisions by consumers.
22
HIPCs would
�only purchase coverage from AHPs.
P a r t i c i p a t i n g AHPs would be
required to o f f e r coverage to a l l members of a HIPC, without
medical review, waiting periods or e x c l u s i o n of coverage f o r
p r e - e x i s t i n g conditions.
The r a t e charged by an AHP to a HIPC
would be the same f o r a l l members of the HIPC e n r o l l e d by the
AHP.
HIPCs would not be complex o r g a n i z a t i o n s i n themselves.
They would have no operational c a p a c i t y —
a l l p a t i e n t care and
any processing of f e e - f o r - s e r v i c e claims would occur i n the AHP.
The HIPC would negotiate r a t e s with the AHPs i n i t s area, and
then p u b l i s h the r a t e s to i t s members, allowing them to switch
plans f r e e l y on an annual b a s i s .
The members would pay only the
incremental c o s t above the cost of the l e a s t expensive AHP i n the
area.
For the l e a s t expensive AHP, the HIPC members would pay
nothing to e n r o l l —
government funding would cover the c o s t .
The key a t t r i b u t e of the HIPC i s o b j e c t i v i t y — independence
from providers and i n s u r e r s .
The Health Insurance
Standards
Board, which would define general HIPC standards, would define
r u l e s designed to prevent c o n f l i c t s of i n t e r e s t .
The National
Health Board d i s c u s s e d below would enforce these r u l e s .
In
addition, s t a t e a u t h o r i t i e s would be given power to prosecute any
v i o l a t i o n s of HIPC c o n f l i c t of i n t e r e s t r u l e s .
Competition
proposal.
geographic
among HIPCs i s not a necessary element of our
There should, i n general, be one HIPC f o r each
area.
T h i s w i l l avoid complexity and f a c i l i t a t e the
development of l o c a l AHPs.
Local AHPs w i l l i n turn be able to
23
�take advantage of innovative low-cost care delivery approaches
involving use of community f a c i l i t i e s , such as the schools.
However, as discussed below, questions such as the size and
method of formation of HIPCs should be l e f t to individual states.
VIII.
Cost Control and the Role of the States
A.
Role of the States
The measures outlined above under Management of Competition
are general enough for national implementation, and the federal
government needs to supply most of the funding for universal
coverage.
However, given the tremendous variations among l o c a l
health care markets, we believe that the states should be allowed
wide latitude to experiment with alternative market regulatory
structures within the national framework.
For example, in rural areas, where most providers operate as
natural monopolies, a direct regulatory structure may
appropriate,
be
possibly a single state-sponsored HIPC with rate-
setting authority over two AHPs who would compete only on the
basis of quality.
HIPC rate-setting power might also be needed
to control costs in some urban areas h i s t o r i c a l l y dominated by
teaching hospitals.
In other urban areas, states might allow the
formation of two or more HIPCs, which would, in turn, work with
one or two dozen AHPs competing for enrollment on the basis of
price as well as quality.
States need to have the motivation as well as the freedom to
experiment with alternative cost-control measures.
For t h i s
reason we suggest that, as a condition of federal funds flowing
24
�to t h e i r HIPCs, states would be required to pay ten percent (for
example) of the cost of coverage for t h e i r population.
Another key role which states are best suited to f u l f i l l i s
expansion of services into needy areas.
With the funding offered
through the universal coverage program, creative state and l o c a l
leaders w i l l be able to a t t r a c t providers to locate i n
underserved areas.
too low.
In some states, health care spending may be
(Proposed national service programs could also be used
to support state and local health care efforts i n needy areas.)
B.
Basic Approach to Cost Control
We recognize the importance of immediately acting to bring
costs under control.
The federal contribution under our plan
would be controlled by a formula which would l i m i t increases on
an annual basis.
Growth rates set as a fraction of GNP growth
rates would be one approach.
49
This mechanism would isolate the
program from annual p o l i t i c a l debate at the federal l e v e l .
States would have the discretion to implement l o c a l
budgeting measures or to rely on competition to control costs.
They would also have discretion to vary the l e v e l of t h e i r
contribution.
The state contribution minimum would be set at a
low l e v e l to allow states to squeeze spending t i g h t l y —
e.g., i f
the federal government contributed an amount equal to 85 percent
of the current l e v e l , the states would only be required to spend
10 percent of the current l e v e l , allowing states the choice to
force an absolute cut i n spending.
(In practice, there would be
some constraint on state spending cuts, because federal funding
25
�would only be available to pay the costs of providing the
federally defined standard benefits package.)
federal c e i l i n g on state spending.
appropriate
There would be no
The heavy debates about the
level of health care spending would occur primarily
at the state level.
We believe that t h i s i s where the debate
should occur — health care i s a local industry, and states have
very different needs.
The AHP/HIPC structure w i l l provide a good vehicle for
tighter budgetary controls.
The subsidy or even the t o t a l AHP
charge (including any consumer contributed
limited.
increment) can be
This approach i s c l e a r l y superior to a more detailed
service-by-service budgeting approach which would put hundreds of
decisions in the hands of bureaucrats.
This point i s discussed
further in Section IX.B.1.
In addition to creating a clean vehicle for implementing
global budgeting, the plan creates a structure i n which
competition can contribute to cost control.
The funding
mechanism and service/benefit standards defined above would
create a level playing f i e l d on which AHPs would have to compete
f i e r c e l y for subscribers from the strong HIPCs.
AHPs w i l l
generally seek to be the lowest cost player i n t h e i r area.
AHPs
costing more w i l l lose patient share because many patients w i l l
want to hold their out-of-pocket contribution to zero.
This
sharp competition, along with the general s i m p l i f i c a t i o n of
administration in AHPs, w i l l result i n s i g n i f i c a n t cost-control.
Further, the benefit standards applied by the National
26
�Health Board may operate t o hold down costs by excluding some
procedures or types o f care or excluding them under c e r t a i n
conditions.
50
This w i l l , o f course, depend on the p o l i t i c a l
guidance given t o the Board.
I n many states and regions of states, i t i s l i k e l y t h a t even
sharpened competition,
combined w i t h s e l e c t i v e l i m i t a t i o n o f
covered b e n e f i t s by the Board, w i l l not s u f f i c e t o adequately
control c o s t s ,
5 1
and i n these states, global budgeting through
the HIPC/AHP model w i l l be necessary.
C.
Implementation Issues i n Cost Control
Among the many issues i n p u t t i n g t h i s program i n t o p r a c t i c e ,
the l a r g e s t i s r a p i d i t y of e f f e c t i v e cost c o n t r o l .
A v i r t u e of
the program i s t h a t while p u t t i n g tremendous bargaining
power i n
the hands o f purchasing cooperatives, i t leaves the problem o f
reorganizing
sector.
h e a l t h care d e l i v e r y i n the hands of the p r i v a t e
Forced t o deal w i t h a s i n g l e funding source i n t h e i r
area, insurance companies, h o s p i t a l s and groups o f physicians
w i l l move r a p i d l y and competitively t o take leadership
o f AHPs.
Once i n AHPs, where they are a l l a t r i s k f o r p r o f i t a b i l i t y ( o r
v i a b i l i t y ) , they w i l l move q u i c k l y t o c o n t r o l costs,
especially
i n states where the AHP budgets are l i m i t e d by r e g u l a t i o n .
I t i s uncertain how long the industry r e c o n f i g u r a t i o n w i l l
take.
I n areas where cost pressures are e s p e c i a l l y severe, we do
not r u l e out t h a t bureaucratic
p r i c e c o n t r o l s may be e f f e c t i v e i n
the near term, e s p e c i a l l y f o r e a s i l y i s o l a t e d segments o f t h e
health care i n d u s t r y (such as diagnostic services and
27
�pharmaceuticals).
I t seems l i k e l y , however, t h a t as a general
matter, such a bureaucratic approach t o c o s t - c o n t r o l w i l l be
slower t o work i f successful a t a l l .
I n our approach, t h e
p r i v a t e sector can be presented w i t h a p o w e r f u l l y enforced
general mandate t o c o n t r o l costs t h a t leaves t h e d e t a i l s t o be
worked out through p r i v a t e c r e a t i v i t y —
very f a s t .
t h e response could be
I n a bureaucratic approach, t h e fees f o r various
s p e c i a l t y services and the budgets o f i n d i v i d u a l h o s p i t a l s would
be set through an i n e v i t a b l y slower a d m i n i s t r a t i v e process.
IX.
A l t e r n a t i v e Approaches t o Reform
A.
The Non-Controversial Elements of Our Approach
There are few, i f any, d i s i n t e r e s t e d observers who disagree
w i t h the need f o r greater standardization i n h e a l t h care
delivery.
The p a r t i c u l a r s t r u c t u r e endorsed here, modelled
after
the S e c u r i t i e s and Exchange Commission, may be improved upon and
we are open t o needed refinement of the s t r u c t u r e .
S i m i l a r l y , many are o p t i m i s t i c about t h e use o f purchasing
cooperatives t o strengthen consumer buying power.
There are many
a l t e r n a t i v e approaches t o a c t u a l l y s t r u c t u r i n g HIPCs; we
generally p r e f e r a geographic approach.
However, our o v e r a l l
p o s i t i o n a t t h i s p o i n t i s not necessarily contrary t o any HIPC
approach, since we put t h i s choice a t the s t a t e l e v e l .
L a s t l y , most observers favor t h e expansion of coverage t o
those not now insured, although, as discussed below there are
considerable v a r i a t i o n s i n approach.
B.
The Controversial Elements of our Approach
28
�it.
Alternative Approaches to Managing Competition
The potentially most controversial element of the approach
to structural reform endorsed i n the section on "Managing
Competition" i s the use of Accountable Health Partnerships as a
vehicle for creating provider accountability.
The alternative
would be to continue to rely on open indemnity models, where
providers are d i r e c t l y reimbursed by payors, as i n today's
Medicare system or in the Canadian health system. Many
physicians prefer the freedom of individual practice, and many
consumers prefer complete freedom of choice i n physicians.
F i r s t , our plan preserves freedom of choice.
In most
markets, consumers w i l l have a choice between several AHPs, and
most AHPs w i l l adopt flexible structures which w i l l give patients
some freedom of choice within their panel and possibly outside of
i t (for an extra charge).
the AHPs —
We would not dictate the structure of
i t i s conceivable that some of them w i l l look l i k e
indemnity insurers.
We would not deny to consumers the right to
spend for health care outside the AHP framework; nor would we
l i m i t the a b i l i t y of the physician or hospital to charge a
private patient the fee they are able to negotiate.
Second, the most effective way to control costs, even i n a
competitive environment, i s to give physicians a budget and ask
them to work together to manage care to that budget.
52
The group
practice model i s well established i n the United States.
Authorities from other countries who have lower costs and
generally more successful health care systems come to the United
29
�53
States to study our HMOs.
Third, the AHP model creates a clean vehicle for global
budgeting where regulation i s deemed necessary.
In a fee-for-
service model, where each service may be b i l l e d separately, the
conceptual problems of global budgeting are enormous —
multiple
t i e r s of price or budget setting must occur under the auspices of
government.
Numerous assumptions about volume need to be made.
In the AHP model, global budgeting can be implemented by
dictating a single per-subscriber budget to the AHP.
I t i s then
the AHP's problem to translate the overall budget into s p e c i f i c s .
In the Canadian system, although public s a t i s f a c t i o n i s
high, the fee for service model has lead to continuing
(54
political
c o n f l i c t and continuing concern about rising costs.
The
Canadian system depends on direct provincial regulation of
hospital budgets and capital expenditures as well as d i r e c t
55
government control of physician fees
. Thus, cost control
depends on sustained force of p o l i t i c a l w i l l by regulators,
exercised through many detailed decisions —
an approach not as
l i k e l y to succeed in the United States with i t s extremely
powerful provider lobbies.
Fourth, group practice has other advantages.
I f , in a group
setting, physicians participate cooperatively in the development
and implementation of care delivery standards, they are much more
l i k e l y to support standardization of c a r e .
5 6
Physicians isolated
in s o l i t a r y fee-for-service practices are much l e s s l i k e l y to
accept and comply with standards developed by others without
30
�t h e i r participation.
Use of the AHP model w i l l preserve choice and w i l l
substantially reduce the role of government i n both standards
implementation and budget setting.
2.
Alternative Approaches to Financing Universal Access
The most controversial element of the plan overall i s the
approach to universal access which we advocate, i n effect, a
single payor approach.
We currently have a hybrid approach to
providing health coverage — part government, part employer
which leaves a significant population uncovered.
—
To f i l l the
gap, one can move to f u l l government funding i n one form or
another (we advocate such an approach), or one can preserve a
hybrid approach, f i l l i n g the gap with incremental measures.
a.
Economic Reasons why Hybrid Approaches F a i l
A principal reason that we support a simplified, governmentsupported approach which covers a l l c i t i z e n s , i s that such an
approach minimizes incentives which distort either the health
care markets or the labor markets.
Some
57
have advocated incremental approaches to expanding
access by providing tax credits or other subsidies to individuals
and/or small businesses who purchase health insurance.
Another
alternative would be to l e t low-income people not e l i g i b l e for
CO
Medicaid buy into Medicaid at a subsidized price.
Let us use
the term " p a r t i a l hybrid" approach to refer to any incremental
approach which does not provide 100% funding for those without
employer-provided insurance.
31
�Any p a r t i a l hybrid approach w i l l r e s u l t i n some people
probably many i n lower income brackets —
insurance coverage.
—
choosing to forego
The available evidence suggests that those
who are very short on resources are w i l l i n g to spend very l i t t l e
on insurance. This choice to go bare w i l l lead to higher costs
for the others, who choose to be insured, i n two ways:
First,
the lack of preventive care among the uninsured w i l l result i n
more serious i l l n e s s e s ;
the costs of these serious
illnesses
(which cannot go untreated) w i l l be shifted indirectly to the
insured.
Second, the pool of people that choose to be insured
using the subsidy w i l l have higher average costs, as they w i l l
disproportionately include the more vulnerable with greater care
needs.
The higher costs of coverage w i l l result in the need for
greater and greater subsidies to maintain a dwindling covered
59
population —
a c l a s s i c "death s p i r a l " .
The death s p i r a l i s
l i k e l y to be accelerated by p o l i t i c a l underfunding of the
program, which w i l l inevitably be viewed as a poor people's
program l i k e Medicaid.
We turn now to what we may c a l l the " f u l l hybrid"
approaches.
By contrast to a p a r t i a l hybrid approach, i n a f u l l
hybrid approach, government f u l l y funds coverage for those
without employer-provided insurance. Some employers continue to
fund coverage for their employees.
F u l l hybrid approaches are
attractive i n that they offer universal coverage while not
completely restructuring the system.
60
In a f u l l hybrid approach, a mandate i s necessary to prevent
32
�many employers from dumping t h e i r employees into the funded plan.
While i t might be possible to lessen dumping with various
incentives and e l i g i b i l i t y limitations, over the long term, a
direct mandate would be necessary.
mandate:
There are two forms of direct
"Play" and "pay or play".
In the "play" variety of f u l l hybrid approach, where most
employers are simply mandated to provide coverage to t h e i r
employees, the net effect would be to s i g n i f i c a n t l y increase the
minimum wage, causing loss of up to 100,000 jobs for the working
poor.
61
The effective minimum wage increase would be greatest
for employees with dependent families (roughly 50% for a family
of four). This could create an especially perverse incentive for
employers to discriminate against potential employees with
families to support.
i s regressive —
From an equity standpoint, a "play" mandate
i t s net effect i s that of a head tax.
In the "pay or play" variety of f u l l hybrid approach,
employers can elect either to provide coverage or to pay a
payroll tax (which would be used to provide coverage to the
uninsured).
"Pay or play" may work as a t r a n s i t i o n a l step to
f u l l government funding, but:
(1) Employers with higher income
employees would a l l choose to "play" rather than "pay".
So, most
of the tax revenue must come from employers with lower-income
employees.
I f the tax were set at a level adequate to fund
insurance for the lower-income employees, not to mention some the
unemployed, i t would have the same effects on these employees and
t h e i r employers as a mandate to "play".
33
(2) I f on the other
�hand, the p a y r o l l tax i s not s e t high enough, more employers w i l l
be incented to dump employees i n t o the "pay" h a l f of the program.
The program w i l l evolve as a bloated general-revenue-funded
program f o r the unemployed and lower income workers, and,
p r o b a b i l i t y , l o s e i t s p o l i t i c a l support,
end up only
in a l l
partially
funded, and trend down the "death s p i r a l " of a p a r t i a l s o l u t i o n .
Three o b j e c t i o n s apply to both f u l l hybrid approaches —
"pay"
and "pay or play" approaches:
(1)
the
Employers w i l l have
increased i n c e n t i v e s to keep employees on a temporary or
contractor s t a t u s (or off-the-books e n t i r e l y ) ;
(2) The
buying
power p o s s i b l e through large geographically focussed HIPCs may
diluted;
be
(3) I n s u r e r s w i l l continue to compete by c h e r r y - p i c k i n g
c o n t r a c t s with employers with young populations.
None of our objections to the f u l l hybrid approaches are
individually fatal.
Cherry-picking can be somewhat
controlled
by mandating community r a t i n g for a l l p o l i c i e s .
Employer based
coverage could be married to the HIPC approach.
Many of the
o b j e c t i o n s about i n c e n t i v e s can be p a r t i a l l y addressed
through
the i n t r o d u c t i o n of various l a y e r s of tax i n c e n t i v e s and
rules.
6 3
other
For example, the d i s t o r t i o n s and r e g r e s s i v e i n c i d e n c e
of a "play" mandate can be addressed
by providing tax c r e d i t s to
low-wage employers based on the h e a l t h insurance needs of t h e i r
employees.
Our most fundamental o b j e c t i o n i s on the grounds of
complexity.
I n f a c t , some have argued t h a t the c o m p l e x i t i e s of
making a hybrid approach work are a t l e a s t as great as those
34
�involved i n construction of a public dominated regime such as
that in B r i t a i n or Canada.
64
I t seems very i l l - a d v i s e d over the
long run to tangle the labor market up with more a r t i f i c i a l
incentives.
This i s p a r t i c u l a r l y true since most of these
incentives w i l l require the use of general revenues and i t may be
d i f f i c u l t p o l i t i c a l l y to preserve an economically
structure ( i f one i s ever achieved).
effective
Lastly, of course, any
hybrid approach requires significant expansion of government
funded health insurance for the unemployed (who w i l l not be
reached by the employer mandate).
65
We believe the approach we offer i s much simpler, cleaner
and more durable.
b.
Structural Objections to Hybrid Approaches
The incentives/complexity analyses aside, we believe
strongly that i t i s time to get employers out of the business of
providing health care.
The fact that United States employers
have been extensively involved i n providing health care i s an
h i s t o r i c a l accident going back to the days of wage controls i n
World War I I — why go to great lengths to make t h i s f a i l e d
arrangement work?
I t i s the patchwork nature of employer-
provided health care insurance that leaves millions uninsured,
millions more at r i s k for loss of coverage, and the health care
system i t s e l f e s s e n t i a l l y unmanaged.
F u l l government funding w i l l allow employers to focus on
what they do best —
creation of jobs and market competition
as opposed to the management of health care.
15
—
I t i s time to take
�h e a l t h care o u t o f t h e board rooms and o f f t h e b a r g a i n i n g t a b l e s .
Management and l a b o r have d i f f i c u l t enough i s s u e s t o d e a l w i t h
w i t h o u t t h e management o f h e a l t h c a r e .
The many minor
employer-
based h e a l t h b u r e a u c r a c i e s and t h e army o f c o n s u l t a n t s t h a t s e r v e
them can be
C.
reemployed.
The Focussed A c c o u n t a b i l i t y Created bv Our Approach
Our approach p u t s b a s i c d e c i s i o n - m a k i n g s q u a r e l y i n t h e
hands o f t h e consumer —
t h e d e s i r e t o appeal t o i n f o r m e d
consumers w i l l c o n t r o l t h e d e c i s i o n - m a k i n g o f AHPs.
c o n c e n t r a t e s consumer buying power i n HIPCs —
the
Our
approach
at the option of
s t a t e s , g e o g r a p h i c a l l y based HIPCs can w i e l d monopsony b u y i n g
power i n t h e i r area.
O p p o r t u n i t i e s f o r gamesmanship by p r o v i d e r s
and i n s u r e r s are s u b s t a n t i a l l y e l i m i n a t e d .
While i n c r e a s i n g government's r o l e i n t h e f u n d i n g o f h e a l t h
care —
66
which, as noted a b o v e , i s a l r e a d y l a r g e a t 42% —
approach w i l l reduce f e d e r a l and s t a t e h e a l t h c a r e
our
bureaucracy.
Medicare and M e d i c a i d as payment mechanisms would go away, w i t h
a l l o f t h e i r a s s o c i a t e d bureaucracy.
Service s p e c i f i c
state
r a t e - s e t t i n g b o d i e s c o u l d a l s o be e l i m i n a t e d i n many i n s t a n c e s .
To t h e e x t e n t t h a t s t a t e governments do need t o c o n t r o l p r i c e s ,
i t w i l l g e n e r a l l y be t h r o u g h a much s i m p l e r f l a t f e e n e g o t i a t i o n .
HIPCs would be independent n o n - p r o f i t e n t i t i e s and s h o u l d be
o r g a n i z a t i o n a l l y simple —
t h e y need no t r a n s a c t i o n p r o c e s s i n g o r
detailed price evaluation capacity.
P r i v a t e bureaucracy
should
a l s o be d r a m a t i c a l l y s i m p l i f i e d by a move away from f e e - f o r s e r v i c e b i l l i n g and a r m s - l e n g t h u t i l i z a t i o n
36
review.
�I t i s d i f f i c u l t for us to see an alternative approach which
so effectively combines universal access i n a one-class system,
the f u l l empowerment of consumers through information and buying
power, and private sector accountability for delivery of r e s u l t s .
I t i s also d i f f i c u l t for us to see an approach which creates
greater long term leverage for cost control. The American people
seem ready for a change of t h i s magnitude.
X.
67
Massachusetts Action Agenda
The approach outlined above depends heavily on national
action.
I f Washington i s unable to move forward,
Massachusetts
w i l l need to move forward on i t s own:
The standard setting for benefits and service and the
data collection can be implemented l o c a l l y , although
probably not with the same thoroughness.
Massachusetts
standards boards (or New England region standards
boards) can be established with the Insurance
Commissioner as the enforcer of defined plan standards.
HIPCs can be created including small group and
non-group buyers. Insurers can be required (as they
are i n our non-group proposal) to end medical
underwriting and l i m i t waiting periods and preexisting
condition exclusions and move to community rating for
these purchasers.
With appropriate Congressional support to avoid ERISA
preemption, the standards setting and the HIPC model
can be extended to a l l large employer benefit plans.
By requiring a l l plans to meet the same standards, and
channelling as much health care purchasing as possible
through large cooperatives, competition would be
strengthened, encouraging the development of effective
provider/insurer partnerships.
The issue of providing coverage to the uninsured
remains very d i f f i c u l t for Massachusetts to address on
i t s own.
Our non-group proposal, which provides for subsidies
for lower-income uninsured, i s a step in the right
37
�direction. However, l i k e any p a r t i a l measure on health
care financing, i t creates unfortunate incentives, as
explained above.
The most serious drawback to state implementation of
the farther reaching national restructuring advocated
in t h i s document i s that i t would require s i g n i f i c a n t
new or increased state taxes. These should only be
imposed with a strong majority consensus of the state's
individual and business taxpayers.
To make the approach f u l l y effective, arrangements
would have to be reached bringing Medicare and Medicaid
payments into the same framework.
Consistent with t h i s view of what i s possible and most
important on the state level, in the f i r s t half of 1993, the
Attorney General's office w i l l focus attention in the following
areas:
The National Debate: Participation in the national debate,
especially focussing on the need for a federal solution to
covering the uninsured. The Attorney General's chairmanship
of the National Association of Attorneys General w i l l give
him a platform for participation.
Development of Purchasing Cooperatives:
the purchasing cooperative concept into
reform proposal. Possible introduction
cooperatives into small group and large
Incorporation of
the Non-Group market
of purchasing
group markets.
Insurance Market Reform: Refinement of the market reform
aspects of the Non-Group proposal presented in December and
sponsored in the legislature by Hon. Carmen Buell. A
particular area which needs further analysis i s the issue of
community rating in the small and non-group markets.
Relief for Non-Group Health Insurance Purchasers: Continued
focus on holding down rate increases for non-group insurance
and development of a subsidy program as outlined in the NonGroup proposal.
Development of Poiicv on Health Care Networks Discussions
with Massachusetts insurers, HMO's, hospitals, physicians
and other providers on approaches to encouraging movement
towards e f f i c i e n t partnerships among them while preserving
competition.
Waste. Fraud and Abuse
Continued efforts to identify and
38
�prosecute wasteful, deceptive or abusive practices in the
health care industry, possibly with increased focus on s e l f r e f e r r a l by physicians and on provider b i l l i n g practices.
U t i l i z a t i o n Review Support for managed care i n i t i a t i v e s but
with s e n s i t i v i t y to privacy and e f f i c i e n c y concerns in
u t i l i z a t i o n review.
Wasteful Hospital Expansion Increased focus on and possible
challenges of investments by hospitals which appear to be
needlessly locking-in higher future costs for health care in
Massachusetts. Support for elimination of b a r r i e r s to lower
cost alternatives to inpatient hospital care.
A v a i l a b i l i t y of Information on Cost and Q u a l i t y
Support
f o r l e g i s l a t i o n and p r i v a t e sector e f f o r t s t o increase
p u b l i c i n f o r m a t i o n on comparative cost and q u a l i t y of
providers and insurers. Related t o i n f o r m a t i o n c r e a t i o n i s
the s t a n d a r d i z a t i o n of claims forms and the s i m p l i f i c a t i o n
of a d m i n i s t r a t i o n .
Urban Health Working w i t h inner c i t y care providers t o
understand how best t o support t h e i r e f f o r t s .
39
�NOTES
1.
See, H i m m e l s t e i n and Woolhandler, The Growing Epidemic o f
Uninsurance. Center f o r N a t i o n a l H e a l t h Program S t u d i e s
(Cambridge, 1992), F i g u r e s 1 and 2.
2.
Employee B e n e f i t Research I n s t i t u t e , Sources o f H e a l t h
Insurance and C h a r a c t e r i s t i c s o f t h e U n i n s u r e d . A n a l y s i s o f t h e
March 1992 C u r r e n t P o p u l a t i o n Survey (Washington, January 1993),
Table 16. N a t i o n a l l y , 99% o f t h e e l d e r l y a r e i n s u r e d , 96% by
Medicare. I d . . Table 1. Note t h a t t h e e s t i m a t e s o f t h e
u n i n s u r e d used here, which are t h e commonly quoted e s t i m a t e s o f
t h e u n i n s u r e d , t h e o r e t i c a l l y r e f e r t o t h e number u n i n s u r e d f o r an
e n t i r e 12 month p e r i o d . However, many r e s e a r c h e r s b e l i e v e t h a t
survey respondents t e n d t o misunderstand t h e q u e s t i o n asked and
respond as t o a p o i n t i n t i m e o r f o r a p e r i o d w i t h i n t h e 12
p e r i o d . I d . . 16. Thus, t h e p o p u l a r number i s p r o b l e m a t i c , and
c o u l d be e i t h e r h i g h e r o r lower t h a n t h e number o f u n i n s u r e d a t
any g i v e n p o i n t i n t i m e .
3.
Id^.
4.
Id^.
5.
Harvard School o f P u b l i c H e a l t h , Department o f H e a l t h P o l i c y
and Management, e t a l . . "A Household Survey o f t h e H e a l t h
Insurance S t a t u s o f Massachusetts R e s i d e n t s " (Boston, 1989),
Table I I I . l .
6.
I c L , Table I I I . 3.
7.
EBRI, supra n.2. Table 14.
8.
See. H i m m e l s t e i n and Woolhandler, The N a t i o n a l H e a l t h
Program Chartbook. Center f o r N a t i o n a l H e a l t h Program S t u d i e s
(Cambridge, 1992), p. 34 ( r e p o r t i n g t h e i r own work p r e v i o u s l y
p u b l i s h e d i n t h e 259 J o u r n a l o f American M e d i c a l A s s o c i a t i o n
2872) .
9.
Weissman, e t a l . . "Delayed Access t o H e a l t h Care: R i s k
F a c t o r s , Reasons and Consequences," 114 Annals o f I n t e r n a l
Medicine 327 (1991).
10. I d . Only t h e l o n g e r s t a y r e s u l t was s t a t i s t i c a l l y
s i g n i f i c a n t ; t h e s e t o f sampled p a t i e n t s who d i e d was s m a l l .
11. Id,.
40
�12. See generally. Harshbarger, Report of the Non-Group Health
Insurance Commission (December 1992).
13. Gabel, et a l . . "Employer-Sponsored Health Insurance in
America," Health Affairs (Summer 1989), 116, 120.
14. See. General Accounting Office, Emplover-Based Health
Insurance — High Costs. Wide Variation Threaten Svstem
(Washington, 1992), pp. 10 - 11. Interestingly and contrary to
some popular reports, although employers quickly accepted
u t i l i z a t i o n review, they were slow to begin to d i r e c t l y cut
policy costs; benefits expanded i n many ways through the SO's.
Jensen, et a l . . "Cost Sharing and the Changing Pattern of
Employer-sponsored Health Benefits", 65 The Milbank Quarterly 521
(1987). Gabel, supra n.13.
15. E.g.. McGann v. H&H Music Company, et a l . . 946 F.2d 401 (5th
Cir. 1991), cert denied, sub nom. Greenberg v. H&H Music Company,
et a l . . 113 S.Ct. 482 (1992); Owens, et a l . v Storehouse, et a l . .
U.S. App. LEXIS 3066 (11th C i r . 1993). See also. Mintz, "More
Retirees are Left in the Lurch as Firms Slash Health Coverage,"
Washington Post. February 28, 1993.
16.
E.g.. GAO,
supra n. 14, at 31.
17. Himmelstein and Woolhandler, supra n.8, p.16
study in Health Affairs 8(1):111 (1989)).
(reporting a
18. See generally the work of John E. Wennberg, e.g., "Small
Area Variations in Health Care Delivery", 182 Science 1102-8
(December 1973).
19.
Cardiac treatment CITE.
20. Solomon, et a l . . "Decisions Near the End of L i f e :
Professional Views on Life-Sustaining Treatments", 83 Am. J . of
Public Health 14, (January 1993).
21. See Newhouse, "Medical Care Costs: How Much Welfare Loss?",
6 Journal of Economic Perspectives. 3, 16 (1992), for the
argument that t h i s phenomenon i s material but often overestimated
as a cost factor.
22. Winslow, et a l . . "The Appropriateness of Performing Coronary
Artery Bypass Surgery," 260 Journal of American Medical
Association 505 (1988).
23. See, Aaron, Serious and Unstable Condition: Financing
America's Health Care. Brookings (Washington 1991), Chapter Four
for international comparisons.
41
�24. Blendon and Donelan, "Public Opinion and E f f o r t s to Refonn
the U.S. Health Care System: Confronting Issues of CostContainment and Access to Care," Stanford Law and Poiicv Review.
F a l l 1991, 146, 147.
25. See Aaron, supra n.23. In fact, the United States generally
does poorly on key health status indicators. However, health
status indicators are a weak indicator of the performance of the
health care system, because they are influenced by a variety of
factors outside the system — generally, poverty.
26. Newhouse, supra n.21, 13. Newhouse analyzes the factors
contributing to the long term steady r i s e in real per capita
health spending. Newhouse compares long term r e a l per capita
growth rates in health expenditures internationally and finds
that the U.S. (at 5%) f a l l s in the middle of a f a i r l y narrow
range (from 3.7% to 8.9%). What distinguishes the U.S. i s i t s
high absolute l e v e l .
27.
See, GAO,
supra n. 14.
28.
Himmelstein and Woolhandler, supra n.8, at p.2.
29. Harley Shaikin, U.C. Berkeley, quoted in Daily Health Line
Newsletter. February 3, 1993. See also. GAO, supra n. 17, at
n.13.
30. We recognize the important role of technological progress in
increasing health care costs. See Newhouse, supra n.21. In
every country, the effect of technological advance in health care
has been to increase costs by making new types of cure procedures
possible, by making existing procedures l e s s risky and painful
and therefore more popular, and by making people l i v e longer and
so have higher lifetime care needs. This does not reduce our
concern about the United States r e l a t i v e l y high absolute l e v e l
of costs. Growth needs to be arrested long enough for the r e s t
of the economy to catch up.
1
31. Employers (excluding the military) purchase coverage for
64.1% of the non-elderly population (60% of the t o t a l
population). See EBRI, supra n.2. Table 1. On an expenditure
basis, they provide less than private households and government
programs. See GAO, supra n. 14, n.3 and Office of National
Health S t a t i s t i c s , "National Health Expenditures, 1990", 13, 49
Health Care Financing Review 29 ( F a l l 1991).
32. Woolsey, "Rochester Health Care, a Recipe for Success,"
Business Insurance. October 26, 1992.
Hawaii may be another
example. There, heavy employer provision of health care was a
legacy of plantation services to workers. "Hawaii Health System:
A Brief Look at Employer Mandated Insurance", Prepared for
Massachusetts Health and Educational F a c i l i t i e s Authority (1992).
42
�33.
See Office of National Health S t a t i s t i c s , supra n.31.
34. Anecdotal evidence indicates that i n Massachusetts hospitals
today, Medicare and Medicaid are both generally paying somewhere
close to the marginal cost of patient care, meaning that most of
the fixed cost base (which should be shared among a l l patients)
i s being carried by private payors.
35. Feder e t a l . . "How did Medicare's Prospective Payment System
Affect Hospitals, 317 New England Journal of Medicine 867 (1987)
(results related to the period 1982 to 1984, and showed
p r o f i t a b i l i t y of many hospitals under the new payment regime).
36. See, generally Pauly, " I s Medical Care Different? Old
Questions, New Answers," 13 Journal of Health P o l i t i c s . Policy
and Law 227 (1988). See discussion below about changes effected
by managed care.
37. Managed care providers (HMO's and PPO's) accounted for 25.3%
of group business nationwide i n 1990, up from 0.3% i n 1982.
Health Insurance Industry Association, Source Book of Health
Insurance Data (Washington, 1991), p.22.
38. Anecdotal evidence indicates that Chapter 495 i s having i t s
intended effect of strengthening competition. Massachusetts has
roughly twice the nationwide level of enrollment in managed care
plans. See I d . at p. 3 2 (comparative s t a t i s t i c s on HMOs only).
39.
See. Pauly, supra n.41.
40. See, K o s t e r l i t z , "Wanted: GPs," National Journal. 9/5/92,
p.2011; Relman, "Reforming the Health Care System," 323 New
England Journal of Medicine 991 (1990).
41. See generally. Harris, "The Internal Organization of
Hospitals; Some Economic Implications", B e l l Journal of Economics
467 (Autumn, 1977) ; Melnick and Zwanziger, "Hospital Behavior
Under Competition and Cost-Containment P o l i c i e s , " 260 J . Am.
Medical Assoc. 2669 (1988).
42. For example, anecdotal evidence indicates that cardiac
catheterization f a c i l i t i e s are currently being overbuilt i n
hospitals. For another example (not exclusively i n hospitals),
see Brown et a l . . " I s the Supply of Mammography Machines
Outstripping Need and Demand?" 113 Annals of Internal Medicine
547 (1990). (Answer: Yes, by a factor of four or more; i t i s
another irony of the health care system that many women do not
have access to the needed screenings at the same time that
equipment i s i n excess supply.) Interestingly, i n Massachusetts,
a state with highly competitive hospitals (at least in the Boston
area), the load of beds per capita i s not above the national
average. However, costs per capita are higher, reflecting higher
43
�staffing l e v e l s and more intensive u t i l i z a t i o n . Access and
Affordability Monitoring Project, "Paying for Our Mistakes",
Boston University School of Public Health (1991), pp. 22-23.
43. A prime example of t h i s i s the rate setting regime i n place
in Massachusetts u n t i l the passage of Chapter 495 i n 1991. Under
t h i s regime, Massachusetts hospitals were able to make very
significant plant investments and accumulate s i g n i f i c a n t cash
reserves, a l l while showing low p r o f i t s . Nancy Kane's work,
discussed i n Knox, "Are Hospitals Crying Wolf?" Boston Globe.
February 3, 1991, and further elaborated i n unpublished
materials. See also, Access and Affordability Monitoring
Project, supra n. 42.
44. See Melnick and Zwanziger, supra n.42; Robinson and Luft,
"Competition, Regulation and Hospital Costs, 1982 to 1986" 260
Journal of the American Medical Association. 2676 (1988). For a
contrary view, see Access and Affordability Monitoring Project,
"Competition i s Costly", Boston University School of Public
Health (1991).
45. See. Johns, "Selective Contracting i n C a l i f o r n i a : An
Update," 26 Inquiry 345 (1989). Shift of a c t i v i t y to ambulatory
care, harder to control in many bargaining frameworks, i s part of
the response of acute care hospitals to competition. The
Massachusetts Hospital Association has recently estimated that
the demand for bed-days in Massachusetts w i l l decrease 30 to 40%
by the year 2000 as a result of the s h i f t towards ambulatory
care. Excess capacity i s not only a matter of beds, but also of
staffing and technology investment.
46.
Private correspondence with insurers.
47. See Woolhandler and Himmelstein, "The Deteriorating
Administrative Efficiency of the United States Health Care
System," 324 New England Journal of Medicine 1253 (1991) for
disturbing comparative estimates of administrative overhead i n
our health system.
48. See. The Jackson Hole Group, "The Jackson Hole I n i t i a t i v e , "
July 10, 1992. See also Enthoven and Kronick, "A Consumer-Choice
Health Plan for the 1990's," 320 New England Journal of Medicine
29 (1989).
49. For example, one could set the fraction a t two-thirds. One
would then allow that i f GNP increased at a rate of 3% i n a given
year, the federal contribution to health spending would be
allowed to increase at a rate of 2% i n the following year. The
mechanism might be made to operate quarterly or otherwise
adjusted to f a c i l i t a t e balancing of the program t r u s t fund and
financial planning by states and the health care industry.
44
�50. Schact, "Desperately Seeking Savings," Regional Review
(Winter 1993), discusses the e f f o r t t o apply outcomes research t o
c o n t r o l costs.
51. Even the strongest advocates o f managed competition admit
t h i s . See, e.g.. Kronick, e t a l . . "The Marketplace i n Health
Care Reform — The Demographic L i m i t a t i o n s of Managed
Competition," 328 New England Journal of Medicine 148 (1993).
52. E.g., Relman, " C o n t r o l l i n g Costs by 'Managed Competition' —
Would i t Work?", 328 New England Journal of Medicine 133, 135
(January 1993). For a concept of how a physician managed concept
might be made t o work, see Rabkin and Cook, "MBI — Management by
Incentives: A Double-Barreled Approach t o Health Care Reform",
Beth I s r a e l Hospital (unpublished) (Boston, 1992).
53. We w i l l not here review the large (and not completely
unanimous) l i t e r a t u r e on the effectiveness of HMOs i n reducing
costs.
54. I g l e h a r t , "Canada's Health Care System" 315 New England
Journal of Medicine 202, 315 New England Journal of Medicine 778
(1986). Fulton and DiGiorgio, "The Best of Both Worlds"
Healthcare Forum Journal. March/April 1991, 49.
55.
I g l e h a r t , supra n. 54.
56.
Relman, supra n.52.
57. For example, the Bush A d m i n i s t r a t i o n . See "Sounding Board,
The Bush Administration's Health Plan" 327 New England J. of
Medicine 801 (September 1992). We have advocated such an
approach as a modest incremental step t o a i d non-group
subscribers i n Massachusetts. See Harshbarger, supra n.15.
58. For an analysis of such an approach see Thorpe and Siegel,
"Covering the Uninsured, I n t e r a c t i o n s among Public and P r i v a t e
Sector S t r a t e g i e s , " 262 Journal of the American Medical
Association 2114 (1989).
59. Prof. Nancy M. Kane of the Harvard School of Public Health
makes t h i s argument i n a l e t t e r submitted as comment on Attorney
General Harshbarger's non-group proposal (November 23, 1992).
60. For examples of f u l l h y b r i d approaches, see "Health Access
America, the AMA Proposal t o Improve Access t o Affordable,
Quality Health Care". American Medical Association (1990);
"Universal Insurance f o r American Health Care: A Proposal of the
American College of Physicians (October 1992) (includes g l o b a l
budgeting as w e l l as a "pay or play" mandate). This type of
approach has drawn considerable recent a t t e n t i o n among Democratic
45
�)
policy thinkers, e.g., "The Clinton Health Care Plan," 327 New
England Journal of Medicine. 804 (September 1992).
61.
See Thorpe and Siegel, supra n.58, a t 2115.
62. Changes i n ERISA would be needed to implement community
rating at the state l e v e l . Also, many employers would s h i f t over
to Administrative Services Only contracts (self-insurance). This
would leave only small employers and employers with aging
employee-groups i n the community rated market.
63. For discussion of some of the other problems which would
have to be addressed by regulation i n an employer-based model,
see Swartz, "Why Requiring Employers to Provide Health Insurance
i s a Bad Idea," 15 Journal of Health P o l i t i c s . Poiicv and Law
779, 786 (Winter 1990).
64. See. Brown, "Policy Reform as Creative Destruction:
P o l i t i c a l and A d m i n i s t r a t i v e Challenges i n Preserving the P u b l i c Private Mix." 29 I n q u i r y 188, 201 (1992). The Catholic Health
Association, has adopted a proposal s i m i l a r i n o u t l i n e t o ours,
a f t e r concluding t h a t the p o l i t i c a l and o r g a n i z a t i o n a l e f f o r t
involved i n "pay or play" approach i s too large i n r e l a t i o n s h i p
t o the improvement i t o f f e r s . See "Frequently Asked Questions
about the CHA Working Proposal," (Catholic Health Association,
Washington, D.C). For another s i m i l a r perspective, see.
Mariner, "Sounding Board, Problems w i t h Employer-Provided Health
Insurance — The Employee Retirement Income Security Act and
Health Care Reform", 327 New England Journal o f Medicine 1682,
1685 (December 1992).
65. Thorpe and Siegel, supra n.58 a t 2115, note t h a t even w i t h
an employer mandate, more than 12 m i l l i o n non-elderly persons
would remain uninsured.
66.
See note 33.
67. Himmelstein & Woolhandler, supra n.10, a t 145: Nationwide
opinion p o l l s c o n s i s t e n t l y show a m a j o r i t y ready t o move t o a t a x
funded system.
46
�STATE OF NEBRASKA
EXECUTIVE SUITE
PO Box 94848
Lincoln. Nebraska 68509-4848
Phone (402) 471-2244
E. Benjamin Nelson
Governor
Hillary Clinton
The White House
1600 Pennsylvania Avenue
Washington, DC 20500
Dear H i l l a r y :
I am e n c l o s i n g f o r your c a r e f u l review, a h e a l t h care plan which
has been formulated by Walter J. Zpevak, FLMI.
Mr. Zpevak i s a colleague of mine who has been involved i n the
insurance i n d u s t r y f o r many years. He i s very knowledgeable
about h e a l t h care insurance and the c u r r e n t c r i s i s h e a l t h care
faces i n t h i s country. I f e e l he has put together a very
t h o u g h t f u l and u s e f u l paper about the causes of the c r i s i s and
what he t h i n k s can f i x i t .
I urge you t o read the r e p o r t f o r i t s valuable i n c i t e .
Sincerely,
E. Benjamin Nelson
Governor
jmc
cc:
cc:
I r a Magaziner
Senior Adviser f o r Policy Development
Walter Zpevak, FLMI
A n tqu.ii Oppnrtunitv/Affirmf)ti\'u Action
PrinieO w n n sov ink on r e c y c l e d paper
Employer
��FOREWORD
The Health Insurance problem in the United States has been with us for many years and the proposed
National plan as detailed herein is a giant step toward its solution:
(1) Every American citizen will have access to quality health care regardless of income.
(2) Every American citizen will have access to quality health care regardless of the condition of his
health or nature of his occupation.
When analyzing the health care problem in the United States, the solution of one problem begets another but in most cases the resulting problem can be turned into an opportunity as the Cause, Effect and
Solution analyses indicate.
Bringing health care to every American will be expensive but the cost of conception -to-the-grave coverage will be well-spent providing everyone involved in the delivery of this badly needed protection will
voluntarily share costs and acceptance of risk to insure that we do not add more taxes to the already
over-burdened taxpayer, nor more expense to the Federal and State governments.
The cost of conception-to-the-grave health coverage for all 250 Million Americans will have to be borne
by approximately 157 Million citizens (117.3 million employed plus 39.4 million Social Security and Railroad Retirement retirees). This will amount to about $638 per 100 Billion of expense per year per each
income-earning individual. If expenses for health care continue to rise it is conceivable that this average
annual cost would explode to $5104 if expenses reach $800 Billion or as much as $6380 if they rise to
$1 Trillion as some are predicting.
We have the best, albeit expensive, medical care in the world and we must not disturb this vital human
service, conversely, we must guard against placing the burden of the cost of the coverage upon the
Federal and State governments. Government operated plans, such as Medicare and Medicaid prove to
be too expensive and inefficient and it is unrealistic to have this fragmented medical protection. It is^best
to have this service concentrated in the private sector and leave the operation of any National health
plan to the insurance industry of the United States. The private sector, with its more than 3000 qualified
Life, Health, Casualty, Blues, and HMO's have the financial wherewithal to fund this plan and to also
make a profit.
The system of insuring this National Plan will be similar to the way in which Federal Employees Group
Life Insurance and Servicemen's Group Life are presently insured in the private sector.
America's two largest Life Insurance companies, namely, Prudential and Metropolitan are the Primary
insurers for the Federal Group and the Servicemens Group respectively. Subsequently, all ofthe other
Life companies that qualify from a financial capacity standpoint are ceded to and assume their proportionate share of the risks.
If our insurance industry resists, there are many foreign (alien) companies that would jump at the
chance to cover our people.
America, with it's 250,000,000 plus citizens, is a true group that has all of the ingredients necessary to
establish a workable, profitable, actuarially sound health insurance system. It possesses large numbers,
spread of the risks, and an established thriving insurance industry is available to make it work,
To sustain itself a true group must have large numbers and a spread of the risks to assure that the
healthy and those with sufficient income can pay for the sick, the poor and the unemployed. From an
Actuarial standpoint, complete, reliable statistics are available from this true group.
�Preventative medicine will be covered, and that, combined with research and development service will
enable constant surveillance of the group, controlled by Social Security number, so that loss experience ratings can be effectively controlled and applied to insure that the lowest possible premiums will
be required at all times. Surveillance is also necessary to help prevent collusion.
The true group of Americans is so well balanced from an insurance standpoint that any one company,
with the help of reinsurance treaties could profitably write this case but no one company could attract all
of the citizens, so the best thing to do is to permit the private sector to underwrite and administer the
plan.
Insurance companies are reluctant to give up their underwritten blocks of health business and are resisting a National Health plan for that reason as well as fear of Federal control of the entire industry.
Under this proposed plan, the industry will not have to fear Federal control and they will be able to enjoy
reasonably profitable business without the expense of commissions and the cost of risk selection.
Federal subsidization may be necessary in the early operating years of this plan but should not be a permanent matter.
Please continue.
�TABLE OF CONTENTS
Page
Problem number one—40,000,000 Americans without Health Insurance.
1
Problem number two—Proposed government coverage.
2
Problem number three—Insuring all Americans through the Private Sector.
3
Problem number four—High cost of medical service.
4
Problem number five—High cost of Hospitalization, Nursing Home and Hospice.
5
Problem number six—Projection 1993 National health costs.
6 &7
Problem number seven—Calculation of premium.
8
Problem number eight—Collection and distribution of premium.
9
Problem number nine—Extent of new plan coverage.
10
Problem number ten—Submission of claim benefits.
11
Problem number eleven—Existing insurance in the private sector.
12
Overall affect of proposal—Recap.
13 &14
Expected state premium taxes—By state Per $100 Billion of health expense.
15
Projected operating requirements— Per $100 Billion of health expense.
16
�HEALTH CARE IN THE UNITED STATES
PROBLEM NO.1:
Almost 40,000,000 American citizens do not have Health Insurance.
Those with coverage and those without breaks down as follows:
Covered
Not Covered
White
205,408,000
24,072,000
Black
Hispanic & Others
29,775,000
6,028,000
19,825,000
255,008,000
5,249,000
34,349,000
CAUSE:
There are two main reasons why this situation exists:
(1 ) The cost of health insurance is prohibitive.
(2 ) The condition of their health is such that they are considered to be poor risks for insurance
companies and are not acceptable under either group nor individual insurance.
NOTE: Some of these uninsureds are employed or otherwise financially able to
afford insurance but are considered to be uninsurable.
EFFECT:
These citizens— Men, Women and Children will continue to go without treatment orthey must
seek out Welfare, Medicaid, Public Health or philanthropic assistance. Except for the philanthropic
assistance, the expense of treating these unfortunate people has become a tax burden for the states
(Medicaid), and the Federal government (Public Health). If this situation continues, the burden will only
become larger and people will go on suffering needlessly while there is a financially sound solution to the
problem.
The Federal Government could, by legislation, provide free health care for each and every citizen, but such
a move would cause hundreds of insurance companies, including Blue Cross-Blue Shield and HMO's into
bankruptcy, seriously impair others, and cause thousands of insurance company employees to lose their
jobs which would adversely affect Federal income taxes.
Individually, the Insurance Industry—Life Companies, Health Companies, Property & Casualty Companies,
The Blues and HMO's can not afford to insure all applicants because they must avoid bad health risks in order
to provide for profitability and do so by selectively underwriting each risk.
SOLUTION: To successfully fund any kind of insurance operation, the following conditions must be
present:
1. Large numbers of people to accumulate the necessary dollars to pay claims, administration
and provide for profit.
2. A spread of the risks by age, sex, births, deaths, illnesses, accidents and the ability to pay
for the coverage.
3. Available reinsurance, coinsurance and stop-loss facilities available to all insurance
companies involved.
In the present scheme of things, selection of risks by well-trained underwriters provides insurance
companies with insulation from the lack of the "spread of risks". Reinsurance and coinsurance
treaties among companies provides the necessary "large numbers" that absorbs the bad health risks.
Despite these safeguards many companies are not able to profit from the risks they accept.
It is impossible for the individual companies to provide coverage to all without access to points 1
through 3.
But the industry as a whole can provide coverage to all by employing coinsurance and reinsurance
among themselves and the insurance industry should be called upon to do so.
ADVANTAGE: Federal and State governments will save $85 Billion in contributions to Medicare,
Medicaid, Welfare and Public Health.
1
�HEALTH CARE IN THE UNITED STATES
PROBLEM NO. 2:
Proposed government coverage is too expensive.
CAUSE:
Any National Health Plan operated by the government would prove to be too
expensive and become a burden to the tax-payers. Witness Medicaid, Medicare and Public Health.
EFFECT:
Federal and State sponsored and operated agencies designed to provide long term
health to all is mired down in bureaucratic red-tape and waste. Medicaid is a disaster, and Medicare
is going broke because the designers of the plan have failed to take into consideration the
"spread-of-the risks" factor. They have one part of the equation required to successfully insure sick
people, the "large numbers", however their large numbers are sick or injured or are in that
time of life when accidents and sicknesses are most likely to occur.
SOLUTION: Use the enormous capacity of the Insurance industry of the United States by executing
a reinsurance/coinsurance treaty covering all of the citizens with premiums paid by those
income-earning citizens that are financially able to do so.
ADVANTAGE:
Everyone will be insured at fair rates.
Government will utilize the enormous resources of the Insurance Industry
to the advantage of the entire populace.
Federal and State governments will be rid of the costs of Medicare and Medicaid.
The insurance industry will not be adversely affected by government coverage.
�HEALTH CARE IN THE UNITED STATES
PROBLEM NO. 3:
Insuring the National Health Plan within the private sector—Life Insurance Companies,
Health Insurance Companies, Property & Casualty Insurance Companies, Blues, and
HMO's.
CAUSE:
The Life companies and Health companies are resisting a Government National Health Plan
because they are enjoying income of over $57 Billion dollars against losses of $42 Billion and with a
composite loss ratio of 72 %. They have the benefit of investment income from the difference between the
incurred and underwriting loss ratios.
The Casualty companies are resisting for similar reasons but to a lesser extent. Their
profitability is not as good, having $2.1 Billion in losses against 2.9 Billion in Written premiums.
The Blues and the HMO's are entirely different problems. The Blues are having financial
problems and could well profit from participation in a National Health plan.
HMO's present still another problem but since many of them are outgrowths of either Life
company or Casualty company needs and could easily be absorbed in any National Health Plan.
All insurance companies fear Federal control of their industry.
EFFECT:
The Insurance industry is a powerful financial giant and the majority of the companies can
continue to thrive but unless their assets are used to install an effective health insurance program they will
suffer from any federally funded plan.
SOLUTION: Under the auspices of the Federal Government, those companies that qualify financially
would accept the liability of insuring a National Health Plan bringing the entire responsibility for accounting
and administering the plan to the private sector, saving billions in government funds while maintaining a
strong tax-producing insurance industry.
The largest insurance company in the United States, Prudential or Metropolitan, would be
assignedto bethe "Master" company with authority to assume and then cede all premiums, losses, reserves
investment income and profit to each and every company that qualifies to be a reinsurer in amounts
proportionate to their surplus funds. Compromise may dictate regional "Master" companies.
This method is similar to the way Federal Employees Group Life Insurance and
Servicemen's Group Life Insurance is presently handled.
ADVANTAGE:
The powerful resources of the insurance industry will provide the administration expertise
to make for a competent service operation.
The insurance industry will have a profitable operation and be free of underwriting costs,
commission expense and have reduced administration costs.
The government will not have to raise taxes to support the plan.
The premiums charged to the income-earning healthy people that will be paying for this plan
will be calculated on loss-experience that will provide for the lowest possible premium contribution
from the citizens.
The Federal government will receive taxes on the profitability ofthe insuring companies.
States will receive taxes of 2 % of all premiums or Two Billion dollars per $100 Billion
of health expenses (Premium).
DISADVANTAGE:
Some employees in the private sector will lose their jobs, but the benefits to the masses far
outweigh the disadvantages.
�HEALTH CARE IN THE UNITED STATES
PROBLEM NUMBER 4:
High cost of medical service.
CAUSE:
The cost of the present high quality, effective medical service is affected by the high
cost of diagnostic equipment, medical research, drugs and other ancillary services. The high cost
of malpractice insurance is due to the high awards emanating therefrom.
EFFECT:
The costs of medical service drives up the cost of health insurance placing the
burden of paying for the sick uninsured upon the State and Federal governments. The medical
profession and their suppliers are aware of this fact but unless all businesses involved in the
medical profession make a concerted effort to help control the costs of medical service any
national plan will fail.
Those that are involved in the medical profession will profit from a National Plan
whether it is Federal or from the Private Sector and their profitability will be dependent upon the
ability of the citizenry and/or the government to pay for their services.
SOLUTION: Doctors will be paid to submit claims for benefits and shall be entitled to add 2% to
their bill for this clerical service not to exceed $25.
ADVANTAGE:
Doctors will be paid for their clerical expenses. Income of $2,900,000,000 to 482,490
Doctors or about $6010 per doctor.
Additional Income tax, approximately $290,000,000.
The public will benefit from continuing high quality medical service.
�HEALTH CARE IN THE UNITED STATES
PROBLEM NO. 5:
High cost of Hospitalization, Nursing Home and Hospice service.
CAUSE:
This situation exists from the same causes that keeps Medical costs high (see
Problem 4) except that considerable expense is due to necessary research and construction.
EFFECT:
The high costs of these institutional services drives up the cost of insurance
placing the burden of paying for the sick uninsured upon the State and Federal governments.
SOLUTION: These institutions and their suppliers should, in recognition of this fact, make a
concerted effort to help control the costs of medical service. Those that are involved in the
medical profession will profit from a National Plan whether it is Federal or from the Private
Sector and their profitability will be dependent upon the ability of the citizenry and/or the
government to pay for their services.
The granting of health care to all will provide profitable patients, but it will not guarantee
100% occupancy and might, due to preventive care and out-patient care reduce the revenue to
the hospitals and here is where the Federal Government should subsidize in order to retain the
excellent service that these institutions provide.
Medical institutions will be paid to submit claims on behalf of patients and shall be entitled
to add 2% to their patients bill for this clerical service not to exceed $25 Those institutions that
adhere to a schedule of payments for services performed by them will be permitted a 2% reduction of income taxes.
They shall be entitled to special Federal grants for Research and Construction.
Whenever the institution does not adhere to the scheduled fee, they shall not be entitled
to special grants nor income tax reduction.
ADVANTAGE:
Institutions will be paid for their clerical expense.
Additional income of $840,000,000 or about $2,400,000 for each of the
approximately 7000 hospitals.
Additional income taxes of about $84,000,000.
They will profit from tax reduction for helping to control expenses.
They will be subsidized for lack of occupancy.
�HEALTH CARE IN THE UNITED STATES
PROBLEM NO. 6:
Projection of 1993 Health Costs.
CAUSE:
Health care costs in the past have been reported from many and varied
sources; Medicare, Medicaid, Public Health, Mental Health, The Blues, HMO's, Life
Companies, Health Companies and Casualty companies.
EFFECT:
Each of these entities have their own way of reporting and reserving for losses
and as a result the figures are not entirely comparable. Reporting periods during the year are
not uniform and the figures from Medicaid, Medicare and Public Health are hardly ever reported
to the public regularly.
SOLUTION: Base the 1993 Health expense and all future years expense upon the figures as
they are available, but have the expenses monitored by the Master company quarterly so that
the experience-rating can be calculated frequently enough to provide each citizen with the lowest
possible premium.
Based upon health care costs in previous years and partial figures for 1992, it is estimated that
the following costs can be expected for 1992:
*Life and Health Companies Group
34,395,251,000
.05
Individual
.02
7,578,927,000
'Casualty and Health Companies Group
1,194,640,000
.01
Individual
921,948,000
.00
*Blues, estimated
.02
9,636,000,000
'Medicare (1991)
Part A
222,986,780,000
.33
PartB
.07
42,302,112,000
Drugs and other nondurables
41,000,000,000
.06
**Dental Services
30,400,000,000
.05
**Home Health Care
4,900,000,000
.01
"Vision products & Medical durables
.03
18,800,000,000
"Nursing Home
.08
50,100,000,000
"Other personal Care
.02
9,900,000,000
"Gov't Public Health
18,900,000,000
.03
Salary Continuance
.22
152,000,000,000
$686,015,658,000
100
* Includes Hospital Expense
" Many of the Medicaid expenses are included above.
Health expenses for 1988 were $520.5 Billion. With those expenses in mind we have interpolated for 1992
and 1993.
In addition we have included Salary Continuance coverage, Mental Health Expense, Vision products and
examinations, Medical durables, Nursing Home, Public Health and Personal Care in this Projection.
...Continued
�PROBLEM 6 Cont:
Projection of 1993 Health Expense
Hospital
Medical
Drugs and other non-durables
Nursing Home
Dental Services
Vision products & Medical durables
Salary Continuance (Disability)
Leave Time
Mental Health
300,987,000,000
155,015,658,000
50,000,000,000
68,100,000,000
39,400,000,000
16,800,000,000
145,000,000,000
85,000,000,000
20,000,000,000
880,302,658,000
.34
.184
.06
.08
.04
.02
.16
.096
.02
100
Former Medicare expenses, $265 Billion, Gov't Public Health $18.9 Billion, Home
Health Care 5.9 Billion, and Medicaid $7.5 Billion are included in all but Mental Health,
Salary Continuance, and Leave Time.
Note: The Salary Continuance coverage will continue the insured employee's salary for
ninety days of disability and at 60% of monthly salary for long term disability to age 65.
Leave Time for family leave will pay to the employer the amount of the "leave" employ
ees salary for three months to cover retraining and the cost of part-time employee.
The overall cost for National Health Care in 1993 would normally exceed $700,000,000,000
but the inclusion of Mental Health and Salary Continuance and Leave Time increases the
projected costs for 1993 to $880,302,658,000.
ADVANTAGE:
Every citizen will have comprehensive health care.
All services will be paid for by the income-producing citizens with tax
deductions for that portion of their cost (approximately 28%) of covering
the unemployed, the sick and those that cannot afford the coverage.
Americans have always been willing to help the needy and here is a way to not only help
the needy but to reduce government spending and continue quality health care as well.
�HEALTH CARE IN THE UNITED STATES
PROBLEM NO. 7:
Calculation of Premium
CAUSE:
No Premium, or other cost has ever been calculated to determine how much
each citizen must pay for National Health Coverage.
EFFECT:
As indicated in Problem No. 6, the expenses for 1993 will amount to over $800
Billion and the cost for the coverage will have to be paid by the 156,782,000 income-earning
citizens in order to defray the costs for all 250,000,000 Americans.
SOLUTION: The cost for each income-earning citizen, employed and retired, averages $638 per
year for each $100 Billion of costs.
The burden that must befall the employed and retired income-earning public would, on average,
amount to:
100 Billion $ 638 per year or $ 53 per month 200 Billion $1276 per year or $106 per month
300 Billion $1914 per year or $160 per month 400 Billion $2551 per year or $213 per month
500 Billion $3190 per year or $266 per month 600 Billion $3828 per year or $319 per month
700 Billion $4465 per year or $372 per month 800 Billion $5102 per year or $425 per month
900 Billion $5740 per year or $478 per month 1 trillion $6380 per year or $532 per month
It is impractical to spread the cost ofthe new program evenly per employed person because
dividing the cost equally would work a hardship on those that have low incomes and therefor the
premium must be charged according to income as follows:
PER $100 BILLION of HEALTH EXPENSES (PREMIUM)
Assumption: Approximately 157,000,000 people employed
Income
Under 5,000
5000 -9999
10000-14999
15000-24,999
25000-34,999
35000-49,999
50000-74,999
75000-99,999
100000-149999
170,000 over
%
.06
.09
.10
.18
.16
.17
.15
.04
.03
.02
Population
9,796,800
14,695,200
15,929,000
28,103,763
24,963,000
27,161,000
22,765,000
6,824,808
4,525,772
2,936,420
157,600,763
Annual
Prem
x 60
x 120
x 300
x 450
x 600
x 782
x 1074
X1275
x 1425
X1500
Total
Ann.Prem.
587,808,000
1,763,424,000
4,778,700,000
12,646,933,500
14,977,800,000
21,243,524,600
24,446,324,600
8,701,630,200
6,449,225,100
4,404,630,000
100,000.000.000
%
.005
.022
.053
.13
.15
.21
.24
.09
.06
.04
100
Per. Mo.
Per. Person
5
10
25
37.50
50
65.16
89.50
106.25
118.75
125
%
Income
.01
.01
.03 -.02
.03-.018
.02-.017
.02-.015
.02 -.014
.017-.012
.014-.01
.01-.008
The above assumes that the premium charged to the income-earning citizens, including Social Security
and Railroad Retirement recipients and the total premium will equal the health expenses which will
determine the experience-rating for future premiums.
ADVANTAGE: The cost of the program will be equitably distributed among the income-earners.
8
�HEALTH CARE IN THE UNITED STATES
PROBLEM NO. 8:
Collection and distribution of premium.
CAUSE:
No method exists to collect and distribute premiums.
EFFECT:
A system will be installed to collect premium by payroll deduction or, in the case of
Medicare and Railroad Retirement, by deduction from the retirement proceeds of each
retired individual.
SOLUTION: Employers will deduct from the wages of each employee, the necessary premium
each month and deposit, properly identified (Social Security number), with a depository, a
National Bank, similarly as is now being done for Social Security. Self-employed people will
submit premiums in the same way that they submit Social Security collections.
The Banks will be instructed to submit the premiums net of their 2% fee, properly identified to the
"Master" Company.
The Social Security System will transfer the funds, currently being held, properly identified,
comprising the premium for Medicare Retirees and Railroad Retirement Retirees to the "Master"
Company.
The Social Security System will deduct from the checks of Social Security retirees and pay
directly to the "Master" company the amount of premium necessary to provide the new National
Health coverage which will replace Medicare.
ADVANTAGE:
The government will be freed of the expense of administering Medicare.
Banks will have income from which additional taxes will be paid.
Approximately $2,000,000,000 Per $100 Billion of health expenses (premium) or
$142,857 for each of 14,000 banks. At $800 Billion of health expenses (premium)
the income would be $16,000,000,000 or 1,142,857 per bank.
All banks may not qualify for participation.
Federal taxes of approximately $1.6 Billion will be available.
�HEALTH CARE IN THE UNITED STATES
PROBLEM NO. 9:
Extent of Health Coverage
CAUSE:
There has never been a program specifically tailored for the entire populace.
EFFECT:
If the extent of coverage is not determined it will be impossible to provide "conception-tothe-grave" coverage. The new National Plan must cover everyone for any and all kinds of sickness or
injury. It must include maternity, mental health, pre-existing conditions, dental services, vision care and
products, nursing home service, drugs, alcohol and chemical abuse, and salary continuance and leave
time.
SOLUTION: The new plan will cover any and all kinds of sickness or injury and all health costs, including Mental Health, Maternity, Vision care and products, Dental, Nondurables, Durables, Home Health
Care, Nursing Homes, Gov't. Public Health, and Loss of Income /Leave Time.
Loss of Income/Leave Time is a new coverage that will pay for the insured's salary for ninety days of
disability plus Long Term Disability to age 65. Family Leave Time will reimburse the employer for two
months of the "leave time" employee's salary
Under the new plan, the Federal government would be relieved of Gov't Public Health expenses, Medicare, Medicaid and Mental Health as these costs will be included under the new National Health Care
Plan underwritten by the Private Sector.
Conception-to-the grave Covered expenses will include:
A) $3,000,000, lifetime medical expense per person.
B) $250 annual deductible per year per person. No deductible
if income is under $15,000.
C) All Hospital Costs with Semi-private room
D) Miscellaneous Hospital Expenses.
E) All physicians fees and physical therapy,
F) All physicians prescribed services
G) All medical supplies and equipment—Durables and Non-Durables.
H) All maternity and complications of pregnancy up to $4000.
I) Outpatient surgery
J) All Professional fees for non-emergency home or office visits.
K) Use of doctor of patients choice.
L) Mental, nervous, alcohol and chemical abuse up to $4000 per year.
M) Home health care.
N) Hospice care.
O) Emergency Care for injury or acute medical condition.
P) Drug Benefit, $50 deductible per year.
Q) Routine Physical peryear and preventive medicine.
R) X-ray and Lab expense.
S) Salary Continuance—60% of monthly salary for 3 months; Maximum $600 per.
month for long term disability up to age 65.
T) Leave Time—3 months of Leave Time employees salary paid to employer.
U) Dental, Preventive, Basic, Major and Orthodontic ($3000 limit).
V) Vision care and products. 80%.
The cost of this plan, exclusive of Leave Time, underwritten , from a private insurer would cost, depending on age, occupation, and condition of health approximately $180 to $350 per month for a single
person and $ 353 to 600 per month for a family of three or more..
10
�HEALTH EXPENSE IN THE UNITED STATES
PROBLEM NO. 10:
Submission of claim benefits
CAUSE:
No system exists for submitting claims benefits under the new National Health Plan.
EFFECT:
Under the present method of insuring health coverage claims are now submitted by
the doctor, or institution or the insured patient to the writing company. Delays by the doctor or the
institution are prevalent and many times the insured must follow-up several to obtain the completed
papers. The Medicare claims are handled directly from the doctor or the institution to the assigned Medicare claim handler. There are still some delays, but they are due mostly to the time spent in evaluating
claims before payment.
SOLUTION: The doctors, institutions and employers will be compensated for their time and
effort in providing this very necessary clerical function. Delays will be rare because the doctors will be
permitted to add 2% to their bill, limited to $25, for each benefit claim that they promptly submit on
behalf of an insured patient.
Institutions, will be entitled to add 2% to their bill for clerical service, limited to $25 for each benefit
claim that they promptly submit on behalf an insured patient.
The details of claim reporting will be much easier as doctors and institutions will not be harassed to defend the need for particular treatments that may be prescribed since everyone will be covered regardless of the treatment.
Claims will originate and be submitted by the doctor, institution, dentist or employer (Leave Time).
The doctors, dentists and institutions are expected to perform this clerical service for the convenience ofthe patient. The same is true in the case of employers regarding the claims emanating
from the new Leave Time coverage.
A simple, standard, short form, containing necessary identifying information that can be produced by computer or manually will be used for reporting claim benefits
All benefit payments shall be made directly to the Doctor, Institution or Employer by the "Master"
company. This claim form must be accompanied by itemized bill showing amount of service plus 2% for
clerical service limited to $25.
Telefax!ng of the information is encouraged and will reduce expenses.
Everyone must be alert to collusion and the insuring company will verify identify and approve all
claims as to validity before making payment.
11
�HEALTH CARE IN THE UNITED STATES
PROBLEM NO. 11:
Existing insurance with Life, Health, Casualty, Blues and HMO's.
CAUSE:
Health coverage, existing prior to the adoption of a National Health Care Plan for
which the entire premium has been paid but not earned must be accounted for. Pending claims
must be honored.
EFFECT:
All unearned premiums will be properly credited and pending claims under cover
age of those insured by the private sector previous to the adoption of the new National Plan, as
well as those insured under government plans will not be interrupted.
SOLUTION: The National plan will immediately accept liability of those insureds that are not in
the pendency of a claim. Those insureds that have pending claims and no unearned premium is
available will also be covered by the National plan immediately. Where unearned premium remains to be earned, coverage by the National plan will be accepted on the date that the last
premium becomes earned.
The entire premium and loss record of Medicaid programs, properly and individually identified will be transferred to the Master Company and will become the permanent record of the new
National Health plan and will be merged accordingly.
The Military programs will not be affected.
The Veterans health care should also be transferred to the national health plan if this is feasible.
Company health service can continue if the company so chooses. They can either run-off their
experience to expiry or merge immediately.
12
�OVERALL AFFECT OF PROPOSAL
1.
Every citizen of America will have complete health care from conception- to-the-grave.
2.
Employed citizens, Railroad Retirement and Social Security retirees will pay for the cost of sick
and unemployed to the extent and proportion of their overall income to the cost of the plan.
3.
Cost for complete care will result in an increase in premium to those retired on Railroad Retirement, Social Security (Medicare). The present premium for Medicare cost is $31.80 per month and
under this proposed National Plan, in some cases it may remain the same, and in others it will increase
because the premium for the new plan will be charged in proportion to income.
4.
Under the new plan, supplements to Medicare will be unnecessary in many cases if the Medical
Sen/ice sector accepts prescribed charges, because the new plan will cover practically all health costs.
Those insurance companies that have suffered losses from the issuance of Medicare supplements will
be able to enjoy their proportionate profitable share of the new plan which will more than offset the loss
of the 'Supplement' income.
The new plan will include comprehensive coverage which will include unlimited Nursing home,
Dental, Vision, Drugs and Mental Health. There will be no need for Federal contribution to Medicare
thereby saving $40 Billion.
5.
No commissions will be paid, and the insuring companies will profit therefrom. Those agents now
selling health insurance will suffer a loss in income, possibly as much as $10,000,000,000 but this loss to
agents will be a gain to all as this amount will go toward paying benefits.
6.
All insurance companies, Blues and HMO's will have a built in, regulated profit of 12% provided
that they qualify from a capacity standpoint based upon the amount of their Surplus.
7.
Doctors, Institutions, Employers and Banks will be compensated in the amount of 2% of the premiums for the involvement in clerical work each month. Self-employed will be compensated similarly.
8.
The premium paid by the employer on behalf of employees will be considered as income to the
employee and will be treated accordingly for tax purposes.
9.
Employees will be entitled to a full tax deduction for that percentage of premium that is withheld to
defray the cost of coverage of the unemployed uninsureds which will amount to about, 28%.
10.
Those unemployed uninsured that heretofore did not qualify for insurance due to their health
condition, occupation or ability to pay will be covered under the new plan.
11.
In those cases where the uninsureds are employed, premiums will be collected and submitted
for them and /or their dependents by their employer.
12.
New taxes will be generated upon the remaining 72% of premium (approximately $576 Billion).
This will amount to about $7.2 Billion per $100 Billion of health expenses (premium).
13.
Insuring companies will be subject to state premium taxes of 2 % without exemption from the tax
on this insured health program. This tax will be shared by each state according to the population in the
state or about eight dollars per citizen per $100 Billion of expenses (premium) per year.
13
�14.
The following chart indicates the distribution of income and taxation that will be derived from the
gross premium (health expenses) that will be paid for coverage under the proposed by the incomeearning citizens for all 250 Million Americans.
The income figures are true percentages. The tax figures are mere estimates. The Federal and State
contributions of $85,000,000,000 will not be necessary.
Expenses (Premium)
$100,000,000,000
Income Insurance Industry
$100,000,000,000
Est.Profit Insurance Industry
Retention $12,000,000,000
Inv.lnc.
$5,830,000,000
Profit
$17,830,000,000
Income to Fed. Gov'
Tax on Insurance Industry
$1,248,000,000
$1,248,000,000
Income Doctors
$2,900,000,000
Tax to Doctors
$290,000,000
290,000,000
Income Hospitalsl
$840,000,000
Tax to Hospitals
$84,000,000
84,000,000
Income Employers
$2,000.000.000
Tax to Empoyers
$200.000.000
200,000,000
Income Banks
$2,000,000,000
Tax to Banks
$200,000,000
200,000,000
Income Earners
$100,000,000,000
Taxable Earners
$72,000,000,000
Tax to Earners
$7.200.000.000
State Premium Taxes @ 2 % of Health Expenses
(Premium) amounts to: $2,000,000,000 per.$100 Billion.
Note:
At $800 Billion of expenses the taxes would be over
$72 Billion plus savings in Medicare and Medicaid
contributrions of $85 Billion or $157 Billion overall.
14
i2QaQ0Q,QQQ
Total $9,222,000,000
PLUS
Savings—Medicare &
Medicaid Contributions
$85,000,000,000=
$94,222,000,000
�State Premium Taxes Developed Per Each $100 Billion Of Premium
$100,000,000,000 x 2%= $2,000,000,000 + 250,000,000 = $8.00 per citizen per year
Each states share is as follows:
State Population
Cal. 29,063,000
N.Y. 17,950,000
Tex. 16,991,000
Fla. 12,671,000
III.
11,658,000
Ohio 10,907,000
Mich. 9,273,000
N.J.
7,736,000
6,571,000
N.C.
6,436,000
Ga.
6,098,000
Va.
Mass. 5,913,000
5,593,000
Ind.
Tenn. 4,940,000
Wis.
4,867,000
Wash. 4,761,000
Md.
4,694,000
4,382,000
La.
Minn. 4,353,000
4,118,000
Ala.
Ky.
3,727,000
Ariz.
3,556,000
3,512,000
S.C.
State
Population
Colo.
Conn.
Okla.
Iowa
Ore.
Miss.
Kan.
Ark.
W.Va.
Utah
Prem. Tax
Per. 100 Billion
$ 232,504,000
143,840,000
135,928,000
101,368,000
93,264,000
87,256,000
74,184,000
61,888,000
52,568,000
51,480,000
48,784,000
47,034,000
44,740,000
39,520,000
38,936,000
38,088,000
37,552,000
35,056,000
34,824,000
32,944,000
29,816,000
28,849,000
28,090,000
3,317,000
3,239,000
3,224,000
2,840,000
2,820,000
2,621,000
2,513,000
2,406,000
1,857,000
1,707,000
1,611,000
1,528,000
1,222,000
1,111,000
1,107,000
1,014,000
998,000
806,000
715,000
673,000
660,000
604,000
567,000
527,000
475,000
Neb.
N.M.
Me.
Nev.
N.H.
Ida.
R.I.
Mont.
S.D.
Del.
N.D.
D.of C.
Vt.
Alas.
Wyo.
15
Prem.Tax
Per. 100 Billion
$26,536,000
25,922,000
25,792,000
22,720,000
22,560,000
20,968,000
20,104,000
19,248,000
14,856,000
13,656,000
12,888,000
12,224,000
9,776,000
8,888,000
8,856,000
8,112,000
7,984,000
6,448,000
5,720,000
5,384,000
5,280,000
4,832,000
4,536,000
4,216,000
3,800,000
�NATIONAL HEALTH EXPERIENCE PER $100 BILLION OF HEALTH EXPENSE
(PROJECTED)
$100,000,000,000
Health Expense (Premium)
Insurance Industry Retention
Doctors Clerical Income 2%
Hospital Clerical Income 2%
Employers Clerical Income 2%
Banks Clerical Income 2%
State Premium Tax 2%
12,000,000,000
2,900,000,000
2,000,000,000
2,000,000,000
2,000,000,000
2,000,000,000
Benefit payments
22,900,000,000
$ 78,000,000,000
The necessary operating expenses of $22.9 Billion per $100 Billion of health expenses will be
required to support $78 Billion of actual health costs.
16
�COMMONWEALTH OF KENTUCKY
ERNESTO SCORSONE
HOUSE OF REPRESENTATIVES
SEVENTY-FIFTH DISTRICT
FRANKFORT, KENTUCKY 40601
804 FIRST NATIONAL BUILDING
LEXINGTON, KENTUCKY 40507
HOME 606-254-3681
OFFICE 606-254-5766
March 23, 1993
Ms. H i l l a r y Rodham C l i n t o n
Commission f o r Health Care Reform
The White House
Washington, D.C. 20500
Re:
/
Health Care Reform
Dear Ms. C l i n t o n :
As t h e h e a l t h care reform debate u n f o l d s , your advisers
appear t o be pushing i n the d i r e c t i o n o f a managed competition
approach t o reforming the current system. While I believe
t h a t managed competition o f f e r s some improvement on t h e
c u r r e n t system, I hope t h a t your task f o r c e does not l i m i t i t s
c o n s i d e r a t i o n t o managed competition models.
There are strong i n d i c a t o r s t h a t t h e only way t o get a
good handle on h e a l t h care costs and, a t t h e same time,
r e d i r e c t p r i o r i t i e s i n our h e a l t h care system i s t o have a
s i n g l e payer system.
As one who ha s been involved i n h e a l t h care reform e f f o r t s
a t t h e s t a t e leve 1, I would urge t h a t your reform commission
keep open the opt n o f a s i n g l e payer p l a n . I f changes are
io
made i n the s h o r t term t h a t are something less than a complete
and u n i f i e d s i n g l e payer system, then a t l e a s t thought should
go toward making those p r e l i m i n a r y changes c o n s i s t e n t w i t h the
development of a s i n g l e payer plan i n t h e long run.
I thank you i n advance f o r your c o n s i d e r a t i o n of t h i s
recommendation.
Very r e s p e c t f u l l y yours,
Ernesto Scorsone
State Representative
ES:kjt
3SP2/
�Cily of Chicago
Richard M. Daley, Mayor
January 29, 1993
Chicago Departmenl on Aging
Donald R. Smith
Commissioner
510 North Pcshtigo Court
Chicago, Illinois 60611
(312) 744-4016 (Voice)
(312) 744-6777 (TDD)
(312) 744-0680 (FAX)
H i l l a r y Rodham C l i n t o n
Chairperson
Universal Health Care Plan Task Force
The White House
Washington D.C. 20500
Dear Mrs. C l i n t o n :
Congratulations on being appointed Chairperson of the
task force on Universal Health Care. I c e r t a i n l y f e e l
very c o n f i d e n t t h a t you and your s t a f f w i l l come up
w i t h a National Health Care Plan t h a t w i l l t r u l y be
u n i v e r s a l and include everyone.
As we a l l know, Health Care i s t h e #1 issue f a c i n g
America today.
I thought I would send you a
collection
of a r t i c l e s
and m a t e r i a l regarding
Universal Health Care t h a t I have c o l l e c t e d over the
past few years.
By the way, please g i v e my best t o Ms. Pat S o l i s , she
helped Ms. Miriam Santos, C i t y Treasurer of Chicago,
i n p r e p a r a t i o n f o r a c e l e b r i t y cookoff t h a t raised
money f o r our "Meals on Wheels" program.
Best Wishes,
/
Donald R. Smith
Commissioner
enclosures
DRS/lw
'Creating options for an aging society:
�
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [3]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
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Box 36
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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3/16/2015
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42-t-12092971-20060885F-Seg3-036-007-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/8fa3393befad5854be41dfcd1b07746a.pdf
dd00199c9624f9af95e93569673598ca
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1985
FolderlD:
Folder Title:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [2]
Stack:
Row:
Section:
Shelf:
Position:
s
56
2
4
1
�VAT*
USTOT
I I U I H I I
Columbus
43215
March 16,1993
Hillary Rodham Clinton, Esq., Chairwoman
President's Task Force on National Health Care Reform
White House
1600 Pennsylvania Avenue, NW
Washington, DC 20500
Dear Ms. Clinton:
On behalf of the Miami Valley Health Improvement Council of which I am a trustee, we want to
invite you to be our guest speaker at our Annual Meeting. At this time, our Annual Meeting is
scheduled for the afternoon of May 19,1993, and is being hosted by Kettering Medical Center,
Kettering, Ohio. The date can be changed to meet your schedule, should that be needed.
The Council is a consortium made up of public officials, employers, providers and consumers
representing the health care interests of the 1.1 million residents of our designated health service
area.
We of the Council believe that health carereformstarts in our local communities: health care is a
local industry, its services are produced, utilized and paid for locally. We believe that the Dayton
area is an outstanding area for consensus building which must be accomplished if we are to have
effective health care reform.
I have enclosed a number of documents for your review. This type of information is needed if we
are to be responsible consumers of health care services.
The facility where we plan to hold our meeting seats 530 people and we do not plan to charge a fee
for this meeting. We hope you will be able to come to Dayton and brief us on the President's
health care reform package and what we can do to insure it is carried out. If you would like for us
to put together a Community Town Hall Meeting, we can_do that also.
IcLin
State RefiFesentative
Ohio House District 38
�sa
Enclosures:
MVHIC, Our Mission
MVHIC Guide to Hospital Utilization and Charges. 1992
MVHIC "Bywoids in Health Newsletter"
Problems and Prospects on the U.S. Health Care System
Report on MVHIC from Business & Health. March, 1993 issue
Viewpoint Newsletter of the GDAHA
�OUR MISSION as a community based organization
currently representing the health care needs of 1.1
million citizens of the Miami Valley Health Service
Area, is to work with health care providers,
consumers, payers, employers and government to
insure that accessible, cost-effective, quality health
care is available for our community.
OUR
MISSION
As the designated community health planning
organization, we see our role in accomplishing this
mission by:
1.
Conducting community
health
planning
development and implementation
for
Champaign, Clark, Darke, Greene, Miami,
Montgomery, Preble, and Shelby Counties;
2.
Supporting community health education
program development and implementation;
3.
Conducting the regional Certificate of Need
(CON) program for Ohio HSA II,
4.
Serving as a health information clearinghouse
for the area;
5.
Advising the community and leadership on
health issues affecting the residents of the
area;
Providing testimony to elected and appointed
local, state and federal officials regarding
concerns, issues, and programs that address
access to quality health care and its costs;
Providing such other functions as needed as
the designated Health Service Agency for HSA
II.
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�S
E
M
I
N
A
R
PROBLEMS
AND PROSPECTS
THE
UNITED STATES
HEALTH CARE
SYSTEM
|*|
October 5, 1989, Dayton, Ohio
�Problems and Prospects
of the
United States
Health Care System
SUMMARY
Scott R. Stiens
MVHIC
Mr. Robert Thimmes
March 20, 1990
�Summary
Ambrose M. Hearn
Perspective/Background
The Canadian heallh care system has existed almost 45 years. It consists of
twelve provinces interlocked to serve as a facilitator for the federal government
(evidenced by the payment system).
The federal government
does not
mandate the delivery of health care, but offers the provinces $.50 for each
$1.00 spent on health services. In 1947, the provinces agreed to those health
services according to the federal government. Thus, the federal government has
not legislated national health care, bul has relied on merely
persuading
member provinces lo deliver national health care.
All hospitals are not owned by the State and all doctors are not employed by
the State.
In fact, both are paid on a fee for service basis. The hospitals are
typically owned by community based boards. The system is not government
owned and controlled. This provincial system covers all necessary hospital and
doctor visits.
Because Canadian heallh insurance is not universal, some
provinces extend care beyond federal coverage. Also, employers sometimes offer
private insurance, which in no way effects access to quality care, but adds
reimbursement to the providers.
All citizens have the right lo receive care without a deductible, co-payments, or
point of service hurdles. In some provinces a premium or tax is charged for
health care.
The system is simple and efficient - one paymaster,
the
government.
The Canadian system is 85% accepted and popular in Canada. With physicians,
61% were satisfied, some 25% were dissatisfied, and others were undecided.
However, the paperwork was considered unreasonable by 31% of doctors. The
changes underway are computerization of the paperwork. In 1988, most of the
professional groups were satisfied overall. Sixty- one percent of the physicians
thought that the system has a positive effect on the health status of Canadians.
Evolution/Problems
In the initial slages of the system, fees for service deterred some patients. The
government challenged this because it prevented access of all - the federal
government goal.
The result led to the 1984 Canada Heallh Act which
penalized provinces dollar for dollar in the event of extra billing or user charges.
Such roundabout rules came because the federal government could not legislate
such sweeping rules, but could effect the provinces though disincentive. So now
there are no such 'user charges' hinder access or create an exclusive health care
system.
General success indicates we accomplished what we set out to do - provide all
Canadians with reasonable access to comprehensive health care on uniform
terms and conditions. Canada thinks it has accomplished this goal. Health care
�Summary
costs indicate Canada at 8.7% vs. US at 11.5% of GNP. Canada is succeeding in
cost; even though it could improve, its people are content.
Universality simplifies the general administration,
which removes competition
for profits through uniform pricing.
Cost of administration
is 2-3% of net
revenue in Canada vs. 17% in the U.S.
Population growth is rapid in Canada and by adjusting bed capacity the health
service hopes to meet the changing needs of the growing population.
The cost of
technology is prohibitive,
but accessibility is preserved by gate-keepers and
central stationing of the M.R.I.s and C.A.T. scanners. Physician supply is to large
and poor distribution leads to vast over-doctoring.
Future/Suggestion
No fundamental changes will be made lo the Canadian Comprehensive Health
Care System, but some fine tuning will occur. Because this system develops
within the Canadian culture and political system, a parliamentary
system, its
adaptability
is limited and would not necessarily fit the needs of America. It
works for Canada, but I cannot absolutely recommend it to the people of United
States.
�Summary
Judith C. Waxman
Perspective/Background
in addressing the United States national and state perspectives. Congress
watches how the stales approach health care and hopes to fall in step, but it is
often difficult to follow divergent paths.
During 1988, the Pepper Commission was formed through a compromise. It
addresses two issues: long-term care and access to health care. The Commission
Report was released in March of 1990. The commission has 15 members: 6
from the House, 6 from the Senate, and 3 through the White House. Senator
Rockefeller chairs the commission and members from Ohio include Messrs
Gradison, Stokes, and Oakar.
Three mandates for the commission:
1.
2.
3.
Comprehensive Health Care for All Americans
Comprehensive Heallh Care for the Elderly
Long Term Care for All Americans
Evolution/Problem
The Commission findings address the population of some 31-37 million without
heallh insurance: 33% children, 80% worker family, and a vast majority of
poor. Health care cost is the major area of concern. Many are going without
care due to the sheer expense. With the U.S. health care cost rising out of reach,
no relative change in health status, and decreasing numbers of insured; the
commission seeks to unify our fragmented health care system.
Future/Suggestion
In the Public Sector, the Commission suggests intervening on access issues. By
expanding Medicaid to cover 100% of the medically indigent and Medicare to
cover everybody including the elderly, then some 30% of the aforementioned
could receive care. If eligibility levels were changed to become more realistic,
some 40% - 50% would then be covered.
In the Private Sector, price is the major obstacle to access. High prices and
passing costs are industry responses to an unusually high expectation of
By pooling services, bringing companies together, and forcing insurers to
open enrollments, health care rate increases should slow and make health
more affordable for the other 50% of the consumers.
hefty
care.
have
care
The Commission might recommend a tax credit incentive plan (acting with the
regulatory sector and) encouraging the private sector to lower cost. Such action
would generally alleviate 40% of the problem.
Also, the Commission may
�Summary
recommend a Comprehensive Health Care Plan to encourage
distribution of quality care. Such a plan would require:
1.
2.
3.
4.
the
equitable
Mandated insurance by employer and have government pay for
all unemployed. Unfortunately, this would raise the wage burden
of the employer, but it would provide coverage for all. (OR)
Instead of a mandate, an employer could pay health tax and get
lax credit if the employer pays out for private
company-wide
insurance. (OR)
Some kind of government insurance would be available to the the
employer for his employees. (OR)
A British prototype would provide government health insurance
and pay the private sector or public sector providers.
As the health cost rises and the private market erodes, less accessibility results.
We must act now and develop programs like this to initiate change in the
system.
�Summary
Cale A. Drapala
Background/Perspective
Health Care Financing Administration
(H.C.F.A.) administers Medicare to 30
million elderly beneficiaries, and another 3 million disabled.
Together, the
states also administer Medicaid to another 23 million poor and medically needy.
For Fiscal Year 1990, the combined budget will reach $140 billion
which
translates into many medical services for the anticipated
11 million
hospital
admissions during 1990. About $30 billion will be attributable
to physician
services. Overall, this accounts for 1/4 of the U.S. health care expenditure. By
the year 2000, Medicare alone will be the largest entitlement program in the
United Stales.
United States citizens have come to appreciate the American health care system
- couched in a decentralized government of checks and balances, separation of
powers, and general federation. However, an outpouring of legislation, like the
Omnibus Budget Reconciliation Act (O.B.R.A. '87) and others, presents the
problem of centralization
vs. decentralization
in health care decision making.
Although
centralization
has its advantages,
state governments
favor
decentralized decision authority.
Evolution/Problem
Many influences act on the American health care system, but the prime force is
economic. Health care takes an increasing portion of the budgetary pie. This
truism effects private industry, federal, stale, local, and personal budgets. Over
the last 10 years, health care has grown from 9% to 11.5% of the CNP. In
comparison with other industrialized
countries, the U.S. spends the most
without drastically improved heallh status. Medicare's total outlays increased
162% during the 1980s.
Over the last 10 years, Medicare payments to
physicians have compounded annually at 16%.
Demographics also aggravate heallh care utilization and cost. The U.S. along
with many other industrialized countries is aging. By year 2000, 13% of the
United States population will be over 65 years (roughly 35.5 million people).
The cost implications for heallh care are enormous.
Future/Suggestion
Because H.C.F.A. programs account for a quarter of personal health care
expenditures, the aforementioned trends will have a wide impact.
Managed
care is one possible avenue to cost control and quality improvement.
Managed
care would include health maintenance organizations, prepaid health plans,
preferred provider organizations,
or case management approaches. Now 28
state agencies contract with nearly 200 prepaid heallh plans that serve about
2.3 million Medicaid recipients. H.C.F.A. supports such proposals.
�Summary
Another avenue to cost containment and quality is effective use of health care
dollars. In other words, we need to know what works in the practice of
medicine. H.C.F.A. investigates debated practices, not to develop government
standards, but to disseminate accurate information. Such investigations would
dovetail with the Rand Corporation's J.C.H.O. "Agenda for Change." Also, a
Resource Based Relative Value Scale (R.B.R.B.S.) could be applied to physician
reimbursement because it represents such a large component of the health care
expenditure. Unfortunately, the R.B.R.B.S. alone does not have any built in
incentives to control the volume of services - a critical component of physician
services.
In summary, a forum, such as this one sponsored by the Miami Valley Health
Improvement Council, is a tremendous public service in opening the debate.
�Summary
James R. Castle
Background/Perspective
Since the late 1930s, incentives have encouraged health care providers to
expand services and accessibility.
The thrust was to expand the services
available to rural America through federal grants. This step was followed by
insurance programs that expanded the people, services, and dollar levels
covered.
By the middle 1960s the Medicare and Medicaid programs were
implemented.
By the 1970s we realized that we had promised more than we
could deliver. Over the past 20 years we have just tinkered with the system P.P.O.s and P.S.R.O.s.
Evolution/Problem
The problem lies in the health care expectations of the American public. Because
America has one of the most advanced, quality, health care systems in the
world, we - as Americans - cannot imagine change. The system initially evolved
in response to attitudes and expectations.
To change the system to meet
today's financial constraints, we must change our values and expectations.
Some specific examples of our values follow: DIVERSITY: here we are proud of
our different values - North lo South, East to West. We must appreciated that
when we fashion a nationalized
health care system. FREEDOM of CHOICE:
Americans expect the full range of options - from the most aggressive treatment
to the least. In Canada the physician need not fear litigation for not "fully
informing" the patient of all the options, but here that is not the case. Can
Americans accept limited choice or a "lower level" of care?
DEATH is
UNACCEPTABLE: illness, sickness, and death are not easily accepted with our
high hopes in technology.
Future/Suggestion
In a slow movement toward a nationalized system, we need to change our
expectations as Americans.
Essentially, we want Cadillac health care on a
Chevy budget. As Americans we need to reconcile our values and expectations
with our willingness and ability lo increasingly spend.
�Summary
Carol Regan
Background/Perspective
As the health care
International
Union,
reduction problem is a
term national solution
legislative
representative
of the Service Employees
we fight the reductions of employee benefits.
This
popular theme today amid high heallh care costs. A long
has been researched and may be helpful in our future.
Evolution/Problem
Many have no health insurance - even as working members of society. Many
hard working families can no longer afford the family insurance and some with
pre-existing conditions can no longer even buy heallh insurance.
Employers
who buy health insurance undergo 20% - 30% increases annually.
This
situation exacerbates the cost competition from abroad. Much of the insurance
cost increases subsidize higher hospital costs and those employers who refuse to
carry health insurance plans. Unfortunately, many cost effective services like
pre-natal care, are not included in the coverage offered. Incredibly, the portion
of uncompensated care still rises; no other nation spends so much and gets so
little!
The unions are organized to help industry competitiveness - in this
example, through work force health.
Future/Suggestion
Some form of cost rationing is in order and will probably come. Cost sharing is
one option, but it is only a short term strategy. It may aid employer saving
initially, but does not solve the overriding problem - a provider driven system of
health care. Part-time jobs with no benefits, particularly in the service sector,
present a growing and potential problem. Also, the answer will not come about
on an employer by employer basis. Unions play a coordinating
role in the
settlement of health care issues. National comprehensive solutions must be and
can be achieved through effectiveness and efficiency. The goal is a combined
Federal/State program that adopts cost, quality, and access solutions under the
guise of social justice.
�Summary
Ronald L Fletcher, M.D.
Background/Perspective
The U.S. seems to be looking for some 'silver bullet' to kill the evil of our system,
but we need to focus on three concerns: quality, cost containment, and access.
By focusing on one area like access, we deprioritize the other two. However, in
Ohio we try to address these three all at once through rationalization.
What
will temper and balance these goals? The CON and Office of Primary Care meet
this goal, not some 'silver bullet.'
E
volution/Problem
Our major problem is the inconsistency of our fragmented health care delivery
system. We cannot rely on some 'crazy quilt' of health care delivery, but need
to find some unity.
In Ohio, our program has selected several programs:
modified benefit packages, trust funds, and employer-employee cost sharing.
From such a structure the State hopes to find the most successful program that
effectively addresses the needs of Ohio.
Future/Suggestion
The public health sector has told us, by investing in pre-natal care and
inexpensive vaccines, we shall save hand-over-fist in the latter years. We must
focus on the prevention aspects of health care. We must intervene before we
need to use expensive technology. We must proact early, not react later.
�Summary
Beach B. Hall
Background/Perspective
As the representative of 'BIG Business' from General Motors (G.M.), it must be
made perfectly clear that quality care is cost effective care. G.M. insures about
1% of the U.S. population and in Dayton we cover about 100,000 people. The
Dayton, Ohio employee base comparatively represents a very high cost region
in health care, especially as compared to Rochester, New York. In 1988, G.M.
spent about $3 billion on health care. G.M. is self insured and thereby tries to
avoid the administrative
costs mentioned earlier.
Thus, G.M. offers three
options to the employee. The P.P.O.s and H.M.O.s typically offer higher quality
and lower cost care. Sixty-six percent of our employees are enrolled in managed
care.
Evolution/Problem
Of the overall cost of our average vehicle, $600 is due to health care expense.
This is a funny number, but it means that we are now less competitive with the
foreign producers. There is no level playing field - we are at a disadvantage.
Competitiveness is the major problem for G.M.
By looking at participating
hospitals and P.P.O.s, we found they are not very
cost effective. These all contribute to the high heallh care expenses and the
higher cost of our average vehicle.
Future/Suggestion
In an effort to control cost, we have found hospitals and P.P.O.s to be less cost
effective than H.M.O.s and generally out of line with health care inflation
indicators.
Therefore, G.M. relies more and more on H.M.O.s, which are most
cost effective. Through some consulting, G.M. is examining the cost and the
quality of alternative approaches.
Outpatient options are of interest, but
H.M.O.s are the most encouraging
in quality
improvement
and cost
containment.
G.M. believes that through trust and team work, work force
health and heallh care value will improve.
10
�Summary
Amy
Showalter-Newman
Background/Perspective
As executive director of the Ohio Small Business Council (O.S.B.C.), a division of
the Ohio Chamber of Commerce, I represent the owners and executives with
250 or fewer employees. Small businesses are greatly concerned about the
increasing cost of health insurance. Their concerns are of concern to the general
population
because small business comprises such an integral part of our
economy. In Ohio alone, 73% of our businesses have 9 or fewer employees, 85%
have 19 or fewer employees, and 93% have 49 or fewer employees. Thus, small
businesses are a driving force in Ohio's economy.
Evolution/Problem
At any point in time, Thirty percent of Ohio's small businesses are new, having
been in existence a year or less. Obviously, a great portion of that 30% is in the
start-up phase and unable to provide comprehensive health care. This is a
problem, because heallh care cost is prohibitive. The magnitude of the problem
is due to the fact that over half of the nation's work force is employed by small
business.
When one examines and understands the extremely small profit
margins on which start up businesses operate, one understands health care
costs consume a substantial part of the small business budget.
Future/Suggestion
In the past and now, Slate mandated health benefits force the premiums up
and up. The option of mandated benefits legislation invariably will make health
insurance more expensive. The trend of increasing mandated benefits disturb
small business.
The members of the Ohio Small Business Council initially
1.
2.
3.
suggest:
Greater education of consumers/employees as to the real cost of
the health insurance. Many suggest higher deductibles and coinsurance to accomplish this.
Encourage enactment of tort reform to reduce medical
liability
costs.
Encourage small business pools for self-insurance purposes.
Overall, O.S.B.C. urges general reform of the American health care system and
expresses concern with the government taking over the health care system,
especially if new employer taxes primarily fund the system.
11
�Summary
Donald T. Lewers, M.D.
Background/Perspective
As a physician representing the medical practitioner, I am unwilling to accept
compromises in my country's heallh care system. Our system is not perfect, but
at its best, it is without comparison anywhere in the world. Our challenge is to
strengthen our current system, not destroy it, or replace it with something
totally foreign and probably unacceptable to American culture. H.L Menkin
once said, "For every problem there is a solution that is simple, neat, and
absolutely wrong."
The lessons of England, Canada, and other
industrialized
nations bear testimony to the wisdom of Menkin's observation.
Evolution/Problem
We need to be smart enough to develop a unique solution to address our
problems. As Americans, we have unreasonable expectations; a situation which
delivers an insolvablc problem.
Other problems include professional
liability,
rising health care cost, 37 million uninsured, and adjustments to Medicare and
Medicaid.
In addressing these problems, Americans need to develop our own
unique American solution that is compatible with our cultural values.
Future/Suggestion
1.
2.
3.
4.
5.
6.
Expand health insurance through
the private sector to all
employed Americans through employer based health insurance.
Create a Medicare commission lo develop reforms that would
ensure continued access lo older persons.
Enact legislation to address the financial inadequacies of the
Medicare program by replacing the current pay as you go system
by a pre-funded, actuarially sound system.
Develop a long-term care financing system encouraging public and
private
partnerships.
Reform Medicaid to provide medical care to all of poor, instead of
the forty percent now receiving care.
Establish risk pools to provide access to coverage for persons
between 100 and 200 percent of the poverty line with premium
assistance for those between 100 and 150 percent.
Generally, the reforms should be based in Abraham Lincoln's definition of good
government - one that does for the people things that they cannot do for
themselves.
12
�Summary
Geoff Mortimer
Background/Perspective
Health care provision in any country is ultimately a balance between what is
desirable and what is affordable.
For most 'first world' countries, those to be
compared now, there is a link between wealth and health status as measured
by life expectancy.
The relationship between health care inputs and health
status outputs may be debatable, but those countries with significantly
better
heallh status might expect a higher health expenditure. However, health care
value varies by country with some receiving comparatively
more for their
money.
The British National Health Service (N.H.S.) may not have the best health care
service in the world, but we are definitely the 'best buy' in terms of money.
Both our funding and provider systems relate to effective health care spending.
In the United Kingdom (U.K.), the N.H.S. supplies over 90% of the health
services. At this lime virtually no public funding is used to buy private health
care. The N.H.S. employs 1.2S million people under a $41 billion dollar budget
and provides virtually a free health care system from before the cradle to just
before the grave for the total British population of 57 million people.
The function of the N.H.S. depends greatly on the General Practitioner (G.P.),
with whom the patient chooses to register. The G.P. serves as the gate keeper
to the larger N.H.S. Very few charges are applied to a visit, but for the low-cost
prescription that is even reduced by 75% for pregnant women or social security
beneficiaries.
As for the private sector, its size and function change. The size varies with the
demand for elective services and the function varies with those services
demanded.
The private sector is small - only 14% of the U.K. health care
spending was private.
The services generally include hernias, varicose veins,
hemorrhoids, and minor gynecological, orthopaedic and E.N.T. procedures.
Evolution/Problem
One obvious disadvantage to the British system is the 'unlimited' demand for
limited resources. The result is waiting lines for treatment, which are probably
more a feature in Britain than in comparable countries. However, the problem
is usually overstated and 44% of the cases never wait, especially if they are
urgent conditions.
However, the inevitable delays only fuel the demand for
immediate, private
treatment.
Another major disadvantage
provider, which leads to the
the benefits in terms of cost
financed, both in comparison
is the State's predominant
role as funder and
system being under-resourced,
notwithstanding
effectiveness. As a result the system is underwith what is elsewhere and against the need for
13
�Summary
care in Britain. Even though I believe we get the best value for the money
anywhere, we still spend too little to match the best standards in the world.
Future/Suggestion
What can we learn from each other? I think it would be bold and probably
foolish of me to try and tell you what America could learn from the British
system of health care. Instead I have told you a little of how we do things, and I
leave you as the experts on your own system to decide whether our way can
contribute anything to your own progress.
14
�COALITION REPORT
Ohio group ranks hospitals on costs, usage
By Rosalind Resnick
T
rying to spur price competition
among providers, an Ohio
health care coalition has released a
controversial report that ranks area
hospitals by cost and utilization of
medical procedures. The report
has been sent to public libraries to
encourage patients to press the
hospitals for change; it has forced
employers to evaluate the hospitals
they use for employee health care;
and, it called for further investigation into three disturbing trends
that emerged from the data.
The Miami Valley Health Improvement Council, a 100-member
consortium of employers, providers, public officials, and consumers
in the Dayton area, released the
survey results in November. Council members, two-thirds of whom
represent employers, account for
about .100,000 covered lives in
eight counties. The council members include employees from large
corporations such as General Motors, Navistar Corp., a heavy truck
manufacturer in Springfield, Ohio
and PMI Food Equipment Group, a
manufacturer of food preparation
equipment, in Troy, Ohio.
trators to explain their facilities' po-' council simply hired Medical Mansitions in the ranking.
agement Group Inc., Columbus,
"The report has done what it Ohio, a consulting firm, to crunch
was meant to do, and that is to the numbers for the top 25 Diagnostimulate discussion," says Robert sis Related Groups (DRGs) that acThimmes, the council's president count for more than 55% of the toand chief executive. In addition, he tal hospital charges for private pay
notes, "some of our members are DRGs in the area. The results were
now beginning to look at what then mailed to each hospital for review and comthey're paying
ment. The data
for."
cover the five
;,;"0ur first.
But that's not
years from Jan.
all. In addition
purpose is to
1, 1987, to Dec.
to ranking the
31, 1991. Thimhospitals, the
encourage the
mes estimates
report calls for
:•. hospitals t o J i S the survey's
further investicost ,.
at
gation
into
improve. WefiM $100,000, inthese trends:
cluding coali• The
large
also hope thatj
tion staff time.
number of psyemployers will|
chosis cases diWhile the reagnosed in the
port does not
reward hospitals
Dayton area relexplore the reaative to the rest
2 that rank well/^ll sons why hospiof the state of
tal charges can
Ohio;
vary, it sheds
considerable
• The relatively
large number of coronary bypass light on wide discrepancies in pricing among hospitals throughout
operations;
Ohio. The survey'sfindingsreveal
• The relatively high number of Csections performed in cases in that prices vary widely among hoswhich the mother had no previ- pitals and municipalities even for
Naming hospitals
something as routine as neonatal
The council's "Guide to Hospital ously reported complications.
Utilization and Charges 1992" actu"We've got some of the highest care. For example, the average
ally names names—showing C-section rates in the state in some cost of caring for a normal newwhich local hospital, for example, of our hospitals," Thimmes say. born was $677 in Lima, $732 in
Cincinnati, and $832 in Dayton, the
had the highest Cesarean-section "This study is only the start."
rate and which hospital charged
Interestingly, the information report says. In Dayton alone,
the most for coronary bypass oper- contained in the council's report is charges to care for new, healthy
ations. As a result, the survey's find- not new. It's simply compiled in an babies ranged from $338 at one
ings have forced hospital adminis- eye-catching manner. Because hospital to $1,608 at another.
Ohio hospitals are required by law These figues do not include
Rosalind Resnick writes about coali- to report cost and usage data to the charges for the delivery itself or for
Ohio Department of Health, the the care of the mother.
tions for B&H.
Business & HealtlVMarch 1993 49
�Coalition report
"The guide was not designed to
embarrass the hospital industry or
any particular institution but rather
to provide comprehensive utilization charge data so that rational decisions can be made," Thimmes
says. "We are well aware that
cheapest does not always mean
the best, but, conversely, neither
does most expensive."
$22,808 for each case of psychosis
it treated—more than double the
average charge at any other area
hospital and more than 2 / times
the state average. However, since
the cut-off point was only $18,777,
more than 50% of the hospital's
discharges were classified by the
state as outliers. (A cutoff point
was established for statistical purposes. Charges considered abnormally high or low were omitted
The report's limitations
from the final numbers.)
Despite the survey's broad sweep,
the report's authors noted several
The council nevertheless opted
methodological problems that may to include the outliers in its study
limit the study's usefulness in gaug- because, Thimmes says, "we felt
ing hospital costs. For one, the data that this presents a truer picture."
reflect only inpatient hospital
charges and not outpatient ser- Employers approach with caution
vices, lab fees, or doctors' fees. For Despite such shortcomings, emanother, the data are not adjusted ployers and providers find the surfor severity of illness. The lack of vey results to be useful.
severity adjustment means that
James Engle, a member of the
hospitals that treat a higher share council committee that developed
of Medicare and Medicaid patients, the guide and manager of GM's
and thus receive a correspondingly Dayton Regional Personnel Center,
lower level of reimbursement, may says the study shows that some of
be penalized for trying to make up the hospital data are "out of line
any losses from Medicare and Med- from where it should be."
icaid patients by inflating the bills
The automaker employs 19,500
for private-pay patients.
people in the Dayton area and acLikewise, a hospital that admits counts for 80,000 covered lives. GM
a high percentage of high-risk pa- spent roughly $220 million last year
tients who received little or no pre- on health care in the Dayton area.
natal care may have a higher C-sec- In recent years, GM's health care
tion rate than facilities with lower- costs have risen about 12% annurisk patients.
ally. Engle has sent the report to
The biggest barrier to adjusting GM headquarters in Detroit for
the hospital data was the state's consideration in the company's fuflawed formula for calculating se- ture health care purchasing.
verity, Thimmes says. Under "They're reviewing thefiguresjust
Ohio's reporting guidelines, hospi- as we are locally," Engle says.
tals are allowed to exclude soAt PMI Food Equipment Group,
called "outlier" cases, in which Richard Smith, director of compencharges are substantially more or sation and benefits, says he hopes
less than the average. What this the guide will help reduce local
procedure means can be illus- health care costs by encouraging
trated by the following example: hospitals to price their services
Dartmouth Hospital in Dayton more competitively and turn emposted an average charge of ployers into savvier health care
50 Business & Health/March 19!)3
l
2
buyers. PMI employs 1,800 workers in the Miami Valley area and
has 6,500 covered lives.
"Our first purpose is to encourage the hospitals to improve themselves," Smith says. "If a particular
hospital is not showing up that well
in the report, it would be hoped
that they would want to improve
their position. We also hope that,
as employers find out about the
data, they will reward the hospitals
that rank well."
At the same time, Smith cautions, "I think that anybody who
takes this report and runs with it
without following it up with conversations with specific hospitals is
making a mistake."
- •• '•' >"•
Bill Thornton, chief operating officer of Miami Valley Hospital,
agrees. The survey shows that Miami Valley, an 800-bed acute care
facility that is the largest area hospital, had the highest C-section
charge of any Dayton area hospital.
Its average cost of $4,423 for a Csection had risen 48.2% from 1987
to 1991. However, this particular
hospital tended to attract more
high-risk cases.
While Thornton insists that his
hospital attempts to provide quality
care in a cost-effective manner, he
believes his facility—and the others
in the Miami Valley area—still have
room for improvement.
Employers and providers agree
that the guide may not bring about
a radical shift in health care purchasing patterns overnight. Yet
they do believe that the guide and
studies like it are a first step toward
developing a more quantifiable
system for making health care
choices. The council plans to update the guide annually and is trying to obtain Medicaid and Medicare data to include in future versions, Thimmes says. •
1
�February 1993
Issue Number 35
Hospitals Support Meaningful Reform
•
I ealth care refonn is both important and immii J M ncnt. At no other time in history has a PrcsidcnI
I tial Administration so clearly identified health
care reform to be of such significance.
Hillary Rodham Clinton is a good choice to head the
President's Task Force on National Health Reform.
She's bright, articulate, inquisitive and of course, has the
President's confidence and his car. She's willing to get
involved in tlie details. While some argue that her
afilliations with the legal community may impair her
objective views for reform, il must also be argued lhal
her experience will aid in the development of a reform
plan which is congruent wiih lhe Presideni's philosophy for global governmental reform! This philosophy
of "shared burden" emphasizes the importance of contributions by all constituencies. Hopefully, initial shared
sacrifices will eventually lead to shared benefits for all
Americans.
The challenges facing those responsible for health
care reform are great; in fact, in many cases seemingly
insurmountable. The following issues appear central to
any reform efforts:
*
*
*
*
*
*
*
Tort reform is key - defensive medicine is no longer
affordable. Let's put reason back in our health care
system for unfortunate outcomes.
Fraud and abuse must be curbed - the culprits must
be prosecuted.
Physician self-referral shouldn't be allowed to continue - it undermines the credibility of the health care
system.
Pharmaceutical pricing must come under control profits yes, a financial bonanza, no!
Technology advancements - important, but
American's appetite must be moderated - for extending life regardless of quality or cost benefit.
Duplication of services and equipment - driven
unfortunately by the competitive environment of the
past - that's passe -collaboration is the approach of
the future.
Government regulations, administrative requirements and just plain insurance paperwork arc burdening the system - it's too costly. Streamlining is
fundamental to reducing costs.
*
*
*
Anti-trust regulations must be relaxed - collaboration won't happen without that.
Insurance - community premium rates, portability,
insurability - essential to improve access to millions.
The patients - must become more financially accountable for their own health through prevention,
cost sharing and the end of societal self indulgence.
We urge Mrs. Clinton to put a priority on those
elements for which her background provides unique
expertise. These would include issues like tort reform,
eliminating excessive and costly record keeping, excessive pharmaceutical prices and relaxed antitrust regulations. These changes can have immediate impact on
health care cost containment without a reduction in the
quality of patient care.
The global efforts put forth in coming years to
improve the American health care system will certainly
have both long-term and wide-spread effects on American society. A healthier society clearly translates into a
more successful and productive one. Health care providers must be patient, as total changes will not occur
overnight and most certainly not without significant
sacrifice from all participants. Through collaborative
efforts, providers can and should be able to play a
significant role in reshaping the system.
Good luck Mrs. Clinton! We encourage you to use
your legal and consensus building skills to bring about
tort reform, break through the special interest and government lobbies and allow local communities to achieve
relief from high health care costs. Just allowing our
physicians to practice their profession without the ever
present threat of lawsuit aficr lawsuit, will go a long way
towards reinstating confidence in the system. Your task
is awesome. We appreciate your unique background to
address these issues.
^
^
^
Robert L Willett
President and CEO
Kettering Medical Center
GREATER ° DAYTON ° AREA
HOSPITAL ASSOCIATION
^
^
�Bywords in Health
January-March, 1993
Newsletter ofthe Miami Valley Health Improvement Council, Inc.
M V H I C P U B L I S H E S G U I D E T O HOSPITAL
U T I L I Z A T I O N AND C H A R G E S
The Miami Valley Heahh Improvement Council has
published a Guide to Hospital Utilization and Charges. The guide presents discharge and average charge
data on the top 25 private pay Diagnosis Related
Groups (DRGs) for all hospitals in the region for the
period 1987 through 1991. This initial effort to
publish hospital charge data is a result of a cooperative agreement between MVHIC and Medical Management Group, a Columbus based consulting firm.
The MVHIC Board of Trustees adopted three (3)
action items relating to the guide at the Board meeting on November 18, 1992. Committees of the
Board will address the following issues in the coming
year:
1)
DRG 430, psychoses, is the number one (1)
ranked DRG in this region and is ranked
number two (2) in Ohio. The MVHIC
Mental Health Planning Advisory Committee
will conduct further analysis of this concern.
2)
DRGs relating to diseases and disorders of
the circulatory system are ranked number
two (2), four (4), six (6), thirteen (13),
seventeen (17), twenty-two (22) and twentythree (23) of the top twenty-five (25) reported DRGs. The MVHIC Heart Task
Force will conduct an in-depth analysis of
these and other data pertaining to heart
disease.
3)
A MVHIC task force will be established to
address concerns relating to cesarean section
deliveries without complications or comorbidities in this health service area.
MVHIC COMMITTEE TO ADDRESS MENTAL
HEALTH CONCERNS
DRG 430, psychoses, has been chosen for further
study by the MVHIC Board of Trustees as this DRG
had the highest expenditures of all DRGs in the
MVHIC area. Furthermore, while the average charge
Volume 1, Number 1
in Ohio increased 40% in the 1987-1991 period, the
MVHIC average charge increased by 74%. The
MVHIC average charge in 1991 for hospital treatment
of 2,343 private pay patients was $10,394 while the
average charge statewide was $8,359. Dartmouth
Hospital led all MVHIC area hospitals with a 1991
average charge of $22,808.
While the number of discharges for psychoses grew
only 4% in Ohio from 1987-1991, discharges in the
MVHIC area grew by 25% during this period. St.
Elizabeth Medical Center led area hospitals with 627
patients discharged in 1991.
The MVHIC Mental Health Planning Advisory
Committee will address issues in 1993 related to
charges and utilization of mental health care in the
region. Among the questions to be addressed will be
the following: 1) Why are charges for inpatient care
higher in the MVHIC area? 2) What are the reasons
for the wide variation among charges of MVHIC area
hospitals? 3) Is length of stay higher for the MVHIC
area? 4) Are the needs of discharged patients effectively met with the support of community based programs? 5) What changes in the system are needed to
meet the needs of the community with cost-effective,
high quality, mental health care?
BYWORDS IN HEALTH SCHEDULED FOR
QUARTERLY RELEASE
The quarterly publication of Bywords in Health will
promote the mission of the Miami Valley Health
Improvement Council, Inc. by advising the membership and the community on health care issues affecting the residents of the Miami Valley. This newsletter issue provides an update of several MVHIC
accomplishments in 1992 and notes some of the
programs planned for 1993. Bywords in Health will
be distributed to the Board, membership, and committees of MVHIC and to community businesses,
agencies, providers, consumers, elected officials, and
the news media. Suggestions of issues and information to be addressed in the newsletter are welcomed from area individuals and organizations. A
Editorial Committee is being established with Len
Holihan, Chair, Mark Hess, M.D. and Nancy Williams.
�COUNCIL ADOPTS PROGRAMS FOR CALENDAR YEAR 1993
The MVHIC Board of Trustees acted at their meeting on November 18, 1992 and approved ten programs for 1993.
The main activities that will receive Council attention are as follows:
1.
Conduct the regional Certificate of Need (CON) program.
2.
Provide liability insurance coverage to committees of the Board who conduct county-level health fairs or
festivals.
3.
Council staff to provide support to the Board and its committees.
4.
Develop a new Long-Term Care Community Health Services Guide.
5.
Develop a new Acute Care Community Health Services Guide.
6.
Council volunteers and staff to participate in activities regarding health care reform.
7.
Council staff to provide assistance, if required, to Board members for securing funds for Council activities.
8.
Engage in, or provide support for, community health education, prevention and information activities.
9.
Council volunteers and staff to continue efforts for the resolution of the uncompensated care problem.
10.
Develop consumer information guides pertaining to effective use of the health care system.
BOARD OF TRUSTEE MEETING DATES SCHEDULED FOR 1993
The MVHIC Board of Trustees has approved the following schedule of meeting dates 1993. Board meetings are
rotated among sites throughout the MVHIC eight county health service area.
January 20, 1993
3:00 P.M.
Miami County, Troy
(Hosted by PMI Corp.)
March 17, 1993
3:00 P.M.
Montgomery County, Dayton (Hosted by Woolpert Corp.)
May 19, 1993
3:00 P.M.
Montgomery County (Hosted by Kettering Med. Center)
May 19, 1993,
5:00 P..M.
- ANNUAL MEETING
Montgomery County (Hosted by Kettering Med Center)
July 21, 1993
3:00 P.M.
Shelby County, Sidney (Hosted by Wilson Hospital)
September 15, 1993
3:00 P.M.
Darke County, Versailles (Hosted by Midmaxk Corp)
November 17, 1993
3:00 P.M.
Greene County, Xenia (Hosted by Greene County Commission)
�TWENTY-NINE CERTIFICATE OF NEED APPLICATIONS REVIEWED IN 1992
The Miami Valley Health Improvement Council reviewed a total of twenty-nine (29) Certificate of Need applications
during 1992. The capital costs proposed by all applications totaled $59,721,430. The MVHIC Board of Trustees
took action to approve nineteen (19) projects totaling $37,695,393 and to disapprove nine (9) projects for
$21,773,537. The Board took no action (tie vote) on one (1) project for $252,500. Information relating to the
individual projects is shown below.
NAME OF
APPLICATION
PROJECT
DESCRIPTION
PROJECTED
COST
Trinity
Community
Center
Renovate
facility; add 34
purchased beds
$3,861,101
Springmeade
Add 12 nursing
beds
Pi qua Manor
MVHIC
ACTION
ODH
DECISION
Approved
Concurred
$250,630
Ranked #\ in
Miami County
Did not concur
(Disapproved)
Add 12 nursing
beds
$253,219
Ranked #2 in
Miami County
Did not concur
(Approved)
Sunny Acres
Add 49 nursing
beds
$1,292,925
Approved
Concurred
McCauley Center
Add 29 nursing
beds
$850,200
Approved
Concurred
Versailles
Health Care
Add 13 nursing
beds
$25,000
Approved
Concurred
Pillars
Nursing Home
Add 4 nursing
beds with
renovation
Tie vote
Approved
Brookhaven
Nursing and
Care Center
Add 20 nursing
beds
$24,500
Approved
Concurred
Friendly Nursing
Home
New facility
with 14 added beds
$1,730,303
Approved
Concurred
Shiloh Springs
Care Center
Add 16 nursing
beds
$5,000
Approved
Did not concur
(Disapproved)
Canterbury
Care Center
Add 20 nursing
beds
$596,000
Approved
Concurred
Bethany
Lutheran
Village
Add 20 nursing
beds to new
facility
$8,000,000
Approved
Concurred
Montgomery
County Nursing
Center
Add 20 beds to
previous approval
$1,116,555
Approved
Did not concur
(Disapproved)
Wood Glen
Nursing Center
Add 50 nursing
beds
$31,000
Approved for 50
beds
Approved for
23 beds
St. Leonard
Center
Add 60 nursing
beds
$415,219
Approved for 60
beds
Approved for
30 beds
$252,500
�NAME OF
APPLICATION
PROJECT
DESCRIPTION
PROJECTED
COST
MVHIC
ACTION
ODH
DECISION
Alta Nursing
Home
Add 50 nursing
beds
$1,447,589
Approved for 50
beds
Approved for
30 beds
Wilmington Place
Health Center
Construct 100
bed nursing home
$4,129,621
Disapproved
Concurred
Forest View
Nursing Center
Establish 100 bed
nursing home
$2,620,000
Disapproved
Concurred
Eastside Manor
Construct 100
bed nursing home
$3,609,290
Disapproved
Concurred
Lincoln Park
Manor
Add 48 nursing
beds to
Lincoln Park
$470,752
Disapproved
Concuned
Montgomery
County Geriatric
Construct 100
bed nursing home
$5,5.00,000
Disapproved
Concurred
Montgomery
Park Manor
Construct 120
bed nursing home
$4,590,655
Disapproved
Concurred
Heartland of
Oak Ridge
Add 50 nursing
beds
$600,000
Disapproved
Concurred
Carriage Inn
of Dayton
Add 15 nursing
beds
-0-
Disapproved
Concurred
Kettering Medical
Center
Expand radiation
oncology
$9,174,137
Approved
Concurred
Miami Valley
Hospital
Replace
cardiovascular laboratory
$2,186,553
Approved
Partial
approval granted
Miami Valley
Hospital
Establish
bone marrow
transplantation
$400,000
Approved
Did not concur
(Disapproved)
Greene Memorial
Hospital
Establish
radiation therapy
$3,274,220
Approved
Concurred
St. Elizabeth
Medical Center
Renovation of
obstetrical areas
$3,014,461
Approved
Concurred
SAMARITAN NORTH HEALTH CENTER IS
PROPOSED
Good Samaritan Hospital and Health Center, Dayton
has submitted a Certificate of Need application to
construct the Samaritan North Health Center in
Englewood. The center would consist of 148,420
sq.ft. of comprehensive outpatient health care space.
The project cost as estimated is $33,660,000.
The following health care services are proposed for
the center: a medical office building housing approximately thirty (30) physicians; a comprehensive cancer
treatment center with a linear accelerator; an imaging
center with a MRI system and a CT Scanner; an
outpatient laboratory and pre-admission testing
services; cardiopulmonary and neurology testing; a
rehabilitation and fitness center; an education and
conference center.
The application was received on November 13, 1992
and is in the initial stages of the review process. The
review and action on the application by the Acute
Care Review Committee and the MVHIC Board of
Trustees is expected to be completed in the first half
of 1993.
(CONTINUED ON PAGE 6)
�MVHIC BOARD OF TRUSTEES MEMBERSHIP AT FORTY-FIVE
The MVHIC Board of Trustees is now comprised of forty-five members with the recent addition of Thomas
Hennigan of Clark County and Nancy Williams of Preble County. There is currently one vacancy on the Board for
a consumer from Champaign County.
NAME
COUNTY
CATEGORY
Richard N . Adams.PhD, Commissioner
(MVHIC Chair)
Rose M . Stoia, EdD, RD
(MVHIC 1st Vice Chair)
Phillip C. Bunton
(MVHIC 2nd Vice Chair)
Sherlie Baker, NHA
(MVHIC Secretary/Tres)
L. Adele Bashore, N H A
Gloria M . Bell
Robert C. Bergin
Barbara Bollenbacher
Thomas J. Boecker
Herman G. Brant, PhD
Paul W. Campbell
Arthur Caviness
Gary W. Crim, Esq
Forrest J. Curtin
James L. Engle
Stanley R. Evans, Esq
Julia K. Frantz, RN
Richard A. Graeff, Commissioner
Kathryn K. Hagler, Commissioner
Thomas E. Hennigan
B. Mark Hess, M D
F. Leonard Holihan
David C. Hunter
Neal E. Kresheck
Vivian F. Lewis, PhD
W. J. Lewis, M D
Joseph Litvin, Esq
Leroy Lyons
Cheryl A. Maurana, PhD
Donna J. McDowell
Doris A. McGehee
Rhine McLin.Rep. 38th House Dist.
Donna B. Moon, Commissioner
J. Steven Morris
Morton Nelson, M D , MPH
Marios Panayides, M D
Michael Peterson
Donald W. Pohlman, M D
Alvin E. Rodin, M D
Earl R. Schatzman, DO
Richard Smith
Robert J. Suttman
Richard H. Tapogna, M D
W. I . Thieme
Nancy Williams
Miami
Consumer
Greene
Consumer
Montgomery
Consumer
Greene
Provider
Preble
Montgomery
Montgomery
Miami
Shelby
Montgomery
Montgomery
Montgomery
Montgomery
Clark
Montgomery
Shelby
Shelby
Darke
Greene
Clark
Miami
Greene
Champaign
Clark
Greene
Montgomery
Montgomery
Clark
Montgomery
Montgomery
Champaign
Montgomery
Montgomery
Preble
Montgomery
Clark
Clark
Darke
Greene
Montgomery
Miami
Montgomery
Clark
Darke
Preble
Consumer
Consumer
Provider
Consumer
Provider
Consumer
Provider
Provider
Consumer
Consumer
Consumer
Consumer
Provider
Consumer
Consumer
Provider
Provider
Consumer
Provider
Provider
Consumer
Provider
Consumer
Consumer
Provider
Provider
Provider
Consumer
Consumer
Consumer
Provider
Provider
Provider
Provider
Provider
Provider
Consumer
Consumer
Provider
Consumer
Consumer
�PEDIATRIC SUB-ACUTE APPLICATION FILED
WOOD GLEN CONVERSION PROPOSED
Upper Valley Medical Center has submitted a Certificate of Need application proposing the construction
of a sixteen (16) bed, sub-acute, pediatric transitional
care unit at a cost of $713,824. The unit would be
located on the Dettmer Hospital campus in Miami
County.
Wood Glen Nursing Center has submitted a Certificate of Need application proposing to convert an
eighteen (18) bed rest home located at the facility to
twenty-five (25) nursing beds. The applicant has
purchased the twenty-five (25) beds of Linden Nursing Home and proposes to move these beds to Wood
Glen. The estimated project cost is $370,330.
As a step-down unit, the facility would provide
transition from the intensive medical environment of
the hospital to a more homelike rehabilitative
environment. As needed, parents would be taught
how to care for their children after discharge. A
secondary focus for the program would be to provide
pediatric respite care.
The review of this project is in the initial stage. The
first round of questions have been forwarded to the
applicant. MVHIC and ODH may ask two rounds of
questions before an application is declared complete
Wood Glen is a 123 bed long-term care facility for
individuals with Alzheimer's Disease and related
illnesses. The review of this application is in the
initial stage as the first round of questions has recently been answered.
MVHIC ED|TORIAL COMMITIEE:.
:
tioNAW) F. HolllwS, CttAiR
B: MAKk Htib. M.D.
.; NANCY WILUAMS
: :
MVHIC STAFF: . .
. Robent P. TMMMES, PnESldENr/CEO
JotiN F. Phillips, VICE PBesldeiwi
Hfl<V» L. Htwplilll, txtctilvi Sicy
MVHIC
7039 Taylorsville Road
Ruber Heights, Ohio 45424-3103
Bywords
in
Health
THE NEWSLETTER OF THE MIAMI V A L L E Y HEALTH IMPROVEMENT COUNCIL, INC.
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�MIAMI VALLEY HEALTH
IMPROVEMENT COUNCIL, INCORPORATED
(MVHIC)
GUIDE TO HOSPITAL
UTILIZATION AND CHARGES
1992
�It takes work to regain healthy heart
"Working toward a healthy heart," the slogan for Cardiac Rehabilitation Week, says
what most cardiac patients know: it takes work to regain a healthy heart.
Heart attack, the number one killer in this country, strikes one-and-one-half million
Americans each year. Many of these men and women, still in the prime of their lives, find
the road to recovery long and difficult.
St. Francis Memorial Hospital Cardiac Rehabilitation Program is here to help you in that
endeavor. Our comprehensive outpatient cardiac rehabilitation program is designed for
individuals who have had a heart attack, stable angina, coronary artery bypass surgery or
other heart conditions and who are trying to make the fullest recovery possible.
Through exercise, one-on-one and group counseling, our team will help you build a
healthy new lifestyle. The Cardiac Rehabilitation Department is located on the first floor
of St. Francis Memorial Hospital in the northeast corner (just east of the family waiting
area). Carol Franzluebbers, R.N. Pam List, R.N., and Diane Persson, R.N., workwitharea
physicians and other medical professionals in helping design a program that is geared
specifically for patients' individual needs. We have a variety of fitness machines available
for cardiac patients to use. A cardiac clinic is now held at the hospital twice a month.
Pacemaker clinics are also scheduled on a regular basis.
New step machine available
If you or someone you love is a recovering cardiac patient, call St. Francis Memorial A new step machine, the StairMaster 4000 CT, has
Hospital Cardiac Rehabilitation Department at 372-2404 for further information about our been added to the wellness equipment available at
St. Francis. The Stairmaster 4000 CT exercise
Cardiac Rehabilitation Program.
system is a vertical climbing machine which provides an aerobic workout equivalent to climbing
stairs, without theinertialloadsandskeletaltrauma
St. Francis Memorial Hospital
common to most aerobic activities. The system is
computer-controlled to offer automated, timed
Specialty Clinics
workouts from one to 45 minutes as selected by
(Physician referral required)
Girls were clearly in the majority in the number the user. It provides a choice of eight
Cardiology • Urology • OB/GYN
of babies bom at St. Francis Memorial Hospital inpreprogrammed workouts, each with ten levels of
Ears, Nose.Throat
intensity, as well as a non-programmed self-pace
1992. A total of 108 babies—70 females and 38 workout. The machine is available for Phase III
Opthamology • Orthopedic
males—were born here last year. The disparity cardiac patients and other individuals who use the
Pulmonology • Sports Medicine
in numbers is unusual, said Marguerite Kaup, wellness program at St. Francis, located in the first
RN, OB nurse. "Usually they're within a few of floor exercise area. In the photo above, Mary
Other Special Programs
each other, one way or the other," she said. "But Theiler, a wellness participant, takes a turn on the
• CPR, third Monday of month, pre-register
StairMaster.
lastyear, the girls clearly outnumbered the boys!"
• Early Lamaze, Lamaze and Refresher courses
Gsrlsoutnumber
b o y s in 1992
• Cardiac Rehab-exercise for heart patient
• Wellness - exercise program for the general public
• Lifeline - personal emergency response system
St. Francis Memorial Hospital
• Freedom from Smoking
430 North Monitor
• Lifesteps Weight Management
West Point, NE 68788
For more information about any of these
services, please call the hospital at 372-2404
US Postage
PAID
West Point, NE
Non-profit
Permit #115
St. Francis Memorial Hospital
West Point, Nebraska
Medical Staff Directory
West Point Medical Clinic
Scott Green, M.D.
Dan Hakel, P.A.C.
539 E. Decatur, 372-2477
Elkhorn Valley Clinic, P.C.
Eugene L. Sucha, M.D.
Thomas R. Tibbels, M.D.
Linda Cihacek, P.A.
435 N. Monitor, 372-2446
Postal customer
Rural route or P.O. box
SAINT FRANCIS
MEMORIAL
HOSPITAL
W CARING FOR YOU
430 North Monitor Street, West Point, Nebraska 68788-0287 (402) 372-2404
Sponsored by the Franciscan Sisters of Christian Charity
February, 1993
Combining dietary departments results in savings
Cooperation between sister facilities has resulted in more cost-efficient
service to patients of St. Francis Memorial Hospital and residents of St. Joseph's
Retirement Community in West Point. That
cooperation, consolidating the dietary departments into one in March, 1992, has
had many additional benefits, says dietary
manager Jean Meiergerd.
"The initial savings came about when
thedecision was madeto movethedietary
department to St. Joseph's," she said.
"The hospital kitchen was getting to the
point where it would need major renovation, which would have been very expensive. St. Joseph's, which is operated by
the Franciscan Sistersof Christian Charity
(who also operate the hospital), has a
wonderful kitchen. It was decided that our
staff would move to St. Joseph's where,
along with their staff, we would prepare
the food for both facilities."
Three months before the merger officially took place, Meiergerd and dietary
staffs from both facilities began working
on the transition. "It was challenging, and
it took some time to figure out how to do
it," she said. "Everyone was good about
working together. We had monthly meetings before the merger so we could talk
about howthings would be implemented."
Because the hospital patients' food
would have to be transported from St.
Joseph's, a new insulated tray system
was purchased. "It's a divided tray that
keeps cold food cold and hot food hot,"
Meiergerd said. "It's working well. Patients who had been at the hospital before
and after the merger say they like the new
system better. We're glad to hear that."
Meiergerd's staff of 14 full- and parttime workers prepare a lot of food each
Dietary department workers Julie Meister and Joan Wolken prepare trays for patients at St. Francis
Memorial Hospital. Meals for both facilities are prepared at St. Joseph's Retirement Community.
day. "In addition to the food for the hospital patients and St. Joseph's residents
(74 at the present time), we also prepare
almost all of the food for the hospital
vending machines, including sandwiches,
salads, desserts and breakfast items for
hospital employees and visitors," she said.
"They're also welcome to come down to
eat at St. Joseph's whenever they wish."
The dietary department prepares an
average of 260 meals each day. That
translates into 2,000 each week, or
104,000 meals each year. "The biggest
advantage we've had is in the savings we
obtain from cooperative buying,"
Meiergerd said. "There's an economy of
scale that extends to the food preparation
area, as well. It doesn't take much longer
to make meat loaf for 70 rather than 20.
The facilities save approximately $2,000
each month."
Everyone on the dietary staff is crosstrained. "All of the staff members know
each of the areas so they can fill in if
needed," Meiergerd said. "We have cooks,
salad preparation workers, production
assistants, dietary clerk and a dietitian,
Mary Clare Stalp, who is here five hours
each week to assist with menu planning."
Menus are on a four-week cycle. Surveys
(continued on page 3)
Inside this issue:
President's message:
Insuring a high quality of care for
you and your family
2
Certification:
Radiology department technicians
become registered diagnostic
medical sonographers
2
Renovation:
18 patient rooms, nurses' station
get new look
3
Working toward a healthy heart:
Cardiac Rehabilitation Department
assists heart patients
.4
�. , ...
. ,,
.
Staff members become
A facility SUlted for tOday, tOmOrrOW registered diagnostic
by Sister Helena Young
medical sonographers
President, St. Francis Memorial Hospital
Two radiology department technicians, Sandy
As you read this issue of Caring for You, notice especially the effortKnobbe and Alice Klitz, RTM, ROMS, recently
we take to insure a high quality of care for you and your family. Whether
passed final testing to become registered diagthat be the board, the staff or the physicians, everyone has had a hand
nostic medical sonographers. Sonography is an
in what we have today. We take a great deal of pride in our present ultrasound method of testing using sound waves
facility, especially our ongoing renovation, but we want to insure that we
instead of X-rays. While X-rays catch a still
have a facility suited for tomorrow also.
photo, ultrasound shows an image of the area
When we began our renovation a few years ago, we tried to foretell
while organs are functioning.
the future of health care in our area. We knew our heating and cooling Becoming certified, said Knobbe, is similar to
systems needed to be more energy-efficient and easier to monitor andbecom ing certified in X-ray or any area. The tests
maintain. We also knew we needed to be a modern facility with all the
demand a specific level of knowledge in that
best design and layout ideas; that includes relocating departments and particular area. Knobbe and Klitz have been
even making the main entrance more accessible to everyone in the future. We also know the direction
working toward this goal for two years.
of things to come: we'll see fewer inpatients, perhaps, but we'll certainly provide more outpatient
"When we started this ultrasound service here,
services and procedures.
this was something we decided we wanted to
achieve," Knobbe said. "We set our goals toWe are still in the process of formulating new ideas and approaches suited to the public need, while
gether, and decided on about two hours of study
at the same time being careful to keep our excellent care level, and avoid sacrificing one iota in patient
satisfaction. We want to continue our improvements at a steady pace and avoid any pitfalls, all the a day." After eight months, they went to Denver
to take the first test in October, 1991.
while not losing sight of the day-to-day operation of the hospital.
After about a two-month break, they began
It is very easy for us to recognize outstanding levels of accomplishment displayed by our
studying for the second phase. They traveled to
employees. Our dietary staff has gone beyond what is typically expected of employees. They've done
things we hear about larger companies doing to survive: pooling resources, cross-training, and Rochester, MN last October to take the final test.
Both
making sure the clientele's satisfaction always comes first, and all the while relying on self- motivation. passed.
They are now certified specifically to perform
Teamwork and dedication have also been seen in other areas of our hospital. We see our
abdominal and OB-GYN ultrasonographies. "All
environmental services staff take on cleaning and preparing our newly-renovated area as a personal
the
crusade for insuring that every possible particle of dust has been removed, that every room is in perfect ultrasound that we do here are covered in
those areas," Knobbe explained. "Our goal was
condition for public inspection. Our maintenance staff has shouldered tasks that easily could have
to give better and more informative scans for the
been left to outside contractors; instead, they chose to do things themselves at a substantial cost
radiologists and for our physicians here."
savings to us. And, through it all, our staff has never let typical daily demands go by without attention.
The two agree that it's a satisfying feeling
This has been a demanding process on all our other departments at the hospital, too. We especially
having the certification, and are ready for a break
recognize our nurses and physicians for all the inconveniences they have dealt with during this recent
from studying. "I'm very proud of what Alice and
renovation, including performing in temporary work areas. Furthermore, we especially want to thank
I have done," Knobbe said. "You always strive for
all our patients and visitors for being so understanding during some of the more disruptive days. We've
more knowledge and more proficiency in your
appreciated all the nice comments like, "It's such a beautiful area, it's a shame I wasn'tsicka little later."
profession. The more knowledge we have, the
Finally, look forward to only more changes in the future. We intend to continue to update our more we are giving to the patients. And I suspect
hospital and improve our care for you. We do this to give you the best care possible at the most it might make a difference in the future."
affordable price possible by people with familiar faces, people who "CARE FOR YOU."
—West Point News
Outpatient specialty clinics offered at St. Francis
Outpatient visits in the specialty clinics at St. Francis Memorial Hospital totaled 2,181 in 1992, according to Rhonda
Ehrisman, R.N., emergency room supervisor.
Clinics currently offered at St. Francis,
clinician(s) and frequency of clinics include: Urology, Dr. Khan, twice a month;
Cardiology, Drs. Rovang and Woodruff,
twice a month; ENT, Dr. Simons, twice a
month; Audiology, Kent Webb, twice a
month; OB-Gyn., Dr. Schulte, once a
month; Ophthamology, Dr. Haskins, once
a month; Orthopedics, Dr. Bergstrom,
twice a month; Sports Medicine, Dr.
Neumann, every three weeks; and
Pulmonology, Dr. Barker, once a month.
Most of the clinics have been here for
a number of years. Beginning in February, the Cardiology Clinic is at the hospital twice a month instead of once a month,
because the clinic became too large for
two cardiologists to see all the patients in
one day.
One of the newer clinics is
Pulmonology, which deals with lung dis-
eases. The newest clinic is Sports Medicine. Dr. Neumann has started doing
knee arthroscopies here, which also
makes good use of some of the equipment
needed for laparoscopic surgeries. He
has already done two procedures.
Dr. Bergstrom, orthopedic specialist,
has increased his days in West Point to
two times per month. He is also planning
to do arthroscopies here.
Your local physician is able to help
you with referral and scheduling for any of
the clinics at the hospital.
Patient rooms, nurses' station remodeled
A total of 16 ptient rooms in the east wing have been remodeled .
The nurses' station and the adjacent waiting area also have a new look.
Phase III of the renovation project at St. modeled with a curved oak work station installed, "We washed every inch of window, inside and
Francis Memorial Hospital is now complete. The providing more room for hospital personnel. The out," Klitz said. "We also took every light fixture
latest areas to be remodeled are 18 patient newly-added wall in the waiting area provides and grill apart and washed them, along with the
rooms and hallway on the second floor, east wingboth families and nursing staff more privacy. The sinks, tile, base cove, and doors. The floors have
of the hospital and the second floor nurses' hallway in the east wing has had new lighting andbeen stripped, scrubbed with a power scrubber
station. In addition, a privacy wall has been wallcovering installed, matching the other reno- and had seven coats of finish applied to them.
added to the waiting area on the second floor. vated areas in the hospital. Kathy Schlecht, R.N., There shouldn't be any germs anywhere!"
The renovation project has been a coopera- CS/Purchasing, helped coordinate the interior
Klitz credits her co-workers for a job well done.
tive effort involving several hospital departments design of the renovated area.
"It took the cooperation of the entire environmenas well as outside contractors, according to Todd
The maintenance and environmental ser- tal services department," she said. "In fact, it took
Consbruck, hospital marketing director. The vices departments have been important members the cooperation of numerous departments in the
newly-remodeled areas "are more aesthetically of the renovation project. Maintenance workers hospital to get this project completed. It's not
pleasing with softer, more soothing colors," he Larry Schmader and Ray Fast helped prepare anything that just one department could do."
said. Three colors—blue, mauve and peach- the rooms for renovation, installed all the new
The next planned phase of the renovation
have been used throughout the patient rooms. ceiling panels in the patient rooms, ran necessary project will include the west wing on the second
Patient rooms have been painted, with one of wiring and installed the new medicine cabinets in floor, an additional which includes a new surgical
wing and an expansion of radiology. This phase
three coordinating wallpaper designs on one wall the rooms.
in each room. New recliners were purchased by
In addition, they're also responsible for the will need a certificate of need application submitthe hospital auxiliary for the rooms, and new heating and cooling systems in the hospital. "Weted for State Department of Health approval. The
windows have been installed throughout. The have a computerized heating and cooling system final planned phase will include the remaining
window renovation, which was begun in 1990, now," said Schmader. "We still work with the old areas of the hospital.
was financed by the St. Francis Memorial Hospital steam system for that part of the hospital that
"This renovation project has been planned for
Foundation. Old steam heating vents have been hasn't been renovated yet, as well as with the a long time," Consbruck said. "It is something
removed and individual heating/cooling panels new hot water system."
that has been needed. St. Francis Memorial
for each room installed in the ceilings, which were
The environmental services department, Hospital was a Cadillac when it was built in 1950,
lowered. Oak medicine cabinets, new television headed by Theresa Klitz, has also been busy but it has needed to be updated and renovated.
sets and telephones have been installed in the with the newly-remodeled area. They installed We're pleased with the progress to date."
patients' rooms.
wallpaper in the 18 patient rooms, and have
An open house for the newly-remodeled arThe nurses' station has been completely re- painstakingly prepared each room foroccupancy. eas will be planned for this spring.
Combining dietary departments results in savings
(continued from pagel)
for St. Joseph's residents and St. Francis
Memorial Hospital staff are conducted
every six months to see if changes need
to be made.
An extra benefit for the dietary staff,
Meiergerd said, is the interaction with St.
Joseph's residents and hospital patients.
"Our staff members help deliver the trays
to the hospital patients, giving us direct
contact with the patients," she said.
"The staff members who moved down
from the hospital to St. Joe's appreciate
the residents. They always stick their
heads in and say 'thanks.' That means a
lot."
The hospital was recently awarded the
bid for the West Point nutrition site meals,
a one-year contract that will begin in July.
"We're looking forward to providing those
meals," Meiergerd said.
"We feel that the arrangement we now
have will make projects like this feasible
for us to do. We're very pleased with how
the merger is working out."
�a community with a caring commitment
to the present and future
health care needs of its citizens.
We invite you to take a closer look.
�.... • i . y i
:,
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>
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>
:;
"
:
SAINT FRANCIS :
HOSPITAL
:
._
v-
\ ^di.ci^X}:;-
: 430 North Monitor Street ;
.
Sponsored
{402)372-2404
hyiheFrmciscanSisier
The roots of caring and compassion run deep in the northeastern
nity of 'West Toint.
Beginnings
tybraska
Tl'iis is sfwiun in tlie c\ccCCcnt fieaCtfi care system
commu-
that Had its
more tfian SO years ago. Since 1905, tile vision of Monsignor
'J{uesing and the ^Franciscan Sisters of Christian
ruraC northeast
tybraskji
its sponsor, the franciscan
Charity of bringing heaCth care to
has been reaUz-ed and continues
'This vision is best epitomized
togroiu.
in the mission of St. frauds
Sisters of Christian Charity.
you, the peopCe of northeastern
Joseph
McmoriaCfKospitaC
That mission is to "care for
O^braska, by providing quality hcatth care
related services as echoed by the zoords of St. francis
and
ofAssisi:
andlieafth-
'to hcaCzuounds, to bind
what is broken, and to bring home those who are Cost'" (Legends of the Three Companions,
5S).
The mission statement
health care community
summarizes
what St. Jrancis
Memorial hospital
in the West Toint area is all about: caring, healing, and
all people zvho come to them in need. Through the efforts of the St. (Francis
hospital
filled.
board, administration,
Also committed
is the St. frauds
from
'West Toint
volunteer
physicians
and staff
foundation
and the surrounding
hours soliciting
this mission statement
and Au.xjliary, consisting
communities.
These groups
of members
dedicate
many
equipment
and educational
programs to assure that the finest
to the people of northeast
of many, is truly a health care community
run deep.
Olospital
activities
In it, you zoillsee that the ^est Toint community,
compassion
is ful-
and sponsoring
to raise money for the
9{ebraska.
iVc invite you to take a fezu moments to read the information
foresight
Memorial
funds
in medical services are available
pages.
serving
to the existence and grozoth of St. (Francis Memorial
Memorial hospital
purchase of up-to-date
and the
on the
follozoing
through the dedication
and
zahere the roots of caring and
�Planning
for
present,
future
health
needs
Strategic planning is a very important part of the health care
process. Planning for the future can be done only after a thorough
and objective evaluation of current programs and services, as well
as a realistic projection of anticipated future needs. Recently,
through the coordination of the f i r m . Rural Health Development,
a strategic planning session was undertaken by officials of St.
Francis Memorial Hospital to assess the current and future health
care needs of the area. More than 60 individuals participated in
the process, which resulted in the following five goals:
1. Develop a health care delivery system that is comprehensive
and addresses and meets the health care needs of the entire area.
2. Merge the two clinics in West Point to create the positive
outcome that improves physician recruitment efforts, efficiency
with an economy of scale and business management.
3. Recruit more physicians as the patient base in West Point
and the surrounding area is very high with health care needs.
4. Coordinate the resources necessary to meet the health care
needs of the area, including patient, community education and
health information programs; collaboration of services through
communication and networking with communities; marketing of
existing and future services; continued improvement of the hospital physical plant; and continued support of physicians.
5. Support community development and economic development efforts and communicate the importance of the medical and
health care component of the economic climate.
New services
Much has been done to implement the goals of the strategic
planning session. Recent services to be added to the hospital are
pulmonology and vascular clinics as well as laparoscopic surgery.
Other services which are presently being considered are: respiratory therapy, oncology, sports medicine, telecommunications center, and a hospital-based home health care program.
Facility renovation,
addition
One of the most visible projects is the facility renovation which is
scheduled for completion in five years. Included in this extensive
project is the relocation of the obstetric department to the south
wing of the patient care floor to implement the concept of LDR—
labor, delivery, and recovery care taking place in one home-like
room; the relocation and renovation of the emergency department;
relocation of the chapel; renovation of patient rooms; the addition
of new surgical suites and expansion of the radiology department;
the expansion of the laboratory; the creation of a new outpatient
department from the present surgery suite; and the relocation and
enlargement of the physical therapy department. Plans for the
addition/renovation' project are included on the following pages.
The entire hospital will be touched in this multi-phased project.
�Following is a list of planned remodeHng.'anci equipment purchases at St. Francis Memorial Hospital. Completed purchases
have an asterisk (*) beside them.
Area
Cardiac Rehab
Purchase
Stress Test Machine & Treadmill
Telemetry Units
Weight Equipment
Stair Stepper
Radiology
Ratheon System
C - Arm
Tele-radiology System
Ultrasound Tabic and Transducer
Pharmacy
Personal Computer
Vertical Flow Laminar Hood
Physical Therapy
Orthotron Unit
10,000
Medical - Surgical
Computer system
25,000
Obstetrics
Warmer and Bassinet
Fetal Monitor
10,000
12,000
Surgery
OR Table - C - A r m compatible
Laparoscopy Equipment
33,000
45,000*
Central Supply
Steam Sterilizer
80,000
Laboratory
Data Management (Monarch)
Hematology Analyzer
17,000
42,900
Patient Rooms, East Wing
Surgery/Radiology Addition
Second Floor, West Wing
Equipment/Furniture
Expand Laboratory
Establish Outpatient Department
New Entrance/Relocate Business
Office and Admissions
Relocate and Expand Physical
Therapy and Cardiac Rehab.
3
Cost
$20,280*
20,000
5,000
3,000
46,000*
65,000
19,000
22,000
2,000*
4,000
333,400
1,828,700
312,000
160,000
141,000
325,000
285,000
271,200
Remodeling
and
equipment
purchases
�EMERGENCY
AND
OUTPATIENT
SURGERY
SUPPORT
SPACES —
WEST
POINT, NE.
SAINT FRANCIS
MEMORIAL HOSPITAL
ADDITION
AND
REMODELING
v.v. y.-. v. v.
OB. DEPT. AND
BIRTHING ROOMS-
THIRD FLOOR PLAN
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ADDITION
v.-Jii.-.W-tt^.;.^.-.-. f
REMODEL
mm
JACKSON - JACKSON & ASSOCIATES
ARCHITECTS
& ENGINEERS
OMAHA, NE.
R^SSSN
SCALE
TIT
100
�PHYSICAL
THERAPY
RADIOLOGY
WEST
POINT, NE.
SAINT FRANCIS
MEMORIAL HOSPITAL
ADDITION
AND
REMODELING
JACKSON - JACKSON & ASSOCIATES
ARCHITECTS
& ENGINEERS
OMAHA, NE.
CARDIAC REHAB. AND
WELLNESS DEPT.-
�St. Francis
Memorial
Hospital
St. Francis Memorial Hospital continues the caring tradition the
Franciscan Sisters of Christian Charity started in 1923 at St. Joseph's
Home and Hospital in West Point. The hospital serves as a vital
resource for inpatient and outpatient medical and surgical care,
emergency treatment (new department with a radiology room),
maternity care (new labor/delivery/recovery - birthing rooms,
nursery), radiology, laboratory, physical therapy, cardiac rehab,
wellness program, CAT scanner, doppler studies, echo cardiology
and a wide variety of health care education programs. In addition
to West Point's three board-certified family practice physicians
and one physician assistant, a number of consulting specialists
from Omaha and Fremont come to St. Francis on a regularlyscheduled basis.
Licensed by the Nebraska Department of Health, St. Francis Memorial Hospital is a leader in up-to-date technology. The 49-acute
care/swing bed facility is a member of the Catholic Hospital
Association, the American Hospital Association and the Nebraska
Hospital Association. The hospital is non-profit and receives
support from the community through the hospital foundation and
auxiliary, which have been instrumental in raising nearly $1 million for needed equipment and programs at St. Francis Memorial
Hospital.
Medical Staff
and Clinics
The health care professionals of St. Francis Memorial Hospital
play an important role in the health care delivery system, providing the greater Cuming County area's 10,000-plus residents with a
f u l l range of medical and health care services.
Within the community of West Point are two modern clinic buildings, both of which are conveniently located across from the
hospital. St. Francis Memorial Hospital, Elkhorn Valley Clinic,
P.C. and West Point Medical Clinic, P.C. are staffed by three
board-certified family practice physicians.
Elkhorn Valley Clinic, P.C. is staffed by Dr. Eugene Sucha and
Dr. Thomas Tibbels. West Point Medical Clinic, P.C. is staffed by
Dr. Scott Green, assisted by Dan Hakel, PAC. Both clinics have
newly-updated facilities and equipment to provide quality services to their patients.
As a result of one of the goals of the recently-completed strategic
planning session, discussions are in process for the merging of the
two clinics into one. This would "create the positive outcome that
improves physician recruitment efforts, efficiency with an economy
of scale and business management" (Strategic Planning Goal #2).
�Plans for opening satellite clinics in towns surrounding West
Point are also in their initial stages. These satellite clinics will be
opened contingent upon available health care personnel to staff
them.
A number of specialists are available to area patients through
referral by their physicians. The specialists listed below may be
seen by appointment in the specialty outpatient clinic, and are
also available in emergency situations.
Specialty
Cardiology
ENT
Audiology
OB-Gyn.
Urology
Orthopedics
Pulmonology
Ophthamology
General Surgery
Internal Medicine
Radiology
Pathology
Dental
Physician(s)
Creighton Cardiac Center
Dr. Gerald Simons
Craig Rawson
Dr. Ray Schulte
Dr. Ansar Khan
Dr. Richard Bergstrom
Dr. James Barker
Dr. Gregory Haskins
Dr. Dale Brett
Dr. Stephen Dreyer
Dr. Martin Sears
Radiology Nuclear Medicine
Pathology, Inc.
Dr. Jay Hansen
Dr. David Mlnarik
Consulting Staff
Location of Practice
Omaha
Omaha
Ft. Dodge, Iowa
Omaha
Fremont
Fremont
Omaha
Fremont
Omaha
Fremont
Fremont
Omaha
Omaha
West Point
West Point
Emergency medical assistance is provided by 13 area community rescue units. Personnel on these units are trained EMT's.
The West Point rescue unit is equipped with an auto defibrillator
and has certified EMT-A-D's as members.
Emergency
Medical
System
St. Elizabeth's Hospital in Lincoln provides special ground
transport for neonatal emergencies.
Ambulance Service
Air emergency transport is provided by Omaha's Life Flight and
Sky Med agencies, Marian Air Care in Sioux City, and St. Elizabeth's
Star Care in Lincoln. All have 20-minute arrival time.
Air Ambulance
Service
�Library
The John A. Stahl Library, built in the early 1980's w i t h donated
funds, provides citizens with excellent library services and programs, including a statewide computer network. It is supported
by the Library Foundation.
Cuming County
Historical Society
Dedicated to the preservation of the early history of Cuming
County, this group is responsible for the displays at the annual
Cuming County Fair in West Point at the depot museum, caboose,
and one-room school house located on the fairgrounds.
Sunshine Center
A gathering place for senior citizens, the Sunshine Center offers a
variey of activities and services, including noon lunches, social
events, and informational meetings.
West Point Brush
Strokes Art Club
A local group of artists who meet regularly, sponsor an annual art
show, and host workshops featuring regional artists as guest
instructors.
West Point
Community Theatre
This group of local actors present theatrical productions and are
in charge of special entertainment events in the community
throughout the year.
Recreation
West Point has four city parks that cover 160 acres. Neligh Park
is a place of beauty each summer with many flower beds adding
color to its 12 acres of picnic and recreation facilities. A fishing
pond is located in the park for youngsters and the elderly. Adjacent to the park are the Cuming County Fairgrounds and the
Cuming County Museum complex. Wilderness Park is a unique
120-acre natural preserve on the east edge of town. Timmermann
Park , on the western edge of West Point, is home to several ball
diamonds and tennis courts. A roller skating rink is also located
there. One mile south of town on #275 is the Izaak Walton League
park and lake for members and guests.
Other area recreation includes:
• Golf - Indian Trails Country Club, an 18-hole golf course
with clubhouse and restaurant, is located in Beemer,
10 minutes from West Point. Several area nine-hole
golf courses are located in other area towns.
• Swimming - a new municipal swimming pool is located
in Neligh Park in West Point.
• Baseball - T-ball, Softball, Legion baseball, and the local
town team, the West Point Bombers.
• Bowling - eight-lane bowling alley in West Point
16 •
�H u n t i n g - excellent hunting for waterfowl, pheasant,
quail and deer
Fishing - fishing opportunities abound in local
lakes and ponds, the Elkhorn and Missouri Rivers.
Camping - just nine miles south of West Point is Dead
Timber Stale Recreation Area, a favorite for camp
ing, fishing and picnicking.
Racquetball - a racquetball court is located in West Point.
centrally
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If you would like to receive more infonnation
about the
Jtcaltli care programs and services in West Point, please
contact President, St. Francis Memorial Hospital,
430
North Monitor Street, West Point, Nebraska
6S7S8-02S7.
The hospital telephone number is (402) 372-2404.
This booklet and the accompanying
video give you a
sampling of zuliat West Point has to offer the medical
professional.
We'd like to show you in person. West Point
is a family-oriented
community ivhose roots of caring aud
compassion run deep. Wc hope you'll give West Point a
closer look.
17
For more
�Referral Hospitals
Extended
Care Facilities
Hospital
Bergan Mercy
Methodist/Children's
Immanuel
St. Joseph's
UNMC
Clarkson
St. Luke's
Marian
Lincoln General
St. Elizabeth's
Bryan Memorial
Location
Omaha
Omaha
Omaha
Omaha
Omaha
Omaha
Sioux City, Iowa
Sioux City, Iowa
Lincoln
Lincoln
Lincoln
Distance
70 miles
70 miles
70 miles
70 miles
70 miles
70 miles
60 miles
60 miles
85 miles
85 miles
85 miles
Fourteen nursing care faci lities are located in the greater Cuming
County area. West Point Living Center, a a 70-bed ICF with an
Alzheimer's unit, and St. Joseph's Retirement Community, a 75unit assisted-living facili ty, are located in West Point. Other
extended care facilities are:
Facility
Colonial Haven
Good Samaritan
Location
Beemer
Scribner
Parkview Home
Wisner Manor
Stanton Nursing Home
Dodge
Wisner
Stanton
Schuyler Manor
Pender Care Center
Oakland Heights
Logan Valley Manor
Schuyler
Pender
Oakland
Hooper Care Center
Columbus Manor
Colonial Manor
Hooper
Columbus
Clarkson
Lyons
Certification
ICF
ICF,SNF,
non-Medicare cert.
ICF
ICF
ICF,SNF,
Medicare certified
ICF
ICF
ICF
ICF, SNF,
Medicare certified
ICF
ICF
ICF, SNF
�Medical
services
The Cardiac Rehabilitation Department at St. Francis Memorial
Hospital includes a three-phase inpatient/outpatient cardiac rehabilitation program plus a variety of other services to assist the
physician in the care of his or her patients. The department is
staffed by three trained RN's and several professional assistants.
Stress testing is available at St. Francis Memorial Hospital using
the Quinton 4000 stress testing machine with a Quinton treadmill.
The Cardiac Rehabilitation Department also coordinates the Lifeline
program.
Cardiac
Rehabilitation
Emergency service is provided by St. Francis Memorial Hospital 24
hours a day, seven days a week. Medical staff coverage is provided
on a rotating "on-call" schedule with all of the physicians and
physician's assistant sharing the coverage evenings and weekends. Thirteen area communities in the greater Cuming County
area support rescue and EMS personnel.
Emergency Service
The hospital's emergency area is fully equipped to handle most
any emergency. The emergency area has recently been relocated
and renovated to provide more space and easy access for nursing
personnel. A LifePac 8 heart monitor with external pacemaker
and defibrillator enhance emergency care.
The laboratory at St. Francis Memorial Hospital is well equipped
with up-to-date instrumentation including the Baker 8000 (eight
parameter hematology instrument), IL 1304 (self-calibrating blood
gas instrument). Monarch 2000 (general chemistry analyzer, capable
of adapting to a wide variety of applications). There are 101
different test procedures on the laboratory menu. Bergan Mercy
Hospital in Omaha provides reference laboratory services, and a
pathologist makes a consultative visit once a month. The lab is
staffed by four medical lechnoiogists and a secretary/phlebotomist.
Lab personnel make weekly visits to seven area nursing homes and
provide 24-hour service.
Laboratory
Mobile services available to physicians and patients include:
Nuclear Medicine, Vascular Studies, Echocardiograms, and CT
scans.
Mobile Diagnostic
Services
�Obstetrics and
Gynecology
Elkhorn Valley Clinic, West Point Medical Clinic and St. Francis
Memorial Hospital offer the latest in maternity care and programs.
The hospital is equipped to handle natural deliveries as well as
cesarean and multiple births. The hospital's new Labor/Delivery/
Recovery suites feature new birthing beds, fetal monitors, and
complete infant warmer/recovery units. The hospital offers
Lamaze classes, sibling visitation, fathers in delivery, and many
other options. The hospital has had a 23% increase in births over
the last two years, averaging over 100 babies delivered at St.
Francis Memorial Hospital each year.
Pharmacy
The pharmacy at St. Francis Memorial Hospital is staffed by
licensed pharmacists. The pharmacy department provides a f u l l
range of services to assure quality drug therapy for inpatients and
outpatients. Services to be added include computer kinetics for
drugs such as theophylline, aminoglycosides, et cetera, and online hook-up with UNMC SYNAPSE program which w i l l provide
accessibility to drug information, patient education materials,
databases, et cetera. The pharmacists provide 24-hour coverage.
Physical Therapy
The physical therapy staff at St. Francis Memorial Hospital provides a wide variety of professional physical therapy services.
Services are provided to patients of area physicians as well as
those of physicians outside the referring area of West Point,
Nebraska. The staff at St. Francis is current and progressive in
treating both inpatients and outpatients, and constantly strives to
improve their clinical skills to provide the best quality care possible to the patients receiving physical therapy. The department
has four licensed physical therapists, a physical therapy assistant,
and a physical therapy technician. The staff provides consultative
physical therapy to several area nursing homes. They also provide
pediatric physical therapy to the West Point and surrounding
school districts.
Radiology
The radiology department provides diagnostic, fluoroscopic,
mammographicand ultrasound exams. The department is staffed
by radiologic technologists, to include two registered diagnostic
medical sonographers, available on a 24-hour basis. CT scan
service is available at the hospital twice weekly by Memorial
Mobile Imaging, of which St. Francis Memorial Hospital is a part
owner along with three other health care facilities. CT scans are
available at other times at neighboring hospitals within a 45-mile
radius of West Point.
10
�Procedures ranging from local endoscopy to major surgery are
performed in the hospital's surgical suite. The surgery area
consists of two operating rooms and a recovery room. A new
surgery wing is planned for 1993-1994 as part of the renovation
project. Surgery is performed by the St. Francis Memorial Hospital
medical staff, a general surgeon, and the consulting physicians
and surgeons. They are assisted by a CRNA and trained surgical
nurses. The operating room is well equipped with up-to-date
equipment including an Ohmeda Modulus II Anesthesia Machine,
Minolta Plus Oximeter, Capuometer, Bard Infus O.R. Pump, two
Valleylab Force II Electrosurgical Generators, two Olympus CLK
Cold Light Sources, Critikon Dinamap, two cardiac monitors, two
fiberoptic headlights, and laparoscopic surgical and video
equipment.
Surgery
Hospital
Organization
One of the key groups involved in both the present and the future
operation of St. Francis Memorial Hospital is the board of directors, representing the communities of West Point, Wisner, Beemer,
Scribner and Dodge, the president of the medical staff, as well as
three members of the Franciscan Sisters of Christian Charity.
These board members, working with the hospital president, a
director ex-officio, have full authority for the operation, business
and governance of the hospital. A major responsibility of the
board is to ensure quality health care delivery with state-of-theart equipment. The board members also work with hospital
personnel in short- and long-range planning.
Board of Directors
and
Administration
St. Francis Memorial Hospital employs over 100 area residents.
These employees play a vital role in the hospital operations and
their communities. A l l of the departments, their directors and
employees are part of a "team" approach to the health care provided
by St. Francis Memorial Hospital.
Employees
One of the most important resources any hospital has is its nurses.
St. Francis Memorial Hospital has an experienced and dedicated
nursing staff, most of whom are ACLS and NALS certified. The
hospital offers monthly programs to update their skills. A total of
20 registered nurses, six licensed practical nurses and 16 nurse
assistants are on the hospital staff.
Nursing Services
11
�Support
Services
Community
Education
St. Francis Memorial Hospital is the source for health-related education classes held in its service area. The hospital sponsors CPR
classes, first aid classes for lifeguards and day care providers,
advanced cardiac life support, and neonatal advanced life support
classes.
Adult education classes on diabetes, breast cancer prevention, and
advanced directives are held at the hospital and at meetings of
clubs and service organizations. Educational services to the community include osteoporosis education, hospice training, stress
management. Lifeline installation, school health education, nutrition education, sports medicine, and prenatal/childbirth' education (Lamaze), materials and counseling.
The hospital also
sponsors a year-round wellness program, smoking cessation, and
weight management class twice a year.
•
A health fair and a booth at the Cuming County Fair provide the
public with heallh information. The education department coedits a newsletter, Caring for You, printed quarterly and mailed to
more than 8,400 households in the surrounding area.
Home Health
Home Health services are currently available through the Burt/
Washington
Home Health Care Program from Memorial!
County
Community
Hospital in Blair. Nursing visits average 156 per
month, and Home Health aide visits average 47 per month.
St.
Francis Memorial Hospital is currently in the process of organizing
its own Home Health Service.
•
Mental Health
Mental health services are provided to area residents through
Monroe Mental Health. An outpatient clinic is available at the
hospital on a regular basis.
Social Services
The Director of Patient Care is in charge of social services at St.
Francis Memorial Hospital. She has daily contact with patients
and, if possible, with their families, physicians and other health
care providers.. She is responsible for discharge planning and
arranges for equipment and additional services needed by patients
upon their return home or makes arrangements to an appropriate
facility after dismissal. The director arranges for skilled swing bed
admissions and interhospital transfers.
12
�St. Francis Memorial Hospital provides services to all persons,
regardless of their ability to pay. The hospital's ongoing commitment of offering many worthwhile services to those in need can
be seen in the services and assistance that are given or written off
under the hospital's Charity Care/Assistance Program, including
those unpaid costs of public programs such as Medicaid and
Medicare. In addition, many services are offered as free, low- or
no-margin to the public to help promote good health and fitness
within the community and surrounding areas.
Social
Accountability
Support
Organizations
St. Francis Memorial Hospital Foundation was established in 1962.
The foundation plays a major role in the support the community
and surrounding area provides St. Francis Memorial Hospital. The
foundation's annual fund drive raises needed funds for hospital
equipment purchases and the hospital's scholarship program. Since
its inception, the foundation has raised nearly $1 million for the
hospital.Each year, foundation scholarships are awarded to one
high school student from all of the area schools who have enrolled
in a health-related program. The foundation also provides a
tuition assistance program to health professionals interested in
continuing their education.
The foundation is playing a major
financial role in the hospital's renovation and addition project.
St. Francis Memorial
Hospital Foundation
St. Francis Memorial Hospital Auxiliary, founded in 1953, has
served the hospital and community in many ways. Through the
years, the auxiliary has raised nearly $30,000 for equipment and
other items for the hospital. The money has come from annual
fund-raising events including an annual hospital bazaar, flea
market, handcrafted items sold in the hospital gift shop, and
others. Auxiliary members serve as hostesses in the patient waiting
room, and provide patient tray favors each month.
St. Francis Memorial
Hospital Auxiliary
A hospital volunteer program was recently started. In its first five
months of existence, the 36 members of the organization have
donated nearly 13,000 hours of their lime to the hospital. The
volunters provide assistance to patients, visitors and hospital
staff.
Volunteer Program
13
�About West
Point...
West Point is a progressive community of 3,400 located along the
Elkhorn River in northeast Nebraska. It is the county seat and
largest town in Cuming County. The county is in a rich agricultural
area which has long been the predominant livestock county in the
state. While agriculture remains the primary economic base of the
area, industry, trade and retail sales combine with agriculture to
contribute to the city's and county's solid economic standing. The
population of Cuming County is well over 10,000.
West Point is located in the southeastern part of Cuming County,
and is served by U.S. Highways #275 and #32. West Point is 40
miles southeast of Norfolk, 35 miles northwest of Fremont, 70
miles northwest of Omaha, 85 miles north of Lincoln, and 55 miles
southwest of Sioux City, Iowa.
j
Government
West Point is governed by a mayor and city council assisted by a
city administrator. A planning commission operates within the
framework of a comprehensive municipal code. Property taxes are
below average and are augmented by moderate state sales and
income taxes. The city operates its own utility department with
supplementary power purchased from Nebraska Public Power
Pool, and enjoys one of the lowest utility rates in the state.
Because it is the county seat of Cuming County, most state and
federal offices are located in West Point.
Businesses and
Services
A variety of businesses and services are provided to the residents
of West Point and the surrounding area. Retail clothing stores,
pharmacies, furniture, grocery, hardware, and other specialty
businesses are located in West Point. A mall located just south of
town on #275 has been steadily growing, and includes both retail
and service businesses. Professional services available, in addition
to medical and dental services previously mentioned, .include
attorneys, certified public accountants, optometrist, chiropractor,
veterinarians, interior decorating, public relations and financial
services. Several restaurants and a motel are located in West Point.
In addition to St. Francis Memorial Hospital, major employers in
West Point are Iowa Beef Processors, Wimmers Meat Products, and
West Point Dairy. Many other ag-related industries and government offices provide employment. Three banks and one pavings
and loan institution are located here. The community is served by
a weekly newspaper, The West Point News, a radio station, KWPN,
and cable television. West Point has a very active Chamber of
Commerce.
14
�It is estimated that 75% of the homes in West Point are owneroccupied. Several realty companies are located in West Point to
assist those wishing to purchase or sell a home.
West Point Baptist
West Point Church of Christ
Grace Lutheran (ELCA)
Jehovah's Witnesses
Redeemer Lutheran (Lutheran Church of the Reformation)
St. Mary's Catholic
St. Paul Lutheran (Missouri Synod)
Trinity Church (UCC-UMC)
Education is very important to the citizens of West Point. Three
strong school systems, two parochial and one public, have a long
history of serving the youth of West Point and of working together
to the benefit of all. The West Point Public Schools offer a comprehensive special education program, serving not only area students
but also those whose school districts contract with the West Point
Public Schools to educate them. A class-sharing program is also in
effect between the schools, offering students the opportunity to
take classes not available at the school they are attending.
West Point Schools include:
• Central Catholic High School (9-12)
• Grace Lutheran Pre-School
• Guardian Angels Elementary School (K-8)
• St. Paul's Lutheran School (Pre-school - 8)
• West Point Elementary School (K-6)
• West Point Junior-Senior High School (7-12)
In addition to the K-12 system. West Point residents are also able
to take advantage of classes offered through the community education program in cooperation with Northeast Community College
in Norfolk. Both college credit and non-credit classes are offered
in West Point. Other area colleges and their distance from West
Point include:
• Wayne State College, Wayne (35 miles)
« Midland Lutheran College, Fremont (35 miles)
• Dana College, Blair (45 miles)
• University of Nebraska-Omaha, Creighton University,
College of St. Mary, all in Omaha (70 miles)
• University of Nebraska-Lincoln, Wesleyan University,
Union College, all in Lincoln (85 miles)
• Morningside College, Sioux City (60 miles)
15
Housing
Churches
Schools
�Library
The John A. Stahl Library, built in the early 1980's with donated
funds, provides citizens with excellent library services and programs, including a statewide computer network. It is supported
by the Library Foundation.
1
Cuming County
Historical Society
Dedicated to the preservation of the early history of Cuming
County, this group is responsible for the displays at the annual
Cuming County Fair in West Point at the depot museum, caboose,
and one-room school house located on the fairgrounds, i
Sunshine Center
A gathering place for senior citizens, the Sunshine Center offers a
variey of activities and services, including noon lunches, social
events, and informational meetings.
West Point Brush
Strokes Art Club
A local group of artists who meet regularly, sponsor an annual art
show, and host workshops featuring regional artists as guest
instructors.
West Point
Community Theatre
This group of local actors present theatrical productions, and are
in charge of special entertainment events in the community
throughout the year.
Recreation
West Point has four city parks that cover 160 acres. Neli'gh Park
is a place of beauty each summer with many flower beds adding
color to its 12 acres of picnic and recreation facilities. A fishing
pond is located in the park for youngsters and the elderly. Adjacent to the park are the Cuming County Fairgrounds ;and the
Cuming County Museum complex. Wilderness Park is a unique
120-acre natural preserve on the east edge of town. Timmermann
Park , on the western edge of West Point, is home to several ball
diamonds and tennis courts. A roller skating rink is also located
there. One mile south of town on #275 is the Izaak Walton League
park and lake for members and guests.
!
Other area recreation includes:
• Golf - Indian Trails Country Club, an 18-hole golf course
with clubhouseand restaurant, is located in Beemer,
10 minutes from West Point. Several area nine-hole
golf courses are located in other area towns.
• Swimming - a new municipal swimming pool is located
in Neligh Park in West Point.
• Baseball - T-ball, softball. Legion baseball, and the local
town team, the West Point Bombers.
'
• Bowling - eight-lane bowling alley in West Point
16
�• H u n t i n g - excellent hunting for waterfowl, pheasant,
quail and deer
• Fishing - fishing opportunities abound in local
lakes and ponds, the Elkhorn and Missouri Rivers.
• Camping - just nine miles south of West Point is Dead
Timber State Recreation Area, a favorite for camp
ing, fishing and picnicking.
• Racquetball - a racquetball court is located in West Point.
centrally
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If you would like to receive more information about the
health care programs and services in West Point, please
contact President, St. Francis Memorial Hospital,
430
North Monitor Street, West Point, Nebraska
6S7S8-0287.
The hospital telephone number is (402) 372-2404.
This booklet and the accompanying
video give you a
sampling of luhat West Point has to offer the medical
professional.
We'd like to show you in person. West Point
is a family-oriented
conununity ivhose roots of caring and
compassion run deep. Wc hope you'll give West Point a
closer look.
17
For more
�
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Title
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Health Care Task Force Records
Creator
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White House Health Care Task Force
Is Part Of
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [2]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
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2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 36
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
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Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
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42-t-12092971-20060885F-Seg3-036-006-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/83fdd306d5ad4ccbf79b675fa991a7b7.pdf
4c2c8949bf9b24203eeeac70f806c7be
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1985
OA/ID Number:
FolderlD:
Folder Title:
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [1]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
4
1
�STATE
OF
EXECUTIVE
M A R Y L A N D
DEPARTMENT
W A S H I N G T O N
4 4 a
NORTH
CAPITOL
WASHINGTON,
WILLIAM
D O N A L D
D.
OFFICE
ST.. N W
C.
2
*2I5
0001
S C H A E F E R
March 17, 1993
Hillary Rodham Clinton
The White House
Washington, D.C. 20500
Dear Mrs. Clinton:
As you diligently pursue comprehensive health care reform, I would like you to
consider the progress Maryland has made in controlling health care costs and
expanding access to health insurance. We have successfully controlled hospital health
care costs through regulation. We are building on this success and are pursuing
some important state based reforms that I know will be of relevance to your efforts.
Maryland's All Paver Hospital System
Maryland is the only state in the country to regulate the reimbursement of hospitals by
all payers, including Medicare and Medicaid. The Maryland Hospital system has a 17
year record of keeping hospital costs well below the national average. In 1992 the
costs of a hospital admission in Maryland rose at less than half the rate of the rest of
the nation.
Additional information on our hospital system is attached.
State Based Reforms
Building on our successful hospital cost containment efforts, our legislature is drafting
legislation to increase access to health insurance coverage and establishes a
framework for cost containment by implementing new market rules for insurers and
providers.
I am enclosing a copy of the bill as passed by the Maryland House of Delegates. The
Senate is considering this and several other legislative proposals on health care and it
is expected that final action will be taken in both Chambers in the next few weeks.
�Hillary Rodham Clinton
March 17, 1993
Page 2
Because your task force is moving forward rapidly, I wanted to provide you with
information on action in Maryland. I will, of course, keep you advised of developments
and provide you with a copy of the final legislation when approved by the General
Assembly.
The House bill requires insurers to follow certain uniform rules, initially in the small
group market and eventually in the entire market. The rules include guaranteed issue
of a comprehensive standard health benefit plan, guaranteed renewal, and adjusted
community rating.
The bill creates a Medical Care Data Review Commission that is modeled after
Maryland's successful Hospital Service Cost Review Commission. The Commission
will develop a medical care data base on health services rendured by physicians,
pharmacists, and office facilities. The data will be used to formulate the
comprehensive standard health benefit plan, foster the development of practice
protocols, and develop cost containment strategies.
The bill increases access to health care coverage in two steps. Immediately, small
group market reform assures access to health care coverage for all small employers.
In the longer term the legislation seeks to assure that all of Maryland's uninsured
population will have guaranteed access to a comprehensive standard health benefit
plan.
The Medical Care Data Review
health benefit plan. All carriers
market -- must sell this policy.
between carriers since carriers
Commission will develop a comprehensive standard
in the small group market -- and eventually in the entire
Small employers will be able to compare costs
must offer the same plan to all employers.
The Commission must also develop a payment system for physician services covered
under the comprehensive standard health benefit plan. The payment schedule may be
a fee schedule but it must include provisions to control the utilization or volume of
health care services.
As you know, access to care and cost containment must be part of any successful
strategy. I strongly support initiatives to eliminate discrimination based on pre-existing
conditions and to implement community rating so that insurance is affordable for all.
�Hillary Rodham Clinton
March 17, 1993
Page 3
Yours is a daunting task, but one that must be undertaken. We in Maryland want to
work with the federal government to implement a successful program of health care
reform. I hope this information is useful to you and gladly offer our resources to you
and your group as you structure a mode! fcr reform.
Thank you for your consideration.
Sincerely,
ZGovernor f
Enclosures
jy
�G'oumwr of the S h i t of lUlaruJiiwi
^UlilfiamlDonaki Schaefer
February 8, 1993
Mrs. H i l l a r y Rodham Clinton
The White House
Washington DC 20500
Dear Mrs. Clinton:
I congratulate you on your appointment to lead the e f f o r t to
reform the nation's health care system and thank you for the time
you spent with the nation's Governors l a s t week. Your
commitment, and that of the President, are evident and much
appreciated. The President was absolutely right i n identifying
health reform as a top p r i o r i t y , and i n recognizing that there
can never be a solution to the budget d e f i c i t problem u n t i l
s p i r a l l i n g health care costs can be brought under control. I
want to promise you my f u l l support in your e f f o r t s to both
increase access to health care for the more than 35 m i l l i o n
persons who lack health insurance (and the millions more who have
inadequate coverage) and to control health care costs.
In Maryland, we have done a number of things to reform the health
care system. Our hospital r a t e - s e t t i n g commission has saved
Marylanders b i l l i o n s of d o l l a r s over the past 15 years, while
guaranteeing access to hospital care for a l l those who cannot
afford i t . There has been considerable debate over the past few
years about additional system reforms, culminating in my proposed
state l e g i s l a t i o n (a copy of which i s enclosed) to reform small
employer group health insurance by spreading the r i s k through a
reinsurance pool, requiring community rating, eliminating most
pre-existing condition l i m i t a t i o n s and guaranteeing renewal. In
our Medicaid program, we have successfully implemented a
statewide managed care plan under federal waiver authority that
now has nearly 80% of a l l Maryland Medicaid b e n e f i c i a r i e s
enrolled i n an H O or with a physician care manager. We also
M
have been successfully operating several home and community-based
s e r v i c e s waiver programs that have saved both the federal and
state governments tens of m i l l i o n s of dollars. We are continuing
�Mrs. H i l l a r y Rodham Clinton
February 8, 1993
Page Two
to develop new and innovative projects to improve costeffectiveness and access i n the Medicaid program. And I am proud
of Maryland's recently-restructured welfare system that requires
AFDC r e c i p i e n t s to ensure regular and primary health care for a l l
dependent children.
I have j u s t submitted the enclosed waiver request to Secretary
Shalala to allow Maryland to provide primary and preventive
health care services to children of the working poor. I am
t h r i l l e d that under the more f l e x i b l e waiver authority that the
President has announced we w i l l be able to expand some v i t a l
Medicaid c h i l d health care services that previously, under the
" a l l or nothing" Medicaid rules, we could not have afforded to
cover.
Again, I am most anxious to support your health system reform
e f f o r t s i n any way that I can. I f your s t a f f need any
information or assistance, or i f there i s any way that we can
help, I urge you to have your s t a f f contact my Secretary of
Health and Mental Hygiene, Mr. Nelson J . Sabatini, a t (410) 2256505.
Sincerely,
Governor
jff
Enclosure
cc:
Mr. Nelson J . Sabatini
�• $ootrnor of th* *>fcrtt of UHarujand
February 8, 1993
The Honorable W i l l i a m J. C l i n t o n
President o f the United States
The White House
Washington DC 20500
Dear Mr. President:
I applaud you f o r the time you spent w i t h the nation's Governors
l a s t week and am impressed and encouraged by your promise t o give
states more f l e x i b i l i t y i n running t h e i r Medicaid programs.
C l e a r l y t h i s o f f e r stems from your understanding o f the problems
w i t h Medicaid and the r i g i d i t y of some of t h e f e d e r a l r u l e s t h a t
govern i t .
I n response t o your o f f e r , Maryland today has requested an HHS
waiver t o enable Maryland t o provide primary ^nd preventive
services t o c h i l d r e n born a f t e r September 30, 1983 whose f a m i l y
income does not exceed 185% of the poverty l e v e l . A copy of t h e
waiver request t o Secretary Shalala i s enclosed. U n t i l now, our
only choices have been t o provide e i t h e r f u l l Medicaid coverage
to these c h i l d r e n or no coverage. Because of revenue
c o n s t r a i n t s , we have not been able t o a f f o r d t o provide a f u l l
package o f Medicaid coverage. Therefore, these c h i l d r e n o f t e n do
not receive the primary and preventive care they need, which
r e s u l t s i n expensive h o s p i t a l i z a t i o n s , which, i r o n i c a l l y ,
Medicaid pays f o r when the c h i l d r e n "spend down" t o poverty
levels.
I f we could e n r o l l these c h i l d r e n i n Medicaid, but l i m i t t h e i r
coverage t o primary and preventive services, we could a f f o r d t o
provide them v i t a l physician, c l i n i c , pharmacy and v i s i o n
services. This would s i g n i f i c a n t l y improve the l i v e s of
approximately 15,000 c h i l d r e n i n Maryland, which I know i s
something o f great concern t o both you and Mrs. C l i n t o n . At t h e
same time, l i m i t i n g the coverage t o primary and preventive care
would be much less c o s t l y t o the f e d e r a l and s t a t e governments
than p r o v i d i n g f u l l Medicaid coverage. And f i n a l l y , t h i s e f f o r t
w i l l demonstrate the value of prevention - something I know you
believe i n .
�The Honorable William J. C l i n t o n
February 8, 1993
Page Two
I am l o o k i n g forward t o quick approval of our waiver request on
behalf of these c h i l d r e n . Again, I thank you f o r your
w i l l i n g n e s s t o allow states the f l e x i b i l i t y t o develop c r e a t i v e
s o l u t i o n s t o Medicaid problems. You can be assured of my support
f o r your reform e f f o r t s r e l a t i n g not only t o the Medicaid
program, but t o the e n t i r e h e a l t h care system.
Enclosure
�DEPARTMENT OF HEALTH AND MENTAL HYGIENE
201 WEST PRESTON STREET
BALTIMORE, MARYLAND 21201
Area Code 410
225- 6 5 0 0
Nelson J . Sabatini
Secretary
William Donald Schaefer
Governor
February 8. 1993
The Honorable Donna E. Shalala
Secretary
Department of Health and Human Services
200 Independence Avenue S
W
Washington DC 20201
Dear Secretary
Shalala:
I am requesting waivers under the a u t h o r i t y of Section 1115 of the Social
Security Act to allow Maryland to e s t a b l i s h a preventive and primary care
program f o r c h i l d r e n w i t h i n the Medicaid program. This request i s to waive
sections 1902(a)(10)(A). 1902(a)(10)(B). 1902(a)(lA), and any other sections
necessary to implement t h i s program.
The population included i n t h i s demonstration program i s a l l c h i l d r e n born
a f t e r September 30. 1983. who are a t least one year old, who are not c u r r e n t l y
e l i g i b l e f o r the Medicaid program, and who l i v e i n f a m i l i e s whose income does
not exceed 185% of the federal poverty l e v e l . There w i l l be no resource
l i m i t a t i o n . Maryland w i l l employ a less r e s t r i c t i v e methodology i n determining
income and resource e l i g i b i l i t y f o r i n d i v i d u a l s under sections
1 9 0 2 ( a ) ( 1 0 ) ( A ) ( i ) ( V I ) and ( V I I ) of the Social Security Act. as permitted under
1902(r)(2), to implement these changes i n conjunction w i t h the waiver approval.
The services o f f e r e d under t h i s demonstration w i l l include preventive
p e d i a t r i c care including w e l l c h i l d v i s i t s , immunization, and screening f o r lead
poisoning and other appropriate conditions. I t also w i l l include sick care i n
physician o f f i c e s and c l i n i c s , diagnostic t e s t s , v i s i o n care i n c l u d i n g
eye glasses, h e a l t h - r e l a t e d special education services d e l i v e r e d i n schools, and
p r e s c r i p t i o n drug coverage w i t h a $5 per p r e s c r i p t i o n co-payment. No h o s p i t a l
i n p a t i e n t , o u t p a t i e n t , or emergency room coverage w'ill be provided.
TDD for the Deaf:
Baltimore Area
D.C. Metro Area
383-7555
565-0451
�The Honorable Donna E. Shalala
February 8. 1993
Page 2
I t i s estimated that approximately 15.000 c h i l d r e n w i l l p a r t i c i p a t e i n t h i s
demonstration project the f i r s t year. The average cost per c h i l d i s estimated
to be S200 per year, f o r a t o t a l f i r s t year cost of S3 m i l l i o n (51.5 m i l l i o n
State funds and SI.5 m i l l i o n Federal funds).
Maryland intends to demonstrate that covering primary and preventive
services to these c h i l d r e n w i l l reduce Medicaid payments by reducing the number
of h o s p i t a l i z a t i o n s of c h i l d r e n who "spend-down" to Medicaid as medically needy
c l i e n t s . These savings are expected to considerably lower the net cost to the
Medicaid program while s i g n i f i c a n t l y improving the health status of these
children.
I would g r e a t l y appreciate whatever you can do to assure prompt action on
t h i s waiver request. Please contact Mr. Joseph Millstone. Director of the
Medical Care Policy Administration, at (410) 225-1432 f o r any a d d i t i o n a l
information that i s required. I am looking forward to being able to provide
these primary and preventive services to Maryland c h i l d r e n as soon as possible.
Sincerelv,
Nelson J. Sabatini
Secretary
NJS:mja
cc: The Honorable William J. C l i n t o n
Ms. H i l l a r y Rodham C l i n t o n /
Mr. Joseph M. M i l l s t o n e
�HEALTH INSURANCE REFORM
Skyrocketing health care costs make it difficult for small businesses to
obtain or afford health insurance coverage for employees. Of the
570,000 Marylanders without insurance, 74 percent are employees or
dependents of employees, many of whom are employed by small
businesses.
While historically health insurers used "community rating," charging
all people in the community or similar businesses the same rate,
insurers have become more selective and charge rates based on a
group's health or claims history. Those varying charges mean
Maryland's small businesses either pay widely different rates for health
insurance or cannot afford to obtain coverage.
Additionally, some employees with pre-existing health conditions find
it hard to change jobs without losing some or all of their benefits
because the new employer's health insurer may impose exclusions
limiting coverage for workers with health problems that pre-date their
employment.
While the debate begins at the federal level on health care reform,
Maryland can move this year to "level the playing field" for small
business in obtaining health insurance, and can ensure that employees
can move freely between jobs without jeopardizing their insurance.
The Administration proposes returning to community rating to spread
the risk across the entire pool of insureds, and proposes prohibiting
insurers from imposing pre-existing condition exclusions so that a
Marylander with a health problem would not lose health coverage just
by changing jobs. These two measurers, complementing proposed
federal reforms, would take Maryland a step closer toward reducing
the ranks of the state's uninsured.
�CODER.
HEALTH CARE TASK FORCE SORTING SHEET
7
TYPE OF MATERIAL:
General mail
.Personal stories
Letterhead
.Offers to help
Letter Campaign
.Policy
.Casework
Employment
.Advocacy
Requests;
-speech
-meeting
Other
Explanation:,
ADVISORY PANEL?
physician
.large employers
r.n.
seniors
small business
.other health provider
other consumers
Explanation:.
PRIMARY TNTBREST:
COST ISSUES
Drug Prices
Physician Fees
Hospital Fees
Unnecessary Procedures
Medical Equipment
Fraud and Abuse
.PUBLIC HEALTH/SPECIAL POPULATIONS
Prevention
AIDS
Women's Health
Immunizations
Rural
Urban
COVERAGE
Working Families
Unemployed/Low Income
Benefits
Providers
GOVERNMENT PROGRAMS
Medicare
Medicaid
Veterans
DoD
ORGANIZATION
Insurance Premiums
Insurance Reform
Insurance Pools
Boards and Oversight
INFRASTRUCTURE/WORKFORCE
Quality Assurance (Guidelines)
Administration. Reimbursement
& Patient Information Systems
Malpractice & Tort Reform
Manpower Issues (Training)
LONG-TERM CARE
MENTAL HEALTH
OTHER
Explanation:.
PLAN PREFERENCE: (Support = +; Oppose = -)
CP
SP
OP
Clinton Plan
Single Payer
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits, Vouchers,
Medical Savings Accts.
CA
BR
GE
Canadian
British
German
�S M A Y AS A E D D
UMR
MNE
H U E BILL 1359: HEALTH INSURANCE REFORM
OS
M R H 9, 1993
AC
This b i l l implements insurance reform, establishes a Medical Care Data
Review Commission to formulate a comprehensive standard health benefit
plan, collect data on outpatient services, and implement cost containment
strategies. These features are described more fully below.
IMMEDIATE INSURANCE REFORMS:
AFFECTING G O P O 2 T 50 EMPLOYEES
RUS F
O
I t is well established that small employers have difficulty purchasing
health insurance coverage for their employees and that rates fluctuate
greatly from one year to the next. The insurance reforms in this b i l l are
designed to guarantee access to health insurance coverage for small
employers and stabilize their rates.
Effective July 1, 1994, for employers with 2 to 50 employees insurers
practices must include the following:
o Guarantee Issue
o Guarantee Renewal
o Consumer Protection: Insurers and health maintenance organizations
must notify employees when a policy is cancelled or non-renewed and
provide notice of conversion rights
o Pre-existing condition limitation: m y be imposed only once for 6
a
months and would be eliminated after October 1, 1996
o Adjusted community rating:
adjusted by age and geography.
may not deviate by more than
decreasing to 33 percent by the
family size
rates for a health benefit plan may be
For the f i r s t year, any adjusted rate
50 percent from the community rate
third year. Premiums may vary based on
o Comprehensive Standard Health Benefit Plan: All carriers in this
market must offer at least this benefit plan, and may market additional
benefits that are priced separately
o Additional requirements on carriers:
In addition to other
requirements imposed on carriers under the Insurance Code, carriers
must have demonstrated a capacity to administer health benefit plans,
have satisfactory grievance procedures, provide for coordination of
multiple coverage, and have policies designed to help ensure adequate
access to providers
�MEDICAL CARE D T REVIEW COMMISSION
AA
Discussions of health care reform have been hampered by the lack of
data on outpatient services. Benefits that must be included in a health
Insurance policy have evolved in a piecemeal fashion through the enactments
of mandated benefits. This Commission addresses both these concerns.
The b i l l establishes a 7-member Medical Care Data Review Commission in
the Department of Health and Mental Hygiene to formulate the comprehensive
standard health benefit plan and establish a health care data base
(effective July 1, 1993).
The Commission's costs will be covered by
assessments on providers (1/3 of total costs) and carriers (2/3 of total
costs) up to a maximum of $2 million.
The medical care data base will include information on health services
rendered by physicians, pharmacists, and office facilities.
The Commission
must adopt regulations to ensure the confidentiality of physician-patient
privilege. The Commission may adopt regulations to include other types of
health care practitioners in the data base after recommending this action to
the General Assembly in its annual report.
GENERAL HEALTH INSURANCE M R E REFORMS:
AKT
(Adjusted Coamunity Rating)
Access to health insurance coverage is a problem both for small groups
and for many individuals.
I f one of two conditions are met (set by the
trigger mechanisms described below) every Marylander would be guaranteed
access to affordable health insurance. Carriers would have to sell the
comprehensive standard health benefit plan and any other plans they write to
any individual or group who wants to purchase insurance.
Once the reforms are effective in the general market, an individual
would be eligible to purchase health insurance after having been a resident
of the State for 60 days. Other reforms would take effect in the same
manner as in the small group market.
TRIGGER #1:
If 37% of the population under 65 years of age would receive health
care coverage through an insurer or health maintenance organization.
Annually by October 1 the Insurance Commissioner must determine how many
individuals under the age of 65 are in the fully insured market or are
covered by an employer who would be willing to leave self-insurance to join
the community pool for a minimum three-year period. These employers would
register with the Insurance Commissioner who would determine when the
trigger has been met.
The insurance reforms would take effect the second
January 1st after the determination.
TRIGGER #2:
I f the federal Employee Retirement Income Security Act is amended to
allow States to control employee health benefit plans. I f such a federal
law change occurs at some future date and Maryland obtains control over
employee health benefit plans, then the reforms contained in House B i l l 1359
would apply to the general market.
�C S C N A N E T STRATEGIES
OT OTIMN
7
The United States spent 9.2 percent of its Gross Domestic Product (GDP)
on health care in 1980, 13 percent in 1990, and is expected to spend 32
percent by 2030. The United States spends more on health care than any
other nation.
Maryland, through the all-payor system, has slowed the increase in
hospital costs. The average cost of a hospital admission in Maryland
increased 3.7 percent last year compared to 8 percent nationally.
This b i l l attempts to slow the increase in health care costs in two
ways. First, i t requires insurers and health maintenance organizations to
submit an annual report to the Insurance Commissioner. The report will
provide information on their loss ratio and expense ratio for Maryland,
benchmarks of an insurer's efficiency. The Insurance Commissioner m y
a
require a carrier to f i l e new rates i f :
(1) i t s loss ratio is below 70 percent for commercial insurers or
health maintenance organizations or 75 percent for non-profit health
services plans; or
(2) its expense ratio exceeds 15 percent for commercial insurers or
health maintenance organizations or 13 percent for non-profit health
service.
Second, the b i l l charges the Medical Care Data Review Commission with
the development of a payment system by July 1, 1996 for physician services
covered under the comprehensive standard benefit plan. The payment system
must be reasonably related to the cost of providing the service, equitable,
and contain incentives to control utilization or volume of health care
services.
Prior to implementing the payment system, the Commission must
submit a progress report to the Governor and the General Assembly by October
1, 1995.
�OVERVIEW OF MARYLAND'S
ALL-PAYER HOSPITAL RATE SETTING SYSTEM
Prepared by
the Health Services Cost Review Commission
February, 1993
�HEALTH SERVICES COST REVIEW COMMISSION
MARYLAND'S ALL-PAYER HOSPITAL RATE SETTING SYSTEM
20 YEARS OF EXPERIENCE
I . BACKGROUND
In 1971, the Maryland General Assembly reacted to the skyrocketing increase in
hospital costs by creating the Health Services Cost Review Commission (the "HSCRC", or
"Commission"), the first hospital rate setting agency in the country. Before 1971, hospitals
in Maryland were reimbursed on the basis of "reasonable costs" incurred. This open ended
financing system guaranteed funds for hospitals, but imposed no constraints on efficiency.
With the creation of the HSCRC, hospitals were to be reimbursed based on the
reasonableness of the relationship between costs and services, as determined by the HSCRC.
HSCRC's rate setting methodology establishes standards of reasonableness that promote
efficient use of resources.
In 1974, after three years of development, the HSCRC began performing rate reviews.
At the same time, the HSCRC began negotiating with the Department of Health and Human
Services for a demonstration project grant which would include a "waiver" of Medicare and
Medicaid reimbursement principles in favor of HSCRC rate setting methodology. The waiver
was considered essential in order to achieve the goal of equitable pricing for all-payer groups.
Finally, after three years of negotiations, the waiver was granted effective July 1, 1977. As
a result, Maryland became one of the first two states to establish an all-payer system. Today,
Maryland stands alone as the one state in the country that maintains the equity in pricing
attributable to an all-payer system.
Under Section 1814B of the Social Security Act,
- 1 -
�Maryland maintains its waiver provided that: (1) the system remains all-payer; and (2) that
the rate of increase in Medicare payments per admission in Maryland remains below the rate
of increase in Medicare payments per admission nationally.
The importance of the waiver cannot be overemphasized. It is because of the waiver
that cost shifting has been eliminated. Further, by regulating the entire revenue of the
hospital, hospitals are encouraged to achieve greater levels of efficiency. Indeed, with a very
few set of assumptions, hospitals are able to predict their revenue stream several years into
the future. As a result, these institutions can focus their attention on the expense side of the
income statement, thereby enhancing their own cost containment efforts.
The equity in pricing of the Maryland system has achieved dramatic results. In
February of 1993, the HSCRC released its annual Disclosure Statement revealing that for the
seventeenth consecutive year, the cost of a hospital admission in Maryland rose at a rate
below the national average. Specifically, the cost per admission in Maryland rose 3.77%,
while the national average was 8.44%. This 4.5% difference translates to savings to Maryland
citizens of over $157.1 million in 1992 alone. It is noteworthy that in 1976, the cost of an
admission to a Maryland hospital was more than 25% above the national average. As a result
of hospitals responding to the incentives of the Maryland rate setting system, the cost per
admission to a Maryland hospital in 1992 was 14% below the national average.
This cost per admission performance is even more remarkable given the fact that
Maryland's per capita income is 16% above the national average (i.e., sixth highest among
the states). It is important to note that these dramatic savings were achieved not in any one
year but rather by beating the national average by 1 and 3% a year each and every year. It
- 2-
�is also important to note that as a result of the all-payer system, Maryland enjoys the lowest
percentage mark-up in hospital rates in the country. In 1991, according to statistics compiled
by the Maryland Hospital Association, the average mark-up between cost and gross charges
nationally was 53%. In Maryland, the average mark-up was 14%. Thus, although the
Commission does not permit discounts from approved rates unless such discounts are cost
justified, payers doing business with Maryland hospitals benefit from a more equitable
"playing field."
The Commission continues to monitor the financial condition of Maryland hospitals.
Hospital profits increased from $58.7 million in 1991 to $108.3 million in 1992. In 1992,
twenty one hospitals showed profits in excess of $2 million, while four hospitals showed losses
in excess of $2 million. In total, forty acute hospitals showed profits while ten hospitals
posted losses. In general, hospital profit levels in Maryland remain below national averages,
as was the case prior to the implementation of rate setting. The system, however, has
provided certain safeguards to assist hospitals entering the capital market.
II. RATE REVIEW METHODOLOGY
The Maryland rate setting system uses a quasi-public utility approach to hospital rate
regulation, in which rates are set and then adjusted for such items as inflation, volume
changes, and productivity gains. The Commission itself is comprised of seven part-time
Commissioners, appointed by the Governor, who serve staggered four year terms. Under the
Commission's enabling legislation (Health-General Article §19-201 et. seq.). no more than
three of the Commissioners may be "provider" members. The Commissioners' budget, which
is funded through user-fees, is $2.1 million (to regulate a $4 billion industry) for fiscal year
-3 -
�1993. The Commission employs a staff of twenty-eight PTE's headed by an Executive
Director.
The details of the rate setting systems are complicated, but conceptually the methods
are straight forward. The HSCRC sets unit rates for each hospital department. Hospitals
are required to charge those rates, and payers pay on the basis of those rates. Incentives are
incorporated to reward institutions that increase productivity or otherwise lower costs. The
system relies on macro-management ~ that is, establishing overall constraints on hospital
revenue, but allowing institutions considerable flexibility in achieving these goals. The system
has as well become largely self-enforcing ~ the HSCRC has conducted only one contested
case hearing in the past nine years.
1
A complete description of the rate review methods is beyond the scope of this paper.
What follows is a brief overview. Hospital rate setting in Maryland currently consists of four
systems: (a) Rate Review; (b) Inflation Adjustment; (c) the Guaranteed Inpatient Review
System; and (d) the Screening System.
A. Rate Review
In reviewing a hospital's request for permanent rates, the HSCRC applies a standard
of reasonableness based on the experience of similar hospitals. A rate review system is used
to develop an initial set of rates approved for units of service in the various revenue
producing departments. The Commission lists the approved rates of the hospital under
review in a "rate order", which sets forth the approved unit rates for up to fifty different
revenue centers of the hospital -- e.g., the rate for a day in the general medical/surgical unit,
1
See the Guide to Rate Re view publisheci by the Maryland Hospital Association.
-4-
�the rate by minute in the operating room, and the rate by relative value unit in the
laboratory. These rates are established initially for each hospital through a process known
as a "full rate review." This process involves the evaluation of all of the cost elements
associated with a particular hospital in order to determine reasonableness. Hospitals whose
costs are below the peer group average ~ adjusted for differences in labor costs, case-mix,
teaching, etc. ~ are deemed reasonable. Hospitals with costs above the peer group average
are given the opportunity to justify these additional expenses, although the burden of proof
is on the institution. Included in the rates approved by the Commission are reasonable
provisions for capital costs including replacement cost depreciation for equipment and a
capital facilities allowance for fixed capital. Every hospital in the State has undergone at least
one full rate review. Most hospitals, however, have their rates adjusted each year through
the Inflation Adjustment System, discussed below.
An important feature of Maryland's rate setting system is that once the Commission
approves departmental unit rates, the rates are "realigned" to ensure a uniform relationship
between costs and charges thereby eliminating cross-subsidization. Thus, for example, the
rate in obstetrics at a particular hospital bears a direct relationship to the costs allocated at
that hospital for the service. Finally, under the system all hospitals are required to annually
submit data on base and budgeted years, using a uniform reporting system. The total
approved revenues are based on four component parts:
direct and allocated indirect
departmental expenses, other financial considerations (inclusion of provisions for reasonable
uncompensated care and working capital), a payor differential, and a capital facilities
allowance for buildings and equipment. All in all, Maryland's rate review system provides an
- 5 -
�equity among classes of patients that far surpasses the pluralistic payment approach of nonregulated states.
B. Inflation Adjustment
The Inflation Adjustment System was instituted to allow hospitals reasonable rate
increases while avoiding the administrative burden of full rate review. It considers inflation
adjustments, volume adjustments, changes in payor and case mixes, and certain limited passthrough costs.
Inflation adjustments are made for: 1) salaries and fringe benefits and 2) food,
supplies, utilities, and other expenses. The inflation adjustment compensates the hospital for
the past year if actual inflation was greater than the projected rate. (Conversely, if the actual
rate is lower than the projected rate, then a deduction will be made in the budget year rate.)
Second, if a correction needs to be made, a price leveling adjustment brings the rates to the
level where they would have been if the inflation rate had been projected accurately. Finally,
the provision for future inflation is established at a level equal to the most recent changes in
inflation.
Volume for the budget year is established at a level equal to the actual volume for the
current year. Different fixed-variable cost proportions have been established for the routine
and ancillary areas as well as for different magnitudes of volume changes.
Pass-through costs are limited to: 1) changes in the federal minimum wage law to the
extent that they exceed wage and salary allowances, 2) actuarially-supported pension cost
increases (only to the extent that such increases were above the allowed increase for
inflation), and 3) incremental costs resulting from compliance with requirements mandated
-6-
�by the Commission.
C. Guaranteed Inpatient Review System
The Commission instituted the Guaranteed Inpatient Revenue (GIR) System because
of concern that the original system, based on rates per units of service, was leading to
increased volume and overuse of hospital services. The GIR system seeks to control the
volume of ancillaries and lengths of stay. It guarantees payment for each case treated by the
hospital. The GIR system determines the average charge for each diagnosis for each type
of payor. The average charge is adjusted for inflation and a minimum 1 percent factor for
growth and technology. The total GIR payment is the product of discharges (by diagnosis
and payor) and adjusted charges. At year end, the GIR payment is compared to the revenue
from the Commission-approved rates charged by the hospital during the year. If the revenue
from rates is less than the GIR payment, the hospital will receive the fixed cost portion of
the savings. However, if the revenues exceed the GIR payment, the Commission will recoup
the additional funds from the hospital in the following year. Another important feature of
the GIR is that hospitals remaining on the GIR receive additional "new service revenue."
The hospital is free to use this revenue to finance new programs and services or for any other
use it deems appropriate. The amount of new service revenue provided GIR hospitals is
approximately 2% a year. The Commission requires hospitals to use the new service revenue
as well as productivity gains under the GIR to finance any new services and programs,
thereby placing an additional constraint on rising hospital costs.
D. Screening System
The Screening System is based on a comparison of hospitals' average charge per
- 7-
�admission after a series of adjustments for cost factors which are either beyond management
control (such as labor market differences) or which the Commission chooses to finance (such
as bad debt and charity expenses). This system, introduced in 1982, was designed to identify
those hospitals appropriate for targeting for HSCRC rate review efforts. The Screening
System also identifies those hospitals eligible for the Inflation Adjustment System. Until 1986,
the comparison of ho; pitals' average charge per admission was done within five groups, and
the cutoff point was mean plus twice the inflation factor for the particular year. Then a
statewide comparison was adopted with additional regression analysis-based adjustments to
each hospital's charge per admission for indirect teaching costs and the presumed cost of
treating low income patients. These regression-based adjustments are similar to those used
for the Medicare Prospective Payment System.
III. UNCOMPENSATED CARE METHODOLOGY
The Uncompensated Care Methodology has been developed in order for hospitals to
recover their reasonable full financial requirements. As with all other components of the
Commission's rate setting system, the uncompensated care provision is subject to a
reasonableness standard. Since 1983, the reasonableness standard has been based upon a
regression analysis conducted annually by the Commission. This regression analysis produces
a predicted level of uncompensated care which serves as the upper limit in the provision of
rates. For each year since 1983, one of the variables that has been used in the analysis has
been the percentage of revenue attributed to Medicaid patients. The actual level of
uncompensated care included in rates is based upon an analysis of the predicted amount, the
actual amount incurred by the hospital, and the amount in rates, as well as the relative profits
-8-
�of the institution and its relative standing in charge per admission.
Notwithstanding the technical soundness of the Commission's uncompensated care
methodology, the Commission has been hard-pressed to keep its adjustments within the zone
of reasonableness envisioned. Hospitals' uncompensated care increased from $36 million in
1977 to $394 million in fiscal year 1992. State budgetary problems have brought about steady
reductions to, or elimination of, State-funded Medical Assistance programs, thereby
compelling the HSCRC to increase rates even beyond the most dire of expectations.
Concomitant with the increase to rates to the hospital industry as a whole has been an
increasing disparity in rates across hospitals, regions, and payers. The Commission believes
fervently that the burden of financing uncompensated care should be distributed equitably
among the various purchasers of health care hospital services. This equity can best be
achieved by providing ready access to affordable, broad based health insurance to all
Maryland citizens.
papere\overview.93
nb
-9-
�HOUSE B I L L 1359
C3
31r3048
By:
The Speaker <HHJ—HH;—EeDnomie—Mutters—Committee, tlie Euonomie Mntters
Cominittee. nnd Delegntes and Delegates Taylor. Cummings, Albin, Alexander,
Barvc, Bozman, Hnsch, Ciirran, Donoghue, Donry, Exum. Caliaz/o, Harrison,
Hurson, ,)oiies, Kach. Kirk. Kolodzic.iski, Krysiak, La Vay, Littrell, McClenahan,
Morsberger, I'insky. Pitkin, Scannello, Wood, Smith, Thomas, Bonsack, Elliott,
LaMotte. and Redmcr
Introduced and read first time: February 15, 1993
Assigned to: Economic Matters
Committee Report: Favorable with amendments
House action: Adopted with floor amendments
Read second time: March 5, 1993
CHAPTER
1
2
AN ACT concerning
Health Insurance Reform —Mnnnged Cooperntion
3 FOR the purpose of creating a new subtitle in the Insuranco Code governing health
4
insurance; establishing certain health insurance reforms including community
5
rating, guaranteed issue of certain health benefit plans, limitation of preexisting
6
condition provisions, and establishment of portability of health benefit plans;
7
establishing enrollment procedures; imposing certain requirements on carriers who
S
offer health benefit plans in tho State; requiring renewal of health benefit plans and
9
providing certain exceptions; establishing the Health Care Benefit and Data
10
Commission; defining certain responsibilities of the Commission; requiring the
Commission to specify a set of effective health care benefits lo be included in health
1
2
benefit plans; establishing criteria for specifying those benefits; requiring the
13
Commission to establish and maintain a unified health care data base; specifying
1
4
information to be included in the data base; providing for funding for the data base;
•15
and generally relating to practices, procedures, and information concerning health
16
care financing in tho State.
1 FOR the purpose of creating a new subtitle in the Insurance Code governing health
.
7
.18
insurance; establishing certain health insurance reforms including adjusted
1
9
community rating, guaranteed issue of certain health benefit plans, limitation of
20
preexisting condition provisions, and establishment of portability of health benefit
21
plans; establishing enrollment procedures; imposing certain requirements on
22
carriers who offer health benefit plans in the State; requiring renewal of health
23
benefit plans and providing certain exceptions and modifications; limiting the
EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
Underlining indicates amendments to bill.
Strike oul indicates matter stricken from the bill by amendment or deleted from the law by
amcnclmcnl.
�2
1
2
3
4
5
6
7
S
9
10
11
.
12
13
1
4
15
16
17
1
8
1
9
20
21
22
MOUSE HILL 1359
application of this Act to certain small employer health insurance carriers until a
certain percentage of the health insurance market is covered under this Act or until
certain other reforms have occurred; providinfi for the general application of the
provisions of this Act pending the occurrence of one of those events; creating the
Medical Care Data Review Commission in the Department of Health and Mental
Hygiene for certain purposes; specifying the membership and terms of the
Commission; authorizing the Commission to appoint an executive director of the
Commission under certain circumstances; requiring the Commission to establish a
statewide Medical Care Data Base to compile certain data; requiring the
Commission to adopt certain regulations specifying a comprehensive standard
health benefit plan; requiring certain confidentiality; requiring the Commission to
publish a certain report, consult with certain representatives, and develop a certain
system to provide certain information to physicians; requiring the Commission to
perform certain duties; authorizing the Commission to adopt certain regulations;
requiring the Commission to prepare a certain report; authorizing the Commission
to contract with certain qualified independent third parties for any service necessary
to carry out certain powers and duties; specifying that the Secretary of Health and
Mental Hygiene does not have certain powers over the Commission; authorizing the
Commission to conduct certain examinations; requiring the Commission to assess
certain fees on payors for health care; requiring the Insurance Commissioner to
transfer certain fees to the Commission; and generally relating to the Medical Care
Data Review Commission and the financing and duties of the Commission.
23 BY adding to
24
Article 'ISA—Insurnnco Code
25
Section 698 through 70S to be under tho now uubtitle "55. Health Insurcmco
26
Reform"
27
Annotated Codo of Maryland
28
(1991. Replacement Volume and 1992 Supplement)
29 BY adding to
30
Article 48A - Insurance Code
31
Section 490R; and 698 through 706 707 to be under the new subtitle "55. Health
32
Insurance Reform"
33
Annotated Code of Maryland
34
(199.1 Replacement Volume and 1.992 Supplement)
35 BY adding to
36
Article - Health - General
37
Section 19-706(h); and 19-1501 through
19-1515 to be under the new
38
subtitle "Subtitle 15. Medical Care Data Review Commission"
39
Annotated Code of Maryland
40
(1990 Replacement Volume and .1992 Supplement)
41 BY repealing and reenacting, with amendments,
42
Article - Health - General
43
Section 19-71.4, .19-716, and .1.9-729(a)
44
Annotated Code of Maryland
45
(1990 Replacement Volume and 1992 Supplement) •
; •
�HOUSE BILL 1359
1 BY repealing and reenacting, with amendments,
2
Article - Health Occupations
3
Section 1.4-309
4
Annotated Code of Maryland
5
(1.991 Replacement Volume and 1992 Supplement)
3
6 BY repealing and reenacting, with amendments,
7
Article 48A - Insurance Code
S
Section 698(c) and 705
9
Annotated Code of Maryland
10
(1.991 Replacement. Volume and 1992 Supplement)
11
(As enacted by Section 2 of this Act)
12 BY repealing
13
Article 48A - Insurance Code
14
Section 698A
15
Annotated Code of Maryland
16
(1991 Replacement Volume and 1992 Supplement)
17
(As enacted by Section 2 of this Act)
IS BY adding to
.19
Article 48A - Insurance Code
21)
Section 702A
21
Annotated Code of Maryland
22
(.1991. Replacement Volume and 1.992 Supplement)
23
Preamble
24
WHEREAS, The nation spent 9.2 percent of our Gross Domestic Product on
25 health care in 1980, 13 percenl in .1990, and is expected to spend 32 percent by 2030; and
26
WHEREAS, Maryland businesses are experiencing increases in health insurance
27 premiums of 15 to 20 percenl each year; and
28
WHEREAS, The high cost of heallh insurance coverage is one of the primary
29 reasons small businesses do not offer coverage to their employees; and
30
WHEREAS, Maryland spent $2 billion on Medicaid during fiscal year 92; and
31
WHEREAS, More than 600,000 Marylanders have no health insurance coverage;
32 and
33
WHEREAS, Maryland has 32 mandated benefits more than any other State; and
34
WHEREAS, Mandated benefits do not apply to self-insured groups, Medicare,
35 Medicaid, CHAMPUS, and health maintenance organizations; and
36
WHEREAS, The mandates impact the health benefit coverage of 20 percent of
37 Maryland's population; and
38
WHEREAS, The growth of self-insurance creates undue and unfair pressures on 20
39 percenl of the population relying on the fully insured mark'et; and
�4
HOUSE HILL 1359
1
WHEREAS, Many uninsured Marylanders are willing to purchase health care
2 coverage but are unable to afford the health insurance premiums or have a health care
3 condition that renders them medically uninsurable; ancl
4
WHEREAS, The increasing number of uninsured citizens is placing a tremendous
5 strain on our health care delivery and financing systems; and
fi
WHEREAS, The amount of uncompensated care provided by Maryland hospitals
7 has increased from $72 million in 1.981 to $354 million in 1992; and
S
WHEREAS, Any initiative to expand access lo quality health care coverage must
9 include measures to contain health care costs; and
1
0
WHEREAS, Maryland's hospital rate setting program has slowed the increase in
1 hospital costs; and
1
1
2
WHEREAS, The average cost of a hospital admission in Maryland increased 3.7
13 percent last year compared to 8 percent nationally; and
L
4
WHEREAS, The passage of the Federal Employee Retirement and Income
15 Security Act (ERISA) permitted employers to self-insure and leave the community pool;
16 ancl
17
WHEREAS, ERISA has destroyed the health insurance market; ancl
IS
WHEREAS. The federal government and the United States Congress have failed to
1 amend ERISA and restore the community pool health insurance; and
.
9
20
WHEREAS, Competition between insurers for healthy risks makes it difficult for
21 individuals and small groups to obtain health insurance coverage at any price; and
22
WHEREAS, Self-insurance and the emphasis on experience rating encourages
23 employers and consumers to only be concerned about their own health care costs and not
24 the entire community; and
25
WHEREAS, Maryland has a comprehensive data base on hospital costs and services
26 but no comparable information on costs and services rendered, by other health care
27 • providers; and
28
WHEREAS, An appropriate mix of private market competition and government
29 controls is necessary to expand access, control costs, and improve quality; and
30
WHEREAS, Self-insurance and experience rating do not provide appropriate
31 incentives to encourage the delivery of quality care by efficient providers; and
32
WHEREAS, Providers, payors, and planners must undertake cooperative efforts to
33 develop appropriate guidelines for the practice of efficient medicine; and
34
WHEREAS, Maryland's corporate, government, ancl nonprofit communities can
35 provide the leadership needed to resolve our health care crisis by voluntarily joining a
36 community insurance pool thereby allowing the managed cooperation of health care
37 providers, payors, and planners; now, therefore, and
38
WHEREAS, The State should apply for a Medicaid waiver that would allow
39 recipients of Aid to Families with Dependent Children (AFDC) benefits to be included in
40 the community pool so that the size of the pool can be enlarged and the overall benefits
41 .of this health insurance reform program can be enhanced; now, therefore,
�HOUSE BILL 1359
1
SECTION
I . BE
IT
ENACTED
5
BY T H E
GENERAL
2
OF
M A R Y L A N D . That the Laws of Maryland read as follows:
3
ASSEMBLY
Article 48A—Insurunce Code
4
5 mr.
6
55. HEALTH INSURANCE REFORM
(A)
IN THIS SUBTITLE THE FOLLOWING WORDS
HAVE THE MEANINGS
7 INDICATED.
S
9
10
11
12
(£}
"CARRIER" MEANS:
fF> AN INSURER THAT HOLDS A CERTIFICATE OF AUTHORITY IN THIS
STATE AND PROVIDES HEALTH INSURANCE IN THIS STATE;
(3)
A HEALTH MAINTENANCE ORGANIZATION THAT IS LICENSED TO
OPERATE IN THIS STATE;
13
{5)
A MULTIPLE EMPLOYER WELFARE ARRANGEMENT;
14
.15
{4) A MULTIPLE EMPLOYER TRUST LOCATED IN MARYLAND OR ANY
OTHER STATE COVERING MARYLAND RESIDENTS:
16
17
A NONPROFIT
OPERATE IN THIS STATE: OR
15
19
(6)
ANY OTHER PERSON OR ORGANIZATION THAT PROVIDES HEALTH
BENEFIT PLANS SUBJECT TO STATE INSURANCE REGULATION.
20
21
(€)
"COMMISSION"
HEALTH SERVICE
MEANS
THE
PLAN THAT IS LICENSED TO
HEALTH
CARE
BENEFIT
AND
DATA
COMMISSION ESTABLISHED UNDER THIS SUBTITLE.
22
fB)
H E A L T H BENEFIT PLAN" MEANS ANY:
23
24
25
26
(1)
HOSPITAL OR MEDICAL POLICY OR CERTIFICATE, INCLUDING
THOSE ISSUED UNDER MULTIPLE EMPLOYER TRUSTS OR ASSOCIATIONS LOCATED
IN MARYLAND OR ANY OTHER STATE COVERING MARYLAND RESIDENTS WHO ARE
ELIGIBLE EMPLOYEES;
27
'
28
29
HEALTH MAINTENANCE ORGANIZATION SUBSCRIBER
GROUP MASTER CONTRACT; OR
30
31
32
{ W j PLAN PROVIDED BY OR THROUGH A MULTIPLE EMPLOYER
WELFARE ARRANGEMENT, OR OTHER BENEFIT ARRANGEMENT OFFERED BY A
MULTIPLE EMPLOYER WELFARE ARRANGEMENT.
(H)
33
34
&
• •
NONPROFIT HEALTH SERVICE PLAN;
"HEALTH BENEFIT PLAN" DOES NOT INCLUDE:
(4)
ACCIDENT ONLY INSURANCE;
35
(H)
FIXED INDEMNITY INSURANCE;
36
(W) CREDIT HEALTH INSURANCE;
37
f*V) MEDICARE SUPPLEMENT POLICIES;
OR
�6
HOUSE BILL 1359
1
(V)
2
fV4) DISABILITY INCOME INSURANCE;
3
(VH} COVERAGE—ISSUED—AS—A
4
LONG TERM CARE INSURANCE;
SUPPLEMENT
TO
LIABILITY
INSURANCE;
5
fVH4)WORKERS' COMPENSATION OR SIMILAR INSURANCE;
6
DISEASE SPECIFIC INSURANCE; OR
7
AUTOMOBILE MEDICAL PAYMENT INSURANCE.
S
9
10
(fi)
"PREEXISTING CONDITION" MEANS:
{4} A CONDITION THAT WOULD CAUSE AN ORDINARILY PRUDENT
PERSON TO SEEK MEDICAL ADVICE, DIAGNOSIS, CARE, OR TREATMENT; OR
11
.
.12
13
(3)
A CONDITION FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE, OR
TREATMENT WAS RECOMMENDED OR RECEIVED DURING A SPECIFIED PERIOD
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF THIS COVERAGE.
14
15
16
fF) "PREEXISTING CONDITION PROVISION" MEANS A PROVISION IN A
HEALTH BENEFIT PLAN THAT DENIES, EXCLUDES, OR LIMITS BENEFITS FOR AN '
ENROLLEE FOR EXPENSES-OR SERVICES RELATED TO A PREEXISTING CONDITION.
17
IS
19
(A) IN ADDITION TO ANY OTHER REQUIREMENTS UNDER THIS ARTICLE, A
CARRIER THAT OFFERS A HEALTH BENEFIT PLAN IN THIS STATE SHALL:
20
21
22
<Aj HAVE DEMONSTRATED THE CAPACITY TO ADMINISTER THE
HEALTH BENEFIT PLAN, INCLUDING ADEQUATE NUMBERS AND TYPES OF
ADMINISTRATIVE STAFF;
23
24
(3)
HAVE THE ABILITY, EXPERIENCE, AND STRUCTURE TO ENSURE THE
DELIVERY OF THE APPROPRIATE LEVEL AND TYPE OF HEALTH CARE SERVICE;
25
26
(3)
HAVE THE ABILITY AND PROCEDURES TO
EVALUATE THE QUALITY AND COST EFFECTIVENESS OF CARE;
27
2S
29
(4)
HAVE THE ABILITY TO ENSURE THAT ENROLLEES HAVE ADEQUATE
ACCESS TO PROVIDERS OF HEALTH CARE, INCLUDING GEOGRAPHIC AVAILABILITY
AND ADEQUATE NUMBERS AND TYPES;
30
31
(5)
HAVE THE ABILITY AND PROCEDURES TO MONITOR ACCESS
INCLUDING APPOINTMENT WAITING TIMES;
32
33
(6)
HAVE A SATISFACTORY GRIEVANCE PROCEDURE AND ABILITY TO
RESPOND TO ENROLLEES' CALLS, QUESTIONS, AND COMPLAINTS: AND
34
35
36
(?)
PROVIDE, IN THE CASE OF INDIVIDUALS COVERED UNDER MORE
THAN ONE HEALTH BENEFIT PLAN, FOR COORDINATION OF COVERAGE UNDER ALL
OF THOSE PLANS IN AN EQUITABLE MANNER.
37
38
'(B) f f ) A CARRIER MAY NOT OFFER ANY HEALTH BENEFIT PLAN IN THE
STATE UNLESS THE CARRIER OFFERS AT LEAST ONE HEALTH BENEFIT PLAN THAT
MONITOR
AND
�HOUSE BILL 1359
7
1 INCLUDES ONLY THE EFFECTIVE BENEFITS SPECIFIED BY THE COMMISSION UNDER
2 § 701 OF THIS SUBTITLE.
3
4
(3)
BENEFITS IN ADDITION TO THE EFFECTIVE BENEFITS MAY BE
OFFERED IF THE ADDITIONAL BENEFITS:
5
6
(1)
ARE OFFERED AND PRICED SEPARATELY FROM BENEFITS
SPECIFIED UNDER § 701 OF THIS SUBTITLE; AND
7
S
BENEFITS.
9
10
{Uj
DO NOT HAVE THE EFFECT OF DUPLICATING ANY OF THOSE
A CARRIER MAY NOT OFFER A HEALTH BENEFIT PLAN THAT HAS
FEWER THAN THE EFFECTIVE BENEFITS.
11
(€)
A CARRIER SHALL RENEW HEALTH BENEFIT PLANS, EXCEPT IN ANY OF
12
THE FOLLOWING CASES:
13
f+)
NONPAYMENT OF THE REQUIRED PREMIUMS;
14
15
16
17
IS
19
(3)
FRAUD—OR—MISREPRESENTATION—OF
AN—ENROLLEE OR—A
REPRESENTATIVE OF AN ENROLLEE;
REPEATED—MISUSE—OF—A—PROVIDER—NETWORK—PROVISION
INCLUDING UNREASONABLE REFUSAL OF THE ENROLLEE TO FOLLOW A
PRESCRIBED COURSE OF TREATMENT, ABUSIVE OVER UTILIZATION BY AN
ENROLLEE, OR VIOLATION OF REASONABLE POLICIES OF A CARRIER; OR
20
21
(4) THE CARRIER ELECTS TO TERMINATE ALL HEALTH BENEFIT PLANS
IN THE STATE.
22
23 SHALL:
A CARRIER THAT ELECTS NOT TO RENEW HEALTH BENEFIT PLANS
24
25
(!)
PROVIDE ADVANCE NOTICE OF ITS DECISION UNDER .THIS
PARAGRAPH TO THE INSURANCE COMMISSIONER;
26
27
28
(H) PROVIDE NOTICE OF THE DECISION TO ENROLLEES AT LEAST
120 DAYS PRIOR TO THE NONRENEWAL OF ANY HEALTH BENEFIT PLAN BY THE
CARRIER.
29
(3) THE CARRIER SHALL BE PROHIBITED FROM WRITING NEW
3(1 BUSINESS IN THE STATE FOR A PERIOD OF 3 YEARS FROM THE DATE OF NOTICE TO
31 THE INSURANCE COMMISSIONER OR UNTIL THE INSURANCE COMMISSIONER
32 INVITES THE CARRIER TO RENEW PARTICIPATION, WHICHEVER IS SOONER.
33
m
34
35
(A) THERE IS A—HEALTH CARE BENEFIT AND DATA COMMISSION
ESTABLISHED AS A NONPROFIT CORPORATION INDEPENDENT OF ALL STATE UNITS.
36
THE COMMISSION SHALL CONSIST OF NINE MEMBERS APPOINTED BY THE
37
GOVERNOR.
38
(G)
39
OFTHE 11 MEMBERS:
(4)
ONE SHALL BE A REPRESENTATIVE OF PHYSICIANS;
�S
HOUSE BILL 1359
1
(3)
ONE SHALL BE A REPRESENTATIVE, OF A HOSPITAL;
2
(3)
TWO SHALL BE REPRESENTATIVES OF PAYORS;
3
4
(4)
ONE SHALL BE A MEMBER OF THE HEALTH RESOURCES PLANNING
COMMISSION REPRESENTING THAT COMMISSION;
5
6
(5)
THREE SHALL REPRESENT EMPLOYERS IN THE STATE; AND
S
f?)
9
TWO SHALL REPRESENT LABOR.
THE TERM OF A MEMBER IS 4 YEARS.
(3)
THE TERMS OF MEMBERS ARE STAGGERED AS REQUIRED BY THE
TERMS PROVIDED FOR MEMBERS OF THE COMMISSION ON OCTOBER 1, 1993.
{4} A MEMBER WHO IS APPOINTED AFTER A TERM HAS BEGUN SERVES
ONLY FOR THE REST OF THE TERM AND UNTIL A SUCCESSOR' IS APPOINTED AND
QUALIFIES.
15
16
r
COMMISSION REPRESENTING THAT COMMISSION;
7
.10
11
12
.13
14
ONE SHALL BE A MEMBER OF THE HEALTH SERVICES COST REVIEW
(4)
THE GOVERNOR MAY REMOVE A MEMBER FOR NEGLIGENCE OF
DUTY, INCOMPETENCE. OR MISCONDUCT.
17
(E)
W E GOVERNOR SHALL APPOINT THE CHAIRMAN OF THE COMMISSION.
IS
19
{ f j (4} THE COMMISSION SHALL APPOINT AN EXECUTIVE DIRECTOR WHO
SHALL BE THE CHIEF ADMINISTRATIVE OFFICER OF THE COMMISSION.
20
21
(3)
COMMISSION-
22
23
24
.
• • (3)
UNDER THE DIRECTION OF THE COMMISSION, THE EXECUTIVE
DIRECTOR SHALL PERFORM ANY DUTY OR FUNCTION THAT THE COMMISSION
REQUIRES.
25
26
, (G) A- MAJORITY OF
COMMISSION IS A QUORUM.
27
28
(14) ¥HE COMMISSION SHALL MEET AT LEAST SIX TIMES EACH YEAR, AT THE
TIMES AND" PLACES THAT IT DETERMINES.
29
30
31
(4)
EACH MEMBER OF THE COMMISSION IS ENTITLED TO REIMBURSEMENT
FOR EXPENSES UNDER THE STANDARD STATE TRAVEL REGULATIONS, AS
PROVIDED IN THE STATE BUDGET.
32
33
(4j W E COMMISSION MAY EMPLOY A STAFF IN ACCORDANCE WITH THE
STATE BUDGET.
34
35
(44)
THE EXECUTIVE DIRECTOR SERVES AT THE PLEASURE OF THE"'
THE
FULL AUTHORIZED
MEMBERSHIP
OF
THE
THE STATE HAS NO PECUNIARY LIABILITY FOR ANY ACT PERFORMED OR
REQUIRED OR PERMITTED TO BE PERFORMED BY THE COMMISSION.
36
m-.
37
38
(A) f t ) THE COMMISSION SHALL SPECIFY THE UNIFORM SET OF EFFECTIVE
BENEFITS TO APPLY UNDER THIS SUBTITLE.
�HOUSE BILL 1359
9
1
2
3
(3)
IN ESTABLISHING BENEFITS, THE COMMISSION SHALL JUDGE
PREVENTIVE SERVICES, MEDICAL TREATMENTS, PROCEDURES, AND RELATED
HEALTH SERVICES BASED ON:
4
5
(J)
INDIVIDUALS; AND
THEIR EFFECTIVENESS IN IMPROVING THE HEALTH STATUS OF
6
(H) THEIR
LONG TERM
IMPACT ON
MAINTAINING
AN©
7 IMPROVING HEALTH AND PRODUCTIVITY AND ON REDUCING THE CONSUMPTION
S . OF HEALTH CARE SERVICES.
9
10
(5) THE COMMISSION MAY EXCLUDE ANY BENEFIT MANDATED UNDER
ARTICLE 48A OF THE CODE.
1 1
(B) A HEALTH BENEFIT PLAN SHALL INCLUDE UNIFORM DEDUCTIBLES AND
12 COST SHARING ASSOCIATED WITH ITS BENEFITS, AS DETERMINED BY THE
13 COMMISSION.
.14
15
IN ESTABLISHING COST •SHARING AS PART OF THE UNIFORM EFFECTIVE
BENEFITS, THE COMMISSION SHALL:
16
17
INCLUDE COST SHARING THAT WILL RESTRAIN CONSUMERS FROM
SEEKING UNNECESSARY SERVICES;
18
19
(3)
BALANCE THE EFFECT OF THE COST SHARING IN REDUCING
PREMIUMS AND IN AFFECTING UTILIZATION OF APPROPRIATE SERVICES; AND
20
21
(3)
LIMIT THE TOTAL COST SHARING THAT MAY BE INCURRED BY AN
INDIVIDUAL IN A YEAR.
22
23
24
25
26
27
28
EXCEPT AS PROVIDED IN PARAGRAPH (3) OR (4) OF THIS
SUBSECTION, CARRIERS MAY LIMIT COVERAGE UNDER ANY HEALTH BENEFIT PLAN
UNDER A PREEXISTING CONDITION PROVISION, BUT ONLY FOR A PERIOD NOT
EXCEEDING 6 MONTHS FROM THE. EFFECTIVE DATE OF COVERAGE FOR ANY
ENROLLEE, FOR ANY PREEXISTING CONDITION THAT EXISTED WITHIN THE 6
MONTHS PRECEDING THE DATE OF COVERAGE FOR THE ENROLLEE UNDER THE
PROGRAM.
29
30
(3) THE EXCLUSION OF COVERAGE FOR PREEXISTING CONDITIONS
DOES NOT APPLY TO HEALTH CARE SERVICES FURNISHED TO NEWBORNS.
31
32
33
34
35
36
(3)
A HEALTH BENEFIT PLAN THAT CHOOSES NOT TO USE A
PREEXISTING CONDITION PROVISION MAY IMPOSE ON ENROLLEES A WAITING
PERIOD NOT TO EXCEED 30 DAYS BEFORE THE COVERAGE UNDER THIS PROGRAM
IS EFFECTIVE. DURING THE WAITING PERIOD, THE HEALTH BENEFIT PLAN IS NOT
REQUIRED TO PROVIDE HEALTH CARE SERVICES OR BENEFITS AND A. PREMIUM
MAY NOT BE CHARGED TO THE ENROLLEE.
37
38
39
40
41
42
43
" (g) A PARTICIPATING CARRIER SHALL WAIVE ANY TIME PERIOD APPLICABLE
TO A PREEXISTING CONDITION PROVISION OR LIMITATION PERIOD WITH RESPECT
TO PARTICULAR SERVICES FOR THE PERIOD OF TIME AN ENROLLEE WAS
PREVIOUSLY COVERED BY A PLAN THAT PROVIDED AT LEAST THE SAME OR
SIMILAR BENEFITS, IF THE QUALIFYING PREVIOUS COVERAGE WAS CONTINUOUS
TO A DATE WITHIN THE 30 DAY PERIOD IMMEDIATELY PRECEDING THE EFFECTIVE
DATE OF THE NEW COVERAGE.
�10
?
HOUSE BILL 135!)
3
(A) (4)
IM. ESTABLISHING THE RATE FOR A HEALTH BENEFIT PLAN,. A
GARRIER SHALL USE A RATING METHODOLOGY:
4
5
(I)
IN WHICH THE PREMIUM IS THE SAME FOR ALL .IN D IV I D.U ALS
COVERED BY THAT HEALTH BENEFIT PLAN; AND
6
7
8
(4+) THAT IS BASED ON THE EXPERIENCE OF THE ENTIRE POOL OF
-RISKS COVERED BY THAT PLAN WITHOUT REGARD TO AGE, GENDER, GEOGRAPHY,
HEALTH STATUS, OR OCCUPATION.
(3)
RATES MAY VARY BASED ON FAMILY COMPOSITION.
.10
(ft) (4)
IN THIS SUBSECTION, "RISK ADJUSTMENT MECHANISM" MEANS A
11 STATISTICALLY BASED PROCESS THAT MAY BE USED TO ADJUST PAYMENTS TO
12 GARRIERS TO OFFSET DISPROPORTIONATE SHARES OF HIGH OR LOW RISK
13 E-NROLLEES BY PARTICULAR CARRIERS.
14
(3) THE COMMISSION SHALL GATHER THE NECESSARY DATA TO STUDY
15 W E NEED FOR A RISK ADJUSTMENT MECHANISM THAT COULD BE IMPLEMENTED
16 TO CARRY OUT THIS SUBTITLE. A RISK ADJUSTMENT MECHANISM MAY BE
17 IMPLEMENTED AS THE COMMISSION DEEMS NECESSARY. A RISK ADJUSTMENT
18 MECHANISM ADOPTED BY THE COMMISSION SHALL BE BASED ON OBJECTIVE
19 DEMOGRAPHIC, GEOGRAPHIC, AND OTHER DATA REFLECTING ENROLLEES'
20 ACTUARIAL RISK, AND THE METHODS AND MECHANISM SHALL BE SUBJECT TO A
21 PUBLIC COMMENT PERIOD. THE COMMISSION SHALL DISCLOSE THE RISK
22 ADJUSTMENT MECHANISM TO CARRIERS BEFORE IT IS IMPLEMENTED.
23
24
(3)
ANY RISK ADJUSTMENT MECHANISM THAT IS ADOPTED AND EACH
IMPLEMENTATION OF THE RISK ADJUSTMENT MECHANISM SHALL BE FILED WITH
25
THE INSURANCE'COMMISSIONER.
26
27
28
m
(A) EACH CARRIER SHALL ESTABLISH
ACCORDANCE WITH THIS -SECTION.
AN ENROLLMENT PROCESS IN
29
(ft) EACH INDIVIDUAL IN THE STATE SHALL BE OFFERED THE OPPORTUNITY
30 TO ENROLL IN A HEALTH BENEFIT PLAN WITHIN 30 DAYS AFTER THE INDIVIDUAL
3.1. ESTABLISHES RESIDENCY IN THE STATE.
32
(€)
EACH CARRIER SHALL:
33
34
35
(4)
ESTABLISH AN ANNUAL PERIOD, OF NOT LESS THAN 30 DAYS,
DURING WHICH INDIVIDUALS MAY ENROLL IN A HEALTH BENEFIT PLAN OR
CHANGE THE HEALTH BENEFIT PLAN IN WHICH THE INDIVIDUAL IS ENROLLED; AND
36
37
38
39
(3)
PROVIDE FOR A SPECIAL ENROLLMENT PERIOD IN WHICH AN
INDIVIDUAL IS PERMITTED TO CHANGE THE INDIVIDUAL OR FAMILY BASIS QF
COVERAGE OR THE HEALTH BENEFIT PLAN IN WHICH THE INDIVIDUAL IS
ENROLLED IF THE INDIVIDUAL:
40 '
(I)
THROUGH MARRIAGE, DIVORCE, BIRTH OR ADOPTION OF A
41 CHILD, OR SIMILAR CIRCUMSTANCES, EXPERIENCES A CHANGE IN FAMILY
42 COMPOSITION; OR
�HOUSE BILL 1359
11
1
(H) EXPERIENCES A CHANGE IN EMPLOYMENT STATUS INCLUDING
2 A SIGNIFICANT CHANGE IN THE TERMS AND CONDITIONS OF EMPLOYMENT.
3
4
5
(©) PLANS FOR OPEN ENROLLMENT AND SPECIAL ENROLLMENT PERIODS
SHALL CE FILED WITH THE INSURANCE COMMISSIONER.
TO4T
6
7
(A)
CARE DATA BASE TO ENABLE IT TO:
8
9
10
11
12
13
14
15
16
THE COMMISSION SHALL ESTABLISH AND MAINTAIN A UNIFIED HEALTH
^
COMPARE COSTS BETWEEN VARIOUS TREATMENT SETTINGS; AND
(3)
PROVIDE INFORMATION TO CONSUMERS AND PURCHASERS OF
HEALTH CARE.
(fi) THE DATA BASE SHALL CONTAIN UNIQUE PATIENT AND PROVIDER
IDENTIFIERS AND A UNIFORM CODING SYSTEM AND SHALL REFLECT ALL HEALTH
CARE UTILIZATION, COSTS, AND RESOURCES IN THIS STATE AND HEALTH CARE
UTILIZATION AND COSTS FOR SERVICES PROVIDED TO MARYLAND RESIDENTS IN
ANOTHER STATE.
m
17
18
19
20
(A) CARRIERS AND GOVERNMENTAL AGENCIES SHALL FILE REPORTS, DATA,
SCHEDULES, STATISTICS,—OR—OTHER—INFORMATION—DETERMINED BY THE
COMMISSION TO BE NECESSARY TO CARRY OUT THE PURPOSES OF THIS SUBTITLE.
THE INFORMATION MAY INCLUDE:
2.1
22
f t ) HEALTH INSURANCE CLAIMS AND ENROLLMENT INFORMATION
USED BY CARRIERS; AND
23
24
(3)
ANY OTHER INFORMATION RELATING TO HEALTH CARE COSTS,
UTILIZATION, OR RESOURCES REQUIRED TO BE FILED BY THE BOARD.
25
26
27
28
{#) TO THE EXTENT PRACTICABLE, WHEN COLLECTING THE DATA REQUIRED
UNDER SUBSECTION (A) OF THIS SECTION THE COMMISSION SHALL USE ANY
STANDARDIZED CLAIM FORM OR ELECTRONIC TRANSFER SYSTEM ALREADY BEING
USED BY PAYORS.
29
30
31
32
33
(€) ON OR BEFORE OCTOBER 1, 1995 AND EACH YEAR THEREAFTER, THE
COMMISSION SHALL PUBLISH AN ANNUAL REPORT ON HEALTH CARE SERVICES
THAT ARE SELECTED BY THE COMMISSION THAT DESCRIBES VARIATIONS IN
REIMBURSEMENT RATES THROUGHOUT THE STATE FOR THOSE HEALTH CARE
SERVICES.
34
35
36
37
{©) RECORDS OR INFORMATION PROTECTED BY THE PROVISIONS OF THE
PHYSICIAN-PATIENT PRIVILEGE, OR OTHERWISE REQUIRED BY LAW TO BE HELD
CONFIDENTIAL, SHALL BE FILED IN A MANNER THAT DOES NOT DISCLOSE THE
IDENTITY OF THE PROTECTED PERSON.
38
39
40
(E) THE COMMISSION SHALL ADOPT A CONFIDENTIALITY CODE TO ENSURE
THAT INFORMATION OBTAINED UNDER THIS SECTION IS HANDLED IN AN ETHICAL
MANNER-
�12
HOUSE BILL 1359
.1 Wfe
2
3
(A) { i j THE COMMISSION SHALL ASSESS A FEL ON ALL CARRIIZRS THAT
OFFER HEALTH BENEFIT PLANS IN THE STATE.
4
5
(3) THE TOTAL FEES ASSESSED BY THE COMMISSION MAY NOT EXCEED
$2,000,000 IN ANY FISCAL YEAR.
6
7
8
(3) THE COMMISSION SHALL PAY ALL FUNDS COLLECTED FROM FEES
ASSESSED IN ACCORDANCE WITH THIS SECTION INTO THE GENERAL FUND OF THE
STATE-.
9
.10
11
12
(B) (4) THE FEES ASSESSED ON CARRIERS IN ACCORDANCE WITH THIS
SECTION SHALL BE APPORTIONED AMONG CARRIERS BASED ON THE RATIO OF
EACH CARRIER'S TOTAL PREMIUMS COLLECTED IN THIS STATE TO THE TOTAL
COLLECTED PREMIUMS OF ALL CARRIERS IN THIS STATE.
13
.14
:I5
(3)' ON OR BEFORE JUNE J OF EACH YEAR, THE COMMISSION SHALL
NOTIFY THE STATE INSURANCE COMMISSIONER BY MEMORANDUM OF THE TOTAL
ASSESSMENT ON CARRIERS FOR THAT YEAR.
i.fi
m
17
.
18
19
(A) (4)
ON OR BEFORE JUNE 30 OF EACH YEAR, THE INSURANCE
COMMISSIONER—SHALL
ASSESS—EACH—CARRIER—A—FEE—ESTABLISHED—H4
ACCORDANCE WITH THE PROVISIONS OF ji 706 OF THIS SUBTITLE.
20
21
(3) THE INSURANCE COMMISSIONER, IN COOPERATION
COMMISSION, MAY MAKE PROVISIONS FOR PARTIAL PAYMENTS.
22
23
(3) THE TOTAL AMOUNT OF THE FEE FOR ALL PAYORS SHALL BE SET
EACH YEAR BY A MEMORANDUM FROM THE COMMISSION.
24
25
26
27
(4) W E INSURANCE COMMISSIONER SHALL APPORTION THE FEE
AMONG THE CARRIERS SUBJECT TO ASSESSMENT UNDER THIS SECTION BASED ON
THE RATIO OF EACH CARRIERS TOTAL PREMIUMS COLLECTED IN THIS STATE TO
THE TOTAL COLLECTED PREMIUMS OF ALL CARRIERS IN THIS STATE.
2S
29
30
(€) ON OR BEFORE SEPTEMBER 1 OF EACH YEAR, EACH PAYOR ASSESSED A
FEE IN ACCORDANCE WITH THIS SECTION SHALL MAKE PAYMENT TO THE
INSURANCE COMMISSIONER.
31
32
33
(©) ON OR BEFORE SEPTEMBER 30 OF EACH YEAR, THE INSURANCE
COMMISSIONER SHALL FORWARD TO THE COMMISSION THE FEES ASSESSED UNDER
THIS SECTION.
34
WITH THE
m
35
36
THIS SUBTITLE MAY BE CITED AS THE "MARYLAND HEALTH INSURANCE
REFORM ACT".
37
38
SECTION 2. A N D BE IT F U R T H E R E N A C T E D , That the terms of the initial
members of the health care planning and data commission shall expire as follows:
39
(4)
Two members in 1997;
40
(3)
Three members in 1999;
�HOUSE HILL 1359
1
(3)
Three meinberr. in 2001; and
2
(4)
13
Three memben; in 2003.
3
4
SECTION 3.
October .1, 11193.
5
6
A N D BE IT F U R T H E R E N A C T E D , That this Act shall take effect
Article 48A - Insurance Code
490R.
7
8
9
10
(A) IN THIS SECTION, "PAYOR" MEANS A HEALTH INSURER. NONPROFIT
HEALTH SERVICE PLAN. OR HEALTH MAINTENANCE ORGANIZATION THAT HOLDS A
CERTIFICATE OF AUTHORITY TO OFFER HEALTH INSURANCE POLICIES OR
CONTRACTS IN THE STATE UNDER THIS ARTICLE.
11
12
13
.
.(B) (T) ON OR BEFORE JUNE 30 OF EACH YEAR. THE COMMISSIONER SHALL
ASSESS EACH PAYOR A FEE ESTABLISHED IN ACCORDANCE WITH THE PROVISIONS
OF § 19-1514 OF THE HEALTH - GENERAL ARTICLE.
14
15
(2) THE COMMISSIONER, IN COOPERATION WITH THE MEDICAL CARE
DATA REVIEW COMMISSION, MAY MAKE PROVISIONS FOR PARTIAL PAYMENTS.
16
17
18
(3) THE TOTAL AMOUNT OF THE FEE FOR ALL PAYORS SHALL BE SET
EACH YEAR BY A MEMORANDUM FROM THE MEDICAL CARE DATA REVIEW
COMMISSION.
19
20
21
22
(4) THE COMMISSIONER SHALL APPORTION THE FEE AMONG THE
PAYORS SUBJECT TO ASSESSMENT UNDER THIS SECTION BASED ON THE RATIO OF
EACH PAYOR'S TOTAL PREMIUMS COLLECTED IN THE STATE TO THE TOTAL
COLLECTED PREMIUMS OF ALL PAYORS IN THE STATE.
23
24
25
(C) ON OR BEFORE SEPTEMBER 1 OF EACH YEAR, EACH PAYOR ASSESSED A
FEE IN ACCORDANCE WITH THIS SECTION SHALL MAKE PAYMENT TO THE
COMMISSIONER.
26
27
28
(D) ON OR BEFORE SEPTEMBER 30 OF EACH YEAR. THE COMMISSIONER
SHALL FORWARD TO THE MEDICAL CARE DATA REVIEW COMMISSION THE FEES
ASSESSED UNDER THIS SECTION.
29
30
31
32
(E) ALL PAYORS SHALL COOPERATE FULLY IN SUBMITTING REPORTS AND
CLAIMS DATA AND PROVIDING ANY OTHER INFORMATION TO THE MEDICAL CARE
DATA REVIEW COMMISSION IN ACCORDANCE WITH TITLE 19. SUBTITLE 15 OF THE
HEALTH - GENERAL ARTICLE.
33
34
35
36
(F) IN MAKING PAYMENTS FOR HEALTH CARE SERVICES, ALL PAYORS SHALL
PAY NO MORE THAN THE FEES SET BY THE MEDICAL CARE DATA REVIEW
COMMISSION UNDER REGULATIONS IT ADOPTS UNDER § 19-1509 OF THE HEALTH GENERAL ARTICLE.
�14
HOUSE HILL 1359
1
Article - Health - General
2
SUBTITLE 15. MEDICAL CARE DATA REVIEW COMMISSION
3
4
19-1501.
(A)
IN THIS SUBTITLE THE FOLLOWING WORDS
HAVE THE MEANINGS
5 INDICATED.
6
(B)
"COMMISSION" MEANS THE MEDICAL CARE DATA REVIEW COMMISSION.
7
8
9
(C) "COMPREHENSIVE STANDARD HEALTH BENEFIT FLAN" MEANS THE
COMPREHENSIVE STANDARD HEALTH BENEFIT PLAN ADOPTED IN ACCORDANCE
WITH ARTICLE 48A, § 700 OF THE CODE.
'0
11
12
f € } U21 LL) "HEALTH CARE SERVICE" MEANS ANY HEALTH OR MEDICAL
CARE PROCEDURE OR SERVICE RENDERED BY A PHYSICIAN, PHARMACIST, OR
OFFICE FACILITY THAT:
13
14
(1)
PROVIDES TESTING, DIAGNOSIS, OR TREATMENT OF HUMAN
DISEASE OR DYSFUNCTION; OR
15
16
(U) DISPENSES DRUGS, MEDICAL DEVICES, MEDICAL APPLIANCES,
OR MEDICAL GOODS FOR THE TREATMENT OF HUMAN DISEASE OR DYSFUNCTION.
18
(2)
"HEALTH CARE SERVICE" DOES NOT INCLUDE HOSPITAL SERVICES
AS DEFINED "iN ji 19-201 OF THIS TITLE.
.19
20
fD)
(E)
(1)
"OFFICE FACILITY" MEANS THE OFFICE OF ONE OR MORE
PHYSICIANS IN WHICH HEALTH CARE SERVICES ARE PROVIDED TO INDIVIDUALS.
21
(2)
"OFFICE FACILITY" INCLUDES A FACILITY THAT PROVIDES:
22
(I)
AMBULATORY SURGERY;
23
(ID
RADIOLOGICAL OR DIAGNOSTIC IMAGERY; OR
24
(HI] LABORATORY SERVICES.
25
26
27
(3)
"OFFICE FACILITY" DOES NOT INCLUDE ANY OFFICE, FACILITY, OR
SERVICE OPERATED BY A HOSPITAL AND REGULATED UNDER SUBTITLE 2 OF THIS
TITLE.
28
.29
30
31
(g) (F) "PAYOR" MEANS A HEALTH INSURER, NONPROFIT HEALTH SERVICE
PLAN, OR HEALTH MAINTENANCE ORGANIZATION THAT HOLDS A CERTIFICATE OF
AUTHORITY TO OFFER HEALTH INSURANCE POLICIES OR CONTRACTS IN THE STATE
IN ACCORDANCE WITH ARTICLE 48A OF THE CODE.
32
33
34
35
36
19-1502.
(A)
THERE IS A MEDICAL CARE DATA REVIEW COMMISSION.
(B) THE COMMISSION IS AN INDEPENDENT COMMISSION THAT FUNCTIONS IN
THE DEPARTMENT.
(C)
THE PURPOSE OF THE COMMISSION IS TO:
�HOUSE BILL 1359
15
1
(1)
DEVELOP COST CONTAINMENT STRATEGIES TO HELP PROVIDE
2 ACCESS TO APPROPRIATE QUALITY HEALTH CARE SERVICES FOR ALL
3 MARYLANDERS;
4
5
(2)
FOSTER THE PUBLIC DISCLOSURE OF DATA FOR THE DEVELOPMENT
OF PUBLIC POLICY:
6
7
(31
MARYLAND;
S
9
(4)
ESTABLISH AND MAINTAIN A STATEWIDE MEDICAL CARE DATA
BASE TO ENABLE IT TO:
10
11 AND
L2
.13
DEVELOP A PLAN FOR AN ELECTRONIC DATA INTERCHANGE IN
(H
COMPARE COSTS BETWEEN VARIOUS TREATMENT SETTINGS;
(JD PROVIDE INFORMATION TO CONSUMERS, PROVIDERS, AND
PURCHASERS OF HEALTH CARE SERVICES;
14
(51
FOSTER THE DEVELOPMENT OF PRACTICE PROTOCOLS: A W
.15
16
17
(6]
DEVELOP A UNIFORM SET OF EFFECTIVE BENEFITS TO BE
INCLUDED IN THE COMPREHENSIVE STANDARD HEALTH BENEFIT PLAN TO APPLY
UNDER SUBTITLE 55 OF ARTICLE 4SA OF THE CODE; AND
15
19
20
(71 DEVELOP A PAYMENT SYSTEM, INCLUDING A FEE SCHEDULE, FOR
HEALTH CARE SERVICES PROVIDED BY PHYSICIANS AND COVERED UNDER THE
COMPREHENSIVE STANDARD HEALTH BENEFIT PLAN.
21
19-1503.
22
23
(A) ( D
THE COMMISSION SHALL CONSIST OF SEVEN MEMBERS APPOINTED
BY THE GOVERNOR.
24
25
26
(2] OF THE SEVEN MEMBERS, FOUR SHALL BE INDIVIDUALS WHO DO
NOT HAVE ANY CONNECTION WITH THE MANAGEMENT OR POLICY OF A HEALTH
CARE PROVIDER OR PAYOR.
27
(B)
(D
THE TERM OF A MEMBER IS 4 YEARS.
28
29
30
(2]
A MEMBER WHO IS APPOINTED AFTER A TERM HAS BEGUN SERVES
ONLY FOR THE REST OF THE TERM AND UNTIL A SUCCESSOR IS APPOINTED AND
QUALIFIES.
31
32
(3). THE GOVERNOR MAY REMOVE A MEMBER FOR NEGLIGENCE
NEGLECT OF DUTY, INCOMPETENCE, OR MISCONDUCT.
33
34
TERMS.
35
36
37
(Cl TO THE EXTENT PRACTICABLE, WHEN APPOINTING MEMBERS TO THE
COMMISSION, THE GOVERNOR SHALL ASSURE GEOGRAPHIC BALANCE IN THE
COMMISSION'S MEMBERSHIP.
38
19-1504.
39
(4)
A MEMBER MAY NOT SERVE MORE THAN TWO CONSECUTIVE
THE GOVERNOR SHALL APPOINT THE CHAIRMAN OF THE COMMISSION.
�16
HOUSE KILL 1359
1
19-1505.
2
3
4
(A) WITH THE APPROVAL OF THE GOVERNOR, THE COMMISSION SHALL
APPOINT AN EXECUTIVE DIRECTOR WHO SHALL BE THE CHIEF ADMINISTRATIVE
OFFICER OF THE COMMISSION.
5
6
(B) THE
COMMISSION.
7
8
9
(C) UNDER THE DIRECTION OF THE COMMISSION, THE EXECUTIVE
DIRECTOR SHALL PERFORM ANY DUTY OR FUNCTION THAT THE COMMISSION
REQUIRES.
EXECUTIVE
DIRECTOR
SERVES AT THE
PLEASURE
OF
THE
10
1.9-1506.
11.
12
13
14
(A) A MAJORITY OF THE FULL AUTHORIZED MEMBERSHIP OF THE
COMMISSION IS A QUORUM. HOWEVER, THE COMMISSION MAY NOT ACT ON ANY
MATTER UNLESS AT LEAST FOUR OF THE VOTING MEMBERS IN ATTENDANCE
CONCUR.
.1.5
16
(B) THE COMMISSION SHALL MEET AT LEAST SIX TIMES EACH YEAR, AT THE
TIMES AND PLACES THAT IT DETERMINES.
17
15
.19
(Cl EACH MEMBER OF THE COMMISSION IS ENTITLED TO REIMBURSEMENT
FOR EXPENSES UNDER THE STANDARD STATE TRAVEL REGULATIONS, AS
PROVIDED IN THE STATE BUDGET.
20
2.1
( D l THE COMMISSION MAY EMPLOY A STAFF IN ACCORDANCE WITH THE
STATE BUDGET.
22
19-1507.
23
24
25
(A] THE COMMISSION SHALL ESTABLISH A MARYLAND MEDICAL CARE DATA
BASE TO COMPILE STATEWIDE DATA ON HEALTH SERVICES RENDERED BY
PHYSICIANS, PHARMACISTS, AND OFFICE FACILITIES.
26
(Bl IN ADDITION TO ANY OTHER INFORMATION THE COMMISSION MAY
27 • REQUIRE BY REGULATION, THE MEDICAL CARE DATA BASE SHALL:
28
29
(11
COLLECT FOR
EACH TYPE OF PATIENT ENCOUNTER
WITH A
PHYSICIAN OR OFFICE FACILITY DESIGNATED BY THE COMMISSION:
30
(11
THE DEMOGRAPHIC CHARACTERISTICS OF THE PATIENT;
31
(Ml
THE PRINCIPAL DIAGNOSIS;
32
(Hi) THE PROCEDURE PERFORMED;
33
(TV) THE DATA AND LOCATION OF WHERE THE PROCEDURE WAS
34
35
36
37
38
PERFORMED;
(V)
THE CHARGE FOR THE PROCEDURE;
( V I I IF THE BILL FOR THE PROCEDURE WAS SUBMITTED ON AN
ASSIGNED OR NONASSIGNED BASIS; AND
(VII) THE PHYSICIAN'S UNIVERSAL IDENTIFICATION NUMBER;
�MOUSE BILL 1359
17
1
2
3
(2)
COLLECT
APPROPRIATE
INFORMATION
RELATING
TO
PRESCRIPTION DRUGS FOR EACH TYPE OF PATIENT ENCOUNTER WITH A
PHARMACIST DESIGNATED BY THE COMMISSION; AND
4
5
6
(3)
COLLECT APPROPRIATE INFORMATION RELATING TO HEALTH
CARE COSTS, UTILIZATION, OR RESOURCES FROM PAYORS AND GOVERNMENTAL
AGENCIES.
7
S
(C) (1) THE COMMISSION SHALL ADOPT REGULATIONS TO ENSURE THAT
CONFIDENTIAL OR PRIVILEGED PATIENT INFORMATION IS KEPT CONFIDENTIAL.
9
10
11
12
(2)
RECORDS OR INFORMATION PROTECTED BY THE PROVISIONS OF
THE PHYSICIAN-PATIENT PRIVILEGE, OR OTHERWISE REQUIRED BY LAW TO BE
HELD CONFIDENTIAL, SHALL BE FILED IN A MANNER THAT DOES NOT DISCLOSE
THE IDENTITY OF THE PERSON PROTECTED.
13
14
(D) TO THE EXTENT PRACTICABLE, WHEN COLLECTING THE DATA REQUIRED
UNDER SUBSECTION (B) OF THIS SECTION, THE COMMISSION SHALL:
15
16
(J)
UTILIZE ANY STANDARDIZED CLAIM FORM OR ELECTRONIC
TRANSFER SYSTEM BEING USED BY PHYSICIANS. PHARMACISTS, AND PAYORS; AND
17
IS
(2)
TAKE INTO ACCOUNT THE REIMBURSEMENT METHODS USED BY
HEALTH MAINTENANCE ORGANIZATIONS.
.19
20
21
(E) BY OCTOBER 1, 1995 AND EACH YEAR THEREAFTER, THE COMMISSION
SHALL PUBLISH AN ANNUAL REPORT ON THOSE HEALTH CARE SERVICES SELECTED
BY THE COMMISSION THAT:
22
23
24
(1). DESCRIBES THE VARIATION IN FEES CHARGED BY PHYSICIANS AND
OFFICE FACILITIES ON A STATEWIDE BASIS AND IN EACH HEALTH SERVICE AREA
FOR THOSE HEALTH CARE SERVICES; AND
25
26
(2)
DESCRIBES THE GEOGRAPHIC VARIATION IN THE UTILIZATION OF
THOSE HEALTH CARE SERVICES.
27
2S
(F) IN DEVELOPING THE MEDICAL CARE DATA BASE, THE COMMISSION
SHALL CONSULT WITH:
29
30
(11 REPRESENTATIVES OF PHYSICIANS, PHARMACISTS, THIRD PARTY
PAYORS. AND HOSPITALS: AND
31
32
33
34
(21 R E P R E S E N T A \ T I V E S OF THE HEALTH SERVICES COST REVIEW
COMMISSION TO ENSURE THAT THE MEDICAL CARE DATA BASE IS COMPATIBLE
WITH AND DOES NOT DUPLICATE INFORMATION COLLECTED BY THE HEALTH
SERVICES COST REVIEW COMMISSION HOSPITAL DISCHARGE DATA BASE.
35
19-1.508.
36
37
3S
39
40
41
( A l THE COMMISSION, IN CONSULTATION WITH INTERESTED PARTIES
INCLUDING PAYORS, THE MEDICAL AND CHIRURGICAL FACULTY OF M A R Y L A N B T
THE MARYLAND PHARMACISTS ASSOCIATION PHYSICIANS, PHARMACISTS, THE
MARYLAND
HOSPITAL ASSOCIATION, AND ANY OTHER
HEALTH CARE
PRACTITIONERS AS APPROPRIATE, SHALL DEVELOP A SYSTEM TO FOSTER THE
DEVELOPMENT OF PRACTICE PROTOCOLS AND TO PROVIDE INFORMATION TO
�18
HOUSE BILL 1359
1 PHYSICIANS CONCERNING THEIR CHARGES AND UTILIZATION OF SERVICES IN
2 COMPARISON TO THEIR PEERS. '
3
4
5
.(B) THE COMMISSION MAY LIMIT THE DEVELOPMENT AND DISTRIBUTION OF
COMPARATIVE INFORMATION TO PHYSICIANS REQUIRED UNDER SUBSECTION (A)
OF THIS SECTION TO:
6
7
(1)
PHYSICIANS WHOSE CHARGES FOR OR UTILIZATION OF HEALTH
CARE SERVICES ARE CONSIDERED OUTLIERS; OR
8
9
(2)
PHYSICIANS WHO RENDER
SELECTED BY THE COMMISSION.
10
CERTAIN HEALTH CARE
SERVICES
19-1509.
J1
(A) BY JULY 1, 1996, THE COMMISSION SHALL ADOPT REGULATIONS
12 ESTABLISHING A PAYMENT SYSTEM, INCLUDING A FEE SCHEDULE, FOR HEALTH
13 CARE SERVICES:
14
15
16
17
.
18
19
20
21
(M)
COVERED
UNDER
THE
COMPREHENSIVE
STANDARD HEALTH
BENEFIT PLAN; AND
(2)
PROVIDED BY A PHYSICIAN OR OFFICE FACILITY.
(B) THE PAYMENT SYSTEM ADOPTED IN ACCORDANCE WITH THIS SECTION
SHALL BE DESIGNED TO PROVIDE REASONABLE ASSURANCE THAT:
(1) THE FEE PAID TO A PHYSICIAN OR OFFICE FACILITY FOR A
COVERED SERVICE IS REASONABLY RELATED TO THE COST OF PROVIDING THE
SERVICE;
22
(2) THE PAYMENT SYSTEM, INCLUDING THE FEE SCHEDULE, APPLIES
23 EQUITABLY TO ALL PAYORS OR CLASSES OF PAYORS WITHOUT UNFAIR
24 DISCRIMINATION;
25
26
27
(3)
THE PAYMENT SYSTEM CONTAINS APPROPRIATE PROVISIONS OR
INCENTIVES TO CONTROL THE UTILIZATION OR VOLUME OF HEALTH CARE
SERVICES RENDERED BY PHYSICIANS AND OFFICE FACILITIES; AND
28
29
30
(4) THE PAYMENT SYSTEM IS COORDINATED WITH THE HOSPITAL RATE
REGULATORY SYSTEM UNDER SUBTITLE 2 OF THIS TITLE AND PROMOTES THE
DEVELOPMENT OF CONSISTENT FINANCIAL INCENTIVES AMONG ALL PROVIDERS.
31
32
33
34
35
[ C l i l l ON OR BEFORE OCTOBER 1, 1995, AND PRIOR TO IMPLEMENTING THE
PAYMENT SYSTEM UNDER THIS SECTION, THE COMMISSION SHALL SUBMIT A
PROGRESS REPORT TO THE GOVERNOR AND, IN ACCORDANCE WITH § 2-1312 OF THE
STATE GOVERNMENT ARTICLE, TO THE GENERAL ASSEMBLY ON THE
DEVELOPMENT OF THE PAYMENT SYSTEM.
36
37
(2)
IN PREPARING THE PROGRESS REPORT, THE COMMISSION SHAEL-.
CONSIDER AMONG OTHER RELEVANT FACTORS:
38
39
40
01
THE CURRENT SYSTEMS USED BY THIRD-PARTY PAYORS TO
REIMBURSE PHYSICIANS AND THE EXTENT TO WHICH THESE SYSTEMS INFLUENCE
THE VARIATION IN PHYSICIAN FEES;
�HOUSE BILL 1359
1
(IT)
2 INFLUENCE FEES;
19
THE EXTENT TO WHICH PHYSICIAN SPECIALTY DESIGNATIONS
3
4
5
(Ul} THE RESOURCE BASED RELATIVE VALUE SYSTEM ADOPTED
BY THE FEDERAL GOVERNMENT FOR PHYSICIANS PAYMENTS UNDER MEDICARE
PART B;
6
7
(IV) THE
GEOGRAPHIC
VARIATION
IN PRACTICE
INCLUDING THE COST OF PROFESSIONAL LIABILITY INSURANCE;
COSTS,
8
(V) THE IMPACT OF ADOPTING A UNIFORM FEE SCHEDULE ON
9 ACCESS TO HEALTH CARE SERVICES RENDERED BY PRACTITIONERS AND OFFICE
10 FACILITIES;
I I
12
(VI) THE IMPACT ON PAYORS OF ADOPTING A UNIFORM FEE
SCHEDULE INCLUDING THE IMPACT ON THE MEDICAL ASSISTANCE PROGRAM;
13
14
15
(Vll) THE FEASIBILITY AND DESIRABILITY OF ADJUSTING THE FEE
SCHEDULE TO INCLUDE THE REASONABLE COST OF BAD DEBT AND CHARITY CARE
RENDERED BY PHYSICIANS AND OFFICE FACILITIES; AND
16
(VIII) THE FEASIBILITY OF INCLUDING ADJUSTMENTS TO THE FEE
17 SCHEDULE TO RECOGNIZE DIFFERENCES IN EXPERIENCE OR EXPERTISE AMONG
IS' PHYSICIANS.
19
(D) IN DEVELOPING THE PAYMENT SYSTEM, THE COMMISSION SHALL
20 CONSULT WITH INTERESTED PARTIES, INCLUDING REPRESENTATIVES
OF
21 .PHYSICIANS. HOSPITALS, PAYORS, AND THE HEALTH SERVICES COST REVIEW
22 COMMISSION.
23
19-1.510.
24
25
26
27
(A) IN ADDITION TO THE DUTIES SET FORTH ELSEWHERE IN THIS SUBTITLE,
THE COMMISSION SHALL ADOPT REGULATIONS SPECIFYING THE COMPREHENSIVE
STANDARD HEALTH BENEFIT PLAN TO APPLY UNDER SUBTITLE 55 OF ARTICLE 48A
OF THE CODE.
28
29
(13) IN CARRYING OUT ITS DUTIES UNDER THIS SECTION, THE COMMISSION
SHALL COMPLY WITH THE PROVISIONS OF ARTICLE 48A, § 700 OF THE CODE.
30
19 .15.10. 19-1511.
31
32
(A) IN ADDITION TO THE AUTHORITY SET FORTH ELSEWHERE IN THIS
SUBTITLE, THE COMMISSION MAY:
33
34
35
(1)
SUBJECT TO THE PROVISIONS OF SUBSECTION (B) OF THIS SECTION,
ADOPT REGULATIONS TO CARRY OUT THE PROVISIONS OF THIS SUBTITLE;
(2)
CREATE COMMITTEES FROM AMONG ITS MEMBERS:
36
37
38
(3)
APPOINT
ADVISORY COMMITTEES,
WHICH MAY INCLUDE
INDIVIDUALS AND REPRESENTATIVES OF INTERESTED PUBLIC OR PRIVATE
ORGANIZATIONS:
39
40
(4)
APPLY FOR AND ACCEPT ANY FUNDS. PROPERTY, OR SERVICES
FROM ANY PERSON OR GOVERNMENT AGENCY;
�20
MOUSE BILL 1359
1
(5)
MAKE AGREEMENTS WIT I-I A GRANTOR OR PAYOR OF FUNDS,
2 PROPERTY, OR SERVICES. INCLUDING AN AGREEMENT TO MAKE ANY STUDY, PLAN,
3 DEMONSTRATION. OR PROJECT; AND
4
5
6
7
S
(6)
EXCEPT
FOR
CONFIDENTIAL
OR
PRIVILEGED
PATIENT
INFORMATION, PUBLISH OR DISCLOSE INFORMATION THAT RELATES TO THE
UTILIZATION AND COSTS OF HEALTH CARE SERVICES RENDERED BY PHARMACISTS,
PHYSICIANS, OR OFFICE FACILITIES AND THAT IS CONSIDERED TO BE IN THE PUBLIC
INTEREST.
9
(B) WITH THE ULTIMATE GOAL OF INCLUDING ALL HEALTH CARE
10 PROVIDERS REGULATED UNDER THE HEALTH OCCUPATIONS ARTICLE, THE
I I COMMISSION SHALL ADOPT REGULATIONS TO INCLUDE OTHER TYPES OF HEALTH
12 CARE PRACTITIONERS IN THE MEDICAL CARE DATA BASE. ADDITIONAL PROVIDER
13 GROUPS MAY BE INCLUDED ONLY IF THE COMMISSION HAD INCLUDED IN THEIR
14 ANNUAL REPORT TO THE GENERAL ASSEMBLY FOR THE PREVIOUS YEAR THE
15 RECOMMENDATION THAT THAT TYPE OF HEALTH CARE PRACTITIONER BE
16 INCLUDED IN THE MEDICAL CARE DATA BASE.
.17
IS
(Cl IN ADDITION TO THE DUTIES SET FORTH ELSEWHERE IN THIS SUBTITLE,
THE COMMISSION SHALL:
19
20
21.
(11 PREPARE ANNUALLY A BUDGET PROPOSAL THAT INCLUDES THE
ESTIMATED INCOME OF THE COMMISSION AND PROPOSED EXPENSES FOR ITS
ADMINISTRATION AND OPERATION; AND
22
(21 ON OR BEFORE OCTOBER 1 OF EACH YEAR, SUBMIT TO THE
23 GOVERNOR, TO THE SECRETARY, AND SUBJECT TO jj 2-1312 OF THE STATE
24 ' GOVERNMENT ARTICLE, TO THE GENERAL ASSEMBLY AN ANNUAL REPORT ON THE
25 OPERATIONS AND ACTIVITIES OF THE COMMISSION DURING THE PRECEDING
26 FISCAL YEAR, INCLUDING ANY POLICY RECOMMENDATION THAT THE COMMISSION
27 CONSIDERS RELEVANT.
28
29
(D) (11 THE COMMISSION SHALL SET REASONABLE DEADLINES FOR THE
FILING OF INFORMATION OR REPORTS IT REQUIRES UNDER THIS SUBTITLE.
30
31
(21 THE COMMISSION MAY ADOPT REGULATIONS THAT
REASONABLE PENALTIES FOR FAILURE TO FILE A REPORT AS REQUIRED.
32
J.5
(El EXCEPT FOR CONFIDENTIAL OR PRIVILEGED PATIENT INFORMATION,
THE COMMISSION SHALL MAKE:
34
35
36
(H
EACH SUMMARY, COMPILATION, AND REPORT REQUIRED UNDER
THIS SUBTITLE AVAILABLE FOR PUBLIC INSPECTION AT THE OFFICE OF THE
COMMISSION DURING REGULAR BUSINESS HOURS; AND
.37
38
(21 EACH SUMMARY, COMPILATION, AND REPORT AVAILABLE TO ANY
OTHER STATE AGENCY ON REQUEST.
39
40
41
(F) ( U
THE COMMISSION
MAY CONTRACT
WITH
A QUALIFIED,
INDEPENDENT THIRD PARTY FOR ANY SERVICE NECESSARY TO CARRY OUT THE
POWERS AND DUTIES OF THE COMMISSION.
42
43
(21 UNLESS PERMISSION
IS GRANTED SPECIFICALLY BY THE
COMMISSION, A THIRD PARTY HIRED BY THE COMMISSION MAY. NOT RELEASE,
IMPOSE
�HOUSE BILL 1359
21
1 PUBLISH. OR OTHERWISE USE ANY INFORMATION TO WHICH THE THIRD PARTY HAS
2 ACCESS UNDER ITS CONTRACT.
3
1!) 15.11. 19-1512.
4
5
6
7
S
(A) THE POWER OF THE SECRETARY OVER PLANS. PROPOSALS, AND
PROJECTS OF UNITS IN THE DEPARTMENT DOES NOT INCLUDE THE POWER TO
DISAPPROVE OR MODIFY ANY DECISION OR DETERMINATION THAT THE
COMMISSION MAKES UNDER AUTHORITY SPECIFICALLY PROVIDED BY LAW TO THE
COMMISSION.
9
10
11
12
(B) THE POWER OF THE SECRETARY TO TRANSFER BY RULE, REGULATION,
OR WRITTEN DIRECTIVE, ANY STAFF, FUNCTIONS, OR FUNDS OF UNITS IN THE
DEPARTMENT DOES NOT APPLY TO ANY STAFF, FUNCTION, OR FUNDS OF THE
COMMISSION.
.13
19-1512. 19-15.13.
14
15
16
IN ANY MATTER THAT RELATES TO THE UTILIZATION OR COST OF HEALTH
CARE SERVICES RENDERED BY PHYSICIANS, PHARMACISTS, OR OFFICE FACILITIES,
THE COMMISSION MAY:
17
(1)
HOLD A PUBLIC HEARING;
IS
(2)
CONDUCT AN INVESTIGATION; OR
19
(3)
REQUIRE THE FILING OF ANY REASONABLE INFORMATION.
20
21.
22
23
24
25
26
19 15:13. 19-1514.
•
IF THE COMMISSION CONSIDERS A FURTHER INVESTIGATION NECESSARY OR
DESIRABLE TO AUTHENTICATE INFORMATION IN A REPORT THAT A PHYSICIAN,
PHARMACIST, OR OFFICE FACILITY FILES UNDER THIS SUBTITLE, THE COMMISSION
MAY MAKE NECESSARY FURTHER EXAMINATION OF THE RECORDS OR ACCOUNTS
OFTHE PHYSICIAN, PHARMACIST. OR OFFICE FACILITY, IN ACCORDANCE WITH THE
REGULATIONS OFTHE COMMISSION.
27 . 19-1514. 19-1515.
28
29
(A)
(1)
THE COMMISSION SHALL ASSESS A FEE ON:
(1)
ALL PAYORS; AND
30
31
( I I ] EXCEPT FOR PHARMACISTS, ALL HEALTH CARE PROVIDERS
REQUIRED TO SUBMIT DATA TO THE COMMISSION.
32
33
34
35
(2] (I)
EXCEPT AS PROVIDED IN SUBPARAGRAPH (II) OF THIS
PARAGRAPH, THE TOTAL FEES ASSESSED BY THE COMMISSION SHALL BE DERIVED
ONE-THIRD FROM HEALTH CARE PROVIDERS REQUIRED TO SUBMIT DATA TO THE
COMMISSION UNDER THIS SUBTITLE AND TWO-THIRDS FROM PAYORS.
36'
37
38
(U)
THE COMMISSION MAY NOT ASSESS A FEE ON PHARMACISTS.
(3] THE TOTAL FEES ASSESSED BY THE COMMISSION MAY NOT EXCEED
$2,000,000 IN ANY FISCAL YEAR.
�22
HOUSE BILL 1359
1
• (4) THE COMMISSION SHALL PAY ALL FUNDS COLLECTED FROM FEES
2 ASSESSED IN ACCORDANCE WITH THIS SECTION INTO THE GENERAL FUND OF THE
3 STATE.
4
5
(5) THE FEES ASSESSED IN ACCORDANCE WITH THIS SECTION SHALL BE
USED ONLY FOR THE PURPOSES AUTHORIZED UNDER THIS SUBTITLE.
G
7
(TS)
THE FEES ASSESSED IN ACCORDANCE WITH THIS SECTION ON HEALTH
CARE PROVIDERS SHALL BE:
8
.Q)
[21
9
INCLUDED IN THE LICENSING FEE PAID TO THE BOARD; AND
TRANSFERRED TO THE COMMISSION ON A QUARTERLY BASIS.
.10
JI
12
13
(Cl ( H THE FEES ASSESSED ON PAYORS IN ACCORDANCE WITH ARTICLE
48A. SECTION 490R OF THE CODE SHALL BE APPORTIONED AMONG EACH PAYOR
BASED ON THE RATIO OF EACH PAYOR'S TOTAL PREMIUMS COLLECTED IN THE
STATE TO THE TOTAL COLLECTED PREMIUMS OF ALL PAYORS IN THE STATE.
14
15
16
(21 ON OR BEFORE JUNE .1 OF EACH YEAR, THE COMMISSION SHALL
NOTIFY THE STATE INSURANCE COMMISSIONER BY MEMORANDUM OF THE TOTAL
ASSESSMENT ON-PAYORS FOR THAT YEAR.
17
Article - Health Occupiitions
IS
14-309.
19
.
20
21
(A]
To apply For a license, an applicant shall:
. (U
Submit an application to the Board on the form that the Board requires;
ancl
(2)
2?
Pay to the Board the application fee set by the Board.
23
24
25
[ B l [ l ] THE BOARD SHALL ASSESS EACH APPLICANT FOR A LICENSE OR A
RENEWAL OF A LICENSE A FEE ESTABLISHED IN ACCORDANCE WITH THE
PROVISIONS OF jj 19-1513 OF THE HEALTH - GENERAL ARTICLE.
26
27
28
(2] THE BOARD SHALL TRANSFER THE FEES ASSESSED UNDER THIS
SUBSECTION TO THE MEDICAL CARE DATA REVIEW COMMISSION ON A QUARTERLY
BASIS.
29
SECTION 2. A N D BE IT F U R T H E R E N A C T E D , That the Laws of Maryland
30
read as follows:
31
Article 48A - Insurance Code
32
33
698,
55. HEALTH INSURANCE REFORM
34
35
[ A ] IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.
36
37
38
39
[ B l "ACTUARIAL CERTIFICATION" MEANS A WRITTEN STATEMENT IN A FORM
APPROVED BY THE COMMISSIONER BY A MEMBER OF THE AMERICAN ACADEMY OF
ACTUARIES OR OTHER PERSON ACCEPTABLE TO THE COMMISSIONER THAT A
CARRIER IS IN COMPLIANCE WITH THE PROVISIONS OF THIS SUBTITLE.
�HOUSE BILL 1359
23
1
2
(C) "CARRIER" MEANS A PERSON THAT OFFERS HEALTH BENEFIT PLANS
COVERING ELIGIBLE EMPLOYEES OF A SMALL EMPLOYER AND THAT IS:
3
4
[1] AN INSURER THAT HOLDS A CERTIFICATE OF AUTHORITY IN THE
STATE AND PROVIDES HEALTH INSURANCE IN THE STATE;
5
(2)
6
OPERATE IN THE STATE;
7
(3)
8
9
A HEALTH MAINTENANCE ORGANIZATION THAT IS LICENSED TO
A MULTIPLE EMPLOYER WELFARE ARRANGEMENT;
(4)
A MULTIPLE EMPLOYER TRUST LOCATED IN MARYLAND OR ANY
OTHER STATE COVERING MARYLAND RESIDENTS;
10
11
(5} A NONPROFIT
OPERATE IN THE STATE; OR
12
1.3
(6)
ANY OTHER PERSON OR ORGANIZATION THAT PROVIDES HEALTH
BENEFIT PLANS SUBJECT TO STATE INSURANCE REGULATION.
14
.
15
(D) "COMMISSION" MEANS THE MEDICAL CARE DATA REVIEW COMMISSION
ESTABLISHED UNDER TITLE 19, SUBTITLE 15 OF THE HEALTH - GENERAL ARTICLE.
16
17
18
(E} "COMPREHENSIVE STANDARD HEALTH BENEFIT PLAN" MEANS THE
HEALTH BENEFIT PLAN ADOPTED BY THE COMMISSION IN ACCORDANCE WITH § 700
OF THIS SUBTITLE AND TITLE 19, SUBTITLE 15 OF THE HEALTH - GENERAL ARTICLE.
19
20
(F) (1] "ELIGIBLE EMPLOYEE" MEANS AN EMPLOYEE WHO WORKS ON A
FULL-TIME BASIS AND HAS A NORMAL WORKWEEK OF 30 OR MORE HOURS.
21
22
23
(2)
"ELIGIBLE EMPLOYEE" INCLUDES A SOLE PROPRIETOR, A PARTNER
OF A PARTNERSHIP, OR AN INDEPENDENT CONTRACTOR WHO IS INCLUDED AS AN
EMPLOYEE UNDER A HEALTH BENEFIT PLAN UNDER THIS SUBTITLE.
24
25
26
(31 "ELIGIBLE EMPLOYEE" DOES NOT INCLUDE AN INDIVIDUAL WHO
WORKS ON A TEMPORARY OR SUBSTITUTE BASIS OR FOR FEWER THAN 30 HOURS IN
A WORKWEEK.
27
28
29
30
31
(Gl
(Ij
HEALTH SERVICE
PLAN THAT IS LICENSED TO
"HEALTH BENEFIT PLAN" MEANS ANY:
(H
HOSPITAL OR MEDICAL POLICY OR CERTIFICATE, INCLUDING
THOSE ISSUED UNDER MULTIPLE EMPLOYER TRUSTS OR ASSOCIATIONS LOCATED
IN MARYLAND OR ANY OTHER STATE COVERING MARYLAND RESIDENTS WHO ARE
ELIGIBLE EMPLOYEES;
32
(II]
NONPROFIT HEALTH SERVICE PLAN;
33
34
(ITQ HEALTH MAINTENANCE ORGANIZATION SUBSCRIBER
GROUP MASTER CONTRACT; OR
35
36
37
(IV] PLAN PROVIDED BY OR THROUGH A MULTIPLE EMPLOYER
WELFARE ARRANGEMENT, OR OTHER BENEFIT ARRANGEMENT OFFERED BY A
MULTIPLE EMPLOYER WELFARE ARRANGEMENT.
38
39
(21
"HEALTH BENEFIT PLAN" DOES NOT INCLUDE:.
(II
ACCIDENT-ONLY INSURANCE;
OR
�24
HOUSE BILL 135!)
1
(U}
2
(IM) CREDIT HEALTH INSURANCE;
3
(IV) MEDICARE SUPPLEMENT POLICIES;
4
(V)
5
(VI) DISABILITY INCOME INSURANCE;
6
(VII) COVERAGE
7
FIXED INDEMNITY INSURANCE;
LONG-TERM CARE INSURANCE;
ISSUED
AS
A
SUPPLEMENT
TO
LIABILITY
INSURANCE;
S
(VIII)WORKERS' COMPENSATION OR SIMILAR INSURANCE;
9
(IX) DISEASE-SPECIFIC INSURANCE;
10
(X)
AUTOMOBILE MEDICAL PAYMENT INSURANCE;
11
(XI) DENTAL INSURANCE; OR
12
(XII) VISION INSURANCE.
13
(H) (J)
"LATE ENROLLEE" MEANS AN ELIGIBLE EMPLOYEE OR DEPENDENT
.14 WHO REQUESTS ENROLLMENT IN A HEALTH BENEFIT PLAN UNDER THIS SUBTITLE
15 FOLLOWING THE INITIAL ENROLLMENT PERIOD PROVIDED UNDER THE TERMS OF
16 THE HEALTH BENEFIT PLAN.
17
18
19 '
20
21
22
(2)
AN ELIGIBLE EMPLOYEE OR DEPENDENT MAY NOT BE CONSIDERED
A LATE ENROLLEE IF:
(!)
THE INDIVIDUAL:
L
WAS COVERED UNDER A PUBLIC OR PRIVATE HEALTH
INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENT AT THE TIME THE
INDIVIDUAL WAS ELIGIBLE TO ENROLL;
23
2.
HAS LOST COVERAGE UNDER A PUBLIC OR PRIVATE
24 . HEALTH INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENT AS A RESULT OF
25 TERMINATION OF EMPLOYMENT OR ELIGIBILITY, THE TERMINATION OF THE
26 OTHER PLAN'S COVERAGE, DEATH OF A SPOUSE, OR DIVORCE; AND
27
28
29
.
3,
REQUESTS ENROLLMENT WITHIN 30 DAYS AFTER
TERMINATION OF COVERAGE PROVIDED UNDER A PUBLIC OR PRIVATE HEALTH
INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENT;
30
31
32
(II) THE INDIVIDUAL IS EMPLOYED BY AN EMPLOYER WHICH
OFFERS MULTIPLE HEALTH BENEFIT PLANS AND THE INDIVIDUAL ELECTS A
DIFFERENT PLAN DURING AN OPEN ENROLLMENT PERIOD;
33
34
(MI) THE INDIVIDUAL REQUESTS ENROLLMENT WITHIN 30 DAYS OF
BECOMING AN EMPLOYEE;
35
36
37
(IV) A COURT HAS ORDERED COVERAGE TO BE PROVIDED FOR A
SPOUSE OR MINOR CHILD UNDER A COVERED EMPLOYEE'S HEALTH BENEFIT PLAN;
OR
�HOUSE BILL 1359
25
1
f V ] A REQUEST FOR ENROLLMENT IS MADE WITHIN 30 DAYS
2 AFTER THE ELIGIBLE EMPLOYEE'S MARRIAGE OR THE BIRTH OR ADOPTION OF A
3 CHILD.
4
5
6
7
8
(11
(H
"MANDATED BENEFIT" MEANS A STATUTE IN THIS ARTICLE OR IN
THE HEALTH - GENERAL ARTICLE OF THE CODE THAT WOULD REQUIRE A
PARTICULAR HEALTH CARE SERVICE, BENEFIT. COVERAGE, OR REIMBURSEMENT
FOR COVERED HEALTH CARE SERVICES TO BE PROVIDED OR OFFERED IN A
HEALTH BENEFIT PLAN ISSUED OR DELIVERED IN THE STATE BY A CARRIER.
9
10
11
12
13
(2)
"MANDATED BENEFIT" INCLUDES A STATUTE THAT WOULD
REQUIRE A HEALTH BENEFIT PLAN THAT PROVIDES REIMBURSEMENT FOR ANY
SERVICE WITHIN THE SCOPE OF PRACTICE OF A HEALTH CARE PROVIDER LICENSED
UNDER THE HEALTH OCCUPATIONS ARTICLE TO PROVIDE REIMBURSEMENT FOR
ALL SERVICES PROVIDED BY THAT PROVIDER.
14
(J)
"PREEXISTING CONDITION" MEANS:
15
16
0]
A CONDITION THAT WOULD CAUSE AN ORDINARILY PRUDENT
PERSON TO SEEK MEDICAL ADVICE, DIAGNOSIS, CARE, OR TREATMENT: OR
17
.IS
19
(2] A CONDITION FOR WHICH MEDICAL ADVICE. DIAGNOSIS. CARE, OR
TREATMENT WAS RECOMMENDED OR RECEIVED DURING A SPECIFIED PERIOD
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF THIS COVERAGE.
20
21
22
[ K ] "PREEXISTING CONDITION PROVISION" MEANS A PROVISION IN A
HEALTH BENEFIT PLAN THAT DENIES. EXCLUDES, OR LIMITS BENEFITS FOR AN
ENROLLEE FOR EXPENSES OR SERVICES RELATED TO A PREEXISTING CONDITION.
23
24
25
26
27
28
29
(L) { l l "SMALL EMPLOYER" MEANS ANY PERSON, FIRM, CORPORATION,
PARTNERSHIP, OR ASSOCIATION ACTIVELY ENGAGED IN BUSINESS AND, ON AT
LEAST 50 PERCENT OF ITS WORKING DAYS DURING THE PRECEDING CALENDAR
YEAR, EMPLOYED AT LEAST TWO BUT NO MORE THAN 50 ELIGIBLE EMPLOYEES, THE
MAJORITY OF WHOM ARE EMPLOYED WITHIN THE STATE. UNTIL SEPTEMBER 30. 1996
CARRIERS WHO DO NOT IMPOSE PREEXISTING CONDITION LIMITATIONS ' MAY
REQUIRE THAT A SMALL EMPLOYER HAVE AT LEAST THREE ELIGIBLE EMPLOYEES.
30
31
32
33
34
£2} IF THE FEDERAL EMPLOYEE RETIREMENT INCOME SECURITY ACT
IS AMENDED TO EXCLUDE EMPLOYEE GROUPS UNDER A SPECIFIC SIZE.
NOTWITHSTANDING PARAGRAPH (1) OF THIS SUBSECTION, THIS SUBTITLE SHALL
APPLY TO ANY EMPLOYEE GROUP SIZE THAT IS EXCLUDED FROM THAT FEDERAL
ACT.
35
36
37
(3)
IN DETERMINING. THE NUMBER OF ELIGIBLE EMPLOYEES,
COMPANIES WHICH ARE AFFILIATED COMPANIES OR WHICH ARE ELIGIBLE TO FILE
A COMBINED STATE TAX RETURN SHALL BE CONSIDERED ONE EMPLOYER.
38
69SA.
39
40
41
"
EXCEPT AS PROVIDED IN jj 706 OF THIS SUBTITLE, THIS SUBTITLE APPLIES ONLY
TO CARRIERS THAT OFFER HEALTH BENEFIT PLANS COVERING ELIGIBLE
EMPLOYEES OF SMALL EMPLOYERS.
�26
1
HOUSli BILL 1359
699,
2
(A) IN ADDITION TO ANY OTHER REQUIREMENTS UNDER THIS ARTICLE, A
.1 CARRIER THAT OFFERS A HEALTH BENEFIT PLAN IN THE STATE SHALL:
4
5
6
(1)
HAVE DEMONSTRATED THE CAPACITY TO ADMINISTER THE
HEALTH BENEFIT PLAN, INCLUDING ADEQUATE NUMBERS AND TYPES OF
ADMINISTRATIVE STAFF;
7
S
(2)
HAVE A SATISFACTORY GRIEVANCE PROCEDURE AND ABILITY TO
RESPOND TO ENROLLEES' CALLS. QUESTIONS, AND COMPLAINTS;
9
10
.
.11
(3)
PROVIDE, IN THE CASE OF INDIVIDUALS COVERED UNDER MORE
THAN ONE HEALTH BENEFIT PLAN, FOR COORDINATION OF COVERAGE UNDER ALL
OF THOSE PLANS IN AN EQUITABLE MANNER; AND
12
13
(4)
DESIGN POLICIES TO HELP ENSURE THAT ENROLLEES OR INSUREDS
HAVE ADEQUATE ACCESS TO PROVIDERS OF HEALTH CARE.
14
(B) [ I ] A CARRIER MAY NOT OFFER ANY HEALTH BENEFIT PLAN IN THE
15 STATE UNLESS THE CARRIER OFFERS AT LEAST THE COMPREFJENSIVE STANDARD
16 HEALTH BENEFIT PLAN SPECIFIED BY THE COMMISSION UNDER § 700 OF THIS
17 SUBTITLE.
.1S
19
f H BENEFITS IN ADDITION TO THE COMPREHENSIVE STANDARD
HEALTH BENEFIT PLAN MAY BE OFFERED IF THE ADDITIONAL BENEFITS:
20
21
(I)
ARE OFFERED AND PRICED SEPARATELY FROM BENEFITS
SPECIFIED IN ACCORDANCE WITH § 700 OF THIS SUBTITLE; AND
22
23
BENEFITS.
24
25
26
27
"
(31 EXCEPT FOR A PLAN OFFERED IN ACCORDANCE WITH PARAGRAPH
(2) OF THIS SUBSECTION, A CARRIER MAY NOT OFFER A HEALTH BENEFIT PLAN
THAT HAS FEWER THAN THE BENEFITS IN THE COMPREHENSIVE STANDARD
HEALTH BENEFIT PLAN.
(HI
DO NOT HAVE THE EFFECT OF DUPLICATING ANY OF THOSE
28 TOO.
29
30
31
32
( A l ( H THE COMMISSION SHALL ADOPT REGULATIONS SPECIFYING THE
COMPREHENSIVE STANDARD HEALTH BENEFIT PLAN TO APPLY UNDER THIS
SUBTITLE. IN ACCORDANCE WITH THE PROVISIONS OF TITLE 19, SUBTITLE 15 OFTHE
HEALTH - GENERAL ARTICLE.
33
34
35
(21 IN ESTABLISHING BENEFITS. THE COMMISSION SHALL JUDGE
PREVENTIVE SERVICES. MEDICAL TREATMENTS, PROCEDURES, AND RELATED
HEALTH SERVICES BASED ON:
36
37
INDIVIDUALS;
38
39
40
(HI THEIR IMPACT ON MAINTAINING AND IMPROVING HEALTH
AND ON REDUCING THE UNNECESSARY CONSUMPTION OF HEALTH CARE SERVICES;
AND
(11
THEIR EFFECTIVENESS IN IMPROVING THE HEALTH STATUS OF
�HOUSE BILL 1359
27
(111) THEIR IMPACT ON THE AFFORDABILITY OF HEALTH CARE
2
COVERAGE.
3
(3)
THE COMMISSION MAY EXCLUDE ANY MANDATED BENEFIT.
4
5
6
(B) THE COMPREHENSIVE STANDARD HEALTH BENEFIT PLAN SHALL
INCLUDE UNIFORM DEDUCTIBLES AND COST-SHARING ASSOCIATED WITH ITS
BENEFITS, AS DETERMINED BY THE COMMISSION.
7
S
(C) IN ESTABLISHING COST-SHARING AS PART OF THE COMPREHENSIVE
STANDARD HEALTH BENEFIT PLAN, THE COMMISSION SHALL:
9
10
(1)
INCLUDE COST-SHARING AND OTHER INCENTIVES
PREVENT CONSUMERS FROM SEEKING UNNECESSARY SERVICES;
TO
HELP
11
12
(2)
BALANCE THE EFFECT OF THE COST-SHARING IN REDUCING
PREMIUMS AND IN AFFECTING UTILIZATION OF APPROPRIATE SERVICES; AND
13
14
(3)
LIMIT THE TOTAL COST-SHARING THAT MAY BE INCURRED BY AN
INDIVIDUAL IN A YEAR.
15 701.
16
17
.18
19
20
21
(A) ( i )
UNTIL SEPTEMBER 30, 1996, CARRIERS MAY LIMIT COVERAGE
UNDER ANY HEALTH BENEFIT PLAN UNDER A PREEXISTING CONDITION PROVISION.
BUT ONLY FOR A PERIOD NOT EXCEEDING 6 MONTHS FROM THE EFFECTIVE DATE
OF COVERAGE FOR ANY ENROLLEE, FOR ANY PREEXISTING CONDITION THAT
EXISTED WITHIN THE 6 MONTHS PRECEDING THE DATE OF COVERAGE FOR THE
ENROLLEE UNDER THE HEALTH BENEFIT PLAN.
22
23
24
25
26
27
(21 IN DETERMINING THE LENGTH OF TIME THAT A PREEXISTING
CONDITION PROVISION APPLIES TO AN ELIGIBLE EMPLOYEE OR DEPENDENT, A
HEALTH BENEFIT PLAN SHALL CREDIT THE TIME THE INDIVIDUAL WAS
PREVIOUSLY COVERED BY PUBLIC OR PRIVATE HEALTH INSURANCE OR BY
ANOTHER HEALTH BENEFIT ARRANGEMENT. AN INDIVIDUAL IS DEEMED TO HAVE
BEEN PREVIOUSLY COVERED IF:
28
29
30
3.1
(1)
AN INTERRUPTION OF NO MORE THAN 60 DAYS HAD
OCCURRED FROM THE TIME THE INDIVIDUAL WAS COVERED BY ANY PUBLIC OR
PRIVATE HEALTH INSURANCE OR BY ANOTHER HEALTH BENEFIT ARRANGEMENT
UNTIL THE EFFECTIVE DATE OF THE NEW COVERAGE; OR
32
33
34
35
36
37
d l ) AN INTERRUPTION OF NO MORE THAN 60 DAYS HAD
OCCURRED FROM THE T1ME THE INDIVIDUAL WAS COVERED BY ANY PUBLIC OR
PRIVATE HEALTH INSURANCE OR BY ANOTHER HEALTH BENEFIT ARRANGEMENT
UNTIL THE INDIVIDUAL BECAME AN ELIGIBLE EMPLOYEE WHO ELECTED TO
ENROLL BUT AGAINST WHOM THE EMPLOYER IMPOSED A WAITING PERIOD PRIOR
TO ENROLLMENT.
38
39
40
(3)
AN EXCLUSION OF COVERAGE FOR PREEXISTING CONDITIONS MAY
NOT BE APPLIED TO HEALTH CARE SERVICES FURNISHED FOR PREGNANCY OR
NEWBORNS.
41
42
(4)
ON AND AFTER OCTOBER 1, 1996, A CARRIER MAY NOT LIMIT
COVERAGE UNDER A HEALTH BENEFIT PLAN FOR A PREEXISTING CONDITION.
�28
HOUSli KILL 1359
1
(B). NOTWITHSTANDING SUBSECTION (A) OF THIS SECTION, A LATE
2 ENROLLEE MAY BE SUBJECT TO A 12-MONTH PREEXISTING CONDITION PROVISION.
3
(Cl A HEALTH BENEFIT PLAN THAT DOES NOT USE A PREEXISTING
4 CONDITION PROVISION MAY IMPOSE ON ENROLLEES A WAITING PERIOD NOT TO
. EXCEED 30 DAYS BEFORE THE COVERAGE UNDER THE HEALTH BENEFIT PLAN IS
5
6 EFFECTIVE. DURING THE WAITING PERIOD. THE HEALTH BENEFIT PLAN IS NOT
7 REQUIRED TO PROVIDE HEALTH CARE SERVICES OR BENEFITS AND A PREMIUM
8 MAY NOT BE CHARGED TO THE ENROLLEE.
9
10
11
12
.
13
14
15
16
17
(D). FOR A PERIOD NOT TO EXCEED 6 MONTHS FROM THE DATE AN
INDIVIDUAL BECOMES AN ELIGIBLE EMPLOYEE, A HEALTH BENEFIT PLAN MAY
REQUIRE DEDUCTIBLES AND COST-SHARING FOR BENEFITS FOR A PREEXISTING
CONDITION OF THE ELIGIBLE EMPLOYEE IN AMOUNTS NOT EXCEEDING ONE AND
ONE-HALF TIMES THE AMOUNT OF THE STANDARD DEDUCTIBLES AND
COST-SHARING OF OTHER ELIGIBLE EMPLOYEES, IF THE EMPLOYEE WAS NOT
PREVIOUSLY COVERED BY PUBLIC OR PRIVATE HEALTH INSURANCE OR BY
ANOTHER HEALTH BENEFIT ARRANGEMENT, AND THE EMPLOYEE WAS NOT
PREVIOUSLY EMPLOYED BY THAT EMPLOYER.
IS
701
PJ
20
21
22
(A) (!)
IN ESTABLISHING A COMMUNITY RATE FOR A HEALTH BENEFIT
PLAN, A CARRIER SHALL USE A RATING METHODOLOGY THAT IS BASED ON THE
EXPERIENCE OF THE ENTIRE POOL OF RISKS COVERED BY THAT PLAN WITHOUT
REGARD TO HEALTH STATUS OR OCCUPATION.
23
24
(21
GEOGRAPHY.
25
26
(31 RATES FOR A HEALTH BENEFIT PLAN MAY VARY BASED ON FAMILY
COMPOSITION.
27
28
(Bl BASED ON THE ADJUSTMENTS ALLOWED UNDERl>UBSECTION (A)(2) OF
THIS SECTION, A CARRIER MAY CHARGE A RATE THAT IS:
29
30
31
( 1 ! 50% ABOVE OR BELOW THE COMMUNITY RATE FOR ANY HEALTH
BENEFIT PLAN ISSUED, DELIVERED, OR RENEWED BETWEEN JULY 1, 1994 AND JUNE
30, 1995;
32
33
54
(21 40% ABOVE OR BELOW THE COMMUNITY RATE FOR ANY HEALTH
BENEFIT PLAN ISSUED, DELIVERED, OR RENEWED BETWEEN JULY 1, .1995 AND JUNE
30. .1996; AND
35
(31
A CARRIER MAY ADJUST THE COMMUNITY RATE FOR AGE AND
33% ABOVE OR BELOW THE COMMUNITY RATE FOR ALL HEALTH
36
BENEFIT PLANS ISSUED, DELIVERED, OR RENEWED AFTER JULY 1, 1996.
37
703,
38
39
40
(A) A CARRIER SHALL APPLY ALL RISK ADJUSTMENT FACTORS UNDER § 702
OF THIS SUBTITLE CONSISTENTLY WITH RESPECT TO ALL HEALTH BENEFIT PLANS
ISSUED. DELIVERED, OR RENEWED IN THE STATE.
41.
42
(Bl (J!
A CARRIER MAY NOT ARBITRARILY TRANSFER A SMALL EMPLOYER
INVOLUNTARILY INTO OR OUT OF A HEALTH BENEFIT PLAN.
�HOUSE BILL 1359
29
1
2
3
(2)
A CARRIER MAY NOT OFFER TO TRANSFER A SMALL EMPLOYER
INTO OR OUT OF A HEALTH BENEFIT PLAN UNLESS THE OFFER TO TRANSFER IS
MADE TO ALL SMALL EMPLOYERS WITH SIMILAR RISK ADJUSTMENT FACTORS.
4
5
(C) A CARRIER SHALL MAKE A
SOLICITATION AND SALES MATERIALS OF:
6
7
8
9
( I ) THE EXTENT TO WHICH PREMIUM RATES FOR A SPECIFIED SMALL
EMPLOYER ARE ESTABLISHED OR ADJUSTED BASED UPON THE ACTUAL OR
EXPECTED VARIATION IN HEALTH CONDITIONS OF THE ELIGIBLE EMPLOYEES AND
DEPENDENTS OF THE SMALL EMPLOYER;
10
11
12
(2) THE PROVISIONS CONCERNING THE CARRIER'S RIGHT TO CHANGE
PREMIUM RATES, INCLUDING ANY FACTORS THAT MAY AFFECT THE CHANGES IN
PREMIUM RATES:
13
14
(3) THE PROVISIONS RELATING TO RENEWABILITY OF POLICIES AND
CONTRACTS; AND
15
16
17
(4)
REASONABLE
DISCLOSURE
IN
ITS
THE PROVISIONS RELATING TO ANY PREEXISTING CONDITION
PROVISION.
(D)
(1)
A CARRIER SHALL BASE ITS RATING METHODS AND PRACTICES ON:
18
0]
COMMONLY ACCEPTED ACTUARIAL ASSUMPTIONS; AND
19
(II)
SOUND ACTUARIAL PRINCIPLES.
20
(2) SUBJECT TO THE APPROVAL OF THE COMMISSIONER, A CARRIER
21 . MAY IMPOSE REASONABLE MINIMUM PARTICIPATION REQUIREMENTS.
22
(E) TO INDICATE COMPLIANCE WITH SUBSECTIONS (C) AND (D) OF THIS
23 SECTION, A CARRIER SHALL MAINTAIN INFORMATION AND DOCUMENTATION THAT
24 IS SATISFACTORY TO THE COMMISSIONER.
25
( f l (H
ON OR BEFORE MARCH 15 OF EACH YEAR. A CARRIER SHALL FILE
26 AN ACTUARIAL CERTIFICATION WITH THE COMMISSIONER THAT IT HAS FOLLOWED
27 • THE RATING PRACTICES IMPOSED UNDER § 702 OF THIS SUBTITLE.
28
(2).
29
INCLUDES A REVIEW OF:
30
31
32
33
THE CERTIFICATION SHALL BE BASED ON AN EXAMINATION THAT
(H
APPROPRIATE RECORDS; AND
( I I I ACTUARIAL ASSUMPTIONS
AND METHODS USED
BY THE
CARRIER.
(Gl
A CARRIER SFIALL:
34
35
36
(I)
RETAIN ALL DOCUMENTS AND CERTIFICATIONS REQUIRED UNDER
THIS SUBTITLE AT ITS PRINCIPAL PLACE OF BUSINESS FOR A PERIOD OF 5 YEARS;
AND
37
38
(21 MAKE THE INFORMATION AND DOCUMENTATION AVAILABLE TO
THE COMMISSIONER ON REQUEST..
�30
HOUSE BILL 1359
.rm
2
3
4
5
(A) (1) A CARRIER SHALL ISSUE ITS HEALTH BENEFIT PLANS TO ANY SMALL
EMPLOYER THAT MEETS THE REQUIREMENTS OF THIS SUBSECTION.
(2}
TO BE COVERED UNDER A HEALTH BENEFIT PLAN OFFERED BY A
CARRIER. A SMALL EMPLOYER SITALL:
6
(H
ELECT TO BE COVERED UNDER THE PLAN;
7
(ID
AGREE TO MAKE THE REQUIRED PREMIUM PAYMENTS; AND
8
9
10
11
12
13
14
15
(IIII SATISFY THE OTHER REASONABLE PROVISIONS OF THE PLAN
AS APPROVED BY THE COMMISSIONER.
(3] ANY REQUIREMENT USED BY A CARRIER IN DETERMINING
WHETHER TO PROVIDE COVERAGE TO A SMALL EMPLOYER GROUP, INCLUDING
REQUIREMENTS FOR MINIMUM PARTICIPATION OF ELIGIBLE EMPLOYEES AND
MINIMUM EMPLOYER CONTRIBUTIONS, SHALL BE APPLIED UNIFORMLY AMONG ALL
SMALL EMPLOYERS WITH THE SAME NUMBER OF ELIGIBLE EMPLOYEES APPLYING
FOR COVERAGE OR RECEIVING COVERAGE FROM THE CARRIER.
16
17
18
(H
A CARRIER MAY ONLY VARY APPLICATION OF MINIMUM
PARTICIPATION REQUIREMENTS AND MINIMUM EMPLOYER CONTRIBUTION
REQUIREMENTS BY THE SIZE OF THE SMALL EMPLOYER GROUP.
19
20
21
(Bl A CARRIER THAT OFFERS COVERAGE TO A SMALL EMPLOYER SHALL
OFFER COVERAGE TO ALL OF ITS ELIGIBLE EMPLOYEES AND, AT THE ELECTION OF
THE SMALL EMPLOYER, DEPENDENTS OF ELIGIBLE EMPLOYEES.
22
23
(Cl (11
COVERAGE:
24
25
(I)
TO A SMALL EMPLOYER THAT IS NOT LOCATED IN THE
HEALTH MAINTENANCE ORGANIZATION'S APPROVED SERVICE AREAS;
26
27
(U) TO AN ELIGIBLE EMPLOYEE WHO DOES NOT RESIDE WITHIN
THE HEALTH MAINTENANCE ORGANIZATION'S APPROVED SERVICE AREAS; OR
28
29
30
31
32
33
( U l l WITHIN AN AREA WHERE THE FIEALTH MAINTENANCE
ORGANIZATION REASONABLY ANTICIPATES, AND DEMONSTRATES TO THE
SATISFACTION OF THE COMMISSIONER, THAT IT WILL NOT HAVE THE CAPACITY
WITHIN THE AREA IN ITS NETWORK OF PROVIDERS TO DELIVER SERVICE
ADEQUATELY BECAUSE OF ITS OBLIGATIONS TO EXISTING GROUP CONTRACT
HOLDERS AND ENROLLEES.
34
35
36
37
38
39
(21 A HEALTH MAINTENANCE ORGANIZATION THAT DOES NOT OFFER
COVERAGE UNDER PARAGRAPH (1)(III) OF THIS SUBSECTION MAY NOT OFFER
COVERAGE IN THE APPLICABLE AREA TO ANY EMPLOYER GROUPS UNTIL THE
LATER OF 180 DAYS FOLLOWING ANY REFUSAL TO DO SO, OR THE DATE ON WHICH
THE CARRIER NOTIFIES THE COMMISSIONER THAT IT HAS REGAINED CAPACITY TO
DELIVER SERVICES TO SMALL EMPLOYER GROUPS.
40
4.1
(D] A CARRIER MAY NOT BE REQUIRED TO OFFER COVERAGE UNDER
SUBSECTION (A) OF THIS SECTION FOR SO LONG AS THE COMMISSIONER FINDS THAT
A HEALTH
MAINTENANCE ORGANIZATION NEED NOT OFFER
�HOUSE BILL 1359
31
1 THE COVERAGE WOULD PLACE THE CARRIER IN A FINANCIALLY IMPAIRED
2 CONDITION.
3
4
5
(E) ( i l TO SELL HEALTH BENEFIT PLANS TO SMALL EMPLOYERS IN THE
STATE, A CARRIER SHALL FILE ITS PROPOSED SMALL EMPLOYER HEALTH BENEFIT
PLANS WITH THE COMMISSIONER ON OR BEFORE MAY 1, 1994.
6
7
8
(2)
UNLESS THE COMMISSIONER HAS PREVIOUSLY DISAPPROVED ITS
USE, THE CARRIER'S HEALTH BENEFIT PLANS FOR SMALL EMPLOYERS WILL BE
DEEMED APPROVED 60 DAYS AFTER FILING WITH THE COMMISSIONER.
9
705.
10
.
11
12
(A) (JJ
EXCEPT AS PROVIDED IN SUBSECTION (C) OF THIS SECTION, A
CARRIER SHALL RENEW A HEALTH BENEFIT PLAN AT THE OPTION OF THE SMALL
EMPLOYER.
13
14
(2)
ON RENEWAL A CARRIER MAY NOT EXCLUDE ELIGIBLE EMPLOYEES
OR DEPENDENTS FROM A SMALL EMPLOYER HEALTH BENEFIT PLAN.
15
16
17
(B)
A CARRIER
MAY NOT CANCEL OR REFUSE TO RENEW A SMALL
EMPLOYER HEALTH BENEFIT PLAN EXCEPT:
(1)
FOR NONPAYMENT OF THE REQUIRED PREMIUMS;
18
19
20
(21 FOR FRAUD OR MISREPRESENTATION OF THE SMALL EMPLOYER OR
THE COVERED INDIVIDUALS OR THEIR REPRESENTATIVES;
(3)
FOR NONCOMPLIANCE WITH OTHER REASONABLE PROVISIONS OF
21
THE HEALTH BENEFIT PLAN AS APPROVED BY THE COMMISSIONER;
22
(4)
FOR REPEATED MISUSE OF A PROVIDER NETWORK PROVISION;
23
24
25
26
(5)
WHERE THE CARRIER ELECTS NOT TO RENEW ALL OF ITS HEALTH
BENEFIT PLANS ISSUED TO SMALL EMPLOYERS IN THE STATE;
(6)
IF THE CARRIER ELECTS NOT TO RENEW THE PARTICULAR HEALTH
BENEFIT PLAN FOR ALL SMALL EMPLOYERS IN THE STATE;
27
28
(7)
IF THE COMMISSIONER
COVERAGE WOULD:
29
30
(1)
NOT BE IN THE BEST INTERESTS OF POLICYHOLDERS OR
CERTIFICATE HOLDERS; OR
31
32
(II)
OBLIGATIONS; OR
33
34
(81 IF THE CARRIER IS A HEALTH MAINTENANCE ORGANIZATION, FOR
REASONS STATED IN § 19-725(B) OF THE HEALTH - GENERAL ARTICLE.
35
36
(Cl WHEN A CARRIER ELECTS NOT TO RENEW ALL HEALTH BENEFIT PLANS
IN THE STATE, THE CARRIER:
37
38
39
40
(1)
SHALL GIVE NOTICE OF ITS DECISION TO THE AFFECTED SMALL
EMPLOYERS AND THE INSURANCE REGULATORY AUTHORITY OF EACH STATE IN
WHICH AN ELIGIBLE EMPLOYEE OR DEPENDENT RESIDES AT LEAST 180 DAYS
BEFORE THE EFFECTIVE DATE OF NONRENEWAL;
FINDS THAT CONTINUATION OF THE
IMPAIR THE CARRIER'S ABILITY TO MEET ITS CONTRACTUAL
�32
HOUSE BILL 1359
1
(2) AT LEAST 30 WORKING DAYS BEFORE THAT NOTICE, SHALL GIVE
2 NOTICE TO THE COMMISSIONER; AND
3
4
5
(3)
MAY NOT WRITE NEW BUSINESS FOR SMALL EMPLOYERS IN THE
STATE FOR A 5-YEAR PERIOD BEGINNING ON THE DATE OF NOTICE TO THE
COMMISSIONER.
6
(D) WITHIN 7 DAYS FOLLOWING CANCELLATION OR NONRENEWAL OF A
7 HEALTH BENEFIT PLAN, THE CARRIER SHALL SEND WRITTEN NOTICE TO EACH
S ENROLLED EMPLOYEE OF ITS ACTION AND THE CONVERSION RIGHTS AVAILABLE
9 TO EACH ENROLLED EMPLOYEE UNDER §§ 354T AND 477K OF THIS ARTICLE.
10
706.
1L
12
13
14
15
16
(A) ON OR BEFORE MARCH 1 OF EACH YEAR, EACH INSURER THAT HOLDS A
CERTIFICATE OF AUTHORITY IN THE STATE AND PROVIDES HEALTH INSURANCE IN
THE STATE, EACH HEALTH MAINTENANCE ORGANIZATION THAT IS LICENSED TO
OPERATE IN THE STATE, AND EACH NONPROFIT HEALTH SERVICE PLAN THAT IS
LICENSED TO OPERATE IN THE STATE SHALL SUBMIT AN ANNUAL REPORT IN A
FORM REQUIRED BY THE COMMISSIONER THAT INCLUDES, FOR THE PRECEDING
17
CALENDAR YEAR, THE FOLLOWING DATA SPECIFIC TO THIS STATE:
IS
(IJ
PREMIUMS WRITTEN;
.19
(2]
PREMIUMS EARNED;
20
(31 TOTAL AMOUNT OF INCURRED CLAIMS INCLUDING RESERVES FOR
21 CLAIMS INCURRED BUT NOT REPORTED AT THE END OF THE PREVIOUS YEAR;
22 •
(41 TOTAL
AMOUNT
OF
INCURRED
EXPENSES,
INCLUDING
23 COMMISSIONS, ACQUISITION COSTS, GENERAL EXPENSES, TAXES, LICENSES, AND
24 FEES, USING ESTIMATES WHEN NECESSARY;
25
(51
LOSS RATIO; AND
26
(61
EXPENSE RATIO.
2728
29
30
31
(B) ( ( I IF THE LOSS RATIO OF AN INSURER OR HEALTH MAINTENANCE
ORGANIZATION IS LESS THAN 70 PERCENT OR IF.ITS EXPENSE RATIO IS MORE TITAN
15 PERCENT, THE COMMISSIONER MAY REQUIRE THE INSURER OR HEALTH
MAINTENANCE ORGANIZATION TO FILE NEW RATES FOR ITS HEALTH BENEFIT
PLANS.
32
33
34
35
36
(2)
IF THE LOSS RATIO OF A NONPROFIT HEALTH SERVICE PLAN IS LESS
THAN 75 PERCENT OR IF THE EXPENSE RATIO OF A NONPROFIT HEALTH SERVICE
PLAN IS MORE THAN 13 PERCENT, THE COMMISSIONER MAY REQUIRE THE
NONPROFIT HEALTH SERVICE PLAN TO FILE NEW RATES FOR ITS HEALTH BENEFIT
PLANS.
37
707.
38
39
THIS SUBTITLE MAY BE CITED AS THE "MARYLAND HEALTH INSURANCE
REFORM ACT".
�HOUSE KILL 135!)
Article - Health - General
1
2
33
19-706.
3
(H) THE PROVISIONS OF ARTICLE 48A, SUBTITLE 55 SHALL APPLY TO HEALTH
4 MAINTENANCE ORGANIZATIONS.
5
1.9-714.
6
Each marketing document that sets forth the health care services of a health
7 maintenance organization shall describe fully and clearly:
S
(T)
The health care services under each benefit package and every other
9 benefit to which a member is entitled;
10
(2)
Where and how services may be obtained;
11
(3)
Each exclusion or limitation on any service or other benefit that it
13
(4)
Each deductible feature: [and]
14
(5)
Each copavment rprovision] PROVISION: AND
12 provides:
15
(6) ALL INFORMATION REQUIRED BY ARTICLE 4SA. § 703(C) OF THE
16 CODE.
17 19-716.
1
S
Annually, each health maintenance organization shall provide to its members and
19 make available to the general public, in clear, readable, and concise form:
20
_T_ A summary of the most recent financial report that the health
()
21 maintenance organization submits to the Commissioner under § 1-9-717 of this subtitle;
22
(2) A description of the benefit packages available and the nongroup rates
23 required by the Commissioner;
24
£3) A description of the accessibility and availability of services, including
25 ' where and how to obtain them:
26
(4) A statement that shows, by category, the percentage of members assisted
27 bv public funds; Tand]
28
.(5) THE INFORMATION REQUIRED TO BE DISCLOSED BY ARTICLE 48A, §
29 703(C) OF THE CODE; AND
30
(6) Any other information that the Commissioner or the Department
31 requires by rule or regulation.
32 .19-729.
33
(a)
34
35 under it;
A health maintenance organization may not:
_(!) Violate, any provision of this subtitle or any rule or regulation adopted
36
(2) Fail lo fulfill its obligations to provide the health care services specified
37 in its contracts with subscribers;
�34
HOUSE BILL 135!)
1
(3) Make any false statement with respect to any report or statement
2 required by this subtitle or by the Commissioner under this subtitle:
3
(4) Advertise, merchandise, or attempt to merchandise its services in a way
4 that misrepresents its services or capacity for service;
5
(5) Engage in a deceptive, misleading, unfair, or unauthorized practice as to
6 advertising or merchandising;
7
(6) Prevent or attempt to prevent the Commissioner or the Department
S from performing any duty imposed by this subtitle;
9
Q)
10 this subtitle;
Fraudulently obtain or fraudulently attempt to obtain any benefit under
1
1
(8) Fail to fulfill the basic requirements to operate as a health maintenance
12 organization as provided in § 19-71.0 of this subtitle; ["or'l
13
(9) VIOLATE ANY APPLICABLE PROVISION OF SUBTITLE 55 OF ARTICLE
1 4SA OF THE CODE; OR
4
15
(10) Fail to provide services to a member in a timely manner as provided in §
16 19-705.1 (b)"(:i) of this subtitle.
17
SECTION 3. AND BE IT FURTHER ENACTED, That the Laws of Maryland
JS read as follows:
19
.
Article 48A - Insurance Code
20 698,
2.1
(c) "Carrier" means [a person that offers health benefit plans covering eligible
22 employees of a small employer and that is]:
23
(T) An insurer that holds a certificate of authority in this State and provides
24 health insurance in this State;
25
(2)
A health maintenance organization that is licensed to operate in this
(3)
A multiple employer welfare arrangement;
26 State;
27
28
(4} A multiple employer trust located in Maryland or any other state
29 covering Maryland residents;
30
(5) A nonprofit health service plan that is licensed to operate in this State;
31 or
32
(6) Any other person or organization that provides health benefit plans
33 subject to State insurance regulation.
34 r698A.
35
Thts Except as provided in § 706 of this subtitle, this subtitle applies only to carriers
36 that offer health benefit plans covering eligible employees of small employers.!
�HOUSE HILL 1359
35
1
7()2A.
2
3
(A) EACH CARRIER SHALL ESTABLISH AN ENROLLMENT PROCESS IN
ACCORDANCE WITH THIS SECTION.
4
5
6
(B) BEGINNING ON THE 60TH DAY AFTER AN INDIVIDUAL ESTABLISHES
RESIDENCY IN THE STATE, THE INDIVIDUAL SHALL BE OFFERED, FOR A 30-DAY
PERIOD, AN OPPORTUNITY TO ENROLL IN A HEALTH BENEFIT PLAN.
7
(C)
EACH CARRIER SHALL:
8
9
10
(1)
ESTABLISH AN ANNUAL PERIOD. OF NOT LESS THAN 30 DAYS,
DURING WHICH INDIVIDUALS MAY ENROLL IN A HEALTH BENEFIT PLAN OR
CHANGE THE HEALTH BENEFIT PLAN IN WHICH THE INDIVIDUAL IS ENROLLED; AND
11
12
13
14
(2)
PROVIDE FOR A SPECIAL ENROLLMENT PERIOD IN WHICH AN
INDIVIDUAL IS PERMITTED TO CHANGE THE INDIVIDUAL OR FAMILY BASIS OF
COVERAGE OR THE HEALTH BENEFIT PLAN IN WHICH THE INDIVIDUAL IS
ENROLLED IF THE INDIVIDUAL:
J5
16
17
(I)
THROUGH MARRIAGE, DIVORCE, BIRTH OR ADOPTION OF A
CHILD, OR SIMILAR CIRCUMSTANCES, EXPERIENCES A CHANGE IN FAMILY
COMPOSITION: OR
15
19
.
(II] EXPERIENCES A CHANGE IN EMPLOYMENT STATUS INCLUDING
A SIGNIFICANT CHANGE IN THE TERMS AND CONDITIONS OF EMPLOYMENT.
20
(D).
PLANS FOR OPEN ENROLLMENT AND SPECIAL ENROLLMENT PERIODS
21
SHALL BE FILED WITH THE INSURANCE COMMISSIONER.
22
705,
23
24
[(a) (1) Except as provided in subsection (c) of this section, a carrier shall renew
a heallh benefit plan at the option of the small employer.
25
26
(2)_ On renewal a carrier mav not exclude eligible employees or dependents
from a small employer health benefit plan.
27
28
(b)
A carrier may not cancel or refuse to renew a small employer health benefit
plan except:
29
(1)
For nonpayment of the required premiums;
30
31
32
(2) For fraud or misrepresentation of the small employer or the covered
individuals or their representatives;
(3) For noncompliance with other reasonable provisions of the health
33
benefit plan as approved by the Commissioner;
34
(4)
For repeated misuse of a provider network provision;
35
36
(5) Where the carrier elects not to renew all of its health benefit plans
issued to small employers in the State:
37
38
(6)
If the carrier elects not to renew the particular health benefit plan for all
small employers in the State;
39
'
£7)
If the Commissioner finds that continuation of the coverage would:
�36
HOUSE KILL 135!)
1
2 or
(i)
Not be in the best interests of policyholders or certificate holders;
3
(n)
Impair the carrier's ability to meet its contractual obligations; or
4
5
(8} I f the carrier is a health maintenance organization, for reasons stated in
S 19-725(b) of the Health - General Article.
6
7
'(c)
carrier:
8
y
10
When a carrier elects not to renew all health'benefit plans in the State, the
(1} Shall give notice of its decision to the affected small employers and the
insurance regulatory authority of each state in which an eligible employee or dependent
resides at least ISO days before Ihe effective date of nonrenewal;
i 1
(2) A l least 30 working days before that notice, shall give notice to the
12 Commissioner; and
13
14
15
(3) May not write new business for small employers in the Stale for a 5-year
period beginning on the date of notice to the Commissioner."]
(A)
A CARRIER SHALL RENEW HEALTH BENEFIT PLANS. EXCEPT IN ANY OF
16
THE FOLLOWING CASES:
.17
(1)
NONPAYMENT OF THE REQUIRED PREMIUMS;
18
19
(2)
FRAUD OR MISREPRESENTATION
REPRESENTATIVE OF AN ENROLLEE;
20
21
22
23
(3)
REPEATED MISUSE OF A PROVIDER NETWORK PROVISION
INCLUDING UNREASONABLE REFUSAL OF THE ENROLLEE TO FOLLOW A
PRESCRIBED COURSE OF TREATMENT, ABUSIVE OVERUTILIZATION BY AN
ENROLLEE, OR VIOLATION OF REASONABLE POLICIES OF A CARRIER; OR
24
25
(4) THE CARRIER ELECTS TO TERMINATE ALL HEALTH BENEFIT PLANS
IN THE STATE.
26 .
(B)
27 SHALL:
(il
OF
AN
ENROLLEE
OR
A
A CARRIER THAT ELECTS NOT TO RENEW HEALTH BENEFIT PLANS
28
29
(il
PROVIDE ADVANCE NOTICE OF ITS DECISION UNDER THIS
PARAGRAPH TO THE INSURANCE COMMISSIONER; AND
30
31.
32
( l l ) PROVIDE NOTICE OF THE DECISION TO ENROLLEES AT LEAST
120 DAYS PRIOR TO THE NONRENEWAL OF ANY HEALTH BENEFIT PLAN BY THE
CARRIER.
33
34
35
36
(2)
THE CARRIER SHALL BE PROHIBITED FROM WRITING NEW
BUSINESS IN THE STATE FOR A PERIOD OF 5 YEARS FROM THE DATE OF NOTICE TO
THE INSURANCE COMMISSIONER OR UNTIL THE INSURANCE COMMISSIONER
INVITES THE CARRIER TO RENEW PARTICIPATION, WHICHEVER IS SOONER.
37
38
39
40
|"(d)1(C) Within 7 days following cancellation or nonrenewal of a health benefit
plan, the carrier shall send written notice to each enrolled employee of its action and the
conversion rights available to each enrolled employee under §§ 354T and 477K of this
article.
�HOUSE BILL 1359
1
2
3
4
5
6
7
8
9
10
11
12
13
37
SECTION 4. AND BE IT FURTHER ENACTED, That the Governor shall
appoint the Maryland Standard Benefit Plan Task Force to advise the Medical Care Data
Review Commission on the initial development of the standard comprehensive health
benefit plan to be adopted in accordance with § 700 of Subtitle 55 of Article 48A and
Title 19, Subtitle 15 of the Health - General Article. When appointing the members of
the Task Force, the Governor shall, to the extent practicable, ensure that the Task Force
is comprised of an appropriate and balanced mix of representatives of practitioners,
hospitals, carriers, employers, labor, and consumers. By December 1, 1993, the Task
Force shall submit recommendations to the Medical Care Data Review Commission on
the overall design of the standard comprehensive health benefit plan including the
specific scope and estimated cost of the benefits covered under the standard health
benefit plan. In making recommendations, the Task Force, among other relevant factors,
shall consider:
14
(a) The health benefit plans typically provided by Maryland employers to their
15 employees, including the difference, if any, between the benefits offered under insured
16 and self-insured benefit plans;
17
(b) The health benefits required to be covered under federal law for federally
18 qualified health maintenance organizations and under standard health benefit plans
19 adopted by other states; and
20
21
(c)
The impact of the proposed comprehensive standard health benefit plan on:
(1)
The ability of employers to offer or continue to offer employment-based
22 health insurance coverage;
23
(2)
Reducing uncompensated care borne by practitioners and hospitals; and .
24
(3)
Encouraging self-insured employers to voluntarily participate in the
25 community rated health insurance pool.
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
SECTION 5. AND BE IT FURTHER ENACTED, That:
(a) (JJ Annually by October 1 the Insurance Commissioner shall determine the
number of individuals in the State who are under the age of 65 and who are covered
under an insured health benefit plan issued by an insurer authorized to engage in the
insurance business in the State or under a prepaid health benefit package of a health
maintenance organization that operates in the State.
(2) The Insurance Commissioner shall accept registration from public and
private employers and employee groups or associations in the State that offer health
benefit plans under the Employee Retirement Income Security Act or other self-insured
plans and that would agree to obtain insured health benefits for their employees or
groups for a minimum period of 3 years under an insurance plan issued by an insurer
authorized to engage in the insurance business in the State or under a prepaid health
benefit package of a health maintenance organization that operates in the State and that
would be subject to Section 3 of this Act. Upon request of the insurer or HMO being
considered by a registering group of up to 250 employees, the registering group shall
provide claims and demographic information sufficient to assist insurers and HMOs to
develop rates that are adequate, not excessive and not unfairly discriminatory, and in
accordance with Article 48A, § 702 of the Code.
(b) When the Insurance Commissioner determines that at least 37 percent of
Maryland's total population under the age of 65 participates in an adjusted community
�1
2
3
4
5
6
38
IIOUS1L HILL 1359
rated pool as specified in Article 4SA, § 702 of- lhe Code as enacted by ihis Act or are
enrolled in plans sponsored by employers or groups for which the Insurance
Commissioner has obtained registrations, excluding individuals under the age of 65
covered by Medicare, Medicaid, CHAMPUS, and Federal Employee Health Benefits
program. Section 3 of this Act shall take effect the second January 1 following the date of
the determination.
7
(c) The Insurance Commissioner must submit an annual report in accordance
8 with § 2-1312 of the Stale Government Article by December 31. of each year. The report
9 must specify the number of individuals under the age of 65 who are covered under an
10 insured health benefit plan and by registered employers.
.11
12
13
1
4
15
16
17
SECTION 6. AND BE IT FURTHER ENACTED, That if Section 3 of this Act
takes effect on the occurrence of the events specified in Section 5 or 7 of this Act, the
Insurance Commissioner shall ensure that contracts ancl policies issued to employers and
groups that are eligible to sponsor health benefit plans under the Employee Retirement
Income Security Act, shall be effective for 3 years ancl that appropriate sanctions are
included in the policies or contracts in the event of cancellation before the end of the 3year period.
IS
19
20
21
22
SECTION 7. AND BE IT FURTHER ENACTED, That if the Employee
Retirement Income Security Act is amended to allow for state control of employee health
benefit plans and the State of Maryland obtains that control in accordance with federal
law, Section 3 of this Act shall take effect on the first January 1 after the date that is 1
year from the date on which the Slate obtains that control.
23
24
25
26
27
28
SECTION 8. AND BE IT FURTHER ENACTED, That the Insurance
Commissioner shall convene a technical advisory committee to provide advice and
recommendations to the Commissioner on the need for a reinsurance pool or other
risk-sharing mechanisms to encourage insurers to remain in or enter the group or
individual health insurance market. The Commissioner shall submit a report in
accordance with § 2-1312 of the State Government Article by January 1, 1995.
29
SECTION 9. AND BE IT FURTHER ENACTED, That the terms of initial
30 members of the Medical Care Data Review Commission shall expire as follows:
31
(J_l Two members in 1996;
32
(2)
Three members in 1997; and
33
£3)
Two members in 1998.
34
35
36
37
38
39
SECTION 10. AND BE IT FURTHER ENACTED, That Sections 1, 4, 5, 6, 7, 8,
ancl 9 of this Act; and Article 48A, § 700 of the Code, as enacted by Section 2 of this Act,
shall take effect July 1, 1993.
SECTION Ll. AND BE IT FURTHER ENACTED, That, subject to the provisions
of Sections 5 and 7 of this Act, Section 2, except for Article 48A, § 700 of the Code, and
Section 3 of this Act shall take effect July 1, .1.994.
�HOUSE B I L L 460
C3
31r2294
CF 31r2295
By: The Speaker (Administration)
Introduced and read first time: January 27, 1993
Assigned to: Economic Matters
A BILL ENTITLED
AN ACT concerning
Health Insurance - Small Employer Group Health Insurance Reiorm
.5
4
5
6
7
8
9
1
.
0
11
12
13
14
15
16
17
FOR the purpose of creating a new subtitle governing certain small employer group
health plans; providing for certain premium rate regulations: providing for certain
eligibility ancl underwriting regulations; providing for certain exceptions to eligibility
and underwriting regulations; providing for certain marketing regulations; requiring
certain record keeping; providing for a certain reinsurance pool; creating a board
with certain powers to perform certain functions on behalf of the reinsurance pool;
requiring small employer carriers to make a certain election; providing that the
Commissioner may grant approvals of certain changes in elections under certain
circumstances; requiring the board to file certain information and plans with the
Commissioner; providing certain procedures for reinsurance by reinsuring carriers;
providing for certain assessments; providing for a certain type of financing for the
pool; providing that nonprofit health service plans shall be subject to this Act;
providing that health maintenance organizations shall be subject to this Act;
defining certain terms; providing for the termination of this Act; and generally
relating to small employer group health insurance.
18 BY repealing and reenacting, with amendments,
.
19
Article 48A - Insurance Code
20
Section 354(a)
21
Annotated Code of Maryland
22
(1991 Replacement Volume and 1992 Supplement)
23 BY adding to
24
Article 48A - Insurance Code
25
Section 700 through 7.12, inclusive, to be under the new subtitle '55. Small
26
Employer Group Health Insurance"
27
Annotated Code of Maryland
28
(199.1 Replacement Volume and 1992 Supplement)
c
29 BY repealing and reenacting, with amendments,
30
Article - Health - General
31
Section 19-714, 19-716, and J9-729(a)
32
Annotated Code of Maryland
EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets] indicate matter deleted from existing law.
�2
I
•
HOUSE BILL 4fl0
(1990 Replacement Volume and 1992 Supplement)
2- BY adding to
. . .
3
Article - Health - General
4
Section 19-706(1-1)
5'
Annotated Code of Maryland
6
(1990 Replacement Volume and 1992 Supplement)
7
SECTION
I.
BE
IT ENACTED
BY T H E G E N E R A L
5
OF
M A R Y L A N D , That the Laws of Maryland read as follows:
9
ASSEMBLY
Article 48A - Insurance Code
10 354.
I 1
1.2
13
14
L
S
16
17
18
19
20
21
22
23
24
25
26
(a) Any corporation without capital stock heretofore or hereafter organized for
the purpose of establishing, maintaining and operating a nonprofit health service plan
whereby
hospital, medical, chiropodial, chiropractic, pharmaceutical,
dental,
psychological or optometric care is provided by a hospital, or hospitals, a physician-OIphysicians, a chiropodist or chiropodists, a chiropractor or chiropractors, a pharmacist or
pharmacists, a dentist or dentists, a duly licensed psychologist or psychologists, or an
optometrist or optometrists, to persons who become subscribers lo such plan under
contracts which entitle each subscriber to certain hospital, medical, chiropodial,
chiropractic, pharmaceutical, dental, psychological, or optometric care or any of them,
shall be governed ancl regulated by the provisions of this subtitle, and of [Subtitle 1 \]
SUBTITLES 11 AND 55 of this article, ancl by no other law relating to insurance unless such
law is referred to under this subtitle, and no law hereafter enacted shall apply to such
corporations, unless they are expressly designated therein, and specifically refer to such
corporations. Notwithstanding this, the Commissioner shall have those powers and duties
necessary to enforce the provisions of this subtitle with respect to nonprofit health service
plans as are granted under §ij 24 and 25 of this article.
27
698. RESERVED.
28
699. RESERVED.
29
55. SMALL EMPLOYER GROUP HEALTH INSURANCE
30 -700.
31
32
(A) IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.
33
34
35
36
37
(B) "ACTUARIAL CERTIFICATION ' MEANS A WRITTEN STATEMENT IN A FORM
APPROVED BY THE COMMISSIONER BY A MEMBER OF THE AMERICAN ACADEMY OF
ACTUARIES OR OTHER INDIVIDUAL ACCEPTABLE TO THE COMMISSIONER THAT A
SMALL EMPLOYER CARRIER IS IN COMPLIANCE WITH THE PROVISIONS OF THIS
SUBTITLE.
7
38
(C)
"BOARD" MEANS THE BOARD OF DIRECTORS OF THE POOL.
39
(D)
-CARRIER" MEANS:
40
4.1
• (1)
AN INSURER WHICH HOLDS A CERTIFICATE OF AUTHORITY AND
PROVIDES HEALTH INSURANCE IN THIS STATE;
�HOUSE BILL 460
(2)
3
A HEALTH MAINTENANCE ORGANIZATION WHICH OPERATES IN
A MULTIPLE EMPLOYER WELFARE ARRANGEMENT;
4
5
(4)
A MULTIPLE EMPLOYER TRUST LOCATED IN MARYLAND OR ANY
OTHER STATE COVERING MARYLAND RESIDENTS WHO ARE ELIGIBLE EMPLOYEES;
6
(5)
A NONPROFIT HEALTH SERVICE PLAN; OR
7
8
9
10
11
(6)
ANY OTHER PERSON OR ORGANIZATION WHICH PROVIDES HEALTH
INSURANCE SUBJECT TO STATE INSURANCE REGULATION.
(E) "COMMUNITY RATE"' MEANS THE SAME RATE FOR A HEALTH BENEFITS
PLAN THAT IS CHARGED TO ALL SMALL EMPLOYERS PRIOR TO ANY ADJUSTMENTS
UNDER § 702 OF THIS SUBTITLE.
12
13
(F) "DEPENDENT" INCLUDES THE SPOUSE OR
ADOPTED CHILD OF AN ELIGIBLE EMPLOYEE.
14
.15
(G) (I)
"ELIGIBLE EMPLOYEE" MEANS AN EMPLOYEE WHO WORKS ON A
FULL-TIME BASIS AND HAS A NORMAL WORKWEEK OF 30 OR MORE HOURS.
16
17
15
(2)
"ELIGIBLE EMPLOYEE" INCLUDES A SOLE PROPRIETOR, A PARTNER
OF A PARTNERSHIP. OR AN INDEPENDENT CONTRACTOR WHO IS INCLUDED AS AN
EMPLOYEE UNDER A HEALTH CARE PLAN OF A SMALL EMPLOYER.
19
20
21
(3)
"ELIGIBLE EMPLOYEE" DOES NOT INCLUDE AN INDIVIDUAL WHO
WORKS ON A TEMPORARY OR SUBSTITUTE BASIS OR FOR FEWER THAN 30 HOURS IN
A WORKWEEK.
22
23
24
25
26
(H)
(1)
NATURAL OR LEGALLY
"HEALTH BENEFIT PLAN" MEANS ANY:
(I)
HOSPITAL OR MEDICAL POLICY OR CERTIFICATE, INCLUDING
THOSE ISSUED UNDER MULTIPLE EMPLOYER TRUSTS OR ASSOCIATIONS LOCATED
IN MARYLAND OR ANY OTHER STATE COVERING MARYLAND RESIDENTS WHO ARE
ELIGIBLE EMPLOYEES:
27
(II)
NONPROFIT HEALTH SERVICE PLAN;
28
29
CONTRACT; OR
30
31
32
(IV) PLAN PROVIDED BY OR THROUGH A MULTIPLE EMPLOYER
WELFARE ARRANGEMENT OR OTHER BENEFIT ARRANGEMENT OFFERED BY A
MULTIPLE EMPLOYER WELFARE ARRANGEMENT.
33
(III) HEALTH
(2)
MAINTENANCE
ORGANIZATION
"HEALTH BENEFIT PLAN" DOES NOT INCLUDE:
34
(1)
ACCIDENT-ONLY INSURANCE;
35
(II)
FIXED INDEMNITY INSURANCE;
36
(HI) CREDIT HEALTH INSURANCE;
37
(IV) DENTAL INSURANCE;
38
(V)
VISION INSURANCE;
SUBSCRIBER
�4
I
HOUSE BILL 460
(VI) MEDICARE SUPPLEMENT POLICIES;
(VII) LONG-TERM CARE INSURANCE;
3
(VIII) DISABILITY INCOME INSURANCE;
4
(IX) COVERAGE
5
ISSUED
AS
A
SUPPLEMENT
TO
LIABILITY
INSURANCE;
6
(X)
7
(XI) DISEASE SPECIFIC INSURANCE;
S
'(XII) AUTOMOBILE MEDICAL-PAYMENT INSURANCE; OR
9
10
WORKERS' COMPENSATION OR SIMILAR INSURANCE;
(XIII) ANY
COMMISSIONER.
OTHER
INSURANCE
PLAN
DEEMED
BY
THE
JJ
(I)
(1)
"LATE ENROLLEE" MEANS AN ELIGIBLE EMPLOYEE OR DEPENDENT
12 WHO REQUESTS ENROLLMENT IN A SMALL EMPLOYER'S HEALTH BENEFIT PLAN
13 FOLLOWING THE INITIAL ENROLLMENT PERIOD PROVIDED UNDER THE TERMS OF
.14 THE HEALTH BENEFIT PLAN.
15
.16
17
(2)
AN ELIGIBLE EMPLOYEE OR DEPENDENT MAY NOT BE CONSIDERED
A LATE ENROLLEE IF:
(I)
THE INDIVIDUAL:
IS
19
20
1.
WAS COVERED UNDER A PUBLIC OR PRIVATE HEALTH
INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENT AT THE TIME THE
INDIVIDUAL WAS ELIGIBLE TO ENROLL:
21
22
23
24
2.
HAS LOST COVERAGE UNDER A PUBLIC OR PRIVATE
HEALTH INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENT AS A RESULT OF
TERMINATION OF EMPLOYMENT OR ELIGIBILITY, THE TERMINATION OF THE
OTHER PLAN'S'CO VER AGE, DEATH OF A SPOUSE, OR DIVORCE; AND
25
26
27
3.
REQUESTS ENROLLMENT WITHIN 30 DAYS AFTER
TERMINATION OF COVERAGE PROVIDED UNDER A PUBLIC OR PRIVATE HEALTH
INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENT;
28
29
30
(II) THE INDIVIDUAL IS EMPLOYED BY AN EMPLOYER WHICH
OFFERS MULTIPLE HEALTH BENEFIT PLANS AND THE INDIVIDUAL ELECTS A .
DIFFERENT PLAN DURING AN OPEN ENROLLMENT PERIOD;
3.1.
32
(Ill) THE INDIVIDUAL REQUESTS ENROLLMENT WITHIN 30 DAYS OF
BECOMING AN EMPLOYEE OF THE SMALL EMPLOYER;
33
34
35
(IV) A COURT HAS ORDERED COVERAGE TO BE PROVIDED FOR A
SPOUSE OR MINOR CHILD UNDER A COVERED EMPLOYEE'S HEALTH BENEFIT PLAN;
OR
36
(V) A REQUEST FOR ENROLLMENT IS MADE WITHIN 30 DAYS
37 AFTER THE ELIGIBLE EMPLOYEE'S MARRIAGE OR THE BIRTH OR ADOPTION OF A
38 CHILD.
�HOUSE BILL 460
5
1
(J)
(1)
''MULTIPLE EMPLOYER WELFARE ARRANGEMENT" MEANS A
2 MULTIPLE EMPLOYER WELFARE ARRANGEMENT AS DEFINED IN § 3 OF THE
3 FEDERAL EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974, 29 U.S.C. § 1001,
4 ET SEQ THAT DIRECTLY OR INDIRECTLY PROVIDES HEALTH INSURANCE TO ONE OR
5 MORE EMPLOYEES OF A SMALL EMPLOYER IN THIS STATE.
6
7
S
9
(2)
"MULTIPLE EMPLOYER WELFARE ARRANGEMENT" DOES NOT
INCLUDE ANY ARRANGEMENT THAT IS FULLY INSURED WITHIN THE MEANING OF §
514(B)(6) OFTHE FEDERAL EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1.974,
29 U.S.C. S .1001, ET SEQ.
10
11
!2
(K) "PLAN OF OPERATION" MEANS THE PLAN OF OPERATION OF THE POOL,
INCLUDING ARTICLES OF INCORPORATION, BYLAWS, AND OPERATING RULES
ADOPTED BY THE BOARD UNDER § 707 OF THIS SUBTITLE.
13
14
(L) "POOL"
MEANS THE
MARYLAND
SMALL
REINSURANCE POOL ESTABLISHED UNDER THIS SUBTITLE.
15
1.6
17
IS
(M) "PREEXISTING CONDITION PROVISION" MEANS A PROVISION IN A
HEALTH BENEFIT PLAN THAT DENIES, EXCLUDES, OR LIMITS BENEFITS FOR A
COVERED INDIVIDUAL FOR CLAIMS INCURRED DURING A SPECIFIC PERIOD
FOLLOWING THE INSURED'S EFFECTIVE DATE OF COVERAGE:
19
20
(.1)
FOR A CONDITION THAT WOULD CAUSE AN ORDINARILY PRUDENT
PERSON TO SEEK MEDICAL ADVICE. DIAGNOSIS, CARE, OR TREATMENT; OR
2.1
22
23
(2)
FOR A CONDITION FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE,
OR TREATMENT WAS RECOMMENDED OR RECEIVED DURING THE 6 MONTHS
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF THIS COVERAGE.
24
25
26
27
2S
(N) "RATING PERIOD" MEANS THE CALENDAR PERIOD FOR WHICH PREMIUM
RATES ESTABLISHED BY A SMALL EMPLOYER CARRIER ARE IN EFFECT, PROVIDED
THAT A SMALL EMPLOYER CARRIER SHALL HAVE ONLY ONE RATING PERIOD IN
ANY CALENDAR MONTH AND NO MORE THAN 12 RATING PERIODS IN ANY
CALENDAR YEAR.
29
30
(O) "REINSURING CARRIER"
PARTICIPATING IN THE POOL.
31
32
(P) "RISK-ASSUMING CARRIER" MEANS A SMALL EMPLOYER CARRIER NOT
PARTICIPATING IN THE POOL.
MEANS
A
SMALL
EMPLOYER
EMPLOYER
HEALTH
CARRIER
34
35
36
37
38
39
(Q) (1)
"SMALL EMPLOYER" MEANS ANY PERSON, FIRM, CORPORATION,
PARTNERSHIP, OR ASSOCIATION ACTIVELY ENGAGED IN BUSINESS AND, ON AT
LEAST 50 PERCENT OF ITS WORKING DAYS DURING THE PRECEDING CALENDAR
YEAR, EMPLOYED AT LEAST TWO BUT NO MORE THAN 50 ELIGIBLE EMPLOYEES, THE
MAJORITY OF WHOM ARE EMPLOYED WITHIN THIS STATE. SMALL EMPLOYER
CARRIERS WHO DO NOT IMPOSE PREEXISTING CONDITION LIMITATIONS MAY
REQUIRE THAT A SMALL EMPLOYER HAVE AT LEAST THREE ELIGIBLE EMPLOYEES.
40
41
42
43
(2)
IF THE FEDERAL EMPLOYMENT RETIREMENT INCOME SECURITY
ACT IS AMENDED TO EXCLUDE EMPLOYEE GROUPS UNDER A SPECIFIC SIZE,
NOTWITHSTANDING PARAGRAPH (1.) OF THIS SUBSECTION, THIS SUBTITLE SHALL
APPLY TO ANY EMPLOYEE GROUP SIZE THAT IS EXCLUDED FROM THAT FEDERAL
44
ACT.
.i j
�6
HOUSli HILL 4(i0
1
(.1)
IN DETERMINING THE NUMBER OF ELIGIBLE EMPLOYEES,
2 COMPANIES WHICH ARE AFFILIATED COMPANIES OR WHICH ARE ELIGIBLE TO FILE
3 A COMBINED STATE TAX RETURN SHALL BE CONSIDERED ONE EMPLOYER.
4
5
(R) "SMALL. EMPLOYER CARRIER" MEANS A CARRIER THAT OFFERS HEALTH
BENEFIT PLANS COVERING ELIGIBLE EMPLOYEES OF A SMALL EMPLOYER.
6
701.
7
S
THIS SUBTITLE SHALL APPLY TO ANY HEALTH BENEFIT PLAN WHICH PROVIDES
COVERAGE TO A SMALL EMPLOYER IN THIS STATE IF:
9
.10
(1)
ANY PORTION OF THE PREMIUM OR BENEFITS IS PAID BY OR ON
BEHALF OF THE SMALL EMPLOYER:
11
12
13
(2)
ANY ELIGIBLE EMPLOYEE OR DEPENDENT IS REIMBURSED,
WHETHER THROUGH WAGE ADJUSTMENTS OR OTHERWISE, BY OR ON BEHALF OF
THE SMALL EMPLOYER FOR ANY PORTION OF THE PREMIUM;
14
(3) THE HEALTH BENEFIT PLAN IS TREATED BY THE EMPLOYER OR ANY
15 OF THE ELIGIBLE EMPLOYEES OR DEPENDENTS AS PART OF A PLAN OR PROGRAM
16 PURSUANT TO THE UNITED STATES INTERNAL REVENUE CODE, 26 U.S.C.
106, 125,
I 7 OR 162; OR
IS
(4)
THE SMALL EMPLOYER HAS PERMITTED PAYROLL DEDUCTION FOR
19 THE ELIGIBLE EMPLOYEE FOR THE HEALTH BENEFITS PLAN.
20
702.
21
22
23
24
(A) (1)
SUBJECT TO SUBSECTION (B) OF THIS SECTION THE PREMIUM RATES
CHARGED OR OFFERED TO A SMALL EMPLOYER SHALL BE ESTABLISHED ON THE
BASIS OF A COMMUNITY RATE, ADJUSTED, AT THE DISCRETION OF THE SMALL
EMPLOYER CARRIER TO REFLECT ONE OR MORE OF THE FOLLOWING RISK
25
CLASSIFICATIONS:
26
(I)
AGE;
27
(II)
GEOGRAPHY:
2S
(III) GENDER; AND
29
(IV) HEALTH STATUS.
30
31
32
33
34
35
36
(2)
A SMALL EMPLOYER CARRIER MAY ALSO ADJUST THE COMMUNITY
RATE CHARGED OR OFFERED ACCORDING TO FAMILY COMPOSITION AND GROUP
SIZE.
(3)
OTHER THAN THE RISK CLASSIFICATIONS SET FORTH IN
PARAGRAPHS (.1) AND (2) OF THIS SUBSECTION, A SMALL EMPLOYER CARRIER MAY
NOT EMPLOY ANY OTHER RISK CLASSIFICATION OR OTHER RATING FACTOR, SUCH
AS CLAIMS EXPERIENCE OR DURATION OF COVERAGE, TO A SMALL EMPLOYER.
37
3S
(4)
HEALTH STATUS INCLUDES REFRAINING FROM TOBACCO USE OR
OTHER'ACTUARIALLY VALID FACTOR.
�HOUSE BILL 460
7
1
(B) A SMALL EMPLOYER CARRIER MAY ADJUST THE COMMUNITY RATE FOR
2 A SMALL EMPLOYER BASED ON THE RISK CLASSIFICATION UNDER SUBSECTION
3 (A)(1) OF THIS SECTION:
4
5
6
(1)
FOR ANY HEALTH BENEFIT PLAN ISSUED, DELIVERED, OR
RENEWED BETWEEN JANUARY I , 1994 AND DECEMBER 31, 1994, BY 50% ABOVE OR
BELOW THE COMMUNITY RATE;
7
S
9
(2)
FOR ANY HEALTH BENEFIT PLAN ISSUED, DELIVERED OR RENEWED
BETWEEN JANUARY I , 1995 AND DECEMBER 31, 1995, BY 40% ABOVE OR BELOW THE
COMMUNITY RATE: AND
10
11
12
(3)
FOR ALL HEALTH BENEFIT PLANS ISSUED, DELIVERED, OR
RENEWED AFTER JANUARY 1, 1996, BY 33% ABOVE OR BELOW THE COMMUNITY
RATE.
13
14
15
(C) A SMALL EMPLOYER CARRIER SHALL APPLY ALL RISK ADJUSTMENT
FACTORS UNDER SUBSECTION (A) OF THIS SECTION CONSISTENTLY WITH RESPECT
TO ALL SMALL EMPLOYERS.
16
17
.
(D) (1)
A SMALL EMPLOYER CARRIER MAY NOT ARBITRARILY TRANSFER A
SMALL EMPLOYER INVOLUNTARILY INTO OR OUT OF A HEALTH BENEFITS PLAN.
IS
19
20
21.
(2)
A SMALL EMPI..OYER CARRIER MAY NOT OFFER TO TRANSFER A
SMALL EMPLOYER INTO OR OUT OF A HEALTH BENEFITS PLAN UNLESS THE OFFER
TO TRANSFER IS MADE TO ALL SMALL EMPLOYERS WITH SIMILAR RISK
ADJUSTMENT FACTORS.
22
23
(E) A SMALL EMPLOYER CARRIER SHALL MAKE A REASONABLE DISCLOSURE
IN ITS SOLICITATION AND SALES MATERIALS OF:
24
25
26
27
(1)
THE EXTENT TO WHICH PREMIUM RATES FOR A SPECIFIED SMALL
EMPLOYER ARE ESTABLISHED OR ADJUSTED BASED UPON THE ACTUAL OR
EXPECTED VARIATION IN HEALTH CONDITIONS OF THE ELIGIBLE EMPLOYEES AND
DEPENDENTS OF SUCH SMALL EMPLOYER;
2S
29
30
(2)
THE PROVISIONS CONCERNING THE SMALL EMPLOYER CARRIER'S
RIGHT TO CHANGE PREMIUM RATES, INCLUDING ANY FACTORS MAY AFFECT THE
CHANGES IN PREMIUM RATES:
3.1
32
(3)
THE PROVISIONS RELATING TO RENEWABILITY OF POLICIES AND
CONTRACTS; AND
33
34
(4)
PROVISION.
35
(F)
36
(1)
THE PROVISIONS
RELATING TO ANY PREEXISTING CONDITION
A SMALL EMPLOYER CARRIER SHALL BASE ITS RATING METHODS
AND PRACTICES ON:
37
(I)
COMMONLY ACCEPTED ACTUARIAL ASSUMPTIONS; AND
3S
(II)
SOUND ACTUARIAL PRINCIPLES.
39
40
41
(2)
SUBJECT TO THE APPROVAL OF THE COMMISSIONER, A SMALL
EMPLOYER CARRIER MAY IMPOSE REASONABLE MINIMUM PARTICIPATION
REQUIREMENTS.
�S
HOUSE BILL 460
1
(G) TO INDICATE COMPLIANCE WITH SUBSECTIONS (E) AND (F) OF THIS
2 SECTION, A SMALL EMPLOYER CARRIER SHALL MAINTAIN INFORMATION AND
3 DOCUMENTATION THAT IS SATISFACTORY TO THE COMMISSIONER.
4
5
6
(1-1) (1)
ON OR BEFORE MARCH 15 OF EACH YEAR, A SMALL EMPLOYER
CARRIER SHALL FILE AN ACTUARIAL CERTIFICATION WITH THE COMMISSIONER
THAT IT HAS FOLLOWED THE RATING PRACTICES IMPOSED UNDER THIS SECTION.
7
S
(2)
THE CERTIFICATION SHALL BE BASED ON AN EXAMINATION THAT
INCLUDES A REVIEW OF:
9
(I)
APPROPRIATE RECORDS: AND
10
(II)
ACTUARIAL ASSUMPTIONS
11
12
AND METHODS USED
BY THE
SMALL EMPLOYER CARRIER.
'
(I)
A SMALL EMPLOYER CARRIER SHALL:
13
(I)
RETAIN ALL DOCUMENTS AND CERTIFICATIONS REQUIRED UNDER
14 THIS SUBTITLE AT ITS PRINCIPAL PLACE OF BUSINESS FOR A PERIOD OF 5 YEARS;
15 AND
.16
17
18
(2)
MAKE THE INFORMATION AND DOCUMENTATION AVAILABLE TO
THE COMMISSIONER ON REQUES T.
703.
19
(A) (1) TO BE COVERED UNDER A HEALTH BENEFIT PLAN OFFERED BY A
20 SMALL EMPLOYER CARRIER, A SMALL EMPLOYER SHALL:
21
(I)
ELECT TO BE COVERED UNDER THE PLAN;
22
(II)
AGREE TO MAKE THE REQUIRED PREMIUM PAYMENTS; AND
23
24
(III) SATISFY THE OTHER REASONABLE PROVISIONS OF THE PLAN
AS APPROVED BY THE COMMISSIONER.
25
26
27
2S
29
30
31
(2)
ANY REQUIREMENT USED BY A SMALL EMPLOYER CARRIER IN
DETERMINING WHETHER TO PROVIDE COVERAGE TO A SMALL EMPLOYER GROUP,
INCLUDING REQUIREMENTS FOR MINIMUM PARTICIPATION OF ELIGIBLE
EMPLOYEES AND MINIMUM EMPLOYER CONTRIBUTIONS, SHALL BE APPLIED
UNIFORMLY AMONG ALL SMALL EMPLOYERS WITH THE SAME NUMBER OF ELIGIBLE
EMPLOYEES APPLYING FOR COVERAGE OR RECEIVING COVERAGE FROM THE
S M ALL E M P LO Y E R CA R RIE R.
32
33
34
(3)
A SMALL EMPLOYER CARRIER MAY ONLY VARY APPLICATION OF
MINIMUM
PARTICIPATION
REQUIREMENTS
AND
MINIMUM
EMPLOYER
CONTRIBUTION REQUIREMENTS BY THE SIZE OF THE SMALL EMPLOYER GROUP.
35
36
37
(B) A SMALL EMPLOYER CARRIER THAT OFFERS COVERAGE TO A SMALL
EMPLOYER SHALL OFFER COVERAGE TO ALL OF ITS ELIGIBLE EMPLOYEES AND, AT
THE ELECTION OF THE SMALL EMPLOYER, DEPENDENTS OF ELIGIBLE EMPLOYEES.
38
39
40
'
(C) (1) TO SELL HEALTH BENEFIT PLANS TO SMALL EMPLOYERS IN
THE STATE, A SMALL EMPLOYER CARRIER SHALL FILE ITS PROPOSED SMALL
EMPLOYER HEALTH BENEFIT PLANS WITH THE COMMISSIONER BY OCTOBER 1, 1993.
�MOUSE BILL 460
9
1
2
3
4
(2)
UNLESS THE COMMISSIONER HAS PREVIOUSLY DISAPPROVED ITS
USE, THE SMALL EMPLOYER CARRIER'S HEALTH BENEFIT PLANS FOR SMALL
EMPLOYERS WILL BE DEEMED APPROVED 60 DAYS AFTER FILING WITH THE
COMMISSIONER.
5
6
7
(D) (1)
EXCEPT AS PROVIDED IN PARAGRAPH (4) OF THIS SUBSECTION,
PREEXISTING CONDITION PROVISIONS IN HEALTH BENEFIT PLANS COVERING
SMALL EMPLOYERS MAY NOT APPLY AFTER DECEMBER 31, 1994.
8
(2)
IN DETERMINING THE LENGTH THAT A PREEXISTING CONDITION
9 PROVISION APPLIES TO AN ELIGIBLE EMPLOYEE OR DEPENDENT, A HEALTH
.10 BENEFIT PLAN SHALL CREDIT TFIE TIME THE INDIVIDUAL WAS PREVIOUSLY
11 COVERED BY PUBLIC OR PRIVATE HEALTH INSURANCE OR OTHER HEALTH BENEFIT
12 ARRANGEMENTS.
13
14
IF:
(3)
AN INDIVIDUAL IS DEEMED TO HAVE BEEN PREVIOUSLY COVERED
15
16
17
IS
(I)
AN INTERRUPTION OF NO MORE THAN 60 DAYS HAD
OCCURRED FROM THE TIME THE INDIVIDUAL WAS COVERED BY ANY PUBLIC OR
PRIVATE HEALTH INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENTS UNTIL
THE EFFECTIVE DATE OF THE NEW COVERAGE; OR
19
(II) AN INTERRUPTION OF NO MORE THAN 60 DAYS HAD
20 OCCURRED FROM THE TIME THE INDIVIDUAL WAS COVERED BY ANY PUBLIC OR
21 PRIVATE HEALTH INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENTS UNTIL
22 THE INDIVIDUAL BECAME AN ELIGIBLE EMPLOYEE WHO ELECTED TO ENROLL BUT
23 AGAINST WHOM THE SMALL EMPLOYER IMPOSED A WAITING PERIOD PRIOR TO
24 ENROLLMENT.
25
26
(4)
(I)
A LATE ENROLLEE MAY BE SUBJECT TO AN 12-MONTH
PREEXISTING CONDITION PROVISION.
27
28
(II)
TO PREGNANCY.
29
30
(E) (1)
COVERAGE:
31
32
(I)
TO A SMALL EMPLOYER THAT IS NOT LOCATED IN THE
HEALTH MAINTENANCE ORGANIZATION'S APPROVED SERVICE AREAS;
33
34
(II) TO AN ELIGIBLE EMPLOYEE WHO DOES NOT RESIDE WITHIN
THE HEALTH MAINTENANCE ORGANIZATION'S APPROVED SERVICE AREAS; OR
35
36
37
38
39
40
(III) WITHIN AN AREA WHERE THE HEALTH MAINTENANCE
ORGANIZATION REASONABLY ANTICIPATES, AND DEMONSTRATES TO THE
SATISFACTION OF THE COMMISSIONER, THAT IT WILL NOT HAVE THE CAPACITY
WITHIN THE AREA IN ITS NETWORK OF PROVIDERS TO DELIVER SERVICE
ADEQUATELY BECAUSE OF ITS OBLIGATIONS TO EXISTING GROUP CONTRACT
HOLDERS AND ENROLLEES.
41
42
43
(2)
A HEALTH MAINTENANCE ORGANIZATION THAT DOES NOT OFFER
COVERAGE UNDER SUBSECTION (E)(1)(III) OF THIS SECTION MAY NOT OFFER
COVERAGE IN THE APPLICABLE AREA TO ANY EMPLOYER GROUPS UNTIL THE
A PREEXISTING CONDITION PROVISION MAY NOT BE APPLIED
A HEALTH
MAINTENANCE ORGANIZATION NEED
NOT OFFER
�10
HOUSli HILL 460
1 LATER OF ISO DAYS FOLLOWING ANY REFUSAL TO DO SO, OR THE DATE ON WHICH
2 THE CARRIER NOTIFIES THE COMMISSIONER THAT IT HAS REGAINED CAPACITY TO
3 ' DELIVER SERVICES TO SMALL EMPLOYER GROUPS.
4
5
6
7
S
(F) A SMALL EMPLOYER CARRIER MAY NOT BE REQUIRED TO OFFER
COVERAGE UNDER SUBSECTION (A) OF THIS SECTION FOR SO LONG AS THE
COMMISSIONER FINDS THAT THE COVERAGE WOULD PLACE THE SMALL EMPLOYER
CARRIER IN A FINANCIALLY IMPAIRED CONDITION.
704.
9
(A) (1)
EXCEPT AS PROVIDED IN SUBSECTION (B) OF THIS SECTION, A
10 SMALL EMPLOYER CARRIER SHALL RENEW A SMALL EMPLOYER HEALTH BENEFIT .
I 1 PLAN AT THE OPTION OF THE SMALL EMPLOYER.
.12
13
14
(2)
ON RENEWAL A SMALL EMPLOYER CARRIER MAY NOT EXCLUDE
ELIGIBLE EMPLOYEES OR DEPENDENTS FROM A SMALL EMPLOYER HEALTH
BENEFIT PLAN.
15
16
(B) A SMALL EMPLOYER CARRIER MAY NOT CANCEL OR REFUSE TO RENEW
A SMALL EMPLOYER HEALTH BENEFIT PLAN EXCEPT:
17
IS
.19
20
21
22
(1)
FOR NONPAYMENT OF THE REQUIRED PREMIUMS;
(2)
FOR FRAUD OR MISREPRESENTATION OFTHE SMALL EMPLOYER OR
THE COVERED INDIVIDUALS OR THEIR REPRESENTATIVES;
(3)
FOR NONCOMPLIANCE WITH OTHER REASONABLE PROVISIONS OF
THE HEALTH BENEFIT PLAN AS APPROVED BY THE COMMISSIONER;
(4)
FOR REPEATED MISUSE OF A PROVIDER NETWORK PROVISION;
23
24
25
26
(5)
WHERE THE SMALL EMPLOYER CARRIER ELECTS NOT TO RENEW
ALL.OF ITS HEALTH BENEFIT PLANS ISSUED TO SMALL EMPLOYERS IN THIS STATE;
(6)
IF THE SMALL EMPLOYER CARRIER ELECTS NOT TO RENEW THE
PARTICULAR HEALTH BENEFITS PLAN FOR ALL SMALL EMPLOYERS IN THE STATE;
27
28
(7)
IF THE COMMISSIONER
COVERAGE WOULD:
29
30
(1)
NOT BE IN THE BEST INTERESTS OF POLICYHOLDERS OR
CERTIFICATE HOLDERS: OR
31
52
(II)
OBLIGATIONS; OR
33
34
35
(S)
IF THE SMALL EMPLOYER CARRIER IS A HEALTH MAINTENANCE
ORGANIZATION, FOR REASONS STATED IN THE HEALTH - GENERAL ARTICLE, §
19-725(B).
36
.37
(C) WHEN A SMALL EMPLOYER CARRIER ELECTS NOT TO RENEW ALL
HEALTH BENEFIT PLANS IN THE STATE, THE SMALL EMPLOYER CARRIER:
38
39
(I) SHALL GIVE NOTICE OF ITS DECISION TO THE AFFECTED SMALL
EMPLOYERS AND THE INSURANCE REGULATORY AUTHORITY OF EACH STATE IN
FINDS THAT CONTINUATION OF THE
IMPAIR THE CARRIER'S ABILITY TO MEET ITS CONTRACTUAL
�HOUSE BILL 460
11
1 WHICH AN ELIGIBLE EMPLOYEE OR DEPENDENT RESIDES AT LEAST 180 DAYS
2 BEFORE THE EFFECTIVE DATE OF NONRENEWAL;
3
4
(2)
AT LEAST 30 WORKING DAYS BEFORE THAT NOTICE, SHALL GIVE
NOTICE TO THE COMMISSIONER; AND
5
6
7
(3)
MAY NOT WRITE NEW BUSINESS FOR SMALL EMPLOYERS IN THE
STATE FOR A .5-YEAR PERIOD BEGINNING ON THE DATE OF NOTICE TO THE
COMMISSIONER.
8
9
10
11
12
(D) WITHIN 7 DAYS FOLLOWING CANCELLATION OR NONRENEWAL OF A
HEALTH BENEFIT PLAN, THE SMALL EMPLOYER CARRIER SHALL SEND WRITTEN
NOTICE TO EACH ENROLLED EMPLOYEE OF ITS ACTION AND THE CONVERSION
RIGHTS AVAILABLE TO EACH ENROLLED EMPLOYEE UNDER §§ 354T AND 477K OF
THIS ARTICLE.
13
705.
14
15
(A) (I)
A SMALL EMPLOYER CARRIER SHALL ELECT TO BECOME A
RISK-ASSUMING CARRIER OR A REINSURING CARRIER.
16
17
IS
(2)
AN ELECTION TO BECOME A REINSURING CARRIER UNDER THIS
SUBSECTION SHALL BE SUBMITTED TO THE COMMISSIONER ON A FORM AND IN A
MANNER REQUIRED BY THE COMMISSIONER BY OCTOBER 1, 1993.
.19
20
21
22
(3)
THE NOTIFICATION OF A RISK-ASSUMING CARRIER SHALL INCLUDE
AN APPROPRIATE OPINION BY AN INDEPENDENT QUALIFIED ACTUARY THAT THE
RISK-ASSUMING CARRIER IS ABLE TO ASSUME AND MANAGE THE RISK OF
ENROLLING SMALL EMPLOYER GROUPS WITHOUT THE PROTECTION OF THE POOL.
23
(B)
(J)
THE ELECTION SHALL BE BINDING FOR A 3-YEAR PERIOD.
24
25
26
(2)
AFTER THE INITIAL 3-YEAR PERIOD, AND EVERY 5 YEARS
THEREAFTER, CARRIERS SHALL AGAIN ELECT TO BE A RISK-ASSUMING OR
REINSURING CARRIER. THE ELECTION SHALL BE BINDING FOR A 5-YEAR PERIOD.
27
2S
(3)
THE COMMISSIONER MAY PERMIT A CARRIER TO CHANGE ITS
ELECTION AT ANY TIME FOR GOOD CAUSE SHOWN.
29
30
(C) IN DETERMINING WHETHER TO APPROVE AN APPLICATION BY A
CARRIER TO CHANGE ITS ELECTION, THE COMMISSIONER SHALL CONSIDER:
31
32
33
(1)
THE APPLICANT'S FINANCIAL CONDITION AND THE FINANCIAL
CONDITION OF ANY PARENT OR GUARANTEEING CORPORATION;
(2)
THE APPLICANT'S HISTORY OF ASSUMING AND MANAGING RISK;
34
35
36
37
38
(3)
THE APPLICANT'S COMMITMENT TO MARKET FAIRLY TO ALL SMALL
EMPLOYERS IN THE STATE OR IN ITS SERVICE AREA:
(4)
THE APPLICANT'S ABILITY TO ASSUME AND MANAGE THF. RISK OF
ENROLLING SMALL EMPLOYER GROUPS WITHOUT THE PROTECTION OF THE POOL;
AND
39
40
(5) THE EFFECT OF APPROVAL
FINANCIAL VIABILITY OF THE POOL.
OF
THE
APPLICATION ON
THE
�12
HOUSE HILL 460
1
(D) IN CONSIDERING AN APPLICATION UNDER SUBSECTION (C) OF THIS
2 SECTION, THE CARRIER MAY REQUEST A HEARING AS PROVIDED UNDER § 242B OF
3 THIS ARTICLE.
4
706.
5
6
7
S
(A) THE COMMISSIONER SHALL ESTABLISH THE MARYLAND SMALL
EMPLOYER HEALTH REINSURANCE POOL, AND SHALL NOTIFY ALL CARRIERS
APPROVED TO BE SMALL EMPLOYER CARRIERS OF STEPS TAKEN TO ESTABLISH THE
POOL.
9
.10
11
.
(B) BY OCTOBER L 1993 THE COMMISSIONER SHALL NOTIFY ALL CARRIERS •
APPLYING TO SELL HEALTH BENEFIT PLANS TO SMALL EMPLOYERS IN THE STATE
OF THE TIME AND PLACE OF THE INITIAL MEETING OF THE BOARD.
12
13
14
(C) THE COMMISSIONER SHALL CONVENE THE INITIAL MEETING AND ALL
SUBSEQUENT MEETINGS OF THE BOARD AND. SHALL ADMINISTER ITS AFFAIRS
UNTIL BOARD MEMBERS ARE ELECTED.
.15
16
(D) THE INITIAL ORGANIZATIONAL MEETING SHALL TAKE PLACE BY
NOVEMBER 1, 1993.
17
18
(E) (I) THE REINSURING CARRIERS SHALL ELECT AN INITIAL BOARD OF
DIRECTORS TO BE COMPOSED OF 7 MEMBERS.
19
20
21
(2)
IF THE INITIAL BOARD IS NOT ELECTED AT THE ORGANIZATIONAL
MEETING, THE COMMISSIONER SHALL APPOINT THE INITIAL BOARD WITHIN 60 DAYS
AFTER THE ORGANIZATIONAL MEETING.
22
23
24
25
(3) THE BOARD SHALL INCLUDE REPRESENTATION FROM CARRIERS
WHOSE PRINCIPAL HEALTH INSURANCE BUSINESS IS IN THE SMALL EMPLOYER
MARKET AND, TO THE EXTENT POSSIBLE, AT LEAST I NONPROFIT HEALTH SERVICE
PLAN AND AT LEAST 1 HEALTH MAINTENANCE ORGANIZATION.
26
27
(4)
NO CARRIER AND ITS AFFILIATES MAY BE REPRESENTED BY MORE
THAN ONE MEMBER ON THE BOARD.
28
29
(5)
THE TERM OF A MEMBER IS 3 YEARS EXCEPT THAT THE INITIAL
MEMBERS' TERMS SHALL BE STAGGERED FOR PERIODS OF 1 TO 3 YEARS.
30
31
(6)
AT THE END OF A TERM, A MEMBER CONTINUES TO SERVE UNTIL A
SUCCESSOR IS ELECTED.
32
33
(7)
VACANCIES SHALL BE FILLED BY AN ELECTION OF THE REMAINING
BOARD MEMBERS.
34
35
(8)
A MEMBER WHO IS ELECTED AFTER A TERM HAS BEGUN SERVES
ONLY FOR THE REST OF THE TERM AND UNTIL A SUCCESSOR IS ELECTED.
36
37
(9)
A MEMBER WHO SERVES 2 CONSECUTIVE FULL 3-YEAR TERMS MAY
NOT BE REELECTED FOR 3 YEARS AFTER THE COMPLETION OF THOSE TERMS.
38
39
(F) (1)
THE BOARD SHALL APPOINT AN EXECUTIVE DIRECTOR WHO IS THE
CHIEF ADMINISTRATIVE OFFICER OF THE POOL.
40
4!
BOARD.
(2)
THE EXECUTIVE DIRECTOR SERVES AT THE PLEASURE OF THE
�HOUSE BILL 460
1
2
(3)
13
UNDER THE DIRECTION OF THE BOARD, THE EXECUTIVE DIRECTOR
SITALL PERFORM ANY DUTY OR FUNCTION THAT THE BOARD REQUIRES.
3
(G)
A CHAIRMAN SHALL BE SELECTED BY THE BOARD.
4
(H) THE POOL MAY EMPLOY A STAFF IN ACCORDANCE WITH THE POOL'S
5 BUDGET.
6
(I)
(1)
WITHIN 120 DAYS AFTER THE ELECTION OF THE INITIAL BOARD,
7 THE BOARD SHALL SUBMIT TO THE COMMISSIONER A PLAN OF OPERATION TO
S ASSURE THE FAIR, REASONABLE, AND FINANCIALLY SOUND ADMINISTRATION OF
9 THE POOL.
10
11
12
(2)
(I)
IF THE BOARD FAILS TO SUBMIT A PLAN OF OPERATION
WITHIN .120 DAYS AFTER ITS ELECTION, THE COMMISSIONER SHALL, AFTER NOTICE
AND HEARING, ADOPT A TEMPORARY PLAN OF OPERATION.
13
14
15
(II) THE COMMISSIONER MAY AMEND OR RESCIND ANY EXISTING
PLAN OF OPERATION IF THE COMMISSIONER FINDS THAT THE POOL IS NOT
OPERATING IN A FAIR, REASONABLE, AND FINANCIALLY SOUND MANNER.
16
(J)
THE POOL SHALL BE OPERATIONAL AND REINSURE CLAIMS OF ELIGIBLE
17 HEALTH BENEFIT PLANS WITHIN 12 MONTHS AFTER THE EFFECTIVE DATE OF THIS
.
18 ACT.
19
20
21
22
(K) THE COMMISSIONER MAY ORDER THE DISSOLUTION OF THE POOL IF THE
COMMISSIONER DETERMINES THAT THE POOL IS NOT FINANCIALLY VIABLE,
PROVIDED THAT PROVISION IS MADE TO ENSURE THE PROTECTION OF INSUREDS
INSURED BY THE MEMBERS OF THE POOL.
23
707.
24
•
(A)
THE PLAN OF OPERATION SHALL, AT A MINIMUM:
25
26
27
(1)
ESTABLISH PROCEDURES FOR THE HANDLING AND ACCOUNTING
OF POOL ASSETS AND MONEYS AND FOR AN ANNUAL FISCAL REPORTING TO THE
COMMISSIONER;
28
29
(2)
ESTABLISH PROCEDURES FOR REINSURING CLAIMS SUBMITTED TO
THE POOL IN ACCORDANCE WITH THE PROVISIONS OF THIS SUBTITLE;
30
31
32
33
(3)
ESTABLISH PROCEDURES FOR COLLECTING ASSESSMENTS FROM
MEMBERS TO REINSURE CLAIMS SUBMITTED TO THE POOL AND TO PAY FOR
ADMINISTRATIVE EXPENSES INCURRED OR ESTIMATED TO BE INCURRED DURING
THE PERIOD;
34
35
36
(4)
ESTABLISH PROCEDURES FOR RECOUPING ANY NET LOSSES TO THE
POOL FOR THE CALENDAR YEAR BY ASSESSING REINSURING CARRIERS AS
ESTABLISHED IN § 709(B) OF THIS SUBTITLE; AND
37
38
(5)
THE BOARD.
39
40
41
(B) THE BOARD SHALL HAVE THE GENERAL POWERS AND AUTHORITY
GRANTED UNDER THE LAWS OF THIS STATE TO HEALTH INSURANCE COMPANIES
AND HEALTH MAINTENANCE ORGANIZATIONS AUTHORIZED TO TRANSACT
PROVIDE FOR ANY ADDITIONAL MATTERS AT THE DISCRETION OF
�14
HOUSE BILL 460
1 BUSINESS, EXCEPT THE POWER TO ISSUE HEALTH BENEFIT PLANS DIRECTLY TO
.
2
EITHER GROUPS OR INDIVIDUALS.
3
4
5
6
7
S
y
(C)
THE BOARD MAY:
(I)
ENTER INTO CONTRACTS AS ARE NECESSARY OR PROPER TO CARRY
OUT THE PROVISIONS AND PURPOSES OF THIS SUBTITLE, INCLUDING AUTHORITY,
WITH APPROVAL OF THE COMMISSIONER, TO ENTER INTO CONTRACTS WITH
SIMILAR PROGRAMS OF OTHER STATES FOR THE JOINT PERFORMANCE OF COMMON
FUNCTIONS OR WITH PERSONS OR OTHER ORGANIZATIONS FOR THE
PERFORMANCE OF ADMINISTRATIVE FUNCTIONS;
I (J
(2)
SUE OR BE SUED, INCLUDING TAKING ANY LEGAL ACTIONS
I I NECESSARY OR PROPER FOR RECOVERING ANY ASSESSMENTS AND PENALTIES FOR,
12 ON BEHALF OF, OR AGAINST THE POOL OR ANY PARTICIPATING CARRIERS;
13
14
(3)
TAKE ANY LEGAL ACTION NECESSARY TO AVOID THE PAYMENT OF
IMPROPER CLAIMS AGAINST THE BOARD;
15
16
17
(4)
DEFINE THE HEALTH BENEFIT PLANS AND MEDICAL CONDITIONS
FOR WHICH CLAIMS MAY BE REINSURED WITH THE POOL IN ACCORDANCE WITH
THE REQUIREMENTS OF THIS SUBTITLE;
18
(5)
ESTABLISH RULES, CONDITIONS, AND PROCEDURES PERTAINING TO
19 THE REINSURANCE OF CLAIMS BY THE POOL;
20
21
(6)
ESTABLISH ACTUARIAL FUNCTIONS AS APPROPRIATE
OPERATION OF THE POOL:
22
23
24
2.5
26
27
(7)
ASSESS REINSURING CARRIERS IN ACCORDANCE WITH THE
PROVISIONS OF § 709 OF THIS SUBTITLE AND MAKE ADVANCE INTERIM
ASSESSMENTS AS MAY BE REASONABLE AND NECESSARY FOR ORGANIZATIONAL
AND INTERIM OPERATING EXPENSES WITH ANY INTERIM ASSESSMENTS TO BE
CREDITED AGAINST ANY ASSESSMENTS DUE FOLLOWING THE CLOSE OFTHE FISCAL
YEAR;
28
29
30
31
(8)
APPOINT APPROPRIATE COMMITTEES AS NECESSARY TO PROVIDE
TECHNICAL ASSISTANCE IN THE OPERATION OF THE POOL, POLICY AND OTHER
CONTRACT DESIGN, AND ANY OTHER FUNCTION WITHIN THE AUTHORITY OF THE
POOL; AND
32
(9)
FOR THE
BORROW MONEY TO CARRY OUT THE PURPOSES OF THE POOL."
33
70S.
34
35
(A) (I)
A REINSURING CARRIER MAY REINSURE WITH THE POOL AS
PROVIDED IN THIS SUBSECTION.
36
37
(2)
WITH RESPECT TO HEALTH BENEFIT PLANS, THE POOL SHALL
REINSURE UP TO THE LEVEL OF COVERAGE DETERMINED BY THE BOARD.
38
39
40
(3)
A SMALL EMPLOYER CARRIER MAY REINSURE AN ENTIRE
EMPLOYER GROUP WITHIN 60 DAYS OF THE COMMENCEMENT OF THE GROUP'S
COVERAGE UNDER A HEALTH BENEFIT PLAN.
�HOUSE BILL 460
15
.1.
2
3
4
5
(4)
A REINSURING CARRIER MAY REINSURE AN ELIGIBLE EMPLOYEE
OR DEPENDENT WITHIN A PERIOD OF 60 DAYS FOLLOWING THE COMMENCEMENT
OF THE COVERAGE WITH THE SMALL EMPLOYER. A NEWLY ELIGIBLE EMPLOYEE OR
DEPENDENT OF A REINSURED SMALL EMPLOYER MAY BE REINSURED WITHIN 60
DAYS OF THE COMMENCEMENT OF HIS OTHER COVERAGE.
6
7
S
9
10
1 1
12
13
14
(5)
(I)
THE POOL MAY NOT REIMBURSE A REINSURING CARRIER
WITH RESPECT TO THE CLAIMS OF A REINSURED EMPLOYEE OR DEPENDENT UNTIL
THE CARRIER HAS INCURRED AN INITIAL LEVEL OF CLAIMS FOR THE EMPLOYEE OR
DEPENDENT OF $5,000 IN A CALENDAR YEAR FOR BENEFITS COVERED BY THE POOL.
IN ADDITION, THE REINSURING CARRIER SHALL BE RESPONSIBLE FOR 10% OF THE
NEXT $50,000 OF INCURRED CLAIMS DURING A CALENDAR YEAR AND THE PROGRAM
SHALL REINSURE THE REMAINDER. A REINSURING CARRIER'S LIABILITY UNDER
THIS SUBPARAGRAPH MAY NOT EXCEED A MAXIMUM LIMIT OF $10,000 IN ANY 1
CALENDAR YEAR WITH RESPECT TO ANY REINSURED INDIVIDUAL.
15
16
17
IS
19
20
21
22
.
(II) THE BOARD ANNUALLY SHALL ADJUST THE INITIAL LEVEL OF
CLAIMS AND THE MAXIMUM LIMIT TO BE RETAINED BY THE CARRIER TO REFLECT
INCREASES IN COSTS AND UTILIZATION WITHIN THE STANDARD MARKET FOR
HEALTH BENEFIT PLANS WITHIN THE STATE. THE ADJUSTMENT MAY NOT BE LESS
THAN THE ANNUAL CHANGE IN THE MEDICAL COMPONENT OF THE "CONSUMER
PRICE INDEX FOR ALL URBAN CONSUMERS" OF THE DEPARTMENT OF LABOR,
BUREAU OF LABOR STATISTICS, UNLESS THE BOARD PROPOSES AND THE
COMMISSIONER APPROVES A LOWER ADJUSTMENT FACTOR.
23
24
25
(6)
A SMALL EMPLOYER CARRIER MAY TERMINATE REINSURANCE FOR
ONE OR MORE OF THE REINSURED EMPLOYEES OR DEPENDENTS OF A SMALL
EMPLOYER ON ANY PLAN ANNIVERSARY.
26
27
28
29
30
31
32
33
34
35
36
37
3S
39
(B) (1) THE BOARD, AS PART OF THE PLAN OF OPERATION, SHALL
ESTABLISH A METHODOLOGY FOR DETERMINING PREMIUM RATES TO BE CHARGED
BY THE POOL FOR REINSURING SMALL EMPLOYERS AND INDIVIDUALS UNDER THIS
SECTION. THE METHODOLOGY SHALL INCLUDE A SYSTEM FOR CLASSIFICATION OF
SMALL EMPLOYERS THAT REFLECTS THE TYPES OF CASE CHARACTERISTICS
COMMONLY USED BY SMALL EMPLOYER CARRIERS IN THE STATE. THE
METHODOLOGY SHALL PROVIDE FOR THE DEVELOPMENT OF BASE REINSURANCE
PREMIUM RATES. WHICH SHALL BE MULTIPLIED BY THE FACTORS SET FORTH IN
PARAGRAPH (2) OF THIS SUBSECTION TO DETERMINE THE PREMIUM RATES FOR
THE POOL. THE BASE REINSURANCE PREMIUM RATES SHALL BE ESTABLISHED BY
THE BOARD AND SHALL BE SET AT LEVELS THAT REASONABLY APPROXIMATE
GROSS PREMIUMS CHARGED TO SMALL EMPLOYERS BY SMALL EMPLOYER
CARRIERS FOR HEALTH BENEFIT PLANS UP TO THE LEVEL OF COVERAGE
DETERMINED BY THE BOARD.
40
(2)
PREMIUMS FOR THE POOL SHALL BE AS FOLLOWS.
41
42
43
(I)
AN ENTIRE SMALL EMPLOYER GROUP MAY BE REINSURED
FOR A RATE THAT IS 1.5 TIMES THE BASE REINSURANCE PREMIUM RATE FOR THE
GROUP ESTABLISHED UNDER THIS SUBSECTION.
44
45
46
(II) AN ELIGIBLE EMPLOYEE OR DEPENDENT MAY BE REINSURED
FOR A RATE THAT IS 5 TIMES THE BASE REINSURANCE PREMIUM RATE FOR THE
INDIVIDUAL ESTABLISHED UNDER THIS SUBSECTION.
�16
1
2
3
4
5
6
HOUSE RILL 460
(3)
THE BOARD PERIODICALLY SHALL REVIEW THE METHODOLOGY
ESTABLISHED UNDER. PARAGRAPH (I) OF THIS SUBSECTION, INCLUDING THE
SYSTEM OF CLASSIFICATION AND ANY RATING FACTORS, TO ASSURE THAT IT
REASONABLY REFLECTS THE CLAIMS EXPERIENCE OF THE POOL. THE BOARD MAY
PROPOSE CHANGES TO THE METHODOLOGY WHICH SHALL BE SUBJECT TO THE
APPROVAL OF THE COMMISSIONER.
7
(C) IF A HEALTH BENEFIT PLAN FOR A SMALL EMPLOYER IS ENTIRELY OR
S PARTIALLY REINSURED WITH THE PROGRAM, THE PREMIUM CHARGED TO THE
9 SMALL EMPLOYER FOR ANY RATING PERIOD FOR THE COVERAGE ISSUED SHALL
10 MEET THE REQUIREMENTS RELATING TO PREMIUM RATES SET FORTH IN § 702 OF
11 THIS SUBTITLE.
J2
13
14
15
16
(D) (I)
PRIOR TO MARCH 1 OF EACH YEAR, THE BOARD SHALL DETERMINE
AND REPORT TO THE COMMISSIONER THE POOL NET LOSS FOR THE PREVIOUS
CALENDAR YEAR, INCLUDING ADMINISTRATIVE EXPENSES AND INCURRED LOSSES
FOR THE YEAR, TAKING INTO ACCOUNT INVESTMENT INCOME AND OTHER
APPROPRIATE GAINS AND LOSSES.
17
IS
(2)
(I)
ANY NET LOSS FOR THE YEAR SHALL BE RECOUPED BY
ASSESSMENTS OF REINSURING CARRIERS.
.19
20
21
(II) THE BOARD SHALL ESTABLISH, AS PART OF THE PLAN OF
OPERATION, A FORMULA BY WHICH TO MAKE ASSESSMENTS AGAINST REINSURING
CARRIERS. THE ASSESSMENT FORMULA SHALL BE BASED ON:
22
23
24
25
1.
EACH REINSURING CARRIER'S SHARE OF .THE TOTAL
PREMIUMS EARNED IN THE PRECEDING CALENDAR YEAR FROM HEALTH BENEFIT
PLANS DELIVERED OR ISSUED FOR DELIVERY TO SMALL EMPLOYERS IN THIS STATE
BY REINSURING CARRIERS: AND
26
27
2S
29
2.
EACH REINSURING CARRIER'S SHARE OF THE PREMIUMS
EARNED IN THE PRECEDING CALENDAR YEAR FROM NEWLY ISSUED HEALTH
BENEFIT PLANS DELIVERED OR ISSUED FOR DELIVERY DURING SUCH CALENDAR
YEAR TO SMALL EMPLOYERS IN THIS STATE BY REINSURING CARRIERS.
30
31
32
33
34
35
36
37
3S
(III) THE FORMULA ESTABLISHED UNDER SUBPARAGRAPH (I) OF
THIS PARAGRAPH MAY NOT RESULT IN ANY REINSURING CARRIER HAVING AN
ASSESSMENT SHARE THAT IS LESS THAN 50% NOR MORE THAN 150% OF AN AMOUNT
WHICH IS BASED ON THE PROPORTION OF THE REINSURING CARRIER'S TOTAL
PREMIUMS EARNED IN THE PRECEDING CALENDAR YEAR FROM HEALTH BENEFIT
PLANS DELIVERED OR ISSUED FOR DELIVERY TO SMALL EMPLOYERS IN THIS STATE
BY REINSURING CARRIERS TO TOTAL PREMIUMS EARNED IN THE PRECEDING
CALENDAR YEAR FROM HEALTH BENEFIT PLANS DELIVERED OR ISSUED FOR
DELIVERY TO SMALL EMPLOYERS IN THIS STATE BY ALL REINSURING CARRIERS.
39
40
41
42
43
44
45
(IV) THE
BOARD MAY, WITH THE APPROVAL OF THE
COMMISSIONER, CHANGE THE ASSESSMENT FORMULA ESTABLISHED PURSUANT TO
SUBPARAGRAPH (I) OF THIS PARAGRAPH FROM TIME TO TIME AS APPROPRIATE.
THE BOARD MAY PROVIDE FOR THE SHARES OF THE ASSESSMENT BASE
ATTRIBUTABLE TO PREMIUMS FROM ALL HEALTH BENEFIT PLANS AND TO
PREMIUMS FROM NEWLY ISSUED HEALTH BENEFIT PLANS TO VARY DURING A
TRANSITION PERIOD.
�HOUSE BILL 460
J7
1
2
3
4
.5
6
(V) SUBJECT TO THE APPROVAL OF THE COMMISSIONER, THE
BOARD SHALL MAKE AN ADJUSTMENT TO THE ASSESSMENT FORMULA FOR
REINSURING
CARRIERS
THAT ARE
APPROVED
HEALTH MAINTENANCE
ORGANIZATIONS WHICH ARE FEDERALLY QUALIFIED UNDER 42 U.S.C. SEC. 300, ET
SEQ, TO THE EXTENT, IF ANY, THAT RESTRICTIONS ARE PLACED ON THEM THAT
ARE NOT IMPOSED ON OTHER SMALL EMPLOYER CARRIERS.
7
5
9
10
(VI) PREMIUMS AND BENEFITS PAID BY A REINSURING CARRIER
THAT ARE LESS THAN AN AMOUNT DETERMINED BY THE BOARD TO JUSTIFY THE
COST OF COLLECTION SHALL NOT BE CONSIDERED FOR PURPOSES OF
DETERMINING ASSESSMENTS.
11
12
13
14
(3)
(I)
PRIOR TO MARCH I OF EACH YEAR, THE BOARD SHALL
DETERMINE AND FILE WITH THE COMMISSIONER AN ESTIMATE OF THE
ASSESSMENTS NEEDED TO FUND THE LOSSES INCURRED BY THE POOL IN THE
PREVIOUS CALENDAR YEAR.
15
(II) IF THE BOARD DETERMINES THAT THE ASSESSMENTS NEEDED
16 TO FUND THE LOSSES INCURRED BY THE PROGRAM IN THE PREVIOUS CALENDAR
17 YEAR WILL EXCEED THE AMOUNT SPECIFIED IN SUBPARAGRAPH (III) OF THIS
IS PARAGRAPH, THE BOARD SHALL EVALUATE THE OPERATION OF THE POOL AND
19 REPORT ITS FINDINGS, INCLUDING ANY RECOMMENDATIONS FOR CHANGES TO THE
20 PLAN OF OPERATION, TO THE COMMISSIONER WITHIN 90 DAYS FOLLOWING THE
21. END OF THE CALENDAR YEAR IN WHICH THE LOSSES WERE INCURRED. THE
22 EVALUATION SHALL INCLUDE: AN ESTIMATE OF FUTURE ASSESSMENTS, THE
23 ADMINISTRATIVE COSTS OF THE POOL, THE APPROPRIATENESS OF THE PREMIUMS
24 CHARGED AND THE LEVEL OF INSURER RETENTION UNDER THE PROGRAM, AND
25 THE COSTS OF COVERAGE FOR SMALL EMPLOYERS. IF THE BOARD FAILS TO FILE
26 THE REPORT WITH THE COMMISSIONER WITHIN 90 DAYS FOLLOWING THE END OF
27 THE APPLICABLE CALENDAR YEAR, THE COMMISSIONER MAY EVALUATE THE
28 'OPERATIONS OF THE POOL AND IMPLEMENT AMENDMENTS TO THE PLAN OF
29 OPERATION THAT THE COMMISSIONER DEEMS NECESSARY TO REDUCE FUTURE
30 LOSSES AND ASSESSMENTS.
31
32
33
34
(III) FOR ANY CALENDAR YEAR, THE AMOUNT SPECIFIED IN THIS
SUBPARAGRAPH IS 5% OF TOTAL PREMIUMS EARNED THE PREVIOUS YEAR FROM
HEALTH BENEFIT PLANS DELIVERED OR ISSUED FOR DELIVERY TO SMALL
EMPLOYERS IN THIS STATE BY REINSURING CARRIERS.
35
36
37
38
(4)
IF ASSESSMENTS EXCEED NET LOSSES OF THE POOL THE EXCESS
SHALL BE HELD AT INTEREST AND USED BY THE BOARD TO OFFSET FUTURE LOSSES
OR TO REDUCE POOL PREMIUMS. AS USED IN THIS PARAGRAPH, "FUTURE LOSSES"
INCLUDES RESERVES FOR INCURRED BUT NOT REPORTED CLAIMS.
39
40
41
42
(5)
EACH REINSURING CARRIER'S PROPORTION OF THE ASSESSMENT
SHALL BE DETERMINED ANNUALLY BY THE BOARD BASED ON ANNUAL
STATEMENTS AND OTHER REPORTS DEEMED NECESSARY BY THE BOARD AND
FILED BY THE REINSURING CARRIERS WITH THE BOARD.
43
44
(6)
THE PLAN OF OPERATION SHALL PROVIDE FOR THE IMPOSITION OF
AN INTEREST PENALTY FOR LATE PAYMENT OF ASSESSMENTS.
45
46
(7)
A REINSURING CARRIER MAY SEEK FROM THE COMMISSIONER A
DEFERMENT FROM ALL OR PART OF AN ASSESSMENT IMPOSED BY THE BOARD. THE
�18
HOUSE BILL 460
1
2
3
4
5
6
7
S
9
.10
.11
COMMISSIONER MAY DEFER ALL OR PART OF THE ASSESSMENT OF A REINSURING
CARRIER IF THE COMMISSIONER DETERMINES THAT THE PAYMENT OF THE
ASSESSMENT WOULD PLACE THE REINSURING CARRIER IN A FINANCIALLY
IMPAIRED CONDITION. IF ALL OR PART OF AN ASSESSMENT AGAINST A REINSURING
CARRIER IS DEFERRED, THE AMOUNT DEFERRED SHALL BE ASSESSED AGAINST THE
OTHER PARTICIPATING CARRIERS IN A MANNER CONSISTENT WITH THE BASIS FOR
ASSESSMENT SET FORTH IN THIS SUBSECTION. THE REINSURING CARRIER
RECEIVING SUCH DEFERMENT SHALL REMAIN LIABLE TO THE PROGRAM FOR THE
AMOUNT DEFERRED AND SHALL BE PROHIBITED FROM REINSURING ANY
INDIVIDUALS OR GROUPS IN THE POOL UNTIL SUCH TIME AS IT PAYS SUCH
ASSESSMENTS.
12
13
14
.
15
16
17
(E) NEITHER THE PARTICIPATION IN THE PROGRAM AS REINSURING
CARRIERS, THE ESTABLISHMENT OF RATES, FORMS, OR PROCEDURES, NOR ANY
OTHER JOINT OR COLLECTIVE ACTION REQUIRED BY THIS SECTION SHALL BE THE
BASIS OF ANY LEGAL ACTION, CRIMINAL OR CIVIL LIABILITY, OR PENALTY AGAINST
THE PROGRAM OR ANY OF ITS REINSURING CARRIERS EITHER JOINTLY OR
SEPARATELY.
IS
709.
19
20
21
22
23
(A) (I)
ALL MONEYS COLLECTED UNDER THIS SECTION, AND ALL OTHER
FUNDS COLLECTED BY OR ON BEHALF OF THE POOL, WHETHER THROUGH
PREMIUM CHARGES,
ASSESSMENTS,
EARNINGS FROM INVESTMENTS, OR
OTHERWISE, SHALL BE MANAGED AND INVESTED BY THE POOL THROUGH A
FINANCIAL MANAGEMENT COMMITTEE COMPRISED OF:
24
(I)
THE EXECUTIVE DIRECTOR; AND
25
(II)
2 MEMBERS OF THE BOARD.
26
27
(2)
ALL OPERATING EXPENSES OF THE POOL SHALL BE PAID FROM
FUNDS COLLECTED BY OR ON BEHALF OF THE POOL.
28
29
ACCOUNT.
30
31
(II) THE FUND ACCOUNT MAY NOT BE DEEMED PART OF THE
TREASURY OF THE STATE.
32
33
34
35
(III) THE
STATE
MAY
NOT
PROVIDE
GENERAL
FUND
APPROPRIATIONS TO THE POOL AND OBLIGATIONS OF THE POOL MAY NOT BE
DEEMED IN ANY MANNER TO BE A DEBT OF THE STATE OR A PLEDGE OF ITS
CREDIT.
36
37
38
39
(IV) ALL DEBTS, CLAIMS, OBLIGATIONS, AND LIABILITIES OF THE
POOL, WHENEVER INCURRED, SHALL BE THE DEBTS, CLAIMS, OBLIGATIONS, AND
LIABILITIES OF THE POOL ONLY AND NOT OF THE STATE, ITS AGENCIES,
INSTRUMENTALITIES. OFFICERS, OR EMPLOYEES.
40
41
42
43
(3)
(B)
(I)
THE ACCOUNT OF THE POOL SHALL BE A SPECIAL FUND
THE POOL IS EXEMPT FROM:
(I)
TAXATION BY THE STATE AND LOCAL GOVERNMENT;
(2)
THE GENERAL PROCUREMENT LAW PROVISION'S OF DIVISION II OF
THE STATE FINANCE AND PROCUREMENT ARTICLE; AND
�HOUSE BILL 460
(3)
19
THE PROVISIONS OF ARTICLE 64A (MERIT SYSTEM) OF THE CODE.
710.
3
4
(A) THE BOARD SHALL REPORT TO THE COMMISSIONER ON JUNE 1 OF EACH
YEAR. THE REPORT SHALL, AT A MINIMUM, DESCRIBE:
5
6
YEAR;
7
S
(2)
A STATEMENT OF THE FINANCIAL CONDITION OF THE POOL AS OF
DECEMBER 3.1 OF THE PRECEDING CALENDAR YEAR; AND
9
10
(3)
A DETAILED STATEMENT OF THE REVENUES AND EXPENDITURES
OF THE POOL MADE DURING THE PRECEDING CALENDAR YEAR.
(!)
1 1
12
.
(B)
(1)
THE OPERATIONS OF THE POOL FOR THE PRECEDING CALENDAR
THE COMMISSIONER SHALL REPORT TO THE GOVERNOR AND THE
GENERAL ASSEMBLY ON THE EFFECTIVENESS OF THIS SUBTITLE.
13
.
(2)
THE REPORT SHALL:
14
15
16
(1)
ANALYZE THE EFFECTIVENESS
OF THE SUBTITLE IN
PROMOTING RATE STABILITY, PRODUCT AVAILABILITY, AND AFFORDABILITY OF
COVERAGE:
17
IS
19
(II) CONTAIN.. AS NECESSARY, RECOMMENDATIONS FOR ACTIONS
TO IMPROVE THE OVERALL EFFECTIVENESS, EFFICIENCY AND FAIRNESS OF THE
SMALL GROUP HEALTH INSURANCE MARKETPLACE;
20
21
22
(III) ADDRESS WHETHER CARRIERS AND PRODUCERS ARE FAIRLY
AND ACTIVELY MARKETING OR ISSUING HEALTH BENEFIT PLANS TO SMALL
EMPLOYERS IN FULFILLMENT OF THE PURPOSES OF THIS SUBTITLE;
23
24
(IV) CONTAIN RECOMMENDATIONS FOR MARKET CONDUCT OR
OTHER REGULATORY STANDARDS OR ACTION;
25
26
27
(V) DISCUSS THE FEASIBILITY AND DESIRABILITY OF REDUCING
THE SCOPE OF THE SUBTITLE TO EMPLOYERS WITH LESS THAN 50 ELIGIBLE
EMPLOYEES;
28
29
30
(VI) REVIEW AND MAKE RECOMMENDATIONS REGARDING ANY
ADJUSTMENTS IN THE RESTRICTION ON PREMIUM VARIATIONS AS ESTABLISHED IN
§ 702(A) OF THIS SUBTITLE; AND
3.1
(VII) CONTAIN OTHER RECOMMENDATIONS THE COMMISSIONER
32
DEEMS APPROPRIATE TO ACHIEVE THE PURPOSES OF THIS ACT.
33
711.
34
THE COMMISSIONER
SHALL ADOPT REGULATIONS TO IMPLEMENT THIS
35
SUBTITLE.
36
712.
37
38
39
THE COMMISSIONER MAY IMPOSE A PENALTY OF UP TO 5500 FOR EACH
VIOLATION OF THIS SUBTITLE OR ANY REGULATION ADOPTED UNDER THIS
SUBTITLE. FOR A VIOLATION THAT IS COMMITTED WITH SUCH FREQUENCY AS TO
�20
HOUSE BILL 4fi0
1
INDICATE A GENERAL BUSINESS PRACTICE, THE PENALTY SHALL BE AS PROVIDED
2
UNDER
12, 55, 55A, AND 215 OF THIS ARTICLE.
3
Article - Health - General
4
19-706.
5
6
7
(H) THE PROVISIONS OF ARTICLE 4SA, SUBTITLE 55 SHALL APPLY TO HEALTH
MAINTENANCE ORGANIZATIONS.
1.9-714.
S
9
Each marketing document that sets forth the heallh care services of a health
maintenance organization shall describe fully and clearly:
10
( I ) The heallh care, services binder each benefit package and every other
11 benefit to which a member is entitled;
12
(2)
Where and how services may be obtained;
13
14 provides;
.
(3)
Each exclusion or limitation on any service or other benefit thai it
15
(4)
Each deductible feature; ['and]
16
(5)
'Each copayment [.provision.] PROVISION; AND
17
.
(6)
ALL INFORMATION REQUIRED BY ARTICLE 4SA, § 703(13).
IS
1.9-716.
19
20
Annually, each health maintenance organization shall provide to its members and
make available lo the general public, in clear, readable, and concise form:
21
22
(1) A summary of the most recent financial report that the heallh
maintenance organization submits to the Commissioner under S 19-7.17 of this subtitle;
23
24
(2) A description of the benefit packages available and the nongroup rates
required by the Commissioner;
25
26
(3) A description of the accessibility and availability of services, including
where and how to obtain them;
27
28
(4) A statement that shows, by category, the percentage of members assisted
by public funds; [ a n d ]
29
30
(5)
703(C); AND
31
(6)
THE INFORMATION REQUIRED TO BE DISCLOSED BY ARTICLE 4SA, §
Any other information that the Commissioner or the
32
requires by rule or regulation.
33
Department
1.9-729.
34
.35
36
(a)
under it:
A health maintenance organization may not:
(.1) Violate any provision of this subtitle or any rule or regulation adopted
�'
>
HOUSE BILL 460
.
21.
1
(2) Fail to fulfill its obligations to provide the health care services specified
2 in its contracts with subscribers;
3
(3) Make any false statement with respect to any report or statement
4 required by this subtitle or by the Commissioner under this subtitle;
5
(4) Advertise, merchandise, or attempt to merchandise its services in a way
6 that misrepresents its services or capacity for service;
7
(5) Engage in a deceptive, misleading, unfair, or unauthorized practice as to
8 advertising or merchandising;
9
(6) Prevent or attempt to prevent the Commissioner or the Department
10 from performing any duty imposed by this subtitle;
11
(7)
12 this subtitle;
Fraudulently obtain or fraudulently attempt to obtain any benefit under
13
Fail to fulfill the basic requirements to operate as a health maintenance
(8)
14 organization as provided in § 19-710 of this subtitle; [or]
15
(9)
VIOLATE ANY APPLICABLE PROVISION OF ARTICLE 48A; OR
16
(10) Fail to provide services to a member in a timely manner as provided in §
17 19-705.l(b)(]) of this subtitle.
18
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect
19 Julv 1, 1993.
�SENATE B I L L 349
C3
3lr2295
CF 31r2294
By: The President (Administration)
Introduced and read first time: January 25, .1993
Assigned to: Finance
A B I L L EN TITLED
1
A N A C T concerning
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Health Insurance - Small Employer Group Health Insurance Reform
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FOR the purpose of creating a new subtitle governing certain small employer group
health plans; providing for certain premium rate regulations; providing for certain
eligibility and underwriting regulations; providing for certain exceptions to eligibility
and underwriting regulations; providing for certain marketing regulations; requiring
certain record keeping; providing for a certain reinsurance pool; creating a board
with certain powers to perform certain functions on behalf of tlie reinsurance pool;
requiring small employer carriers to make a certain election; providing that the
Commissioner may grant approvals of certain changes in elections under certain
circumstances; requiring the board to file certain information and plans with the
Commissioner; providing certain procedures for reinsurance by reinsuring carriers;
providing for certain assessments; providing for a certain type of financing for the
pool; providing that nonprofit health service plans shall be subject to this Act;
providing that health maintenance organizations shall be subject to this Act:
defining certain terms; providing for the termination of this Act; and generally
relating to small employer group health insurance.
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BY repealing and reenacting, with amendments,
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Article 48A - Insurance Code
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Section 354(a)
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Annotated Code of Maryland
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(1991 Replacement Volume and 1992 Supplement)
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BY adding to
Article 48A - Insurance Code
Section 700 through 712, inclusive, to be under the new subtitle "55. Small
Employer Group Health Insurance"
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Annotated Code of Maryland
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(1991 Replacement Volume and 1992 Supplement)
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BY repealing and reenacting, with amendments,
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Article - Health - General
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Section 19-714. 19-7.16. and 19-729(a)
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Annotated Code of Maryland
EXPLANATION: CAPITALS INDICATE MATTER ADDED TO EXISTING LAW.
[Brackets'l indicate matter deleted Irom existing law.
�2
SENATE HILL 349
(1990 Replacement Volume and 1992 Supplement)
7
BY adding to
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Article - Health - General
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Section 19-706(h)
s
A
Annotated Code of Maryland
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SECTION
(1990 Replacement Volume and 1992 Supplement)
1.
BE
IT
ENACTED BY T H E
G E N E R A L ASSEMBLY
5
M A R Y L A N D , That the Laws of Maryland read as follows:
9
OF
Article 4SA - Insurance Code
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354.
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IS
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(a) Any corporation without capital stock heretofore or hereafter organized for
the purpose of establishing, maintaining and operating a nonprofit health service plan
whereby
hospital, medical, chiropodial, chiropractic, pharmaceutical,
dental,
psychological or optometric care is provided by a hospital, or hospitals, a physician or
physicians, a chiropodist or chiropodists, a chiropractor or chiropractors, a pharmacist or
pharmacists, a dentist or dentists, a duly licensed psychologist or psychologists, or an
optometrist or optometrists, to persons who become subscribers to such plan under
contracts which entitle each subscriber to certain hospital, medical, chiropodial,
chiropractic, pharmaceutical, dental, psychological, or optometric care or any of them,
shall be governed and regulated by the provisions of Ihis subtitle, and of [Subtitle 1 L |
SUBTITLES 11 AND 55 of this article, and by no other law relating to insurance unless such
law is referred to under this subtitle, and no law hereafter enacted shall apply to such
corporations, unless they are expressly designated therein, and specifically refer to such
corporations. Notwithstanding this, lhe Commissioner shall have those powers and duties
necessary to enforce the provisions of this subtitle with respect to nonprofit health service
plans as are granted under ijS 24 and 25 of ihis article.
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698. RESERVED.
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699. RESERVED.
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55. SMALL EMPLOYER GROUP HEALTH INSURANCE
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700.
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(A) IN THIS SUBTITLE THE FOLLOWING WORDS HAVE THE MEANINGS
INDICATED.
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34
35
36
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(B) "ACTUARIAL CERTIFICATION" MEANS A WRITTEN STATEMENT IN A FORM
APPROVED BY THE COMMISSIONER BY A MEMBER OF THE AMERICAN ACADEMY OF
ACTUARIES OR OTHER INDIVIDUAL ACCEPTABLE TO THE COMMISSIONER THAT A
SMALL EMPLOYER CARRIER IS IN COMPLIANCE WITH THE PROVISIONS OF THIS
SUBTITLE.
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(C)
"BOARD" MEANS THE BOARD OF DIRECTORS OF THE POOL.
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(D)
"CARRIER" MEANS:
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(I) AN INSURER WHICH HOLDS A CERTIFICATE OF AUTHORITY AND
PROVIDES HEALTH INSURANCE IN THIS STATE;
�SENATE HILL 349
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2
(2)
A MULTIPLE EMPLOYER WELFARE ARRANGEMENT;
(4)
A MULTIPLE EMPLOYER TRUST LOCATED IN MARYLAND OR ANY
OTHER STATE COVERING MARYLAND RESIDENTS WHO ARE ELIGIBLE EMPLOYEES;
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A I-l LA LTH MAINTENANCE ORGANIZATION WHICH OPERATES IN
THIS STATE;
(3)
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5
3
(5)
A NONPROFIT HEALTH SERVICE PLAN; OR
(fi) ANY OTHER PERSON OR ORGANIZATION WHICH PROVIDES HEALTH
INSURANCE SUBJECT TO STATE INSURANCE REGULATION.
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(E) "COMMUNITY RATE" MEANS THE SAME RATE FOR A HEALTH BENEFITS
10 PLAN THAT IS CHARGED TO ALL SMALL EMPLOYERS PRIOR TO ANY ADJUSTMENTS
1 1 UNDER S 702 OF T HIS SUBT ITLE.
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(F) "DEPENDENT" INCLUDES THE SPOUSE OR
ADOPTED CHILD OF AN ELIGIBLE EMPLOYEE.
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(G) (I)
"ELIGIBLE EMPLOYEE" MEANS AN EMPLOYEE WHO WORKS ON A
FULL-TIME BASIS AND HAS A NORMAL WORKWEEK OF 30 OR MORE HOURS.
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IS
(2)
"ELIGIBLE EMPLOYEE" INCLUDES A SOLE PROPRIETOR, A PARTNER
OF A PARTNERSHIP, OR AN INDEPENDENT CONTRACTOR WHO IS INCLUDED AS AN
EMPLOYEE UNDER A HEALTH CARE PLAN OF A SMALL EMPLOYER.
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(3)
"ELIGIBLE EMPLOYEE" DOES NOT INCLUDE AN INDIVIDUAL WHO
WORKS ON A TEMPORARY OR SUBSTITUTE BASIS OR FOR FEWER THAN 30 HOURS IN
A WORKWEEK.
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(H)
(I)
NATURAL OR LEGALLY
"HEALTH BENEFIT PLAN" MEANS ANY:
(!)
HOSPITAL OR MEDICAL POLICY OR CERTIFICATE, INCLUDING
THOSE ISSUED UNDER MULTIPLE EMPLOYER TRUSTS OR ASSOCIATIONS LOCATED
IN MARYLAND OR ANY OTHER STATE COVERING MARYLAND RESIDENTS WHO ARE
ELIGIBLE EMPLOYEES:
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(II)
NONPROFIT HEALTH SERVICE PLAN;
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CONTRACT; OR
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(IV) PLAN PROVIDED BY OR THROUGH A MULTIPLE EMPLOYER
WELFARE ARRANGEMENT OR OTHER BENEFIT ARRANGEMENT OFFERED BY A
MULTIPLE EMPLOYER WELFARE ARRANGEMENT.
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(III) HEALTH
(2)
MAINTENANCE
ORGANIZATION
"HEALTH BENEFIT PLAN" DOES NOT INCLUDE:
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(I)
ACCIDENT-ONLY INSURANCE;
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(II)
FIXED INDEMNITY INSURANCE;
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(III) CREDIT HEALTH INSURANCE;
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(IV) DENTAL INSURANCE:
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(V)
VISION INSURANCE;
SUBSCRIBER
�4
SENATE BILL 349
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(VI) MEDICARE SUPPLEMENT POLICIES;
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(VII) LONG-TERM CARE INSURANCE;
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(VIII) DISABILITY INCOME INSURANCE;
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(IX) COVERAGE
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ISSUED
AS
A
SUPPLEMENT
TO
LIABILITY
INSURANCE;
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(X)
WORKERS'COMPENSATION OR SIMILAR INSURANCE;
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(XI) DISEASE SPECIFIC INSURANCE;
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y
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(XII) AUTOMOBILE MEDICAL-PAYMENT INSURANCE; OR
(XIII) ANY OTHER
INSURANCE
PLAN
DEEMED
BY
COMMISSIONER.
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.
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(I)
(J)
'T,ATE ENROLLEE" MEANS AN ELIGIBLE EMPLOYEE OR DEPENDENT
WHO REQUESTS ENROLLMENT IN A SMALL EMPLOYER'S HEALTH BENEFIT PLAN
FOLLOWING THE INITIAL ENROLLMENT PERIOD PROVIDED UNDER THE TERMS OF
THE HEALTH BENEFIT PLAN.
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(2)
AN ELIGIBLE EMPLOYEE OR DEPENDENT MAY NOT BE CONSIDERED
A LATE ENROLLEE IF:
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(I)
THE
THE INDIVIDUAL:
IS
iy
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I.
WAS COVERED UNDER A PUBLIC OR PRIVATE HEALTH
INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENT AT THE TIME THE
INDIVIDUAL WAS ELIGIBLE TO ENROLL,
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2.
HAS LOST COVERAGE UNDER A PUBLIC OR PRIVATE
HEALTH INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENT AS A RESULT OF
TERMINATION OF EMPLOYMENT OR ELIGIBILITY. THE TERMINATION OF THE
OTHER PLAN'S COVERAGE. DEATH OF A SPOUSE, OR DIVORCE; AND
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3.
REQUESTS ENROLLMENT WITHIN 30 DAYS AFTER
TERMINATION OF COVERAGE PROVIDED UNDER A PUBLIC OR PRIVATE HEALTH
INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENT:
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(II) THE INDIVIDUAL IS EMPLOYED BY AN EMPLOYER WHICH
OFFERS MULTIPLE HEALTH BENEFIT PLANS AND THE INDIVIDUAL ELECTS A
DIFFERENT PLAN DURINC, AN OPEN ENROLLMENT PERIOD;
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(III) THE INDIVIDUAL REQUESTS ENROLLMENT WITHIN 30 DAYS OF
BECOMING AN EMPLOYEE OF THE SMALL EMPLOYER;
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(IV) A COURT HAS ORDERED COVERAGE TO BE PROVIDED FOR A
SPOUSE OR MINOR CHILD UNDER A COVERED EMPLOYEE'S HEALTH BENEFIT PLAN;
OR
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(V) A REQUEST FOR ENROLLMENT IS MADE WITHIN 30 DAYS
AFTER THE ELIGIBLE EMPLOYEE'S MARRIAGE OR THE BIRTH OR ADOPTION OF A
CHILD.
�SENATE 15ILL 349
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1
(.1)
(I)
"MULT I I'LL EMPLOYER WELFARE ARRANGEMENT" MEANS A
2 MULTIPLE EMPLOYER WELFARE ARRANGEMENT AS DEFINED IN 5 3 OF THE
3 FEDERAL EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974, 29 U.S.C. § 1001,
4 ET SEQ THAT DIRECTLY OR INDIRECTLY PROVIDES HEALTH INSURANCE TO ONE OR
5 MORE EMPLOYEES OF A SMALL EMPLOYER IN THIS STATE.
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7
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(2)
•'MULTIPLE EMPLOYER WELFARE ARRANGEMENT" DOES NOT
INCLUDE ANY ARRANGEMENT THAT IS FULLY INSURED WITHIN THE MEANING OF §
514(B)(6) OF THE FEDERAL EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974,
29 U.S.C. ij 1001, ET SEQ.
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(K) "PLAN OF OPERATION" MEANS THE PLAN OF OPERATION OF THE POOL,
INCLUDING ARTICLES OF INCORPORATION, BYLAWS. AND OPERATING RULES
ADOPTED BY THE BOARD UNDER S 707 OF THIS SUBTITLE.
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(L) "POOL"
MEANS THE
MARYLAND
SMALL
REINSURANCE POOL ESTABLISHED UNDER THIS SUBTITLE.
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IN
(M) "PREEXISTING CONDITION PROVISION" MEANS A PROVISION IN A
HEALTH BENEFIT PLAN THAT DENIES, EXCLUDES. OR LIMITS BENEFITS FOR A
COVERED INDIVIDUAL FOR CLAIMS INCURRED DURING A SPECIFIC PERIOD
FOLLOWING THE INSURED'S EFFECTIVE DATE OF COVERAGE:
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(1)
FOR A CONDITION THAT WOULD CAUSE AN ORDINARILY PRUDENT
PERSON TO SEEK MEDICAL ADVICE, DIAGNOSIS, CARE, OR TREATMENT; OR
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(2)
FOR A CONDITION FOR WHICH MEDICAL ADVICE, DIAGNOSIS, CARE,
OR TREATMENT WAS RECOMMENDED OR RECEIVED DURING THE 6 MONTHS
IMMEDIATELY PRECEDING THE EFFECTIVE DATE OF THIS COVERAGE.
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2S
(N) "RATING PERIOD" MEANS THE CALENDAR PERIOD FOR WHICH PREMIUM
RATES ESTABLISHED BY A SMALL EMPLOYER CARRIER ARE IN EFFECT, PROVIDED
THAT A SMALL EMPLOYER CARRIER SHALL HAVE ONLY ONE RATING PERIOD IN
ANY CALENDAR MONTH AND NO MORE THAN 12 RATING PERIODS IN ANY
CALENDAR YEAR.
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(O) "REINSURING CARRIER"
PARTICIPATING IN THE POOL.
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(P) "RISK-ASSUMING CARRIER" MEANS A SMALL EMPLOYER CARRIER NOT
PARTICIPATING IN THE POOL.
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3S
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(Q) (I)
"SMALL EMPLOYER" MEANS ANY PERSON. FIRM, CORPORATION,
PARTNERSHIP, OR ASSOCIATION ACTIVELY ENGAGED IN BUSINESS AND, ON AT
LEAST 50 PERCENT OF IT'S WORKING DAYS DURING THE PRECEDING CALENDAR
YEAR. EMPLOYED AT LEAST TWO BUT NO MORE THAN 50 ELIGIBLE EMPLOYEES, THE
MAJORITY OF WHOM ARE EMPLOYED WITHIN THIS STATE. SMALL EMPLOYER
CARRIERS WHO DO NOT IMPOSE PREEXISTING CONDITION LIMITATIONS MAY
REQUIRE T HAT A SMALL EMPLOYER HAVE AT LEAST THREE ELIGIBLE EMPLOYEES.
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(2)
IF THE FEDERAL EMPLOYMENT RETIREMENT INCOME SECURITY
ACT IS AMENDED TO EXCLUDE EMPLOYEE GROUPS UNDER A SPECIFIC SIZE,
NOTWITHSTANDING PARAGRAPH (I) OF THIS SUBSECTION, THIS SUBTITLE SHALL
APPLY TO ANY EMPLOYEE GROUP SIZE THAT IS EXCLUDED FROM THAT FEDERAL
44
ACT.
MEANS
A
SMALL
EMPLOYER
EMPLOYER
HEALTH
CARRIER
�6
SENATE mi. L M<)
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(3)
IN Dl-TI-KiVIINING THE NUMBER OF ELIGIBLE EMPLOYEES,
2 COMPANIES WHICH ARE AFFILIATED COMPANIES OR WHICH ARE ELIGIBLE TO FILE
3 A COMBINED STATE TAX RETURN SHALL BE CONSIDERED ONE EMPLOYER.
4
5
(K) "SMALL. EMPLOYER CARRIER" MEANS A CARRIER THAT OFFERS HEALTH
BENEFIT' PLANS COVERING ELIGIBLE EMPLOYEES OF A SMALL EMPLOYER.
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7(11.
7
S
THIS SUBTITLE SHALL APPLY TO ANY HEALTH BENEFIT" PLAN WHICH PROVIDES
COVERAGE. TO A SMALL EMPLOYER IN THIS STATE IF:
y
10
(I)
ANY PORTION OF THE PREMIUM OR BENEFITS IS PAID BY OR ON
BEHALF OF THE SMALL E.MPLOYER,
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(2)
ANY ELIGIBLE EMPLOYEE OR DEPENDENT IS REIMBURSED.
WHETHER THROUGH WAGE ADJUSTMENTS OR OTHERWISE, BY OR ON BEHALF OF
THE SMALL EMPLOYER FOR ANY PORTION OF THE PREMIUM;
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(3)
THE HEALTH BENEFIT' PLAN IS TREATED BY THE EMPLOYER OR ANY
OF THE ELIGIBLE EMPLOYEES OR DEPENDENTS AS PAR T OF A PLAN OR PROGRAM
PURSUANT TO THE UNITED ST 'ATES INTERNAL REVENUE CODE, 26 U.S.C.
106, 125,
OR 162: OR
IS
(4)
T HE SMALL EMPLOYER HAS PERMITTED PAYROLL DEDUCTION FOR
19
T'HE ELIGIBLE EMPLOYEE FOR THE HEALTH BENEFITS PLAN.
20
7112.
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(A) (1)
SUBJECT TO SUBSECTION (B) OF "THIS SECTION THE PREMIUM RATES
CHARGED OR OFFERED TO A SMALL EMPLOYER SHALL BE ESTABLISHED ON 'THE
BASIS OF A COMMUNITY RATE, ADJUSTED, AT "THE DISCRETION OF THE SMALL
EMPLOYER CARRIER TO REFLECT ONE OR MORE OF THE FOLLOWING RISK
25
CLASSIFICATIONS:
26
(I)
AGE;
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(11)
GEOGRAPHY:
2S
(III) GENDER; AND
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30
3!
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(IV) HEALTH STATUS.
(2)
A SMALL EMPLOYER CARRIER MAY ALSO ADJUST THE COMMUNITY
RATE CHARGED OR OFFER ED ACCORDING TO FAMILY COMPOSITION AND GROUP
SIZE.
(3)
OTHER TITAN THE RISK CLASSIFICATIONS SET FORTH IN
PARAGRAPHS (I) AND (2) OF 'THIS SUBSECTION, A SMALL EMPLOYER CARRIER MAY
NOT EMPLOY ANY OTHER RISK CLASSIFICATION OR OTHER RATING FACTOR, SUCH
AS CLAIMS EXPERIENCE OR DURATION OF COVERAGE, TO A SMALL EMPLOYER.
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(4)
HEALTH STATUS INCLUDES REFRAINING FROM TOBACCO USE OR
OTHER ACTUARIALLY VALID FACTOR.
�SENATE HILL 349
7
1
(B) A SMALL EMPLOYER CARRIER MAY ADJUST THE COMMUNITY RATE FOR
2 A SMALL EMPLOYER BASED ON THE RISK CLASSIFICATION UNDER SUBSECTION
3 (A)(1) OF THIS SECTION:
4
.
5
6
(1)
FOR ANY HEALTH BENEFIT PLAN ISSUED, DELIVERED. OR
RENEWED BETWEEN JANUARY 1. 1994 AND DECEMBER 31, 1994, BY 50% ABOVE OR
BELOW THE COMMUNITY RATE:
7
N
9
(2)
FOR ANY HEALTH BENEFIT PLAN ISSUED. DELIVERED OR RENEWED
BETWEEN JANUARY I . 1995 AND DECEMBER 31. 1995, BY 40% ABOVE OR BELOW THE
COMMUNITY RATE; AND
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12
(3)
FOR ALL HEALTH BENEFIT PLANS ISSUED, DELIVERED, OR
RENEWED AFTER JANUARY I . 1996, BY 33% ABOVE OR BELOW THE COMMUNITY
RATE.
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15
(C) A SMALL EMPLOYER CARRIER SHALL APPLY ALL RISK ADJUSTMENT
FACTORS UNDER SUBSECTION (A) OF THIS SECTION CONSISTENTLY WITH RESPECT
TO ALL SMALL EMPLOYERS.
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17
(D) (1)
A SMALL EMPLOYER CARRIER MAY NOT ARBITRARILY TRANSFER A
SMALL EMPLOYER INVOLUNTARILY INTO OR OUT OF A HEALTH BENEFITS PLAN.
IS
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20
21
(2)
A SMALL EMPLOYER CARRIER MAY NOT OFFER TO TRANSFER A
SMALL EMPLOYER INTO OR OUT OF A HEALTH BENEFI TS PLAN UNLESS THE OFFER
TO TRANSFER IS MADE TO ALL SMALL EMPLOYERS WITH SIMILAR RISK
ADJUSTMENT' FACTORS.
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23
(E) A SMALL EMPLOYER CARRIER SITALL MAKE A REASONABLE DISCLOSURE
IN ITS SOLICITATION AND SALES MATERIALS OF:
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(1)
THE EXTENT TO WHICH PREMIUM RATES FOR A SPECIFIED SMALL
EMPLOYER ARE ESTAB LI SITED OR ADJUSTED BASED UPON THE ACTUAL OR
EXPECTED VARIA TION IN HEALTH CONDITIONS OF THE ELIGIBLE EMPLOYEES AND
DEPENDENTS OF SUCH SMALL EMPLOYER:
2S
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30
(2)
THE PROVISIONS CONCERNING THE SMALL EMPLOYER CARRIER'S
RIGHT TO CHANGE PREMIUM RATES, INCLUDING ANY FACTORS MAY AFFECT THE
CHANGES IN PREMIUM RATES:
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(3)
THE PROVISIONS RELATING TO RENEWABILITY OF POLICIES AND
CONTRACTS; AND
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(4)
PROVISION.
35
(F)
36
(1)
THE PROVISIONS
RELATING TO ANY PREEXISTING CONDITION
A SMALL EMPLOYER CARRIER SHALL BASE ITS RATING METHODS
AND PRACTICES ON:
37
(I)
COMMONLY ACCEPTED ACTUARIAL ASSUMPTIONS: AND
38
(II)
SOUND ACTUARIAL PRINCIPLES.
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40
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(2)
SUBJECT TO THE APPROVAL OF THE COMMISSIONER. A SMALL
EMPLOYER CARRIER MAY IMPOSE REASONABLE MINIMUM PARTICIPATION
REQUIREMENTS.
�S
SliNA IT-. IUI 1. 34!)
1
(C) TO INDICATE COiVII'LIANCE WITH SUBSECTIONS (E) AND (F) OF THIS
2 SECTION, A SMALL. EMPLOYER CARRIER SHALL MAINTAIN INFORMATION AND
3 DOCUMENTATION THAT' IS SATISFACTORY TO THE COMMISSIONER.
4
5
6
(H) O)
ON OR BEFORE MARCH 15 OF EACH YEAR, A SMALL EMPLOYER
CARRIER SHALL. FILE AN ACTUARIAL CERTIFICAT ION WITH THE COMMISSIONER
THAT IT HAS FOLLOWED THE RATING PRACTICES IMPOSED UNDER THIS SECTION.
7
S
(2)
THE CERTIFICATION SHALL BE BASED ON AN EXAMINATION THAT
INCLUDES A REVIEW OF:
9
(I)
APPROPRIATE RECORDS; AND
10
(II) ACTUARIAL ASSUMPTIONS
1 1 SMALL EMPLOYER CARRIER.
12
(I)
AND METHODS
USED
BY THE
A SMALL EMPLOYER CARRIER SITALL:
13
(I)
RETAIN ALL DOCUMENTS AND CERTIFICATIONS REQUIRED UNDER
14 THIS SUBTITLE AT ITS PRINCIPAL PLACE OF BUSINESS FOR A PERIOD OF 5 YEARS;
15 AND
16
(2)
MAKE THE INFORMATION AND DOCUMENTATION AVAILABLE TO
17
THE COMMISSIONER ON REQUEST.
IS
703.
19
20
(A)
(I)
TO BE COVERED UNDER A HEALTH BENEFIT PLAN OFFERED BY A
SMALL EMPLOYER CARRIER, A SMALL EMPLOYER SHALL:
21
(1)
ELECT TO BE COVERED UNDER THE PLAN:
22
(II)
AGREE TO MAKE THE REQUIRED PREMIUM PAYMENTS: AND
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27
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31
(III) SATISFY THE OTHER REASONABLE PROVISIONS OF THE PLAN
AS APPROVED BY T'HE COMMISSIONER.
(2)
ANY REQUIREMENT USED BY A SMALL EMPLOYER CARRIER IN
DETERMINING WHETHER TO PROVIDE COVERAGE TO A SMALL EMPLOYER GROUP,
INCLUDING REQUIREMENTS FOR MINIMUM PARTICIPATION OF ELIGIBLE
EMPLOYEES AND MINIMUM EMPLOYER CONTRIBUTIONS, SHALL BE APPLIED
UNIFORMLY AMONG ALL SMALL EMPLOYERS WIT IT THE SAME NUMBER OF ELIGIBLE
EMPLOYEES APPLYING FOR COVERAGE OR RECEIVING COVERAGE FROM THE
S M A L L E M P LO Y E R CA R RIE R.
32
33
34
(3)
A SMALL EMPLOYER CARRIER MAY ONLY VARY APPLICATION OF
MINIMUM
PARTICIPATION
REQUIREMENTS
AND
MINIMUM
EMPLOYER
CONTRIBUTION REQUIREMENTS BY THE SIZE OF THE SMALL EMPLOYER GROUP.
35
3d
37
(Lf) A SMALL EMPLOYER CARRIER THAT OFFERS COVERAGE TO A SMALL.
EMPLOYER SITALL OFFER COVERAGE TO ALL OF ITS ELIGIBLE EMPLOYEES AND, AT
THE ELECTION OF 'LITE SMALL EMPLOYER. DEPENDENTS OF ELIGIBLE EMPLOYEES.
38
39
40
(C) (I) TO SELL HEALTH BENEFIT PLANS TO SMALL EMPLOYERS IN
THE STATE, A SMALL EMPLOYER CARRIER SITALL FILE ITS PROPOSED SMALL
EMPLOYER HEALT H BENEFIT PLANS WITH Till COMMISSIONER BY OCTOBER I , 1993.
�SENATE BILL 349
9
1
2
3
4
(2)
UNLESS THE COMMISSIONER HAS PREVIOUSLY DISAPPROVED ITS
USE, THE SMALL EMPLOYER CARRIER'S HEALTH BENEFIT PLANS FOR SMALL
EMPLOYERS WILL BE DEEMED APPROVED 60 DAYS AFTER FILING WITH THE
COMMISSIONER.
5
6
7
(D) (1)
EXCEPT AS PROVIDED IN PARAGRAPH (4) OF THIS SUBSECTION,
PREEXISTING CONDITION PROVISIONS IN HEALTH BENEFIT PLANS COVERING
SMALL EMPLOYERS MAY NOT APPLY AFTER DECEMBER 31. 1994.
8
(2)
IN DETERMINING THE LENGTH THAT A PREEXISTING CONDITION
9 PROVISION APPLIES TO AN ELIGIBLE EMPLOYEE OR DEPENDENT, A HEALTH
10 BENEFIT PLAN SHALL CREDIT THE TIME THE INDIVIDUAL WAS PREVIOUSLY
11 COVERED BY PUBLIC OR PRIVATE HEALTH INSURANCE OR OTHER HEALTH BENEFIT
12 ARRANGEMENTS.
13
14 IF:
15
16
17
18
(3)
AN INDIVIDUAL IS DEEMED TO HAVE BEEN PREVIOUSLY COVERED
(I)
AN INTERRUPTION OF NO MORE THAN 60 DAYS HAD
OCCURRED FROM THE TIME THE INDIVIDUAL WAS COVERED BY ANY PUBLIC OR
PRIVATE HEALTH INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENTS UNTIL
THE EFFECTIVE DATE OF THE NEW COVERAGE; OR
19
(II) AN INTERRUPTION OF NO MORE THAN 60 DAYS HAD
20 OCCURRED FROM THE TIME THE INDIVIDUAL WAS COVERED BY ANY PUBLIC OR
21 PRIVATE HEALTH INSURANCE OR OTHER HEALTH BENEFIT ARRANGEMENTS UNTIL
22 THE INDIVIDUAL BECAME AN ELIGIBLE EMPLOYEE WHO ELECTED TO ENROLL BUT
23 AGAINST WHOM THE SMALL EMPLOYER IMPOSED A WAITING PERIOD PRIOR TO
24 ENROLLMENT.
25
26
(4)
(I)
A LATE ENROLLEE MAY BE SUBJECT TO AN 12-MONTH
PREEXISTING CONDITION PROVISION.
27
28
(II)
TO PREGNANCY.
29
30
(E) (1)
COVERAGE:
31
32
(I)
TO A SMALL EMPLOYER THAT IS NOT LOCATED IN THE
HEALTH MAINTENANCE ORGANIZATION'S APPROVED SERVICE AREAS;
33
34
(II) TO AN ELIGIBLE EMPLOYEE WHO DOES NOT RESIDE WITHIN
THE HEALTH MAINTENANCE ORGANIZATION'S APPROVED SERVICE AREAS; OR
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36
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39
40
(III) WITHIN AN AREA WHERE THE HEALTH MAINTENANCE
ORGANIZATION REASONABLY ANTICIPATES. AND DEMONSTRATES TO THE
SATISFACTION OF THE COMMISSIONER, THAT IT WILL NOT HAVE THE CAPACITY
WITHIN THE AREA IN ITS NETWORK OF PROVIDERS TO DELIVER SERVICE
ADEQUATELY BECAUSE OF ITS OBLIGATIONS TO EXISTING GROUP CONTRACT
HOLDERS AND ENROLLEES.
41
42
43
(2)
A HEALTH MAINTENANCE ORGANIZATION THAT DOES NOT OFFER
COVERAGE UNDER SUBSECTION (E)(J)(III) OF 'THIS SECTION MAY NOT OFFER
COVERAGE IN THE APPLICABLE AREA 'TO ANY EMPLOYER GROUPS UNTIL THE
A PREEXISTING CONDITION PROVISION MAY NOT BE APPLIED
A HEALTH
MAINTENANCE ORGANIZATION NEED
NOT OFFER
�10
SENATE KILL 349
!
2
3
LATER OF 180 DAYS FOLLOWING ANY REFUSAL TO DO SO OR THE DATE ON WHICH
THE CARRIER NOTIFIES THE COMMISSIONER THAT IT HAS REGAINED CAPACITY TO
DELIVER SERVICES TO SMALL EMPLOYER GROUPS.
4
5
6
7
(F) A SMALL EMPLOYER CARRIER MAY NOT BE REQUIRED TO OFFER
COVERAGE UNDER SUBSECTION (A) OF THIS SECTION FOR SO LONG AS THE
COMMISSIONER FINDS THAT THE COVERAGE WOULD PLACE THE SMALL EMPLOYER
CARRIER IN A FINANCIALLY IMPAIRED CONDITION.
S
:
704.
9
10
11
(A) (1)
EXCEPT AS PROVIDED IN SUBSECTION (B) OF THIS SECTION, A
SMALL EMPLOYER CARRIER SHALL RENEW A SMALL EMPLOYER HEALTH BENEFIT
PLAN AT THE OPTION OF THE SMALL EMPLOYER.
12
13
14
(2)
ON RENEWAL A SMALL EMPLOYER CARRIER MAY NOT EXCLUDE
ELIGIBLE EMPLOYEES OR DEPENDENTS FROM A SMALL EMPLOYER HEALTH
BENEFIT PLAN.
15
16
17
(B)
A SMALL EMPLOYER CARRIER MAY NOT CANCEL OR REFUSE TO RENEW
A SMALL EMPLOYER HEALTH BENEFIT PLAN EXCEPT:
(1)
FOR NONPAYMENT OF THE REQUIRED PREMIUMS;
18
19
20
(2)
FOR FRAUD OR MISREPRESENTATION OF THE SMALL EMPLOYER OR
THE COVERED INDIVIDUALS OR THEIR REPRESENTATIVES;
(3)
FOR NONCOMPLIANCE WITH OTHER REASONABLE PROVISIONS OF
21
THE HEALTH BENEFI T PLAN AS APPROVED BY "THE COMMISSIONER:
22
(4)
FOR REPEATED MISUSE OF A PROVIDER NETWORK PROVISION;
23
24
25
26
(5)
WHERE THE SMALL EMPLOYER CARRIER ELECTS NOT TO RENEW
ALL OF ITS HEALTH BENEFIT PLANS ISSUED TO SMALL EMPLOYERS IN THIS STATE;
(6)
IF THE SMALL EMPLOYER CARRIER ELECTS NOT TO RENEW THE
PARTICULAR HEALTH BENEFITS PLAN FOR ALL SMALL EMPLOYERS IN THE STATE;
27
28
(7)
IF THE COMMISSIONER
COVERAGE WOULD:
29
30
(I)
NOT BE IN THE BEST INTERESTS OF POLICYHOLDERS OR
CERTIFICATE HOLDERS: OR
31
32
(II)
OBLIGATIONS; OR
33
34
35
(8)
IF THE SMALL EMPLOYER CARRIER IS A HEALTH MAINTENANCE
ORGANIZATION, FOR REASONS STATED IN THE HEALTH - GENERAL ARTICLE, §
19-725(B).
36
37
(C) WHEN A SMALL EMPLOYER CARRIER ELECTS NOT 'TO RENEW ALL
HEALTH BENEFIT PLANS IN THE STATE, THE SMALL EMPLOYER CARRIER:
38
39
(1)
SHALL GIVE NOTICE OF ITS DECISION TO 'THE AFFECTED SMALL
EMPLOYERS AND THE INSURANCE REGULATORY AUTHORITY OF EACH STATE IN
FINDS THAT CONTINUATION OF THE
IMPAIR THE CARRIER'S ABILITY TO MEET ITS CONTRACTUAL
�SENATE BILL 349
11
1 WHICH AN ELIGIBLE EMPLOYEE OR DEPENDENT RESIDES AT LEAST 180 DAYS
2 BEFORE THE EFFECTIVE DATE OF NONRENEWAL;
3
4
(2)
AT LEAST 30 WORKING DAYS BEFORE THAT NOTICE, SHALL GIVE
NOTICE TO THE COMMISSIONER; AND
5
(3)
MAY NOT WRITE NEW BUSINESS FOR SMALL EMPLOYERS IN THE
f> STATE FOR A 5-YEAR PERIOD BEGINNING ON THE DATE OF NOTICE TO THE
7 COMMISSIONER.
8
9
JO
11
12
(D) WITHIN 7 DAYS FOLLOWING CANCELLATION OR NONRENEWAL OF A
HEALTH BENEFIT PLAN, THE SMALL EMPLOYER CARRIER SHALL SEND WRITTEN
NOTICE TO EACH ENROLLED EMPLOYEE OF ITS ACTION AND THE CONVERSION
RIGHTS AVAILABLE TO EACH ENROLLED EMPLOYEE UNDER SS 354 1 AND 477K OF
THIS ARTICLE.
13
705.
14
15
(A) (1)
A SMALL EMPLOYER CARRIER SHALL ELECT TO BECOME A
RISK-ASSUMING CARRIER OR A REINSURING CARRIER.
16
17
IS
(2)
AN ELECTION '10 BECOME A REINSURING CARRIER UNDER THIS
SUBSECTION SHALL BE SUBMITTED TO THE COMMISSIONER ON A FORM AND IN A
MANNER REQUIRED BY THE COMMISSIONER BY OCTOBER 1, 1993.
19
20
21
22
(3)
THE NOTIFICATION OF A RISK-ASSUMING CARRIER SHALL INCLUDE
AN APPROPRIATE OPINION BY AN INDEPENDENT QUALIFIED ACTUARY THAT THE
RISK-ASSUMING CARRIER IS ABLE TO ASSUME AND MANAGE THE RISK OF
ENROLLING SMALL EMPLOYER GROUPS WI THOUT THE PROTECTION OF THE POOL.
23
(B)
(I)
THE ELECTION SHALL BE BINDING FOR A 3-YEAR PERIOD.
24
25
26
(2)
AFTER THE INITIAL 3-YEAR PERIOD, AND EVERY 5 YEARS
THEREAFTER, CARRIERS SHALL AGAIN ELECT 'TO BE A RISK-ASSUMING OR
REINSURING CARRIER. THE ELECTION SHALL BE BINDING FOR A 5-YEAR PERIOD.
27
28
(3)
THE COMMISSIONER MAY PERMIT A CARRIER TO CHANGE ITS
ELECTION AT ANY TIME FOR GOOD CAUSE SHOWN.
29
30
(C) IN DETERMINING WHETHER TO APPROVE AN APPLICATION BY A
CARRIER TO CHANGE ITS ELECTION. THE COMMISSIONER SHALL CONSIDER:
31
32
33
(I)
THE APPLICANT'S FINANCIAL CONDITION AND THE FINANCIAL
CONDITION OF ANY PARENT OR GUARANTEEING CORPORATION;
(2)
T HE APPLICANT'S HISTORY OF ASSUMING AND MANAGING RISK;
34
35
36
37
38
(3)
THE APPLICANT'S COMMITMENT TO MARKET FAIRLY TO ALL SMALL
EMPLOYERS IN THE STATE OR IN ITS SERVICE AREA;
(4)
THE APPLICANT'S ABILITY TO ASSUME AND MANAGE THE RISK OF
ENROLLING SMALL EMPLOYER GROUPS WITHOUT THE PROTECTION OF 'THE POOL;
AND
39
40
(5)
THE EFFECT OF APPROVAL
FINANCIAL VIABILITY OF THE POOL.
OF
THE
APPLICATION ON THE
�12
SENATE BILL 349
1
(D) (N CONSIDERING AN APPLICATION UNDER SUBSECTION (C) OF THIS
2 SECTION, THE CARRIER MAY REQUEST A HEARING AS PROVIDED UNDER § 242B OF
3 THIS ARTICLE.
4
706.
5
6
7
8
(A) THE COMMISSIONER SHALL ESTABLISH THE MARYLAND SMALL
EMPLOYER HEALTH REINSURANCE POOL, AND SHALL NOTIFY ALL CARRIERS
APPROVED TO BE SMALL EMPLOYER CARRIERS OF STEPS TAKEN TO ESTABLISH THE
POOL.
9
10
11
(B) BY OCTOBER I , 1993 THE COMMISSIONER SHALL NOTIFY ALL CARRIERS
APPLYING TO SELL HEALTH BENEFIT PLANS TO SMALL EMPLOYERS IN THE STATE
OF THE TIME AND PLACE OF THE INITIAL MEETING OF THE BOARD.
12
13
14
(C) THE COMMISSIONER SHALL CONVENE THE INITIAL MEETING AND ALL
SUBSEQUENT MEETINGS OF THE BOARD AND SHALL ADMINISTER ITS AFFAIRS
UNTIL BOARD MEMBERS ARE ELECTED.
15
16
(D) THE INITIAL
NOVEMBER 1, 1993.
17
.18
(E) (I) THE REINSURING CARRIERS SHALL ELECT AN INITIAL BOARD OF
DIRECTORS TO BE COMPOSED OF 7 MEMBERS.
.19
20
21
(2)
IF THE INITIAL BOARD IS NOT ELECTED AT THE ORGANIZATIONAL
MEETING, THE COMMISSIONER SHALL APPOINT THE INITIAL BOARD WITHIN 60 DAYS
AFTER THE ORGANIZATIONAL MEETING.
22
23
24
25
(3)
THE BOARD SHALL INCLUDE REPRESENTATION FROM CARRIERS
WHOSE PRINCIPAL HEALTH INSURANCE BUSINESS IS IN THE SMALL EMPLOYER
MARKET AND, TO THE EXTENT POSSIBLE, AT LEAST 1 NONPROFIT HEALTH SERVICE
PLAN AND AT LEAST I HEALTH MAINTENANCE ORGANIZATION.
26
27
(4)
NO CARRIER AND ITS AFFILIATES MAY BE REPRESENTED BY MORE
THAN ONE MEMBER ON THE BOARD.
28
29
(5)
THE TERM OF A MEMBER IS 3 YEARS EXCEPT THAT THE INITIAL
MEMBERS' TERMS SHALL BE STAGGERED FOR PERIODS OF 1 TO 3 YEARS.
30
31
(6)
AT THE END OF A TERM, A MEMBER CONTINUES TO SERVE UNTIL A
SUCCESSOR IS ELECTED.
32
33
(7)
VACANCIES SHALL BE FILLED BY AN ELECTION OF THE REMAINING
BOARD MEMBERS.
34
35
(8)
A MEMBER WHO IS ELECTED AFTER A TERM MAS BEGUN SERVES
ONLY FOR THE REST OF THE TERM AND UNTIL A SUCCESSOR IS ELECTED.
36
37
(9)
A MEMBER WHO SERVES 2 CONSECUTIVE FULL 3-YEAR TERMS MAY
NOT BE REELECTED FOR 3 YEARS AFTER THE COMPLETION OF THOSE TERMS.
38
39
(F) (1)
THE BOARD SHALL APPOINT AN EXECUTIVE DIRECTOR WHO IS THE
CHIEF ADMINISTRATIVE OFFICER OF THE POOL.
40
41
BOARD.
(2)
ORGANIZATIONAL MEETING SHALL TAKE PLACE BY
THE EXECUTIVE DIRECTOR SERVES AT THE PLEASURE OF THE
�SENATE BILL 349
13
1
(3)
UNDER THE DIRECTION OFTHE BOARD. THE EXECUTIVE DIRECTOR
2 SHALL PERFORM ANY DUTY OR FUNCTION THAT THE BOARD REQUIRES.
3
(G)
A CHAIRMAN SHALL BE SELECTED BY THE BOARD.
4
3
(1-1) THE POOL MAY EMPLOY A STAFF IN ACCORDANCE WITH THE POOL'S
BUDGET.
6
7
5
9
(I)
(1)
WITHIN 120 DAYS AFTER THE ELECTION OF THE INITIAL BOARD.
THE BOARD SHALL SUBMIT TO THE COMMISSIONER A PLAN OF OPERATION TO
ASSURE THE FAIR. REASONABLE, AND FINANCIALLY SOUND ADMINISTRATION OF
THE POOL..
10
(2)
(I)
IF THE BOARD FAILS TO SUBMIT A PLAN OF OPERATION
1 1 WITHIN 120 DAYS AFTER ITS ELECTION, THE COMMISSIONER SHALL, AFTER NOTICE
12 AND HEARING. ADOPT A TEMPORARY PLAN OF OPERATION.
13
14
15
(II) THE COMMISSIONER MAY AMEND OR RESCIND ANY EXISTING
PLAN OF OPERATION IF THE COMMISSIONER FINDS THAT THE POOL IS NOT
OPERATING IN A FAIR. REASONABLE, AND FINANCIALLY SOUND MANNER.
1(»
(.1)
THE POOL SHALL BE OPERATIONAL AND REINSURE CLAIMS OF ELIGIBLE
17 HEALTH BENEFIT PLANS WITHIN 12 MONTHS AFTER THE EFFECTIVE DATE OF THIS
IS ACT.
iy
20
21
22
(K) THE COMMISSIONER MAY ORDER THE DISSOLUTION OFTHE POOL IF THE
COMMISSIONER DETERMINES THAT THE POOL IS NOT FINANCIALLY VIABLE,
PROVIDED THAT PROVISION IS MADE TO ENSURE THE PROTECTION OF INSUREDS
INSURED BY THE MEMBERS OF THE POOL.
23
707.
24
(A)
THE PLAN OF OPERATION SHALL. AT A MINIMUM:
25
26
27
(1)
ESTABLISH PROCEDURES FOR THE HANDLING AND ACCOUNTING
OF POOL ASSETS AND MONEYS AND FOR AN ANNUAL FISCAL REPORTING TO THE
COMMISSIONER;
28
29
(2)
ESTABLISH PROCEDURES FOR REINSURING CLAIMS SUBMITTED TO
THE POOL IN ACCORDANCE WITH THE PROVISIONS OF THIS SUBTITLE:
30
31
.32
33
(3)
ESTABLISH PROCEDURES FOR COLLECTING ASSESSMENTS FROM
MEMBERS TO REINSURE CLAIMS SUBMITTED TO THE POOL AND TO PAY FOR
ADMINISTRATIVE EXPENSES INCURRED OR ESTIMATED TO BE INCURRED DURING
THE PERIOD;
34
35
36
(4)
ESTABLISH PROCEDURES FOR RECOUPING ANY NET LOSSES TO THE
POOL FOR THE CALENDAR YEAR BY ASSESSING REINSURING CARRIERS AS
ESTABLISHED IN Jj 709(B) OF THIS SUBTITLE; AND
37
38
(5)
THE BOARD.
39
40
41
(B) THE BOARD SHALL. HAVE "IT-IE GENERAL. POWERS AND AUTHORITY
GRANTED UNDER THE LAWS OF THIS STATE TO HEALTH INSURANCE COMPANIES
AND HEALTH MAINTENANCE ORGANIZATIONS AUTHORIZED TO TRANSACT
PROVIDE FOR ANY ADDITIONAL MATTERS AT THE DISCRETION OF
�14
SENATE IUI.L 349
1
BUSINESS, EXCEPT THE POWER TO ISSUE HEALTH BENEFIT PLANS DIRECTLY TO
2
EI THER GROUPS OR INDIVIDUALS.
3
(C)
THE BOARD MAY
4
5
6
7
S
9
(1)
ENTER INTO CONTRACTS AS ARE NECESSARY OR PROPER TO CARRY
OUT THE PROVISIONS AND PURPOSES OF THIS SUBTITLE. INCLUDING AUTHORITY,
WITH APPROVAL OF 'THE COMMISSIONER, TO ENTER INTO CONTRACTS WITH
SIMILAR PROGRAMS OF OTHER STATES FOR THE JOINT PERFORMANCE OF COMMON
FUNCTIONS OK WITH PERSONS OR OTHER ORGANIZATIONS FOR THE
PERFORMANCE OF ADMINISTRATIVE FUNCTIONS;
10
I I
12
(2)
SUE OR BE SUED. INCLUDING TAKING ANY LEGAL ACTIONS
NECESSARY OR PROPER FOR RECOVERING ANY ASSESSMENTS AND PENALTIES FOR,
ON BEHALF OF, OR AGAINST THE POOL OR ANY PARTICIPATING CARRIERS;
13
14
(3) TAKE ANY LEGAL ACTION NECESSARY TO AVOID THE PAYMENT OF
IMPROPER CLAIMS AGAINST THE BOARD;
15
16
17
(-I) DEFINE "THE HEALTH BENEFIT PLANS AND MEDICAL CONDITIONS
TOR WHICH CLAIMS MAY BE REINSURED WITH THE POOL IN ACCORDANCE WITH
THE REQUIREMENTS OF THIS SUBTITLE;
IS
(5)
ESTABLISH RULES, CONDITIONS, AND PROCEDURES PERTAINING TO
19 "THE REINSURANCE OF CLAIMS BY THE POOL;
20
21
(6)
ESTABLISH ACTUARIAL FUNCTIONS AS APPROPRIATE
OPERATION OF THE POOL;
22
23
24
25
26
27
(7)
ASSESS REINSURING CARRIERS IN ACCORDANCE WITH THE
PROVISIONS OF $ 7n9 OF THIS SUBTITLE AND MAKE ADVANCE INTERIM
ASSESSMENTS AS MAY BE REASONABLE AND NECESSARY FOR ORGANIZATIONAL
AND INTERIM OPERATING EXPENSES WITH ANY INTERIM ASSESSMENTS TO BE
CREDITED AGAINST ANY ASSESSMENTS DUE FOLLOWING THE CLOSE OF THE FISCAL
YEAR;
28
29
30
51
(8)
APPOINT APPROPRIATE COMMITTEES AS NECESSARY TO PROVIDE
TECHNICAL ASSISTANCE IN THE OPERATION OF THE POOL, POLICY AND OTHER
CONTRACT DESIGN, AND ANY OTTIER FUNCTION WITHIN THE AUTHORITY OF 'THE
POOL: AND
32
(9)
FOR
THE
BORROW MONEY TO CARRY OUT I TIE PURPOSES OF THE POOL.
33
708.
34
.35
(A) (I)
A REINSURING CARRIER MAY REINSURE WITH THE POOL AS
PROVIDED IN THIS SUBSECTION.
36
37
(2)
WITH RESPECT TO HEALTH BENEFIT PLANS, THE POOL SHALL
REINSURE UP 'TO 'THE LEVEL OF COVERAGE DETERMINED BY THE BOARD.
38
39
40
(3)
A SMALL EMPLOYER CARRIER MAY REINSURE AN ENTIRE
EMPLOYER GROUP WITHIN 60 DAYS OF "THE COMMENCEMENT OF THE GROUP'S
COVERAGE UNDER A HEALTH BENEFIT PLAN.
�SENATE HILL 349
15
1
(4)
A REINSURING CARRIER MAY REINSURE AN ELIGIBLE EMPLOYEE
2 OR DEPENDEN T WITHIN A PERIOD OT 60 DAYS TOLLOWING THE COMMENCEMENT
3 OF THE COVERAGE WITH THE SMALL EMPLOYER. A NEWLY ELIGIBLE EMPLOYEE OR
4 DEPENDENT OF A REINSURED SMALL EMPLOYER MAY BE REINSURED WITHIN 60
5 DAYS OF THE COMMENCEMEN T OF HIS OTHER COVERAGE.
6
7
8
9
10
1I
12
13
14
(5)
(I)
THE POOL MAY NOT REIMBURSE A REINSURING CARRIER
WITH RESPECT TO THI:. CLAIMS OF A REINSURED EMPLOYEE OR DEPENDENT UNTIL
THE CARRIER HAS INCURRED AN INI TIAL LEVEL OF CLAIMS FOR THE EMPLOYEE OR
DEPENDENT OF $5,000 IN A CALENDAR YEAR FOR BENEFITS COVERED BY THE POOL.
IN ADDITION, THE REINSURING CARRIER SHALL BE RESPONSIBLE FOR 10% OF THE
NEXT $50,000 OF INCURRED CLAIMS DURING A CALENDAR YEAR AND THE PROGRAM
SHALL REINSURE THE REMAINDER. A REINSURING CARRIER'S LIABILITY UNDER
"THIS SUBPARAGRAPH MAY NOT EXCEED A MAXIMUM LIMIT OF $10,000 IN ANY 1
CALENDAR YEAR WITH RESPECT TO ANY REINSURED INDIVIDUAL.
15
16
17
IS
19
20
21
22
(11) THE BOARD ANNUALLY SHALL ADJUST THE INITIAL LEVEL OF
CLAIMS AND THE MAXIMUM LIMIT TO BE RETAINED BY THE CARRIER TO REFLECT
INCREASES IN COSTS AND UTILIZATION WITHIN THE STANDARD MARKET FOR
HEALTH BENEFIT PLANS WITHIN THE STATE. THE ADJUSTMENT MAY NOT BE LESS
THAN THE ANNUAL CHANGE IN THE MEDICAL COMPONENT OF THE "CONSUMER
PRICE INDEX FOR ALL URBAN CONSUMERS" OF THE DEPARTMENT OF LABOR,
BUREAU OF LABOR STATISTICS. UNLESS THE BOARD PROPOSES AND THE
COMMISSIONER APPROVES A LOWER ADJUSTMENT FACTOR.
23
24
25
(6)
A SMALL EMPLOYER CARRIER MAY TERMINATE REINSURANCE FOR
ONE OR MORE OF THE REINSURED EMPLOYEES OR DEPENDENTS OF A SMALL
EMPLOYER ON ANY PLAN ANNIVERSARY.
26
27
2S
29
30
31
32
33
34
35
36
37
38
39
(B) (I)
THE BOARD. AS PART OF "THE PLAN OF OPERATION, SHALL
ESTABLISH A METHODOLOGY FOR DETERMINING PREMIUM RATES TO BE CHARGED
BY THE POOL FOR REINSURING SMALL EMPLOYERS AND INDIVIDUALS UNDER THIS
SECTION. THE ME THODOLOGY SHALL INCLUDE A SYSTEM FOR CLASSIFICATION OF
SMALL EMPLOYERS "THAT REFLECTS THE TYPES OF CASE CHARACTERISTICS
COMMONLY USED BY SMALL . EMPLOYER CARRIERS IN THE STATE. THE
METHODOLOGY SHALL PROVIDE FOR 'THE DEVELOPMENT OF BASE REINSURANCE
PREMIUM RATES, WHICH SHALL BE MULTIPLIED BY THE FACTORS SET FORTH IN
PARAGRAPH (2) OF 'THIS SUBSECTION TO DETERMINE THE PREMIUM RATES FOR
THE POOL. 'THE BASE REINSURANCE PREMIUM RATES SHALL BE ESTABLISHED BY
THE BOARD AND SHALL BE SET AT LEVELS THAT REASONABLY APPROXIMATE
GROSS PREMIUMS CHARGED TO SMALL EMPLOYERS BY SMALL EMPLOYER
CARRIERS FOR HEALTH BENEFIT PLANS UP TO THE LEVEL OF COVERAGE
DETERMINED BY 'THE BOARD.
40
(2)
PREMIUMS FOR THE POOL SHALL BE AS FOLLOWS.
41
42
43
(I)
AN ENTIRE SMALL EMPLOYER GROUP MAY BE REINSURED
FOR A RATE THAT IS 1.5 "TIMES THE BASE REINSURANCE PREMIUM RATE FOR THE
GROUP ESTABLISHED UNDER THIS SUBSECTION.
44
45
46
( i n AN ELIGIBLE EMPLOYEE OR DEPENDENT MAY BE REINSURED
TOR A RATE THAT IS 5 "TIMES THE BASE REINSURANCE PREMIUM RATE FOR THE
INDIVIDUAL ESTABLISHED UNDER THIS SUBSECTION.
�16
SENATE BILL 349
1
2
3
4
5
6
(.3) THE BOARD I'ERIODICALLY SHALL REVIEW THE METHODOLOGY
ESTABLISHED UNDER PARAGRAPH (I) OF THIS SUBSECTION, INCLUDING THE
SYSTEM OF CLASSIFICATION AND ANY RATING FACTORS, TO ASSURE THAT IT
REASONABLY REFLECTS THE CLAIMS EXPERIENCE OF 'THE POOL. THE BOARD MAY
PROPOSE CHANGES TO 'THE METHODOLOGY WHICH SHALL BE SUBJECT TO THE
APPROVAL OF THE COMMISSIONER.
7
8
9
10
1 1
(C) IF A HEALTH BENEFIT PLAN FOR A SMALL EMPLOYER IS ENTIRELY OR
PARTIALLY REINSURED WITH THE PROGRAM, THE PREMIUM CHARGED TO THE
SMALL EMPLOYER FOR ANY RATING PERIOD FOR THE COVERAGE ISSUED SHALL
MEET THE REQUIREMENTS RELATING TO PREMIUM RATES SET FORTH IN S 702 OF
THIS SUBTITLE.
12
13
14
15
16
(D) (I)
PRIOR TO MARCH 1 OF EACH YEAR, THE BOARD SHALL DETERMINE
AND REPORT TO THE COMMISSIONER THE POOL NET LOSS FOR THE PREVIOUS
CALENDAR YEAR. INCLUDING ADMINISTRATIVE EXPENSES AND INCURRED LOSSES
FOR THE YEAR. TAKING INTO ACCOUNT INVESTMENT INCOME AND OTHER
APPROPRIATE GAINS AND LOSSES.
17
18
(2)
(I)
ANY NET LOSS FOR
ASSESSMENT'S OF REINSURING CARRIERS.
19
20
21
(II) THE BOARD SHALL ESTABLISH. AS PART OF THE PLAN OF
OPERATION. A FORMULA BY WHICH TO MAKE ASSESSMENTS AGAINST REINSURING
CARRIERS. THE ASSESSMENT FORMULA SHALL BE BASED ON:
22
23
24
25
1.
EACH REINSURING CARRIER'S SHARE OF THE TOTAL
PREMIUMS EARNED IN THE PRECEDING CALENDAR YEAR FROM HEALTH BENEFIT
PLANS DELIVERED OR ISSUED FOR DELIVERY TO SMALL EMPLOYERS IN THIS STATE
BY REINSURING CARRIERS; AND
26
27
28
29
2.
EACH REINSURING CARRIER'S SHARE OFTTIE PREMIUMS
EARNED IN THE PRECEDING CALENDAR YEAR FROM NEWLY ISSUED HEALTH
BENEFIT PLANS DELIVERED OR ISSUED FOR DELIVERY DURING SUCH CALENDAR
YEAR TO SMALL EMPLOYERS IN THIS STATE BY REINSURING CARRIERS.
30
31
32
33
34
35
36
37
38
(III) THE FORMULA ESTAB LISH EL") UNDER SUBPARAGRAPH (I) OF
THIS PARAGRAPH MAY NOT RESULT' IN ANY REINSURING CARRIER HAVING AN
ASSESSMENT SHARE THAT IS LESS TITAN 50% NOR MORE 'THAN 150% OF AN AMOUNT
WHICH IS BASED ON THE PROPORTION OF 'THE REINSURING CARRIER'S "TOTAL
PREMIUMS EARNED IN THF: PRECEDING CALENDAR YEAR FROM HEALTH BENEFIT
PLANS DELIVERED OR ISSUED FOR DELIVERY 'TO SMALL EMPLOYERS IN THIS STATE
BY REINSURING CARRIERS TO TOTAL PREMIUMS EARNED IN THE PRECEDING
CALENDAR YEAR FROM HEALTH BENEFIT" PLANS DELIVERED OR ISSUED FOR
DELIVERY TO SMALL EMPLOYERS IN THIS STATE BY ALL REINSURING CARRIERS.
39
40
41.
42
43
44
45
(IV) THE
BOARD
MAY, WITH
THE APPROVAL OF THE
COMMISSIONER. CHANGE THE ASSESSMENT FORMULA ESTABLISHED PURSUANT TO
SUBPARAGRAPH (I) OF THIS PARAGRAPH FROM 'TIME 'TO TIME AS APPROPRIATE.
THE BOARD MAY PROVIDE FOR THE SHARES OF 'THE ASSESSMENT BASE
ATTRIBUTABLE TO PREMIUMS FROM ALL HEALTH BENEFIT PLANS AND TO
PREMIUMS FROM NEWLY ISSUED HEALTH BENEFIT PLANS TO VARY DURING A
TRANSITION PERIOD.
THE YEAR SHALL BE RECOUPED BY
�SENATE HILL 349
17
1
2
3
4
5
6
(V) SUBJECT TO THE APPROVAL OF THE COMMISSIONER, THE
BOARD SHALL MAKE AN ADJUSTMENT TO THE ASSESSMENT FORMULA FOR
REINSURING
CARRIERS
THAT ARE APPROVED
HEALTH MAINTENANCE
ORGANIZATIONS WHICH ARE FEDERALLY QUALIFIED UNDER 42 U.S.C. SEC. 300, ET
SEQ, TO THE EXTENT, IF ANY. THAT RESTRICTIONS ARE PLACED ON THEM THAT
ARE NOT IMPOSED ON OTHER SMALL EMPLOYER CARRIERS.
7
S
9
10
(V[) PREMIUMS AND BENEFITS PAID BY A REINSURING CARRIER
THAT ARE LESS THAN AN AMOUNT DETERMINED BY THE BOARD TO JUSTIFY THE
COST OF COLLECTION SHALL NOT BE CONSIDERED FOR PURPOSES OF
DETERMINING ASSESSMENTS.
11
12
13
14
(3)
(I)
PRIOR TO MARCH 1 OF EACH YEAR, THE BOARD SHALL
DETERMINE AND FILE WITH THE COMMISSIONER AN ESTIMATE OF THE
ASSESSMENTS NEEDED TO FUND THE LOSSES INCURRED BY THE POOL IN THE
PREVIOUS CALENDAR YEAR
15
(11) IF THE BOARD DETERMINES THAT THE ASSESSMENTS NEEDED
16 TO FUND THE LOSSES INCURRED BY THE PROGRAM IN THE PREVIOUS CALENDAR
17 YEAR WILL EXCEED THE AMOUNT SPECIFIED IN SUBPARAGRAPH (III) OF THIS
IS PARAGRAPH, THE BOARD SHALL EVALUATE THE OPERATION OF THE POOL AND
19 REPORT ITS FINDINGS, INCLUDING ANY RECOMMENDATIONS FOR CHANGES TO THE
20 PLAN OF OPERATION, TO THE COMMISSIONER WITHIN 90 DAYS FOLLOWING THE
21 END OF THE CALENDAR YEAR IN WHICH THE LOSSES WERE INCURRED. THE
22 EVALUATION SHALL INCLUDE: AN ESTIMATE OF FUTURE ASSESSMENTS, THE
23 ADMINISTRATIVE COSTS OF THE POOL. THE APPROPRIATENESS OF THE PREMIUMS
24 CHARGED AND THE LEVEL OF INSURER RETENTION UNDER THE PROGRAM, AND
25 THE COSTS OF COVERAGE FOR SMALL EMPLOYERS. IF THE BOARD FAILS TO FILE
26 THE REPORT WITH THE COMMISSIONER WITHIN 90 DAYS FOLLOWING THE END OF
27 THE APPLICABLE CALENDAR YEAR. THE COMMISSIONER MAY EVALUATE THE
2S OPERATIONS OF THE POOL AND IMPLEMENT AMENDMENTS TO THE PLAN OF
29 OPERATION THAT THE COMMISSIONER DEEMS NECESSARY TO REDUCE FUTURE
30 LOSSES AND ASSESSMENTS.
31
32
33
34
(III) FOR ANY CALENDAR YEAR. THE AMOUNT SPECIFIED IN THIS
SUBPARAGRAPH IS 5% OF TOTAL PREMIUMS EARNED THF. PREVIOUS YEAR FROM
HEALTH BENEFIT PLANS DELIVERED OR ISSUED FOR DELIVERY TO SMALL
EMPLOYERS IN THIS STATE BY REINSURING CARRIERS.
35
36
37
38
(4)
IF ASSESSMENTS EXCEED NET LOSSES OF THE POOL THE EXCESS
SHALL BE HELD AT INTEREST AND USED BY THE BOARD TO OFFSET FUTURE LOSSES
OR TO REDUCE POOL PREMIUMS. AS USED IN THIS PARAGRAPH. -'FUTURE LOSSES"
INCLUDES RESERVES FOR INCURRED BUT NOT REPORTED CLAIMS.
39
40
41
42
(5)
EACH REINSURING CARRIER'S PROPORTION OF THE ASSESSMENT
SHALL BE DETERMINED ANNUALLY BY THE BOARD BASED ON ANNUAL
STATEMENTS AND OTHER REPORTS DEEMED NECESSARY BY THE BOARD AND
FILED BY THE REINSURING CARRIERS WITH THE BOARD.
43
44
(6)
THE PLAN OF OPERATION SHALL PROVIDE FOR THE IMPOSITION OF
AN INTEREST PENALTY FOR LATE PAYMENT OF ASSESSMENTS.
45
46
(7)
A REINSURING CARRIER MAY SEEK FROM THE COMMISSIONER A
DEFERMENT FROM ALL OR PART OF AN ASSESSMENT IMPOSED BY THE BOARD. THE
�IS
.SENATE KIM. ?4<)
\
2
3
4
5
6
7
S
y
Id
1 I
COMMISSIONER MAY DEFER ALE OR PART OF THE ASSESSMENT OF A REINSURING
CARRIER IF THE COMMISSIONER DETERMINES THAT THE PAYMENT OF THE
ASSESSMENT WOULD PLACE THE REINSURING CARRIER IN A FINANCIALLY
IMPAIRED CONDITION. IF ALL OR PART OF AN ASSESSMENT AGAINST A REINSURING
CARRIER IS DEFER RED. THE AMOUNT DEFERRED SHALL BE ASSESSED AGAINST THE
O THER PARTICIPATING CARRIERS IN A MANNER CONSISTENT WITH THE BASIS FOR
ASSESSMENT SET FORTH IN THIS SUBSECTION. THE REINSURING CARRIER
RECEIVING SUCH DEFERMENT SHALL REMAIN LIABLE TO THE PROGRAM FOR THE
AMOUNT DEFERRED AND SHALL BE PROHIBITED FROM REINSURING ANY
INDIVIDUALS OR GROUPS IN THE POOL UNTIL SUCH TIME AS FT PAYS SUCH
ASSESSMENTS.
12
13
14
15
16
.
17
(E) NEITHER THE PARTICIPATION IN THE PROGRAM AS REINSURING
CARRIERS, THE ESTABLISHMENT OF RATES. FORMS, OR PROCEDURES, NOR ANY
OTHER JOINT OR COLLECTIVE ACTION REQUIRED BY THIS SECTION SHALL BE THE
BASIS OF ANY LEGAL ACTION. CRIMINAL OR CIVIL LIABILITY, OR PENALTY AGAINST
THF. PROGRAM OR ANY OF ITS REINSURING CARRIERS EITHER JOINTLY OR
SEPARATELY.
IS
70!).
19
(A) (1)
ALL MONEYS COLLECTED UNDER THIS SECTION. AND ALL OTHER
21) FUNDS COLLECTED BY OR ON BEHALF OF THE POOL, WHETHER THROUGH
21 PREMIUM CHARGES.
ASSESSMENTS, EARNINGS FROM
INVESTMENTS. OR
22 OTHERWISE. SHALL BE MANAGED AND INVESTED BY THE POOL THROUGH A
23 FINANCIAL MANAGEMEN T COMMITTEE COMPRISED OF:
24
(I)
THE EXECUTIVE DIRECTOR; AND
25
(11)
2 MEMBERS OF THE BOARD.
26
27
(2)
ALL OPERATING EXPENSES OF THE POOL SHALL BE PAID FROM
FUNDS COLLECTED BY OR ON BEHALF OF THF. POOL.
2S
29
ACCOUNT.
(3)
(1)
"THE ACCOUNT OF THE: POOL SHALL BE A SPECIAL FUND
3(1
( l l j 'THE FUND ACCOUNT" MAY NOT BE DEEMED PART" OF THE
31 TREASURY OF "THE STATE.
32
33
34
35
(III) THE
STATE
MAY
NOT
PROVIDE
GENERAL
FUND
APPROPRIATIONS TO THE POOL AND OBLIGATIONS OF THE POOL MAY NOT BE
DEEMED IN ANY MANNER TO BE A DEBT OF THE STATE OR A PLEDGE OF ITS
CREDIT".
36
.37
38
39
(IV) ALL DEBTS, CLAIMS, OBLIGATIONS, AND LIABILITIES OF THE
POOL, WHENEVER INCURRED. SITALL BE THE DEBTS, CLAIMS. OBLIGATIONS, AND
LIABILITIES OF THE POOL ONLY AND NOT OF THE STATE, ITS AGENCIES,
INSTRUMENTALITIES. OFFICERS, OR EMPLOYEES.
4(1
41
42
43
(B)
THE POOL IS EXEMPT FROM:
(1)
TAXATION BY THE STATE AND LOCAL GOVERNMENT;
(2)
THE GENERAL PROCUREMENT LAW PROVISIONS OF DIVISION II OF
THE STATE FINANCE AND PROCUREMENT ARTICLE: AND
�SLNATT. BILL 349
1
(3)
19
THE PROVISIONS OF ARTICLE 64A (MERIT SYSTEM) OF THE CODE.
2
710.
3
4
(A) THE BOARD SHALL REPORT TO THE COMMISSIONER ON JUNE I OF EACH
YEAR. THE REPORT SHALL, AT A MINIMUM, DESCRIBE:
5
G YEAR;
(I)
THE OPERATIONS OF THE POOL FOR THE PRECEDING CALENDAR
7
S
(2)
A STATEMENT OF THE FINANCIAL CONDITION OF THE POOL AS OF
DECEMBER 31 OF THE PRECEDING CALENDAR YEAR; AND
9
10
(3)
A DETAILED STATEMENT OF THE REVENUES AND EXPENDITURES
OF THE POOL MADE DURING THE PRECEDING CALENDAR YEAR.
I1
12
(B;
(J)
THE COMMISSIONER SHALL REPORT TO THE GOVERNOR AND THE
GENERAL ASSEMBLY ON THE EFFECTIVENESS OF THIS SUBTITLE.
13
(2)
THE REPORT SHALL:
14
15
16
(I)
ANALYZE THE EFFECTIVENESS
OF THE SUBTITLE IN
PROMOTING RATE STABILITY, PRODUCT AVAILABILITY, AND AFFORDABILITY OF
COVERAGE;
17
IS
19
(II) CONTAIN, AS NECESSARY, RECOMMENDATIONS FOR ACTIONS
TO IMPROVE THE OVERALL EFFECTIVENESS, EFFICIENCY AND FAIRNESS OF THE
SMALL GROUP HEALTH INSURANCE MARKETPLACE;
20
21
22
(III) ADDRESS WHETHER CARRIERS AND PRODUCERS ARE FAIRLY
AND ACTIVELY MARKETING OR ISSUING HEALTH BENEFIT PLANS TO SMALL
EMPLOYERS IN FULFILLMENT OF THE PURPOSES OF THIS SUBTITLE;
23
24
(IV) CONTAIN RECOMMENDATIONS FOR MARKET CONDUCT OR
OTHER REGULATORY STANDARDS OR ACTION:
25
26
27
(V) DISCUSS THE FEASIBILITY AND DESIRABILITY OF REDUCING
THE SCOPE OF THE SUBTITLE TO EMPLOYERS WITH LESS THAN 50 ELIGIBLE
EMPLOYEES:
2S
29
30
(VI) REVIEW AND MAKE RECOMMENDAJTONS REGARDING ANY
ADJUSTMENTS IN THE RESTRICTION ON PREMIUM VARIA TIONS AS ESTABLISHED IN
S 702(A) OF THIS SUBTITLE; AND
31
(VII) CONTAIN OTHER RECOMMENDATIONS THE COMMISSIONER
32
DEEMS APPROPRIATE TO ACHIEVE THE PURPOSES OF THIS ACT.
33
711.
34
THE COMMISSIONER
SHALL ADOPT
REGULATIONS 'TO IMPLEMENT THIS
35
SUBTITLE.
36
712.
37
38
39
THE COMMISSIONER MAY IMPOSE A PENALTY OF UP TO .S500 FOR EACH
VIOLATION OF THIS SUBTITLE OR ANY REGULATION ADOPTED UNDER THIS
SUBTITLE. FOR A VIOLATION THAT IS COMMITTED WITH SUCH FREQUENCY AS 'TO
�20
SENATE HILL 349
1
INDICATE A GENERAL BUSINESS PRACTICE. THE PENALTY SHALL BE AS PROVIDED
2
UNDER 8S 12, 55, 55A. AND 215 OF THIS ARTICLE.
3
Article - Health - General
4
10-706.
5
6
(H) THE PROVISIONS OF ARTICLE 4NA. Si Ii i i l l : 55 SHALL APPLY TO HEALTH
MAINTENANCE ORGANIZATIONS.
7
19-714.
S
9
Each marketing ducumenl lhal sets torlh the heallh care services of a health
maintenance organizalion shall descrihe fully and clearly:
10
( I ) The heallh care services under each benefit package and every other
JI benefit to which a member is entitled;
12
(2)
Where and how services may be obtained;
13
(3)
Each exclusion or limitation on any service or other benefit that it
15
(4)
Each deductible feature; [and]
16
(5)
Each copayment [provision.] PROVISION; AND
17
(6)
ALL INFORMATION REQUIRED BY ARTICLE 48A, § 703(13).
14
provides;
IS
19-716.
19
20
Annually, each health maintenance organization shall provide to its members ancl
make available to lhe general public, in clear, readable, and concise form:
21
22
( I ) A summary of the most recent financial report that the health
maintenance organization submits to the Commissioner under § 19-717 of this subtitle;
2.3
24
(2) A description of lhe benefit packages available and the nongroup rates
required by the Commissioner;
25
26
(3) A description of the accessibility and availability of services, including
where and how to obtain them;
27
28
(4) A statement that shows, by category, the percentage of members assisted
by public funds; [and]
29
(5)
31) 703('C); AND
THE INFORMATION REQUIRED TO BE DISCLOSED BY ARTICLE 4SA, §
31
Any other
(6)
inlormalion lhal lhe Commissioner or the
32
requires by rule or regulalion.
33
Department
19-729.
34
55
36
(a)
under it;
A heallh maintenance organizalion may not:
( I ) Violate any provision of this subtitle or any rule or regulalion adopted
�SENATE BILL 349
21
1
(2) Fail to fuH'ill its obligations to provide the heallh care services specified
2 in its contracls with subscrihcrs;
(3) Make any false statement with respect to any report or statement
4 required by this subtitle or by the Commissioner under this subtitle;
5
(4) Advertise, merchandise, or attempt to merchandise ils services in a way
6 that misrepresents ils services or capacity for service;
7
(5) Engage in a deceptive, misleading, unfair, or unauthorized practice as to
S advertising or merchandising;
9
(h) Prevent or attempt lo prevent the Commissioner or lhe Department
Id from performing any duty imposed by this subtitle;
II
(7)
12 this subtitle:
Fraudulently oblain or fraudulently attempt to obtain any benefit under
13
Fail to fulfill the basic requirements to operate as a health maintenance
(8)
1 organization as provided in S 19-710 of this subtitle; [or]
4
15
(9)
VIOLATE ANY APPLICABLE PROVISION OF ARTICLE 48A; OR
16
(10) Fail lo provide services to a member in a timely manner as provided in §
1 19-705.1(b)(1) of this subtitle.
7
18
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect
19 July 1, 1993.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Letters to HRC from State Officials re: Health Care] [loose] [Folder 2] [1]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 36
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-036-005-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/80bc9ef53a339f1aff27bba72be0dbe0.pdf
2ae804b5a329185339422804c76e6436
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1983
FolderlD:
Folder Title:
[Letter from Joan Finney, Governor of Kansas] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
2
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
001. resume
SUBJECT/TITLE
DATE
Robert C. Harder [partial] (1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letter from Joan Finney, Governor of Kansas] [loose]
2006-0885-F
wr832
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy ((a)(6) of the PRA|
b(l) National security classified information 1(b)(1) ofthe FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIAj
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA|
b(S) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOI.\|
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�STATE OF KANSAS
O F F I C E OF THE GOVERNOR
JOAN FINNEY. Covcnwr
Slate Cmntoi 2"" Floor
Topeka. KS 66612-1590
'
923-296-3232
1-800-432-2487
* l-SOO-m-0152
FAX# (913 ) 296-7973
TDD
February 10, 1993
Ms. H i l l a r y Rodham C l i n t o n
F i r s t Lady
The White House
1600 Pennsylvania Avenue, N W
..
Washington, D.C. 20500
Dear Ms. C l i n t o n :
I was pleased w i t h the announcement by President C l i n t o n
t h a t you were going t o be responsible f o r heading up the
Administration's proposal r e l a t e d t o Health Care Reform.
I know you w i l l be g e t t i n g a l o t of pressure from many
d i f f e r e n t sides as t o what ought t o be included i n a
program or i n a reform package.
I am assuming you w i l l
have some type of advisory
committee i n v o l v i n g people from across the country. I f
t h a t i s the case, I ask that you consider Dr. Robert C.
Harder, Secretary of the Kansas Department of Health and
Environment, t o serve on such an advisory committee.
Dr. Harder has been involved i n Kansas s t a t e p o l i t i c s
since 1961. His f i r s t
involvement was as a State
Legislator.
Later he was on the personal s t a f f of
Governor Bob Docking and then became the Secretary of
Social and R e h a b i l i t a t i o n Services.
He now serves my
A d m i n i s t r a t i o n i n the capacity of Secretary of the Kansas
Department of Health and Environment.
Dr. Harder was on Governor Bob Docking's s t a f f when
Medicaid was being implemented i n the State of Kansas. He
has seen the e v o l u t i o n of the program from i t s beginning
to i t s c u r r e n t time. A d d i t i o n a l l y , he has done a l o t of
serious t h i n k i n g about what should be involved i n h e a l t h
care reform.
�Ms. H i l l a r y Rodham C l i n t o n
February 10, 1993
Page 2 of 2
I f you set up an advisory committee, I would be pleased i f
you would give consideration t o Dr. Harder as a member of
such a committee.
I am enclosing h i s resume so you or
someone on your s t a f f might have a more complete p i c t u r e
of h i s background.
I f I can be of f u r t h e r assistance please l e t me hear from
you.
I f you want t o contact Dr. Harder d i r e c t l y , please
do
so by w r i t i n g
Kansas Department
of Health and
Environment, 900 S
W Jackson, Suite 901, Topeka, KS
66612-1290 or c a l l i n g (913) 296-0461.
Sincerely yours.
*—V*-'
an Finney
JF:skb
�ROBERT C. HARDER
Education
B.A.
M.T.
Th. D.
Baker University, 1951
Perkins School of Theology, Southern Methodist University, 1954
Boston University, 1958
Professional Experience
Oct. 9, 1992
Secretary, Department of Health and Environment, State of Kansas
1991 - 1992
The Menninger Foundation, Topeka, Kansas
1989 - Present
Consultant, Mainstream Inc., (Training and Education) Topeka, Kansas
1989 - 1991
Special Assistant to the President, Baker University
1/14/1991 - 8/1/1991
Acting Secretary, Department of Social Rehabilitation Services, State of Kansas
1987 - 1989
Projects Administrator, Topeka State Hospital
1973 - July 1987
Secretary, Department of Social and Rehabilitation Services, State of Kansas
1987 -Present
Adjunct Professor, University of Kansas, Department of Public Administration
1971 -1987
Instructor, University of Kansas School of Social Welfare
1969 -1973
Director, Department of Social Welfare, State of Kansas
1968 -1969
Director, Community Resources Development, League of Kansas municipalities
1967 -1968
Technical Assistance Coordinator, Office of the Governor, State of Kansas
1965 -1967
Director, Topeka Office of Economic Opportunity
1964 -1969
Instructor, Washburn University
1964 -1965
Research Associate, The Menninger Foundation
1961 -1967
Representative, Kansas House of Representatives
1958 -1964
Pastor, East Topeka United Methodist Church
�Robert C Harder
Oreanizations
Kansas Action for Children
Kansas Committee for the Prevention of Child Abuse
Kansas Conference on Social Welfare
Kansas East Conference of United Methodist Church, Elder
Kansas State Employees Health Care Commission
American Society for Public Administration
Rotary Club of Topeka
Shawnee County Association for Mental Health
NAACP
Present/Past Board Memberships
Topeka Day-Care Association
Topeka Legal Aid Society
Topeka Association for Retarded Citizens
Topeka Boys Club
Topeka Institute on Urban Affairs
Kansas State Employment Security Review Board
Kansas Cooperative Area Manpower Committee
Statewide Health Coordinating Council
Topeka Welfare Planning Council
Board of Trustees, Baker University
Corporation for Change
East Topeka United Methodist Church/Fellowship, Inc.
Mainstream, Inc.
Kansas Commission on Children, Youth and Families
Awards
1991
1991
1989
1987
1987
1987
1987
1987
1987
1987
1987
1987
1987
1987
Employer of Excellence Honoree, Topeka, Kansas YWCA
Honorary Doctorate of Humane Letters, Ottawa University, Ottawa, Kansas
Certificate of AppreciationfromGovernor of Kansas, Mike Hayden and Secretary of Social
and Rehabilitation Services, Winston Barton for 27 years of Dedicated and Meritorious
Service to the State of Kansas
Certificate of Recognition from Governor of Kansas, Mike Hayden
Certificate of Recognition from Governor of Kansas, John Carlin
Special Commendation, Kansas Senate
Special Commendation, Kansas House of Representatives
Person of the Year, Kansas Conference on Social Welfare
Certificate of Recognition Association for Retarded Citizens of Kansas
The Outstanding Public Official of the Year Awardfromthe Association of Community
Mental Health Centers of Kansas
Certificate of Appreciation, Kansas Association of Licensed Private Child-care Agencies
Certificate of Appreciation from the Kansas Assodation of the Blind and Visually
Handicapped
Certificate of Appreciation, Kansas Advisory Committee on Hispanic Affairs
Certificate of Outstanding Service, Kansas Industries for the Blind
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. resume
DATE
SUBJECT/TITLE
n.d.
Robert C. Harder [partial] (1 page)
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letter from Joan Finney, Governor of Kansas] [loose]
2006-0885-F
wr832
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIAj
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIAj
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) ofthe FOIAj
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIAj
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) ofthe FOIA]
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) ofthe PRA|
Release would violate a Federal statute 1(a)(3) ofthe PRA]
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA)
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Robert C Harder
(co\
Awards (continued)
1986
1983
1983
1983
1982
1981
1980
1978
1965
1965
1963
Certificate of Appreciation, The Kansas Association for the Education of Young ChUdren
Honorary Doctorate of Humane Letters, Baker University, Baldwin City, Kansas
Certificate of Appreciation, Kansas Neurological Institute
Certificate of Appreciation, Kansas Chapter of the Harvest America Corporation
Certificate of Appreciation Indo Chinese Refugees in the State of Kansas
Certificate of Appreciation, Kickapoo Tribal Council
Public Administrator of the Year, Kansas Chapter of the American Society for Public
Administration
Distinguished Service Award, State of Kansas, Governor Robert Bennett
Romana Hood Award for Outstanding Services in Sodal Service in Topeka, Kansas
Man of the Year in Religion in Kansas, Midway Magazine and Topeka Capital Journal
Distinguished Service Award, East Topeka Civic Assodation
Personal
Date of Birth:
Place of Birth:
Married:
Dorothy Lou Welty, 1953
Two children • Anne and James David
�HEALTH CARE TASK FORCE SORTING SHEET
CODER:_
INPUT DATE:
GENERAT, SORT:
POSTCARD 1:
General mail
Personal stories
.Letter Campaign
Other Health Providers
POSTCARD 2:
FORM LETTER:
REROUTE:
Offers to help/Employment
\/Letterhead
Casework
Policy
Physicians
Scheduling
President
Other
POLICY AND PERSONAL STORTES:
.ORGANIZATION (I)
insurance premiums
insurance reform
insurance pools
boards and oversight
.COVERAGE (H)
working families
unemployed/low income
.benefits
.providers
INFRASTRUCTUREAVORKFORCE (HI)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
.manpower issues (training)
.unnecessary procedures
.GOVERNMENT PROGRAMS (IV)
medicare
medicaid
.veterans
_DoD
Indian health
.COST ISSUES (VI)
drug prices
physician fees
.hospital fees
.medical equipment
fraud & abuse
FINANCING (VH)
MENTAL HEALTH (IX)
LONG-TERM CARE (X)
.PUBLIC HEALTH/
SPECIAL POPULATIONS (XH)
prevention
AIDS
women's health
.immunizations/children
rural
urban
OTHER
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Letter from Joan Cassidy, Governor of Kansas] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 36
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-036-004-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/6bdf01cdf05615a9513c42d8d9370c58.pdf
72910e52db7ec029a4d584ac6430cfab
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1983
FolderlD:
Folder Title:
[Letters from Government Officials and Employees] [loose] [6]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
2
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. list
Commissioner Data Info [partial] (4 pages)
1/22/1993
P6/b(6)
002a. letter
Thomas Reynolds to Hillary Clinton [partial] (2 pages)
3/2/1993
P6/b(6)
002b. letter
Constituent to Thomas Reynolds, re: terminal disease (2 pages)
n.d.
P6/b(6)
003. business card
Theresa Ouellette [partial] (1 page)
n.d.
P6/b(6)
004. letter
Theresa Ouellette to President Clinton [partial] (1 page)
2/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [6]
2006-0885-F
vvr829
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA|
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA]
b(l) National security classified information ((b)(1) ofthe FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIAj
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIAj
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�STATE OF MISSISSIPPI
OFFICE OF THE ATTORNEY GENERAL
MIKE MOORE .
ATTORNEY GENERAL
6
January 28, 1993
The Honorable Albert Gore
Vice-President of the United States
Office of the Vice-President
Old Executive Office Building, Room 272
Washington, D.C. 20501
Dear Mr. Vice-Presidentt
I hope the f i r s t week has been as productive for you i n
Washington as i t has been exciting for us to watch. I appreciate
very much how busy you are, especially during these f i r s t days i n
o f f i c e . I would hope that you can help us with a very special
potential problem.
President Bush appointed a special commission i n November,
as authorized by Congress, to develop "Model State Drug Laws."
This i s a bi-partisan commission which includes many Clinton-Gore
supporters, such as Attorney
General Richard
leyoub from
Louisiana and myself.
Hearings have been scheduled across
America, task forces on criminal j u s t i c e i n i t i a t i v e s , treatment,
prevention, education, community mobilization, and the l i k e have
been working for the l a s t three months. Our f i r s t hearing was i n
San Diego, our most recent was i n Detroit yesterday.
The week
prior to
the Detroit hearing was f u l l of
understandable "transitional" confusion.
The Executive Director
for the Commission was fired along with other s t a f f people who
a l l have been very diligent i n t h i s important bi-partisan e f f o r t .
The Executive Director i s back aboard v i a m m from John Walters,
eo
who appears to be i n command at ONDCP. Though the future of the
Commission appears solid, i t would re-ignite the energy of t h i s
group of dedicated professionals to know we have the confidence
and approval of the new administration.
I would suggest that a small group from the Commission meet
with you or your designee or someone President Clinton would
assign.
We could quickly explain our mission, make sure i t
CARROLL CARTIN JUSTICE BUILDING • POST OFFICE BOX 220 • JACKSON, MISSISSIPPI 392050220
TELEPHONE (601) 359-3680 • TELEFAX (601) 359-3796
�Vice-President Gore
January 28, 1993
Page 2
compliments the new administration's plans and
towards a drug free America.
continue our work
Knowing you as I do, I know you are committed to a
healthier, safer America. I would hope you could give me some
direction on the future of this Commission. I have enclosed a
l i s t of the Commissioners and a copy of
the legislation
authorizing i t , for your convenience.
I feel that t h i s Commission's work i s important, and that
the f i n a l product w i l l be invaluable to the 50 states.
I am
v i t a l l y interested i n our nation's drug problem and think the
Commission's work may
suggest a more uniform and organized
approach.
A l l my best wishes for your continued
success.
nd yours.
Mike Moore
Attorney General
MM/nke
Enclosures
cc: Roy Neal, Esquire, Chief of Staff
Jeffery Watson, Esquire, Deputy Assistant to the President
on Intergovernmental Affairs
Carol Rasco, Esquire, Office of Domestic P o l i c y / ^ "
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. list
SUBJECT/TITLE
DATE
Commissioner Data Info [partial] (4 pages)
1/22/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [6]
2006-0885-F
wr829
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) ofthe PRA|
P2 Relating to the appointment to Federal office 1(a)(2) ofthe PRA]
P3 Release would violate a Federal statute 1(a)(3) ofthe PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA)
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) ofthe PRA)
b(l) National security classified information 1(b)(1) ofthe FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information |(bK4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) ofthe FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�1/22/93
. Kant B.
,
Urban Family Institute
1400 16th 8tr«»t, W
H
8t«. 302
WajhAngten, D 20036-2266
C
(H) mmimmmsm,
{O)T02
FAX 202-939-3492
-939-3490
Staff Contacti
Courtney Byrd
Professional: Alno C. Caxtar
Taak Forest Drug-Free faadlies
L.
State Capitol
Juneau,
99801
(0) 907-465-3431
FAX 907-465-4565
Staff Contaot: Admin:
Ben Orenn
Prgfesaional: Eleanor Roser
Taak Force: Soonoaio Beaedies
WW w w w w w w w w w w
W w w w w w
Rhonda Butterfield
Asst. A ef Alaska
G
1031 W 4th Ave., #200
.
Anohorage, AX 99S01
(0) 907-269-4170
FAX 907-279-5832
BalpkB.
McDonald, Brown ft
Fagen
502 15th Street
Dallas Center, U, 50063
(0) 515-992-3728
FAX 515-992-3971
Staff Contact: Adain: Sharon Priee
Professional:
Task Foroe: Coammlty Moblliiatlon
Batler. Bar, telth jk.
(6} 313-224-1337
rJUE 313-224-1377
Staff Contaot:
Admin: Verllnda
Hallaos
Professional: Andrea Harris
Task Force: Coanmity Hobilixatlon
CaatHlc Ronald D.
Reed, Smith, Shaw & UoClay
2500 One Liberty Place
Philadelphia, P 19103-7301
A
(Hfeflll^)fe ,
OT
(O) 215-241-7990/91/92
FAX 215-851-1420
Staff Contaot: Admin: Susan Meyer
Profeaoienal: •
Taak Foroe: Crimes Code
•
r
— Kay B.
M State Senate
B
400 High Street
Jackson, M 3MQ1
S
(H) ^: ^(bX6>:/. ;ii
(0) 601-359-3237
PAX 601-359-3935
Staff Contaot: Artnrln: Svelyn Garner
Professional:
Task Foroe: Beeacaio Raaedies, Chair
Colettt, Shlrlsqr D.
Operation PAR, Zno.
10901-C Booeevelt Blvd. #1000
St. Petershnro. FL 33716
(H)L__
(0) 813-570-5060
FAX 813-570-5083
Staff Contaot: Adaln: Sua Piatt
Professional: Arnold Andrews
Taak Foroe: Treatment, chair
�Dooghtty, Syl\
Polio* Chief
300 West Haahington St.
Cr^^rii.
27402
(0) 919-373-2450
FAX 919-373-2266
Staff Contact: Adaini Hanoy triaraaa
Frofeaaional: Capt. Anthony Soalaa
Taak Forco: Criaiaa Coda, Chair
! David A.
,
Winatead, Soohreat
& Miniek, P.C.
5400 kenalasanee Tower
1201 Ela St.
Dallaa, TX 75270
(0) 310*603-7727
FAX 310-639-8724
Staff Contact:
Professional:
Adain: Jim MoOlynn
Taak Foroe: Drug-Free Families
Xeyaab, Xiohard
BUte Capitol Bldg.
22nd Floor
P.O. Bos 94005
Baton Afmao, LA 7.0804
(K) mmmmmmm
FAX 504-342-8703
(0) 214-745-5232
FAX 214-745-5390
Staff Contact: Adain: Celeste Karton
Professional: Rider Scott
Task Foroe: Coaanmity Kobilization
Staff Contaot: Admini Jan wilbuxn
Professional: Jack Yelverton
Task Force: Crimea Coda
<lolda^.th, Boaorable
of Tiyttanapolls
2501 City-County Bldg.
200 8. Washington St.
indianaMliM. IB 46208
(H)r
(0)317-327-7977'
Chicago Housing Authority
22 W. Madison Street
Chicago p IL 60602
(H)jr^
FAX 312-791-4601
FAX 317-327-3980
Staff Contaot: Adain: Deborah Brown
Professional: Reginald O'Connor
Taak Foroe: Treatment
Staff Contact: Adain: Singer Hall
Profaseional: John Hatfield
Task Force: Vice-Chair of Conission
Lungzcn, Daniel X.
Belt, Daniel B.
Ahraxaa Foiudation, Zno.
Two Oliver Plasa, #2300
Pittataurofa. P 18222
A
(H)
(0)
PAX 412-562-9406
Staff Contaot: Adain: Vanessa Kramer
Professional:
Task Forco: Treatment
Office of the Atty. Oen.
1515 X Street, #611
6a<3£saaatft _QA__i$8l4
J
i
H
' _
(Or 915.32^5137
FAX 916-324-6734
staff Contaot: Adain:
Johnnie Perkins
Professional:
Task Foroe: Econonic Remedies
�Diyfcrtot Xttoiusf
7th Judloial Oiatriot
320ftobart8. Karr Ava.
Rm. 518
Oklahoaa City.
73102
(0) 405-278-1632
FAX 405-235-1567
Staff Contaot: Adain: Dana Holland
Profoaaional: Richard Wintory
Taak Foroe: Drua-Free Families
r, Heotor
MeQeachy & Hudson
138 Dick Street
Fayetteville. SC 28302
(Hj^^^P^gl
FAX 919-323-9465
Staff Contact: Adain: Linda Griffin
Professional: Donald Hudson
Task Force: Treataent
Millar. XAfla L.
DLstxlot Attorney
Baa Diego County
101 W Broadway, Ra. 1440
.
San Diego, CA 92101
(H)
(O) (619) 531-3522
FAX 619-237-1351
Staff Contact: Adain: Qayle Rolan
Professional: Bill Holaan/223'>e501
Taak Force: Economic Remedies
O'Hair, John D.
Wsyna Coonty Proaeeator
1441 St. Antoine Street
Detroit. MI 46226
(K
(Oi a i A - i i k - i i n
FAX 313-224-0974
Staff Contaot: Attain: Carol May
Professional: Andrea Solak
Taak Foroe: Cooannity Mobilization,
Chair
O'Malley, Jack K.
Stata'a Attorney
Cook County
Daley Center, Ra. 500
Chicago. IL 60602
FAX 312-443-4708
Staff Contact: Adain: Elaine Bielik
Professional: Donald Kixerk
Taak Force: Crimae Code
(0) 801-799-3802
FAX 801-799-3640
Staff Contaot: Adain:
Professional: Lt. M o Connole
a
Taak Foroe: Crimea Code
Jr. Robert T,
ThonpaoaftAssooiatee
2970 Peaohtree Rd., W , #500
H
AUanta. O 30303
A
(H)
FAX 404-816-9115
Staff Contaot: Adain: Leigh Garner
Professional: Dr. Dennis Salty
Direotor, Policy Analysis
SC CeOBisslon on Alcohol ft
Drag Abuse
3700 Forest Dr.
Columbia, SC 29204
(0) 803-734-9577
(F) 803-734-9663
Task Foroe:
Drug-Fzee Families,
Chair
�Xalth X. KaaeaUxo
ProMoatlng JlttorMy
City and County of Honolulu
1060 Richards St., 10th F l .
Honolulu, iff 96013
(H)
FAX 606-627-6831
Staff Contact: Adain: Lynn Nishiki
Profoaaional: Carol Senaga
Task Force: SoonoBic Raaedies
Kike Moor*
Attorney Qaoaeal
Office of the Attorney General
450 High St., 5th Fl.
Jackson. MB
39201
(0) 601-359-3692
FAX 601-359-3441
Staff Contact: Atelnt Hanoy last
Professional: Jla H o od.
Task Force: Drug-Free Faaillea
�102 STAT. 4508
PUBLIC LAW 100-690-NOV. 18, 1988
(c) DISCLOSURE OF RETURN INFORMATION.—Section 6103(d) of the
Internal Revenue Code of 1986 (relating to disclosure to State tat
officiaJs) is amended by adding at the end the following new para,
graph:
"(3)
EXCEPTION
FOR REIMBURSEMENT
UNDER
SECTION
7624.^
Nothing in this section shall be construed to prevent the Secretary from disclosing to any State or local law enforcetaent
agency which may receive a payment under section 7624 the
amount of the recovered taxes with respect to which such a
payment may be made."
(d) CONFORMING AMENDMENTS.—
(1) The table of sections for subchapter B of chapter 78 of the
Internal Revenue Code of 1986 is amended by adding at the end
thereof the following new item:
'7624. Reimbursement to State and local law enforcement agencies.".
(2) The heading for section 6103(d) of the Internal Revenue
Code of 1986 is amended to read as follows:
26 USC 6103
note.
26 USC 7809
note.
26 USC 7624
note.
Y
"(d) DISCLOSURE TO STATE TAX OFFICIALS AND STATE AND LOCAL
LAW ENFORCEMENT AGENCIES.".
(e) EFFECTIVE DATE.—The amendments made by this section shall
apply to information first provided more than 90 days after the date
of the enactment of this Act.
(f) AUTHORIZATION OF APPROPRIATIONS.—There is authorized to be
appropriatedfromthe account referred to in section 7809(d) of the
Internal Revenue Code of 1986 such sums as may be necessary to
make the payments authorized by section 7624 of such Code.
(g) REGULATIONS.—The Secretary of the Treasury shall, not later
than 90 days after the date of enactment of this Act, prescribe such
rules and regulations as shall be necessary and proper to carry out
the provisions of this section, including regulations relating to the
definition of information which substantially contributes to the
recovery of Federal taxes and the substantiation of expenses required in order to receive a reimbursement.
y.:
S E C 7603. DEFINITION FOR MAIL FRAUD CHAPTER OF TITLE 18. UNITED
STATES CODE.
(a) IN GENERAL.—Chapter 63 of title 18 of the United States Code
is amended by adding at the end the following:
"§ 1346. Definition of 'scheme or artifice to defraud'
"For the purposes of this chapter, the term 'scheme or artifice to
defraud' includes a scheme or artifice to deprive another of the
intangiblerightof honest services.".
(b) CLERICAL AMENDMENT.—The table of sections at the beginning
of chapter 63 of title 18, United States Code, is amended by adding
at the end the following:
"1346. Definition of'scheme or artifice to defraud'.".
I
National
Commission on
Measured
Responses to
Achieve a DrugFree America
by 1995
Authorization
Act.
21 USC 1502
note.
Establishment.
SEC. 7604. NATIONAL COMMISSION ON MEASURED RESPONSES TO
ACHIEVE A DRUG-FREE AMERICA BY 1995 AUTHORIZATION
ACT.
(a) SHORT Tmi.—This section may be cited as the "National
Commission on Measured Responses to Achieve a Drug-Free America by 1995 Authorization Act .
(b) COMMISSION.—(1) There is hereby established a Commission to
be chaired by the Director of the Office of National Drug Control
�r u c b i C UAW iUU-byu—iNOV. 18, 1988
tifice to
- of the
ginning
' adding
SES TO
IZATION
lational
i Amerssion to
Control
••.«^iL
102 STAT. 4509
Policy and consisting of 24 members appointed by the President
within 120 days of the date of enactment of this section. Not more
than one-half ofthe members of the Commission may be members of
one political party. The members of the Commission shall include—
(A) State and local law enforcement officers;
(B) Attorneys General and District Attorneys;
(C) State and local elected officials;
(D) experts in the fields of drug abuse prevention, treatment,
education, and law enforcement; and
(E) other appropriate individuals as determined by the
President.
(2) The term of the Commission shall expire 6 months following
the date of appointment of the members thereof.
(c) DUTIES OF THE COMMISSION.—The Commission is established to
develop a proposed uniform code of State laws that represent measured responses to achieve a Drug-Free America by 1995. Among the
types of measured responses that the Commission should consider
are—
(1) appropriate penalties for drug offenses;
(2) participation in rehabilitation and treatment programs;
(3) appropriate use of drug testing;
(4) efforts to educate the public on the dangers of drug abuse
as a means of reducing demand;
(5) forfeiture of assets of violators of State drug laws;
(6) cooperative ventures among the Federal, State, and local
levels;
(7) methods to interdict illegal drugs at our borders, eradicate
crops of illegal drugs, and cease the manufacture of illegal
drugs; and
(8) other means of preventing drug abuse.
(d) REPORT OF COMMISSION.—Within 6 months after the date of the State and local
appointment of its members, the Commission shall submit its pro- governments.
posed uniform code to the Governors of the 50 States and the Mayor
of the District of Columbia.
(e) VACANCIES.—A vacancy in the Commission shall be filled in
the same manner as the original appointment was made. A vacancy
in the Commission shall not affect the powers of the Commission.
(f) QUORUM.—Fourteen members of the Commission shall constitute a quorum, but a lesser number may hold hearings.
(g) COMPENSATION.—(1) Each member of the Commission who is
not an officer or employee of the United States shall be compensated
at a rate established by the Commission not to exceed the daily
equivalent of the annuad rate of basic pay prescribed for grade GSr18 of the General Schedule under section 5332 of title 5, United
States Code, for each day (including travel time) during which such
member is engaged in the actual performance of duties as a member
of the Commission. Each member of the Commission who is an
officer or employee of the United States shall receive no additional
compensation for service on the Commission.
(2) While away from their homes or regular places of business in
the performance of duties for the Commission, all members of the
Commission shall be allowed travel expenses, including per diem in
lieu of subsistence, at a rate established by the Commission not to
exceed the rates authorized for employees of agencies under sections
5702 and 5703 of title 5, United States Code.
(h) ADMINISTRATIVE PROVISIONS.—(1) The Commission shall ap-
point an Executive Director who shall be compensated at a rate
i i-
' i .-
�102 STAT. 4510
Mail.
PUBLIC LAW 100-690—NOV. 18, 1988
established by the Commission not to exceed the rate of basic pay
prescribed for level V of the Executive Schedule under section 5316
of title 5, United States Code.
(2) With the approval of the Commission, the Executive Director
may appoint and fix the compensation of such additional personnel
as the Executive Director considers necessary to carry out the duties
of the Commission.
(3) Subject to such rules as may be issued by the Commission, the
chairman may procure temporary and intermittent services of experts and consultants.
(4) The Commission may use the United States mails in the same
manner and under the same conditions as other departments and
agencies of the United States.
(5) Service of an individual as a member of the Commission, or
employment of an individual by the Commission as an attorney or
expert in any business or professional field, on a part-time or fulltime basis, with or without compensation, shall not be considered as
service or employment bringing such individual within the provisions of any Federal law relating to conflicts of interest or otherwise
imposing restrictions, requirements, or penalties in relation to the
employment of persons, the performance of services, or the payment
or receipt of compensation in connection with claims, proceedings,
or matters involving the United States. Service as a member of the
Commission, or as an employee of the Commission, shall not be
considered service in an appointive or elective position in the
Government for purposes of section 8344 of title 5, United States
Code, or comparable provisions of Federal law.
(1) POWERS OP COMMISSION.—(1) For the purpose of carrying out
this section, the Commission may hold such hearings, sit and act at
such times and places, take such testimony, and receive such evidence, as the Commission considers appropriate. The Commission
may administer oaths or affirmations to witnesses appearing before
the Commission.
(2) Any member or employee of the Commission may, if authorized
by the Commission, take any action which the Commission is authorized to take by this subsection.
(j) SENSE OF THE CONGRESS ON STATE CONFERENCES.—It is the sense
of the Congress that the Governors of the 50 States and the Mayor of
the District of Columbia should convene State conferences for a
Drug-Free America by 1995. These conferences should include attorneys general, district attorneys, mayors, other elected officials, law
enforcement officials, educators, drug prevention and treatment
experts, iind other interested parties. The State conferences should
consider the proposed uniform code described in subsection (c) and
make recommendations thereon.
(k) AVAILABILITY OF FUNDS.—There are hereby authorized to be
appropriated such sums as may be necessary to carry out the
provisions of this section, and they shall remain available for the
term of the Commission. New spending authority or authority to
enter contracts as provided in this section shall be effective only to
such extent and in such amounts as are provided in advance in
appropriation Acts.
SEC. 7605. USE OF EXISTING FEDERAL RESEARCH AND DEVELOPMENT
FACILITIES FOR CIVILIAN LAW ENFORCEMENT.
President of U.S.
(a) COMPREHENSIVE PLAN.—The President of the United States
shall direct the Office of National Drug Control Policy, established
•-••t
�MIKE MOORE
ATTORNEY GENERAL
STATE OF MISSISSIPPI
POST OFFICE BOX 220
JACKSON, MISSISSIPPI 39205
C a r o l Rasco, Esquire
O f f i c e o f Domestic P o l i c y
The White House
"Washington, D.C. 20500
11i
,.
j Ui ll n, il
!
!!i
!
i
i
�CODER t/
HEALTH CAKE TASK FORCE SORTING SHEET
INPUT DATE:
GENERAL SORT:
POSTCARD 1:
General mail
Personal stories
.Letter Campaign
Other Health Providers
POSTCARD 2:
Offers to help/Employment
FORM LETTER:
Letterhead
REROUTE:
Casework
_Policy
.Physicians
v3*
J
Ji
Scheduling
President
Other
POUCY AND PERSON AT, STORTES:
.ORGANIZATION (I)
insurance premiums
insurance reform
insurance pools
boards and oversight
.COVERAGE (II)
working families
unemployed/low income
benefits
providers
.INFRASTRUCTURE/WORKFORCE (IH)
quality assurance (guidelines)
administration, reimbursement
& information systems
^malpractice & tort reform
manpower issues (training)
.unnecessary procedures
.GOVERNMENT PROGRAMS (IV)
medicare
medicaid
veterans
DoD
Indian health
_COST ISSUES (VI)
drug prices
physician fees
hospital fees
medical equipment
fraud & abuse
.FINANCING (VH)
.MENTAL HEALTH (IX)
.LONG-TERM CARE (X)
PUBLIC HEALTH/
SPECIAL POPULATIONS (XH)
prevention
_AIDS
women's health
immunizations/children
.rural
urban
OTHER
�JOHN GARAMENDI
Snsunmre (HommiaaionEr
February 16, 1993
Ms. Hillary Rodham-Clinton
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Hillary:
On February 14, I spoke to the Executive Council of the APL-CIO at their annual
meeting in Bal Harbor, Florida. My talk focused on the concepts that we have
developed. There was intense questioning. A short time after I departed the room, a
new policy resolution was passed that closely tracks your program.
It is clear that the labor movement can be a strong ally and advocate for your
legislation. I strongly recommend that you establish good working relationship with their
key health care leaders and that you give consideration to several of their concerns.
Their health care leaders are :
Lane Kirkland
President, AFL-CIO
- looking for change and wants strong cost control.
- will accept 24 hour care in exchange for universal single
collector and cost control.
John Sweeney
President, SEIU.
- key labor leader on health
- strong supporter of your plan but opposed to taxing health
benefits.
Owen Bieber
President, UAW
- likes the 24 hour concept and our program.
- concerned about retirees' health care benefits and its
impact on the big 3 auto makers.
- If retirees are properly handled in the legislation he can
forge a coalition of support between the UAW to the auto
makers.
FORTY-FIVE FREMONT STREET, TWENTY-THIRD FLOOR
SAN FRANCISCO, CALIFORNIA 94105
PHONE: (415) 904-5410
FACSIMILE: (415) 904-5889
�February 16, 1993
Page Two
Jerrv McEntee
President, AFSCME
- generally supportive of the plan.
- The taxation of health benefits is a problem.
George Koupias
Machinist
- generally supportive.
- concerned about health care costs and Workers's Comp.
costs on jobs in his sector.
Jack Sheinkman
Garment workers
- likes single collector for tax based system.
- will support 24 hour with reservations.
Gene Upshaw
NFL Players Association
- has 2,000 retired players who can not get health insurance
because of injuries.
- A good source of big name players who could demonstrate
the problem of health care.
Bill Wvnn
UFCW
- strong support in the west.
- He's okay with the concepts.
Hillary, you can build a powerful alliance with labor and mainline American
business. I suggest the following strategy:
1.
Meet privately with Kirkland, Sweeney and the others listed above. Ask
Kirkland to set the list of those he wants to attend.
2.
Ask for their support and gather information on what they want in the
legislation.
3.
Listen, but no promises on policy.
4.
Offer to work closely with Karen Ignatti. She is their health policy person.
Very sharp and supportive of your program.
5.
After meeting with labor, ask them to set up meetings with key businesses.
I'd be happy to facilitate or attend the meetings. Call if you need me.
John Garamendi
JG:bg
�7
JOHN WAIHEE
l-:\S»CijSBlgA-. '
GOVERNOR OF HAWAII
l''
' v i - v 8 W K S ^ ' V
STATE
OF HAWAII
DEPARTMENT O F
P. O.
HONOLULU,
C
J
•'
i '-'d ^ \
/
0
H
N
C
-
L E W I N
'
M
0
- -
DIRECTOR OF HEALTH
.\ \
HEALTH
BOX 3 3 7 8
HAWAII
96801
February 12, 1993
\
\J
^
In reply, please refer to:
File:
D HA
DR
Ms. Hillary Rodham Clinton
Chair, President's Health Care Task Force
Executive Office of the President
1600 Pennsylvania Avenue, N.W.
Washington, D.C. 20500
Dear Ms. Clinton:
I am writing to follow up a call by Mr. Atul Gawande requesting information on
the background behind legislation which effected Hawaii's health care system. I am
enclosing for your review a copy of pages from The Aloha Way: Health Care Structure
and Finance in Hawaii by Emily Friedman, a recent publication which outlines the
history of the development of our system. These are the most important pages outlining
the development of Prepaid Health Care and our State Health Insurance Program
(SHIP). We are sending the whole book by separate cover. While the Friedman book
provides the detail I hope will be beneficial to you, I'd like to add several observations:
1.
Both of these major innovations (Prepaid Health Care and SHIP) were
effected into law not so much by an overwhelming community consensus prior to
enactment, but rather because of people (the ILWU and Democratic legislators in
the case of Prepaid Health Care; Governor John Waihee in the case of SHIP)
who were strongly motivated with a vision. They managed to communicate and
convince the large body of people that this vision was not only good but that it
was also doable. In both cases, the large body of antagonistic or apathetic interest
groups/individuals were won over by the force and the effort flowing from a
vision.
2.
Once a vision was accepted and the law enacted, the actors worked
together to effect the innovation, not to block it. Resistance was channeled into
"making the thing work." It must be noted the compliance and active support
from groups that had previously been apathetic or opposed was vital to the
effective implementation of these changes.
3.
While there maybe some disagreement about the specific benefits of the
policy changes, few in our community (perhaps small business is an exception)
would argue that no benefit came from these activities. As I hope you recognized
�Ms. Hillary Rodham Clinton
February 12, 1993
Page 2
on your trip here, there is a consensus that the system works. Even though
resistance to the enactment of legislation existed early on, those very bodies which
resisted are now supportive and recognize the benefit of the change that was
made.
How does all of this factor into health care reform for the nation? I'm sure you
will hear arguments, many of them from important policy analysts, that Hawaii's
experience is unique, but frankly I think our experience shows that health care reform
can be carried out effectively despite opposition. Consensus can be achieved especially if
a clear and positive vision is present and concerted action is taken to achieve that vision.
I believe that this vision can be put together for America. I feel Americans
throughout the country are generally optimistic about what truly can be attained through
health care reform. We in Hawaii look forward to assisting in any way we might with
this critical project.
ry truly yours,
fOHN C. LEWIN, M.D.
tctor of Health
Enclosure
�/ \
-. ' t i / '
JOHN C. LEWIN. M.D.
JOHN WAIHEE
G O V E R N O R OF
D I R E C T O R OF
HEALTH
HAWAII
STATE
OF
HAWAII
DEPARTMENT O F HEALTH
P. O. BOX 3378
HONOLULU. HAWAII 96801
In
reply,
please
File:
March 4 ,
refer
HPEB
1993
Ms. H i l l a r y Rodham C l i n t o n
The White House
Washington, D.C.
2050Q
Dear Ms. C l i n t o n
On b e h a l f o f t h e Hawaii Department o f H e a l t h and t h e people o f
our s t a t e , mahalo f o r making t h e White House smoke-free.
I n 1991, 1,118 people d i e d i n Hawaii n e e d l e s s l y as a r e s u l t o f
s m o k i n g - r e l a t e d i l l n e s s . The impact o f tobacco smoking c o s t our
s t a t e economy $229.5 m i l l i o n i n 1991. These f i g u r e s f o r Hawaii
c o n t r i b u t e t o t h e $65 b i l l i o n i n t o t a l economic impact and
434,000 l i v e s l o s t from smoking across our n a t i o n . Your
c o n t i n u i n g s u p p o r t i s c r u c i a l t o our success i n moving toward a
smoke-free s o c i e t y .
As D i r e c t o r o f H e a l t h and p a s t p r e s i d e n t o f t h e A s s o c i a t i o n o f
S t a t e and T e r r i t o r i a l H e a l t h O f f i c i a l s , I look f o r w a r d t o f u t u r e
p r o - h e a l t h measures from t h e White House. We s t a n d ready t o
a s s i s t you i n any ^ y we can.
Very t r u l y
JOHN C. LEWIJ«,
Director of
to:
�Department of Health
Administration
State of Wyoming
Mike Sullivan,
M a r c h 9,
1993
REF:
Governor
S-93-091
H i l l a r y Rodham C l i n t o n
The White House
1600 Pennsylvania Avenue
Washington, D. C. 20500
Dear Mrs.
1
•i ! ! '
': Il'l:.
Clinton:
The Wyoming Department of Health s t r o n g l y supports a s u b s t a n t i a l
increase i n the Federal excise tax on tobacco from the c u r r e n t 24*
per pack t o a t l e a s t $2.00. N a t i o n a l l y , t h i s t a x would reduce
tobacco consumption by 22%, e v e n t u a l l y saving 2 m i l l i o n l i v e s . I n
a d d i t i o n , i t would r a i s e $35 b i l l i o n annually while reducing
expenditures o f h e a l t h care d o l l a r s now spent t o t r e a t tobacco
r e l a t e d disease. I t would also b r i n g U S . tobacco taxes i n l i n e
..
w i t h those o f other i n d u s t r i a l i z e d nations.
Cigarette smoking i s the leading cause o f preventable death i n the
U.S. .and i n Wyoming as w e l l . A recent analysis we performed on
] ' . ' < 1 9 9 1 Wypming .data found t h a t one i n every f i v e Wyoming deaths t h a t
pltiV- y
was-./tobacco r e l a t e d .
Economically, c i g a r e t t e smoking cost
i
Wyoming r e s i d e n t s $110 m i l l i o n i n h e a l t h care costs and l o s t
p r o d u c t i v i t y i n 1991, o r about $2.20 f o r every pack o f c i g a r e t t e s
sold.
;
e a r
The tobacco i n d u s t r y argues t h a t t h i s t a x w i l l h i t lower-income
groups harder than others because lower-income groups smoke more.
Our p o s i t i o n i s t h a t lower-income groups are also the l e a s t l i k e l y
to a f f o r d . t h e .extra, medical care,expenses caused by a r t i f i c i a l l y
. low c i g a r e t t e p r i c e s .
I t does not make sense t o keep c i g a r e t t e
p r i c e s low so t h a t poor people can smoke more and i n c u r more
smoking-related h e a l t h care costs, i l l n e s s , d i s a b i l i t y , and death.
:
The biggest b e n e f i t o f t h i s .$2/pack proposal i s the e f f e c t i t w i l l
j . h a v e on p r o t e c t i n g c h i l d r e n . The consumption patterns of c h i l d r e n ,
who o f t e n are less addicted and have less disposable income, are
much more s e n s i t i v e t o p r i c e change than a d u l t consumption
j
p a t t e r n s . • Children consuming less tobacco, we believe, w i l l r e s u l t
i n fewer people a c q u i r i n g a l i f e - l o n g n i c o t i n e a d d i c t i o n .
:••,)':
.,VS5-i., —
w
* • 'A V.l :-• •
117 Hathaway Building • Cheyenne, WY 82002
(307)777-7656 .. FAX: (307) 777-7439
�F i n a l l y , the t e r r i b l e problem of what t o do w i t h 35 b i l l i o n e x t r a
f e d e r a l d o l l a r s . Reducing the d e f i c i t and h e a l t h care reform are
top p r i o r i t i e s f o r most people. I n a d d i t i o n t o these, we would
suggest a t l e a s t a small p o r t i o n go back t o states t o help s t a t e s
provide assistance t o the large number of smokers who want t o q u i t
smoking and also t o help states prevent tobacco use i n young
people.
:
]
S'- M'< Sincerely,
111—.
Menlo Futa, Manager
Health Risk Reduction Program
• Jane Sabes
'
•
-Director
•f
lilt- •
mi- • .
m-
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' r. !: '
•
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f
Minnesota
House of
Representatives
Karen Clark
State Representative
District 60A
Minneapolis
vJ^J
,
.iO-v-.-.iss.ij tt^:- i-.-
t s ^ '
ly^i-U.
State Ottice Building. St. Paul. Minnesota 55155
House Fax (612) 296-1563
(612) 296-029
�^
^(X^
^
�State Representative
Karen Clark
District 61A
February^ 1993
Dear President Clinton,
I'm writing to offer your Economic, Health Care, and Environmental Teams the benefit of
information about two dynamic job creation initiatives from Minnesota. They link policy
concerns in all three areas, particularly for urban revitalization efforts. I hope they may
serve as models for your Economic Recovery Team to consider on a national scale:
1) The Minnesota Model for Economic Conversion and supporting documents I offer to
you as Chair of the Minnesota Economic Conversion Task Force for the last 7 years.
2) The Minnesota Model for doing lead-abatement of housing also creates a major publicworks program for residents of affected neighborhoods. I offer this to you bothh as the
chief author of Minnesota's 1992 Toxic Lead Clean-up Bill and as the one state legislator
selected by the National Conference of State Legislatures in 1992 to serve on FOSTTA (the
Forum on State and Tribal Toxics) which advices the EPA.
Each initiative stands alone. Both could also be linked in your administration to create a
powerful, community-based economic recovery tool that matches environmental concerns
with the economy.-particularly in major urban settings. The lead-abatement initiative also
addresses the number one environmental health problem on the children's agenda-childhood lead poisoning.
Each initiative contains unique elements of real community participation in both planning and implementation phases. They require community re-investment that could
strengthen and stabilize at-risk neighborhoods and their residents, creating jobs that stay
there as a matter of public policy. As a result, both physical and human infrastructure are
rebuilt.
Thank you for your attention to this information. I am willing to work with you, your
economic recovery and health care reform teams, or whoever the appropriate persons are
that you designate and provide further details.
Sincerely,
Rep. Karen Clark
�Community-Based Economic Conversion/
Diversification
A unique feature of the Minnesota Model Economic Conversion initiative is the requirement that all three affected parties-I)owners or management of a defense-dependent
company, 2) labor, whether organized or not, and 3) representatives of the community
which is economically damaged by the loss of defense-related jobs and tax base-must come
to the planning table before economic assistance dollars would be allowed to flow. Most
other recent models for economic conversion or diversification leave out the community
partner-thereby allowing companies to demand and receive economic development or
diversification incentives without any loyalty to the specific dislocated workers or community that has become economically dependent on them, built infrastructure to accommodate them, given them previous tax incentives, or located schools and other community
facilities around them.
In Minnesota we studied and documented our military economic dependency county-bycounty and set our priorities accordingly. That could be done on a nation-wide basis using
the computer modeling we designed. We worked with a number of nationally known leaders
as we created our model, including Marion Anderson, with whom I understand you have
also consulted and with Ann Markuson who participated in your Economic Summit. Feel
free to contact either or both of them as a reference.
President Clinton, I previously sent this information to you through my U.S. Senator, Paul
Wellstone. I hope you have received it and will ask your staff to review it. Senator Wellstone
suggested possible testimony before the appropriate Senate Committee and I would also be
glad to provide you and your staff with more detailed information about the history and
course of our efforts in Minnesota. I was recently appointed Vice Chair of the NCSL
Committee on Commerce and Labor and expect to conduct an NCSL workshop on
economic conversion/diversification at our May 1993 meeting.
�Lead Abatement: Addressing Children's Number
One Environmental Health Problem as Housing
Revitalization and Job-creation strategy.
In the Minnesota model, deteriorated inner city neighborhoods are targeted as a priority for lead-abatement.
Further, the number one environmental health problem of American children-childhood lead poisoning-is
addressed in a way that directly combats environmental racism.
It prioritizes prevention and clean-up in census tracts whose children suffer disproportinately from lead
poisoning because of deteriorated housing and decades of heavy automobile traffic patterns within our inner
city neighborhoods. Invariably those patterns reveal high concentrations of children of color.
The Minnesota strategy seeks to provide employment and training opportunites for the very families and
neighborhood most impacted by lead-poisoning. It would create jobs for neighborhood environmental workers
or "Swab Teams" which go through a pre-apprenticeship certification program to learn safe abatement
techniques and to gain marketable skills in an emerging trade.
In keeping with the recent cost-effective trend HUD is taking to encourage more low-tech, in-place management
that creates "lead-safe" housing rather than "lead-free" housing, Minnesota law tips the scales in that direction
both with our lead-abatement standards and our requirement that 50% of all Federal Funding for Leadabatement be used for these job-creating swab-team activities.
President Clinton, I am sending this information to Hillary Clinton and the Health Care Reform Task Force
as well as Vice President Gore's Environmental Policy Group and Henry Cisneros at HUD. In Minnesota we
built a strong coaliton of children's advocates, health care, environmental, housing revitalization, and civil
rights groups in order to pass some o f the toughest standards for lead abatement in the nation. Our unique
feature was to also turn it into a job-creation program for those most affected.
What we did not accomplish in Minnesota was the adequate funding of this program, although we did set
ourselves up for new H U D lead-abatement initiative grants and were recently selected as one ofthe first 10
grantees.
We failed to pass the proper funding mechanism which should and could fund this program nation-wide: a
tax on the historical polluters that created this problems-the petroleum and paint industries. We were looking
at a modest tax on gasoline and paint last year and will attempt to pass the funding mechanism in a somewhat
modified version this year. Making lead abatement one of the beneficiarys of either a sales tax on gasoline or
an "energy tax" are under consideration.
The enormous cost of lead-abatement as documented by states throughout the U.S. certainly justifies this
funding approach nationally. Without a major strategic effort like this, millions of American children will
continue to be damaged, housing revitalization will be cost-prohibitive, and our urban centers will continue
to lose hope. I hope you will consider the Minnesota Model as you proceed with your important work.
�Withdrawal/Redaction Marker
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Thomas Reynolds to Hillary Clinton [partial] (2 pages)
3/2/1993
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C. Closed in accordance with restrictions contained in donor's deed
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�THOMAS U R E Y N O L D S
District 33
Ta»ati«chie. L^aysns and
Yalobusha Counttej
R 0 Drawer 220
C O M M I T T E E ASSIGNMENTS:
Judiciary B, Vice Chairman
Apportionment and Elections
Penitentiary
Ways and Means
O i a r l M o n . Mississippi 38921
Joint Congressional Redistricling
Joint Legislative Reapponionment
March 2 4 ,
1993
Honorable H i l l a r y Rodham C l i n t o n
The White House
1600 Pennsylvania Avenue, N.W.
Washington, D.C. 20500
Dear Mrs. C l i n t o n :
I l i k e o t h e r Americans a r e aware of your e f f o r t s t o t r y t o make
h e a l t h care coverage a v a i l a b l e t o a l l Americans.
I want t o b r i n g t o your a t t e n t i o n an i l l u s t r a t i o n o f why h e a l t h
care p r o t e c t i o n should be a v a i l a b l e t o a l l Americans.
�Honorable H i l l a r y Rodham C l i n t o n
March 24, 1993
Page 2
Sincerely,
Thomas U. R^Vnolds
TUR/jfj
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�/ Researcher addresses
soybean conference
Soy-foods can reduce risk of cancer
Foods made from soybeans have been
shown to play a key role inreducingthe
risk of several kinds of cancer according
to Dr. Marie Messina, a consultant for the
National Cancer Institute (NCI) in Bethesda, Md. This groundbreaking research will be discussed at the luncheon
during the Volunteer Soy Promoter Conference, February 1,1993 at the Holiday
Inn Executive Center in Columbia.
Dr. Messina, the keynote speaker for the
conference, initiated a $3 millioo threeyear research project while at NCI exploring how soybeans may helpfightcancer.
National statistics cite the leading causes
of death in theU.S. to be heart disease and
cancer. According to Messina, heart disease is .almost totally preventable with a
good diet, and evenreversible.And, he
explained, even more good news is that
the same diet lowering the risk of heart
disease also lowers the risk of cancer.
"Besides being low in saturated fat with
no cholesterol, soybeans contain a special
component that mayfightcancer while
improving the standard diet with less fat
and more protein," he said.
The special component, called an
See RESEARCHER, page 2
A
ConfInued from page 1 plant sources of Omega-3 based food product^ may also
fatty acids that some scien"isoTlavbhe," is relatively tists say are essential nutrients.
unique to soybeans.
Researchers already identi- But the soybean's most
fied atkjastfiveanti-carcino- important role may be in
gens iti Soybeans, but more cancer prevention. Scientists
research is necessary. About interested in the low rates of
one million Americans will certain cancers in the Orient
be diagnosed with cancer, have shown the consumption
and 500,000 deaths will be of soy-based foods may be
attributed to cancer this year the answer, said Messina
alone, Messina said:
A U.S. study conducted in
Studies show soy protein 1991 shows women who
actually reduces cholesterol consumed soy foods had a 50
by as much as 15 percent, percent less incidence of
Messina said. He added that cancer than women who did
soybeans are one of the few not eat soy foods. The soy;
be effective inreducingthe
risk of colon, lung and stomach cancers, he explained.
"Soybeans are an extremely
versatile food and can be
easily incorporated into a
diet," Messina said.
Anyone interested in attending the Conference or the
luncheon are welcome.
There is a cost for the luncheon of $5. Space is limited.
Reservations for the luncheon are required and may be
made by calling toll-free in
MO 800-662-3261 by January 28.
Richmond, M
O
NW
ES
Kanut City Mil Ana
Frldar
D 3,231
JAN.
8 . 1993
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Theresa Ouellette [partial] (1 page)
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financial institutions 1(b)(8) ofthe FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA|
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�WARD ONE COUNCILOR
1992-1993
OFFICE
598-4000
'
PHOTOCOPY
PRESERVATION
.HESIDENg
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Theresa Ouellette to President Clinton [partial] (1 page)
2/1993
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information 1(b)(4) ofthe FOIA)
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purposes [(b)(7) ofthe FOIA|
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financial institutions 1(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) ofthe FOIA)
C. Closed in accordance with restrictions contained in donor's deed
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�February 1993
President William J. Clinton
1600 Pennsylvania Avenue
Washington, DC 20500
Eg: National McaUhcare Plan
Dear President Clinton:
I am writing to ask you to include comprehensive coverage for alcoholism treatment with
the implementation of your administration's new national health care plan. This coverage
should include both inpatient and outpatient treatment.
As you no doubt know, alcoholism is a serious public health problem afflicting millions
of people in our nation. According to a recent report of the National Council on
Alcoholism and Drug Dependence, Inc., "As many as 10.5 million Americans show signs
of alcoholism or alcohol dependence, and another 7.2 million show persistent heavy
drinking patterns associated with impaired health and/or social functioning. By 1995
alcohol-dependent adults will number 11.2 million, with the number of persistent heavy
drinkers remaining stable."
Alcoholism wreaks havoc with our social structure, and costs our nation an estimated $86
billion a year. Alcoholism is a disease, and treatment for this disease works.
Please accord the same health benefits to individuals suffering from alcoholism as those
suffering from other medical problems, and incorporate coverage for alcoholism
treatment in your new national health care plan.
Sincerely,
Am u ^ (uaMy* T ^ , ^ ^ ^ ^ 2 W /
c un
�THE ASSEMBLY
S T A T E O F NEW
YORK
ALBANY
SUSAN JOHN
Assemblymemoer H i s t Distnci
D
•
COMMITTEES
Education
Energy
Corporations. Authorities & Commissions
Judiciary
Governmental Operations
REPLY TO.
DISTRICT OFFICE
792 South Clinion AvenuU
Rochester. New York 14620
(716)24^.5255
ALBANY OFFICE
Room 833
Legislative Ottice Building
• Albany. New York 12248
(518) 455-4527
February 19, 1993
H i l l a r y Rodham Clinton
The White House
Washington, D.C. 20500-0001
Re:
Health Care Reform
Dear Ms. Rodham Clinton:
Enclosed for review by your Task Force i s information
regarding the universal health system i n A u s t r a l i a .
Among other interesting features of t h e i r system i s that
Australia spends only 8 percent of i t s GDP on health care and has
three general practitioners for every s p e c i a l i s t rather than the
reverse r a t i o i n t h i s nation. The Australian system retains both
private insurance for those who want additional features (private
room i n a hospital, for example) and freedom to choose one's care
provider. These are some of the reasons I f e l t a review of t h e i r
system i n your process would be enlightening.
In conclusion, as a representative i n the state l e g i s l a t u r e
from Rochester (often cited by President Clinton) and as the lead
delegate for New York's 30th Congressional D i s t r i c t i n the 1992
campaign, I would be pleased to work with anyone on the Task Force
s t a f f to provide any other information or assistance.
Good luck i n t h i s challenging endeavor.
VeryXtruly yours,
Susan John
Member of Assembly
SVJ:pp
Printed on recycled paper.
�PLEASE REFER TO:
STATE CAPITOL
•
SACRAMENTO. CALIFORNIA
NICHOLAS C. PETRIS
95814
19161
445-6577
N I N T H S E N A T O R I A L DISTRICT
ALAMEDA AND CONTRA COSTA COUNTIES
LEGISLATTVF. A D D R E S S .
1970
BROADWAY
•
SUITE 103O
OAKLAND. CALIFORNIA
94612
1510) 4 6 4 1 3 3 3
CALIFORNIA LEGISLATURE
Senate
March 24,
1993
Mrs. H i l l a r y Rodham Clinton, Chair
White House Task Force for
National Health Care
Executive Office of the President
Washington, D.C. 20500
Dear Mrs. Clinton:
For the past several years, I have authored universal
health care b i l l s patterned on the Canadian, s p e c i f i c a l l y
B r i t i s h Columbia, single-payor model. I have received enormous
support from both houses of the Legislature on my proposals,
but i n the f i n a l a n a l y s i s , Governor Wilson's opposition k i l l e d
the b i l l s .
Therefore with the election of President Clinton, I
decided to turn my e f f o r t s toward Washington D.C. and drafted
Senate Joint Resolution 3 (enclosed) which establishes a set
of p r i n c i p l e s r e f l e c t i n g the direction that C a l i f o r n i a believes
health reform should be moving. The Resolution has already
passed the Senate and i s now i n the Assembly. I am moving i t
as quickly as possible and am very optimistic about i t s
passage. SJR 3 b a s i c a l l y establishes our bottom l i n e s , so that
rather than the C a l i f o r n i a Legislature endorsing one p a r t i c u l a r
measure over another, i t focuses on the ingredients that should
be included i n any national health care reform. I hope you
have the opportunity to look i t over.
In addition, since I s t i l l have such a strong b e l i e f i n
the e f f i c a c y of a single-payor system, I have highlighted a
May 2, 1991 New England Journal of Medicine a r t i c l e that
substantiates the many b i l l i o n s of d o l l a r s we could save by
simply switching to a single-payor system. I n the beginning
of the a r t i c l e i n the Abstract i t concludes and I quote:
" I f health care administration i n the United States
had been as e f f i c i e n t as i n Canada, $69.0 b i l l i o n
to $83.2 b i l l i o n would have been saved i n 1987."
�March 24, 1993
Page Two
In 1993 dollars the savings would have ranged between $87.6
b i l l i o n and $105.7 b i l l i o n . That i s a savings generated
without limiting pharmaceutical costs, without r e s t r i c t i n g
physician fees or without impacting hospital charges. I'm not
saying that those reforms should not also be made, but I am
saying that enough savings can be found i n switching to a
single-payor system to coyer every presently uninsured resident
of t h i s country.
I am also including a Los Angeles Times commentary
cautioning us about 'managed competition.'
I know t h i s i s not an easy road to be on as I have fought
the battle since 1989 on t h i s particular issue. The opposition
i s powerful, but the time i s ripe and i f we don't make s i g n i f i cant changes today, I'm afraid that r e a l reform w i l l not occur
in our lifetime. Thank you for your time and attention to t h i s
issue. We are a l l waiting with baited breath for your
proposal. I , for one, am ready to help you i n any way I can.
Sincerely,
NICHOLAS C. PETRIS
NCPrfts
c c . (3)
�\ A M E N D E D IN SENATE MARCH 4, 1993
v
Senate Joint Resolution
No. 3
. Introduced by Senator Petris
(Coauthors: Senators Alquist, Hay den, Marks, Presley,
Rosenthal, Torres, and Watson)
(Coauthors: Assembly Members Alpert,
Archie-Hudson,
Bates, Cortese, Eastin, Escutia, Farr, Terry
Friedman,
, Hauser, Lee, Moore, Napolitano, Sher, and Solis)
January 28, 1993
Senate Joint Resolution No. 3—Relative to universal health
care.
LEGISLATIVE COUNSEL'S DIGEST
; ^ — S J R 3, as amended, Petris. Universal health care.
I
;. ' >- This measure would urge the President and Congress of the
>
United States to evaluate and author proposals for universal
health care based on prescribed criteria.
Fiscal committee: no.
1
1
2
3.
4
56
7
8
9
10
11
12
13
14
WHEREAS, All Califomians have a right to medically
necessary health care, including long-term services; and
WHEREAS, Children, low-income working and
unemployed persons, and persons with disabilities and
chronic conditions, in particular, face deteriorating
access to all levels of medical care; and
WHEREAS, Over six million Califomians presently
have no health insurance, and the number of these
persons is growing at an alarming rate; and
WHEREAS, It has been documented that the lack of
access to, medically necessary health care leads to a
decline in health status including birth-.defects", lifelong
disabilities,* uncontrolled ^diabetes, hypertension, and
untreated chronic conditions; and
98 90
�SJR 3
1
2
3
4
5
6
7
8
9
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11
12
13
14
15
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36
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40
- 2 -
,
WHEREAS, This lack of access to care results in
unnecessary pain and suffering and leads to overuse of
expensive emergency facilities; and
WHEREAS, Providing preventive health care will
efficiently and effectively improve the health of all
Califomians and can significantly reduce the need for
more expensive long-term care later in life; and
- WHEREAS, The health and well-being of individuals is
directly related to their ability to obtain necessary
medical care and health-related support services for
emergency, chronic, and long-term conditions; and
WHEREAS, The integration of long-term care services
with comprehensive health care is cost-effective, protects
persons with disabilities from being impoverished by the
cost of nursing facility care, and allows maximum
independence for those who can remain safely at home;
now, therefore, be it
Resolved by the Senate and Assembly of the State of
California, jointly. That the Legislature of the State of
California respectfully urges the President and the
Congress of the United States to evaluate and author
proposals for universal health care based on the following
set of criteria:
(a) Health care should be available for all residents
regardless of employment status.
(b) Health benefits . should be
comprehensive,
covering all medically necessary care.
(c) People should be assured quality care and choice
of provider, with individuals able to choose freely among
private and public health plans.
(d) Health care should be affordable for every
individual and family. An annual overall budget cap,
determined through a publicly accountable process,
should be established for all health care resources to limit
overall health spending.
(e) Any alternative to.the current health delivery
system
should generate
increased
administrative
efficiency and savings.
(f) Preliminary elements of a social insurance scheme
for long-term care should be put in place at the time a
98
110
�— 3—
1
2
3
4
5
6
7
8
9
10
11
12
SJR 3
, proposal is passed. •
^
(g) Medical care should be culturally appropriate and
linguistically accessible. It should meet the individual
health and social needs of people with disabilities or with
chronic or unusual medical needs; and be it further
'Resolved, That the Secretary of the Senate transmit
copies of this resolution to the President and Vice
President of the United States, to-the Speaker of the
House of Representatives, and to each Senator and
Representative from California in the Congress of the
United States.
O
98 110
�AMENDED IN, SENATE MARCH 4, 1993
Senate Joint Resolution
No. 3
Introduced by Senator Petris
(Coauthors: Senators Alquist, Hay den, Marks, Presley,
Rosenthal, Torres, and Watson)
(Coauthors: Assembly Members Alpert,
Archie-Hudson,
Bates, Cortese, Eastin, Escutia, Farr, Terry
Friedman,
Hauser, Lee, Moore, Napolitano, Sher, and Solis)
January 28, 1993
. Senate Joint Resolution No. 3—Relative to universal health
care.
LEGISLATIVE COUNSEL'S DIGEST
SJR 3, as. amended, Petris. Universal health care.
This measure would urge the President and Congress of the
United States to evaluate and author proposals for universal
health care based on prescribed criteria.
Fiscal committee: no.
1
2
3;
4
5
6
7
8
9
10
11
12
13
14
WHEREAS, All Califomians have a right to medically
necessary health care, including long-term services; and
WHEREAS, Children, low-income working and
unemployed persons, and persons with disabilities and
chronic conditions, in particular, face deteriorating
access to all levels of medical care; and
WHEREAS, Over six million Califomians presently
have no health insurance, and the number of these
persons is growing at an alarming rate; apd
WHEREAS, It has been documented that the lack of
access to medically necessary health care leads to a
decline in health status including birth defects, lifelong
disabilities, uncontrolled diabetes, hypertension, and
untreated chronic conditions; and
98 90
�SJR 3
1
2
3
4
5
6
7
8
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39
40.
—2 —
WHEREAS, This lack of access^ to care results in
unnecessary pain and suffering and leads to overuse of
expensive emergency facilities; and
WHEREAS, Providing preventive health care will
efficiently and effectively improve the health of all
Califomians and can significantly reduce the need for
more expensive long-term care later in life; and
WHEREAS, The health and well-being of individuals is
directly related to their ability to obtain necessary
medical care and health-related support services for
emergency, chronic, and long-term conditions; and *
WHEREAS, The integration of long-term care services
with comprehensive health care is cost-effective, protects
persons with disabilities from being impoverished by the
cost of nursing facility care, and allows maximum
independence for those who can remain safely at home;
now, therefore, be it
Resolved by the Senate and Assembly of the State of
California, jointly. That the Legislature of the State of
California respectfully urges the President and the
Congress of the United States to evaluate and author
proposals for universal health care based on the following
set of criteria:
(a) Health care should be available for all residents
regardless of employment status.
(b) Health benefits should be
comprehensive,
covering all medically necessary care.
(c) People should be assured quality care and choice
of provider, with individuals able to choose freely among
private and public health plans.
(d) Health care should be affordable for every
individual and family. An annual overall budget cap,
determined through a publicly accountable process,
should be established for all health care resources to limit
overall health spending.
(e) Any alternative to the current health delivery
system
should generate
increased
administrative
efficiency and savings.
(f) Preliminary elements of a social insurance: scheme
for long-term care should be put in place at the time a
98 110
)
^)
•
)
^
/
-'"^
�— 3—
SJR 3
1 proposal is passed.
2 -fr
3
4
5
6
7
8
9
10
11
12
(g) Medical care should be culturally appropriate and
linguistically accessible. It should meet the individual
health and social needs of people with disabilities or with
chronic or unusual medical needs; and be it further
Resolved, That the Secretary of the Senate transmit
copies of this resolution to the President and Vice
President of the United States, to the Speaker of the
House of Representatives, and to each Senator and
Representative from California in the Congress df the
United States.
O
/-•\
f
r
98 110
�Cos Anaetes Sftmes
WEONLSDAY. JANUARY I.?. 199.'!
Commentary
Beware of'Managed Competition' Converts
i Health care: We need
reform, but no plan will work
without budgetary caps.
tained? Or would the bargain-basement
Similarly, without a budget, what will
plan leave most people feeling they have
motivate physicians, whose decisions drive
no option but to pay extra lo get the quality
the majority of health-care spending (dibenefits they need? Without a health-care
agnostic tests, hospitalizations, outpatient
budget, that unacceptable outcome is
visits) to gel a grip on the 25% to 35% of
all too likely. Why Because without a
wasteful, inappropriate decisions they
budget, no real reform is demanded of the
make? When physician practice patterns
health plans and health providers who.
are compared from one health plan to
through irresponsible practices, have
another, from one hospital to another, from
fueled today's galloping rate of health-care
one region to another, inexplicable statistiinflation.
cal differentials leap out with no better
outcomes for patients.
Take administrative waste. Contrary to
popular perception, public programs are
Isolated medical communities have, in
I dramatically more efficient than private
fact, been self-motivated to use peer
ones, with Medicare using about 5 cents of
pressure, comparative data and in-service
every health-care dollar for administration
training to squeeze out the 25% to 35%
compared with 15 to 25 cents from the
wasted on unneeded. risky care.
typical, large private insurer.
f
We need a budget on total spending for
So long as health-plan providers can \ each managed competition pool, with no
charge an unlimited amount for the basic < escape valve at the expense of consumers
plan, what will motivate them to streamand no leakage in health-care security
line their administrative practices? But if ^through shrinking benefits. Only a budget
they operate under budget limitations—
can ensure that the trillion dollars the
that is, the extra charges for premium or
United States will spend on health care by
out-of-pocket expenses can exceed the
1994 will produce the universal coverage,
basic, lowest-cost premium only by a set
the quality, the choice and the comprehenpercenuge—then there's pressure on the
sive benefits we deserve.
plans to cut down the administrative
Loxx Salisbury is- chairwoman oj Health
expenses or lose business. If they fail to cut
waste and instead cut back on service or .•UCI'SN. a California consumer coalition, with
oiikes m Los Angeies and San Francisco
quality, consumers would switch plans.
1
By LOIS SALISBURY
What's wrong with this picture? President Clinton unveils his proposal for
health-care reform. Immediately, the
American Medical Assn. and the Health
Insurance Assn. of America rush to embrace it. Consumers beware. If that happens, we know this debate has started out
missing a critical element: a national
health-care budget that would make the
difference between real and ineffective
reform. But these two big vested interests
are working hard to make sure a budget is
written out of the script for reform.
After years of stonewalling to stop
national health care, the AMA and HIAA
now say that everyone should be mandatorily covered through a system of 'managed competition." For these two powerful
interests, however, managed competition
stands for a version of health care reform
that they like. Key features include:
• Consumers choose from a regional
menu of large, prepaid health-care plans
that offer identical basic benefits; prices
can be compared. To assemble the menu,
government, employers and individuals
pool their purchasing power and negotiate
with a limited number of plans.
• Employers would be required to pay
for the lowest-cost plan and would be
penalized for choosing higher-pnce plans
since the additional money expended
would not be tax-deductible.
• Consumers could pay extra for one of
the more expensive plans and there is no
limit on what those plans might charge.
Consumers, however, would have tax and
economic incentives not to pay more since
any extra payment comes out of the
consumer's take-home check, unlike now,
when health benefits paid for by the
employer don't count as taxable income;
• There would be no cap on the extra
charges and no budget for the total dollars
managed through the competitive pools.
Under the AMA's and the HIAA's proposal, would health-care inflation finally
slow down, with choice and quality main-
�1
Abstracts in the
auverasine
The
New England
Journal of Medicine
Established
i n 1812 as The NEW ENGLAND J O U R N A L OF MEDICINE AND SURGERY
V O L U M E 324
MAY
2. 1991
Original Articles
A Randomized C l i n i c a l Study o f a C a l c i u m Entry B l o c k e r ( L i d o f l a z i n e i i n the
Treatment o f Comatose S u r v i v o r s
of Cardiac A r r e s t
HKAIN RKSUSCITATION I ..
Case Records of the
Massachusetts General Hospital
1225
\ I T K I A I . II S n n v
Molecular Basis o f Phenotypic Heterogeneity i n P h e n y l k e t o n u r i a
N U M B E R 18
A 70-Year-Old M a n w i t h Waldenstrom's
Macroglobulinemia F o l l o w e d by Recurrent Lymphadenopathy and Fever
1267
D W I D B. SMITH AND (JAKOLYN K. 1'ETTIT
Editorials
1232
V u l n e r a b i l i t y o f the Brain and Heart a f t e r
Cardiac A r r e s t
YOSHIYI.KI O K A N U . R A N D Y L. KISENSMIIII.
1'l.tMMINO t i i j l T l t R . L ' l A LlCHTKR-KciNtCKI.
DAVID > KONK.CKI. I'RIKDRICII K. TKLKZ.
MARY UASOVICII. 1 AD U A N I ; .
KAREN HENRIKSEN. HANS LOU.
AND SAVIO L.C. WOO
1278
FRED HI.LM
Phenylketonuria — Genotypes and
Phenotypes
1280
CHARLES R. SCRIVER
Ruling Out Acute Myocardial Infarction A Prospective M u l t i c e n t e r V a l i d a t i o n
of a 1 2 - H o u r Strategy f o r Patients at
Low Risk
Medical Decision M a k i n g i n Patients w i t h
Chest Pain
1239
Neurofibromatosis: Past, Present, and
Future
THOMAS H . L E E . GREGORY JUAREZ.
K. FRANCIS COOK. M O N I C A C WEISBERI;.
IJRE(;ORY W. R O H A N . DONALD A. BRAND,
VND L E E G O L D M A N
Neonatal Herpes S i m p l e x V i r u s I n f e c t i o n i n
Relation to A s y m p t o m a t i c Maternal
I n f e c t i o n at the T i m e o f Labor
1283
VINCENT M . RICCAKDI
Correspondence
1247
ZANE A. BROWN. JACQUELINE BENEDETTI.
RHODA ASHLEY, SANDRA BURCHETT.
STACY SELKE. SYLVIA BERRY.
LOUIS A. VONTVER. AND LAWRENCE COREY
Special Article
The Deteriorating Administrative Efficiency
of the U.S. Health Care System
1282
K I M A. EAOLE
1253
STEFFIE WOOLHANDLER AND DAVID U. HIMMELSTEIN
Absence of Siblings — A Risk Factor for
Hypertension?
Atrial Septal Defect
Inhibition of Exercise-Induced Bronchoconstriction by MK-57I, a Potent Leukotriene
04— Receptor Antagonist
Coagulation Inhibition in Venous Thrombosis . .
Histamine?-Receptor Antagonists — Standard
Therapy for Acid-Peptic Diseases
Fulminant Hepatitis in Primary Human Herpesvinis-6 Infection
Experimental Therapy — Who Shall Pay?
1285
1286
1288
1288
1289
1290
1291
Book Reviews
1292
Notices
1295
Review Article
C u r r e n t Concepts: I n i t i a l T r e a t m e n t o f Patients w i t h E x t e n s i v e T r a u m a
1259
DONALD TRUNKEY
Brief Report
Lisch Nodules i n Neurofibromatosis Type 1
MARIE-LOUISE E. LUBS, MISLEN S. BAUER,
MARIA E. FORMAS, AND BORIVOJE DJOKIC
1264
Corrections
Atrial Septal Defect
Reduced Allergen-Induced Nasal Congestion and
Leukotriene Synthesis with an Orally Active
5-Lipoxygenase Inhibitor
Common Solid Tumors of Childhood
1287
Information for Authors
1296
1295
1295
Owned, Published, and OCopynghted. 1991. b the Maaaachuaetta Medical Society
T
T H I New ENGLAND JOURNAL or M E M C W I (ISSN 0028-4793) is published weekly b a n editorial offica at 10 Shattuck Street, Boston, MA 02115-609+.
Subscnpoon price: S89.00 per year. Second-dan postage paid at Boa ton and at additional mailing office*.
POSTMASTER: Send addicn change* to P.O. Box 803, Waltham, M A 022M-O8O3.
�Vol. 324
No
18
A D M I N I S T R A T I V E COSTS OF U.S. H E A L T H C A R E — W O O L H A N D L E R A N D H I M M E L S T E I N
1253
SPECIAL ARTICLE
T H E D E T E R I O R A T I N G A D M I N I S T R A T I V E E F F I C I E N C Y O F T H E U.S. H E A L T H C A R E
SYSTEM
STEFFIE W O O L H A N D L E R .
M.D..
M . P . H . . AND D A V I D U . HIMMELSTEIN.
Abstract Background and Methods. In 1983 the proportion of health care expenditures consumed by administration in the United States was 60 percent higher than in
Canada and 97 percent higher than in Britain. To assess
the effects of recent health policy initiatives on the administrative efficiency of health care, we examined four components of administrative costs in the United States and
Canada for 1987: insurance overhead, hospital administration, nursing home administration, and physicians' billing and overhead expenses. Most data were provided by
the two nations' federal health and statistics agencies,
supplemented by state and provincial data and published
sources. Because data on physicians' billing costs were
limited, we estimated a range for these costs by two methods that rely on different sources of data. All figures are
reported in 1987 U.S. dollars.
Results. In 1987 health care administration cost between $96.8 billion and $120.4 billion in the United States,
amounting to 19.3 to 24.1 percent of total spending on
M
M.D.
health care, or $400 to $497 per capita. In Canada,
between 8.4 and 11.1 percent of health care spending
($117 to $156 per capita) was devoted to administration.
Administrative costs in the United States increased 37
percent in real dollars between 1983 and 1987, whereas
in Canada they declined. The proportion of health care
spending consumed by administration is now at least 117
percent higher in the United States than in Canada and
accounts for about half the total difference in health care
spending between the two nations. If health care administration in the United States had been as efficient as in
Canada, $69.0 billion to $83.2 billion would have been
saved in 1987.
Condusions. The administrative structure of the U.S.
health care system is increasingly inefficient as compared
with that of Canada's national health program. Recent
health policies with the avowed goal of improving the efficiency ot care have imposed substantial new bureaucratic
costs and burdens. (N Engl J Med 1991; 324:1253-8.)
E D I C I N E is increasingly a spectator sport.
Doctors, patients, and nurses perform before an
enlarging audience of utilization reviewers, efficiency
experts, and cost managers (Fig. 1). A cvnic viewing
the uninflected curve of rising health care spending
might wonder whether the cost-containment experts
cost more than they contain: one is reminded of the
Chinese proverb "There is no use going to bed early to
save candles if the result is twins."
In 1J83 the proportion of health care spending consumed by administrative costs in the United Stales
was 60 percent higher than in Canada and 97 percent
higher than in Britain.- Recent U.S. health policies
have increased bureaucratic burdens and curtailed access to care. Vet they have failed to contain overall
costs. This study updates and expands estimates of
the costs of health administration in North America
through 1987.-' The results demonstrate that the bureaucratic profligacy of the U.S. health care system
has increased sharply, while in Canada the proportion
of spending on health care consumed by administration has declined.
were based on populations of 243.934.000 in the United Slates and
25.652.000 in Canada.
Fiuures on insurance overhead in the United States were obtained
from the Health Care Financing Administration^ Although nationwide data on the costs of hospital and nursing home administration
were not available, the California Health Facilities Commission
regularly compiles detailed cost data, based on Medicare cost reports, on that state's hospitals and nursine homes. F~our years
ago we confirmed that administrative costs in California's health
facilities were similar to those in al least two other states. '
Since then, [rends in hospital and nursine home financine and organization in California have paralleled developments in the nation
as a whole. • We computed total hospital administrative costs by
summme costs m lhe followine categories-, eeneral accounting,
patient accountinc. credit and collection, admitting, oiher fiscal
services, hospiial adminisiraiion. public relations, personnel department, auxiliary croups, data processing, communications, purchasing, medical librarv. medical records. medical-stalT administration, nursine administration, in-service education, and other
administrative services. We excluded costs attributed to research
administration, administration of educational programs, printing
and duplicating, depreciation, amortization, leases and rentals, insurance, licenses, taxes, central services and supply, other ancillary
services, and unassigned costs. We assumed that administration
represented lhe same proportion of total hospital costs in California as nationwide. We derived estimates of nationwide administrative costs for nursing homes from the California data in a similar manner.
METHODS
Although Canada's 10 provincial heallh programs differ in some
details, thev share common structural features that tend to streamline bureaucracv. Each proeram provides comprehensive coverage
for virtually all provincial residents under a single publiclv adminisicred plan. Private insurance mav cover additional services, but
duplication of lhe public coverage is proscribed: hospitals are paid a
lump-sum (globalI amount to cover operating expenses, and physicians bill the program directlv for all fees.
The Health Statistics Branch of Health and Welfare Canada and
Statistics Canada's Canadian Center for Health Information provided unpublished data on nationwide spending for insurance, hospitals, and nursing homes. These data were derived from the provincial governments' reports of their expenditures for insurance
administration and from detailed cost reports submitted by hospi-
(
Wc examined four components of admimsiratwe costs in the
United States and Canada: insurance overhead, hospital adminisiraiion. nursing home administration, and physicians overhead
and billing expenses. A l l estimates are for fiscal year 1987. the most
recent year lor which complete data were available. Costs are reported in 1987 U.S. dollars, based on the 1987 exchange rate of
SI.33 (Canadian) - SI (U.S.); calculations of per capita spending
From the Division of Social and Community Medicine. Depanment of Medicine. Cambndge Hospital and Harvard Medical School. Cambridge. Mass.. and
the Public Citizen Health Research Group. Washington. D C. Address reprint
requests to Dr. Himmelstein at 1493 Cambridge St., Cambndge. MA 02139
-
,
,
�I HE N E W E N G L A N D . ( O U R N A L (JK M E D I C I N E
MJ
..lis and nursintr iiomr.s.
rnmDuted total h(.»SDitai administrator
•^[S m sumnnnv: (.OMS MI (tit' inii'V.Mmr catciz'trics: nosuitai atimin:.-irrmnii r'l.iht.T i . .itA^rtisuiL'. ^.^MLiatinn-nu'innrrsniD tcrs. nusiniacintirs. ri il I r a ion tecs, ly^iaet. . aiKJitme and aixciunune'
•.••rs. Diner Dfuit-ssiDiiai lees i SUL'II is i<-L'ai lees but exinudinu medical
i r f s i . ai-rvice-lmreau ires, u-irononr and (clcirraoh. imiemniiv t»
hoard mcmiJers. iravri ana comenuon fxnenscs. medical nx'orcis
ancl Hospital librar\'. ana nursiny anminisiniuon. ^ e excluded atiininistraiu'e and support services iGr eiiucauotial ana researcn oreijrams. insurance, imeresi. onnune. siauonerN' and oihce snuunes.
niaienei manaecmeni. ana central SUDDIV Siatisucs L.anaaa laou'.aies anministraiive costs lor nursine homes as a sinuie raieeorx .
I "nese data are less reliable than the hospiial lieures. since cost
lenoriine bv nursine homes is vnmniarv. and lhe number ot faciiiiies reportine vanes substantiailv iVom vear lo vear
I'inallv. io evaiuaie irenris o\er time, u e recalculated the 1987
ti'jures lo mainiain birici comparatiilitv u n h itic less neiaiied ana
'ess comniete ci.ua lor !'.' 83.- As in our earner naoer.' ••w rsumated
piivsirians' billine ana ovcrneaii costs in- the exnense-basfri mrtnod
•Method h . However. ••••>• excluded ihc C M , , i nhvsicians lime
Ni)ent on oiiliiie necause comoaraule (iaia were unavaiiable lor rj83.
In keenine wnn our earner meinod. we inciuaca maiuracnce cosis
in unvsicians overheao rxoenses but correciea lor increases over
lime in mese costs.
" '' l or each counirv we took avrraee total
ijrotessionai expenses in i''87. suoirarieu lhe averaee 1987 maioraciice oremmm. ihcn added lhe average \\>H'.i malpractice nremium
ail expressed as a perceniaec nf cross incomei. The 1983 lieures
^ere convened io I'j87 dollars with use oi ihe eross-riomesuc-product price nuiex lor each counirv.
'A e conhrmed the accuracv oi ihc Canadian lederal data, usine
more detailed bul incomoieie ciaia irom lirinsh l.inluinbia. me
Maritimes. Ontario. Quebec, ana S a s k a t c h e w a n ' a n d personal
..ommunicaiions: Cunnineham D British Columbia Ministrv oi
l lealih: Lnn H. Cominuine Care t m p i o \ c c Relaiions Assnciaiion 01'
British Columbia: and Davis I . Ontario Ministrv ot' Healthi. Be• ansc these data ecnerallv maicned the national heures. we have not
i'-tiorted them separaielv.
RESULTS
-
* Inlv intiireet or mcnmnteie mirjrmauon is available on ihe biilim:
'Sis ol Canaclian and U.S. Dn\'sicians. vN'e (heretore ustiu two aii:erent methods to estimate these costs, one based on imvsiuans
reporis ol' their prolessional expenses and lhe other on the numoers
"t cmplovees in physicians othces. The expense-based meinod
M e t h o d 11 probably overestimates tlie actual difference in billine
:osts between the two nations, whereas the personnel-based aoprnach I Method 2) may underestimate lhe difl'crence.
Our tirst approach. Method 1. rests on the assumption that the
entire dilferencc in phvsicians billine and overhead expenses lexcludine malpractice premiums '•: between the United States and
Canada is attributable to the excess administrative costs borne bv
American doctors. The Amencan Medical Association t A M A ) estimates U.S. physicians incomes and practice expenses on the basis
ol the results of a survey of a representative sample of nonlederal.
practicing physicians lexcludine interns and residentsi. " Revenue
Canada tabulates physicians professional expenses on the basis of
lax returns 1 Rehmer L. Health Information Division. Heallh and
Welfare Canada: personal commumcatiom. Because these lieures
are 'distorted, primanlv because of the wav group practice phvsicians tend to report expenses (Rehmer 1.. Health Information D i vision. Health and Welfare Canada: personal communication!, we
used Revenue Canada s corrected tabulation, which included onlv
ihe 91 percent of phvsicians who reported professional expenses
amounting to between 5 percent and 300 percent of iheir net i n comes. We added to both the U .S. and Canadian figures an estimate
of the value of the physicians time devoted to b i l l i n g (and Peachey D: personal communication!; we assumed that this time was
valued at the same rate as other professional activity.
1
11
Using Method 2. we also estimated physicians' billing costs on
the basis of data on the number of clerical and managerial personnel employed in their offices, as well as the costs of outside billing
services. For the United Stales, we obtained information on physicians' otfice personnel from data tapes from the Census Bureau s
March 1988 Current Population Survey (CPS). Since comparable
survev data were unavailable for Canada, we used information from
a detailed study of office stalling patterns in the province of Quebec
in 1977. These earlier figures were slightly higher than informal
current estimates provided by the Ontario Medical Associauon
(Peachey D : personal communication). For both the United States
and Canada, we assumed that the total annual cost per employee
averaged $35,000 (including wages, benefits, taxes, work space,
equipment, telephone, supplies, and other costs attributable to the
employee) and that ihe ratio of clerical workers to physicians (excluding residents) was identical in offices and other settings. We
added to both the U.S. and Canadian figures estimates of the value
of physicians' personal time spent on billing, calculated as described above. For the United States we added the cost of outside
billing services as determined by a recent survey by the A M A .
14
15
1 3
,
1
Insurance Overtiead
In 1987 private insurance firms in the United States
retained S18.7 billion lor administration and prohts
uut ol' total premium revenues ol' 5157.8 billion.
Their average overhead costs I 1 1.9 percent ol premiums) ucre consicierablv higher lhan the j.2 percent
administrative costs ol' government heahh programs
such as Medicare and Medicaid 1S6.6 billion out of
total expenditures ot $207.3 billioni.' Together, administration of private and public insurance programs
consumed 5.1 percent ol" the S500.3 billion spent for
health care, or SI06 per capita.
The overhead costs for Canada's provincial insurance plans amounted to S235 million (0.9 percent I of
the S26.57 billion spent bv the plans (and Health
Information Division. Health and Welfare Canada:
personal communication!. The administrative costs of
Canadian private insurers averaged 10.9 percent of
premiums ($200 million of the SI.83 billion spent for
such coverage) (Health Information Division. Health
and Welfare Canada: personal communication). Total
administrative costs for Canadian health insurance
consumed 1.2 percent of health care spending, or $17
per capita.
1
1,
Hospital Administration
Hospital administration represented 20.2 percent of
hospital costs in California in 1987-1988. Extrapolating this figure to the total U.S. hospital expenditures of $194.7 billion in 1987 yielded an estimate of
$39.3 billion, or $162 per capita, consumed by hospital
administration. In Canada, hospital administration
cost $1.27 billion, amounting to 9.0 percent of total
hospital expenditures of $14.14 billion (Health Information Division, Health and Welfare Canada: personal communication), or $50 per capita.
18
2
Nursing Home Administration
The administrative costs in California's nursing
homes accounted for 15.8 percent of total revenues in
1987-1988. On the basis of this figure, we estimate
that administration cost $6.4 billion of the $40.6 billion spent nationally for nursing home care, or $26
per capita. Canadian nursing homes spent $231 million on administration in 1987-1988, amounting to
19
3
�ul. 324
No. IK
ADMINISTRATIVE COSTS OF U.S. HEALTH CARE — WOOLHANDLER AND HIMMELSTEIN
400r
o
300
a
2001
125.=.
the time phvsicians spent on billing was valued at $4.5
billion. In addition. 13.9 percent of phvsicians contracted with outside billing firms, at an av erage annual cost of $23,196 each.' 'for a total of $1.3 billion.
Physicians total billing and clerical expenses amounted to $25.8 billion, or $106 per capita.
The average othce-based general practitioner in
Quebec employed 0.733 receptionists and secretaries
at an annual cost of $25,655 per physician, for a total
of S1.0 billion for Canadian phvsicians. In addition,
the time physicians spent on billing was valued at $58
million. Physicians' total billing and clerical expenses
were thus $1.06 billion, or $41 per capita.
3
15
1980
1987
Figure 1. Growth in the Numbers of Physicians and Health Care
Administrators from 1970 to 1987.
The data are from Statistical Abstract of the United States for
these years (Table 64-2. 109th edition).' Because of a modification in the Bureau of the Census' definition of "health administrators.'' the change between 1982 and 1983 is interpolated rather
than actual.
1J.7 percent of the total expenditures ol Sl.ti9 billion
i Statistics Canada. Canadian Center lor Health Information: personal communication), or S9 per capita.
Physicians' Billing Expense
Method 1
When calculated accordine; to Method 1. U.S. physicians' overhead and billimr expenses, excluding malpractice premiums, made up 43.7 percent of their
gross professional income -' — $44.9 billion of the
S102.7 billion spent for physicians' services. In addition, phvsicians spent an average of six minutes on
each Medicare and Blue Shield claim." Assuming
that the time required to bill other insurers was similar, the average phvsician spent about 134.4 hours per
year (4.4 percent of his or her total prolessional activity i on billiniz: this time had a total value of $4.5 billion. Thus, the total value of U.S. physicians' billing
and overhead was $49.4 billion, or $203 per capita.
Canadian physicians' professional expenses, excluding malpractice premiums, amounted to S1.99 billion, or 34.4 percenl of their gross income (Rehmer L :
personal communication). According to the director
of professional affairs of the Ontario Medical Association. "The commitment of time to billing . . . is
trivial and can be measured in seconds [per claim]"
(Peachey D: personal communication). Assuming that
the average physician spends 1 percent of his or her
professional time on billing, with a total value of $58
million annually, the total cost of phvsicians' billing
and overhead was S2.04 billion, or $80 per capita.
1
1
Method 2
The average office-based phvsician in the United
States employed 1.47 clerical and managerial workers (Himmelstein D U , Woolhandler S: unpublished
data), at an annual cost of $51,564 per physician, for a
total of $20.0 billion. As calculated above (Method 1),
Total Costs of Administration
Table 1 summarizes the per capita costs of health
care administration in the United States and Canada,
including physicians billing and overhead costs as
calculated by the two different methods. Overall expenditures for health care administration in the United States totaled $96.8 billion to $120.4 billion ($400
to $497 per capita), accounting for 19.3 to 24.1 percent
of the $500.3 billion spent for health care. Canadians
spent $3.00 billion to $3.98 billion for health care administration ($117 to $156 per capita), amounting to
8.4 to 11.1 percent of the $35.9 billion spent for health
care. The difference of $283 to $341 in the per capita
cost of health care administration and billing accounted for 43.5 to 52.5 percent of the total difference in
health spending between the two nations. If U.S.
health care administration had been as efficient as
Canada's, $69.0 to $83.2 billion (13.8 to 16.6 percent
of total spending on health care) would have been
saved in 1987.
The difference between the United States and Canada in billing and administrative costs has markedlyincreased since 1983.-' Insurance overhead in the United States has risen from 4.4 percent to 5.1 percent
of total health care spending, whereas insurance
overhead in Canada has declined from 2.5 percent to
Table 1. Cost of Health Care Administration in the
United States and Canada. 1987.
Cost CATEOO«»
SPENDING FER CAPITA"
U.S.
Insurance administration
Hospital administration
Nursing home adminisiraiion
Physicians overtiead and billing
expenses
Expense-based estimate
Personnel-based estimate
Total costs of health care
administration *
High eslimate
Low estimate
CND
AAA
162
26
17
50
9
203
106
80
41
497
400
156
106
117
*AII costs are expressed in U.S. dollars.
The high estimate incorporales physicians adminisiralive costs denved
by lhe expense-based melhod. and Ihc low esnmale costs derived by lhe
penonnel-based method.
+
�i HE NEW KNU.AND l O L R N A L OF MEDICINE
!.'_' :)i:rci.'!it." Hosnnai ariniiiiisirausc msis have risen
irnm !'!.:•; perecm in -'J.L' nereem ni imai Imspi;ai sni.'iidins: in ilic L iiiieri Siaics. '-.viiercas m C'an.uia i nese cosis lia\c eiimhen ^lidulv I'roni ri D pcreein ID '.Ml percent." Administrative expenses in L ..V
niirsuiL' homes rose trom 14.4 percent to I.Vo percent
• if costs, w hereas administration's share ol total costs
rose irom iO..! to 1.3.7 percent in Canada." I'hvsieians
professional expenses lexcludnm malpractice premiums i have increased from 41.4 percent to 4.3.li percent
" I gross income in the I'nited States, whereas the
Canadian figure declined from .3").;) percent to .34.4
percent."
When we recalculated the l Jf37 figures to maintain
eomparabilitv with the less complete \'M'i data, we
found that U.S. administrative costs rose from 'JI.'J
percenl io 2:3.9 percent of health care spending beiween 198!} and 1987. whereas in Canada adminisiralive costs declined from 1:3.7 percent to 1 1.0 percent.Alter adjustment lor imlaiion. die divergence was
even more striking, l he costs of the health care bureaucracy in die I'liited States rose bv S'.Vl.'J. billion
(:37 percentl between 1983 and 1987. an increase of
SI 18 per capita. Administrative costs m the Canadian
health care svstem fell bv 5161 million during this
period, a decrease of S6 per capita.
l
(
Mav 2. I'J'Jl
accnumed for
percent of the nonphvsician emoiovees in doctors oiiices in 1988. and 74.700 more
were added over the ensuing two vears (Himmelstein
DL . Woolhanaler S: unnublished daiai. In contrast,
u.-cnmcians and lechnoiogists accounted for onlv 7.3
percent ot nonphvsician ollice workers in 1988 and for
oniy :V7 percenl m PJ90 (Himmelstein D U . Woolhandler S: unpublished datai. In 1988. the stall" in a
typical U.S. physician's oilicc spent about one hour on
each Blue Shield or Medicare claim." at least 20 times
more than in Ontario i Peaciiey 1): personal communii anon: Weinkauf D: personal communication). In a
ivpical practice in Canada. O n e person does all the
billing, bookkeeping and typing . . . for 8 physicians."
Our estimates omit the administrative costs of
union and employer healih-benelit programs and the
administrative work done bv hospital nurses and other
nonphvsician clinical personnel — all probablv greater m ihe United States ttian in Canada. Moreover,
patients m the United Slates spend far more time land
anguish I on insurance paperwork than do Canadians:
ihese costs are nol rellected in our ligures. On the
other hand, some argue lhal funding health services
ihrough taxes, as in Canada, erodes productiviiv
throughout the economy bv discouraging work and
investment — ihe so-called dead-weight loss. ' Within
the range of tax rates in North America, however, the
magnitude, and even existence, of this dead-weight
loss is controversial."
The United States spent 37 percent more in real
dollars on health administration in 1987 than in 1983.
The recent quest for elliciencv has apparently amplilied inelliciencv. Cost-containment programs predicated on stringent scrutiny of the clinical encounter
have required an armv of bureaucrats to eliminate
modest amounts of unnecessary care. Each piece
of medical terrain is meticulously inspected except
lhal beneath the inspectors' feet. Paradoxically, the
cost-management industry is among the fastest-growing segments of the health care economy and is
expected to generate S7 billion in revenues by 1993.
The focus on micromanagement has obscured the
fundamentally inefficient structure required to implement such policies. In contrast, Canada has evolved
simple mechanisms to enforce an overall budget, but it
allows doctors and patients wide latitude in deciding how the funds are spent. Reducing our administrative costs to Canadian levels would save enough
money to fund coverage for all uninsured and underinsured Americans.- Universal comprehensive coverage under a single, publicly administered insurance
program is the sine qua non of such administrative
simplification.
The fragmented and complex payment structure of
the U.S. health care system is inherently less efficient
than the Canadian single-payer system. The existence
of numerous insurers necessitates determinations
1 4
DISCUSSION
Most of our analysis is based on well-substantiated
data, although in some areas reliable ligures are
sparse. The comparability of the data on hospital administrative costs in Canada and the United States is
uncertain. However, we relied on detailed budgetary
categories that appeared closely matched m ihe two
nations. .Although data on the administrative costs of
health maintenance organizations are limited, they do
not appear to differ substantially from those m the
U.S. fee-for-service sector.-" -'"
Both of our methods for estimating physicians' billing costs are imprecise. The expense-based method
(Method 1) may overstate the difference between the
United States and Canada, since it assumes that the
entire discrepancy in the proportion of income devoted to professional expenses was accounted for by malpractice premiums, billing, and administration. The
personnel-based method (Method 2) may understate
the difference because it assumes that aides and other
clinical personnel employed in physicians' offices performed no activities related to billing, that the total
annual cost per clerical worker was no less in Canada
than in the United States, and that Canadian billing
operations have not been streamlined since 1977 despite computerization. An official of the Ontario
Medical Association estimates that electronic claims
submission and reconciliation takes about one sixth as
much stall time as paper-based billing (Peachey D:
personal communication).
In the United States, clerical and managerial staff
1
2
26
7
�ol 324
No. U
ADM INISTRATI \'E COSTS OF U.S. HEALTH CARE — WOOLHANDLER AND HIMMELSTEIN
of dieibiiitv that would be superHuous if evervone
were covered under a single, comprehensive program.
Rather than a single claims-processing apparatus in
each region, there are hundreds. Fragmentation also
reduces the size ol the insured group, limning savings
Irom economies of scale. Insurance overhead lor U .S.
employee groups with fewer than j members is 40
percent of premiums but falls to 5.5 percent for groups
of more than lO.OOO.-' Competition among insurers
leads to marketing and cost shifting, which benefit the
individual insurance firm but raise systemwide costs.
A lack ol comprehensiveness in coverage also drives
up administrative costs. Copavments. deductibles,
and exclusions are expensive to enforce and lead manv
enrollees to purchase secondary ""Medigap'" policies.
The secondary insurers maintain redundant and expensive bureaucracies. •"
The efliciencv of U.S. health care is further compromised bv the extensive participation of private insurance lirms whose overhead consumes I 1.9 percenl of
premiums, as compared with 3.2 percent m U.S. public programs/ Even the "public " figure reflects the
inelliciencv of the private firms that process claims for
Medicare lor an average of S2.74 per claim. " whereas
Ontario's Ministry of Heallh processes claims for
SO.41 each (Davis ] : personal communicauoni. Moreover, the inefficiency ol private insurers is not unique
to the United States. The small private-insurance sectors of Canada, the United Kingdom, and Germanv
have overheads of 10.9 percent. 16 percent, and 15.7
percent, respectively. " - A major advantage of publicprograms in terms ol" efliciencv is their use of existing
tax-collection structures, obviating the need for a redundant bureaucracv to collect monev for health serv ices. Thus, the overhead in Germain's premiumbased, quasi-public sickness funds is between 4.6
percent ' and 4.8 percent (Kuhn H : personal communication I — considcrablv higher than the overhead in
tax-funded systems.
The scale of waste among private carriers is illustrated by Blue Cross/Blue Shield of" Massachusetts,
which covers 2.7 million subscribers and emplovs
6682 workers"' — more than work for all of Canada's
provincial health plans, which together cover more
than 25 million people' (and Davis J: personal communication: Cunningham D: personal communication): 435 provincial employees administer the coverage for more than 3 million people in British Columbia
(Cunningham D: personal communication).
The existence of multiple payers in the United
States also imposes bureaucratic costs on health care
providers. Hospitals must bill several insurance programs with varying and voluminous regulations on
coverage, eligibility, and documentation. Moreover,
billing on a per-patient basis requires an extensive
internal accounting apparatus for attributing costs
and charges to individual patients and insurers. In
contrast. Canada's single-payer system funds hospi1
1
J
1 ,
tals through global budgets, eliminating almost all
hospital billing. The striking administrauve efliciencv
of the Shnners' hospitals in the United States, which
bill neither patients nor third parties and devote only
2 percent of their revenues to adminisiraiion.''' suggests that payment mechanisms rather than cultural
or political milieus determine administrative costs.
Here. too. the European experience parallels North
America's. British hospitals that are assigned global
budgets devote 6.9 percent of spending to administration.''" but those paid on a per-paiient basis (such as
Humana's Wellington Hospital in London) spend 18
percent.'"
The synchronous growih of bureaucratic profligacy
and unmet health needs is reminiscent of Dickens'
somber tale of six poor travelers who were relegated to
outbuildings when the hostel built for them was fullv
occupied bv us charitable administrators.
1 found, too. lhal atiom a iliirticih pan ol' ihe annual revenue was
MOW rxpended on ihc purposes commemoraird in ihi- inscripiion
over the door: ihe rest peine handsomelv laid om in Chaneerv. law
expenses, eolleeiorsinp. reeeiversnm. poundaiie. and oiher appendatres oi manauement. Inuhlv eomniimemarv to the imnortance ol
lhe six Poor Travellers. ''•
The house of medicine is host to a growing arrav of
specialists in lields unconnecied to healing. Al us present rate of growih. administration will consume a
third of spending on health care 12 years hence, and
half of the health care budget in the year 2020.
We are indebted to M r . Lothar Rehmer. Ms. Judith Dowler. Dr.
Jane Fulton, and M r . Gilles Fortin tor pnividint; much ol lhe raw
data on Canadian heallh spending and lo Dr. David H . Bor tor his
invaluable advice
REFERENCES
I.
11
I
1
4
5
b.
7
111
X.
9.
10.
II
12.
13
14.
15.
Bureau ol lhe Census Slalistical abslract ofthe United Slates 102nd- 109th
eds. Washinctun. D C : Cmvemment Pnnnne Ollice. 14X1-IW.
Himmeisicm OU. Wixilhandler S COM without ftencnt: auministraiivc
waste in U.S. health eare N fcncl J Med lyXfv. 314:441-?.
Lcisch SW. Levi! KR. Waldo DR National health enpenanures. 14K7
Heallh Care Financ Kev I4XX: 10(2): 109-::.
Amencan Hospital Association. Hospital stadstics I4H4 ed. Chicago:
Amencan Hospiial Associaiion. I9S4.
Idem. Hospital statistics: 19X8 ed. Chicago: American Hospital Association.
I9SX
Hospiial Slalislics l4Xh-l9X7. Toronto: Queen s Pnntcr. 1987
Oniarto Ministry of Health Annual repon I988-X9 Kingston: Ontario
Mmisirv ol Health. 1989
Recie de L assurance-maladic du Quebec. Rappon Annuel 1986-1987.
Quebec: Government of Quebec. 1987:30
Saskatchewan Medical Care Insurance Commission. Annual report 198586. Rcgina: Government of Saskatchewan. 1986.
Nova Scolia Medical Services Insurance. Annual statisiical tables: tiscal
year 1985-86 Halifax: Governmenl of Nova Scotia. 1986:3
Canadian Medical Prolecnve Association (CMPAI membership fees.
1971-1990. Toromo: Canadian Medical Associaiion. 1989
Gonzalez ML. Emmons DW. eds. Socioeconomic characiensiics of medical
practice 1989 Chicago. American Medical Association. 1989
AMA Cemer lor Heallh Policy Research. The administrative burden of
heallh insurance on physicians. SMS Report 1989: 3(2>:2-4
Bureau of Ihe Census. Current population survey. March 1988: technical
documemaiion. Washineion. D C : Departmem of Commerce. 1988
Bern C. Brewster J A. HeldPJ. KehrerBH. ManheimLM. Remhardt U. A
siudy of the responses of Canadian physicians to lhe introduction of universal medical care insurance: the tirst live years in Quebec. Princeton. N.J.:
Maihematica Policy Research. 1978.
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Organizations
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3/30/93
�Mary Hubler
State Representative
March 23,
1993
Ms. H i l l a r y Rodham C l i n t o n
The White House
1600 Pennsylvania Ave., N
W
Washington, DC 20500
Dear Ms. C l i n t o n :
C u r r e n t l y the f e d e r a l government provides h e a l t h care c l i n i c s w i t h
a n o n - p r o f i t status t h a t enables them t o buy drugs a t lower rates
than r e t a i l pharmacies. These c l i n i c s are able t o purchase drugs
a t 60 t o 90 percent o f f average wholesale p r i c e s . They then o f f e r
consumers these drugs a t a f r a c t i o n o f t h e cost small l o c a l
pharmacies must charge due t o the t w o - t i e r p r i c i n g s t r u c t u r e .
The drug industry's m u l t i - t i e r e d p r i c i n g s t r u c t u r e i s adversely
e f f e c t i n g the small r e t a i l pharmacists who cannot compete w i t h the
lower c l i n i c drug p r i c e s .
Large c l i n i c s , such as the Marshfield
C l i n i c i n my d i s t r i c t , are buying-up l o c a l c l i n i c s , i n s t a l l i n g
t h e i r own pharmacists i n t h e i r c l i n i c s , and o f f e r i n g c u t - r a t e
p r i c e s on drugs i n d i r e c t competition w i t h t h e l o c a l l y owned
pharmacy.
I would appreciate your t a k i n g a look a t t h i s problem. This m u l t i t i e r e d p r i c i n g s t r u c t u r e i s u n f a i r and i s d r i v i n g the small l o c a l
pharmacies out of business.
Thank you.
I look forward t o your r e p l y .
cerely,
IY mrBLi
State Repf/esentative
7 5 t h Assefnbly D i s t r i c t
MH/jms
Office: State Capitol, P.O. Box 8952, Madison, WI 53708 • (608) 266-2519
Home: P.O. Box 544, Rice Lake, WI 54868 • (715) 234-7421
Toll-free Legislative Hotline • 1-800-362-9696
�CCA
PLEASE REPLY TO-
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SACRAMENTO ADDRESS
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(916)445-5405
EDUCATION CHAIRMAN
NATURAL RESOURCES S WILDLIFE
VICE CHAIRMAN
BUSINESS AND PROFESSIONS
DISTRICT OFFICE ADDRESSES
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SUITE 5 0 7
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COMMITTEES:
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CONSTITUTIONAL AMENDMENTS
(Miftfrnia ^tate Rotate
SUBCOMMITTEE ON OFFSHORE OIL ft GAS
DEVELOPMENT. CHAIRMAN
JOINT LEGISLATIVE AUDIT COMMITTEE
GARY K. HART
SENATOR
EIGHTEENTH DISTRICT
CHAIRMAN
EDUCATION COMMITTEE
January 11, 1993
Ms. H i l l a r y Rodham Clinton
Office of the President-Elect and Vice President-Elect
105 West Capitol Street
L i t t l e Rock, Arkansas 72201
Dear Ms. Clinton:
I am advised that Barbara Garcia-Weed has conveyed to
your o f f i c e her i n t e r e s t i n a position i n the Clinton
administration and I am writing on her behalf.
Barbara's accomplishments i n the f i e l d of health care
s e r v i c e s are well known to the many who have worked with her.
Her s e r v i c e to the elderly i s noteworthy and she helped write
the "Abuse of the Elderly" b i l l for the State of C a l i f o r n i a .
Barbara has the a b i l i t y to identify problems and to
find c r e a t i v e and cost e f f e c t i v e solutions to them. She
s u c c e s s f u l l y spearheaded the establishment of the Eldercare
C l i n i c s i n Oxnard, C a l i f o r n i a and Phoenix, Arizona.
Thank you for considering Barbara Garcia-Weed as a
member of the new administration.
GKH:ahr
:i HART
�• * C O M M I T T E E ON ENERGY AND COMMERCE
w
-
-
b
•
»
- THE ENVIRONMENT ^
^ROOM a^B^AYBURN
'
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*
(<
HOUSE OFFICE BUILDING „
* MEMOR^NDUSl^
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�S T A T E
OP
A K K A N S A S
GENERAL ASSEMBL Y
LITTLE
NEE IY CASSADY
Senator. 20lh District
Sovier, I'ike, Howard, I'olk and Hempstead Counties
I'.O. Box 1810
N A S H V I I J . I ; . A R K A N S A S TISS:
February 10, 1993
ROCK, ARKANSAS 72201
COMMITTEES
VICE CHAIRMAN
Public Transportation
MEMBER
Agriculture and Economic
Development
First Lady Hillary Rodham Clinton
White House
1600 Pennsyivania Ave., NW
Washington, DC 20500
Dear Hillary:
I was extremely pleased to learn of your appointment to head the National Health Care Task
Force. This is certainly a tremendous challenge but of utmost importance to all Americans.
I would like to recommend Nancy Hall as a person you may wish to consider involving in
some way in your Task Force efforts. Information regarding Nancy's background and
qualifications is enclosed.
Nancy is extremely knowledgeable of health care problems from the unique perspective of
having had significant experience developing and administering health care programs for
employees first with a Fortune 100 corporation and then with a company that provides such
services to hundreds of small businesses throughout the country. In this latter role, Nancy has
successfully contained health care cost increases to less than one-half the national average.
She has had first-hand experience in reducing health care costs by eliminating misuse, fraud
and abuse by both providers and employees. She has indicated a willingness to volunteer her
time to this important undertaking, and I recommend her highly.
I realize that I may be late in providing this input to you. However, I do feel that Nancy is
uniquely qualified to provide an excellent contribution to your efforts.
I became familiar with Nancy's outstanding abilities through our relationship with her husband,
Morgan Hall, who is a Past-President of the National Trade Association in which one of our
companies, Sunmark, is actively involved. They are both fine people, and Nancy is certainly
worthy of your consideration.
Best wishes in your endeavors. Do not hesitate to call on me if I can ever be of assistance.
All of us in Arkansas are proud of what you and Bill have accomplished and certainly have
a lot of confidence in what you will be able to achieve in the future.
Sincerely,
Neely Ctfssady
�BACKGROUND AND QUALIFICATIONS
Nancy C. Hall, R.N.
An outstanding Administrator who, by virtue of both education and extensive experience, is
completely knowledgeable of all components of the health care delivery system in both the
public and corporate environment. Strengths include outstanding planning and program
development capabilities.
1989 - Present:
Executive Vice President, TFE, Incorporated and Director, T F E
Medical Systems
Responsibilities include the administration of both the Employee Health
Plan and Workers' Compensation program for 8,000 employees. Includes
both ERISA self-funded and traditional indemnity funding devices.
Successfully contained health care cost increases to less than 1/2 the
national average for the past 4 years. Well versed in all system
components including opportunities for system cost savings, misuse, fraud
and abuse by both the provider community and employees. Developed
and responsible for corporate wide ADA compliance programs and
policies.
1976 - 1989
Olin Corporation, Stamford, CT
Occupational Health Nurse
Reported to corporate Medical Director. Developed and administered all
aspects of Occupational Health and Safety programs for Fortune 100
corporation. Managed workers' compensation, employee health care
program and all related issues.
1973 - 1976
Georgia Regional Hospital, Augusta, GA
Unit Director, Alcohol and Drug Unit
1970 - 1973
Medical College of Georgia
Bachelor of Science in Nursing
Contact
Information:
TFE, Inc.
3665 Wheeler Road, Suite 101
Augusta, GA 30909
(706) 855-1014
(706) 855-1475 - Fax
�To.
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�JAMES
H. " J I M " B R O W N
COMMISSIONER
STATE OF
OF
INSURANCE
LOUISIANA
P. O. B o x 911
February 4, 1993
BATON
ROUGE, LOUISIANA
(504)
70821-0911
342-5423
FAX: ( 5 0 4 )
342-8622
Mrs. Hillary Rodham Clinton, Chair
President's Task Force on National
Health Care Reform
c/o The White House
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mrs. Clinton:
My office has recently taken the lead in a broad effort to reform the health care and
health insurance industry in the state of Louisiana. Louisiana alone has approximately one
million of the 36 million uninsured in the United States. This translates to one of every four
citizens in Louisiana having no insurance coverage, including public and private plans. Given
that our state has a large portion of the nation's uninsured, we are particularly aware of the
problems facing the uninsured population and the effect of this population on the health
care industry and to businesses in general.
I would like to volunteer my services as a member of the President's Task Force on
National Health Care Jteform. I would hope that my health care reform initiatives at the
state level and my knowledge of insurance issues as an elected state Commissioner of
Insurance would allow me to make a contribution to the major effort being undertaken by
you and the President. I will be unveiling, within the next two to three weeks, what I
believe to be some substantial health care reform proposals aimed at abating the growing
concerns of the uninsured and under-insured in Louisiana. Included in this proposal will
be measures aimed at the problems of "job lock", insurance rating mechanisms, and provider
billing and audit guidelines.
Please have the appropriate official consider my request to be appointed to this
extremely important Task Force.
Sincerely,
James H. "Jim" Brown
Commissioner of Insurance
JHB:grii
�HEALTH CARE TASK FORCE SORTING SHEET
TYPE OF MATERIAL:
General mail
_Casework/personal stories
Letterhead
_Resames/offers to help
.Requests:
-^>eech
-meeting
Phone call
.Policy papers
.Other
ADYISQESLEANEL?
physician
non-physician health provider
small business
seniors
other consumers
PRIMARY INTEREST:
budgets and caps
_ benefits
HIPC organization
_ employer participation
_ administration, reimbursement,
St patient information systems
organization, boards.
federal and state oversight
_ unemployed/low income
_ medicare
_ insurance reform
_ quality assurance
_ DOD
_ Veterans
_ malpractice & tort reform
_ federal employees
_ prep of health care workers
_ ethical foundations
_ short-term cost controls
_ public financing
_ long-term care
_ mental health
_ economic impacts
_ AIDS
_ women's health
_ immunization programs
_ rural, inner city regions
other
GEOGRAPHY:
Region(NW,SE?):_
Rural, Urban, Suburban?:.
PLAN PREFERENCE:
CP
SP
OP
OT
Endorsed Clinton Plan
Single Payer
Own Plan
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits or Vouchers
�HEALTH CARE TASK FORCE
EN-TAKE ROOM ROUTING SUP
QEEICE:
/
Public Liaison
Intergovernmental
Congressional Relations
First Lady
Other:_
EEQUEST:
leeting
Letter
Speech
Phone Call
Other:
REQUIRES ACTION:
Immediately
By:
Soonj-but ne>t priority
(Date)
�/
Senator John E. Baldacci
District 10
State House Station 3
Augusta, Maine 04333
Y
THE MAINE SENATE
79 Palm Street
Bangor, Maine 04401
116th Legislature
January 26, 1993
H i l l a r y Clinton
F i r s t Lady
White House
Pennsylvania Avenue
Washington, D.C. 20510
Dear H i l l a r y :
I r e a l l y hope that you can read t h i s among the mountain of
papers you are receiving. I was told that I should write to
you.
I f e l t compelled to write to you after seeing you and your
husband at the inaugural a c t i v i t i e s l a s t week and
remembering Jack Kennedy's inauguration i n 1961. My father
was a national delegate and worked with Bobby and Jack back
then and my brother Peter was a national delegate for B i l l
and worked with h i s s t a f f t h i s year. I t was t e r r i f i c .
We have met only once; a year ago i n Bangor, Maine after a
campaign reception, you and your s t a f f came to the
restaurant and had a fine meal and relaxed for a while. You
were very impressive to me and my family and you sent a
lovely picture of yourself that i s proudly hanging i n the
front lobby of the restaurant.
I t ' s time to stand upon the rock and look towards our
destiny and help shape i t . I would r e a l l y l i k e to help our
administration i n a capacity as a domestic policy advisor on
small businesses or i n the small business administratTorn
I believe I could help the President with h i s health care
proposal by consolidating small businesses l i k e my own. We
may be against government interference i n the market place
but we can no longer afford to maintain health care for our
employees and probably ourselves. Small businesses can be
the wedge against the health care industry and big
businesses to galvanize the popular and broad-based support
we need. ,1 am interested i n serving as a smalJMbusiness
advisor to the administration either i n WashingtorPoF Maiine.
�^
H i l l a r y Clinton
January 26, 1993
Page 2
I have enclosed a brief career history as well as several
personal references. I appreciate your consideration and
look forward to hearing from you soon.
John E. Baldacci
/yState Senator
�Senator John E. Baldacci
79 Palm Street
Bangor, Maine 04401
(207)947-6088 (h)
(207)945-5813 (w)
•Graduated from the University of Maine - 1986
Major: American History
Minor: Economics
•Manager: M m a Baldacci's Restaurant i n
om
Bangor, Maine since 1979. This has been
a family owned and operated business since 1933
•State Senator since 1982 - 6 terms
Chair - Business Legislation Committee
*City Councilor - Bangor - 1 term (1978 - 1981)
Personal References
United States Senator George Mitchell (D) Maine
United States Senator William Cohen (R) Maine
United States Representative Tom Andrews (D) Maine
Tom Allen - Clinton campaign coordinator -
Portland, Maine
David Leavy - Clinton/Gore Office - L i t t l e Rock, Arkansas
�HOUSE OF REPRESENTATIVES
FOURTH DISTRICT
LANSING. MICHIGAN
A S S I S T A N T M A J O R I T Y FLOOR
ALMA G. STALLWORTH
STATE CAPITOL BUILDING
LANSING. MICHIGAN 4 8 9 1 3
LEADER
March 23, 1993
LANSING PHONE- 15171 373-2276
COMMITTEES
PUBLIC UTILITIES. CHAIRPERSON
EDUCATIO!.
INSURA.'.CE
PUBLIC HEALTH
SENIOR CITIZENS AND RETIREMENT
Mrs. Hilary Rodham Clinton, Chair
President's Task Force on Health Care
c/o U.S. Secretary on Health
and Human Services Donna Shalala
White House
Washington, D.C. 20510
Dear Mrs. Clinton:
As you address national health care reform, I think the information we have gathered
on the infant mortality problem in Michigan may be useful. Hopefully, some of the
problems we have encountered will not be problems at the national level.
The infant mortality problem in Michigan and the United States needs to be
addressed.
This requires a comprehensive approach with local, state and federal
governments working together to solve the problems that continue to exist.
The infant mortality rate has been a source of concern for a number of years because
it is an indicator of Michigan's health status. The infant mortality rate is based on the
number of babies who die in their first year of life per 1,000 live births. New programs have
been initiated and more people are being served by those programs; however, there are still
women who are not getting prenatal care.
| Recycled
' Paper
�Risk factors for infant mortality include low and high maternal age, low educational
level, low economic status, inadequate prenatal care, and low birthweight. In 1980, the U.S.
Surgeon General proposed that the nation lower its overall infant mortality rate to 9 per
1,000 live births by 1990, with no subgroup's rate to exceed 12 per 1,000.
In 1990, the infant mortality rate in the U.S. was 9.2 per 1,000 births. The United
States ranked behind 19 other nations, including Hong Kong, Spain, Ireland, and Singapore.
Every 14 minutes an infant dies in the first year of life in America.
According to the Michigan Department of Public Health, the infant mortality rate
for 1990 showed a slight improvement.
MiVhiggn r t m t h * p^r 1 f¥Yl T i w Rirthc fnr thg P^rinH IQgS-qi
1985
All Births
Black Infants
White Infants
1986
1987
1988
1989
1990
1991
11.4
23.3
9.2
11.4
23.7
8.9
10.9
22.7
8.4
11.0
22.6
8.5
11.1
22.5
8.2
10.7
21.6
7.7
10.4
21.6
7.5
The percentage of women receiving inadequate prenatal care increasedfrom6.2
percent in 1988 to 7.3 percent in 1989. At the same time, the percentage of women
receiving adequate prenatal care declined from 72.3 percent in 1988 to 70.8 percent in 1989.
Adequate prenatal care is defined as a minimum of 10 prenatal care visits.
Prenatal care is cost-effective. Michigan Department of Public Health statistics show
that in fiscal year 1985-86, routine prenatal care cost $1,000. The average hospital stay
charged to Medicaid for a low birthweight baby in that year was $17,500. The baby's low
�3
birthweight might have been prevented if the mother had received prenatal care. According
to the Children's Defense Fund, every dollar spent on prenatal care saves more than $3 in
the child's first year of life by reducing costly remedial care.
Health care experts know that if women space their pregnancies, eat well, avoid
harmful substances and receive adequate prenatal care, the chances for infant survival
increase dramatically, according to the Michigan Department of Public Health.
In Michigan, we target 13 counties. They were chosen because they are the counties
in which nearly all black infant deaths and a majority of white deaths occur. The chart
below indicates the rates of infant mortahty, with the black rate in parentheses.
1989
1983-85
Berrien 13.8
Calhoun
Genesee
Ingham 10.9
Jackson 11.4
Kalamazoo
Kent
Macomb
Muskegon
Oakland
Saginaw
Washtenaw
Wayne 15.6
(25.7)
132
13.4
(21.0)
(25.1)
13.4
9.4
9.9
9.4
10.0
153
10.5
(23.4)
11.9
(24.4)
(21.6)
7.9
11.1
(24.7)
(23.2)
(22.6)
(15.2)
(21.7)
(28.6)
(18.2)
16.1
(15.3)
133
143
(N.C.)
(N.C.)
10.8
8.9
7.9
10.6
8.7
13.2
8.9
(23.1)
(23.6)
(23.0)
(15.9)
(15.8)
(N.C.)
(21.5)
(223)
(29.7)
(18.8)
NC ~ Rate is not calculated when there are fewer than five deaths because the rate is considered statistically
unreliable.
�Michigan has responded to the problem:
-- Women who are pregnant and under 185 percent of poverty are now eligible to get
their prenatal care through Medicaid.
~ To speed up the process, Michigan adopted a shortened Medicaid form in order
to assist with enrollment.
~ Approximately 80 agencies are certified to be maternal support service providers,
providing nutrition, psychological counseling and childbirth education.
~ We have estabhshed 10 paraprofessional outreach teams to get women into early
prenatal care in areas where the infant mortality rate is the highest.
~ Throughout our WIC program we have maximized the use of federal dollars.
- We have established 19 adolescent health centers.
�5
In March 1991, the House Public Health Subcommittee on Infant Mortality was
appointed by Representative Michael Bennane, Chair of the House Public Health
Committee. The charge to the subcommittee was to investigate the problem of infant
mortality and to recommend some viable solutions that the legislative body might institute
in hopes of lowering the rising infant mortality rate in Michigan.
The following members were appointed to the subcommittee:
Representative Alma Stallworth, Chair (Detroit)
Representative Sharon Gire (Clinton Twp.)
Representative Tracey Yokich (St. Clair Shores)
Representative Jack Horton (Comstock Park)
Representative Margaret O'Connor (Ann Arbor)
The subcommittee held four hearings on infant mortality in 1991. The schedule was
as follows:
May 10, Hutzel Hospital, Detroit
May 20, Saginaw City Council Chambers, Saginaw
June 7, Government Center, Traverse City
July 15, Kent County Health Department, Grand Rapids
�6
We heard the following examples of problems.
~ In Detroit, a Medicaid recipient reported she was only able to obtain prenatal care
at Detroit's Hutzel Hospital. There were no physicians accepting Medicaid clients in her
immediate area.
- In Saginaw, a woman began her prenatal care in her third month and after she
made two doctor's visits and then became eligible for Medicaid, the doctor refused to
provide further care. Saginaw
~ In Traverse City, a new prenatal clinic opened at Grand Traverse Community
Hospital in 1987. In 1987, the number of admissions was 48; in 1990, 144; and a hold on
future admissions took effect in November.
~ In Grand Rapids, women eligible for Medicaid are only able to be served at one
of the area hospital clinics, which has a waiting Ust of four to six weeks to see a nurse for
the initial interview. There is another one- to three-week wait to see a physician.
~ In Lenawee County, a pregnant teenager arrived at a local hospital. The hospital
told her that no physician would assist in the delivery because she was a Medicaid patient
and had no prenatal care. The teenager had to find her own transportation to the
University of Michigan Hospital and the baby was bom prematurely and at a low
birthweight.
�7
- In Ingham County, over 90 percent of the care to Medicaid-eligible women is
provided in five physicians' offices.
In addition, we gathered the following information from the approximately 100
people who have testified.
~ Access to prenatal care is more difficult now, because fewer physicians are taking
Medicaid patients. In spite of the increase to 185 percent of the poverty level to be eligible
for Medicaid, physicians are not available and there are not enough prenatal care clinics
located throughout the state.
~ Transportation to prenatal services continues to be a problem because as clients
locate physicians and/or clinics which will provide prenatal care, they have farther distances
to travel.
~ Clients and providers are concerned about the continued services needed for
children after they have reached three months of age. Recently the Maternal Support
Services Program was expanded to one year after birth.
~ All services, such as substance abuse treatment, family planning and teen health
centers, are stretching their capacity and are unable to meet the demand. The public
�8
information campaign, "Baby Your Baby," launched by the Department of Public Health last
year has helped to inform women about the need for early prenatal care.
-- Medical malpractice costs and the low reimbursement for Medicaid are often cited
as reasons for some of the access problems. Also, certified nurse practitioners want to be
directly reimbursed by third-party payers for their services.
- Overall, clients and providers are pleased with the new initiatives the state has
undertaken during the last several years, such as the paraprofessional outreach program,
maternal support services program and substance abuse treatment programs for pregnant
women; however, none of the programs is meeting the current needs.
- Michigan's Medicaid program should adopt presumptive eligibility so that women
are more easily enrolled.
~ The state should fund the establishment or continuation of neighborhood clinics
which provide an array of prenatal, postnatal and infant care.
When establishing a national program, I think it is important to address some of
these issues:
�9
1.
More physicians, especially primary care physicians, have to participate in the
program you establish. It doesn't do any good to give people Medicaid cards if there are
no physicians in the area accepting Medicaid patients.
2.
Health care programs must be preventive and continuous. We have to see
people throughout their lives in order to keep them healthy.
3.
Health care services need to be available in the local community, be readily
accessible, and open hours other than during the normal 9-5 schedule. In some areas,
supportive services may be needed for transportation and/or child care.
4.
People need to be more educated about their role in maintaining healthy
lifestyles. More education is needed about proper nutrition, avoidance of substance abuse
and the need for exercise.
5.
Special health care programs for those with special needs will need to be
continued.
This testimony provides you with some additional information about Michigan's
problems. Hopefully, you and the task force can learn from our efforts.
Alma G. Stallworth, State Representative
Twelfth House District
�• •.•rs?
HOUSE OF REPRESENTATIVES
FOURTH DISTRICT
LANSING. MICHIGAN
ASSISTANT MAJORITY
ALMA G. STALLWORTH
STATE CAPITOL BUILDING
LANSING. MICHIGAN 4 8 9 1 3
FLOOR
LEADER
March 23, 1993
LANSING PHONE: 15171 373-2276
COMMITTEES
PUBLIC UTILITIES. CHAIRPERSON
EDUCATION
INSURANCE
PUBLIC HEALTH
SENIOR CITIZENS AND RETIREMENT
Mrs. Hilary Rodham Clinton, ChanPresident's Task Force on Health Care
c/o U.S. Senator Donald W. Reigle, Jr.
105 Senator-Dirksen
Washington, D.C. 20510
Dear Mrs. Chnton:
As you address national health care reform, I think the information we have gathered
on the infant mortality problem in Michigan may be useful. Hopefully, some of the
problems we have encountered will not be problems at the national level.
The infant mortality problem in Michigan and the United States needs to be
addressed.
This requires a comprehensive approach with local, state and federal
governments working together to solve the problems that continue to exist.
The infant mortality rate has been a source of concern for a number of years because
it is an indicator of Michigan's health status. The infant mortality rate is based on the
number of babies who die in their first year of life per 1,000 live births. New programs have
been initiated and more people are being served by those programs; however, there are still
women who are not getting prenatal care.
Risk factors for infant mortality include low and high maternal age, low educational
level, low economic status, inadequate prenatal care, and low birthweight. In 1980, the U.S.
®
Recycled
Paper
�Surgeon General proposed that the nation lower its overall infant mortality rate to 9 per
1,000 live births by 1990, with no subgroup's rate to exceed 12 per 1,000.
In 1990, the infant mortahty rate in the U.S. was 9.2 per 1,000 births. The United
States ranked behind 19 other nations, including Hong Kong, Spain, Ireland, and Singapore.
Every 14 minutes an infant dies in the first year of life in America.
According to the Michigan Department of Public Health, the infant mortality rate
for 1990 showed a slight improvement.
Michigan Deaths per 1,000 live Births for the Period 1985-91
1985
All Births
Black Infants
White Infants
1986
1987
1988
1989
1990
1991
11.4
23.3
9.2
11.4
23.7
8.9
10.9
22.7
8.4
11.0
22.6
8.5
11.1
22.5
8.2
10.7
21.6
7.7
10.4
21.6
7.5
The percentage of women receiving inadequate prenatal care increased from 6.2
percent in 1988 to 7.3 percent in 1989. At the same time, the percentage of women
receiving adequate prenatal care declined from 72.3 percent in 1988 to 70.8 percent in 1989.
Adequate prenatal care is defined as a minimum of 10 prenatal care visits.
Prenatal care is cost-effective. Michigan Department of Public Health statistics show
that in fiscal year 1985-86, routine prenatal care cost $1,000. The average hospital stay
charged to Medicaid for a low birthweight baby in that year was $17,500. The baby's low
birthweight might have been prevented if the mother had received prenatal care. According
�3
to the Children's Defense Fund, every dollar spent on prenatal care saves more than $3 in
the child's first year of life by reducing costly remedial care.
Health care experts know that if women space their pregnancies, eat well, avoid
harmful substances and receive adequate prenatal care, the chances for infant survival
increase dramatically, according to the Michigan Department of Public Health.
In Michigan, we target 13 counties. They were chosen because they are the counties
in which nearly all black infant deaths and a majority of white deaths occur. The chart
below indicates the rates of infant mortality, with the black rate in parentheses.
1983-85
Berrien
Calhoun
Genesee
Ingham
Jackson
Kalamazoo
Kent
Macomb
Muskegon
Oakland
Saginaw
Washtenaw
Wayne
13.8
13.2
13.4
10.9
11.4
13.4
9.4
9.9
9.4
10.0
15.3
10.5
15.6
(25.7)
(24.4)
(21.6)
(21.0)
(25.1)
(24.7)
(23.2)
(22.6)
(15.2)
(21.7)
(28.6)
(18.2)
(23.4)
1989
11.9
13.3
14.3
7.9
11.1
10.8
8.9
7.9
10.6
8.7
13.2
8.9
16.1
(15.3)
(23.6)
(23.0)
(N.C.)
(N.C.)
(15.9)
(15.8)
(N.C.)
(21.5)
(22.3)
(29.7)
(18.8)
(23.1)
NC ~ Rate is not calculated when there are fewer than five deaths because the rate is
considered statistically unreliable.
�Michigan has responded to the problem:
- Women who are pregnant and under 185 percent of poverty are now eligible to get
their prenatal care through Medicaid.
- To speed up the process, Michigan adopted a shortened Medicaid form in order
to assist with enrollment.
~ Approximately 80 agencies are certified to be maternal suppon service providers,
providing nutrition, psychological counseling and childbirth education.
~ We have estabhshed 10 paraprofessional outreach teams to get women into early
prenatal care in areas where the infant mortahty rate is the highest.
- Throughout our WIC program we have maximized the use of federal dollars.
- We have established 19 adolescent health centers.
�5
In March 1991, the House Public Health Subcommittee on Infant Mortality was
appointed by Representative Michael Bennane, Chair of the House Public Health
Committee. The charge to the subcommittee was to investigate the problem of infant
mortality and to recommend some viable solutions that the legislative body might institute
in hopes of lowering the rising infant mortality rate in Michigan.
The following members were appointed to the subcommittee:
Representative Alma Stallworth, Chair (Detroit)
Representative Sharon Gire (Chnton Twp.)
Representative Tracey Yokich (St. Clair Shores)
Representative Jack Horton (Comstock Park)
Representative Margaret O'Connor (Ann Arbor)
The subcommittee held four hearings on infant mortality in 1991. The schedule was
as follows:
May 10, Hutzel Hospital, Detroit
May 20, Saginaw City Council Chambers, Saginaw
June 7, Government Center, Traverse City
July 15, Kent County Health Department, Grand Rapids
�6
We heard the following examples of problems.
~ In Detroit, a Medicaid recipient reported she was only able to obtain prenatal care
at Detroit's Hutzel Hospital. There were no physicians accepting Medicaid clients in her
immediate area.
~ In Saginaw, a woman began her prenatal care in her third month and after she
made two doctor's visits and then became eligible for Medicaid, the doctor refused to
provide further care. Saginaw
- In Traverse City, a new prenatal clinic opened at Grand Traverse Community
Hospital in 1987. In 1987, the number of admissions was 48; in 1990, 144; and a hold on
future admissions took effect in November.
-- In Grand Rapids, women eligible for Medicaid are only able to be served at one
of the area hospital chnics, which has a waiting list of four to six weeks to see a nurse for
the initial interview. There is another one- to three-week wait to see a physician.
~ In Lenawee County, a pregnant teenager arrived at a local hospital. The hospital
told her that no physician would assist in the delivery because she was a Medicaid patient
and had no prenatal care. The teenager had to find her own transportation to the
University of Michigan Hospital and the baby was bom prematurely and at a low birthweight.
�7
~ In Ingham County, over 90 percent of the care to Medicaid-eligible women is
provided in five physicians' offices.
In addition, we gathered the following information from the approximately 100
people who have testified.
~ Access to prenatal care is more difficult now, because fewer physicians are taking
Medicaid patients. In spite of the increase to 185 percent of the poverty level to be eligible
for Medicaid, physicians are not available and there are not enough prenatal care clinics
located throughout the state.
~ Transportation to prenatal services continues to be a problem because as chents
locate physicians and/or clinics which will provide prenatal care, they have farther distances
to travel.
~ Chents and providers are concerned about the continued services needed for
children after they have reached three months of age. Recently the Maternal Support
Services Program was expanded to one year after birth.
~ All services, such as substance abuse treatment, family planning and teen health
centers, are stretching their capacity and are unable to meet the demand. The public
�8
information campaign, "Baby Your Baby," launched by the Department of Public Health last
year has helped to inform women about the need for early prenatal care.
- Medical malpractice costs and the low reimbursement for Medicaid are often cited
as reasons for some of the access problems. Also, certified nurse practitioners want to be
directly reimbursed by third-party payers for their services.
~ Overall, chents and providers are pleased with the new initiatives the state has
undertaken during the last several years, such as the paraprofessional outreach program,
maternal support services program and substance abuse treatment programs for pregnant
women; however, none of the programs is meeting the current needs.
~ Michigan's Medicaid program should adopt presumptive eligibility so that women
are more easily enrolled.
~ The state should fund the establishment or continuation of neighborhood clinics
which provide an array of prenatal, postnatal and infant care.
When establishing a national program, I think it is important to address some of
these issues:
�9
1.
More physicians, especially primary care physicians, have to participate in the
program you establish. It doesn't do any good to give people Medicaid cards if there are
no physicians in the area accepting Medicaid patients.
2.
Health care programs must be preventive and continuous. We have to see
people throughout their lives in order to keep them healthy.
3.
Health care services need to be available in the local community, be readily
accessible, and open hours other than during the normal 9-5 schedule. In some areas,
supportive services may be needed for transportation and/or child care.
4.
People need to be more educated about their role in maintaining healthy
lifestyles. More education is needed about proper nutrition, avoidance of substance abuse
and the need for exercise.
5.
Special health care programs for those with special needs will need to be
continued.
This testimony provides you with some additional information about Michigan's
problems. Hopefully, you and the task force can learn from our efforts.
JK:js/93075JK2.JLS
�1.
More physicians, especially primary care physicians, have to participate in the
program you estabhsh. It doesn't do any good to give people Medicaid cards if there are
no physicians in the area accepting Medicaid patients.
2.
Health care programs must be preventive and continuous. We have to see
people throughout their lives in order to keep them healthy.
3.
Health care services need to be available in the local community, be readily
accessible, and open hours other than during the normal 9-5 schedule. In some areas,
supportive services may be needed for transportation and/or child care.
4.
People need to be more educated about their role in maintaining healthy
lifestyles. More education is needed about proper nutrition, avoidance of substance abuse
and the need for exercise.
5.
Special health care programs for those with special needs will need to be
continued.
This testimony provides you with some additional information about Michigan's
problems. Hopefully, you and the task force can learn from our efforts.
Alma G. Stallworth, State Representative
*" Twelfth House District
�John Hall, Chairman
Pam Reed, Commissioner
Peggy Garner, Commissioner
TEXAS WATER COMMISSION
1
PROTECTING TEXASS HEALTH AND SAFETY BY PREVENTING AND REDUCING POLLUTION
March 11, .199 3
H i l l a r y Rodham C l i n t o n , C h a i r
N a t i o n a l Health Care Task Force
The White House
Washington, DC 20500
Dear Chairman C l i n t o n :
I have been honored to serve as Commissioner under the appointment
of Texas' Governor Ann Richards t o t h e Texas Water Commission. I
a l s o s e r v e as a volunteer on t h e Board of the Permian Basin
Regional Council on Alcohol and Drug Abuse (PBRCADA). The Council
c u r r e n t l y s e r v e s 17 counties i n West Texas.
My purpose i n w r i t i n g t o you i s t o r e s p e c t f u l l y request t h a t
a l c o h o l and drug treatment b e n e f i t s be included a s p a r t of any
h e a l t h c a r e reform package.
I s t r o n g l y support c o s t e f f e c t i v e
treatment
f o r a l c o h o l i c s , drug-dependent persons and t h e i r
families.
I n my v o l u n t e e r c a p a c i t y with t h e PBRCADA, I have seen t h e expense
of a l c o h o l and drug a d d i c t i o n treatment and r e a l i z e t h e importance
of s p e c i a l i z e d treatment programs and f a c i l i t i e s .
I hope t h a t
Health Care Reform w i l l deal e f f e c t i v e l y with t h i s i s s u e .
Sincerely,
PeqqyJ corner, Commissioner
Texas Water Commission
PG/av
cc:
Pamela Bowerman, PBRCADA, 3 641 N. D i x i e , Odessa, TX 79762
C h r i s t i n e L u b i n s k i , National Council on Alcoholism & Drug
Dependence, 1511 K S t r e e t , NW, Ste. 926, Washington, DC 20005
'.(). Box i;i087 • 1700 North Congress Avenue • Austin, Texas 78711-3087 • 512/463-7830
�/
JAMES A. BARNES
SPEAKER PRO TEM
MISSOURI HOUSE OF REPRESENTATIVES
JEFFERSON CITY, MISSOURI 65101
February 5, 1993
Mrs. H i l l a r y Rodham C l i n t o n
Chair, President's Health Care Task Force
The White House
Washington, DC
Dear Mrs. C l i n t o n :
Reforming the h e a l t h system i s a complex p r o p o s i t i o n , but one t h a t
must be addressed i f we are t o contain costs and provide a f f o r d a b l e
access t o care f o r a l l who need i t . I n M i s s o u r i , we are working t o
improve access t o caro through an omnibus h e a l t h access package
f i l e d by the Speaker o f the House, Bob F. G r i f f i n , a copy of which
I have enclosed f o r your review.
House B i l l 564 does not attempt t o reform t h e payor system, but
r a t h e r addresses some of the i n f r a s t r u c t u r a l b a r r i e r s t o care t h a t
Missourians face. As Legal Counsel t o the Speaker Pro Tern, I have
been working c l o s e l y w i t h the Speaker and h e a l t h care advocates t o
develop t h i s b i l l and t o work f o r i t s passage.
As t h e b i l l has c i r c u l a t e d , we are hearing three major concerns,
p r i m a r i l y from the insurance lobby, which I b e l i e v e you w i l l hear
from other s t a t e s t h a t are attempting some l e v e l of reform:
1)
mandating community-based r a t i n g f o r p r i v a t e insurance
companies i s u n f a i r , because the p r o v i s i o n s of ERISA
exempt many "communities" from the p o t e n t i a l p o o l ;
2)
any insurance reform we might attempt w i l l have a
negative impact on cost s h i f t i n g because t h e reforms do
not apply t o ERISA plans; and,
3)
President C l i n t o n has i n d i c a t e d he w i l l a c t on h e a l t h
care i n the f i r s t one hundred days, so why don't we w a i t
and see what comes down from the f e d e r a l l e v e l ?
�2/Clinton
I n s p i t e o f t h e s e concerns, we f e e l c e r t a i n t h a t t h e Speaker w i l l
move f o r w a r d w i t h h i s b i l l .
Since these a r e l e g i t i m a t e q u e s t i o n s ,
we must be p r e p a r e d t o p r o v i d e t h e answers. We b e l i e v e t h a t t h e
p r o p o s a l s i n House B i l l 564 a r e c o m p a t i b l e w i t h P r e s i d e n t C l i n t o n ' s
stated
goals
i n addressing
t h e problems
i n h e a l t h care.
N e v e r t h e l e s s , i t would be e x t r e m e l y h e l p f u l f o r us t o hear y o u r
feedback on House B i l l 546 and t o a r r a n g e some means by w h i c h we
can be k e p t i n f o r m e d o f p r o g r e s s on t h i s i s s u e a t t h e f e d e r a l
level.
I w i s h you success w i t h t h e t a s k f o r c e and l o o k f o r w a r d t o h e a r i n g
from y o u .
Sincerely,
Andrea J. Rc
Legal Counsel
O f f i c e o f t h e Speaker Pro Tern
end.
cc
Bob F. G r i f f i n , Speaker o f t h e House
House M a j o r i t y Leader R i c h a r d Gephardt
�SPEAKER GRIFFIN'S HEALTH CARE PACKAGE — L-R. 1279-1
This b i l l concerns the financing and delivery of health care
services. I t addresses the following topics:
STATE LEGAL EXPENSE FOND
The b i l l revises the c r i t e r i a for coverage under the State Legal
Expense Fund for l i a b i l i t y judgments or settlements against
medical care providers. L i a b i l i t y judgements and settlements
against physicians, dentists, nurses, and physician a s s i s t a n t s
who provide noninvasive primary or preventative care for free a t
a c i t y or county health department or nonprofit health center or
at a public elementary or secondary school s i t e w i l l be covered,
as w i l l judgments or settlements against a c i t y or county health
department based upon care provided under i t s contract with a
physician to provide free care at a c i t y or county health
department or nonprofit health center. Until July 1, 1996, the
Office of Administration w i l l purchase insurance p o l i c i e s to
cover the potential l i a b i l i t y described in the previous sentence.
On or before January 1, 1996, the Commissioner of Administration
w i l l prepare a report on the cost-effectiveness of insuring
against potential losses by the d i r e c t purchase of insurance
p o l i c i e s as opposed to self-insuring through the State Legal
Expense Fund. This portion of the b i l l also consolidates
duplicative language describing procedures governing coverage of
l i a b i l i t y awards against health care providers under the State
Legal Expense Fund.
PHYSICIAN LOAN PROGRAMS
Current law allows medical students to receive loans from the
Department of Health of up to $6000 per academic year; repayment
of one-fourth of the p r i n c i p a l and interest of such a loan w i l l
be forgiven for each year that the physician practices in an area
of physician shortage after he or she completes a residency in a
primary care specialty. This b i l l raises the limit on such loans
to $7500 per academic year. I t also allows a fund in the state
treasury currently used to repay the educational loans of
practicing .physicians who work in underserved areas to be used to
make loans and receive payments under the medical student loan
program.
"COLLABORATIVE PRACTICE" AMONG HEALTH CARE PROVIDERS
The authority of a physician, dentist, podiatrist, or optometrist
to cause a nurse or intern to administer a controlled substance
under h i s or her direction and supervision w i l l be done i n
accordance with chapter 334, which governs the licensure of
physicians. The requirement that a physician e s t a b l i s h a
physician-patient relationship before prescribing or dispensing
controlled substances i s repealed. This b i l l permits a physician
�to allow a prescription to be written by a nonphysician under h i s
supervision, instructions, or protocol, so long as the authority
to prescribe w i l l be limited to those health care professionals
authorized to do so under current law. A physician may enter
into a written agreement with another licensed health care
professional or a registered physician a s s i s t a n t to provide
medical examination, medicine, or treatment i n accordance with
the license of the health care professional or the r e g i s t r a t i o n
of the physician a s s i s t a n t . A physician who works under such an
agreement w i l l not be considered to be helping an unlicensed
person practice medicine.
The State Board of Registration for the Healing Arts w i l l not
take licensure d i s c i p l i n a r y action against a physician for acts
arising out of an agreement with a licensed health care
professional or registered physician a s s i s t a n t acting within the
scope of h i s or her license or r e g i s t r a t i o n . After October 1,
1993, any such agreement w i l l be written. The b i l l also provides
for removal and nondisclosure of records of previous licensure
action or investigations against a physician stemming from such
an agreement.
A pharmacist may f i l l a prescription as directed by a licensed
health care professional or registered physician a s s i s t a n t acting
under a written agreement with a physician. The written
agreement w i l l s p e c i f i c a l l y state that the person i s authorized
to d i r e c t a pharmacist to f i l l a prescription on behalf of the
physician. The State Board of Pharmacy may issue implementing
regulations.
COUNCIL ON COMPREHENSIVE SCHOOL HEALTH
The b i l l also creates a "Interagency Council on Comprehensive
School Health Improvement" i n the Department of Elementary and
Secondary Education. I t w i l l be comprised of two gubernatorial
appointees and five state agency directors. The council w i l l
develop plans and funding recommendations to enhance
comprehensive school health. I t w i l l also award grants to school
d i s t r i c t s or local health departments. Grants to l o c a l health
departments w i l l be distributed through the Department of Health.
After establishing quantifiable objectives to be achieved by
grant recipients for each of the various components of school
health as described in the b i l l , the council w i l l make grant
awards based upon applications submitted on a competitive basis.
The grants w i l l be made expressly to allow the r e c i p i e n t s to
achieve those objectives and recipients whose funded projects do
not do so w i l l be i n e l i g i b l e for further grants regarding that
component. The b i l l directs the council to give preference i n
awarding grants to applicants who are determined to be l e a s t able
to improve school health without the grant assistance, or whose
projects concern components of higher p r i o r i t y as l i s t e d i n the
b i l l , or projects that can be continued a f t e r the grant ends.
�Matching funds requirements are established for the grants.
Grants w i l l be made from a separate fund created in the state
treasury.
HEALTH INSURANCE PURCHASING POOL
The b i l l also creates a not-for-profit Health Insurance
Purchasing Pool, which w i l l provide health insurance coverage to
businesses employing f i v e or fewer full-time employees during a
year, the premiums charged for coverage w i l l be s u f f i c i e n t to
cover current and future l i a b i l i t i e s incurred by the pool. The
state may appropriate funds to pay a l l or part of the
administrative expenses of the pool. The benefit plan or plans
offered by the pool w i l l be approved by the director of the
Department of Insurance, who w i l l also set i t s reserve
requirements.
The pool w i l l be governed by a nine-member board of directors
comprised of the director of the Department of Insurance and
gubernatorial appointees representing various i n t e r e s t s . Board
members w i l l not be c i v i l l y l i a b l e for acts or decisions in the
lawful performance of t h e i r duties, other than for reckless or
intentional acts affecting a person's property or r i g h t s . The
board's powers to administer the pool and to contract for
administrative services are described. The board w i l l use
managed care delivery arrangements where they are cost-effective
and provide reasonable access to care. The Division of
Employment Security w i l l make information available to the pool
so as to identify employers e l i g i b l e to participate but the
information released to the pool w i l l not be further disclosed in
a form which i d e n t i f i e s an individual employer or group of
employers.
CONTINUATION OF COVERAGE FOR SURVIVING SPOUSES
The b i l l requires group insurance p o l i c i e s covering hospital or
medical expenses, except p o l i c i e s limited to expenses from
accident or s p e c i f i c diseases, to contain a provision that a
surviving, divorced or legally separated spouse older than 55 may
continue coverage as part of the group. This portion of the b i l l
w i l l apply only to employers of twenty or more and p o l i c i e s ,
contracts, or plans with twenty or more c e r t i f i c a t e holders.
The
monthly premium for continuation of coverage cannot be raised by
more than two percent of current c e r t i f i c a t e holder and group
plan holder contributions.
MEDICAID—BASED INSURANCE PRODUCT
On or a f t e r July 1, 1995, the Department of Social Services may
s e l l a health insurance policy offered through the Medicaid
program. Premiums w i l l be set to pay the f u l l cost of insuring
beneficiaries. The director of the Department of S o c i a l Services
�w i l l determine which Medicaid services w i l l be included i n t h e
b e n e f i t plan. The p o l i c y may be sold t o : (1) s u r v i v i n g spouses
e l i g i b l e f o r but unable t o a f f o r d c o n t i n u a t i o n o f group coverage
under t h e previous s e c t i o n ; (2) a d u l t s over 21 who are n o t
pregnant and reside i n households w i t h incomes which do n o t
exceed two hundred percent o f the f e d e r a l poverty l e v e l f o r t h e
a p p l i c a b l e f a m i l y s i z e ; and (3) dependents of an insured person
who r e s i d e i n households w i t h incomes which do not exceed one
hundred e i g h t y - f i v e percent o f the f e d e r a l poverty l e v e l f o r t h e
a p p l i c a b l e f a m i l y s i z e . A p o l i c y sold under t h i s p a r t o f t h e
b i l l w i l l conform t o requirements governing group h e a l t h
insurance. The Department o f Social Services w i l l e s t a b l i s h
r e g u l a t i o n s governing these p o l i c i e s .
PILOT PROJECT FOR ALTERNATIVE CHEMICAL DEPENDENCY TREATMENT
BENEFITS
Beginning J u l y 1, 1994, the M i s s o u r i Consolidated Health Care
Plan w i l l implement a p i l o t p r o j e c t t o provide an a l t e r n a t i v e s e t
of b e n e f i t s f o r the treatment o f chemical dependency. The
b e n e f i t s w i l l include those o f f e r e d under the Department o f
Mental Health's Comprehensive Substance Treatment and
R e h a b i l i t a t i o n program, commonly r e f e r r e d t o as C-STAR. The
p i l o t p r o j e c t w i l l operate f o r up t o f o u r years. P a r t i c i p a t i o n
w i l l be v o l u n t a r y t o the e x t e n t t h a t i t involves a d d i t i o n a l cost
t o the insured member. The p i l o t p r o j e c t w i l l be evaluated as t o
the costs and b e n e f i t s o f the a l t e r n a t i v e coverage.
EMPLOYER LIABILITY FOR EMPLOYEE MEDICAID EXPENDITURES
An employer of a person who works more than t w e n t y - f i v e hours per
week f o r more than f o r t y - f i v e weeks a year which does not provide
him or her w i t h an insurance plan which meets the standards
established under c u r r e n t law f o r "basic health plans" marketed
to small employers w i l l be l i a b l e t o the s t a t e f o r f o r t y percent
of any Medicaid payment made f o r medical care of t h a t employee
which would have been covered under a basic health plan. This
l i a b i l i t y w i l l not extend t o the care of those who purchase
insurance throu<^fc the Medicaid program as made a v a i l a b l e under
t h i s b i l l . The b i l l describes procedures governing payment
notices and appeals.
INSURANCE RATING PRACTICES AND THE CONTENT OF POLICIES
The b i l l places several requirements on the content and premiums
of h e a l t h insurance p o l i c i e s , plans, and contracts which are
issued, continued, or renewed a f t e r J u l y 1, 1996. Premiums f o r
such p o l i c i e s w i l l be based upon a system o f community r a t i n g
t h a t w i l l regard a l l prospective purchasers as being o f t h e "same
class and hazard" as used i n the U n f a i r Trade P r a c t i c e s Act,
except t h a t d i f f e r e n t premiums may be charged f o r those i n
d i f f e r e n t age cohorts, each o f which w i l l include a t l e a s t t e n
�years. Premiums may also vary between geographical premium
rating areas as established by the director of the Department of
Insurance. Not more than five Standard Metropolitan S t a t i s t i c a l
Areas may be designated as separate premium rating areas and the
geographical areas not included in a Standard Metropolitan
S t a t i s t i c a l Area w i l l be incorporated into not more than f i v e
premium rating areas.
Also, the director of the Department of
Insurance w i l l establish by rule up to f i v e standardized health
insurance benefit packages. After July 1, 1996, health insurance
p o l i c i e s and plans must conform to one of those standardized
benefit packages.
One of the benefit packages established by the director of the
Department of Insurance w i l l provide that a percentage of the
t o t a l premium w i l l be credited to an individual medical account
created on behalf of the insured person and any dependents. The
director of the Department of Insurance w i l l determine the
percentage. Funds in the account may used to pay for medical
expenses and w i l l be free from state income tax when they are
used for that purpose or l e f t in the account. Money unspent at
the end of a year w i l l remain in the account; however, any amount
above a balance as set by the director of the Department of
Insurance may be withdrawn by the insured and w i l l then be
subject to state income tax. The insurer or plan sponsor w i l l
administer the account on behalf of the insured person.
The
portion of the premium not credited to the individual medical
account w i l l be used to purchase or provide insurance coverage of
health care expenses which exceed the amount in the individual
medical account and any deductible or copayment requirement
established by the director of the Department of Insurance.
Before January 15, 1995, the director of the Department of
Insurance w i l l submit a report to the Governor and General
Assembly regarding the effects of establishing community rating,
geographical premium rating areas, and a limited number of
standardized benefit packages and w i l l include recommendations as
to statutory revisions necessary to conform to these requirements
by July 1, 1996.
JOINT COMMITTEE ON HEALTH CARE POLICY AND PLANNING
The b i l l also creates a l e g i s l a t i v e Joint Committee on Health
Care Policy and Planning, comprised of f i v e representatives and
five senators. The committee w i l l monitor the design and
implementation of i n i t i a t i v e s enacted under t h i s b i l l to ensure
t h e i r effective evaluation, monitor the effect of t h i s and other
l e g i s l a t i o n on the delivery of health services, analyze policy
proposals, and make recommendations regarding state health policy
and planning. The Joint Committee w i l l terminate on December 31,
1999.
�EVALUATION OF THE BILL'S EFFECTS
Various s t a t e agencies w i l l conduct evaluations of t h e e f f e c t o f
the components of the b i l l .
CREATION OF A FUNDING ACCOUNT
The b i l l also creates a "Health I n i t i a t i v e s Fund" i n t h e s t a t e
t r e a s u r y . Appropriations from t h e fund w i l l be used s o l e l y t o
provide funding f o r the new programs and i n i t i a t i v e s e s t a b l i s h e d
by t h e b i l l . Money i n t h e fund w i l l not r e v e r t t o t h e General
Revenue fund.
EFFECTIVE DATE OF PREVIOUSLY ENACTED LAW ON SMALL EMPLOYER
POLICIES
The e f f e c t i v e date o f several sections o f law p e r t a i n i n g t o
h e a l t h insurance f o r small employers as enacted i n 1992 w i l l
become e f f e c t i v e on August 28, 1993 r a t h e r than J u l y 1, 1993.
PRE-EXISTING CONDITION EXCLUSIONS IN INSURANCE PLANS
Beginning January 1, 1994, t h e b i l l w i l l r e q u i r e t h a t
p r e - e x i s t i n g c o n d i t i o n r e s t r i c t i o n s as used i n group h e a l t h
insurance p o l i c i e s , i n d i v i d u a l h e a l t h insurance p o l i c i e s , h e a l t h
insurance p o l i c i e s marketed t o small employers, t h e M i s s o u r i
High-Risk Pool, and by t h e Missouri Consolidated Health Plan may
impose coverage exclusions f o r s i x months r a t h e r than t h e c u r r e n t
twelve months. P r e - e x i s t i n g c o n d i t i o n r e s t r i c t i o n s under these
p o l i c i e s w i l l apply t o a c o n d i t i o n f o r treatment was received o r
should have been sought during t h e s i x months p r i o r t o coverage
or t o a pregnancy e x i s t i n g on t h e e f f e c t i v e date o f coverage. A
group or i n d i v i d u a l p o l i c y w i l l waive i t s p r e - e x i s t i n g c o n d i t i o n
exclusion f o r the period o f time t h e insured person was
p r e v i o u s l y covered under another h e a l t h insurance p o l i c y o r plan
t h a t covered or would have covered the excluded services, so long
as t h e previous coverage was continuous t o not less than t h i r t y
days p r i o r t o coverage under t h e new p o l i c y .
MEDICAID EXPANSION
Current law provides Medicaid coverage f o r pregnant women and
i n f a n t up t o age one i n households w i t h incomes o f up t o 13 3% of
the f e d e r a l poverty l e v e l . Pregnant women are covered only f o r
pregnancy-related expenses. This b i l l extends such Medicaid
coverage t o pregnant women and i n f a n t s i n households w i t h incomes
of up t o 150% of the f e d e r a l poverty l e v e l as of January 1, 1994,
165% o f t h e f e d e r a l poverty l e v e l as of January 1, 1995, 175% of
the f e d e r a l poverty l e v e l as o f January 1, 1996, and 185% o f t h e
f e d e r a l poverty l e v e l as o f January 1, 1997.
�Under c u r r e n t Medicaid law, c h i l d r e n age 9 t o 18 i n households
w i t h incomes under the f e d e r a l poverty l e v e l w i l l be made
e l i g i b l e f o r Medicaid coverage over the next nine years, w i t h t h e
oldest i n t h i s group not covered u n t i l 2002. This b i l l provides
f o r coverage o f these c h i l d r e n age nine t o eighteen as o f January
1, 1994. Coverage w i l l be made a v a i l a b l e using a r e v i s e d income
assessment methodology a v a i l a b l e under f e d e r a l law.
Beginning J u l y 1, 1995, Medicaid w i l l be made a v a i l a b l e by
a p p r o p r i a t i o n f o r categories of the "medically needy" whose
incomes are too high t o otherwise q u a l i f y f o r Medicaid
e l i g i b i l i t y under present standards. However, those incomes may
not exceed 133% o f the income e l i g i b i l i t y standard f o r t h e
a p p l i c a b l e f a m i l y s i z e under the A i d - t o Families w i t h Dependent
Children (AFDC) program. The Department o f S o c i a l Services w i l l
determine the amount and scope o f b e n e f i t s by r u l e .
FUNDING
As o f October 1, 1993, the b i l l : (1) r a i s e s the c i g a r e t t e tax by
four cents per pack; (2) r a i s e s the t a x on beer by twenty cents
per g a l l o n ; and (3) d i r e c t s the General Assembly t o appropriate a
percentage o f the s t a t e ' s net gain from the f e d e r a l reimbursement
allowance program established i n 1992.
(The f e d e r a l
reimbursement allowance program l e v i e d a tax on i n p a t i e n t
h o s p i t a l s e r v i c e s ) . I n f i s c a l year 1994, the percentage w i l l be
f i f t e e n percent; i n subsequent f i s c a l years, the percentage w i l l
be twenty percent. The proceeds from these' taxes and
appropriations w i l l be c r e d i t e d t o the Health I n i t i a t i v e s Fund
created e a r l i e r i n the b i l l .
�Clinton Presidential Records
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This marker identifies the place of a publication.
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�si.
FIRST REGULAR SESSION
HOUSE BILL NO. 564
87TH G E N E R A L A S S E M B L Y
INTRODUCED BY REPRESENTATIVES GRIFFIN (Sponsor), GUNN, FARMER,
STEINMETZ, OVERSCHMIDT, SMITH (11), LUMPE, BOUCHER, MAXWELL,
FIEBELMAN, SHEAR, ORDOWER, PARK, SCHEMENAUER, MACDONNELL,
HUMPHREYS, McBRIDE, BLAND, WEBER, WILLIAMS (121), MITCHELL, RIZZO,
KLUMB, POLIZZI, CHATFIELD, HOPPE, SKAGGS, McNEILL, McLUCKIE,
O'NEILL, BRAY, WARD, FRANKLIN, HAGAN-HARRELL, DONOVAN, MAYS,
MOLLOY AND KASTEN.
Read 1st time January 21,1993 and 1000 copies ordered printed.
DOUGLAS W. BURNETT, Chief Clerk
A N ACT
To repeal sections 105.721, 149.011, 149.015, 149.065, 311.520,
312.230, and 376.426, RSMo 1986, and sections 103.098,
105.711, 191.520, 191.600, 195.070, 208.151, 334.100,
376.986, and 379.940, RSMo Supp. 1992, relating to the
delivery of health care, and to enact in lieu thereof fortythree new sections relating to the same subject, with
effective dates for certain sections and a termination
date for certain sections.
Be it enacted
by the General Assembly
of the state of Missouri,
as
follows:
Section A. Section 105.721, RSMo 1986, and sections
103.098, 105.711, 191.520, 191.600, 195.070, and 334.100,
RSMo Supp. 1992, are repealed, and thirty-one new
sections enacted in lieu thereof, to be known as sections
105.711, 105.721, 191.520, 191.600, 195.070, 334.100,
334.104, 338.198, 379.941, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 22, to read as
8 follows:
EXPLANATION—Matter enclosed i n bold faced brackets [thus] i n this b i l l is
not enacted and is intended to be omitted i n the l a w .
�HEALTH CARE TASK FORCE
EN-TAKE ROOM ROUTING SLIP
OFFICE:
Public Liaison
^ Intergovernmental
Congressional Relations
First Lady
Other:_
EEQUEST:
_Meeting
Speech
Letter
Phone Call
Other:
REQUIRES ACTION:
Immediately
^Soon,
^Soon. but not priority
By:
(Date)
�HEALTH CARE TASK FORCE SORTING SHEET
TYPE OF MATERIAL:
General mail
Casework/personal stories
Letterhead
.Resamea/offen to help
Phone call
Jteqaests:
-speech
. ~- -meeting
.Policy papers
Other
ADVTSQRY PANEL?
physician.
non-physician health provider
small business
other consumers
seniors
PRTMAHY TNTERflST:
budgets and caps
_ benefits
HIPC organization
__ employer participation
organization, boards,
federal and state oversight
_ administration, reimbursement,
& patient information systems
_ unemployed/low income
_ medicare
.
_ insurance reform
_ quality assurance
_DOD
_ Veterans
_ malpractice & tort reform
_ federal employees
_ prep of health care workers
_ ethical foundations
_ short-term cost controls
_ public financing
_ long-term care
_ mental health
_ economic impacts
_AIDS
-
_ women's health
immunization programs
_ rural, inner city regions
other
GEOGRAPHY:
Region(NW,SE?):_
Rural, Urban, Suburban?:.
PI^N PREFERENCE;
CP
SP
OP
OT
Endorsed Clinton Plan
Single Payer
Own Plan
Other Plan
• 'S
MC
PP
CV
Managed Competition
Pay or Play
Credits or Vouchers
'
"
�
Dublin Core
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Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Letters from Government Officials and Employees] [loose] [6]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 36
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-036-003-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/b79bfae631114964bf8f8831e2eb2f59.pdf
eadbdbc2fbfad2a40c5ff27639c979a1
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1983
FolderlD:
Folder Title:
[Letters from Government Officials and Employees] [loose] [5]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
2
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001a. letter
Constituent to Hillary Clinton, re: cancer (2 pages)
n.d.
P6/b(6)
001b. statement
From constituent, re: cancer (2 pages)
n.d.
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
O A / B o x Number;
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [5]
2006-0885-F
wr828
RESTRICTION CODES
Presidential Records Act - (44 U.S.C. 2204(a)|
Freedom o f Information Act - (5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency |(b)(2) o f t h e FOIAJ
b(3) Release would violate a Federal statute 1(b)(3) o f t h e FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) o f t h e FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) o f t h e FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) o f t h e FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) o f t h e FOIA]
National Security Classified Information 1(a)(1) o f t h e PRA|
Relating to the appointment to Federal office 1(a)(2) o f t h e PRA|
Release would violate a Federal statute 1(a)(3) o f t h e PRA)
Release would disclose trade secrets or confidential commercial or
financial information ((a)(4) of the PRA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) o f t h e PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) o f t h e PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�THE COUNCIL
OF
THE CITY OF NEW YORK
CITY HALL
NEW YORK, N.Y. 10007
April
23,
1993
Mrs. H i l l a r y Rodham C l i n t o n
The White House
1600 P e n n s y l v a n i a Avenue, NW
Washington, D.C.
20500
Dear Mrs. C l i n t o n :
As t h e Speaker o f t h e C o u n c i l of t h e C i t y o f New York and as
a s e n i o r C o u n c i l Member and Chairman o f t h e C o u n c i l ' s Committee on
H e a l t h , we are v e r y p l e a s e d t h a t t h e C l i n t o n A d m i n i s t r a t i o n has
d e d i c a t e d i t s e l f so a g g r e s s i v e l y t o t h e t a s k o f a d d r e s s i n g t h e
h e a l t h c a r e c r i s i s c o n f r o n t i n g our n a t i o n . The C o u n c i l i s charged
w i t h t h e r e s p o n s i b i l i t y o f r e v i e w i n g t h e programs and s e r v i c e
d e l i v e r y o f C i t y a g e n c i e s , i n c l u d i n g t h e New York C i t y Department
of H e a l t h , t h e New York C i t y Department of M e n t a l H e a l t h , M e n t a l
R e t a r d a t i o n and A l c o h o l i s m S e r v i c e s , and t h e H e a l t h and H o s p i t a l s
Corporation.
I n c o n n e c t i o n w i t h our l e a d e r s h i p p o s i t i o n s on t h e
C o u n c i l , we have r e v i e w e d , a l o n g w i t h t h e members o f t h e Committee
on H e a l t h , most o f t h e major h e a l t h i s s u e s c o n f r o n t i n g t h e C i t y .
As a r e s u l t of our e x a m i n a t i o n of t h e i s s u e s , t h e o p e r a t i o n s of
t h e v a r i o u s agencies and t h e p e r c e p t i o n s of t h e consumer, we have
d e v e l o p e d a unique p e r s p e c t i v e on t h e h e a l t h needs o f New York
City's citizens.
The Committee on H e a l t h has h e l d h e a r i n g s on such c r i t i c a l
t o p i c s as p r i m a r y c a r e , HIV/AIDS, t u b e r c u l o s i s , b r e a s t cancer,
substance abuse and s c h o o l h e a l t h . Testimony has been r e c e i v e d
f r o m hundreds of l a y c i t i z e n s as w e l l as e x p e r t s and p r o f e s s i o n a l s
i n t h e many d i f f e r e n t areas o f h e a l t h c a r e . Where n e c e s s a r y , j o i n t
h e a r i n g s were h e l d w i t h o t h e r C o u n c i l committees t o b e t t e r address
h e a l t h c o n c e r n s . As a r e s u l t of these h e a r i n g s and
extensive
community p a r t i c i p a t i o n , a number of themes have emerged w h i c h
i n d i c a t e t h e enormous d i f f i c u l t i e s
involved i n addressing
the
C i t y ' s h e a l t h care needs.
There are many s i g n i f i c a n t c h a l l e n g e s i n v o l v e d i n p r o v i d i n g
q u a l i t y h e a l t h c a r e s e r v i c e s t o New York C i t y ' s c i t i z e n s . Given
t h e s i z e o f t h e C i t y and
i t s extremely
dynamic q u a l i t y
as
e v i d e n c e d by t h e d i v e r s i t y of neighborhoods i n h a b i t e d by persons
�of every background/origin
and income s t r a t a , h e a l t h c a r e needs
v a r y m a r k e d l y f r o m one area t o a n o t h e r . I n terms o f r e s o u r c e s ,
every t y p e o f h e a l t h c a r e f a c i l i t y and s p e c i a l i s t can be found
w i t h i n t h e b o u n d a r i e s o f t h e C i t y . Some areas o f t h e C i t y , such as
t h e E a s t s i d e o f Manhattan, e n j o y an abundance o f r i c h e s and have
r e s e a r c h , t e a c h i n g , and s p e c i a l t y h o s p i t a l s , w h i l e o t h e r a r e a s ,
such as C e n t r a l B r o o k l y n , o f f e r m o s t l y p u b l i c h o s p i t a l s , where
emergency rooms and h e a l t h s t a t i o n s serve as t h e f a m i l y d o c t o r .
Harlem, East New York, B e d f o r d S t u y v e s a n t , F o r t Greene, and South
Jamaica a r e o t h e r examples o f neighborhoods which a r e u n d e r s e r v e d
and
l a c k basic h e a l t h s e r v i c e s . Quite o f t e n w i t h
disastrous
r e s u l t s , persons i n need o f m e d i c a l a t t e n t i o n a r e d i s c o u r a g e d by
l o n g w a i t i n g t i m e s , l a c k o f m e d i c a l s t a f f and s u p p l i e s , and
e x c e s s i v e and c o s t l y t r a v e l , as w e l l as by a l e v e l o f c a r e w h i c h
can o f t e n be p o o r . U n f o r t u n a t e l y , i n many ways t h e need i s g r e a t e r
for
h e a l t h s e r v i c e s i n t h o s e areas where t o o o f t e n
poverty
compounds t h e r e a l i t y o f sparse o r n o n e x i s t e n t s e r v i c e s . I t i s t h e
C o u n c i l ' s hope t h a t you w i l l r e d r e s s some o f t h e s e problems i n
y o u r p r o p o s a l s t o m o d i f y a h e a l t h care system w h i c h i s o f t e n
c h a o t i c and i n a c c e s s i b l e .
Our
recommendations d e r i v e from t h e assumption t h a t t h e
health
plan
being
discussed
will
have c e r t a i n
fundamental
characteristics,
including paid
universal
coverage
for
a l l
c i t i z e n s and a m i x t u r e o f a c u t e and p r i m a r y c a r e s e r v i c e s . I n
a d d i t i o n , a l t h o u g h t h e recommendations a r e e x p l o r e d f r o m New York
C i t y ' s p e r s p e c t i v e , we b e l i e v e t h a t t h i s p e r s p e c t i v e
i s also
a p p l i c a b l e t o t h e s p e c i a l h e a l t h care needs and problems o f
p o p u l a t i o n s i n a l l l a r g e urban c e n t e r s , which o f t e n d i f f e r f r o m
t h e needs o f o t h e r p a r t s o f t h e n a t i o n .
We b e l i e v e t h a t t h e concerns which have been r a i s e d a t t h e
h e a r i n g s o f t h e Committee on H e a l t h and c h r o n i c l e d i n t h e a t t a c h e d
r e p o r t , w i l l h e l p t o i n f o r m y o u r d e l i b e r a t i o n s as y o u r t a s k f o r c e
f a c e s t h e c h a l l e n g e o f r e f o r m i n g o u r n a t i o n ' s h e a l t h c a r e system.
On b e h a l f o f t h e New York C i t y C o u n c i l and t h e c i t i z e n s o f
our C i t y , we would l i k e t o t a k e t h i s o p p o r t u n i t y t o i n v i t e you and
y o u r t a s k f o r c e t o New York C i t y t o d i s c u s s t h e i m p l i c a t i o n s o f
n a t i o n a l h e a l t h r e f o r m f o r t h e C i t y . I f t h i s i s n o t p o s s i b l e , we
w i s h t o r e q u e s t a meeting i n Washington, D.C.
Sincerely,
f r
F. V a l l o n e
Speaker and M a j o r i t y Leader
Enoch H. W i l l i a m s
Chairman
Committee on H e a l t h
cc: Members o f t h e Committee on H e a l t h
�REPORT TO THE PRESIDENT'S HEALTH CARE TASK FORCE
New York C i t y Council Member Peter F. Vallone
Speaker of the Council
New York C i t y Council Member Enoch H. Williams
Chairman of the Committee on Health
A p r i l 23, 1993
�Acknowledgments
Members of the New
York C i t y Council Committee on Health
Morton Povman
P r i s c i l l a A. Wooten
V i c t o r L. Robles
J u l i a Harrison
New
Jose R i v e r a
C. V i r g i n i a F i e l d s
Una C l a r k e
John Fusco
York C i t y Council D i v i s i o n of Human S e r v i c e s
O l i v e r Gray, D i r e c t o r
Prepared
Mary M a s t r o p a o l o , D i v i s i o n Counsel*
Diane Blanc, L e g i s l a t i v e A t t o r n e y *
C a r l Smith, L e g i s l a t i v e A t t o r n e y
Doris Varlese, L e g i s l a t i v e Attorney*
By:
Perry S t e i n , P o l i c y A n a l y s t *
Anne LaCascia, P o l i c y A n a l y s t *
J a c q u e l i n e La Poche, P o l i c y A n a l y s t
Miriam Burns, P o l i c y A n a l y s t
Hope W i l l i a m s
Rene T a y l o r
We would a l s o l i k e to acknowledge the c o n t r i b u t i o n s
of:
David Beach, I n v e s t i g a t o r *
Haeda M i h a l t s e s , Finance A n a l y s t *
Linda O s t r e i c h e r , Finance A n a l y s t *
Rica R i n z l e r , P u b l i c I n f o r m a t i o n O f f i c e r *
* Members of t h e Task Force t o t h e Committee on
Health
�T A B L E
OF
C O N T E N T S
REPORT TO THE PRESIDENT'S HEALTH CARE TASK FORCE
EXECUTIVE SUMMARY
4
INTRODUCTION
10
I.
ADDRESSING SPECIFIC PRIMARY CARE ISSUES
12
A.
Encouraging Primary Care P r a c t i c e s
12
B.
Ensuring and Expanding School Health S e r v i c e s
14
II.
MEETING THE HEALTH CARE NEEDS OF SPECIAL POPULATIONS... 17
A.
People w i t h AIDS
17
B.
People w i t h Tuberculosis
19
C.
Substance Abusers
21
D.
Low Income and Poor Women
23
E.
The E l d e r l y
25
F.
The Homeless Population
26
CONCLUSION
31
�REPORT TO THE PRESIDENT'S HEALTH CARE TASK FORCE
EXECUTIVE SUMMARY
I . ADDRESSING SPECIFIC PRIMARY CARE ISSUES
New York C i t y e n j o y s an abundance o f h e a l t h care r i c h e s . Yet
despite t h i s ,
a l a r g e number o f communities
i n the City,
e s p e c i a l l y t h o s e neighborhoods p o p u l a t e d by t h e poor and people o f
c o l o r , a r e m e d i c a l l y underserved because o f t h e absence o f p r i m a r y
c a r e p h y s i c i a n s and o t h e r h e a l t h p r o f e s s i o n a l s .
A. ENCOURAGING PRIMARY CARE PRACTICES
M e d i c a l schools and r e s i d e n c y t r a i n i n g programs prepare few
s t u d e n t s f o r p r i m a r y c a r e , p l a c i n g c o n s i d e r a b l e emphasis on
s p e c i a l t y , s u b - s p e c i a l t y , academic p r a c t i c e and r e s e a r c h t r a i n i n g .
Moreover, New York C i t y medical schools t r a i n few people from
l a r g e urban areas and even fewer A f r i c a n - A m e r i c a n s and L a t i n o s .
T h i s poor r e c o r d c o u l d be addressed t h r o u g h s u p p o r t f o r
r e g i o n a l m e d i c a l schools founded a t p u b l i c l y funded c o l l e g e s o r
universities.
Such medical
schools would
provide
financial
s u p p o r t t o s t u d e n t s based on need.
RECOMMENDATIONS
1.
There must be a d d i t i o n a l compensation under a reformed
n a t i o n a l h e a l t h insurance s t r u c t u r e f o r those p h y s i c i a n s who
provide primary c a r e , e s p e c i a l l y i n poor and medically underserved
neighborhoods.
2.
The c o s t s of e s t a b l i s h i n g a primary care p r a c t i c e i n a
community t h a t has a current d e f i c i t of primary care p h y s i c i a n s
should be s u b s i d i z e d by the Federal government on a pro-rated
b a s i s o r , a t a minimum, such p r a c t i c e s should be provided with low
i n t e r e s t F e d e r a l o r Federally-backed loans.
3.
Primary care providers serving areas with a c u r r e n t
d e f i c i t of primary care p h y s i c i a n s should be protected from the
worst impacts of adverse medical malpractice judgments, p o s s i b l y
through F e d e r a l l y subsidized assigned r i s k pools.
4.
The
Federal
government
should
encourage
the
establishment of primary care p r a c t i c e s through medical school
loan
forgiveness,
tuition
reduction
and other
programs,
p a r t i c u l a r l y f o r those p h y s i c i a n s who serve i n medically needy
neighborhoods. Minority and low-income persons should e s p e c i a l l y
be encouraged through such programs.
5.
Each National Health region must have a t l e a s t one t o
two medical schools, depending on population, that a r e devoted
s o l e l y t o the t r a i n i n g of primary care p h y s i c i a n s .
-4-
�6.
A l l medical schools r e c e i v i n g Federal a i d should be
r e q u i r e d t o e s t a b l i s h family p r a c t i c e departments and o f f e r
i n t e r n s h i p s i n areas r e l a t e d to primary c a r e .
7.
H o s p i t a l s r e c e i v i n g F e d e r a l l y subsidized funds should be
r e q u i r e d t o e s t a b l i s h primary care t r a i n i n g programs, or h o s p i t a l s
should be o f f e r e d Federal i n c e n t i v e s to e s t a b l i s h such programs.
B. ENSURING AND EXPANDING SCHOOL HEALTH SERVICES
The School H e a l t h S e r v i c e s Program serves a p p r o x i m a t e l y 1.2
m i l l i o n New York C i t y p u b l i c and n o n - p u b l i c school s t u d e n t s . As a
t r a d i t i o n a l form o f i m p o r t a n t h e a l t h care o u t r e a c h , i t p r o v i d e s
the C i t y ' s c h i l d r e n w i t h a s i g n i f i c a n t s a f e t y n e t o f b a s i c m e d i c a l
s e r v i c e s which a r e a l l - t o o - o f t e n i n a c c e s s i b l e t o them.
Unfortunately,
t h e program,
having
suffered
budgetary
r e d u c t i o n s i n p r e v i o u s y e a r s , does n o t adequately p r o v i d e v i t a l ,
mandated s e r v i c e s .
RECOMMENDATIONS
1.
The Federal government should i n c r e a s e i t s funding to
ensure t h a t every school has a minimum of one f u l l - t i m e h e a l t h
c a r e worker during the school year.
2.
More than one nurse or p a r a p r o f e s s i o n a l should be
assigned t o schools which have a higher l e v e l of student h e a l t h
c a r e needs.
3.
Nurses,
doctors
and
paraprofessionals
should
be
encouraged t o serve i n the School Health S e r v i c e s Program through
loan forgiveness programs.
4.
The Federal government should help ensure t h a t the
School Health S e r v i c e s Program has the resources necessary t o
enable i t to perform i t s r e s p o n s i b i l i t i e s with respect t o hearing
and v i s i o n screenings, p h y s i c a l examinations, lead poisoning and
t u b e r c u l o s i s t e s t i n g , and ensuring the f u l l immunization of the
student population.
5.
The Federal government should play a strong r o l e i n
ensuring t h a t school-based c l i n i c s are e s t a b l i s h e d i n every school
which has a higher l e v e l of student h e a l t h care needs.
II.
MEETING THE HEALTH CARE NEEDS OF SPECIAL POPULATIONS
There a r e , i n New York C i t y , a number o f s p e c i a l p o p u l a t i o n s
who have come t o t h e a t t e n t i o n o f t h e C o u n c i l . The C o u n c i l i s
concerned, however, t h a t u n i v e r s a l h e a l t h care alone w i l l n o t be
a b l e t o meet t h e needs o f such p o p u l a t i o n s i n t h e absence o f an
a c c e s s i b l e h e a l t h c a r e system.
-5-
�RECOMMENDATIONS
1.
National h e a l t h care reform should ensure t h a t the
p r o v i s i o n of general h e a l t h care and p u b l i c h e a l t h campaigns and
other
h e a l t h education
take place
i n a l i n g u i s t i c a l l y and
c u l t u r a l l y appropriate manner.
2.
I n providing
health
care
t o low-income and poor
individuals,
appointments a f t e r
regular
business
hours and
t r a n s p o r t a t i o n or reimbursement of t r a n s p o r t a t i o n c o s t s must be
offered.
3.
National h e a l t h care reform should ensure that primary
c a r e o f f e r s a s s i s t a n c e i n obtaining s p e c i a l t y and s o c i a l support
s e r v i c e s , with arrangements made by the primary care provider, and
t h a t a c t i v e follow-up takes p l a c e .
A. PEOPLE WITH AIDS
New York C i t y
i s t h e AIDS e p i c e n t e r o f t h e n a t i o n .
M i n o r i t i e s a r e d i s p r o p o r t i o n a t e l y impacted by t h e AIDS epidemic.
I n f a c t , m i n o r i t y women a r e now t h e f a s t e s t growing group o f
H I V - i n f e c t e d people i n t h e C i t y .
RECOMMENDATIONS
1.
There must be a s u b s t a n t i a l i n c r e a s e i n Federal funds
targeted
towards State
and l o c a l
AIDS prevention
efforts,
i n c l u d i n g t e s t i n g , counseling, education and partner n o t i f i c a t i o n .
2.
The Ryan White Comprehensive AIDS Resources Emergency
Act of 1990 must be extended beyond i t s present term and higher
funding l e v e l s must be authorized i n order t o ensure the q u a l i t y ,
a v a i l a b i l i t y and organization of h e a l t h care and support s e r v i c e s
f o r i n d i v i d u a l s and f a m i l i e s i n f e c t e d with HIV d i s e a s e .
B. PEOPLE WITH TUBERCULOSIS
D u r i n g t h e l a s t F i s c a l Year, t h e r e were 3,777 new cases o f
a c t i v e t u b e r c u l o s i s (TB) i n New York C i t y .
The C i t y ' s TB case
r a t e o f 50.2 p e r 100,000 i s f i v e times t h e n a t i o n a l average.
Many
of
these
cases a r e M u l t i - D r u g R e s i s t a n t T u b e r c u l o s i s , HIV
i n f e c t e d , homeless, substance abusers o r a c o m b i n a t i o n o f t h e
above.
RECOMMENDATIONS
1.
National h e a l t h care reform should
D i r e c t l y Observed Therapy programs.
include coverage f o r
2.
F e d e r a l a i d must be expanded i n order to f a c i l i t a t e the
h i r i n g of a d d i t i o n a l TB case managers.
3.
National h e a l t h care reform should address treatment f o r
non-compliant TB p a t i e n t s detained by order of the l o c a l Health
Commissioner.
-6-
�4.
F e d e r a l a i d must be expanded t o allow m u n i c i p a l i t i e s t o
i n c r e a s e the number of beds i n s p e c i a l s h e l t e r s designed f o r TB
patients.
5.
F e d e r a l funding must be expanded t o enhance the a b i l i t y
of municipal c o r r e c t i o n a l systems t o detect TB and prevent i t s
spread.
6.
F e d e r a l a i d must be expanded f o r workplace TB i n f e c t i o n
c o n t r o l and worker s a f e t y .
C. SUBSTANCE ABUSERS
The use o f i l l e g a l substances such as c o c a i n e and h e r o i n
c o n t i n u e s unabated.
However, s o c i e t y cannot demand t h a t people
e n r o l l i n t r e a t m e n t programs when t h e r e a r e n o t enough t r e a t m e n t
slots available.
U n f o r t u n a t e l y , i n New York C i t y , t h e r e i s a
severe s h o r t a g e o f needed drug t r e a t m e n t s e r v i c e s .
I t i s w e l l r e c o g n i z e d t h a t substance abuse leads t o l o n g - t e r m
and s h o r t - t e r m s o c i a l c o s t s .
T h e r e f o r e , t h e most c o s t e f f e c t i v e
p o l i c y i n t h e l o n g r u n would be t o reduce demand f o r drugs t h r o u g h
a c o m b i n a t i o n o f p r e v e n t i v e e d u c a t i o n programs and t r e a t m e n t t o
reduce t h e d r u g - u s i n g p o p u l a t i o n .
RECOMMENDATIONS
1.
Any n a t i o n a l h e a l t h care plan must o f f e r substance abuse
treatment s e r v i c e s .
2.
More treatment
slots,
based
on a combination of
o u t - p a t i e n t and r e s i d e n t i a l treatment programs, a r e needed, as
w e l l as program components t o address such c r i t i c a l areas as
education, job t r a i n i n g , housing and general h e a l t h c a r e .
3.
The F e d e r a l government should t a r g e t treatment t o those
most i n need and t o those most l i k e l y t o be i n a p o s i t i o n t o be
i d e n t i f i e d as substance abusers and encouraged
t o undertake
treatment, p a r t i c u l a r l y adolescent substance abusers.
4.
F e d e r a l e f f o r t s must be expanded t o help New York C i t y
set up a treatment r e g i s t r y and a network of intake, assessment
and r e f e r r a l c e n t e r s .
5.
A d d i t i o n a l funding i s needed f o r more a l t e r n a t i v e - t o i n c a r c e r a t i o n p r o j e c t s t o d i v e r t l o w - l e v e l offenders from the
c o u r t s and j a i l s i n t o programs t h a t w i l l address substance abuse
problems and the b a s i c causes of the a n t i - s o c i a l , s e l f - d e s t r u c t i v e
behavior of substance abusers.
D. LOW INCOME AND POOR WOMEN
It
must be r e a l i z e d t h a t women a r e s t i l l
t h e primary
care-givers f o r t h e i r children.
For low income and poor women,
the
l a c k o f adequate c h i l d - c a r e and t r a n s p o r t a t i o n c o s t s t o
facilities
f o r o u t p a t i e n t treatment o r prenatal care i s o f
p a r t i c u l a r concern.
-7-
�RECOMMENDATION
1.
To improve access t o p r i m a r y c a r e , and o t h e r t y p e s o f
h e a l t h c a r e where p r a c t i c a b l e , t h e r e must be o n - s i t e c h i l d - c a r e ,
transportation
reimbursements
f o r accompanying c h i l d r e n , and
appointments a f t e r r e g u l a r business hours.
B r e a s t Cancer
B r e a s t cancer, w i t h i t s h i g h m o r t a l i t y r a t e i n New York C i t y ,
i s one example o f an i l l n e s s whose i d e n t i f i c a t i o n and t r e a t m e n t
has been r a t i o n e d . Medicine has found ways t o i d e n t i f y and t r e a t
b r e a s t cancer, b u t has n o t been a b l e t o b r i n g t h e same l e v e l o f
c a r e t o a l l women.
RECOMMENDATIONS
1.
F e d e r a l a i d t o f a c i l i t a t e New York C i t y breast h e a l t h
education e f f o r t s should be increased.
2.
Medicare and any new programs e s t a b l i s h e d under a
n a t i o n a l h e a l t h care plan should
cover the c o s t s of e a r l y
d e t e c t i o n and treatment f o r breast cancer.
Infant Mortality
Low b i r t h w e i g h t , o f t e n a r e s u l t o f l i t t l e o r no p r e n a t a l
c a r e and poor n u t r i t i o n , has been connected t o i n f a n t m o r t a l i t y .
A t p r e s e n t , 12 o f t h e C i t y ' s 30 h e a l t h d i s t r i c t s have i n f a n t
m o r t a l i t y r a t e s above t h e c i t y - w i d e r a t e and 19 a r e above t h e
national rate.
RECOMMENDATION
1.
Any n a t i o n a l h e a l t h care program should
encourage
prenatal care.
I n p a r t i c u l a r , the s p e c i a l needs of pregnant
teenagers and pregnant substance abusers should be addressed.
E. THE ELDERLY
I n 1991, a p p r o x i m a t e l y 1.3 m i l l i o n New Yorkers were 60 y e a r s
o f age o r over. Moreover, s u b s t a n t i a l growth i n t h e 85-over age
group, t h e m i n o r i t y e l d e r l y and t h e number o f o l d e r persons l i v i n g
a l o n e i s expected t o c o n t i n u e i n t h e 1990s.
Due t o t h e l a c k o f a coherent n a t i o n a l p o l i c y on a g i n g ,
s e r v i c e s f o r o l d e r people a r e supported by m u l t i p l e f u n d i n g
streams t h a t have determined t h e s e r v i c e d e l i v e r y systems.
Thus,
these
systems a r e fragmented
and a r e c h a r a c t e r i z e d by an
inadequacy
o f resources r e q u i r e d t o meet t h e needs o f o l d e r
people.
RECOMMENDATIONS
1.
The Federal government should develop and implement a
coherent
long-term
care
policy
that
protects
against
impoverishment and includes c o s t - s h a r i n g based upon a b i l i t y t o
-8-
�pay.
B e n e f i t s should include coverage of home care s e r v i c e s ,
a d u l t day s e r v i c e s and medical and non-medical r e s i d e n t i a l c a r e .
2.
Any n a t i o n a l
health
care
program
should
include
s u f f i c i e n t reimbursement f o r r e s i d e n t i a l and i n s t i t u t i o n a l care t o
ensure q u a l i t y of l i f e standards,
and f o r adequate s t a f f i n g ,
t r a i n i n g and programming i n r e s i d e n t i a l s e t t i n g s t o address the
needs of the mentally
f r a i l elderly, including
Alzheimer's
patients.
3.
Adequate resources must be a l l o c a t e d t o design and
d e l i v e r g e r i a t r i c mental health s e r v i c e s through s e n i o r c e n t e r s ,
home care and s o c i a l s e r v i c e agencies.
4.
The Federal government should
n u t r i t i o n programs f o r older Americans.
increase
funding f o r
F. THE HOMELESS POPULATION
The homeless c r i s i s i n New York C i t y i s c l e a r l y one o f t h e
most t r o u b l i n g and complex problems encountered by t h e C i t y .
The "homeless" a r e n o t one s i n g l e , e a s i l y d e f i n a b l e group o f
people.
On t h e c o n t r a r y , t h e homeless p o p u l a t i o n i s comprised o f
d i s t i n c t i v e , i f sometimes o v e r l a p p i n g , subgroups.
The h e a l t h
needs o f t h e homeless a r e as numerous and d i v e r s e as t h e
population i t s e l f .
And y e t , what b i n d s these v a r i o u s subgroups,
t h e c o n d i t i o n o f b e i n g homeless, c r e a t e s a d d i t i o n a l b a r r i e r s t o
s e e k i n g and o b t a i n i n g t h e h e a l t h care t h e y so d e s p e r a t e l y need.
RECOMMENDATIONS
1.
Any n a t i o n a l health care program should provide a
standardized,
comprehensive health care system f o r the s i n g l e
homeless, as w e l l as f o r homeless f a m i l i e s .
2.
Any n a t i o n a l health care program must address the
c r i t i c a l needs of the mentally i l l homeless, p a r t i c u l a r l y through
supportive comprehensive community-based p s y c h i a t r i c c a r e .
3.
The Federal government must provide the a d d i t i o n a l
funding needed f o r the thorough and aggressive screening of
homeless i n d i v i d u a l s f o r communicable d i s e a s e s upon entry i n t o the
s h e l t e r system.
4.
Large s h e l t e r s and Emergency A s s i s t a n c e Units should be
downsized and equipped with the proper v e n t i l a t i o n equipment.
5.
New i n i t i a t i v e s
l i v i n g i n p u b l i c areas.
are needed
t o reach
homeless
people
6.
A d d i t i o n a l funding i s needed t o provide c o n t i n u i t y of
care f o r homeless i n d i v i d u a l s .
7.
The only
r e a l comprehensive long-term s t r a t e g y f o r
improving the h e a l t h of the homeless i s e l i m i n a t i n g homelessness.
-9-
�REPORT TO THE
PRESIDENT'S HEALTH CARE TASK FORCE
INTRODUCTION
The New
York C i t y C o u n c i l ' s Committee on H e a l t h has h e l d
h e a r i n g s on such c r i t i c a l t o p i c s as p r i m a r y
care,
HIV/AIDS,
t u b e r c u l o s i s , b r e a s t cancer, substance abuse and school h e a l t h .
The Committee has r e c e i v e d t e s t i m o n y from hundreds of l a y c i t i z e n s
as w e l l as e x p e r t s and p r o f e s s i o n a l s i n t h e many d i f f e r e n t areas
of h e a l t h care.
Where necessary, j o i n t h e a r i n g s were h e l d w i t h
o t h e r C o u n c i l committees t o b e t t e r address h e a l t h concerns. These
h e a r i n g s have r e v e a l e d
t h e enormous d i f f i c u l t i e s i n v o l v e d i n
a d d r e s s i n g t h e C i t y ' s h e a l t h care needs.
There are many unique c h a l l e n g e s
involved i n providing
q u a l i t y h e a l t h care s e r v i c e s t o t h e c i t i z e n s of New York C i t y .
C e r t a i n l y , t h e s i z e of t h e C i t y and
the d i v e r s i t y of i t s
p o p u l a t i o n present the greatest challenges.
The
h e a l t h care
system i n New York C i t y i s o f t e n c h a o t i c and i n a c c e s s i b l e . Some
areas o f t h e C i t y , such as t h e East s i d e of Manhattan, e n j o y an
abundance o f r i c h e s and have r e s e a r c h , t e a c h i n g , and s p e c i a l t y
h o s p i t a l s , w h i l e o t h e r areas, such as C e n t r a l B r o o k l y n ,
offer
m o s t l y p u b l i c h o s p i t a l s , where emergency rooms and h e a l t h s t a t i o n s
serve as t h e f a m i l y d o c t o r .
Harlem, East New
York, B e d f o r d
S t u y v e s a n t , F o r t Greene, and South Jamaica are o t h e r examples of
neighborhoods which
are
underserved
and
lack
basic
health
s e r v i c e s . Q u i t e o f t e n w i t h d i s a s t r o u s r e s u l t s , persons i n need o f
m e d i c a l a t t e n t i o n are d i s c o u r a g e d by l o n g w a i t i n g t i m e s , l a c k o f
m e d i c a l s t a f f and s u p p l i e s , and excessive and c o s t l y t r a v e l , as
well
as
by
a
level
of
care which
can
often
be
poor.
Unfortunately,
i n many ways t h e need i s g r e a t e r f o r h e a l t h
s e r v i c e s i n those areas where p o v e r t y compounds t h e r e a l i t y o f
sparse o r n o n e x i s t e n t s e r v i c e s .
Access t o p r o v i d e r s of p r i m a r y h e a l t h care s e r v i c e s i n New
York C i t y i s l i m i t e d due t o t h e overburdened and c o s t l y n a t u r e o f
such s e r v i c e s and t h e absence of u n i v e r s a l h e a l t h care i n s u r a n c e .
Testimony p r e s e n t e d a t Committee h e a r i n g s has c l e a r l y demonstrated
t h a t a l a c k of adequate p r i m a r y h e a l t h care resources i n t h e C i t y
has a l l o w e d c e r t a i n dangerous diseases t o t h r e a t e n our p o p u l a t i o n .
In
r e c e n t y e a r s , t u b e r c u l o s i s has re-emerged as a s i g n i f i c a n t
p u b l i c h e a l t h t h r e a t , AIDS has spread i n communities of c o l o r a t
an a l a r m i n g r a t e , drugs have ravaged our neighborhoods, and b r e a s t
cancer has s t r i c k e n women i n epidemic p r o p o r t i o n s . Moreover, t h e
lack of a s u f f i c i e n t
number of p r i m a r y
care s e r v i c e s
and
p r a c t i t i o n e r s d i s p r o p o r t i o n a t e l y impacts on t h e most v u l n e r a b l e of
our c i t i z e n s .
The i n f a n t m o r t a l i t y r a t e i s s t i l l much t o o h i g h ,
and t h e l e v e l of h e a l t h care s e r v i c e s f o r t h e homeless i s s t i l l
much t o o low.
I n a d d i t i o n , much of t h e h e a l t h care needs of t h e
C i t y ' s s e n i o r c i t i z e n s and i t s c h i l d r e n , t h e o l d e s t and
the
youngest amongst us, c o n t i n u e t o remain unmet.
New York C i t y , a l r e a d y burdened w i t h a tremendous p o p u l a t i o n
o f w h i c h over one m i l l i o n people are on w e l f a r e and 340,000 people
are r e c e i v i n g unemployment i n s u r a n c e , cannot t a c k l e such d i f f i c u l t
-10-
�problems a l o n e . The F e d e r a l government must n o t o n l y r e f o r m t h e
n a t i o n ' s h e a l t h c a r e system t o ensure t h a t everyone has access t o
a w o r l d - c l a s s h e a l t h c a r e system, b u t i t must a l s o p r o v i d e New
York C i t y w i t h t h e a d d i t i o n a l r e s o u r c e s i t needs t o ensure t h a t
such an a c c e s s i b l e and h i g h q u a l i t y system becomes a r e a l i t y f o r
its citizens.
The f o l l o w i n g pages p r e s e n t a r e p o r t from New York C i t y ' s
h e a l t h c a r e system " f r o n t l i n e s , " and o f f e r s u g g e s t i o n s w i t h
r e s p e c t t o t h e r o l e t h e F e d e r a l government
should play i n
i m p r o v i n g t h e d e l i v e r y o f h e a l t h care s e r v i c e s t o t h e people o f
New York C i t y .
The recommendations s e t f o r t h i n t h i s document
s h o u l d be viewed as complementing t h e p r o p o s a l s o f f e r e d by Mayor
David D i n k i n s i n h i s r e c e n t l y r e l e a s e d r e p o r t e n t i t l e d , " N a t i o n a l
H e a l t h Care Reform Proposals O f f e r e d by New York C i t y , " which we
endorse.
-11-
�I . ADDRESSING SPECIFIC PRIMARY CARE ISSUES
New York C i t y e n j o y s an abundance o f h e a l t h c a r e r i c h e s
symbolized by i t s 7 0 h o s p i t a l s , which i n c l u d e some o f t h e w o r l d ' s
most famous t e a c h i n g and c l i n i c a l i n s t i t u t i o n s .
However, n o t f a r
f r o m many o f these w o r l d - c l a s s h o s p i t a l s a r e some o f t h e most
m e d i c a l l y underserved areas i n t h e n a t i o n .
The C i t y has t h e
l a r g e s t m u n i c i p a l h o s p i t a l system i n t h e U n i t e d S t a t e s w i t h 11
acute care i n s t i t u t i o n s .
Yet d e s p i t e t h i s e x t e n s i v e system, a
l a r g e number o f communities
i n this City, especially
those
neighborhoods
p o p u l a t e d by t h e poor and people o f c o l o r , a r e
m e d i c a l l y underserved because o f t h e absence o f p r i m a r y c a r e
p h y s i c i a n s and o t h e r h e a l t h p r o f e s s i o n a l s .
As a r e s u l t , i n 1990, t h e Community S e r v i c e S o c i e t y found
t h a t low-income New Yorkers a r e most l i k e l y t o d i e from cancer,
s t r o k e and h e a r t d i s e a s e .
Furthermore, poor New Yorkers d i e i n
even g r e a t e r numbers and a t e a r l i e r ages from these "and f r o m
o t h e r , u s u a l l y n o n - f a t a l d i s e a s e s , such as h y p e r t e n s i o n , d i a b e t e s ,
i n f l u e n z a , t u b e r c u l o s i s and pneumonia." The i n c i d e n c e o f l e a d
p o i s o n i n g among t h e C i t y ' s c h i l d r e n i s another d r a m a t i c example o f
t h e f a i l u r e o f government t o ensure t h e d e l i v e r y o f adequate
p r i m a r y c a r e t o a l l communities.
Lead p o i s o n i n g i s t h e most
common and d e v a s t a t i n g e n v i r o n m e n t a l disease which a f f l i c t s young
children.
The key t o r e v e r s i n g these unacceptable outcomes i s t o
emphasize e a r l y i n t e r v e n t i o n and t r e a t m e n t p r o v i d e d by and t h r o u g h
primary care medical personnel.
I n an e f f o r t t o address t h i s d e a r t h o f s e r v i c e s . New York
C i t y has i n i t i a t e d t h e Communi-Care program t o p r o v i d e p r i m a r y
c a r e s e r v i c e s i n t h e C i t y ' s n e e d i e s t neighborhoods.
Phase I o f
t h e program p l a n s t o i n v e s t $48 m i l l i o n i n 20 C i t y f a m i l y h e a l t h
centers.
However, due t o f i s c a l
c o n s t r a i n t s , Phase I , as
a m b i t i o u s as i t i s , i s expected t o meet no more t h a n 6 p e r c e n t o f
t h e need.
Phase I I , as i t i s now proposed, would c r e a t e an
independent c o r p o r a t i o n t h a t , u s i n g C i t y funds as seed money,
would p r o v i d e t h e c a p i t a l needed t o b u i l d a t l e a s t 30 more
neighborhood
clinics.
However, w h i l e Phase I I w i l l
provide
c r i t i c a l c a p i t a l d o l l a r s , concerns remain w i t h r e s p e c t t o t h e
r e c r u i t m e n t and r e t e n t i o n o f p r i m a r y care p r a c t i t i o n e r s . The C i t y
needs F e d e r a l a s s i s t a n c e i n p r o v i d i n g adequate o p e r a t i n g revenues
t o keep t h e c l i n i c s open t o a l l who need them and i n t r a i n i n g t h e
h e a l t h c a r e p r o v i d e r s r e q u i r e d t o s t a f f them.
A. ENCOURAGING PRIMARY CARE PRACTICES
New York C i t y m e d i c a l schools produce 900 p h y s i c i a n s a y e a r .
Y e t , few o f these graduates choose t o u l t i m a t e l y p r a c t i c e i n
m e d i c a l l y underserved New York C i t y neighborhoods.
A r e p o r t from
the
Community
Service
Society
contained
the
following
observations:
*
*
New York C i t y m e d i c a l schools t r a i n few people from l a r g e
urban areas and even fewer A f r i c a n - A m e r i c a n s and L a t i n o s .
M e d i c a l schools and r e s i d e n c y t r a i n i n g programs p r e p a r e
t o o few s t u d e n t s f o r p r i m a r y care b u t p l a c e c o n s i d e r a b l e
-12-
�emphasis on s p e c i a l t y ,
and r e s e a r c h t r a i n i n g .
s u b - s p e c i a l t y , academic
practice
As a r e s u l t o f t h i s l a c k o f emphasis on t h e p r e p a r a t i o n o f
p r i m a r y c a r e m e d i c a l p r o f e s s i o n a l s , major i n n e r c i t y / l o w income
neighborhoods a r e s h o r t a t o t a l o f more t h a n 500 p h y s i c i a n s . The
p r i m a r y c a r e shortage has l e d neighborhood r e s i d e n t s t o r e l y on
p u b l i c h o s p i t a l emergency rooms even when t h e y need non-emergency
m e d i c a l c a r e . T h i s has c r e a t e d e x t e n s i v e w a i t s f o r t r e a t m e n t and
o v e r c r o w d i n g i n these h o s p i t a l f a c i l i t i e s .
A d d i t i o n a l l y , many
p a t i e n t s who a r e aware o f t h e b a c k l o g i n these emergency rooms,
w i l l n o t p r e s e n t themselves f o r t r e a t m e n t u n t i l t h e i r c o n d i t i o n s
a r e c r i t i c a l and t h e r e f o r e d i f f i c u l t and expensive t o t r e a t . The
funds we i n v e s t i n p r i m a r y h e a l t h care today w i l l be more t h a n
compensated f o r by t h e savings r e a l i z e d by foregone
acute,
t e r t i a r y and s p e c i a l i z e d c a r e .
Many f a c t o r s a d v e r s e l y impact on t h e a b i l i t y o f p h y s i c i a n s t o
e s t a b l i s h and m a i n t a i n p r i m a r y care p r a c t i c e s i n low income a r e a s .
Among t h e s e are t h e s m a l l number o f p o t e n t i a l p a t i e n t s w i t h h e a l t h
i n s u r a n c e , inadequate reimbursement r a t e s , and t h e d i f f i c u l t y i n
r a i s i n g the start-up c a p i t a l required t o establish a practice.
I f p r e v e n t i v e medicine and p r i m a r y care a r e t o become an
i m p o r t a n t p a r t o f t h e s t r a t e g y t o i n s u r e t h a t every American i s
provided w i t h a basic l e v e l of health care, t h e lack of primary
c a r e p h y s i c i a n s , p a r t i c u l a r l y i n low income communities, must be
addressed.
R e g i o n a l M e d i c a l Schools
Because t h e r e a r e so few programs f o r p r e p a r i n g h e a l t h
p r o f e s s i o n a l s as f a m i l y o r p r i m a r y care p h y s i c i a n s , i t i s
i m p e r a t i v e t h a t t h e F e d e r a l government s t i m u l a t e t h e c r e a t i o n o f
such programs.
A c o s t e f f e c t i v e means o f d o i n g t h i s would be
t h r o u g h s u p p o r t f o r r e g i o n a l medical schools founded a t p u b l i c l y
funded c o l l e g e s o r u n i v e r s i t i e s .
Such m e d i c a l schools would
p r o v i d e f i n a n c i a l support t o s t u d e n t s based on need.
RECOMMENDATIONS
1.
There must be a d d i t i o n a l compensation under a reformed
n a t i o n a l h e a l t h i n s u r a n c e s t r u c t u r e f o r those p h y s i c i a n s who
p r o v i d e p r i m a r y c a r e , e s p e c i a l l y i n poor and m e d i c a l l y underserved
neighborhoods.
A t t h e p r e s e n t t i m e . New York C i t y p h y s i c i a n s r e c e i v e $11 i n
reimbursement f o r a r o u t i n e o f f i c e v i s i t under M e d i c a i d .
2.
The c o s t s of e s t a b l i s h i n g a primary care p r a c t i c e i n a
community t h a t has a c u r r e n t d e f i c i t of primary care p h y s i c i a n s
should be s u b s i d i z e d by the Federal government on a pro-rated
b a s i s or, a t a minimum, such p r a c t i c e s should be provided with low
i n t e r e s t F e d e r a l or Federally-backed loans.
For example, a p h y s i c i a n who works t h r e e years i n such an
area m i g h t be e l i g i b l e f o r a 30 p e r c e n t s u b s i d y . A p h y s i c i a n who
works seven o r more years might r e c e i v e a 100 p e r c e n t s u b s i d y .
-13-
�3.
Primary care providers s e r v i n g areas with a c u r r e n t
d e f i c i t of primary care p h y s i c i a n s should be protected from the
worst impacts of adverse medical malpractice judgments, p o s s i b l y
through F e d e r a l l y subsidized assigned r i s k pools.
4.
The
Federal
government
should
encourage
the
establishment of primary care p r a c t i c e s through medical school
loan
forgiveness,
tuition
reduction
and
other
programs,
p a r t i c u l a r l y f o r those p h y s i c i a n s who serve i n medically needy
neighborhoods. Minority and low-income persons should e s p e c i a l l y
be encouraged through such programs.
T h i s c o u l d be accomplished, i n p a r t , by b u i l d i n g on programs
such as New York C i t y ' s Sophie Davis B i o m e d i c a l E d u c a t i o n Program,
a s c h o o l which enables i n n e r c i t y s t u d e n t s t o r e c e i v e m e d i c a l
t r a i n i n g . C u r r e n t l y , Sophie Davis i s a two-year i n s t i t u t i o n . The
F e d e r a l government should a c t i n c o n c e r t w i t h s t a t e and l o c a l
governments t o ensure t h a t Sophie Davis and s i m i l a r c o l l e g e s
around t h e c o u n t r y a r e e i t h e r e s t a b l i s h e d as o r expanded t o f u l l
degree g r a n t i n g s t a t u s .
5.
Each National Health region must have a t l e a s t one t o
two medical schools, depending on population, t h a t a r e devoted
s o l e l y t o the t r a i n i n g of primary care p h y s i c i a n s .
6.
A l l medical schools r e c e i v i n g Federal a i d should be
r e q u i r e d t o e s t a b l i s h family p r a c t i c e departments and o f f e r
i n t e r n s h i p s i n areas r e l a t e d t o primary c a r e .
7.
H o s p i t a l s r e c e i v i n g F e d e r a l l y subsidized funds should be
r e q u i r e d t o e s t a b l i s h primary care t r a i n i n g programs, or h o s p i t a l s
should be o f f e r e d Federal i n c e n t i v e s t o e s t a b l i s h such programs.
B. ENSURING AND EXPANDING SCHOOL HEALTH SERVICES
The i n s u f f i c i e n c y o f New York C i t y ' s p r i m a r y care f a c i l i t i e s
i n c r e a s e s t h e C i t y ' s r e l i a n c e upon o t h e r sources o f m e d i c a l c a r e .
One such source i s t h e School H e a l t h S e r v i c e s Program, o p e r a t e d by
t h e New York C i t y Department o f H e a l t h and t h e New York C i t y Board
o f E d u c a t i o n , which serves a p p r o x i m a t e l y 1.2 m i l l i o n New York C i t y
p u b l i c and n o n - p u b l i c school s t u d e n t s . The School H e a l t h S e r v i c e s
Program, a t r a d i t i o n a l form o f i m p o r t a n t h e a l t h care o u t r e a c h ,
p r o v i d e s t h e c h i l d r e n o f New York C i t y w i t h a s i g n i f i c a n t s a f e t y
n e t o f b a s i c m e d i c a l s e r v i c e s which a r e a l l - t o o - o f t e n i n a c c e s s i b l e
t o them.
There a r e a host o f s e r i o u s h e a l t h t h r e a t s which c o m p l i c a t e
t h e d e l i v e r y o f h e a l t h care s e r v i c e s t o t h e c h i l d r e n o f New York
City.
The t u b e r c u l o s i s (TB) epidemic which faces New York C i t y
does n o t spare c h i l d r e n .
Recent s t a t i s t i c s c i t e d i n a r e p o r t by
t h e New York S t a t e E d u c a t i o n Department's Committee on Elementary,
M i d d l e and Secondary E d u c a t i o n , i n d i c a t e d t h a t t h e i n c i d e n c e o f TB
i n f e c t i o n among c h i l d r e n ages f i v e t o 14 i s a p p r o x i m a t e l y f i v e
cases p e r 100,000, and growing r a p i d l y .
The a r r i v a l i n New York
C i t y o f a m u l t i - d r u g r e s i s t a n t s t r a i n o f TB o n l y adds t o t h e
a l r e a d y dangerous t h r e a t TB p r e s e n t s t o t h e C i t y ' s c h i l d r e n .
-14-
�Another epidemic which t h r e a t e n s t h e h e a l t h o f c h i l d r e n i n
New York C i t y i s HIV and AIDS. The S t a t e ' s r e p o r t i n d i c a t e d t h a t
as o f September 30, 1991, n e a r l y 2,000 c h i l d r e n were diagnosed
w i t h AIDS i n New York C i t y . While s t a t i s t i c s d i d n o t r e v e a l how
many c h i l d r e n were HIV p o s i t i v e and would l a t e r develop AIDS, t h e
r e a l i t y t h a t t h e r e are many such young people cannot be i g n o r e d .
Other major h e a l t h t h r e a t s which face t h e c h i l d r e n o f New
York C i t y i n c l u d e substance abuse, c h i l d n e g l e c t and abuse, o t h e r
forms
of violence, suicide,
sexually
transmitted
diseases,
e n v i r o n m e n t a l hazards, and i n c o m p l e t e immunizations f o r common
childhood diseases.
The e x i s t e n c e o f such s e r i o u s h e a l t h r i s k s i s exacerbated by
a v a r i e t y o f n e g a t i v e s o c i a l and economic f a c t o r s w i t h which New
York
City's
children
must
cope.
Such
factors
include
homelessness, p o v e r t y , and newly a r r i v e d immigrant s t a t u s .
Expanding School H e a l t h S e r v i c e s
Unfortunately,
New York C i t y ' s
School
Health
Services
Program, h a v i n g s u f f e r e d budgetary r e d u c t i o n s i n p r e v i o u s y e a r s ,
does n o t a d e q u a t e l y p r o v i d e v i t a l , mandated s e r v i c e s .
As a
r e s u l t , t h e C i t y ' s Department o f H e a l t h has developed a f i v e - y e a r
plan
t o expand
school
health
s e r v i c e s which
will
begin
i m p l e m e n t a t i o n by p r i o r i t y i n h i g h " h e a l t h r i s k " d i s t r i c t s t h i s
year.
Under t h i s p l a n , t h e s e r v i c e s o f medical teams c o n s i s t i n g
of a p h y s i c i a n , a nurse, and a p u b l i c h e a l t h a s s i s t a n t w i l l be
a s s i g n e d t o each o f t h e C i t y ' s 32 school d i s t r i c t s .
However, o n l y
a p a r t - t i m e p u b l i c health a s s i s t a n t , t r a i n e d t o perform c l e r i c a l
work and p r o v i d e f i r s t a i d , w i l l be assigned t o each p u b l i c
e l e m e n t a r y s c h o o l on a d a i l y b a s i s d u r i n g t h e s c h o o l y e a r . The
p l a n a l s o c a l l s f o r one p u b l i c h e a l t h a s s i s t a n t t o be assigned t o
each i n t e r m e d i a t e s c h o o l , w h i l e h i g h schools would c o n t i n u e t h e i r
r e l i a n c e on h e a l t h a i d e s . Thus, even a f t e r t h e new f i v e - y e a r p l a n
i s f u l l y i n p l a c e , many o f o u r schools w i l l s t i l l l a c k a f u l l - t i m e
health
care
professional.
Notably,
t h e Federal
government
c u r r e n t l y p r o v i d e s o n l y about e i g h t p e r c e n t o f t h e t o t a l d o l l a r s
devoted t o t h e p r o v i s i o n o f s c h o o l h e a l t h s e r v i c e s i n New York
City.
RECOMMENDATIONS
1.
The Federal government should i n c r e a s e i t s funding t o
ensure t h a t every school has a minimum of one f u l l - t i m e h e a l t h
c a r e worker during the school year.
2.
More t h a n one nurse o r p a r a p r o f e s s i o n a l s h o u l d be
a s s i g n e d t o s c h o o l s which have a h i g h e r l e v e l o f s t u d e n t h e a l t h
c a r e needs.
C e r t a i n schools i n disadvantaged areas serve a l a r g e number
of s t u d e n t s from p o v e r t y backgrounds who l a c k a c c e s s i b i l i t y t o
h e a l t h c a r e s e r v i c e s and are t h u s a t a h i g h e r r i s k o f poor h e a l t h .
The F e d e r a l government should a s s i s t i n s u b s i d i z i n g t h e a d d i t i o n a l
h e a l t h c a r e s t a f f i n g needed a t such s c h o o l s .
-15-
�3.
Nurses,
doctors
and
paraprofessionals
should
be
encouraged to serve i n the School Health S e r v i c e s Program through
loan f o r g i v e n e s s programs.
W h i l e a l a c k of f u n d i n g i s t h e p r i m a r y reason f o r t h e
s h o r t a g e o f s t a f f workers i n t h e Program, once f u n d i n g i s secured
it
may
be
difficult
to attract
needed
professional
and
p a r a p r o f e s s i o n a l s t a f f t o serve i n t h e program.
4.
The F e d e r a l government should help ensure t h a t the
School Health S e r v i c e s Program has the resources necessary to
enable i t to perform i t s r e s p o n s i b i l i t i e s with respect to hearing
and v i s i o n screenings, p h y s i c a l examinations, lead poisoning and
t u b e r c u l o s i s t e s t i n g , and ensuring the f u l l immunization of the
student population.
5.
The F e d e r a l government should play a strong r o l e i n
ensuring t h a t school-based c l i n i c s are e s t a b l i s h e d i n every school
which has a higher l e v e l of student h e a l t h care needs.
-16-
�II.
MEETING THE HEALTH CARE NEEDS OF SPECIAL POPULATIONS
There a r e , i n New York C i t y , a number o f s p e c i a l p o p u l a t i o n s
who have come t o t h e a t t e n t i o n o f t h e C o u n c i l . These i n c l u d e
people w i t h AIDS and/or t u b e r c u l o s i s , substance abusers, low
income and poor women, t h e e l d e r l y , and t h e homeless.
In
p a r t i c u l a r , t h e r e i s f e a r t h a t u n i v e r s a l h e a l t h care alone w i l l
not be a b l e t o meet t h e needs o f these p o p u l a t i o n s . Access t o
c a r e i s t h e i r shared and o v e r r i d i n g concern, whether t h e o b s t a c l e
i s c u l t u r a l o r language b a r r i e r s , l a c k o f a p p r o p r i a t e h e a l t h
services, t h e high t r a n s p o r t a t i o n costs of m u l t i p l e o f f i c e v i s i t s ,
l i m i t e d and expensive c h i l d - c a r e , o r b a s i c s h e l t e r and f o o d
concerns.
RECOMMENDATIONS
1.
National h e a l t h care reform should ensure t h a t the
p r o v i s i o n of general h e a l t h care and p u b l i c h e a l t h campaigns and
other
h e a l t h education
take place
i n a l i n g u i s t i c a l l y and
c u l t u r a l l y appropriate manner.
Such a manner should i n c l u d e t h e use o f l o w - l i t e r a c y
e d u c a t i o n a l m a t e r i a l s , such as v i d e o s , and o u t r e a c h workers who
speak
people's
native
languages.
Appropriate
educational
m a t e r i a l s and resources n o t o n l y need t o be developed, b u t must be
more a c c e s s i b l e t o t h e p u b l i c .
2.
I n providing
health
care
to low-income and poor
individuals,
appointments a f t e r
regular
business
hours and
t r a n s p o r t a t i o n or reimbursement of t r a n s p o r t a t i o n c o s t s must be
offered.
3.
National h e a l t h care reform should ensure t h a t primary
c a r e o f f e r s a s s i s t a n c e i n obtaining s p e c i a l t y and s o c i a l support
s e r v i c e s , with arrangements made by the primary care provider, and
t h a t a c t i v e follow-up takes p l a c e .
A. PEOPLE WITH AIDS
AIDS i s d e v a s t a t i n g o u r N a t i o n ' s urban c e n t e r s . I t s e f f e c t s
a r e i n c r e a s i n g l y f e l t by i n d i v i d u a l s and groups a l r e a d y a d v e r s e l y
impacted by o t h e r m e d i c a l and s o c i a l i l l s .
New York C i t y i s t h e
AIDS e p i c e n t e r o f t h e n a t i o n . By t h e end o f 1991, 34,994 New York
C i t y r e s i d e n t s had developed AIDS. W i t h a mere t h r e e p e r c e n t o f
the
n a t i o n ' s p o p u l a t i o n , t h i s C i t y has 17 p e r c e n t o f t h e AIDS
cases r e c o r d e d n a t i o n a l l y .
The C i t y ' s c u m u l a t i v e AIDS i n c i d e n c e
r a t e i s 560.2 a d u l t s / a d o l e s c e n t s p e r 100,000 as compared t o a
n a t i o n a l r a t e o f 98.2 p e r 100,000. I n New York C i t y , AIDS i s now
the
l e a d i n g k i l l e r o f men between t h e ages o f 25-44 and women
between 25-34.
The Changing Nature o f t h e AIDS Epidemic
Minorities
are d i s p r o p o r t i o n a t e l y
epidemic.
N a t i o n a l l y , o f 213,614 AIDS
-17-
impacted
by t h e AIDS
cases r e p o r t e d t h r o u g h
�February 1992, 62,333 Blacks were r e p o r t e d t o have AIDS and 34,940
H i s p a n i c s were so r e p o r t e d . I n New York C i t y , Blacks c o n s t i t u t e
24.6 p e r c e n t o f t h e g e n e r a l p o p u l a t i o n b u t r e p r e s e n t 37.4 p e r c e n t
of t h e AIDS cases.
H i s p a n i c s c o n s t i t u t e 23.7 p e r c e n t o f t h e
g e n e r a l p o p u l a t i o n b u t r e p r e s e n t 30.2 p e r c e n t o f t h e AIDS cases.
Testimony p r e s e n t e d
b e f o r e t h e New York C i t y
Council's
Committee on H e a l t h c o n f i r m e d t h a t t h e AIDS epidemic has t a k e n on
a d i f f e r e n t c h a r a c t e r i n communities o f c o l o r . For example, w h i l e
t h e Men Having Sex W i t h Men (MSM) r i s k c a t e g o r y c o n t i n u e s t o be
t h e l a r g e s t group i n t h e g e n e r a l AIDS p o p u l a t i o n , 66 p e r c e n t o f
b l a c k males and 64 p e r c e n t o f Hispanic males c o n t r a c t e d AIDS
t h r o u g h i n t r a v e n o u s drug use (IDU) and o t h e r non-MSM exposures.
I t i s i m p o r t a n t t o note t h a t m i n o r i t y women a r e now t h e f a s t e s t
growing group o f H I V - i n f e c t e d people i n New York C i t y . A m a j o r i t y
o f HIV p o s i t i v e women a r e b e l i e v e d t o have c o n t r a c t e d t h e v i r u s
t h r o u g h h e t e r o s e x u a l sex o r IDU.
N o t a b l y , many women do not l e a r n
of t h e i r
HIV s t a t u s u n t i l
a f t e r they give b i r t h ,
thereby
c o n t r i b u t i n g t o t h e i n c i d e n c e o f p e d i a t r i c AIDS. I n 1990, The New
York Times r e p o r t e d t h a t Dr. Ernest Drucker o f t h e M o n t e f i o r e
M e d i c a l Center s t a t e d t h a t , as a consequence o f AIDS r e l a t e d
deaths among m i n o r i t y p a r e n t s , t h e C i t y can expect
70,000
a d d i t i o n a l orphans i n communities o f c o l o r over t h e next decade.
AIDS has a l s o s e v e r e l y impacted b l a c k and H i s p a n i c young
people.
Only 15 p e r c e n t o f American c h i l d r e n a r e b l a c k and o n l y
10 p e r c e n t a r e H i s p a n i c .
However, b l a c k c h i l d r e n c o n s t i t u t e 53
p e r c e n t o f a l l c h i l d h o o d AIDS cases and Hispanic c h i l d r e n account
f o r an a d d i t i o n a l 22 p e r c e n t o f p e d i a t r i c AIDS cases.
I n 1991, t h e F e d e r a l government d e s i g n a t e d $20,800,000 f o r
AIDS p r e v e n t i o n e f f o r t s i n New York S t a t e . By 1993, t h e l e v e l o f
F e d e r a l a i d had been reduced t o $16,000,000. T h i s r e d u c t i o n has
o c c u r r e d a t t h e same t i m e as t h e demand f o r these s e r v i c e s has
increased.
New York S t a t e Department o f H e a l t h Commissioner Dr.
Mark Chassin s t a t e d t h a t , " [ t ] h i s c o n t i n u i n g e r o s i o n i n F e d e r a l
s u p p o r t has c r i p p l e d New York's p r e v e n t i o n e f f o r t s . "
RECOMMENDATIONS
1.
There must be a s u b s t a n t i a l increase i n Federal funds
targeted
towards State
and l o c a l AIDS prevention e f f o r t s ,
i n c l u d i n g t e s t i n g , counseling, education and partner n o t i f i c a t i o n .
AIDS p r e v e n t i o n
efforts
a r e o f s p e c i a l importance t o
communities o f c o l o r , where AIDS i s o f t e n spread t h r o u g h I V drug
users and t h e i r p a r t n e r s .
T h e r e f o r e , p r e v e n t i o n and t r e a t m e n t
programs t h a t i n c l u d e an e x t e n s i v e a n t i - d r u g component c o u l d
effectively
break t h e c h a i n o f AIDS t r a n s m i s s i o n i n these
communities.
2.
The Ryan White Comprehensive AIDS Resources Emergency
Act of 1990 must be extended beyond i t s present term and higher
funding l e v e l s must be authorized i n order t o ensure the q u a l i t y ,
a v a i l a b i l i t y and organization of health care and support s e r v i c e s
f o r i n d i v i d u a l s and f a m i l i e s i n f e c t e d with HIV d i s e a s e .
-18-
�B. PEOPLE WITH TUBERCULOSIS
The
resurgence
o f t u b e r c u l o s i s (TB)
after
1986
i s an
i n d i c a t i o n o f t h e d e f i c i e n t n a t i o n a l commitment t o our c i t i z e n s '
p u b l i c h e a l t h and w e l f a r e . I n o r d e r t o combat t h i s d i s e a s e , we
must have a n a t i o n a l campaign, i n c o o p e r a t i o n w i t h l o c a l p u b l i c
h e a l t h o f f i c i a l s , t h a t a t t a c k s b o t h t h e medical and non-medical
c o n d i t i o n s t h a t c o n t r i b u t e t o i t s growth.
D u r i n g t h e l a s t F i s c a l Year, t h e r e were 3,777 new cases o f
a c t i v e TB i n New York C i t y . The C i t y ' s TB case r a t e o f 5 0.2 per
100,000 i s f i v e t i m e s t h e n a t i o n a l average.
For New York C i t y
b l a c k males, t h e case r a t e i s 453 per 100,000. On any g i v e n day,
the
City's hospitals treat
approximately
920
suspected
or
c o n f i r m e d TB p a t i e n t s . These numbers r e p r e s e n t 14 p e r c e n t o f t h e
t o t a l TB cases i n t h e e n t i r e U n i t e d S t a t e s .
A c c o r d i n g t o a 1991 New
York C i t y Department o f H e a l t h
s u r v e y , 34 p e r c e n t o f t h e New York C i t y TB p a t i e n t s q u e s t i o n e d
were r e s i s t a n t t o a t l e a s t one or more TB m e d i c a t i o n s .
The
Department e s t i m a t e s t h a t 40 t o 60 p e r c e n t o f New York C i t y TB
p a t i e n t s a r e a l s o HIV i n f e c t e d . An e s t i m a t e d 20 t o 30 p e r c e n t o f
t h e C i t y ' s TB p a t i e n t s are homeless.
Many o f these homeless
p a t i e n t s w i l l not f u l l y complete a 6-12
month course o f TB
t r e a t m e n t . A s i g n i f i c a n t number o f these homeless p a t i e n t s l e a v e
h o s p i t a l s and r e t u r n t o g e n e r a l homeless s h e l t e r s , where t h e y
c o n t i n u e t h e c y c l e o f i n f e c t i o n , p a r t i a l t r e a t m e n t and u l t i m a t e
reinfection.
I n c r e a s i n g l y , r e i n f e c t e d p a t i e n t s have developed a
more d i f f i c u l t and expensive t o t r e a t m u l t i - d r u g r e s i s t a n t form o f
TB.
Additionally,
testimony
presented
before
the
Council
i n d i c a t e d t h a t 4 8 p e r c e n t o f t h e TB p a t i e n t s d i s c h a r g e d d u r i n g
F i s c a l Year 1991 i n New York C i t y had a h i s t o r y o f substance
abuse. T h i s p o p u l a t i o n a l s o r a i s e s concerns w i t h r e s p e c t t o t h e i r
a b i l i t y t o complete t h e a n t i - T B drug regime.
Responding t o T u b e r c u l o s i s
D e s p i t e t h e l a c k o f a n a t i o n a l commitment t o f i g h t TB,
New
York C i t y has f a s h i o n e d i t s own response t o address t h e d i f f i c u l t
m e d i c a l and s o c i a l problems t h a t are connected t o t h e new
TB
epidemic.
The C i t y ' s H e a l t h and H o s p i t a l s C o r p o r a t i o n (HHC) has a l r e a d y
committed $14,000,000 t o t h e C i t y ' s a n t i - T B e f f o r t , which i n c l u d e s
t h e c o n s t r u c t i o n and
r e n o v a t i o n o f hundreds o f
in-hospital
i s o l a t i o n rooms and t h e upgrading o f l a b s a t m u n i c i p a l h o s p i t a l s .
Funds have a l s o been spent upgrading h o s p i t a l v e n t i l a t i o n systems
and i n s t a l l i n g HEPA f i l t e r s and UV l i g h t s i n h o s p i t a l areas where
suspected and/or c o n f i r m e d TB p a t i e n t s s t a y or t r a v e l t h r o u g h . I n
response t o outbreaks o f TB i n t h e C i t y ' s c o r r e c t i o n a l system, a
s p e c i a l c o n t a g i o u s disease u n i t has been c o n s t r u c t e d t o t r e a t
p r i s o n e r s who have a c t i v e TB.
N o t a b l y , p r e l i m i n a r y p l a n s have
been f o r m u l a t e d t o spend an a d d i t i o n a l $18,000,000 on f u r t h e r
anti-TB e f f o r t s .
New
York C i t y ' s H e a l t h Department has a l s o
i n i t i a t e d a program o f D i r e c t l y Observed Therapy (DOT).
Under
t h i s program. C i t y h e a l t h workers observe TB c l i e n t s t a k i n g t h e i r
-19-
�m e d i c a t i o n s i n " f i e l d s e t t i n g s " such as c l i n i c s , t h e c l i e n t ' s home
or on C i t y s t r e e t s .
W i t h o n l y m i n i m a l a s s i s t a n c e from t h e F e d e r a l government, New
York and o t h e r c i t i e s have upheld t h e i r r e s p o n s i b i l i t y t o combat
TB. T u b e r c u l o s i s does n o t r e s p e c t m u n i c i p a l , r e g i o n a l o r s t a t e
b o r d e r s . I t i s a n a t i o n a l , even i n t e r n a t i o n a l , problem w i t h l o c a l
consequences.
T h e r e f o r e , i t i s i m p e r a t i v e t h a t we r e q u e s t a
g r e a t e r ongoing commitment by t h e F e d e r a l government t o p r o v i d e
the
monetary resources needed t o expand l o c a l TB p r e v e n t i o n
c o n t r o l and t r e a t m e n t programs.
RECOMMENDATIONS
1.
National health care reform should include coverage f o r
D i r e c t l y Observed Therapy programs.
A s i g n i f i c a n t number o f p a t i e n t s who f a i l t o f u l l y complete
t h e i r t h e r a p y develop M u l t i - D r u g R e s i s t a n t T u b e r c u l o s i s .
An
expanded F e d e r a l commitment t o support DOT programs would p r e v e n t
many o f these "expensive t o t r e a t " cases, t h e r e b y s a v i n g a l l
l e v e l s o f government s u b s t a n t i a l revenue i n t h e l o n g r u n .
2.
F e d e r a l a i d must be expanded i n o r d e r t o f a c i l i t a t e t h e
h i r i n g o f a d d i t i o n a l TB case managers.
A d e m o n s t r a t i o n p r o j e c t a t Brooklyn's Kings County H o s p i t a l
found t h a t case-managed p a t i e n t s were t w e l v e t i m e s more l i k e l y t o
be on t h e i r t r e a t m e n t schedule and f i v e t i m e s more l i k e l y t o be
non-infectious.
3.
N a t i o n a l h e a l t h care r e f o r m should address t r e a t m e n t f o r
n o n - c o m p l i a n t TB p a t i e n t s d e t a i n e d by o r d e r o f t h e l o c a l H e a l t h
Commissioner.
R e c e n t l y , New York C i t y i n s t i t u t e d a c o s t l y , b u t necessary.
Federal
Centers
f o r Disease C o n t r o l recommended p o l i c y o f
d e t a i n i n g non-compliant TB p a t i e n t s i n a C i t y f a c i l i t y u n t i l t h e y
are c u r e d .
4.
F e d e r a l a i d must be expanded t o a l l o w m u n i c i p a l i t i e s t o
i n c r e a s e t h e number o f beds i n s p e c i a l s h e l t e r s designed f o r TB
patients.
Homeless p a t i e n t s i n TB s h e l t e r s have a t r e a t m e n t c o m p l e t i o n
r a t e o f 4 0 p e r c e n t as compared t o t h e 10 t o 15 p e r c e n t c o m p l e t i o n
r a t e among n o n - s h e l t e r e d homeless p a t i e n t s .
5.
F e d e r a l f u n d i n g must be expanded t o enhance t h e a b i l i t y
of m u n i c i p a l c o r r e c t i o n a l systems t o d e t e c t TB and p r e v e n t i t s
spread.
A number o f TB outbreaks have had t h e i r genesis i n communal
correctional
and c o u r t
facilities.
Additionally,
because
s i g n i f i c a n t numbers o f inmates a r e r a p i d l y r e l e a s e d a f t e r i n i t i a l
c o n t a c t w i t h t h e c r i m i n a l j u s t i c e system, TB cases generated
w i t h i n t h e system may be spread i n t o t h e g e n e r a l p o p u l a t i o n .
6.
F e d e r a l a i d must be expanded f o r workplace TB i n f e c t i o n
c o n t r o l and worker s a f e t y .
I n o r d e r t o p r e v e n t t h e t r a n s m i s s i o n o f TB i n h e a l t h c a r e
s e t t i n g s , many f a c i l i t i e s need t o i n s t a l l expensive v e n t i l a t i o n
systems and implement upgraded i n f e c t i o n c o n t r o l procedures.
-20-
�C. SUBSTANCE ABUSERS
The use o f i l l e g a l substances such as cocaine and h e r o i n
c o n t i n u e s unabated. Each n i g h t , t h e c a s u a l t i e s from t h e drug wars
( t h e overdosed and those shot i n d r u g - r e l a t e d v i o l e n c e ) a r e
t r e a t e d i n New York C i t y ' s emergency rooms.
Additionally, the
misuse o f d r u g i n j e c t i n g equipment i s f u e l i n g b o t h t h e AIDS and TB
epidemics.
A r e a l war a g a i n s t drug abuse must be f o u g h t on two f r o n t s .
C e r t a i n l y , l a w enforcement i s i m p o r t a n t t o c o m b a t t i n g drug abuse.
However, i t may best be used as a means f o r encouraging what Dr.
M i t c h e l l Rosenthal o f t h e Phoenix House r e s i d e n t i a l t r e a t m e n t
f a c i l i t y c a l l s "drug t r e a t m e n t by demand."
S o c i e t y can demand
t h a t a d d i c t s and p e t t y c r i m i n a l s e n r o l l i n t r e a t m e n t programs as
an
alternative
to
incarceration.
Long-term,
drug-free,
a l t e r n a t i v e - t o - i n c a r c e r a t i o n t r e a t m e n t programs c l a i m , based on
in-house s t u d i e s , t o have a lower r e c i d i v i s m r a t e t h a n p r i s o n s
where i n d i v i d u a l s a r e imprisoned w i t h o u t t r e a t m e n t s e r v i c e s .
Unfortunately,
s o c i e t y cannot demand t h a t people e n r o l l i n
t r e a t m e n t programs when t h e r e a r e n o t enough t r e a t m e n t s l o t s
available.
A d d i t i o n a l Drug Treatment Resources Needed
I n New York C i t y , t h e r e i s c u r r e n t l y a severe shortage o f
needed drug t r e a t m e n t s e r v i c e s . There a r e a p p r o x i m a t e l y 42,000
t r e a t m e n t s l o t s t o serve an e s t i m a t e d 200,000 h e r o i n abusers and
400,000 c r a c k / c o c a i n e
abusers.
Methadone maintenance programs
account f o r a p p r o x i m a t e l y 30,000 s l o t s , y e t methadone can o n l y be
used t o t r e a t h e r o i n a d d i c t i o n . There has been no s i g n i f i c a n t
growth i n t r e a t m e n t s l o t s f o r t h e growing c r a c k / c o c a i n e
abusing
p o p u l a t i o n d e s p i t e t h e i n c r e a s e i n t h e i n c i d e n c e o f c r a c k usage
over t h e p a s t s e v e r a l y e a r s .
L a s t l y , t h e r e a r e j u s t over 3,000
l o n g - t e r m r e s i d e n t i a l drug t r e a t m e n t s l o t s i n New York C i t y , b u t
t h e r e a r e 18,000 people i n t h e C i t y ' s j a i l s , many w i t h substance
abuse problems.
A c c o r d i n g t o a 1990 HHC r e p o r t , " p u b l i c l y funded t r e a t m e n t
programs a r e v i r t u a l l y n o n - e x i s t e n t f o r a d o l e s c e n t s . "
This i s
e s p e c i a l l y t r o u b l i n g i n l i g h t o f the various estimates p r o j e c t i n g
t h e number o f a d o l e s c e n t substance abusers i n New York C i t y t o be
between 141,000 and 212,000.
Furthermore,
the Division of
Substance Abuse S e r v i c e s 1990 Annual S t a t i s t i c a l Report i n d i c a t e d
t h a t 66 p e r c e n t o f substance abusers i n t r e a t m e n t were under 21
when t h e y f i r s t used drugs.
For t h i s reason, i t i s c r i t i c a l t o
f u n d a d o l e s c e n t p r e v e n t i o n and t r e a t m e n t programs t o reach a t - r i s k
y o u t h b e f o r e t h e y become s e r i o u s u s e r s .
The s i t u a t i o n i n New York C i t y r e f l e c t s a l a r g e r n a t i o n a l
substance abuse c r i s i s .
As t h e U.S. House o f R e p r e s e n t a t i v e s
s t a t e d i n i t s Report o f t h e S e l e c t Committee on N a r c o t i c s Abuse
and C o n t r o l i s s u e d i n December 1992: "Estimates o f t h e demand f o r
t r e a t m e n t a r e i m p r e c i s e and v a r i e d , and t h e data on t r e a t m e n t
resources a r e incomplete.
Regardless o f t h e exact numbers; t h e
-21-
�o v e r a l l p i c t u r e based on a v a i l a b l e i n f o r m a t i o n i s o f a t r e a t m e n t
system t h a t i s unable t o meet e x i s t i n g needs."
I t i s w e l l r e c o g n i z e d t h a t substance abuse l e a d s t o l o n g - t e r m
and s h o r t - t e r m s o c i a l c o s t s i n t h e forms o f l o s t p r o d u c t i v i t y ,
i l l n e s s , d e a t h , c r i m e , and t h e c o s t o f h e a l t h c a r e and s o c i a l
s e r v i c e s f o r abusers. The most c o s t e f f e c t i v e p o l i c y i n t h e l o n g
r u n would be t o reduce demand f o r drugs t h r o u g h a c o m b i n a t i o n o f
p r e v e n t i v e e d u c a t i o n programs and t r e a t m e n t t o reduce t h e d r u g
using population.
RECOMMENDATIONS
1.
Any n a t i o n a l h e a l t h c a r e p l a n must o f f e r substance abuse
treatment services.
Under t h e c u r r e n t system, drug t r e a t m e n t i s u n d e r i n s u r e d by
p r i v a t e companies, s t a t e o p e r a t e d h e a l t h i n s u r a n c e companies, and
f e d e r a l programs.
2.
More treatment
slots,
based
on a combination of
o u t - p a t i e n t and r e s i d e n t i a l treatment programs, a r e needed, as
w e l l as program components t o address such c r i t i c a l areas as
education, job t r a i n i n g , housing and general h e a l t h c a r e .
O u t - p a t i e n t and r e s i d e n t i a l t r e a t m e n t programs have been
shown t o work by a number o f t r e a t m e n t p r o v i d e r s , such as Phoenix
House, Odyssey House and Daytop V i l l a g e .
O f t e n i n search o f a
" q u i c k f i x " a t budget t i m e , f i n a n c i a l a n a l y s t s have reduced t h e s e
programs' budgets i n o r d e r t o save money on a s h o r t - t e r m b a s i s .
The r e s u l t i s f r e q u e n t and c o s t l y r e l a p s e s i n p a t i e n t s who
complete s h o r t - t e r m programs, r e c e i v e inadequate f o l l o w - u p , and
are n o t o f f e r e d
the educational,
j o b , h o u s i n g , and h e a l t h
components t h a t can make d r u g t r e a t m e n t work f o r t h e l o n g r u n .
3.
The F e d e r a l government should t a r g e t treatment t o those
most i n need and t o those most l i k e l y t o be i n a p o s i t i o n t o be
i d e n t i f i e d as substance abusers and encouraged
t o undertake
treatment, p a r t i c u l a r l y adolescent substance abusers.
Pregnant substance abusers, a d o l e s c e n t s , t h e homeless, and
the mentally i l l
c h e m i c a l abuser p o p u l a t i o n a r e examples o f
s p e c i a l groups i n d i r e need o f t r e a t m e n t . S e r v i c e d e l i v e r y can be
geared t o them t h r o u g h a c o m b i n a t i o n o f c i t y and s t a t e agencies
and n o n - p r o f i t p r o v i d e r s .
4.
F e d e r a l e f f o r t s must be expanded t o help New York C i t y
s e t up a treatment r e g i s t r y and a network of i n t a k e , assessment
and r e f e r r a l c e n t e r s .
When more t r e a t m e n t s l o t s become a v a i l a b l e , i t w i l l be
i n c r e a s i n g l y i m p o r t a n t f o r i n d i v i d u a l s seeking t r e a t m e n t t o o b t a i n
a s s i s t a n c e r e g a r d i n g what t r e a t m e n t s l o t s a r e a v a i l a b l e and which
programs would b e s t serve t h e i r needs.
5.
A d d i t i o n a l funding i s needed f o r more a l t e r n a t i v e - t o i n c a r c e r a t i o n p r o j e c t s t o d i v e r t l o w - l e v e l offenders from the
c o u r t s and j a i l s i n t o programs t h a t w i l l address substance abuse
problems and the b a s i c causes of the a n t i - s o c i a l , s e l f - d e s t r u c t i v e
behavior of substance abusers.
-22-
�There a r e s e v e r a l p i l o t programs o p e r a t i n g o u t o f t h e
D i s t r i c t A t t o r n e y ' s o f f i c e s i n New York C i t y t h a t may m e r i t
expansion.
D. LOW INCOME AND POOR WOMEN
Another l o c a l p o p u l a t i o n o f p a r t i c u l a r concern i s low income
and poor women.
When p r o v i d i n g h e a l t h care t o these women,
p l a n n i n g e n t i t i e s must t a k e i n t o account t h e r e a l i t y t h a t t h e y a r e
s t i l l t h e primary care-givers f o r t h e i r c h i l d r e n .
The l a c k o f
adequate c h i l d - c a r e has been c i t e d i n C o u n c i l h e a r i n g s as a f a c t o r
limiting
women's
ability
t o make
and keep
health
care
appointments.
I n a d d i t i o n , t r a n s p o r t a t i o n c o s t s t o f a c i l i t i e s can
become e x o r b i t a n t , even i n New York C i t y , p a r t i c u l a r l y i f a woman
i s r e c e i v i n g o u t p a t i e n t t r e a t m e n t f o r an i l l n e s s , such as b r e a s t
cancer, o r p r e n a t a l care on a r e g u l a r b a s i s and must have h e r
c h i l d r e n accompany h e r .
RECOMMENDATION
1.
To improve access to primary care, and other types of
h e a l t h care where p r a c t i c a b l e , there must be o n - s i t e c h i l d - c a r e ,
transportation
reimbursements f o r accompanying c h i l d r e n , and
appointments a f t e r regular business hours.
W i t h o u t a "one-stop shopping" approach t o h e a l t h care which
i n c l u d e s these elements, women, e s p e c i a l l y poor women, w i l l be
l e s s l i k e l y t o access needed s e r v i c e s .
B r e a s t Cancer
B r e a s t cancer, w i t h i t s h i g h m o r t a l i t y r a t e i n New York C i t y ,
i s one example o f an i l l n e s s whose i d e n t i f i c a t i o n and t r e a t m e n t
has been r a t i o n e d . Medicine has found ways t o i d e n t i f y and t r e a t
b r e a s t cancer, b u t has n o t been a b l e t o b r i n g t h e same l e v e l o f
c a r e t o a l l women.
B r e a s t cancer remains t h e most common t y p e o f cancer among
women
i n New York S t a t e .
I n New York C i t y ,
each
year
a p p r o x i m a t e l y 4,000 women w i l l g e t b r e a s t cancer and 1,500 women
w i l l d i e of i t .
A 1990 r e p o r t . Poverty and Breast Cancer i n New
York C i t y , i s s u e d by t h e C i t y ' s C o m p t r o l l e r found t h a t t h e C i t y ' s
b r e a s t cancer m o r t a l i t y r a t e i s n e a r l y double t h e n a t i o n a l r a t e .
B r e a s t cancer p a t i e n t s when diagnosed i n stage 1 ( e a r l y ) have a 9 0
percent s u r v i v a l r a t e .
However, a d i a g n o s i s i n stages 3 o r 4
reduces a woman's s u r v i v a l r a t e t o 35 p e r c e n t and f i v e p e r c e n t
respectively.
The C o m p t r o l l e r ' s r e p o r t found t h a t " [ i ] n poor
neighborhoods i n New York C i t y b r e a s t cancer i s u s u a l l y n o t
diagnosed a t stage 1 . " P a r t i c u l a r l y troublesome was t h e f i n d i n g
t h a t " [ a ] p p r o x i m a t e l y 65 p e r c e n t o f t h e b r e a s t cancers d e t e c t e d a t
HHC f a c i l i t i e s a r e n o t d e t e c t e d u n t i l t h e cancer has advanced t o
t h e l a t e stage (3 and 4 ) . By c o n t r a s t , i n t h e c o u n t r y as a whole,
as few as 2 0 p e r c e n t t o 25 p e r c e n t o f t h e b r e a s t cancers a r e
diagnosed t h a t l a t e (stage 3 and 4 ) . "
The C o m p t r o l l e r ' s Report f u r t h e r found, and HHC c o n c u r r e d ,
t h a t " [ p ] o o r women... are more a t r i s k o f d y i n g from b r e a s t
-23-
�cancer...due t o t h e u n a v a i l a b i l i t y o f " s c r e e n i n g mairanographies i n
HHC f a c i l i t i e s .
I n 1991, HHC i s s u e d a Breast H e a l t h Task Force Report, which
d e t e r m i n e d t h a t " [ t ] h e number o f p r e v e n t a b l e deaths from b r e a s t
cancer i s about two and a h a l f times as g r e a t among women o f lower
socio-economic s t a t u s as among women o f h i g h e r SES." The Task
Force r e p o r t e d t h a t r e s e a r c h e r s had found t h a t p o v e r t y o r c l a s s ,
and n o t r a c e , causes t h e d i s c r e p a n c y i n mammography and m o r t a l i t y
rates
between A f r i c a n - A m e r i c a n ,
Hispanic,
and w h i t e women.
D i s t u r b i n g l y , a 1991 survey o f HHC's female p a t i e n t s , most o f whom
are o f a l o w socio-economic s t a t u s , found t h a t o n l y 54 p e r c e n t
even knew what a mammogram was.
In
1992, t h e American Cancer S o c i e t y (ACS) found
that,
n a t i o n a l l y , more women were f o l l o w i n g ACS' mammography g u i d e l i n e s
t h a n i n 1990; however, most o f t h e i n c r e a s e "was i n younger,
w h i t e , educated, middle t o upper income women." D u r i n g t h e same
p e r i o d , b l a c k women experienced no i n c r e a s e i n t h e r a t e a t which
t h e y underwent mammograms.
A d d i t i o n a l l y , low income H i s p a n i c
women aged 50+ were t h e group " l e a s t l i k e l y t o have had a
mammogram o r t o be p l a n n i n g t o have another i f t h e y have had one."
Improving Early I d e n t i f i c a t i o n
Efforts
HHC responded t o t h e C o m p t r o l l e r ' s c r i t i c i s m s by a d o p t i n g t h e
ACS g u i d e l i n e s i n 1991, and making some e f f o r t s t o improve
mammography
services
and f o l l o w - u p .
More
recently, the
C o m p t r o l l e r was a b l e t o i d e n t i f y $3 m i l l i o n i n debt management
s a v i n g s a v a i l a b l e over t h e next f o u r y e a r s , which t h e Mayor has
earmarked f o r new s c r e e n i n g mammography programs a t seven HHC
facilities,
greater
education
and o u t r e a c h ,
and
improved
f o l l o w - u p . However, t h i s f u n d i n g stream w i l l d r y up i n 1997. The
B r o o k l y n Borough P r e s i d e n t , t o h i s c r e d i t , i s p r o v i d i n g funds f o r
the
purchase o f a Mobile
Mammography U n i t .
I n addition,
Communi-Care i s expected t o i n c l u d e s c r e e n i n g mammography.
On t h e F e d e r a l l e v e l . Medicaid covers t h e c o s t o f s c r e e n i n g
mammographies which are performed under t h e g u i d e l i n e s o f t h e ACS.
However, c o n t r a r y t o ACS g u i d e l i n e s , Medicare covers s c r e e n i n g
mammograms o n l y every o t h e r year and t h e n o n l y i f t h e p a t i e n t can
a f f o r d t h e premiums f o r P a r t B coverage.
RECOMMENDATIONS
1.
F e d e r a l a i d t o f a c i l i t a t e New York C i t y breast h e a l t h
education e f f o r t s should be increased.
2.
Medicare and any new programs e s t a b l i s h e d under a
n a t i o n a l h e a l t h care plan
should cover the c o s t s of e a r l y
d e t e c t i o n and treatment for breast cancer.
At
a minimum, any such p l a n should
include
screening
mammography under ACS g u i d e l i n e s .
Infant Mortality
Low b i r t h w e i g h t , o f t e n a r e s u l t o f l i t t l e o r no p r e n a t a l
c a r e and poor n u t r i t i o n , has been connected t o i n f a n t m o r t a l i t y .
A t p r e s e n t , 12 o f t h e C i t y ' s 30 h e a l t h d i s t r i c t s have i n f a n t
-24-
�m o r t a l i t y r a t e s above t h e c i t y - w i d e r a t e o f 11.4 p e r 1,000 l i v e
b i r t h s and 19 a r e above t h e n a t i o n a l r a t e o f 8.9. Of t h e 12, s i x
of these h e a l t h d i s t r i c t s are not r e c e i v i n g p r e n a t a l h e a l t h
s e r v i c e s from e i t h e r t h e New York C i t y Department o f H e a l t h o r New
York S t a t e .
T h i s i n c l u d e s F o r t Greene, which s u f f e r s from t h e
w o r s t i n f a n t m o r t a l i t y r a t e i n New York C i t y , 24.2 p e r 1,000 l i v e
births.
HHC's I n f a n t M o r t a l i t y I n i t i a t i v e ("IMI") has been s h r i n k i n g
s i n c e t h e number o f v i s i t s i n t h e Adolescent Pregnancy Program
peaked i n 1989 w i t h 17,673 v i s i t s .
I M I serves two c r i t i c a l
p o p u l a t i o n s : pregnant teenagers and pregnant substance abusers.
D u r i n g t h e f i r s t f o u r months o f F i s c a l Year 1993, p a t i e n t v i s i t s
f o r t h e A d o l e s c e n t Pregnancy Program (2,882) and t h e P r e n a t a l
Substance Abuse Program (882) decreased 17 p e r c e n t and 15 p e r c e n t ,
r e s p e c t i v e l y , from t h e same p e r i o d d u r i n g f i s c a l year 1992 as a
r e s u l t o f p r o v i d e r shortages and l a c k o f o u t r e a c h and f o l l o w - u p
f o r "no shows."
A September 1992 " P r e n a t a l Care Appointment Study," i s s u e d by
t h e Mayor's A d v i s o r y C o u n c i l on C h i l d H e a l t h , reviewed a l l t y p e s
o f New York C i t y c l i n i c s , p u b l i c and p r i v a t e . The study found
that,
during
January
1992,
"fewer
than
half
of the
English-speaking
c a l l e r s c o u l d make an appointment, and o n l y 20
p e r c e n t o f t h e Spanish-speaking c a l l e r s c o u l d do so." I t a l s o
found t h a t , w h i l e t h e w a i t f o r an i n i t i a l
appointment was
approximately
two weeks, " l e s s than h a l f o f those f a c i l i t i e s
w i l l i n g t o make an appointment c o u l d guarantee t h a t t h e women
would be seen by a p h y s i c i a n a t t h e f i r s t appointment" and "almost
o n e - t h i r d r e q u i r e d a t l e a s t one v i s i t . "
RECOMMENDATION
1.
Any n a t i o n a l
health
care program should encourage
prenatal
care.
I n p a r t i c u l a r , the s p e c i a l needs of pregnant
teenagers and pregnant substance abusers should be addressed.
I t was r e c e n t l y r e p o r t e d t h a t , o f a l l women r e c e i v i n g
p r e n a t a l c a r e a t HHC f a c i l i t i e s , o n l y one t h i r d r e c e i v e i n i t i a l
p r e n a t a l care w h i l e i n t h e i r f i r s t t r i m e s t e r .
I n addition,
a d o l e s c e n t s and substance abusers a r e t h e two p o p u l a t i o n s most
l i k e l y t o give b i r t h t o developmentally disabled c h i l d r e n i f they
do n o t r e c e i v e adequate p r e n a t a l c a r e .
E. THE ELDERLY
I n 1991, n e a r l y one i n f i v e New Yorkers, o r a p p r o x i m a t e l y 1.3
m i l l i o n New Y o r k e r s , was 60 years o f age o r over. Moreover, t h e
r e p o r t o f t h e New York C i t y Commission on t h e Year 2001 found t h a t
s u b s t a n t i a l growth i n t h e 85-over age group, t h e m i n o r i t y e l d e r l y
and t h e number o f o l d e r persons l i v i n g alone i s expected t o
continue
i n t h e 1990s, b o t h i n a b s o l u t e
numbers and as a
p r o p o r t i o n o f t h e t o t a l e l d e r l y p o p u l a t i o n . Poverty w i l l c o n t i n u e
t o be an i m p o r t a n t i s s u e f o r t h e o l d e r p o p u l a t i o n i n New York C i t y
because t h e y a r e t h e p o p u l a t i o n group which tends t o e x p e r i e n c e
the highest poverty r a t e s .
I n a d d i t i o n , due t o t h e h i g h e r
i n c i d e n c e o f poor h e a l t h and f u n c t i o n a l impairment among t h e
-25-
�above-mentioned groups, t h e r e w i l l be an i n c r e a s e d need f o r a
v a r i e t y o f s u p p o r t i v e h e a l t h and s o c i a l s e r v i c e s t o h e l p them
remain i n t h e i r homes and neighborhoods.
Due t o t h e l a c k o f a coherent n a t i o n a l p o l i c y on a g i n g ,
s e r v i c e s f o r o l d e r people i n New York C i t y as w e l l as elsewhere i n
t h e c o u n t r y are supported by m u l t i p l e f u n d i n g streams t h a t have
d e t e r m i n e d t h e s e r v i c e d e l i v e r y systems.
Thus, these d e l i v e r y
systems are fragmented and are c h a r a c t e r i z e d by an inadequacy o f
r e s o u r c e s r e q u i r e d t o meet t h e needs o f o l d e r people.
D e s p i t e s u b s t a n t i a l growth n a t i o n a l l y i n t h e numbers o f o l d e r
people i n t h e 1980s, F e d e r a l f u n d i n g f o r s e r v i c e s f o r o l d e r people
has been c u t o r has not kept pace w i t h i n f l a t i o n and t h e growth i n
demand. For example, t h e 1991 f u n d i n g l e v e l f o r Older Americans
A c t programs decreased 17 p e r c e n t i n comparison t o 1980 f u n d i n g .
Decreased F e d e r a l s u p p o r t has had a tremendous impact on a g i n g
services l o c a l l y .
Gaps i n s e r v i c e s have r e s u l t e d .
There i s no
t a r g e t e d f u n d i n g stream t o support e i t h e r s o c i a l day care o r
non-medical r e s i d e n t i a l care f o r those whose medical needs o r need
f o r s u p e r v i s i o n exceed t h e c a p a c i t y o f in-home and community-based
s e r v i c e s , b u t do not r e q u i r e n u r s i n g home c a r e .
Chronic c a r e
needs o u t s t r i p e x i s t i n g p u b l i c home care r e s o u r c e s .
The C i t y
f a c e s a s h o r t a g e o f n u r s i n g home beds and t h e l a c k o f government
support threatens the continued s t a b i l i t y
o f mental
health
services f o r the aging.
RECOMMENDATIONS
1.
The Federal government should develop and implement a
coherent
long-term
care
policy
that
protects
against
impoverishment and includes c o s t - s h a r i n g based upon a b i l i t y to
pay.
B e n e f i t s should include coverage of home care s e r v i c e s ,
a d u l t day s e r v i c e s and medical and non-medical r e s i d e n t i a l c a r e .
2.
Any
national
health
care
program
should
include
s u f f i c i e n t reimbursement f o r r e s i d e n t i a l and i n s t i t u t i o n a l care to
ensure q u a l i t y of l i f e standards, and f o r adequate s t a f f i n g ,
t r a i n i n g and programming i n r e s i d e n t i a l s e t t i n g s to address the
needs of
the mentally
frail
e l d e r l y , i n c l u d i n g Alzheimer's
patients.
3.
Adequate resources must be a l l o c a t e d to design
and
d e l i v e r g e r i a t r i c mental h e a l t h s e r v i c e s through s e n i o r c e n t e r s ,
home c a r e and s o c i a l s e r v i c e agencies.
4.
The
Federal government should
n u t r i t i o n programs f o r older Americans.
increase
funding
for
F. THE HOMELESS POPULATION
The homeless c r i s i s i n New York C i t y i s c l e a r l y one o f t h e
most t r o u b l i n g and complex problems encountered by t h e C i t y .
C u r r e n t l y , New York C i t y p r o v i d e s emergency housing and s e r v i c e s
t o an e s t i m a t e d 5,600 f a m i l i e s and 7,040 i n d i v i d u a l s .
These
f i g u r e s by no means r e f l e c t t h e e x t e n t of homelessness t h a t e x i s t s
i n t h e C i t y . Thousands o f homeless s i n g l e men and women f a v o r t h e
-26-
�s t r e e t s t o t h e m u n i c i p a l system.
Furthermore,
there are nearly
200,000 d o u b l e d - u p f a m i l i e s and s i n g l e s , a l l o f whom c a n become
p o t e n t i a l c l i e n t s o f t h e C i t y ' s s h e l t e r system i n t h e f u t u r e .
The " h o m e l e s s " a r e n o t one s i n g l e , e a s i l y d e f i n a b l e g r o u p o f
people.
On t h e c o n t r a r y , t h e h o m e l e s s p o p u l a t i o n i s c o m p r i s e d o f
distinctive,
i f sometimes o v e r l a p p i n g , s u b g r o u p s .
The h e a l t h
needs o f t h e h o m e l e s s a r e as numerous and d i v e r s e
as t h e
population i t s e l f .
F o r e x a m p l e , a p r e g n a n t h o m e l e s s woman w o u l d
r e q u i r e d i f f e r e n t h o u s i n g and h e a l t h s e r v i c e s t h a n a h o m e l e s s man
who i s i n f e c t e d w i t h t h e AIDS v i r u s .
And y e t , w h a t b i n d s t h e s e
various
subgroups, t h e c o n d i t i o n o f being
homeless,
creates
a d d i t i o n a l b a r r i e r s t o s e e k i n g and o b t a i n i n g t h e h e a l t h c a r e t h e y
so d e s p e r a t e l y need.
I t s h o u l d be n o t e d t h a t t h e s h e l t e r s y s t e m , t h e p h y s i c a l
setting
a t w h i c h many o f t h e h o m e l e s s c o n g r e g a t e ,
tends t o
e x a c e r b a t e t h e t r a n s m i s s i o n o f communicable d i s e a s e s .
U n l i k e most
s i c k p e o p l e , who a r e i s o l a t e d f r o m t h e h e a l t h y , t h e h o m e l e s s a r e
transient.
Homeless p e o p l e , t h u s , become t h e p r i n c i p a l p o p u l a t i o n
a t r i s k o f c o n t r a c t i n g communicable d i s e a s e s .
Common D i s e a s e s a n d C o n d i t i o n s Among t h e Homeless
It
i s w e l l recognized
t h a t homeless p e o p l e have a l o w e r
s t a n d a r d o f h e a l t h and a h i g h e r r a t e o f m o r t a l i t y t h a n t h e g e n e r a l
d o m i c i l e d p o p u l a t i o n . F o r t h e most p a r t , t h e h o m e l e s s a r e e x p o s e d
to
and e x h i b i t
t h e diseases
and d i s o r d e r s
of the general
p o p u l a t i o n , a l b e i t a t w h a t a p p e a r s t o be a d r a m a t i c a l l y e l e v a t e d
rate.
I t i s a p o p u l a t i o n t h a t t e n d s t o be m a l n o u r i s h e d
and
debilitated.
Therefore,
a
wide
array
of
individual
and
environmental
determinants
(malnutrition
or
undernourishment,
close
quarters, high
stress, lack of primary
medical
care,
n o n - i m m u n i z a t i o n ) c r e a t e a b r e e d i n g g r o u n d f o r w h a t m i g h t be an
e a s i l y t r e a t a b l e c o n d i t i o n f o r a d o m i c i l e d person.
Many o f t h e
c o n d i t i o n s c i t e d h e r e i n a r e described elsewhere i n t h e r e p o r t .
However, b e c a u s e c e r t a i n f a c t o r s a r e e x a c e r b a t e d f o r t h e h o m e l e s s ,
s u c h c o n d i t i o n s d e s e r v e t o be m e n t i o n e d h e r e .
While
investigating
the
shelter
system,
the
Mayor's
C o m m i s s i o n on t h e Homeless n o t e d c e r t a i n t r e n d s t h a t emerged w i t h
r e s p e c t t o h o m e l e s s f a m i l i e s and s i n g l e s .
I n particular, the
Commission f o u n d t h a t about o n e - f i f t h ( 2 1 % ) o f t h e f a m i l y and
s i n g l e s h e l t e r r e s i d e n t s who w e r e s u r v e y e d r e p o r t e d t h a t t h e y h a d
a s e r i o u s o r c h r o n i c h e a l t h problem.
One o f t h e most s e r i o u s and t r o u b l i n g s i t u a t i o n s i s t h a t o f
t h e homeless m e n t a l l y i l l .
According t o t h e C o a l i t i o n f o r t h e
H o m e l e s s , i n O c t o b e r o f 1992, t h e S t a t e O f f i c e o f M e n t a l H e a l t h
e s t i m a t e d t h a t t h e r e w e r e 9,600 s i n g l e homeless a d u l t s d i a g n o s e d
w i t h s e v e r e a n d p e r s i s t e n t m e n t a l i l l n e s s i n New Y o r k S t a t e .
One
y e a r e a r l i e r , t h i s o f f i c e e s t i m a t e d t h a t 84 p e r c e n t o f t h e s e
p e o p l e r e s i d e d i n New Y o r k C i t y .
A d d i t i o n a l l y , 30 p e r c e n t o f t h e
C i t y ' s homeless p o p u l a t i o n a r e s e v e r e l y m e n t a l l y i l l .
The M a y o r ' s
C o m m i s s i o n on t h e Homeless c o r r o b o r a t e d t h e s e numbers w i t h i t s
recent investigation.
The C o m m i s s i o n f o u n d t h a t :
*
19 p e r c e n t o f f a m i l i e s r e p o r t e d t h a t t h e y
t r e a t e d f o r a mental o r emotional problem;
-27-
had
been
�*
*
*
42 p e r c e n t of f a m i l i e s appeared t o have e i t h e r a mental
h e a l t h or a drug abuse problem;
as many as 30 p e r c e n t of homeless s i n g l e a d u l t s
may
s u f f e r from severe mental i l l n e s s ; and
22 p e r c e n t of homeless s i n g l e a d u l t s r e p o r t e d t h a t t h e y
had been t r e a t e d f o r a mental or e m o t i o n a l problem.
These h i g h percentages of mental i l l n e s s are l a r g e l y due t o
t h e f a c t t h a t t h e s h e l t e r system does not p r o v i d e t h e s u p p o r t i v e
comprehensive community-based p s y c h i a t r i c and m e d i c a l c a r e t h a t
was promised when d e i n s t i t u t i o n a l i z a t i o n of t h e m e n t a l l y i l l began
i n t h e 1960s. The consequences are t r a g i c and expensive —
the
homeless m e n t a l l y i l l f i n d themselves bouncing from t h e s t r e e t t o
t h e h o s p i t a l t o t h e s h e l t e r and back a g a i n t o the s t r e e t .
The
C i t y ' s p s y c h i a t r i c emergency rooms and p u b l i c h o s p i t a l s are f o r c e d
t o t r y t o meet comprehensive, c h r o n i c needs w i t h
temporary
solutions.
The g r o w i n g i n c i d e n c e of homeless i n d i v i d u a l s who are
HIV
p o s i t i v e i s a l s o troublesome, e s p e c i a l l y s i n c e t h e v i r u s i s one of
t h e s t r o n g e s t f a c t o r s c o n t r i b u t i n g t o the i n c i d e n c e of TB,
a
h i g h l y communicable disease among the homeless. The Centers f o r
Disease C o n t r o l does not know the o v e r a l l i n c i d e n c e of a c t i v e TB
among t h e homeless p o p u l a t i o n ; however, i t has e s t i m a t e d t h a t t h e
p r e v a l e n c e ranges from 1.6 p e r c e n t t o 6.8 p e r c e n t . The
National
H e a l t h Care f o r t h e Homeless p r o j e c t found an i n c i d e n c e of a c t i v e
TB i n 986 per 100,000 homeless a d u l t s .
In addition. City health
s t a t i s t i c s have e s t i m a t e d t h a t t h e homeless p o p u l a t i o n (40,000) i s
l e s s t h a n h a l f of one p e r c e n t of the t o t a l p o p u l a t i o n of t h e C i t y ;
y e t t h e y comprise 20 p e r c e n t of the a c t i v e TB cases r e p o r t e d t o
t h e Department of H e a l t h . These f i g u r e s are expected t o i n c r e a s e
over t h e next s e v e r a l y e a r s .
Yet a n o t h e r c o n d i t i o n f r e q u e n t l y seen i n the s h e l t e r system
i s low b i r t h w e i g h t among newborns, a l e a d i n g cause of v i s u a l and
hearing
impairment,
behavior
and
learning
problems,
mental
r e t a r d a t i o n and, most s e r i o u s l y , i n f a n t death.
Indeed, homeless
c h i l d r e n become s i c k a t a r a t e many times g r e a t e r t h a n d o m i c i l e d
c h i l d r e n and
o f t e n go u n t r e a t e d u n t i l the c o n d i t i o n
becomes
serious.
The
f i n d i n g s of t h e Mayor's Commission on t h e Homeless
c l e a r l y i n d i c a t e t h e need f o r q u a l i t y h e a l t h care f o r t h e homeless
population,
i n c l u d i n g i n c r e a s e d p r i m a r y c a r e , substance abuse
s e r v i c e s , and mental h e a l t h t r e a t m e n t .
B a r r i e r s t o Seeking and Complying w i t h Treatment
Homeless f a m i l i e s and s i n g l e a d u l t s face a c o m b i n a t i o n of
f i n a n c i a l and systemic b a r r i e r s when seeking h e a l t h c a r e .
More
o f t e n t h a n n o t , t h e r e are h i g h e r p r i o r i t i e s f o r the homeless, such
as o b t a i n i n g f o o d and s h e l t e r , and t h e r e f o r e , a m e d i c a l c o n d i t i o n
may
go u n t r e a t e d u n t i l the case becomes s e r i o u s .
The
crisis
n a t u r e of t h e system causes i m p o r t a n t h e a l t h i n t e r v e n t i o n , such as
s c r e e n i n g , e d u c a t i o n , f a m i l y p l a n n i n g , and p r e n a t a l c a r e , t o be
neglected.
I n a d d i t i o n , much of t h e homeless p o p u l a t i o n i s not covered
by
Medicaid.
According t o C h r i s t i n a
Hoven,
"[n]on-economic
-28-
�b a r r i e r s , mainly a d m i n i s t r a t i v e , are apparently responsible f o r
t h e n o n - e n r o l l m e n t o f t h e homeless, as w e l l as those i n t h e
general
p o p u l a t i o n , who should
be e l i g i b l e .
Organizational/
s t r u c t u r a l b a r r i e r s . . . are p o t e n t i a l l y m u l t i p l i e d many times over
f o r t h e homeless." (The A s s o c i a t i o n o f S e l e c t e d
Demographic
F a c t o r s and H e a l t h and Mental H e a l t h I n d i c a t o r s w i t h M e d i c a i d
S t a t u s Among New York C i t y ' s S h e l t e r e d Homeless, March 1988).
Systemic b a r r i e r s a l s o e x i s t . F a m i l i e s and s i n g l e s a r e o f t e n
d i s p l a c e d from t h e i r neighborhoods, making i t harder t o f i n d
primary h e a l t h care.
Furthermore, because o f t h e t r a n s i e n c e o f
the population, there are d i f f i c u l t i e s
i n o b t a i n i n g medical
r e c o r d s and poor communication w i t h t h e i n s t i t u t i o n s t h a t p r o v i d e
services.
This r e s u l t s i n t h e loss of accurate i n f o r m a t i o n t h a t
may be v i t a l t o d i a g n o s i n g
t h e h e a l t h o f t h e homeless. I n
a d d i t i o n , h e a l t h care p r o v i d e r s may be i n s e n s i t i v e and unaware o f
t h e s p e c i a l needs o f t h e homeless.
The
l a c k o f c o n s i s t e n t care o n l y exacerbates t h e h e a l t h
problems t h a t a l r e a d y e x i s t because i t f o s t e r s noncompliance w i t h
t h e p r e s c r i b e d t h e r a p y and adequate f o l l o w - u p . I t i s d i f f i c u l t t o
comply w i t h a m e d i c a l regime when t h e necessary r e s o u r c e s a r e
i n a c c e s s i b l e o r e n v i r o n m e n t a l c o n d i t i o n s do n o t p e r m i t i t . For
example, t h e s p e c i a l WIC (Women, I n f a n t s , and C h i l d r e n ) supplement
i s u s e l e s s t o a woman who has no space, r e f r i g e r a t o r , o r access t o
a k i t c h e n t o prepare food o r f o r m u l a .
A d i s a b l e d and d e b i l i t a t e d
mother would f i n d i t hard t o keep f o l l o w - u p appointments i f she
c o u l d n o t f i n d day care f o r her c h i l d r e n .
RECOMMENDATIONS
1.
Any n a t i o n a l
health
care program should provide a
standardized, comprehensive health care system f o r the s i n g l e
homeless, as w e l l as homeless f a m i l i e s .
E p i s o d i c c a r e f o r t h e homeless i s a v a i l a b l e , b u t o n l y i f a
c l i e n t seeks m e d i c a l c o n s u l t a t i o n . There a r e no s c r e e n i n g o r
h e a l t h s e r v i c e s extended t o t h e s i n g l e homeless on a r o u t i n e
basis.
2.
Any n a t i o n a l
health
care program must address the
c r i t i c a l needs of the mentally i l l homeless, p a r t i c u l a r l y through
supportive comprehensive community-based p s y c h i a t r i c care.
3.
The F e d e r a l government must provide the a d d i t i o n a l
funding needed f o r the thorough and aggressive screening of
homeless i n d i v i d u a l s f o r communicable diseases upon entry i n t o the
s h e l t e r system.
S c r e e n i n g can be an e f f e c t i v e way o f c o n t r o l l i n g t h e f l o w o f
contagious
c o n d i t i o n s i n t o t h e homeless s h e l t e r system and
s e g r e g a t i n g and s e r v i n g p o p u l a t i o n s w i t h s p e c i a l needs (pregnant
women, m e d i c a l l y f r a i l ) .
Currently, the City i s required t o
screen f a m i l i e s b e f o r e t h e y e n t e r a T i e r I I a p a r t m e n t - s t y l e
s h e l t e r . However, t h e p r e s e n t l e v e l o f f u n d i n g does n o t a l l o w a l l
c l i e n t s t o meet w i t h a h e a l t h p r o v i d e r a t t h e Emergency A s s i s t a n c e
U n i t , t h e most common e n t r y p o i n t t o t h e system.
4.
Large s h e l t e r s and Emergency Assistance Units should be
downsized and equipped with the proper v e n t i l a t i o n equipment.
-29-
�They are b r e e d i n g grounds f o r communicable d i s e a s e s .
5.
New
i n i t i a t i v e s are needed to reach homeless people
l i v i n g i n p u b l i c areas.
Anecdotal; and o t h e r d a t a suggest t h i s p o p u l a t i o n i s even more
t r o u b l e d than the s h e l t e r e d population.
6.
A d d i t i o n a l funding i s needed to provide c o n t i n u i t y of
care f o r homeless i n d i v i d u a l s .
When housed i n a permanent l o c a t i o n , t h e homeless person o r
f a m i l y s h o u l d be i n t r o d u c e d t o t h e l o c a l m e d i c a l s e r v i c e s . I n
a d d i t i o n , t h e i r h e a l t h r e c o r d s should be t r a n s f e r r e d t o t h e
a p p r o p r i a t e neighborhood h e a l t h p r o v i d e r .
7.
The
only r e a l comprehensive long-term s t r a t e g y
for
improving the h e a l t h of the homeless i s e l i m i n a t i n g homelessness.
Whatever e l s e i s done t o a m e l i o r a t e t h e h e a l t h problems o f
t h e homeless, people w i l l not become h e a l t h y unless t h e y have a
stable place t o l i v e .
-30-
�CONCLUSION
The C l i n t o n A d m i n i s t r a t i o n has emphasized t h e importance o f
covenant and r e s p o n s i b i l i t y i n t h e r e l a t i o n s h i p s between d i f f e r e n t
l e v e l s o f government and between government and t h e people.
I n acknowledging t h e c r i t i c a l r o l e i t must p l a y i n e n s u r i n g
an a c c e s s i b l e and q u a l i t y h e a l t h care system f o r a l l t h e people o f
t h i s n a t i o n , t h e A d m i n i s t r a t i o n i s c u r r e n t l y i n t h e process o f
shaping a n a t i o n a l h e a l t h care program which w i l l guarantee t h e
a v a i l a b i l i t y o f a f f o r d a b l e p r i m a r y and acute care s e r v i c e s .
A
n a t i o n a l h e a l t h c a r e program, however, must address more t h a n
p r o v i d i n g u n i v e r s a l h e a l t h i n s u r a n c e t o a l l Americans.
I t must
also
ensure
an
individual's
basic r i g h t
to public
health
p r o t e c t i o n . Moreover, urban c e n t e r s , i n p a r t i c u l a r New York C i t y ,
have unique needs t h a t r e q u i r e a d d i t i o n a l h e a l t h care r e s o u r c e s
f r o m t h e F e d e r a l government.
The e f f o r t t o improve h e a l t h care must b e g i n w i t h i n c r e a s i n g
t h e s u p p l y o f p r i m a r y c a r e p h y s i c i a n s . Medical schools must be
encouraged t o c r e a t e and expand p r i m a r y care programs and m e d i c a l
s t u d e n t s s h o u l d be g i v e n g r e a t e r o p p o r t u n i t i e s and encouragement
t o s t u d y and i n t e r n i n f a m i l y medicine. M i n o r i t y and low-income
m e d i c a l s t u d e n t s , i n p a r t i c u l a r , should r e c e i v e f e d e r a l l y funded
support.
Government programs should a l s o f i n a n c i a l l y
assist
d o c t o r s who e s t a b l i s h o r j o i n p r a c t i c e s i n m e d i c a l l y underserved
urban a r e a s .
I t cannot be s t r e s s e d enough t h a t , w i t h r e s p e c t t o F e d e r a l
s u p p o r t o f t h e urban p r i m a r y care i n f r a s t r u c t u r e and t h e t r a i n i n g
o f p r i m a r y c a r e d o c t o r s , we are p r e s e n t e d n o t o n l y w i t h t h e
o p p o r t u n i t y t o "do t h e r i g h t t h i n g , " b u t a l s o t o s u p p o r t t h e
i n t r o d u c t i o n o f c o s t - e f f e c t i v e medicine i n t o our communities.
P r e v e n t i v e h e a l t h care f o r c h i l d r e n must a l s o be a b a s i c
aspect o f any n a t i o n a l h e a l t h care program.
The l o n g - t e r m c o s t
b e n e f i t s o f such an approach are c l e a r l y v i s i b l e i n t h e i m p o s i t i o n
o f a new S t a t e mandate on t h e C i t y t o supply c o s t l y s e r v i c e s t o
a l l d e v e l o p m e n t a l l y d i s a b l e d i n f a n t s u n t i l t h e y are 3 y e a r s o l d .
For government n o t t o p r o v i d e adequate p r e n a t a l and s c h o o l h e a l t h
c a r e would be b o t h f i s c a l l y and m o r a l l y i r r e s p o n s i b l e .
However, a w e l l - d e v e l o p e d p r i m a r y care system, w h i l e v i t a l t o
t h e n a t i o n ' s h e a l t h , cannot alone s o l v e t h e h e a l t h care c r i s i s .
H o s p i t a l s and n u r s i n g homes have been s t r u g g l i n g w i t h c h r o n i c
u n d e r f u n d i n g . M u n i c i p a l i t i e s have been s u f f e r i n g from e p i d e m i c s ,
caused by d e a d l y c o m b i n a t i o n s o f communicable diseases and poor
p r e v e n t i v e c a r e , and must r e c e i v e a d d i t i o n a l resources t o combat
such i l l n e s s e s e f f e c t i v e l y .
Diseases such as AIDS and TB r e q u i r e
more t h a n p r i m a r y and acute care s e r v i c e s .
Social services f o r
p a t i e n t s and p u b l i c h e a l t h campaigns are a l s o necessary t o p r e v e n t
t h e dangerous spread o f i n f e c t i o n .
Moreover, New
York C i t y , a l r e a d y burdened w i t h over one
m i l l i o n people on w e l f a r e , 340,000 people r e c e i v i n g unemployment
i n s u r a n c e , and t h e s p e c i a l problems o f AIDS and t u b e r c u l o s i s ,
cannot t a c k l e t h e substance abuse problem a l o n e . New York S t a t e
has been e x p e r i e n c i n g budget s h o r t f a l l s f o r a number o f y e a r s
w h i c h have i m p a i r e d t h e C i t y ' s f i g h t a g a i n s t t h i s menace. Thus,
t h e F e d e r a l government must s t e p i n t o address t h e drug s i t u a t i o n
-31-
�which
was
allowed
to
deteriorate
during
the
previous
Administration.
The
s p e c i a l needs of women and t h e e l d e r l y must not
be
f o r g o t t e n . C r i t i c a l i s s u e s , such as t h e epidemic p r o p o r t i o n s of
b r e a s t cancer i n t h e C i t y and t h e l a c k of a f f o r d a b l e l o n g - t e r m
c a r e , must f i n d t h e i r way i n t o any n a t i o n a l h e a l t h care program.
L a s t l y , i t i s l i k e l y t h a t n a t i o n a l h e a l t h c a r e , p r i m a r y or
acute, w i l l
never reach a l l Americans.
Urban c e n t e r s
pose
p a r t i c u l a r problems f o r t h e d e l i v e r y of h e a l t h care s e r v i c e s due
t o t h e i r l a r g e homeless p o p u l a t i o n s .
A s i n g l e or u n i f o r m model
f o r t h e p r o v i s i o n of h e a l t h care s e r v i c e s t o t h e homeless i s not a
p r a c t i c a l o r r e a l i s t i c approach t o a l l e v i a t i n g t h e h e a l t h c a r e
problems o f a v e r y d i v e r s e homeless p o p u l a t i o n .
While making
primary care a v a i l a b l e t o the
underserved or u n i n s u r e d
is
c e r t a i n l y an i m p o r t a n t f i r s t measure, a d d i t i o n a l steps must be
t a k e n t o improve t h e
h e a l t h of those s u f f e r i n g under
the
a d d i t i o n a l burden of homelessness. I n a c o u n t r y as r i c h as o u r s ,
we s h o u l d s t r i v e t o i n s u r e t h a t t h e b a s i c h e a l t h needs of a l l
r e s i d e n t s are met.
In
sum,
the C l i n t o n A d m i n i s t r a t i o n
has
combined a
new
o p t i m i s m f o r t h e c o u n t r y w i t h a c o n c r e t e s o c i a l agenda designed t o
f o s t e r r e a l r e f o r m i n such v i t a l areas as n a t i o n a l h e a l t h c a r e .
I t i s our hope t h a t t h i s r e f o r m w i l l address t h e s p e c i a l h e a l t h
c a r e needs o f New York C i t y .
-32-
�•{•••
California §entor tficgtslature
STATE OF CALIFORNIA
CALIFORNIA SENIOR
LEGISLATURE
California Senior Legislature
C S X .
SENIOR ASSEMBLYWOMAN
GENEVIEVE (JENNIE) DULANY
1387 LICHTVIEW STREET
MONTEREY PARK, CA 91754
(213) 264-3342
February 1, 1993
REPRESENTING OLDER CALIFORNIANS IN
LOS ANGELES COUNTY
First Lady Hillary Clinton.
White House
• ~ "~
"
-
-
Washington, D C 20510
..
Dear Mrs. Clinton:
Congratulations to you on your appointment to Chair the Task Force for
revising the American Health Care System. The successful solution to this
problem is an essential key in solving our social and economic problems. Your
appointment and the task force that you chair is a clear signal that the
matter will receive the serious attention that is required to overcome the
obstacles that impede the corrections needed.
Our $839 billion health care system has collapsed under the weight of the
apparatus that has been uncontrolled for many years. N system in any other
o
developed country is burdened by nearly as much waste as is a part of our
health care system, and that waste is now the source of our problem with the
system.
Without question the greatest source of wasted dollars in the system is the
role of the insurance industry. 1500 companies, with different programs and
claim forms, have added a cost to the system that is estimated to be
approximately 25% of the money spent on the system, while, at the same time
w have managed to provide the same functions for our senior population
e
through the Medicare system for approximately 5% of the money spent.
As a start in your task of revising our system, please establish a uniform
health care program for everyone and administer i t in approximately the same
way that Medicare is administered, with a single payer.
There are too many people in this country who have no health benefits, and the
time has long past when something must be done about i t . Our present health
system is so inadequate.
Please do not hesitate to contact me, i f there is any way in which I can help.
Sincerely,
T"
Genevieve Dulany
Senior Assembywoman
California Senior Legislature
�STATE OF MARYLAND
OFFICE OF THE GOVERNOR
IN REPLY REFER TO
WILLIAM DONALD S C H A E F E R
GOVERNOR
March 17, 1993
Mrs. Hillary Rodham Clinton
Health Care Task Force
1600 Pennsylvania Avenue, N.W.
Washington DC 20500
ANNAPOLIS OFFICE
STATE HOUSE
100 STATE CIRCLE
ANNAPOLIS. MARYLAND 21401
(410) 974-3901
BALTIMORE OFFICE
SUITE 1513
301 WEST PRESTON STREET
BALTIMORE, MARYLAND 21201
(410) 225-4800
WASHINGTON OFFICE
SUITE 311
444 NORTH CAPITOL STREET, N.W.
WASHINGTON. D C . 20001
(202) 638-2215
TDD (410) 333-3098
Dear Mrs. Clinton:
I was pleased to be a part of the group of nurses from the American Nurses Association that
met with you on Wednesday, March 3, 1993. It is very gratifying to have a First Lady and
an Administration that not only understands and is sensitive to health care needs but also
appreciates the role of the registered professional nurse. Thank you so much for meeting
with us.
During the course of the discussion Mary Carpenter, National Commission on Infant
Mortality, pointed out that even with passage of health reform legislation there would still be
an enormous need for outreach and health education. We were assured by you that you did
indeed recognize that attitudinal and cultural barriers could not be overcome by legislation
but need to be addressed through outreach and education. As Executive Assistant for Health
to Governor Schaefer, I developed a set of health initiatives that focus on prevention and
create public/private partnerships. It is our attempt to help our citizens become good health
care consumers while we work with the Legislature to enact meaningful reform legislation.
I have enclosed a description of the initiatives and the report of our Town Meetings and
survey results. I know that you are interested in hearing about states' activities.
I left the March 3rd meeting with confidence in your ability to have legislation ready for
Congress to consider that will encompass the goals and mechanisms to achieve access to
quality and affordable health care by all our citizens. There are many of us who are ready
and willing to do our part to help you in this most important effort.
Sincerely,
Marilynfcloldwater,RN
Executive Assistant for Health
Enclosures
�SI^T^OFMARYLAND
WILLIAM DONALD SCHAEFER, GOVERNOR
MARILYN GOLDWATER, R.N.
EXECUTIVE ASSISTANT
OFFICE OF THE GOVERNOR
STATE HOUSE
ANNAPOLIS. MARYLAND 21401
(410) 974-3004
(301) 261-2177 (D.C. METRO AREA CALLERS)
^
^
Governor W i m a m Donald Schaefer
Partners in
Prevention
�GOVERNOR SCHAEFER AND THB PEOPLE: X PARTNERSHIP FOR HEALTHY
LIVING THROUGH PRACTICING PREVENTION
This proposal i s an opportunity for the Governor to marshall
statewide resources to r a i s e public awareness of issues related
to disease prevention, health education, health promotion, and
health policy. The messages and i n i t i a t i v e s of this proposal
w i l l reinforce and expand upon the vision, mission, programs and
services of the Department of Health and Mental Hygiene and other
Executive Agencies.
Th« Partnership for Healthy Living Through Practicing Prevention
consists of the following three components:
VISION:
That a l l Maryland c i t i z e n s have access to
appropriate health care and that each
individual understands their responsibility
to practice prevention and be a good health
care consumer.
LEADERSHIP:
The Governor w i l l mobilize the State's
public/private health resources to achieve
the vision through several i n i t i a t i v e s .
These i n i t i a t i v e s focus on teaching
prevention to women and children because
women are the key to healthy families, and
children are our future. I f we, as a State
and nation are to remain competitive in this
rapidly changing and complex world, we must
have a healthy population.
LEGACY:
When the Governor leaves office, we w i l l be
known as "Maryland, A State of Healthy
Living".
Prepared by:
Marilyn Goldwater, RN
Executive Assistant for
Health
Governor's Office
�INITIATIVE ONE:
SCHAEFER WELLMOBILE
INITIATIVE TWO:
SCHOOL HEALTH EDUCATION PREVENTION
PROJECTS
1)
2)
NUTRITION PROJECT
3)
PHYSICAL FITNESS PROJECT
4)
INITIATIVE THREE:
TOBACCO FREE POSTER CONTEST
PARTNERSHIP with * SCHOOL
TEACHING CITIZENS TO PRACTICE PREVENTION:
1)
EVERY CHILD BY TWO
IMMUNIZATION CAMPAIGN
2)
INJURY PREVENTION
3)
STATEWIDE WORKSITE HEALTH
PROMOTION RECOGNITION
4)
RELIGIOUS COMMUNITY PROJECT
5)
STATEWIDE COMMUNITY MEETINGS
ON THE FUTURE OF HEALTH CARE
6)
ESTABLISH LOCAL WELLNESS
COUNCILS
�INITIATIVE ONE
SCHAEFER WELLMOBILE
Healthy women and t h e i r families help assure
and maintain the well-being of Maryland
communities. The connection between healthy
families and economic well-being has indeed
been recognized by many State agencies. A mobile
wellness health u n i t w i l l supplement existing community
services, make health care more accessible by
assisting people t o connect with those services,
and teach prevention measures through health education
and promotion a c t i v i t i e s as well as identify and treat
common health problems.
�Governor William Donald Schaefer Wellmobile
BACKGROUND:
Healthy women and their families help assure and maintain the
well-being of Maryland communities. The connection between
healthy families and economic s t a b i l i t y has been recognized by
many State agencies. Maintaining and enhancing the level of
health of women and their families thus becomes a way to
encourage economic recovery while at the same time providing for
basic health needs. A comprehensive program of health services
and education could bridge the health care gap for many of the
underserved and underinsured families within this State. The
establishment of a mobile wellness unit would be a major step in
t h i s endeavor and one that the Governor truly believes w i l l have
an impact on a l l of Maryland's c i t i z e n s .
PROPOSAL:
The purpose of t h i s proposal i s to purchase, equip and operate a
mobile health unit to provide accessible, inexpensive health care
to women and children in medically underserved communities
throughout the State. This unit would supplement existing
community services, make health care more accessible by assisting
people to connect with those services, and teach prevention
through health education and promotion a c t i v i t i e s as well as
identify and treat common health problems.
A l l services provided by the Wellmobile unit w i l l be tailored to
the needs of the population at the pre-selected s i t e s . These
services include:
•
•
•
•
•
immunization of infants and children
i d e n t i f i c a t i o n and treatment of common health problems
assistance with r e f e r r a l to community health and social
resources
education about prevalent health problems with a focus
on prevention
education and promotion of a healthy l i f e style
Governor's Partners
The University of Maryland School of Nursing
Maryland State Health Resources Planning Commission
Private/Public Corporations, Foundations and Community Groups
The Wellmobile unit w i l l be a publie/private partnership and
funds w i l l be s o l i c i t e d from corporations, foundations and
community groups and organizations.
Recognition
A l l support for t h i s project w i l l receive appropriate
recognition. The type of recognition w i l l depend on the level
and type of contribution.
�INITIATIVE TWO
SCHOOL HEALTH EDUCATION
These proposals w i l l teach c h i l d r e n grades K through 12 t h e
importance o f p r a c t i c i n g prevention and e s t a b l i s h i n g l i f e
long good health patterns.
PROPOSED PROJECTS t
SCHOOL HEALTH EDUCATION PREVENTION PROJECTS
1)
TOBACCO FREE POSTER CONTEST
2)
NUTRITION PROJECT
3)
PHYSICAL FITNESS PROJECT
4)
PARTNERSHIP v i t h a SCHOOL
�Tobacco-Free Poster Contest
Proposal:
governor'5
paytneys;
In order to have school-aged children become aware
of the health r i s k s of tobacco and to ensure
tobacco-free graduates, the Governor's Office w i l l
invite f i f t h grade students to participate in an
annual statewide poster contest.
Department of Education
The Orioles
Health Care Community
Maryland League of Women Voters
Maryland State Health Resources Planning
Commission
Implementation:
Smoke-Free Class of 2000 w i l l develop contest
rules by August 1, 1992.
Approval of the rules and selection of judges
w i l l be coordinated through the Governor's
office.
Smoke-Free materials w i l l be sent to a l l
f i f t h grade teachers and principals by
September 30, 1992.
The State Superintendent w i l l also inform the
local superintendents of the contest and urge
their support and participation at the
October State Superintendents' meeting.
Immediately following the October
Superintendents' meeting, a l l elementary
schools w i l l be notified by the State
Superintendent of Schools and be invited to
participate in the contest.
Each local school system w i l l select five
posters to be entered in the State contest.
Each local school system w i l l determine their
own selection process.
A l l posters submitted from each of the 24
counties w i l l be displayed at an Orioles
game.
�The State winner's poster w i l l be displayed
on a b i l l board at Oriole Park at Camden
Yards.
A ceremony w i l l be held before an Orioles
game announcing the winner and unveiling the
billboard.
Local hospitals, HMO's, Malls and the
American Heart Association, the Lung
Association, and the Cancer Society's local
a f f i l i a t e s and other community organization
w i l l be encouraged to select one poster to
display at their f a c i l i t y .
Every student who enters the contest w i l l
receive a letter of commendation from the
State Superintendent of Education. F i n a l i s t s
from each school system w i l l receive a letter
of commendation from the Governor.
The winner of the statewide contest w i l l
receive a citation from the Governor, free
t i c k e t s to an Orioles game for their
immediate family and w i l l be honored at the
Smoke-Free Class of 2000 five year
celebration.
The twelve top posters w i l l be made into a
calendar to be available for sale to the
public.
Make project part of the State health plan to
ensure i t s continuation.
Statu?:
Project underway. Committee w i l l judge
posters on March 8, 1993.
�Nutrition
Proposal:
This proposal w i l l emphasize the importance of
healthy eating habits and encourage schools to
offer affordable, tasty, nutritious meals.
Governor's
Partners:
Maryland State Department of Education
Maryland State Health Planning Resources
Commission
Business and Health Care Community
University of Maryland School of Nursing
Maryland Dietetic Association, Inc.
Implementation:
o
Appoint a Committee to establish process and
evaluate progress.
o
Organize local well-known chefs to work with
cafeteria chefs to prepare tasty, nutritious,
affordable meals; then plan a contest between
chefs.
o
Have dieticians provide continuity through a
variety of ongoing projects.
o
Make project part of State health plan to ensure
i t s continuation.
Kick-off event was held September 22, 1992. Local
school projects are underway. Funding i s being
sought for research project to be conducted by
University of Maryland Center for Health Policy
Research.
�'Get Ready, Get Set,
Eat Breakfast wit* the Governor*
'Gel Ready, Get Set, Eat Breakfast with the Governor" Is a leadership Initiative
coocdved at the direction of Governor Willlim Donald Schaefer. Governor Schaefer
beliercs that good nutrition is essential for srsdent 'readiness to loam' and for
Improved student academic performance. This Initiative focuses on the School
Breakfast Program and encourages clcmenlanr schools to Increase the number of
smdents eating breakfast
The goals of this Initiative are:
.
to increase the number of students who eat school breakfast In Maryland
elementary schools
• to educate parents, students, and school administrators about the value of .
eating breakfast and the convenience of school breakfast
• to provide and support innovative autritlon education and promotional
activities for elementary schools to teach about the value of school breakfast
- to conduct research which studies the relationship between breakfast and
students' academic performance
Gom-nor Schaefer*! leadership Initiative to promote the School Breakfast Program in
Marjland Is a collaboration of efforts and mcwrccs ofthe following agendes and
businesses:
Maryland State Department of Edvcatlon
Maryltnd State Department of Heahh and Mental Hygiene
University of Maryland
Mainland Food Committee
Dairy and Food Nutrition Council ef the Southeast
Dairy Coundl of Greater Metropolitan D.C, Inc
•1-
�GOVERNOR'S LEADERSHIP INITIATIVE PROPOSAL
THE GOVERNOR'S PHYSICAL EDUCATION MERIT AWARD
AND
THE GOVERNOR'S SPECIAL RECOGNITION FOR OUTSTANDING MODEL
PHYSICAL EDUCATION PROGRAMS
This s p e c i a l i n i t i a t i v e was conceived a t the d i r e c t i o n of
Governor W i l l i a m Donald Schaefer, a strong advocate f o r e f f e c t i v e
school programming. Governor Schaefer has been instrumental i n
i n f l u e n c i n g the v i s i o n f o r the State's educational goals, and f o r
student l e a r n i n g outcomes i n a l l subject areas. I n a d d i t i o n , he
and Arnold Scharzenegger, Chair o f the President's Council on
Physical Fitness and Sports, have met and expressed mutual
i n t e r e s t i n improving the f i t n e s s l e v e l s , and r e l a t e d health
s t a t u s , o f Maryland students and a d u l t s through enhanced physical
education programs. These combined n a t i o n a l and s t a t e goals
serve as the basis f o r t h i s i n i t i a t i v e . The f o l l o w i n g p r o j e c t s
are intended t o s t i m u l a t e student and family i n t e r e s t i n pursuing
a f i t n e s s l i f e s t y l e , t o recognize outstanding p h y s i c a l education
model programs, and t o motivate a l l p h y s i c a l education teachers
i n the s t a t e t o seek the Governor's M e r i t Award.
OUTCOMES
This Governor's I n i t i a t i v e
will:
1)
increase the number o f Maryland schools t h a t emphasize
f i t n e s s education f o r a l l students, i n c l u d i n g the
disabled, and t h e i r f a m i l i e s ;
2)
provide s p e c i a l r e c o g n i t i o n t o professionals i n schools
t h a t are selected as Maryland Physical Education
Demonstration Centers d u r i n g 1992-93, or who have
a t t a i n e d Honor R o l l s t a t u s .
3)
i d e n t i f y teachers who meet the c r i t e r i a f o r the
Governor's Physical Education M e r i t Award.
4)
expand p u b l i c awareness o f and student involvement i n
National Physical Education Week, May 1-7, 1993.
PARTICIPANTS
A l l Maryland p u b l i c and nonpublic schools
�ABSTRACT
The Governor's Office, in cooperation with the State
Superintendent, w i l l urge schools to heighten student
and family awareness regarding the benefits of, and
ways to achieve, a healthful, physically active
l i f e s t y l e . In November physical education teachers
w i l l be offered an opportunity to apply for the
Governor's Physical Education Merit Award, established
to encourage a focused emphasis on fitness outcomes
within a balanced physical education program.
To receive the M e r i t Award, an applicant must v a l i d a t e
completion of the f o l l o w i n g four tasks by the dates
s p e c i f i e d f o r each i n the Procedures section of t h i s
proposal, but not necessarily i n the order l i s t e d .
Governor's Physical Education Merit Award Expectancies
The applicant individually or as a participating member
of the school physical education team:
o
evaluates the current physical education program
using the 1992-93 Maryland Physical Education
Demonstration Schools Assessment Instrument.
o
administers either the Maryland Superfit Test or a
national health-related fitness t e s t to a l l
students where possible, or to targeted grade
l e v e l s . The results are used to focus instruction
on individual and group fitness needs.
o
provides evidence that he/she regularly achieves
the Healthy People 2000 national objective that
states, "Increase to at least 50 percent the
proportion of physical education c l a s s time that
students spend being physical a c t i v e — "
o
develops and conducts at least one project that
contributes to the fitness education of students
and t h e i r families.
Physical education teachers who accomplish these four tasks
and submit validation of t h e i r completion according to
guidelines established by the Governor's Steering Committee
w i l l receive both a Governor's Citation and an invitation to
a culminating reception in May that w i l l recognize a l l
honorees identified through t h i s important three-dimensional
Governor's i n i t i a t i v e .
�Partnership with a School
Proposal;
governpr'g
In order to teach prevention and foster healthy
living practices to children grades K through 12,
businesses, local health organizations,
hospitals,and H O s w i l l be encouraged to partner
M'
with a school. They should be encouraged to make
health education curriculum and physical fitness a
priority.
Maryland State Department of Education
Maryland state Health Planning Resources
Commission
Business and Health Care Community
University of Maryland School of Nursing
Kaiser Permente
Implementation:
Appoint a Committee to establish process and
evaluate progress.
Encourage U A and businesses that have
MB
already partnered with a school to make
health education and physical education a
priority.
Make project part of State health plan to
ensure i t s continuation.
Statu?:
Committee w i l l meet February 1, 1993, to
formulate plans for a September conference
that w i l l bring health and educational
professionals together with the business
community.
�Maryland Demonstration Schools
The Governor w i l l encourage excellence in physical education
programming statewide by awarding a Special Governor's
Citation to approximately twelve exemplary programs selected
during this school year through the Maryland Physical
Education Demonstration Schools Project. This long-standing
project, currently supported primarily by the Maryland
Association for Health, Physical Education Recreation and
Dance in cooperation with the Maryland State Department of
Education, should become highly visible and attract
additional candidates through the leadership that the
Governor has demonstrated in this initiative. The
Demonstration Schools Project's support from numerous
agencies and associations, including the President's Council
on Physical Fitness and Sports and the Maryland Physical
Fitness Council, reflects the type of educational
partnerships that the Governor states must occur i f our
schools are to be successful in future years.
Maryland Physical Education professionals who have served at
Demonstration Centers for several years and have thus earned
Honor Roll status w i l l be invited to the Governor's
reception and presented with an appropriate reminder of the
occasion.
Maryland Phygical Education V e K
te
To focus the interest of Maryland's citizens and youth on
the contributions that quality physical education programs
make to students' total learning, the Governor will sign a
proclamation for Maryland Physical Education Week, to be
held May 1-7. Schools will be encouraged to hold special
events that accent physical education goals and activities
during that week. Parents w i l l be involved whenever
possible. The Governor w i l l participate in one of these
functions.
Status:
The Committee i s meeting January 15, 1993, to develop
strategies to implement project.
�INITIATIVE THREE
TEACHING CITIZENS PREVENTION AND TO BE G O
OD
HEALTH CARE CONSUMERS
These proposals w i l l improve the health status of Maryland
c i t i z e n s by teaching prevention and educating them on the
importance o f healthy l i f e s t y l e s , the proper use of health care
services and programs, and how t o be a partner w i t h t h e i r health
care p r o v i d e r .
PROPOSED PROJECTSt
TEACHING CITIZENS TO PRACTICE PREVENTIONZ
EVERY CHILD BY T O
W
IMMUNIZATION CAMPAIGN
INJURY PREVENTION
8TATEWIDB WORKSITE HEALTH
PROMOTION RECOGNITION
ESTABLISH LOCAL WELLNESS COUNCILS
RELIGIOUS COMMUNITY PROJECT
STATEWIDE COMMUNITY MEETINGS
ON THE FUTURE OF HEALTH CARE
�Every Child By Two
Proposal:
governor' s
patrtneys:
I t i s recommended that a l l children by the age of
two years receive basic childhood immunizations.
Every Child By Two proposes to reach the National
Year 2000 Objective that 90% of children w i l l
complete their immunizations. Vaccinations are a
very effective prevention strategy.
Department of Health and Mental Hygiene
Maryland Nurses Association
Maryland State Health Resources Planning
Commission
The Maryland Chapter of the American Academy of
Pediatrics
The Medical-Chirurgical Faculty of Maryland
Local Health Officers
National Guard
Advocates for Children and Youth
Sandy Hillman
Ipplementatign:
Maryland Nurses Association has agreed to
adopt t h i s program for three years. They
w i l l work with the Department of Health and
Mental Hygiene and l o c a l health departments
to develop a plan to expand c l i n i c hours and
s i t e s which they w i l l s t a f f with volunteer
registered nurses.
Governor to issue Proclamation to kick off
Campaign. Mrs. Carter, Mrs. Bumpers,
Secretary Shalala, and Maryland Congressional
Delegation to be invited along with
appropriate state o f f i c i a l s .
Public Service Announcements coordinated with
the National Every Child Bv Two publicity
campaign and The Children's Action Network
for the Preschool Immunization Project.
Make immunization project part of the State
health plan to ensure i t s continuation.
Status:
Maryland Nurses Association i s working with
l o c a l health o f f i c e r s .
Plans being developed for Maryland's
participation i n National Preschool
Immunization Week, A p r i l 24 - 30, 1993.
(Meeting with Governor's Partners
February 19, 1993.)
�Injury Prevention
Proposal:
Governor^
The Governor will launch a Year of Injury
Prevention in September, 1992 to increase public
awareness of and knowledge of injuries as a public
health problem. The focus will be on injuries as
preventable, not accidental.
Department of Health and Mental Hygiene Maryland
Injury Prevention Network
MIEMSS
Johns Hopkins University Injury Control Research
Center; Division of Maternal and Child Health
State Departments: Transportation; Human
Resources; Natural Resources
Jaycees
Kiwanis
SAFE KIDS
Chamber of Commerce
Maryland Chapter of Academy of Family
Practitioners
Med Chi
Associations of Retired Persons
Maryland State Health Planning Resources
Commission
Iroplepenmion;
At the Second Governor's Conference of Injury
Prevention in September, 1992, the Governor
issued a proclamation designating the Year of
Injury Prevention. The conference i s supported by
CDC grant funds.
The conference w i l l be used as a vehicle tb kickoff the 16 month plan of activities (see attached
draft plan). Each month will focus on a different
injury cause with a variety of activities
sponsored by selected departments, counties and
private organizations.
The MIPCP and an Advisory Committee will develop
injury prevention messages for each week which
will be publicized through the media and in a
calendar to be made available to the public.
The MIPCP and the Advisory Committee w i l l develop
sample injury prevention interventions/activities
for each month's injury focus that could be
adopted by various participating groups.
�The MIPCP w i l l develop an information packet
targeted t o health professionals f o r use i n t h e i r
p r o f e s s i o n a l contacts w i t h consumers.
Sponsor a Motherhood and Apple Pie Day f o r the
State l e g i s l a t u r e t o increase awareness of t h i s
p u b l i c h e a l t h problem and provide information
regarding prevention s t r a t e g i e s and current
a c t i v i t i e s i n Maryland.
Make p r o j e c t part of the State health plan t o
ensure i t s continuation.
status:
Project i s underway.
�State-Wide Worksite Health Promotion Recognition
Proposal:
Governor'g
Partner?;
To encourage a healthier Maryland, businesses and
corporations w i l l be rewarded for establishing programs
that help their employees to meet the Year 2 000 health
objectives.
Maryland Chamber of Commerce
Greater Baltimore Committee
Washington Board of Trade
Maryland State Health Planning Resources Commission
Maryland Department of Personnel - Club Maryland
Implementation:
Appoint a Committee to establish the process for
awarding the plaque.
Design tha-William Donald.-Schaefer plaque to be
awarded to the winners.
Make project part of the State health plan to ensure
i t s continuation.
status:
This project i s combined with establishment of
project to develop Local Wellness Councils. The
Committee met on January 7, 1993, to start the
planning process.
�Local Wellness Council
Prppogfrl;
Establish Wellness Councils in as many jurisdictions as
possible as a strategy to encourage people to practice
prevention. Prevention i s a long term cost savings
measure and a good investment in people. Prevention
emphasizes personal responsibility. I t can become a way
of l i f e that can spread to other facets of community life
and help people understand that their personal behavior
and l i f e styles create as well as solve community
problems.
gQvernQr'g
Partner?
Department of Personnel, Club Maryland
Local Elected Officials
Local Health Departments
Local Chambers of Commerce
Local Health Groups
Implementation;
Use Club Maryland as a model to expand the concept of
wellness councils through public/private partnerships.
Through the efforts of Club Maryland, The National
Association of Public Employees Wellness of the Council of
State Governments i s holding i t s conference in Baltimore
in August 1993. This w i l l kick off our efforts. This
project combined with the Worksite Recognition project.
�Project With Religious Community
Proposal:
Governor's
Partners:
Working with the churches, synagogues, and religious
organizations w i l l reach and teach large numbers of people
prevention practices and how to be good health care
consumers.
Leaders of religious communities in a l l segments of our
State
Maryland State Health Planning Resources Commission
Maryland Hospital Association
The Medical-Chirurgical Faculty of Maryland
implementation:
Establish a Committee to develop projects that will reach
members of religious institutions with materials designed
to teach them the importance of maintaining good health
through prevention and being good health care consumers.
Make project part of the State health plan to ensure i t s
continuation.
Status:
This project i s in planning stage.
�Statewide Conununity Meetings on The Future
of Health Care
Pr<?P9g»l;
Partners;
This proposal w i l l organize statewide community meetings
among Maryland citizens and health care policy makers to
determine the public's knowledge of and expectations of
the health care delivery system.
Maryland League of W m n Voters
oe
Maryland Chamber of Commerce
Health Care For A l l Coalition
Maryland State Health Planning Resources Commission
University of Maryland Center For Health Policy Research
University of Maryland Law School
Dr. Neil Solomon's Committee
Implementation;
Design statewide forums for health care reform education
and fact finding.
Work vith Research America to implement surveys and focus
groups that w i l l provide policy makers with information on
what the public knows about and expects from the health
care system and vhat they think the role of government
should be.
This project has been completed. Eight town meetings vere
held across the State. Survey results and the report will
be completed by February 1993.
�GOVERNOR SCHAEFER'S TOWN MEETINGS
ON HEALTH CARE
Marilyn Goldwater, R.N.
Executive Assistant Health Issues
Governor's Programs Office
Kim Parks
Programs Assistant
Governor's Programs Office
�GOVERNOR SCHAEFER'S HEALTH TOWN MEETINGS
Governor Schaefer has formed a partnership with the people to make "Maryland:
A State of Healthy Living Through Practicing Prevention." This campaign is based
on three major initiatives: a mobile health clinic, school health education, and
consumer healthcare education. The initiatives all focus on prevention projects and
build partnerships with the private sector, and community organizations.
One of the projects under the consumer healthcare education initiative was a series
of statewide Town Meetings on Health Care. The meetings began in October,
1992 and ended in December, 1992. They were held in the following locations:
Rockville, (Montgomery County); Ellicott City, (Howard County); Bowie, (Prince
George's County); Boonsboro, (Washington County); Wye Mills, (Queen Annes
County); Cumberland, (Allegany County); Baltimore City and Salisbury, (Wicomico
County). The purpose of these meetings was twofold. First, to provide citizens
with the opportunity to become involved in the health care debate. Second, to
determine the public's knowledge of and expectations from the health care delivery
system. The Governor's partners were: The League of Women Voters of
Maryland; Health Care for All Coalition; AARP: Maryland Long Term Care Action
Group; The Maryland Association of HMO'S; University of Maryland Center for
Health Policy Research; University of Maryland Law School; Maryland Health
Resources Planning Commission; Maryland Chamber of Commerce and Dr. Neil
Solomon's Committee.
�FORMAT OF MEETINGS
Most citizens are accustomed to attending town meetings that serve as a forum
for immediate reaction to a specific issue, with limited time and a very focused
response. Citizens, were pleasantly surprised to find that Governor Schaefer's
Health Town Meetings were loosely structured, "Phil Donahue Show" style. This
structure created an environment that led to strong audience participation in the
form of dialogue rather than testimony. At each meeting there were brief
presentations consisting of an overview of facts and figures of Maryland's system,
of the role of local health, and information about the issues being debated at the
national level.
During the two hours given to audience participation some current issues
surrounding state budget cuts did surface but the moderator, David Chavkin,
Associate Professor of Law at the University of Maryland at Baltimore, kept the
discussion focused on health care reform. He posed several questions to the
audience and the responses led to further questions and the dialogue deepened.
Participants were asked to complete surveys that were designed to gather
information on demographics and how citizens currently use or are presently
affected by the health care delivery system. Results of the survey (attached) were
tabulated by the University of Maryland Center of Health Policy Research.
�THEMES COMMON TO EACH TOWN MEETING
The following issues surfaced at all eight meetings: Prevention, Long Term Care,
Tort Reform, Single Payor System, Rationing, Cost, Quality and Access.
None are new to policy makers, but all of the information that was gathered at the
town meetings affirms that Maryland's citizens believe that we need to have a plan
for health care reform and that priorities need to be established.
Prevention
At each town meeting, the idea that prevention should be practiced by citizens and
rewarded by insurers was loud and clear. The fact that citizens must accept
responsibility for their health was echoed all over the State. People felt that not
practicing prevention creates a heavy burden on the health care delivery system.
Some tax-payers are angry that they, for example, must pay for the care of those
who engage in high risk behavior, such as not wearing a helmet when riding a
motorcycle. Others think that it is unfair that their employers might pay for an
insurance plan that covers treatment of lung cancer patients who have chain
smoked for several years, but the plan may not cover pre-natal care. Many believe
prevention should be rewarded, while those who do not practice prevention should
be penalized.
The fact that citizens must first be responsible health care consumers and that we
should have a health care delivery system consistent with this belief was one of
the most prevalent topics of discussion.
�Long-term Care
The high cost of long-term care provoked some strong and controversial debate.
On one end, many citizens noted that long-term care is not limited to the elderly,
that there are people of all ages who are in need of long-term care. There is also a
distinction between who needs long-term medical and nursing care and those who
do not need medical or nursing care but do need assistance with specific tasks.
Citizens also expressed the need to look at cost differentiation between these two
forms of care.
There was support for the right to die and concern about the high cost to the
system in the use of high-tech life sustaining measures when hope for recovery to
a full and productive life did not appear to be an option. Several people thought
there should be limits on the devices that are available to keep people alive.
Others thought the priority should be basic care for all, and those who want to be
kept alive by life-support systems should have to pay out of pocket costs.
Single Payor System
At least once at every meeting, someone would speak in support of developing a
single payor system. People stated that a single payor system would provide
access for all and keep costs down by getting rid of paper work.
�Tort Reform
Many citizens perceived the high cost of malpractice suits to be an important
reason for escalating costs. Many indicated that there should be a limit to the
amount of money patients could collect and a clearer definition of "pain and
suffering" in law suits. Others also thought the number of tests physicians now
perform to protect themselves from malpractice is unnecessary and duplicative.
RATIONING
Rationing surfaced frequently as a way to control runaway costs. The discussion
on this issue produced controversy over what services should be rationed and
many felt that elimination of waste in the system would make rationing
unnecessary.
COST, QUALITY AND ACCESS
These three issues were raised constantly and people stated that no matter what
changes were made in the system, everyone was entitled to basic high quality
affordable care.
ATTENDANCE
A total of about 1,000 people attended the eight Town Meetings. Additional
people sent written comments.
�SUMMARY
The Governor's Office has received numerous calls and letters of thanks
from constituents who attended the meetings. Citizens genuinely
appreciated the opportunity to voice their opinions prior to the State devising
a plan for health care reform. Even if their ideas are not incorporated in the
final plan, they appreciated being consulted and want to see additional
forums of this nature. We have been urged to have another round of town
meetings in different locations.
Most people were very knowledgeable about the issues. Many knew the
role the federal government must play in making most of the proposed
changes happen. People seemed aware of federal policies and mandates, as
well as President Clinton's potential plans and the need for Maryland to
devise a plan that is feasible and consistent with federal changes.
Despite some confusion between the single payor system and national
health insurance, the single payor concept seemed the most easily
understood and most widely supported by citizens.
People educated each other during Governor Schaefer's Health Town
Meetings. As numerous topics and issues arose, attendees began to
understand how uniquely each is affected by the current system. They
appear to understand that health care reform is complex, complicated and
will not occur overnight. However, there seemed to be a strong feeling that
it is necessary to start the process of change.
�FOLLOW UP
o
The Maryland Health Resources Planning Commission (HRPC) has
contracted with The Schaefer School of Public Policy to do a random
survey on health care issues. HRPC has appointed a committee on
Health Care Reform. HRPC will work with the Governor's Office and
the Town Meeting Partners to follow up with additional Health Care
Town Meetings in the Fall of 1993, and to explore the use of
community television for health educational purposes.
o
Dr. Neil Solomon, Chairman of the Governor's Commission on Drug
and Alcohol Abuse, is advising the Governor on health care reform
issues.
o
The 1993 Legislative Session will provide citizens with further
opportunity to discuss health care reform during public hearings on
bills addressing that issue.
�RESULTS OF THE TOWN MEETING SURVEY
�The Sample
A t o t a l of 493 usable questionnaires were received and entered
for analysis. The amount of usable data varied on the items from a
high of 493 responses on a number of the demographic variables to
a low of 464 responses to the item which asked participants where
they heard
about the meeting which they attended.
The
average
amount of complete information for the questions as a whole was a
quite respectable 97%.
The
respondents'
sociodemographic
characteristics
are
presented in Table 1. The majority of the sample were 45 years of
age or older (66.9%), female
respondents
(69.4%), and Caucasian (91.0%). The
also tended to be quite educated
(almost half, for
example, had engaged in post graduate work and f u l l y 86.3% had at
least attended college) and reported reasonably high income levels
(49.2% reported a family income of $50,000 or more).
As indicated in Table 2, almost the entire sample had some
form of insurance coverage
Maryland
was
the
most
(95.5%). Blue Cross/Blue
common
insurer
(29.0%),
Shield
of
followed
by
t r a d i t i o n a l health insurance (22.2%) and HMOs (20.1%). Over threequarters
of
the
insured respondents
reported
receiving
their
insurance through their employer or their spouse's employer. The
majority of the sample received dependent coverage, although most
(72.3%) did not have long-term
care insurance. In general, the
�2
respondents
seemed
reasonably s a t i s f i e d
with
their
insurance
coverage with 31.0% rating i t as excellent and 48.5% considering i t
good.
Legislative
district.
I t was
not
possible
to
reliably
categorize respondents according to their l e g i s l a t i v e d i s t r i c t s .
Over a third of the sample did not supply t h i s information at a l l
and a large proportion of the remaining respondents appeared to
confuse federal congressional d i s t r i c t s with state
legislative
breakdowns. Most respondents did supply their zip codes, however,
which l i k e the location of the meetings themselves spanned the
geographic spectrum of the State of Maryland.
Results
The respondents were asked to rate their degree of concern
with 12 insurance issues on a five-point scale ranging from a
"great deal" of concern to "not at a l l " (a "not sure" category was
also provided and assigned a "3" as the mid point) . As a whole, the
respondents were r e l a t i v e l y concerned about a l l 12 issues since
none of the 12 means exceeded 3.00 (which was the arithmetic mean
of the s c a l e ) . As indicated in Table 3, r i s i n g health insurance
costs
concerned
the
respondents
the
most,
followed
by
the
d i f f i c u l t y of paying for catastrophic i l l n e s s , cuts in benefits,
higher out-of-pocket costs of insurance, and the p o s s i b i l i t y that
the quality of care which they would receive might decline.
�2
When asked what they considered to be the prime contributors
to the r i s i n g costs of health care, the respondents pointed to the
high administrative costs caused by the complex system of payment
and reimbursement for treatment as the chief offender, followed by
the frequent use of high technology and other expensive equipment,
the costs of running private health insurance companies, and the
aging of the American population (Table 4 ) . The costs associated
with
prevention
was
seen
as
least
problematic
of
the eight
potential contributors l i s t e d .
The f i n a l set of questions dealt with s i x opinions related to
health care coverage. Here the most s t r i k i n g finding was probably
the high degree of agreement with the statement that health care
coverage should be considered a right to which a l l Americans are
entitled regardless of their a b i l i t y to pay. Following t h i s , the
greatest
consensus
revolved around the belief
should play the primary
surprisingly
the
role
statement
that government
in providing t h i s coverage.
eliciting
the
greatest degree
Not
of
disagreement involved the concept that health care coverage should
be p r i o r i t i z e d according to factors such as age and income (See
Table 5 ) .
Factors Related to Concerns and Opinions
The
relationships
between the
socio-demographic/insurance
�4
coverage
variables
and
the
various
health
insurance
concerns/opinions were also examined. The results of these analyses
follow.
Gender. Females tended to be s i g n i f i c a n t l y more concerned than
males with respect to a number of the issues related to health
insurance coverage. S t a t i s t i c a l l y significant differences in this
regard were observed on nine of the 10 items. S p e c i f i c a l l y , women
tended to be more concerned about:
(1) The p o s s i b i l i t y
of loss of insurance
due to health,
i n a b i l i t y to pay, their employers ceasing to offer i t , and
pre-existing conditions.
(2) Limits on wage increases due to insurance costs.
(3) Higher out-of-pocket costs of insurance.
(4) A possible decline i n the quality of care.
(5) The possible loss of choice regarding the provider of care
available to them.
Gender differences were less dramatic concerning differences
in opinions regarding the contributors of r i s i n g costs and health
�5
insurance coverage. Males tended to attribute more importance to
violence as a contributor to costs and tended to believe that the
government should
have a primary role i n providing
coverage.
for the
(Means
statistically
significant
insurance
gender
differences are presented i n Table 6.)
Age. Due to the r e l a t i v e l y few younger respondents, three age
groups were employed i n the analyses that follow: individuals 44
and
younger,
individuals between the ages of 45 and 64, and
individuals 65 years of age and over. The respondents' age did tend
to be related to their degree of concern and opinions
regarding
health insurance. I n general, older respondents (especially those
65 and older) appeared to be less concerned about many of the 12
l i s t e d issues than their younger counterparts.
(Concerns related
to catastrophic i l l n e s s was an exception, with the younger group
registering s l i g h t l y less concern than the two older groups.) A
different pattern held for opinions regarding the contributors to
higher
insurance costs with the younger groups attributing less
importance to the majority
of the eight posited
factors. The
pattern was not quite as clear regarding the s i x a t t i t u d i n a l items,
with the younger group agreeing more f u l l y with the statement that
more taxed w i l l be necessary to pay for health care coverage but
disagreeing that health care coverage should be provided based upon
age and income factors and that the private sector should have a
greater role i n providing coverage. (The s t a t i s t i c a l l y significant
differences among the three age groups are presented i n Table 7.)
�6
Insurance provided bv employer. Respondents whose insurance
was provided by their employers (n=370) were next compared with
those who
covered
either did not have insurance or whose insurance was
from
significantly
another
on
only
source
five
(n=105).
of
the
These
groups
differed
concerns/opinion
items.
Individuals whose insurance was provided by their employers were
naturally more concerned about the loss of insurance because their
employers ceased offering i t , were concerned
that r i s i n g costs
would place l i m i t s on wage increases due to insurance, and f e l t
that government should have a greater role in providing coverage.
They were l e s s l i k e l y to attribute r i s i n g costs to violence or
Americans growing older, however. (The s t a t i s t i c a l l y
significant
differences between these groups are presented in Table 8.)
Education. As stated above, the respondents
in t h i s study
tended to be quite highly educated. For t h i s reason individuals
college
graduates
education
(n=163).
(n=320) were
compared
As
in Table 9,
indicated
to
those
with
these two
less
groups
possessed s i g n i f i c a n t differences on a r e l a t i v e l y large number of
the concerns/opinions dimensions. Individuals with less education
registered
the
following differences as
compared
to college
graduates:
(1) They were more concerned about loss of insurance due to
employers ceasing to offer i t , health, and i n a b i l i t y to pay
for i t .
�7
(2) They were more concerned about paying for catastrophic
illness.
(3) They were more concerned about cuts in benefits, limits on
wage increases due to insurance costs, higher out-of-pocket
costs of insurance, and the need for higher taxes to pay for
coverage.
(4) They were more concerned about a decline i n quality of
care and loss of choice with regard to their providers.
(5) They expressed greater agreement with the statements that
salaries
of
health
professionals
and
violence
were
contributors to the r i s i n g costs of health insurance.
(6) They tended to believe that taxes would have to r i s e to
pay for the increased costs of health insurance and that the
private sector would have to take more of a role i n providing
coverage.
Income. As discussed above, the respondents to t h i s
survey
tended to have r e l a t i v e l y high incomes. In general, however, the
individuals with the highest incomes tended to be less concerned
about losing t h e i r coverage due to health or cuts in their benefits
due
to cost containment. There were also less concerned about
�8
l i m i t s on wage increases due to r i s i n g insurance
taxes
due to the same factor, or to a general
costs, higher
decline
i n the
quality of care they were l i k e l y to receive. They tended to be less
l i k e l y to attribute these r i s i n g costs to Americans growing older,
malpractice, or violence. Finally, they tended to be s l i g h t l y less
likely
to consider
health
care
coverage as a right
for
all
Americans, to believe that the private sector should have a major
role, or believe that current health p o l i c i e s meet the needs of
most families. They did tend to be more l i k e l y to believe that the
government should have more of a role in health care coverage than
did lower income respondents, however.
Other
insurance
factors. Analyses
were also
performed
on type of
coverage and where the respondent learned
about the
meeting. The differences between these various groups, however,
tended to be r e l a t i v e l y inconsistent. This, coupled with the small
numbers
of respondents
i n many
of the groups,
made
these
differences extremely hard to interpret and of dubious value.
�Table 1
Socio-Demographic
C h a r a c t e r i a t i c s o f t h e Reapondenta
N
I
Age
18-29
30-44
45-64
65 o r over
37
126
207
123
7.5%
25.6%
42.0%
24.9%
Male
Female
150
340
30.6%
69.4%
2
9
46
11
105
89
231
.4%
1.8%
9.3%
2.2%
21.3%
18.1%
46.9%
African-American
Asian-American
Caucasian
Hispanic
Other
18
8
446
5
13
3.7%
1.6%
91.0%
1.0%
2.7%
$10,000
$10,001
$25,001
$50,001
$75,001
29
60
153
117
118
6.1%
12.6%
32.1%
24.5%
24.7%
25
6
103
68
2
106
83
8
63
5.4%
1.3%
22.2%
14.7%
.4%
22.8%
17.9%
1.7%
13.6%
Gender
Education
Grade School o r Less
Some High School
High School Graduate
Vocational/Technical
Some C o l l e g e
Four Year C o l l e g e Graduate
Post Graduate Work
Ethnicity
Income
or less
t o $25,000
t o $50,000
t o $75,000
o r over
Where Learned About Meeting
AARP
Chamber o f Commerce
H e a l t h Care I n s t i t u t i o n
H e a l t h Care P r o v i d e r
Insurance
League o f Women V o t e r s
Newspaper
Radio
Other
�Table 2
Insurance
Coverage
N
%
464
22
95.5%
4.5%
105
137
39
95
14
53
30
22.2%
29.0%
8.2%
20.1%
3.0%
11.2%
6.3%
370
105
77.9%
22.1%
319
117
73.2%
26.8%
147
230
84
13
31.0%
48.5%
17.7%
2.7%
130
340
27.7%
72.3%
Presence o f Insurance
Yes
No
Type o f Insurance
T r a d i t i o n a l H e a l t h Insurance
Blue Cross/Blue S h i e l d o f Maryland
PPO ( P r e f e r r e d P r o v i d e r O r g a n i z a t i o n )
HMO ( H e a l t h Maintenance O r g a n i z a t i o n )
Medicaid
Medicare
Other
Insurance t h r o u g h Employer
Yes
No
Dependent
Coverage
Yes
No
Insurance
Rating
Excellent
Good
Fair
Poor
Presence o f Long-Term
Yes
No
Insurance
�Table 3
H e a l t h Insurance Concerns
Rank
Mean'
1
R i s i n g insurance costs.
1.19
.55
2
Paying f o r c a t a s t r o p h i c i l l n e s s .
1.40
.81
3
Cuts i n b e n e f i t s due t o c o s t containment.
1.53
.89
4
Higher o u t - o f - p o c k e t c o s t s o f i n s u r a n c e .
1.53
.88
5
Decline i n q u a l i t y o f care.
1.88
1.24
6
Choice o f p r o v i d e r .
2.09
1.26
7
Higher t a x e s t o pay f o r coverage f o r a l l Americans.
2.14
1.36
8
L i m i t s on wage i n c r e a s e s due t o insurance c o s t s .
2.23
1.39
9
Loss o f i n s u r a n c e due t o h e a l t h .
2.50
1.53
10
Loss o f i n s u r a n c e due t o employer.
2.54
1.62
11
Loss o f i n s u r a n c e due t o i n a b i l i t y t o premiums.
2.72
1.61
12
Loss o f i n s u r a n c e due t o p r e - e x i s t i n g c o n d i t i o n s .
2.76
1.64
*The means were based upon t h e f o l l o w i n g s c a l e : l=Concerned a g r e a t d e a l ,
2=somewhat concerned, 3=not s u r e , 4=not v e r y concerned, and 5=not a t a l l
concerned. Lower means t h u s r e f l e c t e d g r e a t e r concern.
�Table 4
Contributors of Rising Costs of Health Care
Rank
Mean*
S.D.
1
High a d m i n i s t r a t i v e c o s t s due t o complex
payment and reimbursement system.
1.30
.63
2
Frequent use o f h i g h t e c h n o l o g y / e x p e n s i v e equipment.
1.49
.76
3
Costs o f r u n n i n g p r i v a t e h e a l t h i n s u r a n c e companies.
1.63
.92
4
Americans growing o l d e r and needing more care.
1.64
.86
5
Malpractice.
1.77
1.05
6
S a l a r i e s o f h e a l t h care p r o f e s s i o n a l s .
2.13
1.23
7
Violence.
2.38
1.28
8
Prevention.
3.16
1.51
*The means were based upon
2=contributeB somewhat, 3=not
5=contributes not at a l l . Lower
i n question contributes more t o
the f o l l o w i n g scale: l=contributes a great deal,
sure, 4=does not c o n t r i b u t e very much, and
means therefore r e f l e c t a b e l i e f t h a t the item
the r i s i n g costs of health care.
�Table 5
Opinions Regarding Health Care Coverage
Rank
Mean*
S.D.
1
Health Care Coverage i s a r i g h t t o which a l l
Americans are e n t i t l e d regardless of
a b i l i t y t o pay.
1.37
.77
2
Government should have a primary r o l e i n health
care coverage.
2.10
1.30
3
For the most p a r t , the current health care system
meets family needs.
2.23
1.34
4
I n d i v i d u a l s and businesses w i l l have t o pay higher
taxes t o provide health care coverage t o a l l
Americans.
2.39
1.39
5
The p r i v a t e sector should have the primary r o l e i n
2.98
providing health care coverage t o a l l Americans.
1.44
6
Health care coverage should be provided w i t h i n
c e r t a i n p r i o r i t i e s based upon factors such
as age and income.
1.59
3.26
*The means were based on the f o l l o w i n g scale: l = f u l l y agree, 2 = p a r t i a l l y
agree, 3-not sure, 4 = p a r t i a l l y disagree, and 5 = f u l l y disagree. Lower means
therefore r e f l e c t greater agreement.
�Table 6
Gender D i f f e r e n c e s *
Males
Females
(n=150)
(n=340)
1.
Loss o f i n s u r a n c e due t o employer.
2.89
2.38
2.
Loss o f i n s u r a n c e due t o h e a l t h .
2.78
2.38
3.
Loss o f i n s u r a n c e due t o i n a b i l i t y t o premiums.
3.07
2.56
4.
Loss o f i n s u r a n c e due t o p r e - e x i s t i n g c o n d i t i o n s .
3.01
2.66
5.
L i m i t s on wage i n c r e a s e s due t o insurance c o s t s .
2.54
2.09
6.
Higher o u t - o f - p o c k e t c o s t s o f i n s u r a n c e .
1.73
1.45
7.
Decline i n q u a l i t y o f care.
2.14
1.78
8.
Choice o f p r o v i d e r .
2.31
2.00
9.
Violence.
2.96
3.27
10.
Government should have a p r i m a r y r o l e i n h e a l t h
care coverage.
2.01
2.31
•Higher mean scores i n d i c a t e l e s s concern o r agreement w i t h t h e i t e m .
�Table 7
Age D i f f e r e n c e s *
<45
45-64
>64
1.
Paying f o r c a t a e t r o p h i c i l l n e s s .
1.53
1.35
1.31
2.
Loss o f i n s u r a n c e due t o employer.
2.11
2.51
3.27
3.
Loss o f i n s u r a n c e due t o h e a l t h .
2.21
2.49
2.96
4.
Loss o f i n s u r a n c e due t o i n a b i l i t y t o premiums.
2.28
2.73
3.35
5.
Loss o f i n s u r a n c e due t o p r e - e x i s t i n g c o n d i t i o n s .
2.49
2.74
3.24
6.
Cuts i n b e n e f i t s due t o c o s t
1.43
1.50
1.71
7.
L i m i t s on wage i n c r e a s e s due t o i n s u r a n c e c o s t s .
1.69
2.16
3.19
8.
Higher o u t - o f - p o c k e t c o s t s o f i n s u r a n c e .
1.39
1.53
1.74
9.
Choice o f p r o v i d e r .
1.93
2.05
2.42
10.
Frequent use o f h i g h t e c h n o l o g y / e x p e n s i v e
1.71
1.42
1.34
11.
Americans growing o l d e r and needing more c a r e .
2.26
2.28
1.70
12.
Violence.
3.11
3.39
2.80
13.
I n d i v i d u a l s and businesses w i l l have t o pay h i g h e r
t a x e s t o p r o v i d e h e a l t h care coverage t o a l l
Americans.
2.77
2.96
3.32
14.
The p r i v a t e s e c t o r s h o u l d have t h e p r i m a r y r o l e i n
3.47
p r o v i d i n g h e a l t h care coverage t o a l l Americans.
3.28
2.98
15.
H e a l t h c a r e coverage s h o u l d be p r o v i d e d w i t h i n
c e r t a i n p r i o r i t i e s based upon f a c t o r s such
as age and income.
2.45
2.13
containment.
equipment.
2.53
*Higher mean scores i n d i c a t e l e s s concern o r agreement w i t h t h e i t e m .
�Table 8
Respondents w i t h Insurance v s . Those W i t h o u t *
With
Without
(n=370)
(n=105)
1.
Loss o f i n s u r a n c e due t o employer.
2.46
2.89
2.
L i m i t s on wage i n c r e a s e s due t o i n s u r a n c e c o s t s .
2.12
2.66
3.
Americans growing o l d e r and needing more c a r e .
2.22
1.80
4.
Violence.
3.22
2.86
5.
Government s h o u l d have a p r i m a r y r o l e i n h e a l t h
care coverage.
2.06
2.78
*Higher mean scores i n d i c a t e l e s s concern o r agreement w i t h t h e i t e m .
�Table 9
Educational Differences*
Noncolleae
Graduates
(n=163)
Cblleqe
Crpcirtm
(n=320)
1.
Paying f o r catastrophic i l l n e s s .
1.28
1.46
2.
Loss of insurance due t o employer.
2.34
2.68
3.
Loss of insurance due t o health..
2.25
2.62
4.
Loss of insurance due t o i n a b i l i t y t o premiums.
2.39
2.89
5.
Cuts i n benefits due t o cost containment.
1.36
1.61
6.
L i m i t s on wage increases due t o insurance costs.
1.96
2.37
7.
Higher out-of-pocket costs of insurance.
1.38
1.61
8.
Higher taxes t o pay f o r coverage f o r a l l Americans.
1.73
2.36
9.
Decline i n q u a l i t y of care.
1.64
2.01
10.
Choice of provider.
1.85
2.02
11.
Salaries of health care professionals.
1.60
1.87
12.
Violence.
2.69
3.42
13.
I n d i v i d u a l s and businesses w i l l have t o pay higher
taxes t o provide health care coverage t o a l l
Americans.
2.66
3.14
14.
The p r i v a t e sector should have the primary r o l e i n
3.01
providing health care coverage t o a l l Americans.
3.41
•Higher mean scores i n d i c a t e less concern or agreement w i t h the item.
�Table
10
S t a t i s t i c a l l y S i g n i f i c a n t D i f f e r e n c e s Between
High and Low Income Respondents*
<S25,00
(n=89)
>S25,000
(n=388)
1.
R i s i n g insurance costs.
2.20
1.87
2.
Loss o f i n s u r a n c e due t o h e a l t h .
2.09
2.60
3.
Loss o f i n s u r a n c e due t o p r e - e x i s t i n g c o n d i t i o n s .
2.11
2.83
4.
L i m i t s on wage i n c r e a s e s due t o insurance c o s t s .
1.90
2.28
5.
Higher t a x e s t o pay f o r coverage
1.78
2.20
6.
Decline i n q u a l i t y of care.
1.64
1.93
7.
Americans growing o l d e r and needing more c a r e .
1.69
2.24
8.
Malpractice.
1.39
1.69
9.
Violence.
2.64
3.28
10.
H e a l t h Care Coverage i s a r i g h t t o which a l l
Americans are e n t i t l e d r e g a r d l e s s o f
a b i l i t y t o pay.
1.22
1.41
11.
Government should have a p r i m a r y r o l e i n h e a l t h
care coverage.
2.69
3.12
12.
For t h e most p a r t , t h e c u r r e n t h e a l t h care system
meets f a m i l y needs.
1.80
2.18
13.
The p r i v a t e s e c t o r should have t h e p r i m a r y r o l e i n
2.87
p r o v i d i n g h e a l t h care coverage t o a l l Americans.
3.36
f o r a l l Americans.
•Higher mean scores i n d i c a t e l e s s concern o r agreement w i t h t h e i t e m .
�Survey on Selected Health Care Issues
Conducted by the
William Donald Schaefer Center for Public Policy,
University of Baltimore
December, 1992
Introduction
During the fall of 1992, Commission staff were presented with a unique and timely
opportunity to work with the Schaefer Center on Public Policy to develop a series of questions
on health care issues to be included in the Center's annual public opinion survey. This survey,
conducted during the week of December 11-18, 1992, is intended "to provide state officials with
information about citizen attitudes toward taxing and spending issues in Maryland" that is
statistically reliable, and describes the "public perceptions of the choices facing state officials"
during the coming session of the General Assembly.
The series of ten questions whose results are reported in this summary report were
developed as a mutually beneficial collaboration between Commission and Schaefer Center staff.
No survey of current public concerns could ignore the issues of cost, access, and quality in
health care, so the expertise of Commission staff in recommending specific questions and
wording gave the surveyors valuable insight into what policymakers would need to know. And
by affording the Commission a vehicle through which to gauge public opinion on these issues,
the survey provides the Special Committee on Health Policy an accurate "snapshot" of what the
people of Maryland think and believe about the direction health policy should take in this State.
Methodology
The methodological structure of the Schaefer Center's survey is a function of how the
sample is obtained, stratified, and weighted, as well as how the respondents are determined and
what initial demographic information is obtained from them. The margin for error in the survey
was approximately +l-2>%.
A random telephone survey: Surveyors interviewed 1022 Mary landers over the age of
18, whose phone numbers were selected randomly from computer-generated lists of all possible
telephone numbers in the State. The person answering the telephone was asked if he or she was
over 18, and willing to spend the time responding to the surveyor's questions. If no one over
18 was at home, the surveyor moved to the next number. The surveyor explained that the results
of the survey were intended to help the members of the General Assembly better understand the
concerns of their constituents. The only further screening of respondents was to confirm if they
were male or female, since the survey is only statistically sound if the final total of respondents
replicates the gender distribution in the population being surveyed.
�Stratifying the sample: The sample was stratified to account for regional differences
in the State's population: according to 1990 census data, about 81 % of Maryland's people live
in the Baltimore-Washington corridor. These "core" counties include Anne Arundel, Baltimore,
Carroll, Harford, Howard, Prince George's, Montgomery, and Baltimore City. A typical
random survey would only contain about 20% of its respondents from outside this core area,
yielding too few respondents from the remaining regions - Western Maryland, Southern
Maryland, and the Eastern Shore - for a reasonable comparison. The solution to this statistical
dilemma is to stratify the sample into "core" and "non-core" respondents: approximately 505
people were interviewed from the State's metropolitan corridor, and another 517 from the noncore regions, providing a meaningful number for purposes of regional comparisons.
Weighting the sample: Although the data obtained is valid as is for regional
comparisons, in order to derive "aggregate snapshots" of Maryland as a whole, the stratified
sample must be weighted in order to correct for the effects of overcounting respondents outside
the core counties. Weighting factors of 1.61 for core respondents and .39 for non-core
respondents produces a pattern of response in line with the geographic distribution of Maryland's
population. This weighting is used in all aggregate statewide data reports, unless regional
comparisons are made.
Variables: The following demographic information - in addition to their geographical
region - was obtained from each respondent:
o
o
o
o
o
o
o
o
o
o
gender
age (18-34, 35-55, over 55)
race
education (less than high school, GED or high school diploma, some
college, college graduate, graduate or professional education)
marital status
school age children at home
party affiliation (or lack thereof)
ideology (liberal/moderate/conservative)
income (less than $5000, $5000 to $15,000, $15,000 to $25,000,
$25,000 to $50,000, $50,000 to $75,000, $75,000 to $100,000, and over
$100,000)
type/source of health insurance (self-pay, employer-pay or subsidy, or
Medicare/Medicaid)
In addition to the ten health care questions, the Schaefer Center also shared with the
Commission its responses to an interesting initial question: "the biggest problem facing
Maryland." A graphic illustrating the response follows:
�Biggest Problem Facing Maryland
Budget
Taxes
Health Care
Growth Management
Higher Education
Welfare
Unemployment
Public Education
Crime
Drugs
Environment
Other
Don't know
0%
10%
20%
30%
40%
Percent Mentioning Problem
50%
�Clearly, with 38% of the survey's respondents naming it as Maryland's "biggest
problem," the budget crisis is what the public feels its government should be addressing. But
second in incidence, equal to "unemployment" and the catch-all category of "other" - at 11 %
of respondents ~ is health care.
In the following pages, the exact text of each of the ten health care-related questions is
given, with a brief comment on the statewide results and some speculation on what the responses
may indicate. Any significant regional or other variations from the aggregate response will be
noted. The note of "cautious enthusiasm" for public opinion survey data, struck by Schaefer
Center staff in their initial presentation of the data to Commission staff, should be repeated here:
little real significance can be claimed for differences of three to five percentage points, given
the survey's margin for error. There is much data of interest in the extensive sets with which
the Schaefer Center has provided us, but caution should be the rule in interpreting its
significance.
Health Care Questions from the Survey:
Ml.
We'd like to ask a few questions concerning health care in Maryland. Do you
currently have either a health insurance plan or Medicare or Medicaid coverage?
1.
2.
3.
0.
M2.
Yes [go to M2]
No [gotoM3]
Don't know [go to M3]
Refused [go to M3]
How would you describe your health insurance? Is it . . . [read list]
1.
2.
3.
4.
0.
Paid for by you or your family alone, or Does your employer pay all or part of it, or
Is it Medicare or Medicaid.
Don't know
Refused
Of the 87% who reported having some kind of health care coverage, two-thirds of the
respondents have employer-provided or employer-subsidized health insurance, 22%, or just over
one-fifth, pay for their own insurance, and 11% are covered by Medicare or Medicaid.
�Distribution of Health Insurance
in Maryland
Medicare/Medicaid
11%
Employer Paid
67%
Paid By Self
22%
Do you have-health insurance? Who pays for insurance?
�M3.
For each of the following items, please tell me if this is something you are concerned
about a great deal, concerned about somewhat, not very concerned about, or not
concerned about at all:
a.
b.
c.
d.
e.
f.
g.
Rising health insurance costs
Your ability to pay for catastrophic illness
Loss of health insurance coverage
Cuts in your health benefits because of high costs
Limits on wages because of health insurance costs
Higher out-of-pocket costs for health care
Inability to obtain insurance because of an existing illness or condition
The percentages of people reporting "great concern" over this spectrum of cost- and
access-related health care issues is quite high across all demographic variables and all regions
of the State, and is surprisingly uniform across the board. Somewhat higher concern over the
cost of insurance, losing insurance, and being denied insurance because of pre-existing
conditions is more likely to be reported by people of low- to middle-incomes, lower levels of
education, and advanced age. For some of the concerns listed, women show somewhat higher
levels of concern - 57% are greatly concerned over the possibility of being prevented from
obtaining insurance by pre-existing conditions, as opposed to 47% of male respondents.
Overall, however, the most significant indicator of "great concern" over the issues listed
is low income, a pattern repeated in the regions where low income is more prevalent,
particularly Baltimore City.
�Patterns of Health Care Concerns
Rising Health Insurance costs
Ability to pay for
catastrophic illness
Loss of Health
Insurance Coverage
Cuts in benefits due
to high costs
Limits on wages due
to high ins. costs
Higher out-of-pocket
costs for care
Inability to get
insurance because of
pre-existing illness
0%
20%
40%
60%
80%
Percent saying concerned "a great deal"
100%
�M4.
There has been a lot of talk about a national health care plan, but so far no plan has
been adopted. Do you think the state of Maryland should go ahead and develop its
own health care plan, or do you think Maryland should wait until a national plan
is developed?
1.
2.
3.
0.
Maryland should go ahead
Maryland should wait
Don't know, unsure
Refused
Just over half the people surveyed, a consistent percentage of respondents across all
regions and variables, expressed the opinion that Maryland should "go ahead" and develop its
own health care plan. It would be difficult to ascribe this as much to our citizens' awareness
of and faith in Maryland's traditional leadership role in health policy issues, as to a certain
cynicism that the federal government, the new Administration, will ~ or can ~ act as urgently
as people perceive the need for action.
�Should Maryland Develop Its Own
Health Plan or Wait for Federal Gov't
Go Ahead, Develop
Wait for Feds.
Don't know
i
0%
10%
20%
1
30%
;
1
40%
r
50%
60%
70%
�M5.
If you had to make a choice, would you rather lower the amount of money you pay
for health care but give up some of your freedom to choose your own doctors, or
would you rather pay more for health care and maintain complete freedom to choose
your own doctors?
1.
2.
3.
4.
0.
Lower amount, give up freedom
Pay more, keep freedom
Both, some combination [volunteered response]
Don't know, unsure
Refused
The willingness to pay more for health care, in order to retain the freedom to choose
health care providers (for the purposes of the survey specified as "doctors") was supported by
a clear majority of respondents. Nine percent more volunteered the response "some
combination" ~ or compromise -- between total freedom of choice and lower costs.
The most interesting variation from this response came from low-income groups:
respondents with incomes below $5000, presumably accustomed by the "managed care" of
poverty and the restrictions of entitlement programs to less say over their providers, were
willing, by 44% to 39%, to give up freedom of choice for lower cost. As income levels rise
in the sample, so does unwillingness to make that tradeoff: 46% (against 37%) of respondents
in the $5000 to $15,000 income bracket want to keep their freedom to choose their doctor even
if it means they'll pay more for their health care.
The gap between those unwilling to relinquish that freedom and those willing to sacrifice
choice for savings rises steadily across the sample as income rises, to 66% (against 18%) of
those in the highest income bracket stating their willingness to pay more for health care from
the doctor of their choice.
�Freedom to Choose Doctors vs.
Lower Costs of Health Care
Lower costs, give up
some choice
Pay more and retain
choice of doctors
Some Combination
Don't know
0%
10%
20%
30%
40%
50%
60%
70%
�12
M6.
If it meant an increase in your taxes, would you strongly support, support, oppose,
or strongly oppose an increase in government spending to ensure that all people have
access to medical care?
1.
2.
3.
4.
5.
0.
Strongly support
Support
Oppose
Strongly oppose
Don't know, unsure
Refused
The expressed willingness to pay more in taxes ~ the word is used explicitly in the
question - in order "to ensure that all people have access to medical care" shows a clear
majority in support: 72%, as against 23% opposed.
Regions where low income respondents are more prevalent express more support for
increased government spending, but not by great margins: Baltimore City and the Washington
Metro area each register about 75 % support for higher spending to guarantee access to health
care, followed by Southern Maryland (74%), the Eastern Shore (71%), Western Maryland
(70%), and the Baltimore Metro region, at 67% in favor.
Although its increasingly conservative bent in recent elections does show itself, two-thirds
of those polled in the counties surrounding Baltimore City do favor higher government spending
for health care. However, the Baltimore Metro region does show the highest percentage of
"oppose" responses ~ 22%, followed by Western Maryland's 20% - and its percentage of
"strongly opposed," at 6%, second only to the Eastern Shore's 8%.
�Willingness to Pay for Health Care
Spending Increases
Strongly Support
Support
Oppose
Strongly Oppose
Don't know
0%
10%
20%
30%
40%
50%
�14
M7.
There are several different proposals being discussed about how Maryland state
government should go about making sure health insurance is available to everyone
in the state. Please tell me which of the following you think is the best way for the
state to proceed.
1.
2.
3.
4.
0.
Should the state pass laws requiring employers to offer health insurance to
employees, or
Should the state create and administer its own heath insurance plan, or
Should the state use state funds to help people who cannot afford insurance.
Don't know, unsure
Refused
The graphically consistent response to this question, across regions and variables, most
likely demonstrates two things. First, there is clearly no consensus about the best direction for
health policy and financing reform to take in Maryland. Second, and perhaps even more useful
for the Commission and its Special Committee on Health Policy to know, these results surely
indicate the need ~ reported by many of those who attended the recent series of Town Meetings
on Health ~ for a clear and concerted campaign of public information and education about our
health care system, how and why it's "broken," and the options for repairing or rebuilding it.
�Preferences for Alternative Strategies
for Providing Health Insurance
Require employers to
offer insurance
State create and administer plan
Use state funds for
those unable to pay
Don't know
0%
5%
10%
15%
20%
25%
30%
35%
�16
M8.
Some health plans that have been discussed in other places would place limits on the
treatment available to people with diseases that are costly to treat, others have
proposed putting limits on the treatments available to people who would not be
expected to live long even if they receive the treatment.
a.
b.
M9.
Would you favor or oppose a plan in Maryland that would limit the
treatment available for costly illnesses?
1.
Favor
2.
Oppose
3.
Don't know, no opinion
0.
Refused
Would you favor or oppose a plan in Maryland to limit treatment available
to those who would not be expected to live long even if they got the
treatment?
1.
Favor
2.
Oppose
3.
Don't know, no opinion
0.
Refused
Some states have laws that are called right-to-die laws. That is, people are allowed
to appoint someone that has the right to say whether that person should continue to
receive life support in the event that they are unable to decide for themselves.
Would you approve or disapprove of such a law in Maryland?
1.
Approve
2.
Disapprove
3.
Don't know, unsure
0.
Refused
Especially when set against an apparently contradictory response to question M10 below,
this is a striking statement in opposition to any "Oregon-style" health plan that would limit
treatment for people with costly illnesses, and for those whose treatment will not significantly
improve or prolong life. Only twenty-five percent of those responding favored limiting access
to costly medical technology, providers, and drugs for those with costly illnesses, and slightly
less than one-third favored limiting treatment that would not increase life expectancy.
This question does not delve into exactly what kind of treatment the terminally ill should
receive - whether "heroic measures" until the inevitable end, or careful, humane palliative care
- and obviously does not address who will pay the astronomic price for devastating illnesses.
Considered in conjunction with the results of question M9, the next graphic, the responses may
be interpreted somewhat differently, an overwhelming majority of those asked favor the passage
of laws that guarantee "therightto die," by allowing a person to determine in advance the care
he may receive if unable to choose.
�Approval of Placing Limits on
Health Care Availability
Favor 32%
Favor 25%
Don't Know 9%
Don't know 8%
Oppose 66%
Oppose 58%
For costly illnesses,
For those not expected
to live long,
�Approval of Right-to-Die Laws
100%
80% -
60%-
40%
14%
20% -
Approve
Disapprove
Don't know
�Should Families of Elderly Pay a Larger
Share for Health Care Costs?
Strongly Agree
Agree
Disagree
Strongly Disagree
Don't Know
0%
10%
20%
30%
40%
50%
60%
�M10. Currently, a high percentage of Medicare and Medicaid payments go to care for
elderly people who are unable to care for themselves. Some people argue that the
families of those people ought to be required to pay a greater share for this care.
Would you strongly agree, agree, disagree, or strongly disagree with the government
requiring immediate families to pay a larger share of these costs?
1.
2.
3.
4.
5.
0.
Strongly agree
Agree
Disagree
Strongly disagree
Don't know, unsure
Refused
Phrased with great care by its editors -- do you specify "spouses and children," or choose
the less specific "immediate families"? -- this question elicited an emphatic response. Fiftyseven percent of those surveyed disagree with the "government requiring immediate families to
pay a larger share" of the tremendous, crippling cost of long term care. Only slightly more than
one-third agreed with this approach.
Interestingly, by far the most support for families assuming more of this burden came
from respondents with incomes below $5000; only those with incomes over $100.000 showed
comparably "strong support." The strongest opposition, predictably, came from the working
poor and the middle income brackets, with 69% and 63%, respectively, indicating some degree
of opposition.
It is problematic -- and a crucial area for policy analysis and development - whether the
response to this question is as contradictory to Question M8 as it first seems. This clear
opposition to families and individuals assuming a greater share of the costs of long term care
may not be as much a refusal to bear the burden, as it is the insistence that our society must find
a better way to plan for and provide long term care, because the cost - in money and in quality
of life - is just too high.
Conclusion
Much more extensive and detailed research and comparisons can and might be done with
the wealth of data this public opinion survey has provided. The purpose of this cooperative
effort, however, was not to become absorbed in our "snapshots," or in a statistical treasure hunt.
The real applicability of this survey of Marylanders attitudes, beliefs, and knowledge about the
crucial issues facing our health care system is as a starting point. By knowing what our citizens
think and believe about health care, we know where we begin, not what we will eventually
discover, synthesize, and propose. This survey is not intended to provide a menu for reaction,
but to provide the basis for deliberation, and for leadership.
1
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001a. letter
SUBJECT/TITLE
DATE
Constituent to Hillary Clinton, re: cancer (2 pages)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
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Health Care Task Force
Tarmey
OA/Box Number:
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FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [5]
2006-0885-F
wr828
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financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) ofthe PRA)
P6 Release would constitute a clearly unwarranted invasion of
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b(l) National security classified information 1(b)(1) ofthe FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA|
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
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b(7) Release would disclose information compiled for law enforcement
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b(8) Release would disclose information concerning the regulation of
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b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
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PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001 b. statement
SUBJECT/TITLE
DATE
From constituent, re: cancer (2 pages)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
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1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [5]
2006-0885-F
wr828
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) ofthe FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) ofthe FOIA]
b(3) Release would violate a Federal statute 1(b)(3) ofthe FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) ofthe FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) ofthe FOIAj
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) ofthe FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) ofthe FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIAj
National Security Classified Information [(a)(1) ofthe PRA|
Relating to the appointment to Federal office 1(a)(2) ofthe PRA|
Release would violate a Federal statute |(a)(3) ofthe PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) ofthe PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) ofthe PRA|
P6 Release would constitute a clearly unwarranted invasion of
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C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�HEALTH CARE TASK FORCE
EN-TAKE ROOM ROUTING SUP
OFFICE:
Public Liaison
.Intergovernmental
Congressional Relations
_First Lady
Other:,
EEQUEST:
[eeting
Speech
Phone Call
Other:
REQUIRES ACTION:
Immediately
_By:_
_Soon, but-«et^>riority(Date)
�HEALTH CARE TASK FORCE SORTING SHEET
TYTFi OF MATERIAL:
General mail
.Casework/personal atoriee
Letterhead
.Besmnea/offen to help
Phone call
.Policy
Other
_non-phydcian health provider
jMniors
Jtoqaeste:
speech
-meeting
ADVTSORY PANTJ ^
physician
gmall business
other oonsnmers
PRIMARY TNTERF.ST:
budgets and caps
.benefits
HIPC organization
_ employer participation
_ administration, reimbursement,
& patient information systems
organization, boards,
federal and state oversight
_ unemployed/low income
_ medicare
_ insurance reform
_ quality assurance
_DOD
_ Veterans
_ malpractice & tort reform
_ federal employees
_ prep of health care workers
_ ethical foundations
_ short-term cost controls
_ public financing
_ long-term care
_ mental health
_ economic impacts
_AIDS
_ women's health
other
rural, inner city regions
nROORAPHYr
Region(NW,SE?):_
Rural, Urban, Suburban?:,
PT.AN RRRFF.RRNrR,
CP
SP
OP
OT
Endorsed Clinton Plan
Single Payer
Own Plan
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits or Vouchers
�Stale of Michigan
John Engler
Department of
Mental Health
James K. Haveman, Jr.
Director
Governor
MICHIGAN D E V E L O P M E N T A L DISABILITIES C O U N C I L
L
e
w
i
s
C
a
s
s
B u i
,
d i n g
Lansing, Ml 48913
(517) 334-6123
,
0
0
i
n
n
(517) 334-7354 TDD
o
March 23, 1993
,517) 334-7353 FAX
Mrs. Hillary Rodham Clinton
The White House
1600 Pennsylvania Avenue, N.W.
Washington, D.C. 20500
Dear Mrs. Clinton:
The Michigan Developmental Disabilities Council is a 21-member, Governor-appointed body
whose mission is to ensure that persons with disabilities receive the services necessary to achieve
independence, community integration and productivity. On the Council's behalf, I want to
express our appreciation for your work in health care reform and your willingness to examine
the many and often competing proposals offered to provide a more accessible, more inclusive
and cost saving system of health care delivery for all citizens.
We would like to draw your attention to two recent publications prepared by the Council which
highlight the health needs of persons with disabilities in Michigan and recommendations for
improving service delivery. We hope this information will be useful as you work with task force
members to devise a system that provides quality health care for all persons, including those
with multiple and often complex health care needs.
1.
A CHANCE TO CHOOSE
In 1989, the Michigan Developmental Disabilities Council completed a congressionallymandated study of the needs of persons with disabilities called the Consumer Response
Initiative. About 1,300 persons, two-thirds of whom were persons with disabilities,
testified at statewide public forums about the needs of persons with disabilities. Results
of this study were published in the 199 ) report, A Chance To Choose. Among the
participants' major concerns was the need for comprehensive health care and related
services. Enclosed is the chapter on health which highlights these critical health care
needs and recommendations for reform.
Among the issues addressed are:
•
At least 1 million people in Michigan have no form of health care coverage, public or
private. Thirty-one percent of this group are children.
•
People with disabilities have high unemployment rates. Those who do work have
marginal jobs with no fringe benefits. This is the basis for the wide spread lack of
coverage for this population.
0*
�Mrs. Hillary Rodham Clinton
March 23,1993
Page 2
•
Only 18% of the respondents to the Michigan Consumer Response Initiative survey had
private health insurance.
•
As long as insurers view a disability as a pre-existing condition with presumably high
health care costs, they are unlikely to provide adequate coverage.
•
Although advanced technology has aided in the development of many new assistive
devices, persons with disabilities are often unable to obtain them, or must do so with
their own funds at great personal sacrifice
2.
THE HEALTH CARE COVERAGE GUIDE FOR MICHIGAN FAMILIES OF
CHILDREN WITH CHRONIC ILLNESS OR DISABILITY
This publication, funded through a grant with the Michigan Developmental Disabilities
Council, provides information on the major sources of health care coverage for families
who have children with special health care needs, chronic illness or disability. It
describes in detail the fragmented health care resources currently available to individuals
with disabilities in Michigan and discusses the adverse impact on families as they
attempt to deal with these systems.
We would like to draw your attention to a number of important issues, mcluding:
•
Only 53 percent of children with functional limitations are covered by private insurance,
and less than 18 percent of children who have functional limitations and are from
families with low incomes, were covered by private insurance.
•
Of all U.S. children with functional limitations, one in ten has no insurance, public or
private. In low income families, one in five children with functional limitations is
uninsured.
•
Efforts to obtain and maintain health care coverage for a child with special needs have
a strong, direct impact on other family members' health care coverage, employment,
income and well being.
•
Access to health care coverage is directly influenced by a child's "pre-existing condition".
See pages 15-16 for a full discussion of access issues.
•
Finding adequate health care coverage is extremely difficult when a family has a child
with special health care needs. See page 16 for a full discussion of adequacy issues.
•
Children with special health care needs may not be well-suited to the cost containment
oriented, managed care systems of HMOs. Problems identified include denial of access
because the HMO determined care was not medically necessary, insufficient capacity to
serve, cumbersome authorization and control mechanisms, and reduced quality because
of insufficient and impeded access to specialty providers, among others.
�Mrs. Hillary Rodham Clinton
March 23, 1993
Page 3
We hope these resources will be helpful as you work toward a high quality, fair, accessible and
cost effective plan for health care delivery. We particularly want to emphasize that any
comprehensive system must adequately address the needs of persons with disabilities who have
ongoing and often multiple, complex health care needs and their families.
Thank you for bringing your skills and expertise to this complex issue that intimately affects all
of our lives. We appreciate your commitment and that of President Clinton.
Sincerely,
Kate Wolters, Chairperson
�To
B^»^m»m^
W t&T""'
I"
\\
::
'
Iff
People With Developmental Disabilities in Michigan
Michigan Developmental Disabilities Council
Pecember 1989
�A
Chance to Choose is a
report to Michigan's
Governor and Legislature
on the lives of people with
developmental disabilities in
Michigan in 1989. The report will go
from the Governor to the U.S.
Secretary of Health and Human Services. The Secretary will compile it
with similar reports from every U.S.
state and territory and submit the
result to Congress and the President.
The Michigan Developmental Disabilities Council developed A Chance
to Choose in response to requirements
in the reauthorization of the Developmental Disabilities Assistance and Bill of
Rights Act (P.L. 100-146). It addresses
developmental disabilities as defined
in P.L. 100-146. This definition is
broad and functional, referring to all
severe disabilities that originate early
in life and are expected to continue
throughout life. The report is based
on a complex two-year effort to
gather information, identify issues
and develop recommendations for
change. Sources of information included a review of state programs
and services, a survey of over 300
people with developmental disabilities, forums and focus groups in
six areas of the state that were attended by 1300 people (about twothirds of whom were people with
disabilities), national level data supplied by a project coordinated by the
National Association of Developmental Disabilities Councils, the Michigan
Developmental Disabilities Council's
own Family Support Action Plan, other
work of the Council, and relevant
studies done by others.
People with developmental disabilities have the right, and must be
afforded the opportunity, to participate fully in their communities
and contribute to the diversity of our
state. They should have all the rights
and responsibilities, choices and risks
that other citizens have. They also
should have whatever special supports they need to enable them to participate fully and as independently as
they choose.
A Chance
to Choose
Executive
Summary
�Vision
Health
E
verybody has access to a full
range of health care services, equipment, and supplies, when needed,
regardless of income. They can
choose from among an array of
providers. Health care providers do
not equate disability with illness and
dependence. Health care providers
are knowledgeable about the health
care needs of people with disabilities. They are responsive to
needs for ongoing and preventive
care, and they arrange provision of
related health services in ways that
do not interfere with the normal activities of life.
From the
Forums
P
eople at the CRI Forums
said that the health care system is bureaucratic, confusing, and not responsive to
their needs. They saw health care as
a means to both physical and emotional independence. People talked
about the need for open and empathetic doctors, dentists, and emergency room personnel, who are
knowledgeable about disability.
They also need more accurate diagnoses, funding for Personal Care Attendants, and more reasonably
priced equipment (such as wheelchairs, spare tires, and assistive devices). Barriers to obtaining health care
include policies and regulations,
both of the state and of insurance
companies; confusion about what a
program covers; and the attitudes of
many in the medical profession.
People talked about inadequate
Medicaid coverage and the need for
affordable health insurance. In the
Upper Peninsula, they often mentioned the lack of specialists, and
other health care problems.
�Michigan Developmental Disabilities Coundl
Health
Critical Issues
"Currently, home care for technology-dependent
children is constrained by lack of private and public
insurance coverage. Most private insurers have
limited or no coverage for such extensive care. Yet,
the cost of care at home is, overall, a fraction of the Access to Health Care
cost in a hospital setting. More importantly.
The current health care financing
Medicaid does not pay for full time home nursing or 1. system leaves many people vulother complex medical services. Also, while most
nerable to bankruptcy from illness, accident, and ongoing
technology-dependent children are eligible for
disability.
Medicaid while in hospitals, due to their being in
• At least 1 million people in
Michigan, out of a population
out-of-home placement for more than 30 days, their
of over 9 million, have no form
eligibility ends once they return home. The only
of health care coverage, public
way to become eligible for Medicaid is for their
or private (Michigan League
for Human Services [MLHS],
families to become impoverished."
— Office of Technology Assessment Report, 1987.
Quoted in the Family Support Hearings.
1988). Thirty-one percent (over
300,000) of this group are
children (MLHS, 1989).
• Although 85% of Americans
covered by health insurance
receive it as a fringe benefit of
.>x:v:-:«wX-:^o.^-----y.:--.:o:
:
Jerome
At thirty-five years old, Jerome's hearing and speech impediments and diagnosis of mild
retardation have not stopped him from being self-sufficient. This is no mean feat in the rural area
where he lives. Jerome reported that he worked as a mechanic's helper in his job before supported employment, but it ended when he was injured in a car accident. Jerome's job was to
pick up cars for a local car company, not mechanics per se. The car accident occurred as he
was transporting a car for this company. Unfortunately, his employer was paying him "under the
table" and was not willing to pick up the costs of his medical care. Jerome didn't have his own insurance and the accident left him with back problems that now prevent heavy lifting. The job
coach told us that Jerome still does not understand that the company does not accept liability
for his disability just because they were paying him. Jerome had instigated court proceedings at
the time we visited him.
:
::
;;;:; :
:
:
••<:-:;:::;-:o:::::^:v:":-::-:-:->:
Page 136
1990: A Chance to Choose
�Health
Michigan Developmental Disabilities Coundl
Figure 24
Health Care Coverage and Lack ofHeatlh Care Coverage of Michigan Residents
Receive coverage
- a s a fringe benefit
of employment
Michigan residents
without coverage
65.0%
Working adults &
their families
ililiiiiiiiiiP
I n c r e a s e I n M e d i c a l C a r e C o s t s In U . S .
1980-87
C o s t of M e d i c a l C a r e
C o s t of A l l
Goods &
Services
IlllfiiiiPliiil:;;
20%
30%
40%
Hil
50%
60%
Percentage Increase
70%
80%
.
90%
S O U R C E : Health Cara Flnanoa Review. Summer 19SO.
Figure 25
1990: A Chance lo Choose
Page 137
�Michigan Developmental Disabilities Council
Health
employment, 65% of the total
uninsured population are working adults and their families
(Michigan Department of
Public Health [MDPH1,1986).
• Between 1980 and 1987, while
the cost of all goods and services rose by 38%, medical care
rose by 76% (Lublitz & Pine,
1988).
Nationwide, Medicaid paid for
health care for less than 40% of
the poor in 1984. (The federal
poverty income guideline, issued in February 1989, is
$12,100 for a family of 4.)
(MDPH,1986.)
Sixty-one percent of Americans
surveyed stated that they
would favor a system like that
in Canada where "the government pays most of the cost of
health care for everyone out of
taxes, and the government sets
all fees charged by hospitals
and doctors." (Harris Poll,
1988.)
2. People with disabilities have high
unemployment rates. Those who
do work often have marginal jobs
with no fringe benefits. This is the
basis for the widespread lack of
coverage for this population. (See
also the "Jobs" Critical Issue
Paper.)
• Only 19% of the people with
developmental disabilities who
responded to Michigan's Consumer Survey (WSU, unpublished) reported working
full time for an employer,
workshop, or self; while 26% of
respondents reported working
part time.
• The U.S. Census Bureau reports
that the share of men with disabilities who work full time
dropped from 29.8% in 1981 to
23.4% in 1988. Women with disabilities gained more full time
work in the same period (from
11.4% to 13.1% working full
time). However, the proportion
of women working full time
C o m p a r i s o n of Michigan a n d U . S . U n i n s u r e d R a t e , 1987
Percent Uninsured
All Persons
All Under 65 years
AGE
Under 19 vears
20 to 24 years
25 to 44 years
45 to 64 years
Over 65 years
SEX
Male
Female
RACE
White
Black
Other
Michiqan
10.3 %
11.4
United States
13.3 %
15.0
11.2
27.5
9.5
7.7
0.6
14.6 (under 18)
24.7 (18 to 24)
14.8
10.0
0.7
10.8
9.7
14.3
12.4
9.3
15.0
13.3
12.4
19.6
15.5
S O U R C E : Tha U n i n s u r e d P r o b l e m In M i c h i g a n : Size a n d Characteriatics o f the
P o p u l a t i o n w i t h o u t Public o r Private Health Care Coverage. M i c h i g a n L e a g u e for H u m a n S e r v i c e s . M a r c h 1989.
Table 5
Page 138
1990: A Chance to Choose
�Health
Michigan Developmental Disabilities Council
remains significantly lower
than of men. (Schmid, 1989.)
3. Section 1619(b) of the Social
Security Act allows people with
disabilities to "take a risk" with
employment opportunities that
do not provide medical coverage.
Use of this provision has increased steadily in the past few
years, espedally since it became
permanent. Usage should continue to increase, because 1619(b)
provides an important risk protection for people with disabilities
who want to work.
• Section 1619(b) of the Social
Security Act allows people to
maintain their Medicaid
benefits while employed.
Coverage by this Act increased
from 303 people in Michigan in
January 1986 to 704 in June
1988. (Office of Supplemental
Security Income, 1988.)
4. Access to private insurance
depends largely on the size of the
group with whom one shares the
risk, not on one's medical condition.
• Seventy-five percent of all
employers have fewer than 10
employees (ICF Incorporated,
1987). It is unrealistic to expect
small businesses to solve the
health insurance problem (especially for people with disabilities) without help.
However, this help is most likely to be provided if all
employers are required to provide coverage e.g.. Senator
Kennedy's (D-MA), Basic
Health Benefits for AU Americans
A:tofl989 (S.768).
5. As long as insurers view a disability as a pre-existing condition
with presumably higher health
care costs, they are unlikely to
provide adequate coverage.
• Most private insurance companies either refuse to insure,
or limit coverage to those with
pre-existing conditions
(Michigan Developmental Dis-
1990: A Chance to Choose
abilities Council [MDDC],
1988).
• Blue Cross/Blue Shield is the
only insurer in Michigan mandated by state law to offer the
opportunity to purchase
coverage to everyone regardless of pre-existing medical conditions. (MCLA 550.1101, the
"Non-Profit Health Care Corporation Reform Act"). However, cost may be so high and
coverage so inadequate as to
render it useless for people
with disabilities.
• Only 18% of the respondents to
the Michigan Consumer Survey (WSU, unpublished) had
private health insurance. Most
of the 18% were from urban
communities and in the 18 to
25 year age range. Satisfaction
with private health insurance
was comparatively low, at only
59% overall. People with physical disabilities, in particular, indicated dissatisfaction with
private health insurance coverage. The satisfaction rate
among members of this group
was only 29%. Reasons cited
for dissatisfaction included
"not receiving enough," "too
expensive," and "not suited to
need."
• The Family Support Action Plan
(MDDC, 1988) suggests that factors such as pre-existing conditions, and lifetime coverage
caps may often result in a family member having to change
jobs based on the need for insurance coverage.
6. No matter how progressive a state
has become in regulating private
insurers to broaden the scope of
coverage for people with disabilities, they cannot be fully
effective as long as the federal
Employee Retirement and Income
Security Act (ERISA) preemptions continue to exist.
• Although insurance is supposedly regulated at the state
level, only two states (Hawaii
"Our insurance
refused to pay
some of the bills
until we
threatened to go
to the
newspapers."
—Family at the
Grand Rapids
Family Support
Hearing.
Page 139
�Michigan Developmental Disabilities Council
Health
The High Cost of Health Care
iii
1
m
I
ii
II
The following examples of monthly premiums lor various insurers were compiled to underline
the problem of health care availability for people who do not have coverage through employment. Most of these rates are based on a comprehensive policy for a sample family with 35 year
old parents, and with 8 and 11 year old children living in the suburban Detroit area. It should be
noted that deductibles, co-pays, waiting periods, and coverages will vary from policy to policy.
1
1
HMOs
Physicians Health Plan
Blue Care Network of SE Michigan . . :
Blue Care
Commercial Insurers
American Community
Mutual of Omaha
Time Insurance Company
Blue Cross/Blue Shield
1
m
m
$256
$285
$262
$340
isis
si?
Iii
M
These rates apply to a "typical family." Families with a member who has a disability often
face additional problems, including:
1.
Reluctance to insure people with pre-existing conditions;
2.
Limited coverage for home care and for various assistive devices; and
3.
Lifetime maximums (typically $ 1 million) which can be reached very quickly by families
li
with members who have high health care needs.
1
1
iii
$326
$331
$318
i
(Information received from the Office of Market Standards. Michigan Department of Licensing and Regulation. Insurance Bureau. 1989.)
and Massachusetts) have
passed laws requiring
employers to provide health insurance. In addition, self-insurers are exempt from state
regulation because of the
Federal Employee Retirement
and Income Security Act,
which does not contain federal
standards for health insurance.
(National Assodation of
Developmental Disabilities
Coundls [NADDC], 1989.)
Page 140
Availability and
Eligibility
7. The two year waiting period for
Medicare was originally set up
for cost containment purposes
and to avoid creating a disincentive for private insurers to cover
health care for a worker with a
recently acquired disability. However, the waiting period can interfere with early medical treatment
that may be essential for people
to improve.
1990: A Chance to Choose
�Health
Michigan Developmental Disabilities Coundl
• People who qualify for
Medicare because of disability
must wait 24 months after the
onset of their disability. During
this waiting period, as many as
one-third of Social Security Disability Insurance (SSDI)
beneficiaries are uninsured at
some point (World Institute On
Disability [WID], 1988.)
• Many SSDI beneficiaries die
before becoming eligible for
Medicare (Lublitz & Pine, 1988).
8. Medicare's acute nature and its
"medically necessary" approach
has created major gaps in
Medicare coverage for people
with disabilities. Personal assistance with self-care and
household chores are not
covered. Coverage for durable
medical equipment is limited.
• Medicare benefits often do not
cover preventive or wellness
care, or ongoing maintenance
services, because Medicaid is
patterned on the acute care
orientation of private health insurance (WID, 1988 -1989).
9. Many people with disabilities need
occupational therapy, physical
therapy, medical equipment and
supplies, and home health care in
order to live independently in the
community. The institutional
funding bias (paying for services
while in a hospital, nursing
home, etc., but not in a person's
own home) of health coverage
plans is a serious concern for this
population.
• Services such as physical, occupational, and speech
therapy, medical equipment
and supplies, and home health
care are the least likely to be
fully covered by public and
private funding. They also require higher copayment than
other services and are subject
to more limitations. (Vanderbilt
N u m b e r of Participants
900
800
—
700
—
600
500
r
400
300
200
100
*
(100)
4f
s
s
s
s
Date
1618(a)
1619(b)
—
-
Figure 26
Number of Participants SSI 1619 (a) & (b): 1982-September 1988
1990: A Chance to Choose
Page 141
�Michigan Developmental Disabilities Council
Health
Health Care Needs of People with Disabilities
I
iii;
m
I
II
Many people with developmental disabilities are in good health and have health care
needs very similar to those of the nondisabled population. However, the presence of a disability
may affect their health care needs in various ways. Some people with chronic conditions have
predictable needs and higher levels of health care utilization for both acute care and non-acute
care services. Non-acute care services include physical therapy, occupational therapy, or lanm guage therapy, to improve or maintain functioning. They also include ongoing maintenance services such as medical equipment, assistive devices, drugs, and personal care assistance.
"Preventive services are needed for edrly detection and treatment to avoid unnecessary comi i plications and secondary disabilities.
m
iiii
is?
i
i
;>v::o::::::N::;:::>::::o>:<:i:x:>;:^:::^^'-'
"There is a lack of therapy; the
shortage of physical therapists
causes extreme stress by making
the parent the main provider of
these services. I do not have the
expertise and cannot provide the
quality of therapy they can
Quality respite care providers are
few, due to too low pay
Medicaid Waiver II, Family
Support, Permancy Planning are
all good ideas—but without
adequate funding, not much help.
Being put on a waiting list because
your needs are deemed 'not high
priority' is very frustrating. Will
life pass her by while she waits to
become 'a priority?'"
— Jane Heinz, parent, at the
Lansing CRI Forum.
Page 142
Institute for Public Policy
Studies [VIPPS], 1983.)
The Michigan Consumer Survey (WSU, unpublished) found
that fewer respondents
received health-related services, such as medical equipment and supplies, and
physical, occupational, and
speech therapies than received
general medical care, medication, and dental care. The satisfaction rates for medical
equipment and supplies were
low, especially among people
with physical disabilities and
those in the middle age range.
Reasons for dissatisfaction included: "not receiving
enough," "poor quality," 'lack
of respect for personal dignity," "too expensive," and
"not appropriate to need."
The Michigan Consumer Survey also found that the highest
levels of need were for adaptive equipment/ assistive
devices, speech therapy, and
medical equipment and supplies. Need for these services
1990: A Chance to Choose
�Health
Michigan Developmental Disabilities Council
Optional Services offered by Medicaid in Michigan
Podiotric Services
Chiropractic Services
Vision Services for Age 21 and
Older
Dental Services for Age 21 and
Older
Hearing and Speech Services for
Age 21 and Older
Physical and Occupational
Therapy and Speech Pathology in
Settings Other than Skilled Nursing
Homes
1.
2.
3.
4.
.5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Durable Medical Equipment and
Oxygen
Pharmacy Services for Age 21 and
Older
Orthoses and Prostheses
Intermediate Nursing Home Care
Substance Abuse Services.
Institutional Mental Health Services for
under Age 21 and Over Age 65
Diabetes Outpatient Education
Hospice Services
(From: Response to the Michigan Developmental Disabilities Council on Budget Issues, by
the Michigan Department of Social Services, March, 1989.)
;f
|
U
;|
3
5
?
•a
^
:
:£::>*:o: :::*^
appeared to be greater for rural
respondents and for people
with physical disabilities. The
major reasons cited for not
receiving needed services included "service is not appropnate to needs," "service is
not available in the area," "service is too expensive," and "not
eligible by type or degree of
disability."
10. Much new technology is available
in assistive devices. However, access problems (primarily funding)
mean that people with disabilities
are often unable to obtain them,
or must do so with their own
funds—if possible—at great personal sacrifice.
• Most funding for assistive
devices is tied to specific purposes or activities (i.e., education or rehabilitation), and is
1990: A Chance to Choose
subject to age, type of disability, or other eligibility requirements. Some also may be
so expensive as to be out of
reach for all but a few families
or organizations. (PAM
REPEATER, Sept 1987).
11. People with disabilities who are
eligible for Medicaid, their
families, and advocates are often
unaware of the optional services
available under Medicaid that
can be used to obtain supports
for independent, integrated lives.
• Michigan provides, with very
few exceptions, the entire
range of optional medical services allowed under Title XIX
(Medicaid). Eligibility and the
amount of funds available for
each service vary. (See Sidebar,
"Optional Services Offered by
Medicaid in Michigan.")
Page 143
�Michigan Developmental Disabilities Council
Health
Medicaid Waivers in
Michigan
"We were told that
our daughter
would have to stay
in the hospital for
over two hundred
more days before it
would be 'cost
effective' for her to
go home.
— Parents of a
child w i t h
developmental
disabilities, at the
Family Support
Hearings.
Page 144
12. Michigan has obtained several
waivers from federal restrictions
on Medicaid coverage. The
waivers are intended to allow
coverage for community-based
services that are not included in
the regular Medicaid program.
The state is required to show that
use of the waivers will result in
less federal cost than hospital or
institutional services. Waivers are
not available to families who
have insurance that covers hospital but not in-home care. It is not
always possible to show immediate short term cost savings. The
waiver requirement of "otherwise
needing Intermediate Care
Facility/Mental Retardation
(ICF/MR) care" is a problem because of Michigan's progressive
policy of not approving admission for children into state institutions or nursing homes.
13. Michigan families with members
who have high health care needs
report eligibility criteria that create barriers to fuller use of the
Model Home and CommunityBased Services Waivers. Despite
the barriers, waivers are an important interim financing option for
home-based care. (MDDC, 1988.)
14. Many of the supports that
children with disabilities need in
order to obtain an education are
based on health care. The Individual Education Plan (IEP)
process and the Individual Family Support Plan (IFSP) process in
Part H of the federal Education
for Handicapped Children Act of
1975 (EHA) can help assure that
these services will be provided to
children at no cost to the family.
It is essential that education staff
be fully aware of available funding options for these supports.
• The EHA is the strongest legal
mandate for health care for
people with disabilities. The Act
guarantees a free, appropriate
public education for all children
with handicaps aged 3 to 21.
The Act also requires that the
services and supports, including
health care, needed to obtain
this education must be provided
at no cost to the family. Part H
of the EHA extends this program to infants and toddlers.
(P.L. 94-142 and P.L. 99-457,
Part H, 1975.)
Quality Health Care
15. Increases in coverage for health
care are vitally important, without
recognition by health care professionals of the value of people with
disabilities, these gains will be
limited. Professionals must recognize that people with even the
most severe disabilities, can, with
proper supports, become contributing members of their communities.
16. Because developmental disabilities
are lifelong conditions that cannot
be "cured," it is important that
health care services are provided
in ways that do not interfere with
normal life activities. Many of
these services empower people to
manage their disabilities so that
they can live as independently as
possible in their own homes, function productively on their jobs,
and participate as active members
of their communities.
• Most of the health care system
uses an acute care model (often
called a "medical model"). The
model assumes that the
recipient will maintain a "sick"
role of passive conformity to the
requirements of the health care
provider. This assumption contributes to conflicts and
misunderstandings when
people with disabilities assert
their dignity and independence.
1990: A Chance to Choose
�Health
Michigan Developmental Disabilities Council
A survey conducted by the
Michigan Developmental Disabilities Council's Regional Interagency Coordinating
Committees (Regional Interagency Coordinating Committees, ancedotal data), and
testimony at the Consumer
Response Initiative Forums
show that the negative attitudes of many providers
toward people with disabilities, especially those with
severe disabilities, are a serious
barrier to achieving quality
health care.
Prenatal Care and Early
Intervention
17. The infant mortality rate is one indicator of the general health care
adequacy of an area. Michigan
has improved from 20.9 to 10.9
deaths per 1,000 since 1970. However, the rate of infant mortality
in Michigan is still above the national average. (MDPH, 1989.)
• The infant mortality rate for
Michigan for 1987 was 1,538 or
10.9 per 1,000. The national rate
is 10.0 per 1,000. (MDPH, 1989).
18. Early and adequate prenatal care
for pregnant women can increase
babies' birth weights and reduce
risks that may contribute to death
or disability. Therefore, improved
prenatal health care, preventive
programs, and early intervention
programs will improve birth
weights and provide for early
treatment of identifiable condi-
1990; A Chance to Choose
tions to prevent or reduce secondary illness or disability.
• The proportion of mothers
receiving only late or no prenatal care fell in the late 1970s
from 8% to 5%. This proportion
then rose slightly. However, as
of 1987, it had failed to
decrease from 6% for the fourth
consecutive year. The percentages of white and black
mothers receiving late or no
prenatal care were unchanged
at 5% and 11%, respectively.
Regardless of race, more than
20% of mothers younger than
15 received late or no prenatal
care. Thirteen percent of all
mothers younger than age 20
received late or no care. "Most
recent numbers reveal another
gloomy picture of prenatal
care, birth-weight, and teen
births." (CDF Reports, 1989.)
"Another problem my brother and I have is with
doctors... They almost always only talk to mom
and dad ... I can say for myself how I feel...
Thank you for giving us the chance to tell you how
we feel."
— Robert Kowalzyk, at the Saginaw/Bay
City/Midland C R I Forum.
Page 145
�Michigan Developmental Disabilities Council
Health
RECOMMENDATIONS
Access to health care
1. The Michigan Coalition for Access
to Health Care, serving as the
liaison between the Governor's
Task Force on Access to Health
Care and people with disabilities
and chronic illness, should work
with advocacy groups, consumers, health care providers,
and others to promote changes in
national and state priorities.
• There should be one system of
health care financing that addresses the needs of all. Health
care for people with disabilities
and their families should be addressed in the broader context
of equitable health care for
everyone. Health care financing should address need rather
than income level, age, or
ability to work (as with
Medicaid and other public
programs). People with disabilities should not have to pay
a greater percentage than
others of their often already
inadequate income for this
coverage.
• Health care coverage must be
provided for the "working
poor" in marginal jobs with no
fringe benefits.
• Congress should pass Medicaid
reform, with significant changes in Medicaid reimbursement
policies to provide an array of
community-based health care
services, and eliminate the "institutional bias" of current
medical policy.
• The payment system should
reinforce and promote prevention by favoring primary and
preventive care for all people.
Page 146
• The federal government should
use its leverage to require
group insurance policies to
meet certain minimal standards
in order to qualify for a tax subsidy. Policies must look beyond
budgetary implications to individual health care needs and
assuring choices of providers.
Standards should be established for all health insurance
plans that take into account the
range of individual health care
needs.
• Medical and health insurance
benefits must continue when a
person begins to work.
• Adequate coverage for medical
care, including psychiatric services, should be assured.
2. The Social Security Administration
(SSA) should increase public
awareness of the 1619(b)
Medicaid continuation provision
in the Social Security Act. SSA
should undertake active outreach
to people with disabilities and
train its own staff about the
availability and application of
this work incentive. SSA also
should participate, with the
Michigan Interagency Task Force
on Disability (MITF/D) and advocacy organizations in statewide
work incentive training, to increase the use of work provisions
and promote understanding of
the needs of people with developmental disabilities. (See also the
"Income" Critical Isssue Paper.)
3. Congress should enact legislation
prohibiting insurers from excluding, terminating, or otherwise
limiting coverage to any individual based on a pre-existing
condition. It also should prohibit
"experience rating" to avoid ex-
1990: A Chance to Choose
�Health
Michigan Developmental Disabilities Council
cessively high premiums. HR
2649, the Federal Health Insurance Equity Act of 1989,
would accomplish this.
4. Congress should amend the federal
Employee Retirement and Income
Security Act (ERISA) to allow the
state regulation of self-insured
employers in regard to health insurance plans. The State of
Michigan should take a stronger
role in regulating private insurers
to broaden the scope of coverage
for people with disabilities.
5. Congress should pass comprehen. sive Medicaid reform legislation
(the Chafee Amendments) to
allow flexible funding for the support people with disabilities need
to live independent, integrated,
productive lives in the community.
Services Availability and
Expanded Eligibility
6. Congress should enact the following changes in the Medicare Program:
• Eliminate the two year waiting
period for Medicare;
• Remove, in all new Medicare
legislation initiatives in Congress, the distinctions between
acute and chronic care needs,
and the arbitrary exclusions for
various assistive devices and
environmental controls essential to improved functioning
for people with disabilities; and
• Develop a long term home care
benefit, as proposed by the late
Representative Claude Pepper
(D-FL), that will benefit
families with children with disabilities.
7. The Michigan Department of Social
Services (DSS) should encourage
expanded use of Medicaid optional services that provide community-based care and supports
for people with disabilities, in-
1990: A Chance to Choose
cluding occupational therapy,
physical therapy, orthosis, and
prosthesis.
• DSS should explore ways of
getting coverage for additional
services. These should include,
but not be limited to, massage
therapy, chiropractic services,
acupuncture, acupressure, expanded dental coverage, and
expanded home health care.
They also should include more
types of innovative technology
(such as cochlear implants) that
have proven successful in increasing independence for
people with disabilities.
8. The Department of Social Services,
Medical Services Administration,
should review the Medicaid payment and reimbursement system
and:
• Streamline the reimbursement
system for physicians;
• Shorten the time needed for
Medicaid prior authorizations;
and
• Assure that Medicaid reimbursements are sufficient to
remove disincentives for service to people with disabilities.
9. The Human Services Cabinet Cound l should explore, the Legislature
should fund, and the Departments of Sodal Services, Public
Health, and Mental Health
should implement methods of financing home care for people
with high health care needs. This
should include family-centered
home care for children with
severe disabilities or chronic
medical conditions. This effort
should:
• Work to assure continuity of
care, regardless of the source of
reimbursement;
• Develop simplified means of
qualifying for the Medicaid
waiver programs;
• Address the gaps between
private insurance coverage and
eligibility for publicly-funded
health programs; and
Page 147
�Health
Michigan Developmental Disabilities Council
• Improve responsiveness to the
needs of families who are
providing care, and to adults
who need home care assistance.
10. The Michigan Department of
Education (DOE) should assure
inclusion in the Individual Education Plan (IEP) and Individualized Family Support Plan (IFSP)
process of all health-related needs
that must be met for the student
with disabilities to benefit from
other Special Education Services.
This will require that Special
Education Services staff are
knowledgeable about the variety
of alternative public and private
funding sources. DOE must document the needs, and estimate the
costs and long range effectiveness
of providing these health-related
services. It must then coordinate
with advocates and others to
document this need for congressional action.
Quality Health Care
11. The Michigan Department of
Public Health, with handicapper
groups and the Developmental
Disabilities Institute at Wayne
State University, should develop
a plan to increase medical and
health service providers' understanding of the health care and
empowerment needs of handicappers. School curriculum for all
programs leading to careers in
the health care field should in-
Page 148
clude training on this issue. This
training must emphasize that
people with disabilities are valuable, contributing members of
society.
12. Advocacy organizations and local
service providers should develop
outreach plans so that people
with disabilities who need health
care and community services
know where to obtain them. The
information provided should include:
• Service delivery agencies;
• Potential funding sources;
• Client services management to
get through the system;
• Outreach by service providing
agencies; and
• Linkages to support groups for
various disabilities.
Prenatal Care &
Reduction of Infant
Mortality
13. The Governor and the Legislature
should expand active implementation of the Department of
Public Health's Infant Mortality
Prevention program.
1990: A Chance to Choose
�Michigan Developmental Disabilities Council
Health
Reference List: Health
Griss, B. (1988 -1989). Access to Health Care, 1(3-4). World Institute On Disability.
ICF Incorporated. (1987, April). Health care coverage and costs in small and large business. Washington, DC.
Lublitz, J. & Pine, P. (1988). Health care use by Medicare's disabled enrollees. Health Care Finance Review, 7(4).
Michigan Department of Public Health. (1986). Report on access to health care. (Availalbe from Michigan Depatment
of Public Health, 500 N. Logan, P.O. Box 30035., Lansing, MI: 48909.)
Michigan Developmental Disabilities Council. (1988, April). Family support action plan. (Report submitted to the
Human Services Cabinet Council, James J. Blanchard, Governor.) (Available from the Michigan Developmental Disabilities Coundl, Lewis Cass Building, 6th Floor, Lansing, MI 48913.)
Michigan League for Human Services. (1989, March). Children's needs in Michigan. (Available from Michigan
League for Human Services, 300 N. Washington Square, Lansing, MI.)
Michigan League for Human Services. (1988, January). The uninsured population in Michigan. (Available from
Michigan League for Human Services, 300 N. Washington Square, Lansing, MI.)
Most recent numbers reveal another gloomy picture of prenatal care, birth-vvcight, teen births, CDF Reports, 11(2),
4-5.
National Association of Developmental Disabilities Coundls. (1989). NAADC sourcebook for Developmental Disabilities Councils' 1990 report. (Available from the National Assodation of Developmental Disabilities Councils, 1234 Massachusetts Avenue, N.W., Suite 203, Washington, DC 20005.)
Office of Supplemental Security Income, Division of Program Management and Analysis. (1988, December). Section 1619 quarterly statistical report.
PAM Assistance Centre. (1987, September). Assistive devices: Funding resources in Michigan. PAM Repeater.
Regional Interagency Coordinating Committees. (1987, December). (Anecdotal data obtained in response to a request from the Michigan Department of Mental Health.)
Schmid, R. E. Disabled people less likely to be employed than in '81. Deroif Free Press, August 16,1989.
Vanderbilt Institute for Public Policy Studies. (1983, April). A preliminary report of the project "Public Policies Affecting Chronically 1 1 Children and Their Families — Chronically III Children in America: Background and Recom1
mendations." Nashville, TN: Vanderbilt Institute for Public Policy Studies, Center for the Study of Families
and Children.
World Institute On Disability. (1988). Access to Health Care, 1(1-2).
1990: A Chance to Choose
Page 149
�ft"*
Department of Health Professions
Bernard L. Henderson, Jr.
6606 West Broad Street, Fourth Floor
Richmond, Virginia 23230-1717
D l r e c u > r
March
4,
1993
(804)662-9900
FAX (804)662-9943
TDD (804) 662-7197
The Honorable H i l l a r y Rodham Clinton, Chair
President's Task Force on Health Care Reform
The White House
Washington, D.C. 20510
Dear Ms. Clinton:
Dr. Clementine Pollok wrote you on February 22 and sent our study of
access and b a r r i e r s to the services of nurse p r a c t i t i o n e r s . At her
suggestion, I enclose a copy of two additional reports. The f i r s t
addresses the use of nurse midwives, and the second r e s u l t s from our
review of the effects of managed care on health care cost, access
and quality.
Our structure for the regulation of health occupations
and
professions i n V i r g i n i a i s unique. Twelve regulatory boards are
administered by a single agency. These boards l i c e n s e or c e r t i f y
more than 200,000 providers who practice i n more than 50 regulated
professions.
In addition, the Board of Health
Professions,
appointed by the Governor, advises the Executive and L e g i s l a t i v e
branches on a l l issues involving the system for health professional
regulation.
Labor costs consume more than one-half the national health care
budget. As executive director of the Board of Health Professions,
and as a member of the board of directors of the national Council on
Licensure, Enforcement and Regulation (CLEAR), I am concerned that
the system for professional regulation i n the United States fosters
and maintains labor market i n e f f i c i e n c i e s that are inconsistent with
national reform i n i t i a t i v e s .
In my personal view, unless health
care reform confronts these i n e f f i c i e n c i e s , we as a nation w i l l be
writing a blank check for business as usual.
I t i s my hope that your Task Force w i l l examine health professional
licensure issues and seek solutions to the problems licensure
presents. We i n V i r g i n i a are proud of our modest e f f o r t s and we
have many suggestions for reform your Task Force may wish to
consider.
Board ol Audiology & Speech-Language Pathology • Board ol Dentistry - Board ol Funeral Directors & Embalmers - Board ol Medicine - Board ol Nursing
Board ol Nursing Home Administrators • Board ol Optometry - Board ol Pharmacy • Board ol Prolessional Counselors
Board ol Psychology • Board of Social Work • Board ol Veterinary Medicine
Board of Health Professions
�The Honorable H i l l a r y Rodham Clinton
March 4, 1993
Page two
I join Dr. Pollok in her wishing your Task Force success and in
expressing appreciation to you and President Clinton for your
courage i n t a c k l i n g the complex issues of health care reform.
You have only to c a l l upon us for any assistance we may
provide.
Sincerely,
son, Ph.D.
RicharB D. Morris
Executive Director
Board of Health Professions
xc:
Clementine S. Pollok, RN,
Ph.D.
�
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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White House Health Care Task Force
Health Care Task Force
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administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1983
FolderlD:
Folder Title:
[Letters from Government Officials and Employees] [loose] [4]
Stack:
Row:
Section:
Shelf:
Position:
s
56
2
3
2
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001a. letter
Zell Miller to Thomas Palmer [partial] (1 page)
2/26/1993
P6/b(6)
001b. letter
Thomas Palmer to Hillary Clinton [partial] (I page)
2/12/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [4]
2006-0885-F
wr827
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA)
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�HoufiE of <SEprESEntattueB
STATE OF OKLAHOMA
February 8,
1993
The Office of the F i r s t Lady
Mrs. H i l l a r y Rodman Clinton
1600 Pennsylvania Ave.,
N.W.
Washington, D.C.
20500
Dear F i r s t Lady:
Please l e t me extend my congratulations to you and President
Clinton. Your commitment to the people of t h i s country and your
willingness to serve are confirmed by the work that you do.
I
have no doubt that the future of our nation and the world w i l l be
positively impacted by the Clinton administration.
May I also commend you for your efforts in the areas of health care
and children's issues.
For more than 10 years, I have worked
toward health care reform in Oklahoma and throughout the country.
I t i s extremely invigorating to have a President and F i r s t Lady who
are so keenly involved in this issue.
As you may be aware, Oklahoma Governor David Walters, who also
serves as President of the National Governor's Association, has
become very involved in health care reform in Oklahoma as well as
on a national l e v e l .
Because of his interest and leadership,
Oklahoma i s one of 12 states to receive a P»ebart Wood Johnson
Foundation Grant addressing new
i n i t i a t i v e s in health care
financing.
During the past several years, I have had the opportunity to work
with and learn from many individuals involved in reforming our
nation's health care system. My participation on the Board of
Directors of the State Alliance for Universal Health Care, an
organization of State l e g i s l a t o r s from across the country committed
to health care reform, has also afforded the opportunity to
participate in and help shape the health care agenda throughout the
nation. Additionally, a recent appointment to the E d i t o r i a l Board
for Primary Care News, a publication of the Primary Care Resource
Center of
George Washington University, w i l l
also a v a i l
opportunities for my continued involvement in the health care
reform debate in this country.
�The Office of the F i r s t Lady
H i l l a r y Rodman Clinton
Page 2
I say a l l of t h i s simply to demonstrate the involvement of
Oklahoman's in national health care reform as well as our
commitment to positive change in Oklahoma. However, you can boost
our efforts even more so by accepting an invitation to come to
Oklahoma to speak on health care reform and/or any other subject
you desire.
The Oklahoma Legislative Black Caucus sponsors a biennial A. C.
Hamlin Awards Banquet, named for the f i r s t African-American to
serve in the Oklahoma Legislature. Our most recent speaker was
Virginia Governor Douglas Wilder. This event i s one of the most
well attended political/community a c t i v i t i e s in Oklahoma, and your
participation as the 1993 Guest Speaker would certainly continue
the legacy of outstanding speakers.
No s p e c i f i c date has been set for the A. C. Hamlin Awards Dinner at
this time. We are very f l e x i b l e and w i l l accommodate any available
date you have between mid-April and mid-May.
For your information. Professor Anita H i l l w i l l be presented the
National Builders Award from the National Black Caucus of State
Legislators during this year's banquet. I t would be a great honor
to have both you and Anita H i l l j o i n us during t h i s event.
We look forward to your response and i t i s our sincere hope that
you can be with us. Feel free to contact my office at (405) 5577393 for any additional information. Of course, we w i l l a s s i s t
your s t a f f i n making any arrangements you deem necessary. For your
convenience, the fax number at the State Capitol i s (405) 557-7351.
Again, we hope you w i l l accept this invitation. Your participation
w i l l certainly make this a most memorable as well as motivating
banquet. Thank you f c r your time and consideration of our request.
Sincerely,
0lUk*—^
Angela Z. Monson, Chair
Oklahoma Legislative Black Caucus
Oklahoma State Legislature
AZM:ch
cc:
Members, Oklahoma Legislative Black Caucus
David Walters, Governor, State of Oklahoma
�iputt Common €muci(
CITY OF HARTFORD
550
MAIN
STREET
HARTFORD. CONNECTICUT
Carrie Saxon Perry, Mayor
Henrietta Milward, Deputy Mayor
Yolanda Castillo, Majority Leader
Eugenio Caro, Sr., Councilman
Fernando Comulada, Councilman
Anthony DiPentima, Councilman
Nicholas Fusco. Councilman
Elizabeth Horton Shell, Councilwoman
Sandra E. Little, Councilwoman
Louise B. Simmons, Councilwoman
06103
Clerk
Daniel M. Carey
March 22, 1993
This i s t o c e r t i f y t h a t a t a meeting o f t h e Court of Common Council,
March 22, 1993, t h e f o l l o w i n g RESOLUTION was passed.
WHEREAS, F i r s t Lady H i l l a r y C l i n t o n i s undertaking t h e mission o f
c h a i r i n g a Task Force t o develop proposals f o r healthcare reform i n the
United States; and
WHEREAS, Healthcare reform i s a t o p i c of p a r t i c u l a r concern and
urgency i n urban areas; and
WHEREAS, W i t h i n the C i t y o f H a r t f o r d , there are pressing healthcare
needs f o r t h e medically underserved, r i s i n g costs among those on p u b l i c
assistance who receive healthcare, and many f a m i l i e s and i n d i v i d u a l s who
have no insurance o r who are underinsured; and
WHEREAS, Many i n d i v i d u a l s are forced t o choose between employment
w i t h no h e a l t h b e n e f i t s or remaining on p u b l i c assistance i n order t o
receive healthcare coverage; and
WHEREAS, Among the C i t y of Hartford's own budgetary pressures,
r i s i n g healthcare costs f o r C i t y and Board of Education employees are one
of t h e major f a c t o r s c o n t r i b u t i n g t o f i n a n c i a l d i s t r e s s f o r t h e C i t y ,
i n c l u d i n g t h e p o s s i b i l i t y o f the C i t y having t o l a y o f f employees i n order
t o keep up w i t h these r i s i n g costs; now, t h e r e f o r e , be i t
RESOLVED, That the Hartford Court of Common Council commend H i l l a r y
Rodham C l i n t o n f o r her involvement i n t h i s important issue; and be i t
further
RESOLVED, That the Court of Common Council urge the F i r s t Lady's
Task Force t o consider the needs and perspectives o f urban areas
exemplified above i n devising p o l i c i e s t o address healthcare reform; and
be i t f u r t h e r
�- 2 RESOLVED, That t h e Court o f Common C o u n c i l f o r w a r d t o t h e F i r s t
Lady's Task Force a copy o f t h e H e a l t h c a r e R e s o l u t i o n passed by t h e
H a r t f o r d Court o f Common C o u n c i l on January 27, 1992; and be i t f u r t h e r
RESOLVED, That t h e H a r t f o r d Court o f Common C o u n c i l urges t h e F i r s t
Lady's Task Force t o a c t as e x p e d i t i o u s l y as p o s s i b l e t o complete t h e i r
work and f o r w a r d t h e i r recommendations t o Congress so t h a t h e a l t h c a r e
r e f o r m can be d i s c u s s e d , v o t e d upon, and soon become a r e a l i t y i n o u r
Country.
Attest:
D a n i e l M. Carey,
City Clerk.
Copies t o : C i t y Manager, D i r e c t o r o f H e a l t h , F i r s t Lady H i l l a r y
Clinton
�(putt
common Council
CITY OF HARTFORD
550
HARTFORD.
Carrie Saxon Perry, Mayor
Eugenio Caro, Sr., Councilman
Yolanda Castillo. Councilwoman
Fernando Comulada, Councilman
Anlhony DiPentima, Councilman
Nicholas Fusco, Councilman
Elizabeth Horton Shell, Councilwoman
Sandra E. Utile, Councilwoman
Henrietta Milward, Councilwoman
Louise B. Simmons, Councilwoman
MAIN
STRECT
CONNECTICUT
0 6 1 0 3
Clerk
Sebaslian A. Sanliglia
January 27, 1992
T h i s i s t o c e r t i f y t h a t a t a meeting o f t h e Court o f Common C o u n c i l ,
January 27, 1992, t h e f o l l o w i n g SUBSTITUTE TO THE SUBSTITUTE RESOLUTION
was passed.
WHEREAS, H e a l t h care c o s t s a r e r i s i n g a t t w i c e t h e r a t e o f
i n f l a t i o n , and t h e U n i t e d S t a t e s now spends 25% - 60% more p e r c a p i t a on
h e a l t h care t h a n any o t h e r i n d u s t r i a l i z e d n a t i o n ; and
WHEREAS, D e s p i t e t h i s e x o r b i t a n t spending, 37 m i l l i o n Americans l a c k
any form o f h e a l t h i n s u r a n c e . More t h a n 300,000 C o n n e c t i c u t r e s i d e n t s o r
1 1 % o f t h e n o n - e l d e r l y p o p u l a t i o n a r e u n i n s u r e d and hundreds o f thousands
more have inadequate i n s u r a n c e ; and
WHEREAS, L a t i n o / a r e s i d e n t s a r e almost t w i c e as l i k e l y t o be
u n i n s u r e d as Whites, and 10% o f A f r i c a n - A m e r i c a n s a r e u n i n s u r e d ascompared t o 8% o f Whites; and
WHEREAS, People w i t h o u t h e a l t h care coverage a r e f a r more l i k e l y t o
be i n poor h e a l t h t h a n t h o s e w i t h h e a l t h i n s u r a n c e , and a r e o f t e n f o r c e d
t o go w i t h o u t needed p r e v e n t i v e , p r i m a r y and f o l l o w - u p m e d i c a l c a r e . The
u n d e r i n s u r e d r i s k f i n a n c i a l r u i n i f f a c e d w i t h a s e r i o u s i l l n e s s ; and
WHEREAS, The S t a t e and n a t i o n ' s h e a l t h care c r i s i s i s even more
d r a m a t i c i n c i t i e s l i k e H a r t f o r d , where c l i n i c s a r e underfunded, h o s p i t a l
emergency rooms a r e overburdened, p h y s i c i a n s exclude M e d i c a i d
b e n e f i c i a r i e s , and t h e i n f a n t m o r t a l i t y r a t e f o r L a t i n o / a and A f r i c a n American b a b i e s exceed t h a t o f many poor, t h i r d - w o r l d n a t i o n s ; and
WHEREAS, I n d i v i d u a l s w i t h c h r o n i c i l l n e s s e s and d i s a b i l i t i e s a r e
d i s c r i m i n a t e d a g a i n s t and d e n i e d needed h e a l t h coverage; and
WHEREAS, S o a r i n g h o s p i t a l and h e a l t h i n s u r a n c e r a t e s a r e
overwhelming businesses s t r u g g l i n g t o m a i n t a i n b e n e f i t s f o r t h e i r
employees. American c o r p o r a t i o n s spend f a r more on h e a l t h b e n e f i t s t h a n
t h e i r i n t e r n a t i o n a l c o n p e t i t o r s , j e o p a r d i z i n g t h e i r a b i l i t y t o compete i n
t h e w o r l d m a r k e t ; and
�-2WHEREAS, H e a l t h care c o s t s a r e i n c r e a s i n g l y passed on t o employees,
s t r a i n i n g t h e budgets o f w o r k i n g f a m i l i e s t r y i n g t o make ends meet. Outo f - p o c k e t h e a l t h care e x p e n d i t u r e s f o r workers a r e i n c r e a s i n g t h r e e f o u r t i m e s f a s t e r than s a l a r i e s ; and
WHEREAS, Four o u t o f every f i v e l a b o r s t r i k e s a r e over h e a l t h
b e n e f i t s ; and
WHEREAS, The C i t y o f H a r t f o r d commends t h e S t a t e f o r i t s e f f o r t s t o
expand access t o care and i n c r e a s e i n s u r a n c e coverage t h r o u g h t h e e f f o r t s
of t h e Blue Ribbon Commission on S t a t e H e a l t h I n s u r a n c e , t h e enactment o f
P u b l i c A c t 90-134, and t h e on-going work o f t h e H e a l t h Care Access
Commission; and
WHEREAS, S h o r t - t e r m programs t h a t meet t h e immediate h e a l t h care
needs o f t h e u n i n s u r e d a r e c r i t i c a l , b u t w i l l n o t c o n t r o l s k y r o c k e t i n g
c o s t s and guarantee u n i v e r s a l access t o h i g h q u a l i t y c a r e ; now,
t h e r e f o r e , be i t
RESOLVED, That S t a t e and F e d e r a l lawmakers should enact a
comprehensive r e f o r m measure a f t e r c o n s i d e r a t i o n o f t h e major r e f o r m
a l t e r n a t i v e s b e f o r e Congress, i n c l u d i n g t h e p r o p o s a l s sponsored by
Congresswoman K e n n e l l y , R e p r e s e n t a t i v e Russo and Senator M i t c h e l l ; and be
i t further
RESOLVED, That reforms enacted by t h e S t a t e L e g i s l a t u r e and U. S.
Congress s h o u l d be based on t h e f o l l o w i n g p r i n c i p l e s :
•Coverage must be u n i v e r s a l and e q u a l : I n s u r a n c e and access t o c a r e must
be p r o v i d e d e q u a l l y t o every i n d i v i d u a l , r e g a r d l e s s o f r a c e , e t h n i c i t y ,
n a t i o n a l o r i g i n , sex, age, income, employment s t a t u s , s e x u a l o r i e n t a t i o n ,
m e d i c a l c o n d i t i o n , and f a m i l y c i r c u m s t a n c e .
Support f o r community h e a l t h c e n t e r s and o t h e r community p r o v i d e r s
s h o u l d be i n c r e a s e d , and o t h e r s e r v i c e d e l i v e r y o p t i o n s s h o u l d be
i n i t i a t e d t o ensure access t o c u l t u r a l l y a p p r o p r i a t e c a r e .
• B e n e f i t s must be comprehensive: F u l l and a p p r o p r i a t e b e n e f i t s must be
provided, including preventive, s u r g i c a l , dental, v i s i o n , therapeutic,
r e h a b i l i t a t i v e , c h r o n i c , and r e p r o d u c t i v e h e a l t h s e r v i c e s , as w e l l as
p r e s c r i p t i o n drugs and mental h e a l t h and substance abuse t r e a t m e n t .
A S t a t e w i d e e d u c a t i o n campaign s h o u l d be r e g u l a r l y conducted t o
promote p r e v e n t i v e care. S p e c i f i c measures t o p r e v e n t over u t i l i z a t i o n
of s e r v i c e s s h o u l d be employed.
•Costs must be e f f e c t i v e l y c o n t r o l l e d : A s i m p l i f i e d f i n a n c i n g system
must be e s t a b l i s h e d t o slow m e d i c a l i n f l a t i o n , reduce waste, a c h i e v e
a d m i n i s t r a t i v e s a v i n g s , t a k e advantage o f economies o f s c a l e , f a c i l i t a t e
h e a l t h care p l a n n i n g , and p r o v i d e needed care t o m e d i c a l l y - u n d e r s e r v e d
areas.
•High q u a l i t y care must be u n i f o r m : A s y s t e m a t i c s t r a t e g y f o r a s s u r i n g
maximum q u a l i t y i n a l l aspects o f t h e h e a l t h d e l i v e r y system must be
employed, i n c l u d i n g q u a l i t y o f care o v e r s i g h t , t e c h n o l o g y assessment and
p r a c t i c e g u i d e l i n e s which encourage a p p r o p r i a t e t r e a t m e n t by p r o v i d e r s
and u t i l i z a t i o n by consumers.
�-3and be i t f u r t h e r
RESOLVED, That any r e f o r m measure enacted should i n c l u d e j o b
r e t e n t i o n and c o n v e r s i o n i n i t i a t i v e s , and o t h e r j o b p r o t e c t i o n measures
f o r i n s u r a n c e i n d u s t r y employees; and be i t f u r t h e r
RESOLVED, That t h e C i t y o f H a r t f o r d w i l l work w i t h t h e H e a l t h Care
Access Commission and t h e General Assembly, t o ensure t h a t t h e programs
e s t a b l i s h e d by t h e H e a l t h Care Access Commission, as w e l l as t h e programs
e s t a b l i s h e d under P. A. 90-134, a r e f u l l y funded; and be i t f u r t h e r
RESOLVED, That t h e C i t y o f H a r t f o r d s h a l l e s t a b l i s h a Working Group
on H e a l t h Care Access t o d e v e l o p l o c a l and r e g i o n a l p r o p o s a l s t o reduce
h e a l t h care c o s t s , expand i n s u r a n c e coverage and i n c r e a s e access t o
c u l t u r a l l y appropriate services.
The Working Group s h a l l have 15 members appointed by t h e Mayor: one
member r e p r e s e n t i n g a commercial insurance c a r r i e r d o m i c i l e d i n H a r t f o r d ,
one member r e p r e s e n t i n g o r g a n i z e d business, one member r e p r e s e n t i n g s m a l l
business, one member r e p r e s e n t i n g consumers, one member r e p r e s e n t i n g
p h y s i c i a n s , one member r e p r e s e n t i n g c h i l d r e n , one member r e p r e s e n t
community h e a l t h p r o v i d e r s , one member r e p r e s e n t i n g h o s p i t a l s , one member
r e p r e s e n t i n g people w i t h d i s a b i l i t i e s , one member r e p r e s e n t i n g l a b o r , one
member r e p r e s e n t i n g m e d i c a l l y - u n d e r s e r v e d
communities, one member
r e p r e s e n t i n g people who t e s t H I V - p o s i t i v e , one member r e p r e s e n t i n g t h e
C i t y A d m i n i s t r a t i o n , and one member o f C o u n c i l from each p o l i t i c a l p a r t y .
At t h e d i s c r e t i o n o f t h e Mayor, a d d i t i o n a l members may be added t o t h e
Working Group.
The Working Group s h a l l make a f i n a l r e p o r t o f recommendations on
June 15, 1992, and s h a l l make an i n t e r i m r e p o r t o f a c t i v i t i e s by A p r i l 1,
1992.
The Working Group s h a l l c o n s i d e r o p t i o n s i n c l u d i n g b u t n o t l i m i t e d
t o : expanding community h e a l t h c e n t e r c a p a c i t y , i n c r e a s i n g p r i v a t e
p h y s i c i a n acceptance o f M e d i c a i d p a t i e n t s , d e v e l o p i n g l o c a l and r e g i o n a l
economies o f s c a l e f o r m u n i c i p a l employee h e a l t h b e n e f i t s , i m p r o v i n g
access t o needed immunizations f o r c h i l d r e n , and more.
The Working Group s h a l l conduct i t s a c t i v i t i e s w i t h i n a v a i l a b l e
a p p r o p r i a t i o n s ; and be i t f u r t h e r
RESOLVED, That a copy o f t h i s r e s o l u t i o n be t r a n s m i t t e d t o members
o f t h e C o n n e c t i c u t General Assembly and t o C o n n e c t i c u t ' s C o n g r e s s i o n a l
Delegation.
Attest:
s a s t i a n A. S ^ n t i g l i a ,
City Clerk.
Copies t o : C i t y Manager, C o r p o r a t i o n Counsel, Mayor, A l l Councilmen,
D i r e c t o r . o f Finance. D i r e c t o r o f Management o f Budget, D i r e c t o r o f He a l t h
He
adget,
C o n n e c t i c u t General Assembly and C o n n e c t i c u t C o n g r e s s i o n a l D e l e g a t i o n .
al
igr
�STATE OF
DELAWARE
DELAWARE
HEALTH CARE
1901
N. D U P O N T
COMMISSION
HIGHWAY
ADMINISTRATIVE B U I L D I N G - FIRST
S T E P H E N T. G O L D I N G . CHAIRMAN
NEWCASTLE. DELAWARE
FLOOR
19720
TELEPHONE: ( 3 0 2 ) 5 7 7 - 4 5 0 3
M A R C E L L A A. C O P E S . PH.D.
S C O T T R.
T H O M A S P.
SALLY
(302)
577-4501
DOUGLASS
EICHLER
GORE
R O B E R T G. K E T T R I C K .
D A V I D N.
M.D.
LEVINSON
T E M P E B. S T E E N . ESQUIRE
GREGORY J. WILLIAMS
K A Y E. H O L M E S . DIRECTOR
January 26, 1993
H i l l a r y Rodman C l i n t o n
White House
1600 Pennsylvania Ave. N.W.
Washington, D.C. 20510
Dear Mrs. C l i n t o n :
The Delaware Health Care Commission has been i n existence
since A p r i l 1991. Our primary purpose, l i k e t h a t of many s t a t e
h e a l t h commissions and councils, i s t o develop s t r a t e g i e s t o
address t h e issues of health care access and cost containment. The
Commission chose t o begin i t s work incrementally w i t h the
expectation t h a t a n a t i o n a l s o l u t i o n would be proposed and we would
be ready t o work w i t h i n t h a t s o l u t i o n . To t h a t end we placed an
emphasis on increased access t o health care f o r c h i l d r e n .
I am enclosing a copy of the Delaware Health Care Commission's
Annual r e p o r t t o Governor Thomas Carper and the Delaware General
Assembly. I hope i t may be of some use t o you as you begin t o
address these very d i f f i c u l t issues.
The Delaware Health Care Commission w i l l continue i n i t s
e f f o r t s t o expand access t o care and i d e n t i f y cost containment and
insurance reform s t r a t e g i e s t h a t w i l l allow f o r us t o go forward
w h i l e you are looking f o r answers. I f I or the Delaware Health Care
Commission can be of any assistance t o you i n t h i s e f f o r t please
have someone from your s t a f f contact me.
yn&a—
Kay E. Holmes
Executive D i r e c t o r
�PAUL SIVLEY
MAYOR
CITY HALL
415/973-6534
FAX 415/972-6905
666 ELM STREET
SAN CARLOS, CA 94070- 3085
POLICE/FIRE
802-4321
MAYOR/CITY COUNCIL
802-4231
PUBLIC WORKS (Complaints)
802-4302
CITY CLERK
802-4219
PLANNING DEPT.
802-4267
ECONOMIC DEVELOPMENT
802-4209
CITY MANAGER
802-4228
BUILDING INSPECTION
802-4260
FIRE DEPT. (Admin.)
802-4281
FINANCE
802-4213
PARKS & RECREATION
802-4286
POLICE DEPT. (Admin.)
802-4246
PUBLIC WORKS (Admin.)
802-4202
PERSONNEL DEPT.
802-4287
RECYCLED
PAPER
CLINTON LIBRARY PHOTOCOPY
�CITY OF SAN CARLOS
CITY COUNCIL
CITY COUNCIL
HAUL SIVLEY, MAYOR
666 ELM STREET
JOHN HOFFMANN, VICE MAYOR
SAN CARLOS, CALIFORNIA 94070 30H5
SALLY E. MITCHELL
TELEPHONE (-1 IS ) S93-K011
KEVIN KELLY
FAX ( 415) 595-2044
THOMAS.I DAVIDS
February 2,1993
First Lady Hillary Rodham Clinton
1600 Pennsylvania Avenue, N.W.
Washington, D.C. 20500
FFR 2 5 1993
Dear Ms. Rodham-Clinton:
I want to thank you for your ban on smoking in the White House. This
initiative is very important in terms of practical and symbolic impact.
Many local elected officials such as myself are striving to enact smoke free
workplace ordinances (including restaurants). We face a public which is
inadequately informed about the severe health effects of secondhand smoke,
and a tobacco lobby which has effectively blocked all legislation at the state level.
Your action gives courage and support to those of us working on the local level
to prevent the 53,000 deaths which occur each year as a result of secondhand
smoke. I hope the Clinton Administration will ban smoking in all federal
buildings, as recommended by the EPA and HHS Secretaries in the closing days
of the Bush Administration.
I hope that I have the opportunity to meet you and President Clinton in the
future. I am in Washington annually, including this February 28-March 4.
I wish you both the best in your challenging responsibilities. Thank you for your
leadership on this important health issue.
Paul Sivley
Mayor, City of San Carlos
666 Elm Street
San Carlos, CA 94070
(415) 973-6534 (o)
RECYCLED
PAPER
�BOARD OFSUPERVISORS
COUNTY OF LOS ANGELES
IIWi KtNNCTM HAHN HALL 01 ADMINISTRATION / LOS ANCELI'S, CAI.II'OKNIA 'MOIJ / Q I ill 'I7-1^22
YVONNE BRATHWAITE BURKE
J
MFMHEKS OF THE BOARD
GLORIA MOLINA
YVONNE BRATHWAITE BURKE
EDMUND D. EDELMAN
DEANE DANA
MICHAEL D. ANTONOVICH
SUPERVISOR, SECOND DISTRICT
February 3, 1993
Mrs. H i l l a r y Rodham Clinton
Presidential Task Force on Health Reform
The White House
2600 Pennsylvania Avenue
Washington, D.C. 20510
Dear Mrs. Clinton:
Free vaccines for a l l children i s a wise and timely proposal. Not
only i s i t common sense, i t i s a prudent way of diminishing costly
future i l l n e s s e s . I commend your timely actions.
As I wrote on January 28, 1993, Los Angeles County i s at your
service. Los Angeles County has the second largest public health
care system. Our system includes six public hospitals (one i s the
largest i n the nation), 47 health centers and hundreds of special
health service contracts with private sector providers.
We are working now with the private sector to planning a Countywide managed-care network for a l l Medicaid and uninsured persons.
Los Angeles i s a logical location for a Federal Health Care Reform
Demonstration Project.
Again, Los Angeles County i s at your service - for information,
public meetings, tours and demonstration projects.
Very truly yours.
YVONNE
Super
YBB: y
THWAITE BURKE
Second D i s t r i c t
�CODER:
HEALTH CARE TASK FORCE SORTING SHEET
TYPE OF MATERIAL:
.Employment
Offers to help
Letterhead
_Policy
Letter Campaign
Requests:
-speech
-meeting
.Advocacy
.Personal stories
General mail
Casework
Other
Explanation:.
ADVISORY PANEL?
physician
.large employers
r.n.
.other health provider
seniors
small business
other consumers
Explanation:.
PRIMARY TNTBREST:
COST ISSUES
Drug Prices
Physician Fees
Hospital Fees
Unnecessary Procedures
Medical Equipment
Fraud and Abuse
.PUBLIC HEALTH/SPECIAL POPULATIONS
Prevention
AIDS
Women's Health
Immunizations
Rural
Urban
COVERAGE
Working Families
Unemployed/Low Income
Benefits
Providers
GOVERNMENT PROGRAMS
Medicare
Medicaid
Veterans
DoD
ORGANIZATION
Insurance Premiums
Insurance Reform
Insurance Pools
Boards and Oversight
INFRASTRUCTUREAYORKFORCE
Quality Assurance (Guidelines)
Administration. Reimbursement
& Patient Information Systems
Malpractice & Tort Reform
Manpower Issues (Training)
LONG-TERM CARE
MENTAL HEALTH
OTHER
Explanation:.
PLAN PREFERENCE: (Support = +; Oppose = -)
CP
SP
OP
Clinton Plan
Single Payer
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits, Vouchers,
Medical Savings Accts.
CA
BR
GE
Canadian
British
German
�CODER.
HEALTH CARE TASK FORCE SORTING SHEET
INPUT DATE:
ftENERAT, SORT-
POSTCARD 1:
.Personal stories
.General mail
.Letter Campaign
Other Health Providers
POSTCARD 2:
.Offers to help/Employment
.Physicians
FORM LETTER:
Letterhead
.Policy
REROUTE:
Casework
.Scheduling
POLICY AND PERSONAL
President
Other
as.-
.ORGANIZATION (I)
insurance premiums
insurance reform
insurance pools
boards and oversight
.COVERAGE (H)
working families
unemployed/low income
benefits
providers
.INFRASTRUCTURE/WORKFORCE (IH)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
.manpower issues (training)
.unnecessary procedures
.GOVERNMENT PROGRAMS (IV)
medicare
medicaid
veterans
DoD
Indian health
.COST ISSUES (VI)
drug prices
physician fees
hospital fees
.medical equipment
fraud & abuse
FINANCING (VH)
.MENTAL HEALTH (IX)
LONG-TERM CARE (X)
.PUBLIC HEALTH/
SPECIAL POPULATIONS (XH)
prevention
AIDS
women's health
.immunizations/children
rural
urban
OTHER
�0
HOUSE OF REPRESENTATIVES
LANSING, MICHIGAN
FOURTH DISTRICT
ALMA G. STALLWORTH
ASSISTANT MAJORITY
FLOOR
LEADER
STATE CAPITOL BUILDING
COMMITTEES.
LANSING. MICHIGAN 48913
PUBLIC UTILITIES. CHAIRPERSON
EDUCATION
LANSING PHONE 1 5 1 7 ) 3 7 3 - 2 2 7 6
INSURANCE
March 9, 1993
PUBLIC HEALTH
SENIOR CITIZENS AND RETIREMENT
Ms. Hillary Clinton
The-White House
Washington, DC
Dear Ms. Clinton:
We are very pleased you are coming to Michigan to discuss the status of Health Care
and other ancillary services. I take this opportunity to extend a hearty "welcome" and to
request inclusion in the meeting scheduled March 23rd through Senator Don Riegle's Office
whom I've sent a similar letter.
For the past eight years I've served as chair of the House Sub-Committee to Public
Health on Infant Morality, I am also Chair of Legislative Exchange for the National Order
of Women Legislators, and a member of the Board of Directors. Additionally, I am
President of the Metro-Detroit Affiliate of the National Black Child Development Institute.
I mention these affiliations to emphasize my continuing interest in future health care
policies which will enhance services to children and families within Michigan.
There are two other persons I like to have included:
Karen Hemy, Chair Public Policy, National Black
Child Development Institute - Metro Detroit
16148 Griggs"
Detroit, MI 48221
Robin Barclay, Chief Executive Officer
LifeChoice Quality Health Plan, Inc.
2401 20th Street
Detroit, MI 48216
Please accept my sincere appreciation for your efforts in behalf of us all. I look
forward to seeing you during your visit to Michigan.
Recycled
Paper
ALMA G. STALLWORTH
STATE REPRESENTATIVE
TWELFTH DISTRICT
�Detroit City Council
Detroit, Michigan 48226
MEL RAVITZ
COUNCILMAN
February 15, 1993
President B i l l Clinton
F i r s t Lady H i l l a r y Rodham Clinton
The White House
Washington, D.C. 20500
Dear Mr. President and Mrs. Clinton:
Just a note to urge you to adopt a National Health Care Plan
similar to Canada's but adapted to our particular needs. Such
a plan should have long term care as an integral part of i t ,
not only for seniors but for a l l Americans who need i t . I f
Canada can cover a l l i t s citizens on a smaller percentage of
cost than we do now, we should be able t o do as well or
better.
I support the health care proposals of the National Council of
Senior Citizens of which I am a member.
Thank you.
Sincerely,
MR:ab
�0,
WORKERS' COMPENSATION COMMISSION
CHARLES G. JAMES, cuAinwAN
DIVISION OF CRIME VICTIMS' COMPENSATION
ROBERT P. JOYNER, COMM.SSIONER
WILLIAM E. O'NEILL, COMMISSIONER
LAWRENCE D. TARR, CHIEF DEPUTY COMMISSIONER
ROBERT W ARMSTRONG DOCTOR
M
P. O. BOX 5423
RICHMOND. VIRGINIA 23220
A
|
N
N
U
M
B
E
3 7_g
(V/TDD)
( 8 0 4 )
6
R
'
6 8 6
January 28, 1993
Mrs. H i l l a r y Clinton, Chairperson
National Health Reform Committee
1600 Pennsylvania Avenue
Washington, DC 20500
Dear Chairperson:
I am writing i n regards to your committee for the development of a
national health care program.
F i r s t , I would l i k e to point out that
Virginia's Crime Victims' Compensation
Formerly I served as a police o f f i c e r
Police from July 1964 to January 1979.
of my l i f e has been in public service.
I have been the Director of
Program since January 1979.
with the Richmond Bureau of
As you can see, the majority
As Director for Crime Victims' Compensation, my d a i l y a c t i v i t i e s
primarily include verifying the a v a i l a b i l i t y of health insurance
coverage or the lack of same for crime victims and t h e i r families.
The majority of victims are without health insurance and must pay for
their medical care d i r e c t l y , f i l e for bankruptcy, rely on public
assistance, or default on payment of their b i l l s . Surveys within my
own agency reveal that s i x t y - s i x percent (66%) of victims are without
any form of health insurance.
I have witnessed numerous cases wherein private hospitals s h i f t
patients to state hospitals as soon as Medicaid benefits expire,
patients who need corrective surgery including dental care, and
victims, e s p e c i a l l y children, who have suffered physical and sexual
abuse need treatment but cannot afford same.
There are many programs available that provide payment for health care
other than private insurance such as Medicaid, Medicare, Champus, FHC,
VA Hospitals,
Hill-Burton,
Workers' Compensation,
State-Local
Hospitalization, Crime Victims' Compensation, e t c . While these
programs are helpful, they s t i l l have many shortcomings of which I can
elaborate i f requested.
I believe a National Health Care Program can be developed without
causing a l o t of negative feedback and can be a p o l i t i c a l asset to the
presidency i f i t i s c a r e f u l l y constructed and articulated.
�Mrs. H i l l a r y Clinton, Chairperson
January 27, 1993
Page 2
The public i s worried that a national health plan w i l l cause an
increase i n taxes and reduce the quality of health care.
Both of
these concerns can be abated by pointing out how much current programs
such as Medicaid, Medicare, Champus and VA Hospitals already cost
taxpayers.
Then point out how every time a patient defaults on
payment of their medical b i l l s the costs are passed on to everyone who
seeks medical insurance or medical care through higher insurance
premiums and higher fees for medical treatment. Also, there are the
indirect costs such as the need for courts and personnel to handle
lawsuits and judgments f i l e d by medical providers against t h e i r
patients.
Currently medical providers who treat patients under Medicaid or
Medicare are only being reimbursed at about forty-eight percent (48%)
of the actual charges, depending on whose side you l i s t e n to. Anyway,
i t i s low and a f a i r and equitable health care system could improve
this condition. Medical providers also claim a national health care
program w i l l diminish their i n i t i a t i v e to improve the quality of
health care i f limits are placed on the amount providers can charge.
In either of these cases, i f medical providers know they are going to
receive f u l l compensation from a l l patients and not just a select few,
the quality of medical care should improve and there should not be a
need to pass on an increase in the cost of health care or taxes to the
public.
There are numerous options available in creating a national health
plan. Based upon my experiences, the opinions of my colleagues and
numerous medical providers, I would prefer to see a singular health
care system i n s t a l l e d and the elimination of a l l other federal health
programs. The savings in administrative costs alone could fund a
national system, and other limits in areas such as malpractice s u i t s
could save millions annually.
I f you feel that I may
services.
be of value to your committee, I offer my
Respectfully,
<U,f.
.
Robert W. Armstrong
Director
RWA/rac
cc:
Dan Eddy, Executive Director
National Association of Crime Victim Compensation Boards
�STATE OF WYOMING
MIKE SULLIVAN
GOVERNOR
OFFICE OF THE GOVERNOR
CHEYENNE 82002
A p r i l 9,
1993
I r a Magaziner, Coordinator
Health Care Task Force
The White House
Washington, D.C. 20501
Dear I r a :
We are t h r i l l e d to hear that Washington i s taking leadership
in examining the wonderful opportunity of using smartcards to
carry medical history on microchips. You are to be encouraged
and congratulated.
As you can see with the enclosed sample card. Western
Governors' Association Health Passport abstract and l i s t i n g of
goals and objectives, WGA i s proposing a smartcard for maternal
and c h i l d primary health care and the WIC n u t r i t i o n program.
Five s t a t e s . North Dakota, Montana, Idaho, Nevada, and Wyoming
are working together to e f f e c t t h i s regional system solution.
We would welcome the opportunity to work with you i n
developing t h i s important opportunity that could ultimately
benefit a l l Americans.
I f you wish to discuss t h i s issue, please give me a c a l l at
(307)777-7434, or contact Tom Singer, Ph.D., Director of Research
at WGA (303)623-9378 or Terry Williams, Smartcard Manager on my
s t a f f , a t (307)777-7494.
Sincerely,
Mike Sullivan
Governor
/mas
Enclosures
CO:
�WESTERN GOVERNORS' ASSOCIATION
HEALTH PASSPORT PROJECT
Abstract
The Western Governors' Association (WGA)
proposes
to
increase
at
the
access
to
Health Passport Project
health
same time achieve
care
for mothers
cost
and
children,
and
containment,
utilizing
integrated e l e c t r o n i c technology to combine individual
electronic benefits with a portable health record.
the
combination of portable
significant
gains
in
health
efficiency,
and
We believe that
benefit data
reliability,
by
promises
validity,
and
security i n the delivery of and payment for health care s e r v i c e s .
The governors of f i v e western s t a t e s — I d a h o , Montana, Nevada, North
Dakota, and Wyoming—have joined to conduct a regional f e a s i b i l i t y
study and
demonstration of the phased addition of health care
programs to the WIC EBT smartcard system that was the subject of a
successful 1991-2 Wyoming demonstration.
The
proposed approach
would combine one or more services such as Medicaid, Children with
Special Health Care Needs, Immunization, Prenatal Care, and Head
Start with WIC on a smartcard in each state, and then combine a l l
programs into an integrated multi-state system.
the
project
governors
will
have
require
established
a
public/private
a
WGA
Health
Recognizing that
partnership,
Passport
Task
the
Force
representing s t a t e and federal agencies and regional health care,
retail,
banking, insurance,
and
computer s e r v i c e s i n t e r e s t s to
provide stakeholder input and support for the project.
�HEALTH PASSPORT PROJECT GOALS AND OBJECTIVES
1.
Empower participants as partners i n family-centered managed
health care through the use of secure, portable, microtechnology data bases.
2.
Demonstrate a portable, shared data base, that l i n k s e x i s t i n g
d i s s i m i l a r systems among public and private health care
providers and builds an integrated system of health care,
identifies
authorization,
eliminates
duplication, and
encourages the provider to p r a c t i c e better medicine.
3.
U t i l i z e smartcards as a portable health record to increase
e f f i c i e n c y , r e l i a b i l i t y , v a l i d i t y , and s e c u r i t y i n the
delivery of and payment for s e r v i c e s .
4.
Increase access to health care, p a r t i c u l a r l y for children and
pregnant women, with more emphasis on preventative measures.
5.
Using a secure, portable data base, eliminate redundant data
gathering, for application, e l i g i b i l i t y determination, and
service delivery. Adjunctive e l i g i b i l i t y w i l l be determined.
The system w i l l identify f o r the c i t i z e n and service s t a f f ,
the f u l l range of services the applicant may be e l i g i b l e for
and e l e c t to access.
6.
At l e a s t p a r t i a l l y automate and track r e f e r r a l s . S t a f f w i l l
be able to confirm that r e f e r r a l s were completed. Parents of
infants and children w i l l receive e l e c t r o n i c reminders of the
next scheduled WIC c e r t i f i c a t i o n , immunization appointment,
etc.
7.
Demonstrate regional service delivery that provides for
t r a n s f e r of benefits and health records across state l i n e s to
a s s i s t relocating families, migrant a g r i c u l t u r a l workers, and
provision of regional medical care.
8.
Enable federal and state agencies to c o l l e c t data on service
and
outcomes i n achieving
the "Healthy People 2000"
objectives.
�Diin o pb Ha
is f ul et
vo
i l
c h
Department of Health
j . Richard Hillman, M.D.
Administrator
Ref:
S
t
a
t
e
o
f
W
y
o
r
a
i
n
J
EBT4\C2W93119
G
Mike Sullivan, Governor
March 11,
1993
H i l l a r y Clinton
Chair, Health Reform Committee
The White House
Washington, D.C. 20501
Dear Mrs.
g
Clinton:
My boss. Governor Mike Sullivan, recently wrote to you
describing the Health Passport demonstration project we are in
the process of putting into place through the Western Governors'
Association. This Health Passport w i l l use "Smart Cards" as the
vehicle to l i n k mothers and children with health services.
I am writing t h i s note to you today to provide you with a
copy of the A p r i l 1990 Smartcard Monthly special issue on health
care. This issue summarizes the many exciting projects that are
taking place in Europe and the P a c i f i c Rim countries in smartcard
applications to health care.
In view of the recent Washington Times a r t i c l e on privacy
concerns over medical ID cards, I respectfully submit that the
Republic of France has developed a solution to t h i s problem. The
French are in the process of issuing a Health Professional
I d e n t i f i c a t i o n Card to a l l licensed health practitioners in
France. When the patient brings his/her health card to receive
care, i t can only be read in combination with the physician's
card, a f t e r both have entered t h e i r individual PIN numbers. This
methodology provides the high level of security desirable for
medical records.
In our smartcard program application that would involve
administrative, program benefits such as WIC prescriptive foods
and medical information, we anticipate dividing the card memory
into three secure and separate areas. Access to each area i s
r e s t r i c t e d by the type of service. For example, as the WIC
mother comes to the c l i n i c (after she enters her own s e l f selected secure PIN number), the secretary would be able to
update administrative data on the card and refresh the
supplemental food program benefits according to program status.
The t h i r d health data area, however, could only be accessed in
the privacy of the c l i n i c o f f i c e after the WIC mother again
entered her PIN and the WIC nurse or n u t r i t i o n i s t or physician
entered t h e i r card and PIN number. The point i s , the medical
data area of the card could only be accessed when the patient
i n i t i a t e d the process by entering his/her PIN number and when the
WIC Program • Hathaway Building, 4th Floor • Cheyenne, WY 82002
(307) 777-7494 • FAX: (307) 777-5402
�H i l l a r y Clinton
Chair, Health Reform Committee
March 11, 1993
page 2
patient's card was joined by the card authorized and issued to
the health provider.
Use of smartcards makes a great deal of common sense. I t i s
estimated that 85% of the information needed to provide the next
service i s common information between services. For example,
information provided by the parent/guardian and health assessment
completed at the time of WIC e l i g i b i l i t y / c e r t i f i c a t i o n , can be
used i n i n i t i a t i n g immunization service, prenatal care, Head
Start health assessment, etc. Carrying relevant health
information on the card can improve treatment, eliminate
duplicative testing, redundant e l i g i b i l i t y determinations, and
share c r i t i c a l information essential before beginning emergency
treatment. For example, a l l e r g i e s to certain medications,
immediate past health history status, and chronic conditions such
as diabetes.
In the event that the patient l o s t t h e i r card or the license
of the health practitioner was suspended, a block or h o t - l i s t i n g
would be put into the system so the card could be no longer used.
F i n a l l y , thank you for your courage and leadership i n
addressing t h i s absolutely c r i t i c a l issue of our time.
Respectfully Yours,
J . Terry Williams
EBT/Smartcard Manager
/mas
Enclosures
�Special Issue on Health Care
Smart Card Monthly
Published by Smart Card Concepts
©April 1990
Single Issue price: $79
In This Issue
Smart Cards in the French
Health Sector, p. 1
Coordinated Action in the Field
of Patient Data Cards, p. 8
By Mrs. Elsbeth Monod, Guy Peyronnet, and Gilles Taib
Ministry of Health—France
Smart Cards in the
French Health Sector
Health Cards—The Move Towards Standards, p. 11
Health Care Capsules, p. 14
The Exeter Care Card, p. 15
French Mutual Insurance (FMF)
Cards, p. 19
Description of the Hippocarte
System, p. 20
SM
Intelliscan : A Patient Card
That Aids Health Care Marketing, p. 22
Mutusant* Card, p. 24
The Optical Memory Card: A
Portable Medical Record, p. 26
West London Maternity LaserCard™ Update, p. 30
Santal, p. 32
CPS: A Health Professional
Smart Card, p. 34
Editorial, p. 3
News, p. 36
Calendar, p. 37
Health Expenditures
The main features and trends in health and welfare
services show a considerable growth in health expenditures
in all developed countries. For 1988, the French health and
social budget was 1,300 billion francs. The health expenditure alone was over 450 billion francs, which represents
8,300 francs per person per year, 8.8% up from the year
before, increasing three times faster than inflation.
France's health expenditure (9.3% of its GNP) puts it
third worldwide behind the USA and Sweden. By the year
2000, it might well absorb 20% of the disposable income of
each French citizen, becoming the first priority before housing and food.
Health Infonnation and Communication Growth
At the same time, infonnation and communication between all the public and private health professionals and
institutions in this sector (GP and specialists, chemists,
paramedical staff, hospitals, laboratories, etc..) is developing
rapidly. The exchange of medical and administrative data
More, next page...
�Smart Card Monthly
April 1990 1 2
••••••••••• «
a
••
French Health
between the patients and of
the Social Security organisation, the "non profit" insurance companies known as
"mutuelles", and the private
insurance companies shows
a similar trend.
In addition, medical
information using telematic
systems is expanding and
the health Smart Card electronic flow is expected to be
greater than that of the
banking cards.
Reducing Costs
The national cost of
health care is not going to
decrease, but its growth can
be reduced. How do the
public authorities and financial structures that provide
health coverage view this?
On the one hand, the
financial structures concerned with health risks all
have a direct interest in the
implementation of any
technology that would
enable them to either reduce
their costs or to enlarge the
scope of their services to
obtain new customers.
Secondly, the public
authorities are also concerned with the reduction of
health costs, but they also
want to guarantee, in cooperation with the authorities
representing the health
professions, the fundamental
principles of the French
health service:
• free choice of health services for patients as well as
for doctors, in their
methods, conditions, and
areas to establish medical
practice,
• respect of medical secrecy,
• protection of individual
rights.
Common Features
The twenty or so Card
systems experiments which
have been implemented in
the French health sector
have certain features in
common:
• The majority of them use
microprocessor technology, which offers an
extremely wide scope of
applications in the health
field, and opportunities
for a large number of
Last, but not least, in this
creative purposes. It
prevalent cost-containment
answers problems of
atmosphere, the medical
storage and communicacommunity will want to
tion of individual mediknow how Smart Cards, or
cal data, while at the
any other technological
same time, it respects
developments, can help
medical secrecy.
them lower their expendi• They all use a profestures, while ameliorating the
sional microprocessor
quality of health care.
health Card for access to
the patient Card content.
• Patients and doctors volunteered to use the
The Most Significant
Cards.
French Health Smart Card
Experiments
Part of the applications
have already been put into
Differences
practice for several years.
• The objectives either conThey are being assessed, and
cern health or quality
show relevant material for
hospital management
the socio-technical decisions
and administration.
required to envisage pro• Those participating in the
gressive, widespread use of
experiments belonged
such a tool in the near future.
More, page 4 ...
�Smart Card Monthly
April 1990 I 3
EDITORIAL
Smart Card Monthly
Editor
Stephan Seidman
Designer & Art Director
Mark Olson
© 1990 Smart Card Concepts.
All rights reserved. Electronic
storage and/or reproduction in
any form are forbidden without
written permission from the
publisher. The information in
this document is gathered from
reliable sources and is believed
to be accurate. Beyond that.
Smart Card Monthly cannot
guarantee its completeness or
accuracy.
US Health Care Spending Outstrips
Worldwide Visa and MasterCard
Not only is the cost of health care worldwide going up at a frightening rate, the
forecasts of these costs seem to go up with
equal abandon. In the spring of 1986, the
Health Care Financing Review forecast that
1990 expenditures for health care in the
United States in 1990 would be 11.3% of Gross National
Product (GNP), amounting to $640 billion. That's fifty
percent more than the total volume of transactions worldwide for MasterCard and Visa combined.
In July of 1989, Hospitals magazine reported the results of
their annual survey, indicating a range of %GNP forecasts
for 1990 with 11.3% as a minimum, 11.9% as a mean, and
12.5% as a maximum.
Biggest Spender Has Smallest Interest
The Economist says that Americans, "obsessed about their
health... spend nearly twice as much per head on it as the
French or Germans, three times as much as the British."
What you will find in this issue is that the French and the
British (and the Japanese) have made serious commitments
to the incorporation of Smart Cards and/or other advanced
technology cards into their health care systems. Canada,
Statements and opinions exfalling just between France and the US in health care expenpressed by contributing authors
ditures, is starting in the pharmacies. As far as we can
are not necessarily those of the
Editor or Publisher of Smart Card determine, Americans are doing precious little. Aside from
Monthly.
Affiliated Health Care (Princeton, NJ), which keeps a pretty
low profile regarding its Smart Card program, we don't
Smart Card Monthly (ISSN 0893know of any long term US efforts in this application.
9462) is published 11 times each
With Americans spending over $2,000 per capita on
year by Smart Card Concepts,
140 University Avenue, Number
health care, I wonder how much a fully amortized IC Card42, Palo Alto, California 94301,
based health care record system would have to cost before it
U.S.A.; Telephone: (415) 326were considered to be "too expensive"? Or how much it
4357, FAX: (415) 326-3325. A
would have to save, or generate in marginal revenues, to be
one-year subscription is $475 for
North American delivery or $500 considered a "good investment"?
elsewhere. First-class postage
paid at Palo Alto, California.
STEPHAN SEIDMAN
Editor
�Smart Card Monthly
•
April 1990 I 4
-
••*.
.I.....
French Health
either to the public or to
the private sector.
The Card contents have
either or both medical
and administrative data.
The target population is
either general or specific.
SESAM PROJECT
Among these experiments, the Social Security's
SESAM project is the most
impressive because of the 27
million people involved. [27
million is a figure which
represents the number of
people who are insured,
altogether covering more
than 45 million people].
SESAM is a system targeting the substitution of the
Sodal Security insurance
paper card (45 million issued
every year) by a microchip
card which is called the
"portable family administrative file". All paper transactions will be replaced by
electronic flows.
The Card contains:
• personal identification
• rights and affiliation
1985: First Phase
The first experiments
were set-up in 1985 at four
sites: Charleville-M£zi£res,
Lens, Blois and Rennes. Five
thousand people were involved.
These experiments aimed
at the assessment of technology, functionality, and sociotechnical conditions of appropriation by users.
quality and reduce costs,
while projects as SANTAL,
DALYBRE and TRANSVIE
deal with patient health
information.
In the case of SANTAL,
the Card contains general
health data for patients being
hospitalized, whereas DIALYBRE and TRANSVIE
focus on haemodialysis and
blood transfusion.
1990: Second Phase
In 1990, the second phase
will be the national widespread use of SESAM, beginning with 130,000 Smart
Cards now being distributed SANTAL
in Boulogne sur Mer.
Santal is the most advanced health Smart Card
application in France, if not
in the world, regarding the
Objectives
The objectives of SESAM innovative uses and practices
which have constantly been
are:
assessed and improved.
• to improve the effiency
Twenty four thousand
of the Social Security organisation by dispensing people as well as hundreds
with paper forms, includ- of health professionals and
ing the 770 million claims employees are involved.
More details are given by
for reimbursement per
year, which is increasing Philippe Cirre describing the
whole project and its future.
10% per year.
[Ed: see separate article in
• to simplify red tape and
this issue, p32].
increase productivity by
collecting the information
at the source.
DIALYBRE
Dialybre is a project
SANTAL, DALYBRE,
conducted by the FoundaAND TRANSVIE
tion for the Future, and is
The essential reason for
supported by the French
the SESAM project is to
mutuality organisations.
improve administrative
[Ed:The Foundation for the
�Smart Card
April 1990 I 5
•••••••••
a
Future for Medical Applied
Research was created by the
Mutual Insurance Company
for Civil Servants, and accepted by the Government
authority as an official public
service. Its aim is to adapt
novel technical and scientific
progress to therapeutic
methods.]
The early pilot study was
launched in 1988. It consists
of giving a Smart Card, used
as a handportable, minimum
medical file, to every patient
with terminal renal failure
treated by haemodialysis.
The Card contains:
• biological and medical
data
• technical data spedfyng
the dialysis treatment
•
Surgical Medical Center
of the Porte de Choisy, in
Paris
• General Public Hospital,
in Colmar
• Clinic Delay, in Bayonne
The DIALYBRE Card
carries the minimum data
records concerning the care
given to a special kind of
patient. Each patient has his
own Card. Five hundred
Cards are already in use.
There are about nineteen
thousand people in France
suffering from terminal renal
failure.
rologists and the haemodialysis patients, especially
within the European Economic Communities countries, where the scientific and
medical exchanges are already commonplace, and
where patient behaviour is
quite similar.
TRANSVIE
In 1986, Trans vie was
developed by the University
Hospitals and the Blood
Transfusion Center of Brest.
It brings answers for the two
crucial periods of blood
transfusion: processing data
Objectives
about the donor, and the
The objectives of Dialybre transfusion to the patient.
are:
Up to now, more than
• to increase patients' aufive thousand Cards have
Patients undergoing
tonomy so they can travel been distributed. The Card
haemodialysis may travel
contains:
and have more mobility,
from center to center, for
• to keep the medical infor- • personal identification
medical, professional or
mation up to date
• biological identity
leisure reasons, thanks to the
• history of hospital admistreatment facilities of some
The 1990s objective is to
sions, history of blood
centers. Travelling patients
set up a national DIALYBRE
donations, regular antinecessitate a whole range of
network, allowing the haembodies, vaccinations, etc.
information exchange by
odialysis patients to travel
traditional means (telephone, without increasing the work- Objectives
mail and files) which enables load of the centers in France.
The objectives of Transvie
the centers to provide care to
Moreover, 1992 will
are:
patients they did not previgreatly increase mobility
• to improve the reliability
ously know.
among the European counof the link between donor
and user, and.
tries. This prompted the
As of 1989, three centers
have been connected by the
Foundation to work in strict
telematics network:
collaboration with the nephMore, next page...
�Smart Card Monthly
• ••
*
French Health
•
to get quick information
about the patient's hospitalization history.
In 1987, the Mutuelle
decided to launch the Smart
Card project for its members.
In the near future, 37,500
The experiment has
people will be involved, and
worked well and now the
the project will then cover
idea is to create a personal
the whole department of the
health file including health
Alpes de Haute Provence.
and administrative data
within the Card.
Discussions have been in
progress with Social Security, so as to gather social
security as well as mutuelle
From Public to Private
information on the same
Sector
The previous descriptions Card.
all concern projects or exObjectives
periments run by the public
sector. The MUTUSANTE or
The objectives of the
S ANTE-SOLID ARTTE appli- project are:
cations belong to the private • to simplify and reduce
sector. They are conducted
administrative proceby mutuality organisations.
dures
• to replace financial paper
transactions by electronic
MUTUSANTE
flows between the differMutusant£ is a Smart
ent organisms involved
Card issued by the Mutuelle • to allow prepaid health
Chirurgicale et M6dicale des
care services for drugs or
Alpes, in the south of France
laboratory analyses, etc...
It is delivered free of charge
In 1990, we are beginning
to the members of the Mutua large scale implementation,
elle. The Card contains:
which is described in an
• personal identification
• identification of all mem- article on p.24 of this issue.
bers of the family who
are covered by the insurance
SOLID ARITE-SANTE
This project is being run
• type of coverage
by the Federation des Mutu• rights and dates of valielles de France. The Smart
dation
April 1990 I 6
•
.
Card is an individual portable file which holds administrative infonnation.
The Card contains :
• rights concerning the
Sodal Security and the
Mutuelle
In the near future, it will
contain:
• individual health information
• emergency data (the
same as the European
Health Emergency Card)
• a "warning device" such
as types of examinations,
dates, places, results,
etc...
• infonnation concerning
health professional safety
(prevention)
During 1990, there will be
an implementation of the
project at three sites throughout France: Martigues,
Maubeuge, and a health care
center near Paris. By 199293, the Solidarit6-Sant<§ Card
should have been issued to
450.000 members
Objectives
The objectives of Solidarit6-Sant6 are:
• to offer new services to
members of the mutuelle
• to establish new partnerships with health profes-
�Smart Card Monthly
mmm*u»ammmmmmmmmummm» w+ m
sionals in offering new
services, in particular,
financial ones.
The future of the Solidarit6-Sant£ Card is based on its
ability for wide diffusion in
Europe, particularly in Italy
and in Eastern European
countries.
Conclusion
The most significant
existing applications and
systems of the public or
private sector have been
briefly presented here. As
one can see, the Ministry of
Health, Welfare and Social
Security is open to and
encourages technological
innovation.
However, with more
than twenty experiments in
the Health and Sodal Security field, communication,
coherence and safety are
getting to be imperative
requirements, so as to protect the prindples of the
French health system as well
as the fundamental rights it
guarantees. The use of a
"Health Professional Card"
is the main key which will
promote such coherent
communication and security
between all the different
health information systems
April 1990 I 7
••••
(patient Smart Card systems
and traditional medical
infonnation systems). [Ed:
see CPS artide, page 34, in
this issue].
With this artide we have
stressed the fact that most
developed countries have
and will have to cope with a
continuous growth in health
expenditures, and will then
have to reduce it one way or
another. If this leads to
common goals concerning
the implementation of health
Smart Cards in those countries, the ways and means of
setting up the applications
will depend on each
country's own health system.
For more information,
contact Elsbeth Monod or
Guy Peyronnet or Gilles
Taib, Ministfere de la Solidarity, de la Sante et de la
Protection Sodale, Dorique,
Pifece 2432,14 avenue
Duquesne, 75007 Paris,
France. Tel: (33)-l40.56.60.78. Fax: (33)-l40.56.50.43.
••••
. . . . 4
».
�Smart Card Monthly
April 1990 I 8
By Dr. S. S. Baig
AIM Coordinator, Commission of the European Communities
Coordinated Action in the Field of
Patient Data Cards
Task 330: Assessment of the needs and organizational
impact of the Patient Data Cards
Introduction
The AIM exploratory
action was launched on Mth
February 1989, when more
than 200 proposals were
presented to the Commission. After the technical
audit, 43 projects were accepted, covering the tasks as
defined in the AIM
workplan. Nine proposals
were received covering task
330 but none were accepted,
as all covered field trials
with little or no R&D aspect.
The Commission therefore
proposed that the coverage
of this task be referred to the
AIM Management Committee.
A I M Management
Decisions
The AIM Management
Committee (AMC) decided
on the 3rd of July 1989, to
address the task coverage in
this area by the formation of
a Working Group to produce
a Report, by June 1990, with
the objectives and structure
(2) Health care is now commonly provided by a team of
professionals who have to
share information about their
patients.
Patients and professionals must be able to access
health data when it is
needed, regardless of
whether they are visiting
their family physidan or
attending an emergency
department in a foreign
country. Relevant information on health care provided
to a dtizen in one region
must be easily available
when needed for other
Background
health care providers, reTwo conditions have
gardless of the country.
created an increasing dePatient Data Cards (PDC)
mand for good communications across Europe, between are already available, and
permit part or all of the
health care users, among
doctors and other health care medical record to be carried
by the subject of the record.
providers, among health
They have been impleadministrations and third
mented in several field trials,
party payers. (1) Both pausing several alternative
tients and doctors have
technologies. They may
gained increased mobility,
improve the quality and
seeking care at different
effidency of care by enabling
institutions, in different
places, in different countries; the patient to have greater
described below. The Working Group will consist of two
representatives from each
Member State, a Commission
representative, and a representative from the AMC.
The representatives will be
experts in the field of medicine, health administration,
or medical informatics.
The AMC also proposed
that the Working Group
should have its first meeting
on the 7th of September
1989.
�Smart Card Monthly
April 1990 I 9
mmmmmmmmmfmmmmmmmmmmn*
mobility and choice, by
improving the speed and
accuracy of communications
between professionals, and
by offering the patient more
responsibility in health.
They may offer health care
professionals greater opportunity for interacting, provide immediate access to
vital information in case of
an emergency, and can cut
much of the work in record
administration. They may
also act as a bridge between
different financial systems,
and as an integrator in the
European health care environment.
Besides the possible
functions defined above.
Patient Data Cards must also
ensure confidentiality and
data security, avoiding the
possibility that unauthorized
persons have access to sensitive information.
Objectives
This task aims at harmonizing the development and
•
implementation of data cards
and associated technologies,
and to examine their impact
in the wider context of an
Integrated Health Environment in the Community.
It is proposed by the AIM
Management Committee
(AMC) to establish a Working Group whose responsibility will be to present a
Report to the AMC in June
1990. This Report will contain the following:
• an assessment of the state
of the art of Patient Data
Cards, including hardware, software and existing experiences on a
national and/or international level;
• a description of the requirements and conditions for preserving
confidentiality of the data
and privacy, and an
assessment of the use of
PDC within a well defined specific area of
health care;
• recommendations for
future cooperation be-
*
tween different organizations of the health sector
of the Member States;
an agreement on a common data requirement for
registration, structure
and protection, in order
to reach a Standard.
Practical Approach
Standards need to be
devised for PDC, regarding
the content of cards, the type
of cards, and PDC readers. It
is not a problem of having
further field trials nor product development but, instead, having a broad coordinated action to bring about
the definition of necessary
needs in terms of information requirements across
Europe, across health care
providers and third party
payers, and among manufacturers of PDC technologies.
• the PDC Working Group
should be well balanced
between medical/mediMore, next page ...
�Smart Card Monthly
April 1990 I 10
mmmmmmmmmmmmmmmmmmmmmmmm
*
Patient Data Cards
5. Analysis of functional
spedfications on security
and confidentiality of
data contained in Patient
Data Cards, and on
•
access to health data in
case of emergency.
Key results and
6. Forecast of the future
milestones
options in Data Card
•
1. Report on past and curTechnology (DCT) as
rent Patient Data Card
related to user requireinitiatives in Europe.
ments.
2. Review and strategic
assessment of current and 7. Proposal for a European
strategy on Patient Data
planned initiatives in the
Cards, acceptable at the
United States and Japan
social and medical levels.
with respect to technological options and mar•
ket perspectives.
For more information,
3. Proposal about the needs
contact Dr. S.S.Baig, AIM
and options for harmonizing Patient Data Card Coordinator, Commission of
the European Communities,
technologies across
Diredorate General Xm/F,
•
Europe, across health
Telecommunications, Inforcare providers and third
mation Industries and Innopayers. The proposal
vation, TRE 1/23 Rue de la
should reflect a wide
Loi 200, B-1049 Brussels,
consensus among the
Belgium. Tel: (32)-2-236main actors in the field
3512. Fax: (32)-2-236-0181.
and indude the views of
•
patients, health care
providers and administrators, third party payers, and data card technology manufacturers.
The Working Group will 4. Analysis of functional
also define a precise working
spedfications for technifuture strategy, taking into
cal requirements, on
account the characteristics of
content and data structhe action (duration, budget
ture in Patient Data
for Community fund contriCards.
cal informatics and health
administration experts
who will be nominated
by the AMC;
the Working Group will
be composed of two representatives from each
Member State;
a European group of key
industries involved in
this technology in terms
of hardware, software
and services will be
formed to interact directly with the Working
Group in a series of
hearings;
to enhance efficiency, for
particular expert knowledge in this field, expert
help will be sought on
contractual bases;
a Commission representative will act as a coordinator for the working
group, with responsibility of reporting to the
AMC on its developments (Project Officer);
representatives from the
AMC with specific interest in this field will also
join the Working Group.
butions) and the necessity to
establish dear coordination
on spedfic tasks and time
schedule.
�Smart Card Monthly
••••••a •
•••••
By Tim Benson
Abies Informatics Ltd.
April 1990 I 11
••.«•
••
• • *
•
Health Cards- •The Move Towards
Standards
Mag Stripe Cards Alreday
in Use
Patient-held computerreadable medical cards will
be one of the major growth
areas of the 1990's. The first
generation of magneticstripe health cards are already being introduced for
the entire populations of
Portugal, Spain, West Germany and the Canadian
Provinces of Saskatchuan
and British Columbia. These
cards are essentially aids to
patient identification and
billing, and operate rather
like medical credit cards.
the consultation. Patients are
notoriously poor historians,
and the availability of a full
validated history at the start
of every new episode of care
can save much doctor's time
and prevent many clinical
tragedies, where inappropriate treatment is given simply
because the patient was too
ill or too forgetful to give the
doctor a full history (or
maybe the doctor forgot to
ask). The Smart Card will
save taking repetitive medical histories and may reduce
the risks of malpractice.
Accurate knowledge of
past history and prevention
status may be used to
prompt the doctor to carry
out prophylactic and preventive medicine procedures
such as tetanus boosters and
cervical smears at the approved intervals.
Smart Cards Offer
Benefits
This paper concentrates
on the Smart Card, containing a computer and memory
on an integrated circuit chip.
The medical Smart Card is a
patient-held electronic medical record, offering benefits
Improved Patient
to doctors, patients and
Participation
payment authorities.
We live in an increasingly
For doctors, the medical
consumerist society, in
Smart Card offers the availa- which the patients want to
bility of up-to-date, accurate be involved in their own
patient history at the time of health care. In most coun-
tries, the patient can choose
which doctor to visit, but any
encounter with a new doctor
requires an extensive history-taking process which is
error-prone and expensive in
time. The availability of the
medical history on a Smart
Card will revolutionise
patients' opportunities to
choose their clinicians, while
avoiding information loss
and risks which occur now.
Patients have a right to
inspect and check data held
on electronic computer
systems under most data
protection legislation. It is
an easy matter for patients to
be offered access to a unit
where they can check the
contents of their own medical cards, after entering their
own PINs (Personal Identification Numbers). The
availability of such data to
patients leads to a new sense
of partnership between patients, their doctors and
other members of the health
care team having access to
the Smart Card, such as
nurses, dentists, pharmacists.
More, next page...
�Smart Card Monthly
April 1990 I 12
Health Cards
dental practice, two accident
and emergency centres and a
diabetic clinic (1). More than
9,000 patients have been
issued Smart Cards, and
patient acceptability has
been excellent. The Cards
used are Bull CPS, and these
are read using the Abies
Clinical Information System
Saving Money, Too
and special Care-Card AcPayment organisations
cess Software (CCAS) develstand to gain, too. The cost
of caring for a patient can be oped by Abies Informatics,
Ltd. (2).
cut by reducing repetitious
The system allows each
history-taking, examination
and testing. If a patient takes member of the health care
team to read and update
a second or third opinion,
relevant parts of a shared
the data from the previous
medical record for each
encounters is available to
patient. Each Card has its
each clinician. It would be
own personal identification
open to the payment agennumber (PIN), which procies not to pay for purely
tects the data held on the
repetitious data collection.
Card.
Furthermore, the reliability
A Card may be viewed
and validity of patient idenby the patient inserting it
tification and clinical data is
into a reader and typing the
likely to be far higher if the
correct PIN, similar to the
same data is used both to
method used in bank cash
treat the patient and for
dispensers. Authorised
billing purposes.
users have special key-cards,
which are also secured by
the use of a PIN, and which
Exeter Care Card Trial
The major trial of medical determine access to those
parts of a patient's record
Smart Cards in the UK is
which they can see.
being undertaken at the
In the Exmouth project,
seaside town of Exmouth in
the Smart Card is used
Devon. It involves eight
family doctors in two clinics, principally as a way of
carrying medical record data
eight pharmacies, a large
and the emergency services.
The availability of a full
accurate medical history
increases the feeling of
involvement of the ancillary
medical services, the patient,
and the family.
from one place to another in
a secure way; from the
diabetic clinic to the GP,
from the GP to the pharmacist, to the dentist or to the
emergency services. Each
user keeps his or her own
separate database, and one
of the jobs of the Care Card
Access Software is to ensure
the consistency of the data
held on the different databases.
Need For Universality
The ideal medical Smart
Card would be as universal
as a credit card. That is, it
could be read equally well in
London, Tokyo or Paris.
This will require standards.
It is not a practical proposition to require that all clinicians world-wide will have
to use Abies Clinical Software, or to require that all
patients use Bull CPS Smart
Cards. What is needed is a
set of standard interface
messages which will allow
any compliant clinical supplier to write to any compliant Card. This standard
should not restrict itself to
purely Chip Cards, but
should also extend to include
the needs of optical cards.
From a logical point of
view, the links between a
�Smart Card Monthly
April 1990 I 13
mmmmmmmmmmmmmmmmmmmmmmmm
clinical system and a medical
Smart Card is just a special
case of the wider problem of
electronic data interchange
between heterogeneous
computers, which is already
the subject of standardization activity such as IEEE
P1157Medix.
•
on a printout. The use of
codes and local interpretation tables is what permits
translation of the medical
Smart Card into English,
French or Japanese.
Summary
In condusion, the medical Smart Card offers major
potential benefits to diniSpecial Problems in
Coding
dans, patients and payment
One special problem in
agendes by reducing the
medidne is that of coding
need for repetitive history
(3). Coding is essential in
taking, and by providing
medical Smart Cards because relevant information where
of size limitations, and also
and when it is needed. The
because computers cannot
goal of a universal medical
handle the ambiguities of
Card will require further
normal medical terminology. work on achieving consensus
The Exmouth projed uses
about medical coding systhe Read Codes, the most
tems and the interface mescomprehensive medical
sages between various clinicoding system in widespread cal software and proprietary
use anywhere. This covers
Cards.
the whole breadth of dinical
medidne with some 100,000
codes covering diagnoses,
References:
procedures, history, examination, tests, andll forms of (1) Hopkins R, 'The Exeter
therapy and administrative
Care Card" Proceedings of
arrangements, using the
UK Conference on Patient
form and language normally Held Computer Readable
used by doctors.
Medical Cards, 1990 Exeter.
Data is held on the medi(2) Markwell D, "Software
cal Smart Card in coded
form which is interpreted by Integration of Smart Cards
the reading computer system with an Existing Clinical
Information System" Profor display on the screen or
*
ceedings Smart Card '89
London
(3) Read J and Benson T,
"Comprehensive Coding"
BJHC Vol 3 No. 2, May 1986,
pages 22-25.
For more information,
contart Tim Benson, Abies
Informatics Ltd., Swan
Centre, Fishers Lane,
Chiswick, London W4 1RX,
England. Tel: (44)-l-9951331. Fax: (44)-l-994-2193.
�April 1990 I 14
Smart Card Monthly
Health Care Capsules
The following are brief
items about health care
projects reported in earlier
issues of Smart Card
Monthly [issue date is shown
in parentheses].
Blood donor control
[8/88-pll].; In an effort to
control the spread of AIDS,
Smart Cards are being tested
in France for use by blood
donors. Holland is expected
to implement a similar
project in 1989.
Florida Hospital trial
[ll/88-pl5]; A six-month
trial has been completed at
Florida Hospital, where
AT&T contactless Cards
have been used with 300
selected patients.
Pharmacy program
[ll/88-pl2,12/88-pl3, and
2/89-pl3]; In Ontario, Canada, 4,000 pharmacists will
be wired into a Smart Card
system to provide intervention in harmful drug dispensing practices. Toshiba
Cards are being used.
Optical cards for medical
records
[5/89-pl6]; Olivetti purchased $128,000 worth of
Drexler LaserCards™ for
20,000 patient "Individual
Health Booklets" project on
Sardinia.
tient administrative and
basic medical information.
JC Sante—A Personal
Health Card Program
[2/88-pl3]; Implemented in
Japan in 1985. About 50
hospitals are linked to the
system which stores information relative to medical
examinations about 1,500
people.
Welch School of Pharmacy
[6/87-p9 and 6/88-pl4];
Using GEC Contactless IC
Memory Cards.
Seibu Saison Issues Cards
[2/88-pl3]; As of January
1986,12,000 Smart Cards,
with 64kbits of memory,
were issued for personal
health records. Now, 300
hospitals are linked.
IC Memory Card-based
Medical Card System
[ll/88-pl6]; Developed by
Fujitsu and Towa Electron.
Initial distribution of Cards
to 200 parents of infants in
the village of Sasauchi-mura.
Trial on Awajishima Island
[2/89-pll]; A 500-participant trial, in response to
desires of the Ministry of
Health, using 64 kbit ISOconfigured IC Cards.
Swiss Medical Technical
Institute 'Sanacard'
[6/89-p6]; Three thousand
CPS Cards, containing pa-
Limited Patient's Rights
[7/89-p8]; Twenty-one
American States have no
laws guaranteeing patients
access to their hospital and
physicians' office records.
Only 23 States and the District of Columbia let patients
see both kinds of records.
[From Hippocrates, magazineMarch/April 1989].
�Smart Card Monthly
April 1990 I 15
By Dr. Robin J Hopkins
Bsc Med Sci, MB CHB, MRCGP
The Exeter Care Card
A CP8-bused global health care record for the United
Kingdom's National Health Service.
Background
In the United Kingdom,
health care delivery is provided by a distributed framework of "Care Providers"
ranging from the Family
Doctor to specicdized hospital services. Within these
boundaries lies a diversity of
services such as doctors,
dentists, community pharmacists, opticians and nursing staff.
Traditionally, the central
medical record co-ordination
has been produced by directing all information flows
towards the family doctor.
Add to this the diversity of
patient contacts, the unpredictable nature of their
movements within the
Health Service plus a large
number of discrete health
provider sites, and an information transfer nightmare
becomes apparent.
The advent of computerization heralded some hope
for improvement, and at
present, every Family Practitioner Committee and District Health Authority in the
U.K. is computerized. Over
30% of family doctors' sur-
geries, 16% of dentists, 8% of
opticians and a large proportion of pharmacists are
similarly equipped.
Within this information
framework, multiple types of
shared care record already
exist to aid information flow,
health care delivery and to
act as "aid memoires" to the
provider. These records tend
to be directed at specific subgroups of the population,
such as diabetics, hypertensives and pregnant women.
They depend on the patient
retaining the record and
being responsible for its care,
distribution and access by a
multidisciplinary health care
team. With increasing computerization, further shared
care mechanisms were developed, and a whole new
range of needs were identified as it became apparent
that better health care could
be provided by a health care
team operating from a single
unified health record.
Computer Link-ups
Required
Medical computing in the
U.K. has had a staggered
start, and a multiplicity of
systems have developed
with little thought given to
standardization of systems
or intersystem communication. This has resulted in the
situation where massive
national investment in information technology (IT) has
produced systems and hardware that are often incapable
of direct communication.
Current NHS strategy is
to develop a continuous
integrated OSI(P88) compatible network to link all
family practitioner service
regions, the Central NHS
Register, The Prescription
Pricing Authority, and the
Dental Estimates Board with
all family doctors, dentists,
pharmacists and opticians.
There will be nodes on the
network that can be accessed
by Regional Health Authorities and individual hospitals.
Such a system is satisfactory
for bulk deliveries of nonsensitive data, but is not
appropriate for the passage
of individual patient inforMore, next page...
�Smart Card Monthly
April 1990 I 16
Exeter
mation that has to be both
secure and "on line" over a
large number of provider
sites.
2)
Smart Card Health
Record Project Initiated
In 1987, the Department
of Health instituted a pilot
project to investigate the use
of a patient-portable computerized medical record using
a Smart Card. A working
relationship was created
between D.H., Exter University Postgraduate Medical
School's Department of
General Practice and Bull
[HN Information Systems,
the prime contractor], with
the added help ofAbies
Informatics, AAH Meditel
and Data Card U.K., to
design, build and evaluate
the use of such a record
within the U.K.
Computer System
Requirements
Despite the excellent
work carried out in this area
throughout the world, none
of the existing systems
matched the needs of the
N.H.S. which were:
1) To allow the unambiguous communication of information
3)
4)
5)
between" dissimilar
computing systems",
both in terms of software
and operating systems.
To allow patients to have
secure copies of their
medical records, to which
they also would have
access, in their possession
at all times, and thereby
allow operation from a
common dataset.
For the computerized
record to act as a global
health record from which
each health care
professional's computer
could pull data sets,
appropriate both in terms
of security and information needs.
To cater for the mobility
of both patients end
health care providers.
That the system should
allow graded levels of
access to information,
appropriate to the needs
of the user, who should
have the possibility of
movement to any NHS
site, and still be able to
interact with any site's
computer system.
Read Clinical
Classification Adopted
In order to allow the
unambiguous communica-
tion of data within such a
network, a common coding
system has to be used on the
Card, which can then be
translated into the host
system's code on reading.
The Care Card is designed to
store information using the
Read Clinical Classification,
as investigation revealed that
this was the only coding
system capable of encompassing all the information
transfers required within the
NHS.
The Read Clinical Classification is a five digit alphanumeric hierarchical classification using both upper and
lower case characters, and
has a theoretical maximum
number of codes in excess of
256 million. It contains both
proper terms and synonyms,
encompasing the whole of
ICD-9, ICD-9 CM, RCGP
codes, ICHPPC, CPS and
OPCS codes, and will map to
many others. It allows for
easy computer handling,
with automatic code look up,
and can be used by all sections of the Health Service.
In addition to the use of
the Read code for data storage on the Card, a data
compression technique was
developed to allow full use
of the 16kbit CPS Card used
for the trial.
�Smart Card Monthly
April 1990 I 17
mmmmmmmmammmmmmmmmmmmtrmm
Security Issues and
Solutions
Security of the system is
provided by in-built CP8
security, the use of passwords and PINs. It is by the
use of these devices that a
health care professional is
able to pass information
from his "Key Card"(an
identical CPS Card), to allow
access to different computer
systems, configure the terminal at which he intends to
work, and also gain access to
data on patient held Care
Cards.
Access to data contained
on the Card is determined by
codes built into the Key Card
and an interplay of security
statements and software
routines built into both host
system and the Care Card
itself.
An intensive investigation discovered that the
information needs of the
health service required three
levels of security to information.
1) Some information e.g.
registration details and
health care provider
details could be regarded
as protected access, but
should be freely available
within the service once
entry to the system had
been granted.
*
2) A second level of information needed further
security but should be
freely available, in a lifethreatening situations, to
paramedical staff and to
some other health professionals such as pharmacists.
3) A third level of information required a yet higher
degree of security and
should only be granted to
doctors and dentists.
nity pharmacist, as well as
the distant District General
Hospital. [Ed: Cards were
issued to all patients belonging to one practice, plus all
those aged over 65 and
under 5 years of age from a
second practice, and all
diabetics in the Exmouth
area].
All the sites have discrete
computer systems that are
not linked in any other way,
which, with the exception of
the dentist and pharmacists,
were already in existence
Within this framework,
prior to the start of the trial,
there exists a matrix of read
and write statements appro- and have only had the Care
Card interface added to their
priate to each user.
existing software—thereby
mimicking the global NHS
situation.
The Trial at Exmouth
At the doctors' surgery,
The trial has been conlike other sites, the Card
ducted in the Devon town of
allows instant identification
Exmouth (population
of the appropriate patient
32,000), the site being chosen
for having a socio-economic record (gone is the nightdistribution closely matching mare of writing things in the
that of the national distribu- wrong notes), and transmits
information from other sites
tion, and also for having a
to the doctor's computer.
contained environment.
Eight and a half thousand During the consultation,
Care Cards were distributed information is added to the
to patients for the start of the computer and at the end, this
data, plus an electronic
trial on 1st March 1989, and
have been in continuous use prescription, can be transmitsince that time, allowing the ted to the data base on the
Card. The system in use at
passage of information
between family doctor,
dentist, hospital and commuMore, next page...
�Smart Card Monthly
April 1990 I 18
mmmmmmmmmmmmmmmmmmmmmmmm
•
Exeter
the two doctors' [GPs] sites
in the trial is also available
on a laptop computer for use
on home visits or at a branch
surgery or clinic.
Upon leaving the
doctor's, patients are able to
take the Card to one of the
eight pharmacies in
Exmouth, and use it to
provide both clinical information for use in pharmacy
prescribing, and over-thecounter sales, as well as the
electronic prescription. The
pharmacist is able to use the
data automatically provided
to maintain adequate patient
dinical records as well as
automatically produce dispensing labels. On completion of dispensing, he updates the Card, thereby
passing a dispensing marker
identifying the dispensing
pharmacy, which also acts as
a first line patient compliance check for the doctor.
At the [single] Dental site
involved in the trial, data on
the Card can be read and
added to the dinical notes of
the dentist.
Because of the complexity
of the system, and the fad
that over one- third of doctor
attendances will result in a
prescription, plus the impad
of repeat prescribing, a large
number of Card interactions
takes place every day, and
the system appears to be
both robust and meeting the
information needs of users.
The trial evaluation
ended on 1st March 1990, and
a full evaluation report will
be published.
Note: Items in [brackets]
were inserted by the editor.
Dr. Robin Hopkins is the
research fellow assodated
with the Exeter Care Card
Projed, and is contadable at
The Dept. of General
Practice.University of
Exeter,Postgraduate Medical
School, Barrack Road, Exeter,
Devon, EX2 5DW England.
Tel: (44)-392-31159. Fax:
(44)-395-276156.
�Smart Card Monthly
April 19901 19
• ••••••••••n
a
*
Gemplus Card International
French Mutual Insurance (FMF)
Cards
Multi-function Card
Ready to Go
The health Card of Les
Mutuelles de France is now
operational, and large-scale
distribution is planned for
1990,1991, and 1992.
The product applies
Smart Card technology to
the fields of health and Social
Security in France. It has
been designed to fulfil multiple functions, and currently
offers three types of service
to its users:
1. Portable administrative
file centralizes all information concerning identification and opening of
rights to insurance coverage. The file replaces
paper copies, and is used
for off-line management
of transactions in complete security. If necessary, remote updating
can be carried out from
the practitioner's or the
insurance company's
offices.
2. Mode of payment for
medical and paramedical
expenses. It operates
witohout reference to an
authorization data base,
in the context of deferred
payments by bank debit
or revolving credit systems.
3. Portable medical file,
comprising the bearer's
emergency health Card,
established in accordance
with European standards,
and a personalized preventive information area.
or existing computer
equipment.
• A database used to:
— carry out remote collection of financial operations and to interface
with banking organizations.
— carry out remote
updates of portable administrative files.
The medical file is updated by the supervising
Readers are connected to
practitioner. Read and
the database by means of a
write access are protected TRANSPAC [X.25 packet
by the bearer's secret
switching network] link.
code.
The technical design of
the system enables it to
adapt easily to all existing
computer environments.
Technical Details
The technical architecture
For more information,
of the system is based on:
contact Ms. Aline Calvo,
• a microprocessor-based
Public Relations, or R6my
Smart Card (COS 32k
Toimac, Marketing Manager,
EPROM, from Gemplus
Healthcare, Gemplus Card
Card International), for
International, Pare d'activites
which specific security
de la Plaine de Jouques,
functions have been
Avenue du Pic de Bertdeveloped to meet the
agne—B.P.100,13881 Gerequirements of medical
menos Cedex, France. T61:
privacy.
(33) 42.32.50.03. Fax: (33)
• A low cost Smart Card
42.32.50.90.
read unit installed in the
practitioner's premises,
operating in liaison with
a teletex unit ("Minitel")
�Snwt Card Monthly
April 1990 I 20
Gemplus Card International
Description of the Hippocarte
System
Combining Health and Payment Functions
Multiple-Function Health
Card
This health practitioner's
authorization Card provides
three functions:
1. Access control to the files
on the patient Card, or to
a data bank.
2. Electronic signature of all
write operations on the
patient Card, or of any
telematic transaction.
3. Encryption of data destined for secure and
confidential transfer of
personal medical information.
gency files are automatically
created on all Cards. The
other files are created by
medical practitioners, according to their authorizations and the space available
on the Card.
The application is designed to incorporate specific
files as required. The initial
Cards selected are Gemplus
Card International's COS 8,
32kbit EPROM Cards.
nation of a patient Card with
a practitioner Card. Possible
applications of the system
will be easy to imagine.
Launch
The application will be
launced in the Calvados and
Manche departments in
March 1990. One million
inhabitants and 1,800 doctors
are involved. Planned penetration in the first year is 3%
[Ed: 30,000 patient Cards].
This will require coordiThe Card Reader
In the Hippocarte system, nation of the training of
a reader dedicated to a single practitioners, supply of
reading equipment and
application is not required.
Hence, the idea of combining authorization Cards, supply
The Patient Card
the health application with a of equipment to treatment
This is the Portable
centers, and distribution of
Health Record of the patient, bank electronic payment
patient Cards via previously
applications. CARTSAGE
organized into files, taking
500 terminals, manufactured established distribution
into account the European
by SAGEM, and installed by networks. After a first evaluEmergency Norm:
ation, at the end of 1990, the
the Credit Agricole de la
• Identity
model tried out in NorManche, are capable of
• Emergency treatment
mandy will be transferable to
performing this dual func• Health record
other regions. Contacts have
tion.
• Prescriptions
already been made.
Similarly, the reader
• Biological information
authorizes user connection to
• Specific applications (e.g.,
sports health card, mater- remote data gathering centers or databases. These
nity care, etc.).
Evaluations
connections are protected
Technical: Gemplus Cards
and identified by the combi- have already been used in
The Identity and Emer-
�Smart Card Monthly
the health field. This is,
however, the first time that a
health function has been
combined with a payment
function. Evalimtion Managers: P. Lesteven, G. LeFay
Medical: This will be the
first time that enough practitioners have had the equipment to circulate validated
medical information. Evaluation Manager: Dr. P. Aubourg
Commercial: This will be the
first time the "CarteSante"
has been marketed outside of
experiments. Strategy will
be based on a marketing
analysis designed to allow
self management.Evaluah'on
Manager: P. Coppin.
For more information,
contact, at Gemplus Card
International, Aline Calvo,
Public Relations, (33)42.32.50.03, or Remy de
Tonnac, Marketing Manager,
Healthcare, (33)^2.32.50.22,
or Bernard Morvant, Marketing, (33)-42.32.50.26.
Gemplus' fax number is (33)42.32.50.90.
April 1990 I 21
�Smart Card Monthly
April 1990 I 22
mmmmmmmmmmmmmmmmmmmmmmmm
*
SM
IntelliScan : A Patient Card That
Aids Health Care Marketing
many hospitals are customizing patient cards with hospital logos or marketing program names. The customized card, carried by the
patient, then serves as a
repeat reminder of that
hospital being one that
provides modem, technology-based patient-oriented
services, and enhances the
hospital's overall image.
The Patient Card system
enables marketing directors
to generate additional high
margin revenue. The marketing director can identify a
specific patient group, develop a program and/or
service, and promote a
campaign that utilizes the
Patient Card system to reach
this target audience.
Buzz Tanner, Director of
Marketing for Charter Medical Corporation's Middle
Georgia Hospital in Macon,
Georgia has just introduced
their "Priority Plus" program, using IntelliScan
cards. The Priority Plus card
holders are entitled to discounts at all three hospitals,
the Charter Urgent Care
Center, and participating
retailers, which include a dry
Card is a Marketing Aid
To encourage immedicate cleaner, a pharmacy, a durable medical equipment
recognition and loyalty.
Card Uses Optical Data
Encoding
American Medical Data
Corporation currently provides patient care cards
which use an optical data
encoding vehicle called a
datastrip. AMD gathers,
enters and stores petinent
demographic, insurance,
medical, and other patient
data on a wallet-sized card,
and mails it to the patient.
On the back of the IntelliScan ^ Patient Card are up to
350 chararacters of human
readable text and a datastrip
that holds up to 850 characters of optically encoded
data. When the cardholder
comes to the hospital for
services, the Admitting staff
place the card in an optical
reader, and the information
contained on the card appears on the clerk's computer terminal to be verified
and transferred to the Admission software. The elimination of the necessity for
manual forms increases
accuracy, reduces time, and
speeds payment for services.
51
distributor, a beauty salon,
and a barber shop. Using
direct mail and a Preferred
Provider Organization (PPO)
to promote Priority Plus, the
hospitals' goal is to distribute 10,000 cards within the
first year.
As another component of
AMDC's IntelliScan program, the marketing Director
is provided with a monthly
tracking report which measures the use of the card by
each patient group. Custom
database reports are also
available which allow the
marketer to gather information on cardholders that will
guide decisions on future
hospital services and marketing programs.
Card Service Pays For
Itself
According to AMD, if a
hospital goes in-house to
create the simplest laminated
paper patient card, riting
only the hospital's name and
program to be promoted, the
cost for labor and equipment
can run from $6.23 to $7.90
per card. For slightly more,
AMD provides a complete
turnkey patient card system.
The incremental high margin
�Smart Card Monthly
• •••••••••••••••••••a
revenue generated by the
sytem, combined with the
potential savings for Admission, Business Office and
Medical Records, can return
the hospital's initial investment many times over.
For more information,
contact Beverly Korfin,
Director of Marketing,
American Medical Data
Corp., Suite 500,125 Clairmont Avenue, Decatur, GA
30030 USA. Tel: (l)-404-3719393. Fax: (l)-404-373-9493.
[Ed: The data strip on the
back of the card is about 2-1/
2 inches long and 9/16ths
inch wide, with over a dozen
closely packed tracks running ihe length of the strip,
and encoded in black ink on
a white background. It has
somewhat the appearance of
a super-complex bar code.]
April 1990 I 23
• •••••
•••••
» .»•••• ••
» •.••»••
4
�S i ^ t Card Monthly
April 1990 I 24
Gemplus Card International
MUTUSANTE Card
In France, medical treatreceive the complementary
ment is carried out under
reimbursement.
one of two diffemt scenarios,
After processing the
as follows:
form, the insurer reimburses
the patient.
Usual Procedure
The patient gives the
payment for treatment (examination, medicines, analyses, etc.) directly to the
practitioner.
The practitioner fills in a
medical form, certifying the
nature of the treatment
given, and gives it to the
insured patient.
The patient sends this
form to the local Social
Security Office (SSO).
The SSO processes the
medical form and reimburses the insured patient
the portion of the cost covered by the National Social
Security System.
If the insured patient has
complementary coverage
with an insurance organization (mutual insurance
society or private insurance
company), the SSO sends
that patient a form stating
the amount of the expenses
not covered.
The insured patient sends
this form to the insurance
organization in order to
Procedure of Direct
Payment by Insurers
This procedure only
applies to medical practitioners who have signed a
direct-payment agreement
with the SSO.
Ths insured patient
presents a plastic card issued
by the SSO. The card contains information about the
patient's reimbursement
rights, together with the
expiry date. It must be
updated regularly.
This card entitles the
holder to be exempted from
paying the costs covered by
the Social Security. The
holder only pays the difference.
The medical practitioner
fills in a form listing the
details of the treatment rendered, and sends it to the
SSO.
The SSO sends the patient a statement to be sent to
any complementary organization, in order to receive
reimbursement.
Simplifying the
Procedure
It will be seen that the
situation is similar for both
the procedures described:
• There are a large number
of documents to be filled
in, exchanged and processed.
• Management costs are
immense, and there is
considerable room for
mistakes. It should be
pointed out that 1.7
million medical forms are
processed each day.
Nevertheless, in spite of
the complexity of the system,
there are undeniable benefits
in the direct payment system, whereby the patient no
longer has to advance costs.
Hence the concept developed by the Mutuella Chirurgicails et Medicals des
Alpes (MCMA), in collaboration with the regional SSO,
to replace all these complex
and clumsy paper transactions with an electronic
exchange of information by
means of a Chip Card: the
MS Mutasant6 Card. This
Card's memory stores the
identification of each insured
patient and the extent of the
patient's coverage.
�Smart Card Monthly
April 1990 I 25
that the system would produce an annual savings of
one million francs, and
therefore did not hesitate to
invest the six million francs
required for the operation.
The MCMA and PCS,
No Investment by the
who have constructed the
Practitioner
Using the MS Mutusante system, chose the COS 32k
EPROM Card produced by
Card, the advantages of
direct payment (particularly Gemplus Card International.
for households with modest This Card is the ideal answer
to the problem of providing
incomes) can be extended
a secure, portable file for any
easily. Practitioners will
have no investment outlay to application.
The MCMA plans in the
make, since the terminal
near future, to indude the
required is supplied free of
patient's medical history in
charge.
the information stored on the
On the contarary, practiCard, to give a more secure
tioners wil increase their
earnings due to thetimeand and rapid health service.
Simplified Statement
effort saved through simpliThe practitioner has no
For more information,
fied management. Claims
more coupons to collect, no
contact Ms. Aline Calvo,
forms to fill in, and no more are processed faster, with
almost no risk of error, and a Public Relations, or Remy
cheques to take to the bank.
Treatment is paid for, within dramatic reduction in paper- Tonnac, Marketing Manager,
Healthcare, Gemplus Card
work results.
five days, by direct transfer
In short, the MS Mtusante International, Pare d'activites
into the practitioner's bank
de la Plaine de Jouques,
account by the MCMA or the Card will considerably reAvenue du Pic de Bertduce the cost of processing
SSO. Until now, it has, in
agne—B.P.100,13881 Geclaims and paying for treateffect, been the practitioner
menos Cedex, France. Tel:
who has advanced payment ment, since these will be
(33)-42.32.50.03. Fax: (33)carried out directly.
while waiting, often for
42.32.50.90.
several weeks, to receive
payment from the SSO and
insurance organizations.
Savings of 1 Million
The lack of funds thereby Francs per Year
The MCMA estimated
created was very expensive
Greater Ef iciency For
Practitioners
The MS Mutusant<§ Card
will provide the patient with
a much faster service. Once
the Card has been inserted in
the practitioner's portable
terminal, the practitioner
only has to enter the price of
the treatment. The system
calculates the total amount,
taking into account the
different rates of coverage
and the different V.A.T.
(Value Added Tax) rates. It
then gives a direct printout
of the medical form, and the
process is complete.
for the practitioner, and
obstructed the development
of direct payment procedures.
�Smart Card Monthly
April 1990 I 26
mmmwmmmmmmmmmmmtmmmmmmma
*
By E. W. Bouldin and Robert Callen
Eirexler Technology Corp.
The Optical Memory Card: A
Portable Medical Record
Background
The optical memory card
manufactured and marketed
by Drexler Technology
Corporation under the LaserCard™ trademark, is a
credit card-sized optical data
storage device presently
configured to hold up to 4.11
Mbytes of WORM (Write
Once Read Many) and/or
ROM (Read Only) data.
Drexler Technology
Corporation (DTC) filed its
first patent applications on
optical memory cards in
March of 1981. Since that
time, 41 U.S. patents on
cards and equipment have
been issued in the U.S.A. and
assigned to DTC. Patent
applications have been filed
in 20 other countries as well.
Japanese companies have
been the most active in
designing and building
read/write drives. Preproduction models (Model
LC-302K) have been available from Nippon Conlux
Company since June of 1988,
and small quantities of
production level machines
became available in February
of 1989. A more advanced
production level machine
will become available in June
of 1990, in quantities of
hundreds per month.
Read/write drives are
available from Olympus
Optical Company in evaluation quantities now, and
Omron Corporation will
introduce production level
read/write drives in evaluation quantities in mid-1990.
These R/W drives all conform to the recently issued
DELA (Optical Memory
Card Standard). LaserCards
written on Omron and
Olympus machines will be
interchangeable with each
other and with optical cards
written on Nippon Conlux
machines.
Canon Inc. has indicated
that read/write drives in
evaluation quantities will be
available in mid-1990, and
plans to enter full production
in 1991.
CSK Corporation, having
successfully completed its
field trials at the Baylor
College of Medidne in Houston, plans to increase the
marketing of its Health
Passport System. CSK is a
leading Japanese software
company and has optical
card R/W drives produced
by Kyocera Corporation.
Optical Memory Card
Standards
Standardization of optical
memory cards is now taking
place worldwide. Such
standards promote rapid
development of compatible
systems, ensuring interchange of digital information
encoded on LaserCards.
• The DELA Optical Memory Card Standard was
published by the European Optical Memory
Card Forum and is based
on the LaserCard.
• The American National
Standards Committee
X3B10.4 is writing a U.S.
standard for optical
cards. This committee
was instrumental in
drafting the DELA Standard.
• The Japan Business Machine Makers Association
ad hoc committee under
the Japanese National
Committee, JTC1/SC17,
�Smart Card Monthly
April 1990 1 27
mmmmmmmmmmmmmmmmmmmmmmmm
•
health examination data
which are stored on personal
health data cards, providing
an offline medical database.
The Ministry of Education is subsidizing a test of
optical memory cards using
Field Trials of Optical
Conlux equipment at hospiMemory Card Medical
tals affiliated with these
Records:
universities:
The application of the
Tokyo Medical & Dental
LaserCard as a portable,
University, Tokyo
personal medical record is
currently the most fully
Jikeikai Medical Univerdeveloped, and as such is
sity, Sapporo Medical
being evaluated in numerous
College, Kinki University,
field trials worldwide.
Jichi Medical University,
Yamaguchi University,
University of Tokyo,
Kochi Medical UniverJapan:
sity, Chiba University,
Odawara City Fhysicians
Kyushu University,
Association has developed a
Nigata University, Saga
medical information system
Medical University,
using optical cards as a
Shimane Medical Univerdecentralized database. The
sity, Nagasaki University.
system uses CSK equipment
to store pediatric examinaIn a joint effort with
tion data on Nyoyoji (babies
Tapan Medical Information
and infants) Health Cards.
Olympus has been evalu- Center and other firms,
Olympus has developed a
ating the "Optical Card
Health Examination System" dialysis data management
system using optical memin municipal and privateory card technology. The
sector clinics in Hakushusystem allows patients to
cho, Yamanashi Prefecture.
The system gathers periodic keep track of their therapy
has recently published an
Optical Memory Card
Standard (Draft), JBMS39-1990, Edition 1.1.
,
and, if put into wide use,
would allow patients to
receive treatment at any
hospital in the country. The
test program will cover
dialysis patients at
Yokohama Dai-Ichi Hospital.
Kurashiki Central Hospital, Okayama Prefecture, has
been testing CSK's optical
card in a health maintenance
system at the hospital's
Center for Total Health
Management. The testing has
shown promising results for
using optical cards as an
integral part of a health
maintenance medical record
system.
The evaluation of
Matsushita's (Panasonic)
medical information system
was successfully completed
at Nahtmec Nanasato Hospital in Saitama Prefecture.
Workstations with clinical
files for particular departments were established for
direct access capability. Data
from other clinical departments were retrieved
through optical LAN or via
optical memory card. DeMore, next page...
�Smart Card Monthly
April 1990 I 28
• •••••••••• •
•••••••••a
•
••I
••
Optical Memory Card
centralized systems appear
to be more efficient and offer
excellent possibilities for
expansion.
Omron installed its
Medical Care Data Control
System at the Mikage Clinic
in Tokachi, Shimizu-cho,
Hokkaido Prefecture. The
system includes the Consultation Room System, which
records doctor's notes to the
patient's card, and the Reception Office System, which
records patient information,
medication dosage data, and
cumulative diagnosis data to
the patient's card.
The Sukoyaka (meaning
healthy) Cards Study Group,
working with the Tokai
University School of Medidne and its affiliated hospitals, has been using optical
memory cards for promoting
a healthy life for the dtizens
of Isehara in Kanagawa
Prefecture. Today, the system stores periodic renal
examination data of elementary and junior high school
students. An optical memory card system for geriatric
health examinations is
planned for the future.
Tapan Assodation for
Maternal Welfare announced
they had introduced a computer-aided system into the
perinatal center of Kagawa
Medical School. This system
uses optical cards in a management system for high-risk
pregnandes, redudng perinatal mortality and morbidity rates.
In late Odober 1989, it
was announced that clinical
trials of a medical data
recording system using
optical memory cards for
patients with pacemakers
would soon start at Teikyo
University Hospital.
Europe
The Department of Obstetrics at West London
Hospital has been conduding a field trial using Conlux
units to read and write
prenatal data, test results
and ultrasound information
of expedant mothers onto
LaserCards. Mr. Alan Willis
of British Telecom and Dr.
Simon Jenkinson, a Research
Fellow at Charing Cross
Hospital and Westminster
Medical School, have
worked on this program. The
trial, initiated in November
of 1988, originally involved
100 maternity patients but
has now been expanded so
that 500 expectant mothers
are carrying prenatal data on
LaserCards. Mr. Willis
conduded, in his address at
the International Seminar on
Optical Cards in Healthcare,
Tokyo 10/89, "The technology has been transformed
from a laboratory demonstration into a system that
has proven itself robust
enough to withstand daily
use in hospitals and offices."
Olivetti, working in
conjunction with the Italian
Ministry of Health, announced a program on the
Island of Sardinia that will
involve 20,000 patients at
hospitals, specialty clinics
and physidan offices. Besides its immediate epidemiological functions, the LaserCard is expeded to streamline the functionality and
effediveness of the health
system and reduce public
health care expenditures.
United States
Dr. J.H.U. Brown, of the
Baylor College of Medidne
in Houston, Texas, has
completed testing of CSK's
Health Passport System at an
outpatient clinic. LaserCards
were used to store patient
medical, diagnostic and
pharmaceutical information.
The Houston Veterans
Affairs Medical Center,
working in conjundion with
Baylor College of Medidne,
�Smart Card Monthly
mmmmmmmmmmmammmmmmmmurmm
will soon begin testing an
advanced version of CSK's
Health Passport System in a
field trial involving 1,000
patients.
The Department of Veterans Affairs Technological
Development Center (Troy,
New York) has demonstrated a Drexler/Conlux
system for storing patients'
medical records. If deemed
practical, this technology
will mean an enormous
saving of time, space, and
money for the 172 VA hospitals and outpatient clinics
nationwide.
For more information on
LaserCards™ or these apecific programs, contact Robert
Callen, VP Technical Services, at Drexler Technology
Corporation, LaserCard
Division, 2557 Charleston
Road, Mountain View, CA
94043, USA. Tel: (l)-415-9697277. Fax: (1)-415-969-6121.
[Ed: Portions of this
paper were presented at the
SPIE/SPSE Symposium on
Electronic Imaging, February
1990].
April 1990 I 29
*
�April 1990 I 30
Smart Card Monthly
• ••••••^••••••••••••••"fca •
By Stephan Seidman
West London Maternity
LaserCard™ Update
In the January 1989 issue
of Smart Card Monthly, we
reported on the live trial of
the LaserCard™ in the UK.
That trial, sponsored by
British Telecom, a Drexler
Technology Corp. licensee,
is now completed, and is
considered to have been
satisfactory. In fact, requests
have been submitted to
continue the use of the
LaserCards at the hospital,
which was, by the way. West
London Hospital.
The following notes are
abstracted from a slide
presentation made to a
Japanese audience, by Dr.
Simon Jenkinson, Research
registrar at the Charing
Cross and Westminster
Medical School, and a significant member of the
LaserCard trial program:
Prenatal System at West
London Hospital
• 547 patients were recruited to the trial. All
gave their informed
consent to be randomly
allocated to the study
groups. 251 subsequently
had, or intended to have,
full antenatal care. The
last patient in the trial
delivered in August,
1989.
• The experimental group
would use the computer
system and carry their
notes on the optical card.
The control group would
have records in a booklet
designed specifically for
the trial, as a full antenatal record containing
exactly the same data
items as the computer,
and would carry this also.
• In addition to evaluating
the performance of the
technology, the hypotheses to be tested were that,
for the computer and the
optical card system,
when compared with a
conventional system of
record-keeping:
—there would be no differences in attitudes of
the patients;
—there would be no difference in attitudes of the
hospital staff users;
—there would be no difference in the consultation times;
—there would be no difference in the number of
data items recorded.
Approximately 100 staff
use the system at one
time or another, including clerks, midwives,
doctors, ultrasonographers, dieticians, and the
patients themselves. All
computers are linked to a
local area network
(LAN), which allows easy
sharing of data. All
computers require password security clearance
before patient data can be
viewed or manipulated.
This function is handled
by the LAN. All the data
is stored on the optical
card, which is held by the
patient. This allows
transfer of this data to
other health workers in,
for example, peripheral
clinics or GP surgeries.
Review of regular visits
displays the data in a
tabular format. Ultrasound reports are
availalable at once.
Measurements can be
plotted quickly to demonstrate fetal growth. All
data in the record is
scanned at the end of a
visit to display action
�Smart Card Monthly
suggestions.
• At the time of this presentation, 3300 consultation had taken place on
the optical card system.
The functional error rate
recorded overall is 3.5%.
• Patients perceived the
computer system to be
quicker and more efficient, but less useful to
them and more likely to
be lost.
• Plans are now in hand to
expand the system to
include GPs and peripheral clinics adopting
shared antenatal care
between 2 sites.
For more information,
contact Alan Willis, British
Telecom, General Manager
Customer Skill Centres, Rm
9042, Tenter House, 45
Moorfields, London EC2Y
9TH, England. Tel: (44)-l250-8118. Fax: (44)-l-2508988. Dr. Simon Jenkinson
is a Clinical Research Fellow,
Department of Obstetrics
and Gynaecology, Charing
Cross and Westminster
Medical School, London W6
7DQ England.
April 1990 I 31
�Smart Card Monthly
April 1990 I 32
By Philippe Cirre
Association Santal
•* •
•
&
Santal
"The Health Card to
Make Your Life Easier"
The Santal operation is a
unique trial being run in the
region of Saint-Nazaire in
western France, backed by
the Ministry of Health, and
managed by health professionals.
The project entails testing
and evaluating the potential
for using a Bull CPS Smart
Card as a portable patient
file. The function of the Card
is to streamline the transfer
and processing of information in the health domain.
The Card is supplied to
the public through the Santal
Association, which embraces
public and private hospitals,
general practitioners, test
laboratories, the Security
Sodale (national sodal
insurance), and private
health insurance organizations within the region. It is
created when the patient is
admitted, but can be refused
without affecting the standard of care given.
Three Data Areas
The Card contains three
data areas, immediately
available when presenting
the Card:
• Administrative area: contains holder's identity,
personal data, and medical insurance coverage.
• Medical area: this is not a
comprehensive record,
but essential information
for earlier and safer care
management. Itindudes
the patient's background,
hospital stays, treatments, main examinations, etc.
• Blood Group area: These
data can be accessed
without a professional
authorization Card and
holder's consent.
the on-Card microprocessor,
vital health information is
supplied to the physidan,
espedally important in case
of emergency, to provide a
better understanding of the
patient's medical background, and to foster a more
accurate diagnosis. Santal is
a communications system.
The Card really excels in
a hospital environment, but
is also used by general practitioners.
Civil Liberties Protected
The Santal trial does not
infringe upon dvil liberties.
The French National Commission on data processing
and Civil Liberties has given
Designed to Lighten the
a go-ahead for the Santal
Load
The Santal Card is made operation, with:
—patient and doctor volto lighten administrative
untarily praticipating
formalities and make the
—medical secret preserpaitient's life easier; one
vation
small Card instead of many
—access control via audocuments, with automatic
thorization Card
entering of data into the local
—full access for the
system. Admission is that
patient through medical
much faster.
mediation
It makes it easier to
asume medical responsibility: Santal Card is designed
as a high-security multiAcceptance Level High
purpose Card. Proteded by
The early Santal project
•
�Smart Card Monthly
assessment (start-up was on
January 1988) shows an
excellent acceptance level
from patients, with 25,000
Cards created, and good
convenience of the data
content for the 200 doctors
involved.
1990 Plans Include
Foreign Cooperation
For 1990, Santal incentives are to facilitate the use
of the Card with new and
ergometric software, and to
cooperate with foreign
experimenters by working
together on the health Card
concept and medical content.
For more information,
contact Philippe Cirre,
Assodation Santal, Centre
Hospitaller General, 44606
Saint-Nazaire, France. 161:
(33)-40.90.60.11.
April 1990 I 33
�Smart Card Monthly
April 1990 I 34
Bull CPS
Gemplus Card International
Minisfere de la Solidarity de la Sante et de la Protection Sodale, France
CPS: A Health Professional Smart
Card
Nationwide Identification of Healthcare Professionals:
Background
A large number of projects using the Smart Card in
healthcare services exist in
France, as discussed elsewhere in this issue.
Some of these projects are
aimed at improving administrative productivity, as the
Sodal Security's SESAM
projed which will involve 27
million "insured" people, or
the Mutusante, SolidariteSante and Sant6-Pharma
projeds set-up by private
insurance companies or nonprofit insurance companies
known as "mutuelles".
Other projects have medical
goals for which Cards store
patient health data, like the
Santal, Transvie and Dialybre schemes.
Besides, use of telematics
systems is very widespread
in France. More than five
million French Telecom
"Minitel" terminals are in
use (60% of doctors are
equipped). Microcomputers
are also very common, as are
telematics services dealing
with individual medical
Professionnel de Sante"
(CPS). The institutional,
administrative and legal
aspeds involved in attributing and issuing the CPS are
currently being studied.
This Card also encourages communication and exchange of data between the
different medical information systems.
From a technical point of
view, the CPS will be a
microprocessor Card guaranteeing a given security
level. It will also be capable
of recording the read and
write access rights to the
various patients' infonnation
categories, according to its
holder's title, qualifications,
Professionals to Receive
function, etc.
Smart Cards for I D and
A Smart Card with the
Access Control
Bull CPS MP mask has been
In order to provide every
chosen to serve as the base
health professional with a
for detailed technical specifisingle means of identificacations, which are currently
tion system, the French
being defined.
Ministry of Health and Sodal
Welfare has dedded, with
authorities representing the
health professions, to issue
Bull and Gemplus to
and to distribute one single
Cooperate
Card, called "Carte du
Within the scope of this
data. These services are used
espedally by medical analysis laboratories for communicating with doctors.
French concerns to proted individual rights has led
them to the decision to
restrict read and write access
to healthcare professionals,
particularly regarding computer files. For this reason,
they have to supply the
computers with an electronic
identification, unique for
each system, with a confidential code for computers,
and a Smart Card for access
to patient medical files.
�Smart Card Monthly
major project, two large
Smart Card manufacturers.
Bull CPS and Gemplus Card
International, have decided
to combine their resources to
offer two sources of supply
and distribution to the future
issuer of the CPS Card. This
issuer will therefore benefit
from the manufacturing
expertise and distribution
networks of both companies.
This agreement is significant because of the large
number of professionals
involved (1.3 million), and
also because of the size and
state of development of
French Smart Card projects
in the healthcare field.
The CPS will be an important technological meeting point for the systems
using it to identifify doctors
and other health professionals, and for authorizing them
to read or write on Smart
Cards allocated to patients or
insured people.
For more information,
contad Mrs. Elisabeth
Monod, Ministerede la
April 1990 I 35
Solidarity, de la Sante et de la
Protection Sodale. DORIQUE, pi^ce 2432,14, avenue
Duquesne, 75007 Paris,
France. Tel: (33)-l40.56.60.78. Fax: (33)-l40.56.50.43. At Gemplus
Card International, contad
Remy Tonnac, Marketing
Manager, Healthcare, Pare
d'activites de la Plaine de
Jouques, Avenue du Pic de
Bertagne—B.P.100,13881 Gemenos Cedex, France. Tel:
(33)-42.32.50.03. Fax: (33)42.32.50.90.
�Smart Card Monthly
April 1990 I 36
«•
»
•"
«
•
NEWS
Blood and Urine Testing
at Home
Toto Ltd., a major Japanese bathroom fixture
manufacturer, Omron Tateishi Electronics Co.. and NTT
have developed a home
health management aid—an
Intelligent Toilet (K-0001)
that tests urine and blood
pressure.
The toilet consists of a
Toto fixture with a urine
testing screen, and an Omron
finger-sphygmomanometer
for blood pressure measurement. Data is displayed on a
panel, and printed out or
stored on an IC Card for
later analysis by computer.
Future plans call for transmission of the data via an IC
Card telephone to a central
medical health facility, as
part of a comprehensive
personal health management
and monitoring system.
[From NTT Newsletter, Vol.2
No2. December 1989].
estimated 250,000 annual
Japanese visiting travelers.
The center can accommodate
20-30 patients per day. The
Practice will emphasize
preventive medidne, and
provide exhaustive yearly
checkups, as is customary in
Japan. It is financed through
a $1 million grant from Tokio
Marine and Fire Insurance
Companyu, to Beth Israel
Medical Center, which
operates it. Japanese language and Japanese health
care protocols, particularly
relating to personal privacy,
will be the norm. Phone (1)212-889-2119. [From New
York Times, Jan27,1990].
•
uling, materials management, the executive and
physidan offices, and a
home health care network.
A sample of the technologies
which will be featured indude bar coding. Smart
Cards, laser-optical memory
cards, hand-held terminals,
computerized pneumatic
tube transport, radiographic
imaging, electronic billling,
and electronic data interchange (EDI).
Hospital of the Future
will open its doors in May
1990. Contad Larry Farrell,
(l)-214-746-3472.
Lens Card™ Uses
Microfilm
A flexible credit-card
Andersen Consulting's
shaped piece of plastic with
HotFut
a microfilmed medical recHospital of the Future
ord laminated inside, with
(HotFut) represents Andersen Consulting's vision of an optical magnifying lens
the systems technologies that mounted on the opposite
end comprise the Lenswill support the health care
delivery system of the 1990s. Card™ personal medical
The 7,000 square foot exhibit record card. The card is
simply bent U-shape and
Social Differences Impact is now under development
held to any source of light to
at the Infomart in Dallas.
Health Care
be read. Contad Thomas J.
Systems represented in
The Japanese Medical
Taylor, LensCard Systems,
the exhibit indude ADT,
Practice, on East 34th street
P.O. Box 17375, Salt Lake
nursing (including bedside
in New York City, has
City,UT 84117 USA. Tel:
terminals), pharmacy, laboopened to make available
(l)-801-355-3255. Fax: (1)ratory, respiratory therapy,
Japanese-style health care for
medical records, the business 801-355-3261.
the 40,000 local Japanese
community as well as for an office, operating room sched-
�Smart Card Monthly
April 1990 I 37
CALENDAR
I May I WO
21-23 M.iv 1990
Advanced Card Applications Symposium '90
European Financial SelfService 90
YsmSLWinnipeg Convention Centre
Contact: Lome Boates,
ACT Canada, Suite #5,65
Gloucester St., Toronto,
Canada, M4Y1L8. Phone:
(1MI6-962-4I94. Fax:
aHU-925-24588.
Venue: Sheraton Hotel
Edinburgh, 1 Festival
Venue: Ramada-RenaisSquare, Edinburgh EH3
sance Hotel, Montreal,
9SR, Scotland. Phone:
Canada.
<44)-31-229-9131.
Contact: Steria Canada,
Qmm.: Jacqui Ball,
Inc., 695, Blvd. St. Cyrille
Events Manager, RMPD Quest, Quebec G1S1T1
Ltd. Pjhone: (44)-273Canada. TZ: (1 HI8-681722687. Fax: (44)-2737939. Fax: (1)-418-681821463, or Jimmy Heugh, 7636.
Conference Director, Phone:
(44)-292-313203.
This 3-day program is
organized by Steria
Canada, Inc., sponsored
This fourth annual
by CommunicationsConference and ExhibiQuebec Government and
tion is sponsored by the
Desjardins Group, in
Scottish Electronics
cooperation with CanaTechnology Group. A
dian Telematics Forum,
session on Smart Cards
Advanced Card Technoland Biometrics is
ogy Association of
planned for Wednesday
Canada (ACT Canada),
23 May, but has not yet
and with the support of
been defined.
Alcatel and Bull. Fees
are Can$450 before May
l,and Can$500 after
Mayl. Simultaneous
French-English translation (both ways) will be
available. Speakers and
exhibitors listed in the
program are principally
of French or Canadian
origin.
"Exhibit area will be
open on May 1st and
2nd. Fifteen exhibitors
are already committed.
Simultaneous translation,
French-English Qjoth
ways), available on one
of the two program
tracks. Cost of registration after April 15, $200
for ACT members, $250
for non-members." This
Symposium will immediately precede a Federal/
Provincial personal
health card symposium.
May 1990
International Seminar
on Smart Card Applications
29 M.iv-l Jinn- 1990
SCAT/ASrr'90 Conference and Exhibition
Venue: Techxuorld. Washington, DC, USA.
Qmm. Paul Oyer, The
Information Exchange,
2026C Opitz Boulevard,
Woodbridge,VA22191
USA. Phone: (l)-703-4903300. Fax: (l)-7034908615.
Jack Kilby, inventor of
the integrated circuit (IC)
microchip in 1958, will
deliver the keynote
address at the Fourth
Annual International
Smart Card Applications
and Technologies Conference and Exhibition
(SCAT'90). His presentation will complement
the theme of the Conference, which is, "Systems
are your solutions, technologies are your tools".
The Conference will
present 30 one-hour
program sessions, in
three concurrent tracks,
focusing on both industry and government.
Over 2,000 attendees are
expected.
�Smart Card Monthly
April 1990 I 38
CALENDAR
5-7 Si-pk-mtuT 1990
24-26 October 1990
ESCAT (European
SCAT)
Smart Card 2000
Venue: Hotel Kalastajatorppa, Helsinki,
Finland
Contact: ESCAT Office.
Meritullinkatu 33,00170
Hebinki, Finland. Tel:
(358)-0-135 5826. Fax:
(358)-0-135-2985.
Theme is "Europe and
Smart Cards in 1992—
Top Management
Challenge". Keynote
speaker will be Georges
Kayanakis, Managing
Director, Schlumberger
Smart Cards and Systems.
Venue: Stadthalle on the
Nectar, Heidelberg,
Germany
Contact: David Chaum,
Paulus Potterstraat 40,
1071 DB, Amsterdam, the
Netherlands. Tel: (31)-20751-808. Fax: (31)-20-6628136.
Conference brochure
with full programme and
list of exhibitors will be
available in June. Meanwhile, the Programme
Committee has issued a
Call for Papers, to be
received not later than 30
April. Submissions are
invited on any topioc
related to current and
future IC Card technology. Submit five copies
of a 3-6 page Executive
Summary.
�Smart Card Monthly
Stephen Seidman
(415)728-3920
Editor^ Rjblisher
1168 Date Street
P.O. Box 370968
Montora, CA 94037 USA
FAX: (415) 728-8675
1992 LITERATURE ORDER FORM
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�Smart Card Monthly
Published by Smart Card Concepts
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Smart Card Concepts is a consulting company which publishes Smart Card
Monthiy and the Smart Card Annual. Our consulting work is oriented toward
market research and new product introduction. To obtain an information
packet which includes our consulting terms and fees, listings of market research reports written, conference presentations made, and articles published
about Smart Cards since 1985, contact Stephan Seidman, President, Smart
Card Concepts, P. O. Box 70968, Montara, CA, 94037, USA.
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�70346 12305
MAR-
3 - 9 3 WED
1S:Q4
SCIA
ICS, POUCY AND ANALYSIS
Privacy concerns arise
over medical ID cards
By Karen Riley
THE WASHlNOtCm Tiucs
President Clinton's task force on health
care reform Is under fire from civil libertarians on the right and the left over a proposed
cradle-to-grave medical "smart card" for all
Americans that some say smacks of'Nazism.
The American Civil Liberties Union has
been so galled by what they view as the task
force's apparent disregard for privacy concerns that it intends to send a letter on the
subject as early as today to first lady Hillary
Rodham Clinton, the task force chairman, The
Washington Times has learned.
"The task force does not address this issue
al all," complained Janlori Goldman, director
of the ACLU's project on privacy und technology, who drafted the letter.
Meanwhile, the U.S. Privacy Council, a coalition of individuals and groups committed
to strengthening the right of privacy in the
United States, is expected to discuss the
health task force at the council's meeting in
San Francisco next month, according to members.
Lost week, Ira Magaziner, the senior White
House aide who coordinates the day-to-day
work of the task force, spoke fondly of the
medical smart card, an idea first broached by
Mr. Clinton durinc tho cmiipal«ii.
"We want to creulo an integrated system...
with a card that everyone will gel tit birth," Mr.
Magaziner said.
Mr, Clinton promised to "work to provide
everyone with smart cards coded with personal medical information" in his campaign
manifesto, "Putting People First."
" I just don't like it one bit. This is going to
be a veiy dangerous thing," said Arnold
Beichman, a senior fellow at the conservative
Hoover Institution.
Smart cards look like credit cards, but instead of having a magnetic strip on the back,
they have a computer chip on the front. Smart
Cards arc already being used for a variety of
purposes both in the public and private sector.
They have replaced food stamps in some jurisdictions to cut down on fraud and are under
consideration by the Army to be used in place
of dog tags.
While patients keep their own cards,
there's a risk that tl\e information could be
copied when patients submit their cards to be
read by their doctors' or Insurers' computers,
explains Ronald Plesser, who specializes in
privacy law at Piper & Marbury in Washington.
"Will those smart cards contain information about how many abortions a woman has
had, whether you're HIV-positive or are an
AIDS carrier and other information regarded
as too personal for Big Brother's prying
eyes?" Mr. Beichman asked
"It's reminiscent of N ^ i Germany," said
Robert Ellis Smith, publisher of the Privacy
Journal and & member of the privacy council.
Mr. Smith said he fears the smart card
would "evolve very quickly into a national
identifier for other purposes."
"If we all carry a plastic health ID card," ho
said, "il would very quickly become the standard for cashing checks and proving you're a
citizen."
Moreover, requiring Americans to carry a
medical smart card would make it more difficult for people to pursue unorthodox medical
remedies they might believe In, he said.
The smart card isn't the only reason privacy experts See potential problems with
health care reform. Mr. Clinton has also proposed replacing the complex financial forms
and accounting procedures now found in the
heallh insurance system with a simplified
hilling .system with one claim form.
"Wlieu you're automating and linking
health cure records, you have lo put proteclions in place," Ms. Goldman said.
A draft of the ACLU letter intended for'
Mrs. Clinion notes: "It is Important that national policies be developed to give people
some control over personal health information, particularly in the absence of any comprehensive federal legislation on medical and
insurance records."
Ms. Goldman, who has set aside the next
two years to work on the issue of privacy and
medical records, said she is optimistic Mrs.
Clinion will respond favorably to her letter.
Questions being raised about the task force
and privacy come at a time when privacy in
health records is getting ever greater attention by both the public and private sector.
A study by the Congrusslpnul Office of
Technology Assessment on the confidentiality of cumpuiemed medical records will be
released soon. And the National Academy of
Sciences Institute of Medicine is drafting a
report on the privacy of regional'health data
networks.
�THE A S S E M B L Y
S T A T E O F NEW
YORK
ALBANY
RICHARD N. GOTTFRIED
64th Assempiy Dislrict
CHAIRMAN
Committee on Health
Room 822
Legislative Office Building
Albany. New Yoik 12248
(518) 455-4941
COMMITTEES
Rules
Higher Education
Codes
Insurance
Social Services
Majority Steering Committee
270 Broadway
Room 1516
New York. New York 10007
(212) 385-6642
March 3 ,
1993
Ms. H i l l a r y Rodham Clinton
The White House
Washington, DC 20500
Dear Ms. Rodham Clinton:
This past June the New York State Assembly approved, by a
bi-partisan vote of 91-53, single-payor health care l e g i s l a t i o n ,
which I sponsored. The l e g i s l a t i o n , e n t i t l e d NEW YORK HEALTH,
was passed following a dozen town meetings on health care reform
held by Governor Cuomo, enormous grassroots support from
throughout the State and a f u l l consideration by my colleagues i n
the Assembly of the benefits that single-payer would offer to the
state's taxpayers, businesses and consumers. As the Chair of the
Assembly Health Committee I have come to see that the detailed
solutions we incorporated i n our l e g i s l a t i o n would solve many of
the problems of health care finance and delivery with which our
Committee i s regularly confronted.
For many reasons we believe that only single-payer
l e g i s l a t i o n w i l l address the health care c r i s i s i n New York. We
hope you w i l l consider the following as you design your proposal:
* Only single-payor w i l l r e s u l t i n universal coverage.
Single-payor extends coverage to a l l U.S. residents, regardless
of employment status. While 80% of New York's uninsured are
working, most have part-time jobs, jobs i n the service sector,
are self-employed, immigrants (legal and i l l e g a l ) or work i n the
"underground" economy. Employer-based health care reform,
including managed competition, only guarantees health coverage
for full-time workers and t h e i r families. As a r e s u l t , under
managed competition: hundreds of thousands of New Yorkers and
t h e i r families won't be covered; hospitals w i l l s t i l l be flooded
with emergency cases, and; there w i l l not be the coverage base to
fund primary care i n the inner c i t y and rural areas.
* Managed competition won't work i n the inner c i t y or rural
areas. Managed competition assumes that you have competing
networks of health care providers. Underserved areas i n New York
lack s u f f i c i e n t numbers of providers to form even one network;
the idea that competing networks w i l l be established to hold down
�costs i s sheer fantasy. New York needs to dedicate funds toward
establishing primary care practices in underserved areas, as can
be readily accomplished in a single-payor, public health
insurance program.
* Managed competition groups w i l l not want to compete for
s i c k populations or public health disaster areas. Managed care
networks w i l l want to compete for healthy populations. Requiring
community rating and open-enrollment won't change that
motivation, only the t a c t i c s ; managed competition networks w i l l
avoid covering the sick and disabled by using s e l e c t i v e marketing
and establishing provider networks which don't include enough
medical s p e c i a l i s t s . Single-payor health insurance i s t r u l y
community rated, since a l l Americans are covered under one,
comprehensive plan. And Americans with special health needs w i l l
have equal access to medical s p e c i a l i s t s , rather than being
r e s t r i c t e d to a limited panel included in a managed competition
network.
* Managed competition i s a loser for middle and upper-income
New Yorkers, who have good health benefits from the provider of
t h e i r choice. Managed care currently has very l i t t l e penetration
in New York. And New York's highly unionized workforce means
that many New Yorkers have wrap-around benefits, including
r e t i r e e paid Medigap coverage. But managed competition would
s t a r t taxing these better benefits and r e s t r i c t i n g freedom of
choice — meaning that middle and upper income New Yorkers, and
r e t i r e e s , would be losers from health care reform.
* Single-payor financing w i l l save New York state and local
governments $2 b i l l i o n immediately on t h e i r employee health care
costs. For example the 7.94% payroll tax rate included i n The
American Health Security Act compares favorably with an average
of 12% now being paid by public employers in New York. This
means a cut of 33% in health costs, which we estimate at $2
b i l l i o n a year savings for state and local governments i n New
York. None of these savings are available under managed
competition, since employers would s t i l l purchase private
insurance.
* New York's private employers would also see a cut in
health care costs of 33% or more under The American Health
Security Act. The U.S. Chamber of Commerce found that private
employer health care costs in the Northeast are s i g n i f i c a n t l y
higher than other regions of the nation. Which means that New
York businesses that insure t h e i r workers would benefit more than
employers in other regions from The American Health Security
Act's low health premium tax rate. But managed competition would
require a l l New York employers to pay high, private insurance
premiums.
Assembly members did not vote for NEW YORK HEALTH l i g h t l y ,
as i t included $28 b i l l i o n of NEW YORK HEALTH premiums, which
might otherwise be known as taxes. Many of my colleagues
�campaigned on their vote for NEW YORK HEALTH, and did so
successfully.
I have included a copy of the l e g i s l a t i o n , a detailed report
on the b i l l ' s finances and some other material, for your review.
I know you share our concern that any federal solution
address the problems states face i n financing and delivering
health care. The Assembly i n New York believes that single-payor
proposals w i l l give us the tools to provide affordable, quality
health care to a l l 18 million of our residents.
Richard N. Gottfried
Chairman
Assembly Committee on Health
RNG/lmd
33clint
�4 :•<
N W YORK STATE ASSEMBLY
E
M M R N U IN SUPPORT OP LEGISLATION
EOADM
B i l l No. Assembly 8912-A
Senate
Memo on Original B i l l
x Memo on Amended B i l l
Introduced by: Member of Assembly Gottfried, et a l Senate
T i t l e ; AN ACT t o amend the p u b l i c health law, t h e s t a t e
finance law, and the t a x law, i n r e l a t i o n t o t h e establishment of
the New York Health Plan.
Purpose: To e s t a b l i s h a comprehensive system o f u n i v e r s a l
access t o h e a l t h insurance by a l l residents o f New York State,
access t o and choice of h e a l t h care providers, c o n t r o l s on health
care costs, development of h e a l t h care services, and a mechanism
f o r f i n a n c i n g o f the program.
Summary: Section 1 amends the Public Health Law by adding a
new A r t i c l e 51 e s t a b l i s h i n g the New York Health Plan. A r t i c l e 51
sets f o r t h t h e a d m i n i s t r a t i v e s t r u c t u r e of the New York Health
Plan ( i n c l u d i n g i t s establishment as an independent p u b l i c
b e n e f i t c o r p o r a t i o n ) , the powers and duties of t h e governing
board, the scope of b e n e f i t s , payment mechanisms and cost controls.
Key features o f New York Health include t h e f o l l o w i n g :
• Benefits would include medically necessary h e a l t h services
i n c l u d i n g preventive and primary care, h o s p i t a l care, dent a l , eye care, p r e s c r i p t i o n drugs, mental h e a l t h , treatment
f o r drug and alcohol a d d i c t i o n s , and r e h a b i l i t a t i v e care;
• Coverage would be extended t o residents o f New York State
without regard t o age, income, health or employment s t a t u s ;
• Payment f o r provider services would be on the basis o f
g l o b a l budgets f o r h o s p i t a l s and other i n s t i t u t i o n a l p r o v i d ers, i n d i v i d u a l p r a c t i t i o n e r s would be able t o choose feef o r - s e r v i c e , c a p i t a t i o n or be s a l a r i e d by a g l o b a l budget
institution.
There would be no out-of-pocket charges f o r
i n d i v i d u a l s , and no balance b i l l i n g ;
• A d m i n i s t r a t i o n of the plan, as an independent p u b l i c
b e n e f i t c o r p o r a t i o n , would be by an 18-member Board o f
Governors, appointed by the Governor and confirmed by t h e
Senate. The Board would be representative o f consumers and
providers o f health care services, as w e l l as labor and
business;
• Financing o f the program would be through several sources.
Current f e d e r a l , s t a t e and l o c a l expenditures f o r h e a l t h
care services - p r i m a r i l y through Medicare and Medicaid page 1
�pointments t o the New York Health Board of Governors;
• by March 31, the Department of Social Services i s d i r e c t e d
to apply f o r necessary f e d e r a l waivers t o allow f o r the
p a r t i c i p a t i o n of Medicare and Medicaid i n the New York
Health Plan;
• by December 31 the Board of Governors and the Department
of Social Services s h a l l develop a procedure f o r the deposit
of Medicare and Medicaid funds i n t o the New York Health
Trust Fund;
• on January 1 premium payments and New York Health Plan
b e n e f i t s would begin.
J u s t i f i c a t i o n : Today, New Yorkers spend an e x o r b i t a n t
amount of money f o r a patchwork of health coverage programs t h a t
f a i l s t o cover m i l l i o n s of i n d i v i d u a l s , that f a i l s t o provide
needed services, and f a i l s t o c o n t r o l costs. Huge and growing
amounts are spent on paperwork and administration, r a t h e r than
health care services. New York Health o f f e r s an o p p o r t u n i t y t o
provide q u a l i t y health care coverage t o a l l New Yorkers, w h i l e
also containing increases i n medical costs.
Nearly 2 m i l l i o n New Yorkers lack health insurance coverage
while another 3 m i l l i o n are underinsured. I n a d d i t i o n , more and
more New Yorkers are confronted w i t h the choice of m a i n t a i n i n g
coverage i n the face of mounting costs and health insurance
premiums, or going without coverage. Rising out-of-pocket
expenses, lack of coverage f o r p r e - e x i s t i n g c o n d i t i o n s , and
d i s c r i m i n a t o r y underwriting p r a c t i c e s are a l l f a c t o r s t h a t lead
t o the erosion of coverage and a lack of access t o needed h e a l t h
care services.
The New York Health Plan seeks t o address the needs of t h a t
p o r t i o n of the population lacking health insurance coverage, as
w e l l as the needs of the growing number of New Yorkers who are
f r u s t r a t e d w i t h the coverage they have. Through establishment of
a uniform and universal b e n e f i t plan coverage could be extended
t o a l l New Yorkers while also reducing expenditures and c o n t r o l l i n g h e a l t h care costs.
The New York Health Plan achieves savings through the
c o n s o l i d a t i o n of health care expenditures under a s i n g l e , p u b l i c a l l y financed, insurance program. Such a program e l i m i n a t e s more
than $5 b i l l i o n i n a d m i n i s t r a t i v e waste, i n c l u d i n g excess i n s u r ance company a d m i n i s t r a t i o n and costs of b i l l i n g and c o l l e c t i n g
f o r h o s p i t a l s , physicians and other health care providers. I t
also provides s t a b i l i t y t o New York's h o s p i t a l s , f r e e i n g up
resources f o r p a t i e n t care.
The savings would be used t o finance increased h e a l t h care
page 3
�pointments to the New York Health Board of Governors;
• by March 31, the Department of Social Services i s d i r e c t e d
t o apply f o r necessary f e d e r a l waivers t o allow f o r the
p a r t i c i p a t i o n of Medicare and Medicaid i n the New York
Health Plan;
• by December 31 the Board of Governors and the Department
of S o c i a l Services s h a l l develop a procedure f o r the deposit
of Medicare and Medicaid funds i n t o the New York Health
Trust Fund;
• on January 1 premium payments and New York Health Plan
b e n e f i t s would begin.
J u s t i f i c a t i o n ; Today, New Yorkers spend an e x o r b i t a n t
amount of money f o r a patchwork of health coverage programs t h a t
f a i l s t o cover m i l l i o n s of i n d i v i d u a l s , that f a i l s t o provide
needed s e r v i c e s , and f a i l s t o c o n t r o l costs. Huge and growing
amounts are spent on paperwork and a d m i n i s t r a t i o n , r a t h e r than
h e a l t h care s e r v i c e s . New York Health o f f e r s an o p p o r t u n i t y t o
provide q u a l i t y health care coverage t o a l l New Yorkers, w h i l e
also c o n t a i n i n g increases i n medical costs.
Nearly 2 m i l l i o n New Yorkers lack health insurance coverage
while another 3 m i l l i o n are underinsured. I n a d d i t i o n , more and
more New Yorkers are confronted w i t h the choice of m a i n t a i n i n g
coverage i n the face of mounting costs and health insurance
premiums, or going without coverage. Rising out-of-pocket
expenses, lack of coverage f o r p r e - e x i s t i n g c o n d i t i o n s , and
d i s c r i m i n a t o r y underwriting p r a c t i c e s are a l l f a c t o r s t h a t lead
t o the erosion of coverage and a lack of access t o needed health
care s e r v i c e s .
The New York Health Plan seeks t o address the needs of t h a t
p o r t i o n of the population lacking health insurance coverage, as
w e l l as the needs of the growing number of New Yorkers who are
f r u s t r a t e d w i t h the coverage they have. Through establishment of
a uniform and u n i v e r s a l b e n e f i t plan coverage could be extended
to a l l New Yorkers while also reducing expenditures and c o n t r o l l i n g h e a l t h care costs.
The New York Health Plan achieves savings through the
c o n s o l i d a t i o n of health care expenditures under a s i n g l e , p u b l i c a l l y financed, insurance program. Such a program e l i m i n a t e s more
than $5 b i l l i o n i n a d m i n i s t r a t i v e waste, i n c l u d i n g excess insurance company a d m i n i s t r a t i o n and costs of b i l l i n g and c o l l e c t i n g
f o r h o s p i t a l s , physicians and other health care providers. I t
also provides s t a b i l i t y t o New York's h o s p i t a l s , f r e e i n g up
resources f o r p a t i e n t care.
The savings would be used t o finance increased h e a l t h care
page 3
�STATE OF NEW YORK
8912—A
1991-1992 Regular Sessions
IN ASSEMBLY
September 18, 1991
Introduced by M. of A. COMMITTEE ON RULES ~ (at request of M. o£ A.
Gottfried,
Brennan,
Gantt,
Harenberg,
Jacobs,
Seminerio,
E. C. Sullivan, Tonko, Weinstein, Abbate, Aubry, Barbaro, Bennett,
Bianchi, Boyland, Brodsky, Butler, Catapano, Clark, Colman, Conners,
Cook, Crowley, Daniels, Davis, Dearie, Del Toro, Diaz, DiNapoli,
Dugan, Englebright, Eve, F a r r e l l , Feldman, Friedman, Genovesi, Click,
Grannis, Green, Greene, Griffith, Gromack, Hevesi, Hikind, H i l l , H i l l •an, Blnchey, W. Hoyt, Jenkins, John, Kaufman, Roppell, Lafayette,
Lashtr, Lentol, Lopez, Mayersohn, Murtaugh, Nadler, Nolan, Norman,
Pheffer, P i l l i t t e r e , Pordum, Ramirez, Ravitz, Rosado, Sanders, Schmidt, Seabrook, Sidikman, Silver, Sweeney, Tocci, Vann, Weisenberg,
Yoswe In, Young) — read once and referred to the Committee on Health
—
recommitted to the Committee on Health in accordance with Assembly
Rule 3, sec. 2 — reported and referred to the Committee on Ways and
Means —
committee discharged, b i l l amended, ordered reprinted as
amended and recommitted to said committee
AN ACT to amend the public health law, the state finance law and the tax
law in relation to the establishment of the New York health plan and
making an appropriation to the temporary commission on implementation
of the New York health plan and providing for the repeal of certain
provisions upon expiration thereof
The People of the State of New York, represented in Senate and Assembly, do enact as follows;
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Section 1. The public health law i s amended by adding a new article 51
to read as follows:
ARTICLE 51
NEW YORK HEALTH PLAN
Section 5100. Legislative findings.
5101. Short t i t l e .
5102. Definitions.
EXPLANATION—Matter in i t a l i c s (underscored) i s new; matter in brackets
[ ] i s old law to be omitted.
LBD12238-06-2
�A. 8912—A
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5103. Plan created.
5104. Board of governors.
5105. Powers and d u t i e s of the board.
5106. Powers and d u t i e s of the executive d i r e c t o r .
5107. Plan e l i g i b i l i t y .
5108. Plan b e n e f i t s .
5109. Payment f o r s e r v i c e s .
5110. O u t - o f - s t a t e p a r t i c i p a t i o n and payments.
S 5100. L e g i s l a t i v e f i n d i n g s . The l e g i s l a t u r e f i n d s and declares that
a l l r e s i d e n t s o f the s t a t e of New York have the r i g h t
to health serv i c e s , yet an i n c r e a s i n g number of New yprkers are unable t o exercise
t h i s r i g h t because o f a lack o f h e a l t h coverage. New Yorkers have experienced
a r a p i d r i s e i n the cost o f h e a l t h care i n recent years. This
increase has r e s u l t e d i n a large number of people
who have had t o
d i s c o n t i n u e . t h e i r h e a l t h coverage. Businesses have a l s o experienced ext r a o r d i n a r y increases i n the costs of h e a l t h care b e n e f i t s f o r t h e i r
employees. Over two m i l l i o n New Yorkers have no h e a l t h coverage, and
another estimated three m i l l i o n are severely underinsured. H o s p i t a l s and
other h e a l t h care p r o v i d e r s are a l s o a f f e c t e d by inadequate h e a l t h i n surance coverage i n New York s t a t e . A l a r g e p o r t i o n of v o l u n t a r y and pub l i c h o s p i t a l s , h e a l t h centers and other p r o v i d e r s now experience sub, s t a n t i a l losses due t o the p r o v i s i o n o f care t h a t i s uncompensated. To
address the f i s c a l c r i s i s f a c i n g the h e a l t h care system and t o assure
New Yorkers can exercise t h e i r r i g h t t o h e a l t h care, a f f o r d a b l e and comprehenslve h e a l t h coverage must be provided.
Pursuant t o the ,state
c o n s t i t u t i o n ' s charge t o the l e g i s l a t u r e t o provide f o r the h e a l t h o f
New Yorkers, t h i s a r t i c l e i s an enactment o f s t a t e concern f o r the purpose of e s t a b l i s h i n g a comprehensive u n i v e r s a l h e a l t h care coverage p r o gram and a h e a l t h care cost c o n t r o l system f o r the b e n e f i t o f a l l r e s i dents of the s t a t e o f New York.
5 5101. Short t i t l e . This a r t i c l e s h a l l be known and may be c i t e d as
the "New York h e a l t h p l a n " .
. 5 5102. D e f i n i t i o n s . For the purposes of t h i s a r t i c l e , unless the cont e x t c l e a r l y r e q u i r e s otherwise:
1. "Board" means the board o f governors o f the New York h e a l t h plan as
created by s e c t i o n f i f t y - o n e hundred four o f t h i s a r t i c l e .
2. "Plan" means the New York h e a l t h plan as created by s e c t i o n f i f t y one hundred three of t h i s a r t i c l e .
3. "Plan member" means any person who q u a l i f i e s f o r b e n e f i t s under the
plan under s e c t i o n f i f t y - o n e hundred seven o f t h i s a r t i c l e .
4. - " P a r t i c i p a t i n g p r o v i d e r " means any person, p a r t n e r s h i p , c o r p o r a t i o n
or other e n t i t y , authorized t o f u r n i s h covered s e r v i c e s pursuant t o t h i s
article.
5. "Plan r a t e " means the r a t e of payment f o r a covered s e r v i c e , under
the p l a n , e s t a b l i s h e d i n accordance w i t h t h i s a r t i c l e .
6. "Global budget" means an i n s t i t u t i o n - w i d e budget f o r the f i x e d and
o p e r a t i n g costs f o r the p r o v i s i o n o f h e a l t h care s e r v i c e s , e x c l u s i v e of
c a p i t a l expenditures
covered under subparagraph f i i i ) of paragraph f e )
o f s u b d i v i s i o n one o f s e c t i o n f i f t y - o n e hundred f i v e o f t h i s a r t i c l e .
7. "Resident" means a person who has e s t a b l i s h e d t h e i r primary place
o f abode i n t h i s s t a t e , as determined according t o r e g u l a t i o n s of the
board.
5 5103. Plan created. There i s hereby e s t a b l i s h e d the New York h e a l t h
p l a n , t o -provide, as set out i n t h i s a r t i c l e , and r e l a t e d l e g i s l a t i o n ,
u n i v e r s a l h e a l t h coverage f o r a l l r e s i d e n t s of t h i s s t a t e , access t o and
choice o f h e a l t h care p r o v i d e r s , c o n t r o l s on h e a l t h care c o s t s , develop-
�A. 8912—A
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ment of health care services, and public financing for the program.
Such plan shall be a corporate governmental agency constututing a public
benefit corporation.
S 5104. Board of governors. 1. A board of governors to administer the
plan i s hereby created. The board shall be composed of eighteen members,
to consist of the chair and seventeen additional members, appointed by
the governor with the advice and consent of the senate. The commissioner, the commissioner of social services, the superintendent of i n surance, and the commissioner of taxation and finance shall serve as
nonvoting ex o f f i c i o members of the board.
Of the seventeen additional members appointed by the governor:
(a) f i v e shall be representative of health care consumer advocacy orqanizations which have a statewide or regional constituency,
who "have
been involved, in a c t i v i t i e s related to health care consumer advocacy,
including issues of interest to low and moderate-income individuals;
(b) three shall be representative of labor organizations;
(c) three shall be representative of business and industry;
(d) two shall be representative of hospitals;
(e) two shall be representative of physicians; and
( f ) two shall be representative of licensed non-physician health care
professionals.
2. Members shall serve for a term of five years, each term shall end
on December t h i r t y - f i r s t . Each member of the board shall hold o f f i c e
from the date of q u a l i f i c a t i o n for o f f i c e u n t i l the end of the term for
which the member was appointed. Any member appointed to f i l l a vacancy
occurring prior to the expiration of a term, shall hold o f f i c e for the
remainder of that term.
3. Each member shall continue in o f f i c e subsequent to the expiration
date of the term u n t i l a successor takes o f f i c e .
4. The governor may remove the chair of the board for qood cause prior
to the expiration of his or her term. In the event of a vacancy in the
chair, the governor may appoint a person to be acting chair u n t i l a
chair shall be confirmed by the senate.
5. The board shall meet at least four times in a calendar year.
6. Meetings shall be held upon the c a l l of the chair and as provided
by the board.
7. Ten members of the board shall constitute a quorum, and the affirmative vote of ten members shall be necessary for any action to be
taken by the board.
8. The board may establish an executive committee to carry out any
powers or duties of the board as i t may provide, and other committees to
assist the board or the executive committee. The chair of the board
shall be the chair of the executive conunittee and shall appoint the
chairs of other committees. The board may also establish advisory committees, consisting of persons other than members of the board.
9. Members of the board, with the exception of the chair, shall serve
without compensation, but shall be reimbursed for their necessary and
actual expenses incurred while engaged in the business of the board.
10. Notwithstanding any inconsistent provisions of law, general, spec i a l or l o c a l , no o f f i c e r or employee of the state or of any c i v i l d i v i slon thereof shall be deemed to have f o r f e i t e d or shall f o r f e i t his or
her o f f i c e or employment by reason of being a member of the board.
S 5105. Powers and duties of the board. 1. Except as otherwise 11mited by t h i s a r t i c l e , the board shall have the following corporate
powers:
(a) To sue and be sued;
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(b) To have a seal and alter the same at pleasure;
2
(c) To make and execute contracts and a l l other instruments necessary
3 or convenient for the exercise of i t s powers and functions under this
4 article;
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(d) To make and alter by-laws for i t s organization and Internal
6 management;
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fe) To acquire, hold and dispose of personal property for i t s cor8 porate purposes;
9
(f) To appoint officers, agents and employees, prescribe their duties
10 and qualifications and fix their compensation;
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(g) To borrow money and issue negotiable notes, bonds or other obliga12 tions for i t s corporate purposes and to provide for the rights of the
13 holders thereof;
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(h) To invest any funds held in reserve ot sinking funds, or any
15 monies not required for the immediate use or disbursement, at the
16 discretion of the plan, in obligations of the state or the United States
17 government, or in any other obligations in which the comptroller of the
18 state of Mew York is authorized to invest pursuant to section ninety19 eight of the state finance law;
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( i ) To accept any gifts or grants or loans of funds or property or
21 financial or other aid in any form from the federail government or any
22 agency or instrumentality thereof or from the state or from anyother
23 source and to comply, subject to the provisions of this article, with
24 the terms and conditions thereof; and
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( j ) To do any and a l l things necessary or convenient to carry out i t s
26 purposes and exercise the powers expressly given and granted in this
27 article.
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2. The board shall have the additional power to do the following;
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(a) ( i ) Establish a budget to Include a l l health care expenditures
30 made by the plan, including the establishment of aggregate expenditure
31 targets applicable to categories of health services, ( i l ) In establish32 Ing the budget, the board shall limit the annual aggregate level of ex33 penditures for any year to a sum equivalent to the level of expenditures
34 in the preceding year increased by one hundred twenty percent of the an35 nual increase in the consumer price index - urban as developed by the
36 United States department of commerce, ( i i i ) In establishing the budget,
37 global budgets, allocations for capital expenditures, and other budget
38 and expenditure actions, the board shall consider regional needs and
39 resources, for regions that are geographical areas reasonably related to
40 the need for,-and delivery and use of, particular health care f a c i l i t i e s
41 and services, and shall encourage the sharing and cooperative use of
42 f a c i l i t i e s and services by health care providers.
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fb) Establish plan rates, in accordance with section fifty-one hundred
44 nine of this article;
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(c) Establish global budgets, and develop rules and regulations
46 concerning allowable expenditures to be included in global budgets, for
47 Institutional providers of services, in accordance with section f i f t y 48 one hundred nine of this article;
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(d) Administer, implement and monitor the operation of the plan;
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(e) Administer the New York health trust fund created pursuant to sec51 tion ninety-seven-nn of the state finance law, and include within the
52 fund allocations for the following purposes;
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( i ) health promotion and primary prevention programs, including pro54 grams which utilize community settings, schools and places of work, to
55 promote healthy lifestyles, enable consumers to make informed health
56 decisions and provide screening tests not performed as part of routine
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care. Money allocated for this purpose shall equal at least one-half of
one percent of the monies In the trust fund;
( i i ) paying participating providers in accordance with section f i f t y one hundred nine of this a r t i c l e ;
( i i i ) capital expenditures for the following purposes:
(A) construction, renovation, and equipping of health care i n s t i t u tions, including i n s t i t u t i o n a l providers of inpatient care and ambulatory f a c i l i t i e s f o r diagnosis, treatment and surgery, diagnostic and
treatment centers providing a comprehensive range of primary health care
services, and major medical equipment acquired for use in private practitloner offices;
(B) a loan program for f a c i l i t i e s and equipment for use by health care
professionals who desire to establish practices in areas of this state
i n which, according to c r i t e r i a established by the board, the level of
delivery of health care services i s inadequate;
( i v ) transportation of plan members from one globally-budgeted i n s t i tutlon to another for the provision of covered services, and otherwise
to effect cooperation and communication between i n s t i t u t i o n s for the
delivery of health care services; and
(v) education and training of workers i n the health care f i e l d , i n eluding, but not limited to, retraining of workers who experience job
loss or dislocation associated with the implementation of the New York
health plan; and a program of loan repayments or other incentives to encourage health care practitioners to serve in underserved areas, spec l a l t i e s or f a c i l i t i e s . Monies allocated^ shall . equal at least onequarter of one percent of the monies in the trust fund.
( f ) I n carrying out i t s powers and duties, establish reasonable and
effective means o f :
(1) cost containment, including but not limited to: reducing i n e f f i clencies in health care delivery; promoting effective and appropriate
use of advancements in c l i n i c a l practice and technology; encouraging the
use of less costly alternative providers where appropriate; and establlshing treatment norms f o r providers to reduce the inappropriate
provision or use of services;
, (11) quality assurance. Including but not limited to: developing c l i n leal practice guidelines; and promoting systems for review of patient
outcomes, and quality and appropriateness of services;
f i i i ) promoting access to services, including but not limited to:
a v a i l a b i l i t y of primary, preventive and other services for continuity of
care; assuring consumers freedom to select among q u a l i f i e d providers for
appropriate services w i t h i n their recognized scope of practice; respecting the professional judgment of providers and the rights of patients,
and their families and representatives where appropriate, to p a r t i c i p a t e
i n decisions affecting their care; and eliminating and preventing ineq u i t i e s i n , or barriers to, access to services based on geography,
social or economic status, race, r e l i g i o n , gender, age, e t h n i c i t y , language sexual orientation, family status or d e f i n i t i o n , and health condltion;
(g) Establish, as the board considers i t necessary, a system to
promote continuity of care;
(h) Establish an indemnity plan to carry out the purposes set f o r t h In
section fifty-one hundred ten of t h i s a r t i c l e ;
( i ) Establish a prescription drug formulary, in accordance with sect i o n fifty-one hundred eight of this a r t i c l e ;
f
^ £
p w r o o ON •KVCLC C O « « »
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( i ) Award contracts to administer the payment of covered services to
participating providers, and other elements of the plan as the board
deems appropriate;
(k) ( i ) Study and evaluate the operation of the plan, including but
not limited to the adequacy and quality of services covered under the
plan, the cost of each type of service and the effectiveness of cost
containment measures under the plan; and
( i i ) Study u t i l i z a t i o n of health care services under the plan, e n r o l l ment of new plan members, effect of the plan on providers and p r a c t i tioners, including recruitment and retention of p r a c t i t i o n e r s , and other
matters relating to plan experience, operation and impact. The board
shall especially examine the phenomenon of individuals becoming members
of the plan (other than by b i r t h ) for the purpose of obtaining plan
benefits for pre-existing conditions for which they had inadequate or no
health care coverage, and i t s extent, nature and f i n a n c i a l and health
care system impacts. The board shall consider the need f o r , and probable effectiveness, advantages and disadvantages of, possible changes in
the plan including l i m i t i n g plan benefits for such conditions for a
period of time to exclude such conditions or impose requirements such as
deductibles, maximum benefits or co-insurance;
(1) Report annually to the governor and the legislature on i t s a c t i v i t i e s and recommend any changes in laws to improve access to q u a l i t y
health care and to more e f f e c t i v e l y control costs of services provided
under the plan, consistent with4quality health care;
(m) Disseminate, to providers of services and to the public, information concerning the plan and the persons e l i g i b l e to receive the benef i t s under the plan;
(n) Conduct necessary investigations and inquiries and require the
submission of information, documents and records i t considers necessary
to carry out i t s duties under t h i s a r t i c l e ;
(o) Create a program for the resolution of complaints brought by plan
members or participating providers regarding any matter associated with
coverage under the plan, or the operation of the plan;
(p) Wo later than f i v e years after the effective date of the plan,
develop a proposal for provision by the plan of long-term care
coverage, including the development of a proposal for i t s funding. In
developing the proposal; the board shall consult with an advisory
committee, appointed by the chair of the board, including representatives
of consumers and potential consumers of long-term care, providers of
long-term care, business, labor, social services d i s t r i c t s , and other
interested parties;
(q) Develop a plan to coordinate i t s a c t i v i t i e s , including planning
for the adequacy of health care services and the approval of c a p i t a l expenditures, with appropriate state and local bodies, including health
systems agencies and the hospital review and planning council;
( r ) No later than one year after the effective date of the plan,
recommend to the governor and state legislature the reorganization of
state government agencies to most e f f e c t i v e l y carry out a c t i v i t i e s to be
conducted by the board; and
(s) Conduct other a c t i v i t i e s necessary and appropriate to carry out
the purposes of this a r t i c l e , including the employment of s t a f f and an
executive director.
3. The board, after providing notice to the public and interested
parties, may hold hearings in connection with any a c t i v i t i e s i t proposes
to urn?
>ke.
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4. The board shall maintain the c o n f i d e n t i a l i t y of a l l data and other
information collected in f u l f i l l i n g i t s duties when such data would be
normally considered confidential data between a patient and health care
provider. Aggregate data which is derived from confidential data but
does not violate patient c o n f i d e n t i a l i t y shall be considered public
informat ion.
S 5106. Powers and duties of the executive director. 1. The executive
director of the plan shall be the chief executive o f f i c e r of the plan.
2. The, executive director shall perform such duties in the administration of the plan as the board may assign, including the employment and
supervision of s t a f f .
3. The board may delegate to the executive director any of i t s functions or duties under this a r t i c l e other than the issuance of rules and
regulations and the establishment of the annual plan budget.
S 5107. Plan e l i g i b i l i t y . 1. Every person who is a resident of t h i s
state is e l i g i b l e to receive benefits for covered services under the
plan and shall be a plan member.
2. Everv- plan member is e n t i t l e d to receive benefits for any covered
service furnished within t h i s state by a p a r t i c i p a t i n g provider, i f the
service is necessary or appropriate for the maintenance of health or for.
the diagnosis or treatment of, or r e h a b i l i t a t i o n following, i n j u r y , d i s a b i l i t y or'disease.
S 5108. Plan benefits. 1. Covered services under the plan shall i n elude, but are not limited t o , a l l of the following medically necessary
inpatient and outpatient services^:
(a) hospital services;
(b) medical and other professional services furnished by authorized
health care professionals who are authorized to provide such services
under the laws of t h i s state including primary, preventive and specialty
services;
(c) laboratory tests and imaging procedures;
(d) short-term home • health services for persons requiring services
performed by or under the supervision of professional or technical personnel;
(e) r e h a b i l i t a t i v e services where a patient is receiving active care
with a therapeutic outcome;
( f ) prescription drugs and devices, provided, however, that the plan"
shall p a r t i a l l y cover the cost of a drug dispensed in a package, or form
.of dosage or administration, as to which the board determines that a
less expensive package, or form of dosage or administration is available
that i s -pharmaceutically equivalent and equivalent in i t s therapeutic
effect. I f a plan member chooses to purchase a more expensive drug that
has a pharmaceutical and therapeutic equivalent, the plan member shall
be f i n a n c i a l l y responsible for paying the amount equal to the difference
between such drug and i t s equivalent unless the prescribing practitioner
c e r t i f i e s that the more expensive drug is medically necessary, in which
case the plan shall cover the f u l l cost;
(g) mental health services subject to appropriateness guidelines and
review;
(h) substance abuse treatment services;
( i ) primary and acute dental services;
( j ) vision appliances, including lenses, frames and contact lenses,
according to a schedule established by the board;
(k) medical supplies, durable medical equipment and selected assistive
devices; and
(1) hospice care.
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2. Covered services do not include any of the following;
(a) surgery for cosmetic purposes other than for reconstructive
surgery;
(b) medical examinations conducted and medical reports prepared for
any of- the following purposes;
( i ) purchasing or renewing l i f e insurance;
( i i ) applications for employment; or
( i i i ) participating as a plaintiff or defendant In a c i v i l action for
the recovery or settlement of damages;
(c) basic or custodial care rendered In a nursing home;
(d) custodial care rendered In a f a c i l i t y licensed under the mental
hygiene law; or
(e) cosmetic dental services.
3. Coinsurances, deductibles and copayments shall not be applicable to
benefits covered under the plan.
4. Insurers authorized to underwrite coverage pursuant to the insurance law or a health maintenance organization certified in accordance
with article fortv-four of this chapter, may offer benefits that do not
duplicate coverage that is offered under the plan but may not offer
benefits that duplicate coverage that is covered by the plan. Provided,
however, that nothing in this subdivision shall prohibit the offering of
benefits to or for persons, including their families, who are employed
or self-employed in this state but are not residents of the state.
5. M participating provider shall refuse to furnish services to a
o
plan member on the basis of race, color, creed, age, national origin,
alienage or citizenship status, gender, sexual orientation, disability,
marital status, or arrest record, except as appropriate to the
provider's professional specialization, or other medically appropriate
circumstances. .
6. A plan member may choose any participating provider, whether practlcing on an independent basis. In a small group, -or in a. capitated
practice. A plan member who enrolls in a capitated practice shall be
subject to rules and requirements of the plan as to disenrollment,
choice of provider, and availability of benefits outside the capitated
practice.
5 5109. Payment for services. 1. The plan shall pay the expenses of
Institutional providers licensed under article twenty-eight of this
chapter for covered services on the basis of global budgets that are approved by the board.
2. The global budget of each institutional provider shall he set annually by the plan after consultation and negotiation with the institutional providers; and shall cover the costs of i t s anticipated services
for the next year, based on past performance and projected changes in
factor prices and service levels.
3. Every individual health care provider employed by a globally budgeted Institutional provider shall be paid through and in a manner determined by the institutional provider.
4. The budgeting procedure described in subdivisions one, two and
three of this section also applies to Institutions that provide plan
services and that are funded by any political subdivision or any agency
or Instrumentality of a political subdivision.
5. The plan shall reimburse non-institutional participating providers
on a fee-for-service basis, established by the board. The fee schedule
shall vary the payment amount among different service's based on the
relative value of the input factors to provide the services.
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6. Fee schedules may take into account recognized differences among
geographic areas regarding cost of practice.
7. To the greatest extent feasible, 'fee schedule categories shall inelude payment for a l l procedures routinely performed for a given
diagnosis.
8. (a) A multi-specialty organization of providers may elect to be
reimbursed on a capitation basis. In lieu of a fee-for-service basis.
(b) I f the organization meets enrollment and other requirements established by the board, the organization may elect to have included In i t s
capitation payments. Inpatient services provided by Institutions funded
under a budget described in subdivision one of this section. Upon that
election, the Institutional budgets of such Institutions shall be adlusted accordingly.
„
(c) I f the organization elects, and meets requirements of the board,
the board may include In the organization's capitation payments funds to
be passed on by the organization to plan members who are i t s enrolled
members as a rebate or Incentive to encourage membership in the organizatlon; provided that the board finds that the rebate or Incentive i s in
the financial Interests of the plan.
9. Every participating provider shall furnish to the plan such information, and permit examination of i t s records by the plan, as may be
reasonably required for purposes of utilization review, qualify assurance, cost containment, for the making of payments and for s t a t i s t i cal or other studies of the operation of the plan.
10. Rates of payment established under this section shall be considered payment in f u l l . A provider of services shall not charge rates that
are in excess of such reimbursement levels, nor charge separately for
covered services provided under section fifty-one hundred eight of this
article. Provided, however, the provisions of this subdivision shall not
apply to services rendered outside of this state, or to services rendered to persons who are not plan members.
S 5110. Out-of-state participation and payments. 1. (a) The plan, tn
accordance with subdivision four of this section and except as provided
In paragraph (b) of this subdivision, shall pay for services rendered to
plan members while they are out ot the state (1) while they are temporarlly out of the state for reasons other than to obtain the services
or (11) where the plan member obtains the services out of the state for
compelling reasons relating to the suitability of services, the nature
of the condition and personal circumstances.
(b) Where the plan member is eligible for health benefits under t i t l e
XVIII or t i t l e XIX of the federal social security act, then out-of-state
services for the plan member shall, to the extend allowed by law, be
paid for under those t i t l e s .
2. Where an employee or self-emplove'd individual is not a resident of
New York state (and therefore not eligible to be a plan member) but is
employed or self-employ«4 in the state, the employer or the employee, or
the self-employed individual, may purchase health coverage for the person, including the person's family, from any entity authorized to offer
that coverage or from the plan pursuant to subdivision five of this
section.
3. Any private or state college, university or other Institution of
higher education situated in this state may purchase coverage under the
plan for any student, or their dependents, who i s not a resident of
this state.
4. The board shall establish and operate an indemnity plan to provide
payments for services under subdivision one of this section. The
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payments shall be made at the rates established by the board for benef i t s for comparable services provided by the plan in this state. Charges
in excess of the payment rates established in accordance with t h i s section shall be the responsibility of the plan member.
5. The board shall establish and operate an indemnity plan to provide
health coverage for employees and self-employed individuals who are not
residents of this state but, are employed or self-employed in the state,
Including their families, to be offered for purchase by the employer or
employee, or self-employed . individuals, under subdivision two of this
section. The indemnity plan shall be offered on a n o t - f o r - p r o f i t basis.
I t s scope of benefits and rates of payment shall be established by the
board and shall, to the extent practicable, be comparable to those under
the Sew York health plan.
6. Nothing in this a r t i c l e shall Impact the existing or future obligations of employers to provide supplementary health benefits to retirees
who no longer reside in this state.
S 2. The state finance law is amended by adding a new section 97-nn to
read as follows:
5 97-nn. New York health, trust fund. I . There is hereby established in
the j o i n t custody of the state comptroller and the commissioner of taxation and finance a special revenue fund to be known as the "New York
health trust fund", hereinafter known as "the fund".
2. The fund shall consist of:
(a) a l l monies obtained from premium payment revenues pursuant to art i d e t h i r t y - f i v e of the tax law;
(b) federal payments received as a result of any waiver of requirements granted by the United States secretary of health and human services for health care programs established under t i t l e s XVIII (medicare)
and XIX (medical assistance for needy person) of the federal social
security act;
(c) the amounts paid by the department of social services and by local
social service d i s t r i c t s that are equivalent to those amounts that are
paid on behalf of residents of this state under t i t l e s XVIII (medicare)
and XIX (medical assistance for needy persons) of the federal social
security act, and a r t i c l e f i v e , t i t l e eleven of the social services law
for health benefits which are equivalent to health benefits covered under a r t i c l e fifty-one of t h i s public health law;
(d) a l l surcharges that are imposed on residents of t h i s state to
replace payments made by the residents under the cost-sharing, provisions
of t i t l e XVIII of the federal social security act;
;
(e) federal, state and local funds for purposes of the provision of
services authorized under t i t l e XX of the federal social security act
that would otherwise be covered under a r t i c l e fifty-one of the public
health law; and
( f ) state and local government monies that would otherwise be appropriated to any governmental agency, o f f i c e , program, instrumentality or
i n s t i t u t i o n which provides health services, for services and benefits
covered under a r t i c l e f i f t y - o n e of the public health law. Payments to
the fund pursuant to this paragraph shall be in an amount equal to the
monev appropriated for such purposes in the f i s c a l year
immediately
preceding the effective date of a r t i c l e f i f t y - o n e of the public health
law. Payments to the fund pursuant to this paragraph shall be in an
amount egual to the money appropriated for such purposes in the f i s c a l
year immediately preceding.the effective date of a r t i c l e f i f t y - o n e of
the public health law.
�A. 8912—A
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3. Monies in the fund shall only be used .for purposes established under a r t i c l e fifty-one of the public health law.
4. Revenues held in the fund shall not be subject to appropriation or
allotment by the state or any p o l i t i c a l subdivision thereof.
5. The board of governors of the New York health plan under a r t i c l e
fifty-one of the public health law s h a l l ;
(a) administer the fund and shall conduct a quarterly review of the
expenditures from and revenues received by the fund; and
(b) invest the fund in investments that are authorized by the laws of
t h i s state for the investment of the c a p i t a l , surplus and accumulations
of domestic l i f e insurance companies. The l i m i t a t i o n s set f o r t h in these
laws apply to the invesfwents of the fund.
S 3. The tax law is amended by adding a new a r t i c l e 35 to read as
follows:
ARTICLE 35
N W Y R HEALTH PLAN PREMIUM PAYMENTS
E OK
Section 1700. Definitions.
1701. Premium payments.
1702. Procedural provisions.
5 1700. Definitions. For the purposes of t h i s a r t i c l e , unless the context clearly requires otherwise:
1. "Employ" means :o suffer or permit to work.
2. "Employer" means an individual, partnership, association, corporat i o n , business t r u s t , the state of New York, i t s instrumentalities and
i t s p o l i t i c a l subdivisions and their instrumentalities, or any person or
qroup of persons, acting in the Interest of an employer in relation to
an employee.
3. 'Employee' means any Individual who works for an employer.
S 1701. Premium payments. For the purpose of providing revenue for the
New York health plan established pursuant to a r t i c l e f i f t y - o n e of the
public health law, and to pay the expense of plan administration, the
following premium payments are hereby levied:
1. On each employer, a premium payment equal to ten percent of the
employer's payroll. The employer may choose, subject to c o l l e c t i v e bargaining agreements, to deduct two percent (2%) of each employee's wages
or gross salary as p a r t i a l payment of t h i s premium payment;
2. On each self-employed individual, a premium payment equal to ten
percent of the individual's self-employment income, subject to the l i m i t
on taxable self-employment income for medicare hospital insurance under
the "federal insurance contributions act", 68A s t a t . 415 (1954), 26
U.S.C.A. 3101, as amended.
3. A person subject to taxation under this chapter, other than a person who is e n t i t l e d to coverage under t i t l e XVIII of the federal social
security act, who has not had the premium paid on f i f t y percent or more
of his or her adjusted gross income under subdivision one or two of this
section, shall make a premium payment equal to ten percent of the d i f f erence between f i f t y percent of individuals adjusted gross income and
the t o t a l amount of income on which the individual has had premiums paid
under subdivisions one and two of this section; provided, however, that
the t o t a l amount of adjusted gross income subject to premium payments
under this subdivision shall not exceed the l i m i t on taxable s e l f employment income for medical hospital insurance under the "federal i n surance contributions act," 68A stat. 415 (1954), 25 U.S.C.A. 3101, as
amended.
4. (a) Where a New York state resident is employed outside the state
by an employer that does business in the state, or that elects to be
/
T ^ j
PRMTtO Oh RICVCLIO mu*
�A. 3912—A
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subject t o t h i s s u b d i v i s i o n , then the employer s h a l l pay the premium under s u b d i v i s i o n one of t h i s s e c t i o n , c a l c u l a t e d on the pro r a t a
portion
of the employer's p a y r o l l a t t r i b u t a b l e t o a l l New York s t a t e r e s i d e n t s
employment by the employer.
(b) Where a New York resident i s employed outside the state by an employer that does not do business i n the s t a t e and t h a t does not e l e c t t o
be subject to t h i s subdivision, then the employee s h a l l pay the premium
under subdivision one of t h i s section, as i f the employee's income from
the employer was self-employment income.
5. Where an employee i s not a resident of New York state (and therefore not e l i g i b l e to be a New York health plan member), and the employer
purchases health coverage for the employee, including the employee's
family, under subdivision two of section fifty-one hundred ten of
the
public health law,
the employer may take a c r e d i t against the premium
paid under subdivision one of t h i s section, up to the pro
rata portion
of the employer's premium a t t r i b u t a b l e to that employee, for the amount
paid by the employer to purchase that coverage. Where such an employee
purchases or pays a portion of the cost of such coverage, the employee
may take a c r e d i t for the amount paid by him or her for that coverage
against any premium the employee i s required by the employer to pay under subdivision one of this section.
6. Where a self-employed individual i s not a resident of New York
state (and therefore not e l i g i b l e to be a New.York health plan member),
and
the person purchases health coverage under subdivision two of section fifty-one hundred ten of the public health law,
the self-employed
individual may take a c r e d i t for the amount paid by him or her for that
coverage against the premium paid by the self-employed person under subd i v i s i o n one of t h i s section.
7. The
total amount of c r e d i t s taken under subdivisions f i v e and s i x
of t h i s section, against premiums paid under t h i s section, for health
coverage for a person, including that person's family, s h a l l not exceed
the total amount of premium paid by or a t t r i b u t a b l e to that person,
whether paid by that person or by an employer.
8. New York health plan members e n t i t l e d to coverage under t i t l e XVIII
cf the federal s o c i a l s e c u r i t y a c t , who are not axso e n c i c i e a co
covreaerai s o c i a l s e c u r i t y acc, wno are noc a l s o e n t i t l e d to
coverage ' under t i t l e XIX of the federal s o c i a l s e c u r i t y act, s h a l l make
under
premium payments equal to the premium payment developed by the federal
sccretai
ry of health and human s e r v i c e s for coverage under part b of
t i t l e XVIII of the federal s o c i a l s e c u r i t y act; provided, however, that
-.Ian members who
make premium payments d i r e c t l y to the secretary of
health and human s e r v i c e s s h a l l be e n t i t l e d to a c r e d i t against
the
-inount paid under t h i s subdivision.
S 1702. Procedural provisions. The board of governors of the New York
health plan s h a l l adopt rules regarding the levy and c o l l e c t i o n of
the
premium payments under t h i s a r t i c l e and may enter into contracts with
the department for the c o l l e c t i o n of the premium payments levied by t h i s
a r t i c l e . For purposes of enforcement, premium payments due under t h i s
a r t i c l e s h a l l be subject to the provisions of t h i s chapter applicable to
income taxes due under a r t i c l e twenty-two of t h i s chapter.
S 4. 1. There i s hereby established a temporary commission on implementation of the New York health plan, hereinafter to be known as
the
commission, consisting of f i f t e e n members: f i v e members, including the
chair, s h a l l be appointed by the governor; f i v e members s h a l l be
appointed by the president pro tern of the senate, two of which s h a l l be
upon recommendation of the senate minority
leader: and,
f i v e members
s h a l l be appointed by the speaker of the assembly, two of which s h a l l be
PRWTID OH OfC 'CLtO IkPIR
�A. 8912--A
13
1 upon recommendation of the assembly minority leader.
The commissioner
2 of health, the commissioner of social services, the superintender.t of
3 insurance, and the commissioner of taxation and finance, or tnc-.r riesig4 nees shall serve as non-voting e x - o f f i c i o members of the commission.
5
2. Members of the commission shall receive such assistance as r,-y be
r£.
6 necessary from other state agencies and e n t i t i e s , and shall receive
7 necessary expenses incurred i n the performance of their duty. The com8 mission may employ s t a f f as needed, prescribe their duties, and f i x
9 their compensation within amounts appropriate for the commission.
10
3. The commission shall examine the statutes of this state and nake
11 such recommendations as are necessary to conform the laws of this s.ate,
12 and to eliminate any inconsistency between the laws of t h i s state, and
13 the provisions of a r t i c l e 51 of the public health law establishing the
14 New York health plan as added by section one of this act, and other
15 provisions of law relating t o the New York health plan, and to improve
16 and implement the plan.
17
4. On or before two hundred seventy days subsequent to the enactment
18 of this act, the' commission shall report to the governor and the
19 legislature, with recommendations, as provided in subdivision three of
?0 this section.
21
S 5. The superintendent of insurance, i n consultation with a techni22 cal advisory committee which shall include representation from insurers;
23 consumers, organized labor, and business, shall examine the premiuir, rate
24 structure for insurance underwritten and offered in this state by i n 25 surers licensed pursuant to the insurance law, and determine the extent
26 to which such premiums r e f l e c t expenditures for health care services
27 covered under the provisions of a r t i c l e 51 of the public health law es28 tablishing the New York health plan as added by section one of this act.
29 On or before two hundred seventy days following the enactment of this
30 act, the superintendent shall report to the governor and the legislature
31 on the extent to which the premium rate structure for insurance, by l i n e
32 of insurance, underwritten and offered in this state reflects expendi33 tures for health care services covered under article 51 of the public
34 health law as added by section one of this act, and make such recommen35 dations as are necessary for an adjustment in such premium rate struc36 tures to reflect a reduction in health care expenditures due to imple37 mentation of the New York health plan.
38
S 6. The sum of f i v e hundred thousand dollars ($500,000), or so much
39 thereof as may be necessary, i s hereby appropriated to the temporary
40 commission on implementation of the New York health plan created pur41 suant to section four of t h i s act out of any moneys i n the state treas42 ury i n the general fund to .the credit of the state purposes account not
43 otherwise appropriated. Such sum shall be payable on the audit and war44 rant of the state comptroller on vouchers c e r t i f i e d or approved by the
45 chair of the temporary commission on implementation of the New York
46 health plan created pursuant to section four of this act.
47
S 7. (a) This act shall take effect on the f i r s t day Of January next
48 succeeding the date on which i t shall have become a law provided, how49 ever, that sections four and f i v e of this act shall take effect iir.;nedi50 ately and shall remain i n f u l l force and effect u n t i l the f i r s t day. , of
51 January following the date upon which benefits under a r t i c l e 51 cf the
52 public health law as added by section one of t h i s act shall take effect
53 after which such sections shall be deemed repealed.
54
(b) Not later than the t h i r t y - f i r s t day of March following the effec55 t i v e date of t h i s act, the department of social services shall do both
56 of the following:
;
MMTID ON DICVCLEC »«»«»
�A. 8912~A
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1. Apply to the secretary of health and human services for a l i waivers
of requirements under health care programs established under
titles
XVIII and XIX of the federal social security act that are necessary to
enable t h i s state to deposit a l l federal payments under those programs
in the state treasury to the credit of the New York health trust fund
created pursuant to section 97-nn of the state finance law, as added by
section two of t h i s act;
2. I d e n t i f y any other federal programs that provide federal funds for
payment of health care services to individuals. The department shall
comply with any requirements under those programs and apply for any
waivers of those requirements that are necessary to enable t h i s state to
deposit such federal funds to the credit of the New York health trust
fund.
(c) No later than the t h i r t y - f i r s t day of December following the effeetive date of t h i s act, the board of governors of the New York health
plan and the department of social services shall explore and cooperate
with, enter into any necessary contract or other arrangement with, and
otherwise pursue any other reasonable.course of action with, the secretary-of health and human services to establish procedures, standards
and conditions under which the department shall pay to the New York
health trust fund amounts equivalent to those amounts that, on the effective date of t h i s section, are paid on behalf of residents of this
state for health benefits covered under the plan under t i t l e s XVIII and
XIX of the federal social security act.
(d) Commencing on the f i r s t day of January following the effective
date of t h i s act the following shall occur:
1. New York health premium payments that are authorized pursuant to
a r t i c l e 35 of the tax law, as added by section three of t h i s act, shall
be levied.
2. Benefits under the New York health plan established pursuant to art i d e 51 of .the public health law, as added by section one of t h i s act
shall begin.
3. Payments into the New York health trust fund created pursuant to
section 97-nn of the state finance law shall begin.
(e) Not later than the twenty-eighth day of February following the effective date of t h i s act, the governor shall make the i n i t i a l appointments to the board of governors of the New York health plan established
pursuant to a r t i c l e 51 of the public health law, as added by section one
of this act, provided, however, that of the i n i t i a l appointments made by
the governor, four shall be for a term of one year; four shall be for a
term of two years; three shall be for a term of three years; three shall
be for a term of four years; and four, including the chair, shall be for
a term of five years. Thereafter, a l l appointments shall be for a term
of f i v e years, except in those instances where an appointment is to f i l l
a vacancy occurring prior to the expiration of a term.
�New York Health (A-8912): Universal Health Coverage
What's Covered:
Most Everything
NEW YORK HEALTH covers all out-patient and inpatient health care including preventive, primary, hospital,
specialist, lab, dental, eye, prescription drugs, mental health
and treatment of drug or alcohol addiction.
Who's Covered: All
New Yorkers
All residents of New York would be covered under one
health care plan. Your source of coverage is not dependent
on work, health, age or income.
What Do I Pay: Nothing Out-of-Pocket
There are no out-of-pocket costs. No co-payments, deductibles or coinsurance. And no extra bills from doctors or other
providers.
What Does It Cost:
Less than We Spend
Now
NEW YORK HEALTH eliminates as much as $5 billion in
administrative waste. The plan will control costs by setting
fees and rates so that we can increase health care use and
still reduce costs. Future cost increases are tied to the growth
of New Yorkers' incomes.
How's It Paid For:
Through Current
Sources
Current Sources: Current spending from Medicaid and
Medicare, and other local and state health care programs
would be merged into the NEW YORK HEALTH Trust
Fund. So would Medicare "Part B" premiums. (But there
would be no more Medicare co-payments, deductibles or
extra charges).
And a Fair Health
Premium
The NEW YORK HEALTH Premium: Employers who now
provide health coverage would no longer spend 10% to 12%
for premiums. Instead, every employer would pay a NEW
YORK HEALTH premium of 8%% of payroll. This
premium would replace all private health insurance
premiums and worker's compensation health care costs.
Employees would pay 2% of payroll (which the employer
could pay as a job benefit). Self-employed people would pay
9% of earnings. There would be a premium paid by people
with high investment income.
... please turn over
�Where Do I Go for Care:
It's Up to You
Under NEW YORK HEALTH the patient will choose his
or her own doctor or other professional, hospital, H.M.O.
or health center. The health care provider will be paid
directly by NEW YORK HEALTH.
How Do Health
Providers Get Paid:
Hospitals are on
Budgets
Hospitals and other institutions would be on global
budgets which include all their operating costs. NEW
YORK HEALTH would provide steady funding,
eliminating the need to file claims case-by-case. Expenditures for new buildings or equipment would be approved
separately.
Individual Health Care
Providers Choose
Doctors and other individual health care providers have a
choice of payment method. Most payments would be feefor-service, according to rates set by NEW YORK
HEALTH. Payment could also be on a set (capitated) or
salary basis^ through an H.M.O, hospital or clinic.
What's Left Out
How's It Run: By a
Board of Governors
Legislative History
NEW YORK HEALTH does not cover cosmetic surgery
(except reconstructive work following injury or illness).
Unfortunately, it does not cover long-term care, although
Medicaid coverage will continue. Within five years the
NEW YORK HEALTH Board will develop a plan for
long-term care.
The Board of Governors, made up of representatives of
consumers, business, labor, hospitals, doctors and nonphysician health care professionals, would manage the
health care system.
NEW YORK HEALTH was passed by a vote of 91-53 by
the New York State Assembly, on June 25, 1992. The
prime sponsor of NEW YORK HEALTH is Richard
N.Gottfried, Chair of the Assembly Health Committee.
To Help Win NEW YORK HEALTH, contact the New York State
Health Care Campaign:
Statewide & Albany: Richard Kirsch, Citizen Action, 94 Central Avenue, Albany, NY 12206. Call: 518-465-4600.
New York City. Anjean Carter, Community Service Society, 212-614-5406. Or Gene Carroll, Jobs With Justice, 212-344-7332.
Long Island: Steve Harvey, LIPC, 516-691-3689. Or Donna Kass, Nassau Coalition for a National Health Plan, 516-829-1225.
Binghamton: Mary Clark, Citizen Action, 607-723-0110.
Syracuse: Paulette Johnson, Citizen Action, 315-479-7156
Buffalo: Arlette Slachmuylder, Citizen Action, 716-884-4033.
�WHO SAVES MONEY UNDER NEW YORK HEALTH
NEW YORK HEALTH Will Save Billions Of Dollars For
Families, Businesses And Taxpayers.
Families
95% of New York families will save money under NEW YORK HEALTH.
A family of four who earns $55,000 a year will save $1,700. A family who earns 40,000 will save $1,600.
(Source: U.S. Bureau Of Labor Statistics)
Businesses
Businesses who provide decent health care to their employees will see their health premiums cut by
35%. In addition, workers 'compensation costs for all employees will be cut by 50%.
Under our current system, businesses paid 10% of payroll in 1990 for employee health care premiums;
they will pay 123% in 1994. NEW YORK HEALTH will cut their premium costs to 8% of payroll - plus
cut workers compensation in half.
(Source: U.S. Chamber Of Commerce)
Taxpayers
Local government taxpayers will save more than $1 billion on NEW YORK HEALTH.
In 1990, local governments spent more than 10% of their payroll on health care; by 1994 it will be over
12%, compared to 8% for NEW YORK HEALTH.
State goverment will save too. In the last statefiscalyear, the State was paying 11.6% of payroll for
health care costs. The 8% NEW YORK HEALTH premium will save State government $461 million a
year on employee health benefit costs.
(Source: Public Policy and Education Fund of New York)
How to Win With
NEW YORK HEALTH
Prepared for the New York State Health Care Campaign by
Citizen Action of New York, 94 Central Avenue, Albany, New York 12206 (518) 465-4600
�NEW YORK HEALTH IS GOOD BUSINESS FOR NEW YORK
A small manufacturer of
machine tools in Orleans County will save $1100 per employee
under New York Health.
NEW YORK HEALTH will cut employee health
costs by 33% plus.
Employee health care costs as a
percentage of payroll jumped
44% during the 1980s according
to the U.S. Chamber of Commerce.
NEW YORK HEALTH will stabilize employee
benefit costs.
Health care costs are now more
than 100% of corporate profits,
up from only 15% in 1965, according to the White House Office of Management and Budget.
NEW YORK HEALTH will boost corporate profits.
,
Employers are expected to pay an average of 12% to 13% of payroll on health
care in 1994. The NEW YORK HEALTH cost will be only 8%, a savings of
at least one-third. NEW YORK HEALTH replaces private health insurance
premiums and cuts workers' compensation costs in half.
Health care costs are the fastest growing part of employee benefits. The U.S.
Chamber of Commerce points out that a decade of shifting costs to workers,
cutting benefits and introducing managed care hasn't slowed employee
health benefit inflation. NEW YORK HEALTH will stabilize employer
health care costs at 8% of payroll. The legislation calls for health care inflation to be held to 20% more than general inflation. At that rate, the payroll
premium will not have to be increased to keep up with health spending.
Health care costs are gobbling up corporate profits. Unless we put a halt to
runaway health care inflation, our state's and nation's competitive position
will continue to deteriorate. NEW YORK HEALTH, will put money back
into profits immediately, by lowering employee health care costs by 33%. And
will mean that New York firms will see their competitive advantage increase
each year, over other states.
Health care costs are more expensive in the Northeast than in
any other region of the nation
(U.S. Chamber of Commerce.)
NEW YORK HEALTH will attract the jobs New
York needs.
Four out offivestrikes in the
U.S. are over health care
benefits.
NEW YORK HEALTH will take health care off the
picket lines.
NEW YORK HEALTH will cut
Erie County's payroll costs by
$3.6 million; the East Ramapo
School district will save $2 million.
New York's economic growth will be built on jobs which bring money into
the state, high-tech, manufacturing,financialsector jobs with good wages and
good benefits. NEW YORK HEALTH will attract these businesses to New
York, by offering lower and stable employee health care costs.
From the bus strike in New York City to the 17 week strike at New York
Telephone, the biggest stumbling block to labor agreements is health care.
With NEW YORK HEALTH, health benefits will no longer be an item for
bargaining, and lower health costs will mean more money available for wages
and other benefits.
NEW YORK HEALTH is good for public employers
too.
Local government savings on health benefits will amount to more than $1 billion under NEW YORK HEALTH. That's property tax relief to local governments starved for funds. A mandate which local governments can celebrate.
Prepared by Citizen Action of New York, 94 Central Ave., Albany, 12206.
�HOW NEW YORK HEALTH WOULD HELP
New York's Seniors
Major Provisions
* New York's senior citizens would receive the same NEW YORK HEALTH benefits package as all other state residents.
* New York's senior citizens would continue to pay the Part B premium to Medicare.
* New York would apply for a federal waiver to include Medicare beneficiaries under
NEW YORK HEALTH, and for the New York Health Trust Fund to receive the Part A
and Part B premium income.
Major Benefits
* Lower Costs: New York's seniors would no longer pay out-of-pocket costs for health
care, including the Medicare deductible (currently $100), Medicare co-payments (20% of
many services) or physician overcharges (which are prohibited in NEW YORK
HEALTH).
* Lower Costs: New York's seniors would no longer need to purchase a Medigap policy,
an average savings of $60/month.
* New Benefits: Like all New Yorkers, seniors would receive prescription drug, dental
and eye coverage, services not now included in Medicare.
How to Win With
NEW YORK HEALTH
Prepared for the New York State Health Care Campaign by
Citizen Action of New York, 94 Central Avenue, Albany, New York 12206 (518) 465-4600
��The Public Policy and Education Fund of New York
NEW YORK HEALTH
Fiscal Analysis of a Public Health Insurance Plan
June 1992
Richard Kirsch
Acknowledgements
We gratefully acknowledge the contributions of the following to this paper: Paul Boldin, Ph.D., of the Public Policy Department of the American Federation of State,
County and Municipal Employees contributed the analysis of the NEW YORK
HEALTH growth target and suggested the revised target. Len Rodberg, Ph.D., of the
Department of Urban Studies, Queens College, provided the sources for the impact
of public insurance on health utilization and assisted in developing the NEW YORK
HEALTH budget model. Ruth Finklestein, Ph.D., of Gay Men's Health Crisis and
Aviva Goldstein, of the Public Policy and Education Fund, assisted in conceptualizing the paper and in editing.
Funding for this report was provided by the New York Community Trust.
Copyright: the Public Policy and Education Fund of New York
94 Central Ave., Albany, NY 12206. June, 1992.
�Table of Contents
Executive Summary
i
Introduction
1
Public Health Insurance Models
2
Revenues and Expenditures in 1991
5
Revenues and Expenditures in 1994
11
Health Inflation and Income
15
Conclusion
22
Endnotes
23
Appendices
Appendix A
NEW YORK HEALTH Fact Sheet
Revenue Calculations for NEW YORK HEALTH, 1990
Local Government Savings Under NEW YORK HEALTH
Appendix B
Estimated Sources of Personal Health Expenditures, 1990
National Health Expenditure Aggregate and Per Capita Amounts, Percent Distribution, and
Average Annual Growth Rate, by Source of Funds: Selected Calendar Years 1965-2000
Health Insurance by Firm Size, United States, 1987
�NEW YORK HEALTH
PAGE i
Executive Summary
HThe current report provides afiscalanalysis of NEW YORK HEALTH, legislation proposed in New
York State to establish a public health insurance program for all New York residents. The legislation would establish a new authority to administer a government-sponsored health insurance program.
The plan would include health coverage for a broad package of preventive, primary and acute health
care services. The authority would be empowered to establish a global budget for the health care system, determine reimbursement rates for providers, and institute quality assurance measures.
NEW YORK HEALTH would be funded through current federal, state and local funds for Medicare,
Medicaid and other health programs and by a health insurance premium, levied as a percentage of
wages, salaries and self-employed income in New York.
The analysis constructs a model for revenues and expenditures under NEW YORK HEALTH for 1991,
including interactions with current state revenue streams and expenditures on health care. The model
analyzes projected program savings from instituting NEW YORK HEALTH and increased expenditures from providing additional health services. The model projects 1991 expenditures through 1994,
the year in which the plan would begin providing health coverage.
The analysis concludes that the basic financing model for NEW YORK HEALTH is sound: revenues
raised are sufficient to fund health expenditures, and allow for growth in health services. The analysis
also concludes that employers who now provide health care benefits and 95% of New York families,
would save money under the proposed financing package. However, the following recommendations
are made for changes in the NEW YORK HEALTH legislation:
* The NEW YORK HEALTH premium of 9% was adequate for 1991, but because health care inflation is currently much greater than wage inflation, the 9% premium will not raise sufficient revenue
in 1994. The analysis recommends increasing the premium to 10% in 1994. The analysis concludes that
because of the rapid increase in health care inflation, the higher rate will result in relatively larger
savings on health care to employers who currently provide health care and to families, in 1994, than
the lower rate would have provided in savings in 1991.
* The expenditure growth rate established by the legislation, equal to the average growth of personal income during the most recent three years, is found to be too great and would lead to revenue
shortages in future years. The analysis recommends instead setting a growth target of 120% of general
inflation. Such a rate will account for changes in demographics and general inflation, but not allow excess medical inflation. Over time, the 120% of general inflation growth rate is lower than the growth
of wages, assuring that the NEW YORK HEALTH premium will not have to be increased and that
sufficient revenues will be generated to establish a reserve fund for recessionary years.
A final recommendation is made on a revenue-neutral way of phasing-in the payroll premium on
employers who do not now provide health care benefits to their employees.
�NEW YORK HEALTH
PAGE ii
The analysis concludes that a public insurance proposal, such as NEW YORK HEALTH, is able to
provide universal access to health coverage without increasing overall health expenditures and should
allow control of future health care spending. The cost of implementing such a proposal increases with
each year of runaway health inflation, as do the savings that such a plan would provide.
�NEW YORK HEALTH
PAGE 1
Introduction
Jn September 1991, the Chair of the New York State Assembly Health Committee, Assemblyman
Richard Gottfried, was joined by 54 of his colleagues in introducing legislation titled The NEW
YORK HEALTH plan (A-8912). (A summary of the bill's key provisions is included in Appendix A).
NEW YORK HEALTH is a public health insurance proposal, which would establish a new authority
to administer a government-sponsored health insurance program for all New York State residents. The
legislation gives the NEW YORK HEALTH Authority broad powers, including the establishment of
a global budget for the health care system, reimbursement rates for providers, and quality assurance
measures. NEW YORK HEALTH would be administered by a Board of Directors, appointed by the
Governor with the consent of the State Senate. The Board's members would include consumers, representatives of labor, business and health care providers.
The legislation would establish a broad package of benefits, including access to all preventive, primary
and acute care, prescription drug, dental and vision care and treatment for mental health and alcohol
and substance abuse. Long-term care services are not included in the benefit package.
The legislation also specifies that the bill be funded by a combination of the following revenue items:
* A 9% premium tax on gross wages and salaries and on the earning of the self-employed;
* Federal, state and local funds currently provided for services included in the NEW YORK
HEALTH benefits package;
* A tax on those with both high unearned income and low earned income.
The legislation establishes a target growth rate for the NEW YORK HEALTH Trust Fund equal to
the average of the previous three years growth in state personal income.
The purpose of the current paper is to build a financial model for NEW YORK HEALTH that, compares revenues with expenditures, explores some of thefiscaldynamics of introducing a public health
insurance program, analyzes the viability of its budgetary target, and makes recommendations for changes.
�PAGE 2
NEW YORK HEALTH
Public Health Insurance Models
Tn 1989, an organization of physicians published a proposal for public health insurance in the New
England Journal of Medicine (1). The proposal, modeled after the Canadian public health insurance
system, envisioned the United States establishing a tax-payer financed public health insurance program
to replace the current system of multiple private health insurance companies. The authors projected
that public health insurance would provide substantial administrative savings to the United States,
based on a comparative analysis of administrative costs in the United States and Canada (2).
Administrative savings do not explain the entire difference between health care spending in Canada
and the United States; in 1987 administrative costs represented 55% of the difference (3). (The United
States spends some 40% more per capita and a similar percentage more of GNP on health care when
compared with Canada). The remaining difference comes from the control of all health expenditures
by the Canadian provincial governments. Through their budgeting authority, particularly controlling
prices for hospital and physician services, Canadians have been able to hold health care inflation to a
steady share of their economy. A key feature of public insurance models is the establishment of
governmental authority to establish global budgets to control health care spending.
The Physicians for a National Health Program (PNHP) proposal generated an enormous amount of
interest in the Canadian health care system and its usefulness as a model for the United States. Canada
had, beginning in the 1960's, replaced its private, multipayor health care system with a public insurance
system (called Medicare). The result of the introduction of public insurance was health coverage for
virtually all Canadians and a slowing of the rapid rate of increase in the share of Canada's economy
Table!
Health Spending in Canada and the United States as a Percentage of Gross National Product
Percent of GNP
12
^ Canada Enacts
National Health
Program, 1971
1960
1965
1970
1975
United States
souoc oeco
Canada
1980
1985
1989
�NEW YORK HEALTH
PAGE 3
(gross national product) spent on health care (Table I). Public opinion polls indicated that Canadians
had the highest levels of satisfaction with their health care system of compared, with other developed
nation (4) and excellent health statistics, as measured by life expectancy, infant mortality, and maternal mortality (5).
In the United States, satisfaction with the health care system was deteriorating, as the nation suffered
a combination of poor health outcomes and expensive health care when compared with other developed
nations (Table II). During the 1980's the number of Americans with private health insurance declined
steadily, from 83% at its historical peak in 1978, to less than 75% (6). It is not surprising then that the
same polling showed the lowest level of public satisfaction with health care in the United States.
As a result of the comparative analysis of the two nation's experiences, and the proposal by the
Physicians for a National Health Program, several legislative proposals were introduced into both
houses of Congress and in state legislatures throughout the country (7). The proposals do not strictly
follow the Canadian model; they have different benefit packages, governance structures, federal-state
fiscal and administrative relationships and revenue sources. But a common theme is the replacement
of all or most of the private insurance industry with a tax-financed public health insurance program
which would entitle all residents (of the nation or state) to a comprehensive set of benefits. The public
insurance programs would be funded in part by the savings from reducing the administrative waste of
the multipayer health insurance system. In addition, the public health insurance proposals control future health care spending, by establishing growth targets for the health care system.
Table II
Infant Mortality, Child Mortality and Per Capita Spending
Among 22 Developed Nations
Infan!
Mortality
1
2.
3
4.
5.
6.
7.
8.
9.
10.
11
12.
13.
H
15.
16.
17.
18
19.
20.
21.
22.
Child
Mortality
Par Capita
Health S p e n d i n g
Iceland
Finland
Sweden
Japan
Denmark
Ntihetlands
Nonvay
Switzerland
France
Lraemhoure
Canada
Australia
Ireland
Germany
Singapore
Hcng Kong
Great Britain
Spain
Belgium
Austria
Germany. E
UNITED STATES
Iceland
Finland
Sweden
Swiueiland
Japan
Candada
Denmark
Netherlands
Noway
Australia
Fiance
Luxembourg
Singapore
Spain
Great Britain
Ireland
Germany
Austria
Belgium
UNITED STATES
New Zealand
Italy
UNITED STATES
Canada (72r*)
Iceland (61%)
Sweden (607c)
Switzerland (60%)
Norway (MTc)
France (H°i)
Germany (52%)
Luxembourg (51%)
Netherlands (51%)
Austria (48%)
Finland (467c)
Australia (46%)
Japan (45%)
Belgium (43%)
Italy (41%)
Denroaik (37%)
Great Britain (37%)
New Zealand (31%)
beland (27%)
Spain (25%)
Portugal (19%)
Note: Dumhfn In paTembesb Indicate the aitlon'i per esplu beiltb exptftdiiaies
as • p*TCTn?3|f of thf Unhfd Suies's. Foi example. Spilo. which has a lower
fnfin) tnoruhty rue than lhe United Stales spends only 25* as much per capita
on beatlb care.
Soarcei: World P»nt. Children s Defense Fond, OECt»
�NEW YORK HEALTH
PAGE 4
In 1991, the original work of PNHP was updated. The first study of administrative waste found that the
United States spent 60% more on health administration than the Canadians in 1983. By 1987, the
proportion of health care spending in the United States was found to be at least 117% higher than in
Canada (3). A revised PNHP plan to implement public insurance was published, along with other
proposals for health care reform, in the Journal of the American Medical Association of May 15,1991
(8).
A Dynamic Model
'T'he several legislative proposals (7) use a similar method of analysis: the revenues established by the
bill are calculated, current expenditures on health measured, administrative savings counted and a
surplus is maintained to pay for higher utilization by those who are currently uninsured or underinsured. The original analysis for NEW YORK HEALTH (Appendix A) used this methodology.
The current analysis departs from the analysis used in these proposals by building a dynamic model for
projecting the cost of implementing public insurance. The original NEW YORK HEALTH projections
showed adequacy of revenues for 1990, the last year for which figures were available. The dynamic
model allows the following adjustments:
* Projects revenues and expenditures through 1994, the year in which NEW YORK HEALTH
would be implemented;
* Analyzes the impact of NEW YORK HEALTH on state revenues and expenditures;
* Analyzes phase-in of administrative savings and increased utilization expenditures;
* Explores the long-term adequacy of the NEW YORK HEALTH growth target.
These .adjustments will enable policy makers to better measure the adequacy of the NEW YORK
HEALTH finance plan.
�PAGE 5
NEW YORK HEALTH
Revenues and Expenditures in 1991: Table III
'J'he analysis in Table III calculates revenues and expenditures in 1990 and 1991.
Table III
NEW YORK HEALTH Budget Model - Base Calculations: 1990 and
1991
(All Figures in millions (000,000))
im
1221
Revenues
Wage Base
Self-Employed
Total Earnings
9% Premium
Public Programs
Medicare
Medicaid
Other Public
Total Public
Premium Tax
$233,812
$ 13,327
$247,139
$ 22,243
$235,812
$ 13,441
$249,253
$ 22,433
$ 10,273
$ 6,600
$
825
$ 17,698
($
45)
$ 11,526
$ 7,400
$
936
$ 19362
($
50)
Total Revenues
$ 39,896
$ 42,245
Total Spending
Nursing Home
Home Care
Total w/o LTC
Public Share
Private Share
Total before public insurance
State Hlth Premiums
Workers' Comp Savings
Admin Savings
$ 50,355
($ 5,841)
($ 3,319
$ 41,195
$ 17,698
$ 23,497
$ 41,195
($ 178)
($
33)
($ 5,809
$
($
($
$
$
$
$
($
($
($
Total Expenditures
$ 35,176
$ 38,804
Surplus
$
$
Expenditures
4,720
55,944
6,490)
3,863)
45,592
19,656
25,936
45,592
317)
43)
6,428
3,441
�NEW YORK HEALTH
PAGE 6
Revenues
Payroll Premium: The largest source of funding for NEW YORK HEALTH is a 9% premium on gross
wages and salaries and on self-employment earnings (subject to the Medicare cap of the first $125,000
of earnings).
Wage and salary data were obtained from the New York State Department of Labor, Division of
Research and Statistics. In 1990, gross wages and salaries were $233,812 million. As of April, 1991, data
was only available for the first three quarters. Due to the recession, there was only a growth of $1,002
million for the first three quarters. The fourth quarter is anticipated to see a jump in earnings due to
robust profits in the financial sector. For purposes of estimating, we have assumed that the 1991 gross
wages increased by $2,000 million over 1990, to a total of $235,812 million.
Direct data on self-employed earnings in New York are not kept by the Department of Labor. According to the Social Security Administration, Office of Research and Statistics, self-employed earnings
were 7.8% of wages in 1987 and 4.2% of wages in 1988; the two most recent years available for New
York. The office also indicated that 90% of all wages were below the Medicare cap (nationally), in
1989. However, in 1991 the Medicare cap was increased from less than $60,000 to $125,000. To estimate self-employed wages we used the average ratio of self-employed to total earnings (6.0%) and
assumed that 95% (a conservative estimate) were under $125,000; self-employed earnings are estimated at $13,441 million in 1991. Applying the 9% premium tax to the total of wages, salaries and
self-employed results in 1991 revenues of $22,433 million.
Public Programs: The second major category of revenues is current public spending. NEW YORK
HEALTH would capture funding from all current public programs for the services included in the
NEW YORK HEALTH benefits package. This includes all Medicare funding, Medicaid funding with
long-term care excluded, and funding from other public programs. (The legislation instructs the NEW
YORK HEALTH board to seek Medicaid and Medicare waivers from the federal government so as
to capture the funding and allow conformity with NEW YORK HEALTH reimbursement methods.)
The Medicare and other public program spending levels for 1991 were calculated from a state-by-state
total health expenditure model constructed by the health consulting firm of LEWIN/ICF. Figures for
all health expenditure by sector were published for 1990 by LEWIN/ICF (9) and are found in Appendix B. We also received from LEWIN/ICF their inflation percentages by sector for 1990 (Appendix B)
and used these to estimate 1991 data when 1991 data was not directly available. Calculations in Table
III for Medicare and "Other public" are the 1990 LEWIN/ICF data inflated for 1991.
We calculated Medicaid spending from New York State Department of Social Service Data, Division
of Medical Assistance. The total spending for federal fiscal year 1991 was $ 14,395 million. We deducted
the following categories for long term care (LTC): Institutional LTC ($3,105 million); non-institutional LTC ($1,845 million); Office of Mental Health (OMH) outpatient ($85 million); OMH inpatient
($735 million) and Office of Mental Retardation inpatient ($1,006 million). The balance to be trans-
�NEW YORK HEALTH
PAGE 7
ferred to NEW YORK HEALTH in 1991 was $7,031 million, for federal fiscal year, 1991. However,
the NEW YORK HEALTH calculations, are on a calendar year. From 1990 to 1991, Medicaid spending on other-than-long-term-care grewfrom$5,818 million to $7,031 million, a 21% increase. Assuming that growth continued at that rate for the last quarter of 1991, Medicaid would spend an additional
$369 million, for a total of $7,400 million.
Tax on Unearned Income: NEW YORK HEALTH includes a tax on unearned income, for those who
do not have substantial earned income. The purpose of the tax is to be certain that all New Yorkers
who have the means to contribute to the cost of their health care benefits. The tax requires that taxpayers, other than Medicare beneficiaries, who have not been subject to the payroll premiums on half
of their adjusted gross income, shall pay an additional payroll premium, such that the taxpayer pays 9%
on at least half of his adjusted gross income, but on no more than the Medicare cap (currently $ 125,000
of earnings).
We have not made any estimates of revenue from this tax measure as sufficient tax data are not publicly available.
Insurance Premium Tax: We also investigated the loss of premium income from private health insurance premiums, which would result from NEW YORK HEALTH. Commercial insurance companies, which are subject to the taxes, make up 37% of health insurance premiums in New York (10).
Since detailed data to measure the cost to the state of the loss of insurance premium taxes are not
publicly available, we made the following estimate. In 1992 the state projects it will raise $280 million
from the Additional Franchise Tax, of which 17%, or $48 million, is from life and health policies. Total
insurance tax collections are estimated to be $623 million; if the 17% rate applies to these, collections
from life and health would be $106 million in 1992. If we take the midpoint of these numbers in 1992,
$77 million, and make the conservative assumption that 67% is health insurance premiums, then the
1992 loss of revenues would be $51.6 million. For 1991, we have estimated a loss to the state from
premium tax collections of $50 million. (Note that some supplemental health insurance policies, for
such items as private hospital rooms, will continue to be written and generate premium tax income).
Corporate Franchise Tax: We also attempted to investigate whether the premium tax requirement in
NEW YORK HEALTH would lead to a loss of state corporate franchise tax revenues. In 1990, the
employers' share (7.5%) of the premium tax in New York would have resulted in total employer expenditures on health care $6,200 million higher than the current employer contribution (see Revenue
Calculations for NEW YORK HEALTH, 1990, in Appendix A). However, the 7.5% rate established
by NEW YORK HEALTH is considerably less than the current cost of health premiums for firms who
now provide health insurance. The national average, according to the United States Chamber of Commerce annual benefit survey, in 1990, was 10.2%, for services covered by NEW YORK HEALTH (11).
The 10.2% figure is an average for all firms in their survey;firmswith more than 100 employees have
higher costs. The Chamber study also indicates that the cost of medical benefits in the Northeast is
much greater than the national average; New Yorkfirmsare likely to pay more than the 10.2%. The
7.5% payroll premium in NEW YORK HEALTH is likely to decrease expenses for New York's
medium and large businesses; suchfirmsare also more likely to be currently profitable and the result
would be increased corporate franchise taxes from many firms.
�NEW YORK HEALTH
PAGE 8
Only those businesses which do not pay for health benefits, or whose benefit package is very poor, will
incur increased expenses, under NEW YORK HEALTH. LEWIN/ICF published national data in 1987
on health insurance status byfirmsize. The data, found in Appendix B, shows that overall, 73% of
workers receive health insurance, including 91% of those who work for firms of more than 100
employees; 77% of those who work for firms with 25 to 99 employees and 66% of those who work for
firms with 10 to 24 employees.
Businesses with 10 or fewer employees are most likely to be small shops or family enterprises, are less
likely to have substantial profits and are more likely to be paying New York's minimum corporate
franchise tax. Below we discuss one proposal to phase in the NEW YORK HEALTH payroll premium
for such firms.
As a result of the above discussion, we conclude that New York is not likely to lose corporate franchise
tax revenues from the NEW YORK HEALTH premiums: in fact, an increase is just as likely.
The total revenue projections from NEW YORK HEALTH for 1991 are $42,038 million.
Expenditures
Long Term Care Adjustment: NEW YORK HEALTH does not include funding for long term care.
However, the LEWIN/ICF model includes long-term care. To calculate current health expenditures
in New York for long-term care wefirstinflated, using the LEWIN/ICF data, the 1990 spending to 1991
levels, for total spending of $55,944 million. According to the State Department of Health, 11.6% of
health spending in New York is on nursing home care, or $6,490 million. In order to estimate the proportion of home care we assumed that the Medicaid ratio of institutional to non-institutional long-term
care was the same outside of Medicaid. Applying this ratio we calculated that in 1991, $3,863 million
were spent on home care. We deducted the nursing home and home care figures from the total expenditure figure to arrive at a total expenditures without long-term care of $45,592 million in 1991.
Public Spending: Since public revenues and spending on health are the same, we used the public
revenue calculations described above.
Private Spending: Private spending is simply the difference between total spending and public spending.
Total Before Public Health Adjustments: This simply restates the figure for total spending without
long-term care.
Savings from State Employee Health Insurance Premiums: The NEW YORK HEALTH premium
rate will apply to public employees. In the state fiscal year ending March 31,1992, the New York State
Department of Civil Service, Division of Employee Benefits, reported total health insurance premiums
of $894 million, up from $834 million in FY 19901/91. Total wages, salary and overtime for the state,
�NEW YORK HEALTH
PAGE 9
according to the State Comptroller, was $7,697 million in FY 1991/92; $8,745 million in FY 1990/91.
(The payroll and premium figures are for the general fund and special revenue funds).
In FY 1991, employee health insurance premiums were 9.5% of payroll; in 1992 11.6%. Savings to the
state from the NEW YORK HEALTH premium of 7.5% would have been $178 million in FY 1990/91
and $317 million in FY 1991/92.
Savings from State Workers' Compensation. Since NEW YORK HEALTH covers all health expenditures, the medical portion of workers compensation will no longer be an expense to employers, including the State. The Department of Civil Service calculates these costs as $33 million in FY 1990/91;
$43 million in FY 1991/92.
Administrative Savings. The foundation work for estimating the administrative savings from public
health insurance are the New England Journal of Medicine articles (2),(3) by David Himmelstein and
Steffie Woolhandler, of the Harvard Medical School. Their research calculates the difference between
Canadian and United States spending on the billing and collection of health care dollars in several sectors: insurance, hospital, nursing home and physician.
Himmelstein and Woolhandler use two sets of estimates for the physician component of their administrative cost savings; one set of estimates is almost twice as high as the other. Incorporating the
higher esimate of physician savings into the overall administrative cost savings would have lowered
total health expenditures by 17.4%. Instead we used the lower estimate, 15%, in our study.
Administrative cost savings in the Himmelstein and Woolhandler study, using the lower physician estimate, are distributed as follows:
* Insurance administration
- 31%
* Hospital administration
- 40%
* Nursing home administration - 6%
* Physician administration
- 23%
Since NEW YORK HEALTH does not include nursing homes the savings in our model were reduced
by deducting the nursing home share. Applying the administrative savings figures to the total spent on
health care results in estimated savings in 1991 of $6,428 million.
The Public Policy and Education Fund directly measured insurance administrative waste in New York,
as compared with Medicare administrative costs (10). The excess insurance administration was $2.4
billion in 1991 (this includes the commercials and non-profits, but excludes many large HMO's).
Medicare costs are also higher than we would anticipate under NEW YORK HEALTH since claims
processing under the program would not involve deductibles, co-payments or excess billing calculations, which Medicare currently calculates.
The full administrative savings in 1991 in New York would be, using the Woolhandler and Himmelstein
lower boundfigures,without nursing homes, $6,428 million. Insurance administration savings, at $2,400
�NEW YORK HEALTH
PAGE 10
million is 38%, rather than the 31% Himmelstein and Woolhandler estimate. This means that hospital and physician administrative savings could be $449 million less in 1991 than assumed and still not
impact the overal savings estimates.
Surplus: The difference between revenues and expenditures is the amount available for increased
utilization, by the uninsured and underinsured; $3,441 million in 1991.
�NEW YORK HEALTH
PAGE 11
Revenues and Expenditures in 1994: Table IV
T^he NEW YORK HEALTH legislation would implement the public health insurance plan in 1994.
In Table IV we project revenues and expenditures through 1994.
Revenues
Payroll Premium: Total earnings were inflated by Wharton Economic Forecasting Associates (WEFA)
April, 1992 projection of the annual growth in New York wages and salaries. WEFA makes such projections through 1994: 4.9% in 1992; 2.8% in 1993; 3.4% in 1994. Earnings in 1994 are projected to be
$277,927 million, resulting in revenues of $25,013 million.
Public Programs: LEWIN/ICF projects growth in health care for all expenditures for public programs,
with separate calculations for federal and state-and-local (Appendix B). However, LEWIN/ICF has estimates for 1992 and 1995; not the two intervening years. For 1992 and 1993 we used the LEWIN/ICF
inflators for 1992. For Medicare we used the federal inflator; for Medicaid we used the mean of federal
and state-and-local; for "other public" we used the state-and-local inflator.
Nineteen-ninety-four will be the first year of NEW YORK HEALTH spending caps. For Medicare
and Medicaid, the amount of revenues received will be determined by the terms of the waivers with
the federal government. The NEW YORK HEALTH budget cap is less than the growth in Medicare
and also less than the growth in health care inflation. We assume that negotiations with the federal
government will result in sharing the savings from lowered growth in New York, between the state and
federal governments. Therefore, we have used the WEFA projections of the growth in medical inflation, to estimate the growth in Medicare revenues in 1994. For Medicaid, we have used the average
between the growth in medical inflation and the NEW YORK HEALTH budget cap. For "other public"
we have used the NEW YORK HEALTH budget cap.
The result is total revenues from public programs of $25,846 million.
Premium Tax: We have increased the loss of payroll premium revenue by the growth in private health
expenditures, according to LEWIN/ICF. The projected forgone tax revenue in 1994 is $64 million.
Total Revenues: The model projects total revenues in 1994 from NEW YORK HEALTH at $50,795
millions.
Expenditures
Public Share: Public expenditures equal public revenues, calculated above: $25,524 million.
�PAGE 12
NEW YORK HEALTH
Table IV
NEW YORK HEALTH Budget Model - Annual Budgets 1990 1994
(Allfiguresin millions (000,000))
1990
1991
1992
1994
1993
NYHEALTH
Revenues
$233,812
$ 13,327
$247,139
$ 22,243
$235,812
$ 13,441
$249,253
$ 22,433
$247,367
$ 14,100
$261,467
$ 23,532
$254,293
$ 14,495
$268,788
$ 24,191
$262,939
$ 14,988
$277,927
$ 25,013
$ 10,273
$ 6,600
$
825
$ 17,698
($
45)
$ 39,896
$ 11,526
$ 7,400
$
936
$ 19,862
($
50)
$ 42,245
$ 12,760
$ 8,214
$ 1,041
$ 22,015
($
54)
$ 45,493
$ 14,17.5
$ 9,118
$ 1,159
$ 24,401
($
59)
$ 48,533
$ 15,015
$ 9,619
$ 1,212
$ 25,846
($
64)
$ 50,795
Total Spending
Nursing Home
Home Care
Total w/o LTC
Public Share
Private Share
Tot. before public ins.
State Hlth Premiums
Workers' Comp
Admin. Savings
(80% of possible)
Cover Uninsured
$ 50,355
($ 5,841)
($ 3,319)
$ 41,195
$ 17,698
$ 23,497
$ 41,195
($ 178)
($
33)
($ 4,647)
$
($
($
$
$
$
$
($
($
($
5,944
6,490)
3,863)
45,592
19,656
25,936
45^92
317)
43)
5,143)
$
$
$
$
($
($
22,015
28,167
50,181
344)
47)
5,660)
$ 24,401
$ 30,589
$ 54,990
($
374)
($
51)
($ 6,203)
$ 25,524
$ 31,996
$ 57,520
($
406)
($
55)
($ 6,488)
$
$
1,137
$
1,251
$
$
Total Expenditures
$ 37,371
$ 41,227
$ 5381
$ 49,739
$ 52,010
Amount Available For
Utilization Increases
$ 2,524
$
$
($ 1,206)
($
Wage Base
Self-Employed
Total Earnings
9% Premium
Public Programs
Medicare
Medicaid
Other Public
Total Public
Premium Tax
Total Revenues
Expenditpreg
1,034
Private Share as
9.5%
Proportion of Total Earnings
1,018
10.4%
111
10.8%
1,376
11.4%
1,440
1,215)
11.5%
�NEW YORK HEALTH
PAGE 13
Private Share: Private expenditures are inflated by the LEWIN/ICF inflator for private health expenditures. For 1994, the NEW YORK HEALTH budget cap was used. The result is total private share
expenditures of $31,996 million.
Total Before Private Insurance: The sum of public and private expenditures in 1994 is projected to be
$57,520 under NEW YORK HEALTH.
Savings in State Employee Health Insurance Premiums. Assuming that the State's savings would grow
at the rate of private sector health inflation, the savings in 1994 would be $406 million.
Savings from State Workers' Compensation: Inflating the savings by the LEWIN/ICF inflator in private
health expenditures results in projected savings in 1994 of $55 million.
Administrative Savings: Administrative savings should be captured quickly. NEW YORK HEALTH
would allow the state to contract with private insurers to administer claims. Currently, three private insurance companies (Empire Blue Cross and Blue Shield, GHI and Blue Shield of Western New York)
administer Medicare claims in New York State and could expand their processing to all claims under
NEW YORK HEALTH.
The Medicare fee processing rate, of 2.1% of claims, will be further reduced under NEW YORK
HEALTH. The introduction of uniform fee schedules, service codings and utilization guidelines, plus
the elimination of the need to calculate deductibles, co-payments and excess charges, would mean significant additional savings for the outpatient claims which would be processed under NEW YORK
HEALTH. At the same time, the most complicated billing, that for hospital services, would be entirely eliminated under NEW YORK HEALTH, which establishes global budgets for hospitals and other
article 28 corporations.
For providers, the main delay in achieving the administrative savings, will be from continued collection for services provided before NEW YORK HEALTH is implemented.
We estimate that 80% of potential administrative savings would be realized in thefirstyear of the
program's implementation: $6,488 million in 1994.
Covering the Uninsured: Those who are uninsured consume health care services which are paid for
out-of-pocket, by public programs and through hospital uncompensated care pools. In addition, data
has shown that while the uninsured receive fewer health care services, the intensity of the services consumed is greater than those who have health insurance (13). LEWIN/ICF estimated that the additional health expenditure for each uninsured New Yorker in 1990 would have been $470 (13). Inflating that
cost to 1991 and applying it to the 2.2 million New Yorkers without health insurance, would result in
an additional cost of $1,034 million. To calculate the cost in 1994 we have increased spending by 10%
a year, from 1991 to 1993; and by the NEW YORK HEALTH budget cap in 1994. The total needed to
cover the uninsured, in 1994, will be $1,440.
Total Expenditures: The total expenditures in 1994, under this model, would be $52,010 million.
�NEW YORK HEALTH
PAGE 14
Amount Available for Utilization Increases: Offering all New Yorkers comprehensive health benefits
without out-of-pocket costs will also lead to utilization increases. Two different measurements are
available for estimating the increase in expenditures from eliminatingfinancialbarriers to care: the actual Canadian experience and an experiment done by the Rand corporation with a few thousand
Califomians.
The Canadian experience is clearly more relevant, since it applied to an entire population in an operating health delivery system. A detailed study by Robert Evans, a health economist at the University of
British Columbia, concluded that in studying the impact on hospital care,"... national health insurance
did not have any observable effect on utilization." (14; page 146) Evans finds that health expenditures
in Canada increased with an increase in supply, not coverage. Evans continues:" If not correlated with
insurance, [hospital] utilization does move very closely with bed availability."
Evans found similar results for physician care. 'The before and after Medicare study of physician utilization in Montreal reports that aggregate visit rates did not rise in response to insurance and that physician
work hours did not increase" (14; page 161).
But removingfinancialbarriers to care does change the utilization patterns of income groups. According to a study of elimination of out-of-pocket costs in Quebec: "Physician visits per person per year
remained constant at about five but were markedly shifted from persons in higher to lower income
groups" (15; page 1174). Similarly, a study of a short-lived program in Saskatchewan to establish copayments found reduced utilization by lower-income groups; increased by upper income (15).
The Rand Health Insurance Experiment (16) found that introducing financial barriers to care
decreased utilization in the small, controlled population, studied. The Rand results are entirely compatible with the Canadian results; in the absence of co-payments utilization increases, when supply is
available. When supply is not available, eliminatingfinancialbarriers to care simply shifts care to those
with low incomes, who have been most impeded by the out-of-pocket costs..
New York probably has less surplus health supply than any state in the nation. Our hospital occupancy rate is among the highest in the nation, 82.1% in 1991, according to the State Department of Health,
Health Facilities Planning Bureau. We have a severe shortage of primary care facilities in low-income
areas where increasing coverage and eliminating financial barriers to care would, without supply limitations, lead to the most increase in health expenditures. As a result of these supply limitation, we should
not anticipate large increases in health care utilization in New York from moving to universal coverage,
without also increasing health care supply.
While large utilization increases are not anticipated, the current financing of NEW YORK HEALTH
is clearly inadequate to fund utilization increases in 1994. While $1,018 million would have been available for increased utilization in 1991, there is a shortfall of $1,215 million in 1994.
�NEW YORK HEALTH
PAGE 15
Health Inflation and Income
Impact on Employers
'T'he original budget model for NEW YORK HEALTH was based on 1990figuresand showed a large
surplus, $2,524 million. As Table IV shows, that surplus shrinks with each year. Why?
The fundamental reason is that health care spending in the private sector is increasing much faster than
earnings. From 1990 to 1994, private sector health care spending will increase by 36.2%, while earnings will increase only 12.5% (WEFA). The trend may also be viewed by looking at the final line of
Table IV, the private share of health spending (which includes public employee health benefits) as a
percentage of earnings. In 1990, spending was 9.5% of earnings; by 1993 it will be 11.4%. But in 1994,
when health growth is kept to a lower rate through the implementation of NEW YORK HEALTH,
the private health spending remains virtually the same percentage of earnings (11.5%).
The trend here is not new: it is a fundamental problem of our health care system and is found throughout
the nation. According to the Federal Office of Management and Budget, wages as a percent of payroll
increased from 2% in 1965 to more than 8% in 1989 (5). The impact on corporate profits has been
devastating. OMB reports that health benefits went from less than 15% of after-tax corporate profits
to more than 100%, from 1965 to 1989.
The Chamber of Commerce annual benefits report focuses on this problem in its 1991 edition. The
Chamber reports that, despite aggressive efforts at cost control - raising deductibles, increasing the
employees' share of premiums and introducing managed care systems - "health premiums are rising
faster than pay, rather than in tandem with pay" (11, page 40). The Chamber reports that health and
dental costs increased as a percentage of payroll by 44%, from 5.5% in 1980 to 7.9% in 1990. (These
figures do not include all health benefits, and apply to all firms surveyed, including those that do not
pay health benefits).
In 1990, the Chamber reports thatfirmsthat pay health benefits, spent 10.2% of their payrolls for health
benefits which are covered by NEW YORK HEALTH. While the Chamber does not break this down
regionally, it does indicate thatfirmsin the Northeast are likely to pay even more for health care. Firms
in the Northeast paid an average of $4,103 per employee for health care, compared with $3,197 nationally.
NEW YORK HEALTH would establish a 7.5% payroll premium on employers (the remaining 1.5%
is on employees). In 1990 this would have compared to at least 10.2% for firms who currently provide
health benefits; a savings of more than 25%. Public employers suffer the same costly trend. An extreme
case was discussed above, when New York State's cost of health benefits as a percentage of payroll
jumped from 9.5% to 11.6% from 1990 to 1991. The State reduced its workforce by thousands of
employees due to the recession, but health premiums still increased.
�NEW YORK HEALTH
PAGE 16
State government in New York is not alone in paying a substantial portion of its payroll for health
benefits. In 1990, health premiums were 9.8% in the City of Buffalo; 10.4% in the Brentwood, Long
Island School District; 12.8% in the City of Albany. The Public Policy and Education Fund found that
for 47 local governments in New York health care costs averaged 10.2% of payroll in 1990 (Appendix
A). The NEW YORK HEALTH employer premium of 7.5% of payroll would provide significant
savings to local governments.
What can employers expect to pay in 1994? Applying the projected growth in earnings to private health
spending, firms that paid an average of 10.2% of their payrolls in 1990, can expect to pay 12.3% in 1994
(Table VI).
Revising the NEW YORK HEALTH Premium
^"EW YORK HEALTH proposes to bring health care spending in New York in line with growth of
income, through its budgeting authority. The lack of such a budgeting authority now means that the
9% payroll premium established by NEW YORK HEALTH will not be sufficient by 1994. However,
increasing the payroll premium to 10% in 1994 (Table V), will raise an additional $2,779 million, leaving NEW YORK HEALTH with a surplus to pay for the underinsured of $1,565 million in 1994.
Consider the impact of raising the employer's share of payroll premiums from 7.5% to 8% (Table VI).
In 1990, the 7.5% premium would have saved employers 25% on health benefits. By 1994, despite increasing the NEW YORK HEALTH premium to 8%, the savings to employers will jump to 35%.
Impact on Small Employers
l a b i l e NEW YORK HEALTH will provide substantial savings to those businesses that now provide
health care, what about those firms that do not? As we discussed above, in the section on corporate
franchise tax, these firms are mostly small businesses, employing 10 or fewer workers.
Currently, firms which provide health benefits to their workers are subsidizing those who do not. In
New York, uncompensated care is paid for by an add-on to hospital bills and by public programs; as
taxpayers and as employers, firms that provide health benefits are subsidizing those that fail to.
NEW YORK HEALTH would level the playing field; lowering costs for those who provide health
benefits by 25% or more and raising the cost to those who do not. Of course, the NEW YORK
HEALTH premium rate would be substantially less than that currently charged by private insurers.
Still, businesses who do not now provide health benefits will face an increase. Some have suggested
phasing in the employer premium to soften the financial impact on small employers. The problem, of
course, is that such a phase-in would result in lost revenue to the NEW YORK HEALTH fund.
�PAGE 17
NEW YORK HEALTH
Table V
NEW YORK HEALTH Budget Model -1994 Implementation
With 10% Payroll Premium
(Allfiguresin millions (000,000))
1994
Revenues
Wage Base
Self-Employed
Total Earnings
10% Premium
Public Programs
Medicare
Medicaid
Other Public
Total Public
Premium Tax
$262,939
$ 14,988
$277,927
$ 27,793
Total Revenues
$ 53,575
$ 15,015
$ 9,619
$ 1,212
$ 25,846
($
64)
Expenditures
Public Share
Private Share
Total before public insurance
$ 25,524
$ 31,996
$ 57,520
State Hlth Premiums
Workers' Comp Savings
Admin Savings (80% of possible)
($ 406)
($
55)
($ 6,489)
Cover Uninsured
$
Total Expenditures
$ 52,010
Amount Available For
Utilization Increases
$
1,440
1,565
�NEW YORK HEALTH
PAGE 18
The current disparity, between employers who provide health benefits and those who do not, suggests
a revenue-neutral solution. NEW YORK HEALTH could capture a portion of the savings experienced
by employers who provide health care, and use that to subsidize the new costs borne by employers who
have not provided health care. A possible mechanism would be to have employers calculate how much
they saved under NEW YORK HEALTH, compared to their previous year's health costs, and pay half
of that savings to the State. The State could use that pool of funds to subsidize employers who had not
provided health care costs. Such subsidies could be restricted by firm size and profitability.
Any such phase-in should last only a few years; no more than three. Implementing such a proposal will
impose measurement, gaming and distribution problems which are only solvable in a short time frame.
Table VI
Employer Health Costs As A Percentage Of Payroll
(Does not include employees' share of costs)
im
CURRENT COSTS
NEW YORK HEALTH
NEW YORK HEALTH SAVINGS
NEW YORK HEALTH
SAVINGS AS % OF CURRENT COSTS
1224
10.2%
7.5%
2.7%
26.5%
12.3%
8.0%
4.3%
35.0%
Current data is average benefit cost as percent of payroll for companies paying employee benefits, 1990. The
following benefits are included: a) hospital, surgical, medical and major medical insurance premiums (net):
7.4%; b) retiree premiums: 1.4%; dental: 0.8%; other (vision, physical and mental fitness, benefits for
former employees): 0.6%.
The data are national: firms headquartered in the Northeast pay health care benefits which are, on the
average, 28% higher than the national average. Source is the 1991 edition of Employee Benefits: Survey Data
from Benefit Year, 1990, U.S. Chamber of Commerce.
NEW YORK HEALTH premium includes all of the costs included in the Chamber of Commerce survey,
with two exceptions: retirement benefits for retirees who do not live in New York and physical and mental
fitness.
However, NEW YORK HEALTH will also eliminate the health care portion of workers' compensation, a
significant savings not reflected in the table.
�PAGE 19
NEW YORK HEALTH
Impact on Employees
"tfow would an increased payroll premium impact on employees, who would pay 1.5% of payroll under
NEW YORK HEALTH? Table VII shows the amount and percentage of personal income spent
on health care, by income groups, nationally, in 1990. Health spending is very regressive; those in the
lowest income quintile spend 8.2% on health; the top 5% spends only 1.1%. The NEW YORK
HEALTH rate of 1.5% would save money for all families other than the top 5%. Even these most wealthy families might not spend more, since the NEW YORK HEALTH rate only applies to earned income.
Personal income in New York, from 1990 to 1994, is expected to increase by 12.8%, while private health
expenditures will increase by 36.2%. The poorest 20% of New Yorkers will be spending 9.9% of their
income on health care; the richest 5% will spend 1.3% of their income on health by 1994 (Table VII).
NEW YORK HEALTH could raise the employees' share of payroll to 2% and still provide substantial savings. Assuming that personal income increases equally for all income groups, the 1994 savings,
at a 2% employee payroll premium, would range from $1,142 peryear for the poorest quintile, to $1,524
for those in the 80th-to-95th percentile of personal income. Again, only the top 5% will pay more and
the cost shown here is highly overstated, since the most wealthy are likely to have substantial unearned
income.
Tabl? VII
Health Spending By Income • United States 1990
(Family of Four)
Income Group
Average Income
Lowest 20%
$12,800
Second 20%
$27,400
Third 20%
$39,200
Fourth 20%
$54,000
Next 15%
$81,600
Top 5%
$322,600
Average Spending
$ 1,050
$ 1,650
$ 1,930
$ 2,130
$ 2,470
$ 3,500
% of Income
8.2%
6.0%
4.9%
3.9%
3.0%
1.1%
NYHEALTH Spending:
1990
NYHEALTH Savings:
1990
Health Spending as
% of Income:
1994
NYHEALTH Savings:
1994
$
192
$
$
$
810
$ 1,224
$ 4,839
$
858
$ 1,239
$ 1,342
$ 1,320
$ 1,246
($ 1,339)
9.9%
7.3%
5.9%
4.8%
3.7%
1.3%
$ 1,242
$ 1,630
$ 1,745
$ 1,683
$ 1,524
($2,510)
411
588
�PAGE 20
NEW YORK HEALTH
Budget Target
'T'he United States, unlike its industrial competitors, does not set a health care budget; as a result
health care inflation knows no limits. NEW YORK HEALTH establishes a budgeting authority for
health care spending in New York and establishes a budget target for the authority to follow.
The growth target established in the NEW YORK HEALTH legislation is the average personal income growth of New Yorkers over the most recent three years. Personal income was chosen in order
to have health care spending reflect the growth of wealth in the state, and to approximate the main
NEW YORK HEALTH revenue source, the premium tax on wages. A three year average was chosen
to smooth the impact of economic cycles.
While the growth of wages and personal income are related, New York has seen a greater increase in
personal income. According to Wharton Economic Forecasting Associates (WEFA), from 1975 to
1991, personal income in New York grew 226% while wages grew 204%.
The faster growth of personal income is most noticeable in a recession. Table VIII compares the growth
rate of wages in New York to the NEW YORK HEALTH cost limit, since 1985, and projected forward
to 1994. From 1985 to 1988, wages kept pace or exceeded the three year average growth in personal
income. But as the New York economy began to slow down, in 1989, personal income exceeded wage
growth, which is hurt more by tough economic times. By 1993, assuming the recession has ended, wage
growth is expected to catch up to personal income again.
Table VIII
Growth in Wages and NEW YORK HEALTH Budget Target: 1985-1994
-2*
86
87
80
85
iNY~Wag« and Salary
3NY Hialth Cott Limit
89
90
91
92
93
94
Sources: WEFA, 4/92; AFSCME
�PAGE 21
NEW YORK HEALTH
We may also question whether personal income makes sense as a growth target for health care spending. During the 1980's, health care spending rose approximately twice as fast as general inflation. According to the Health Care Financing Administration, 40% of the growth came from general inflation
and 10% from population changes, factors over which NEW YORK HEALTH would not have control. The balance came from reimbursement and volume changes in the health care sector, factors which
would be under NEW YORK HEALTH'S control.
The growth of personal income, on the other hand, is not directly related to demand for health care.
Personal income fluctuates with economic conditions, not with health needs or inflation. Perhaps, it
would make more sense to set a NEW YORK HEALTH budget cap related to growth which is relevant
to the health sector.
Alternative Budget Target
Tn Table IX we compare wage growth in New York from 1981 to 1994 with a revised NEW YORK
HEALTH budget target: general-inflation-plus-20%. As the Table shows, growth in wages exceeds
the revised budget limit for most of the decade, 1982 to 1988. In the recession year of 1981 and the
downturn beginning in 1989, general-inflation-plus-20% exceeds wage growth. For the entire decade,
personal wages grew at a faster rate, 204% compared with 181% for general-inflation-plus-20%. In
1994, the year in which NEW YORK HEALTH would be implemented, wages and the revised NEW
YORK HEALTH inflator are nearly equal. Thus setting a NEW YORK HEALTH growth target of
inflation-plus-20% would both take better account of the factors driving health care inflation and raise
sufficient revenues over time to fund health care spending and allow the establishment of a reserve
fund for recessions.
Table IX
Growth in Wages and Alternative NEW YORK HEALTH Budget Target: 1981-1994.
14x
v
-1
61
82
83
84
0 Inflation + 20x
05
06
87
A
O
09
7
90
91
92
93
94
Sources: WEFA, 4/92; AFSCME
�NEW YORK HEALTH
PAGE 22
Conclusion
HPhe longer we wait to implement health insurance reform, the more expensive it will become. With
each year that health insurance costs soar, well beyond increases in income and general inflation,
more and more of our economy is eaten up by health care costs. Government is forced to cut back on
other vital programs, businesses are using funds better spent investing in research, development and
job creation, consumers are avoiding preventive and primary care.
The impact of the inflationary trends is reflected in the NEW YORK HEALTH budget model. A
revenue model based on dedicating 9% of earned income in New York in 1990 would have been more
than sufficient to fund a public insurance program in New York. By 1994, it will be necessary to dedicate at least 10% of earned income to fund the same program.
Nevertheless, the relative merits of such a program, increase over time. In 1990 a business that now
provides health benefits would have seen its health care costs cut by 25% after paying the 7.5% NEW
YORK HEALTH premium. The same business will save 35% in 1994, paying an 8% NEW YORK
HEALTH premium.
A family of four that earns $54,000 in 1990 would have reduced its spending on health care by $1,320,
paying the 1.5% employee payroll premium. Four years later, the same family would save $1,680 paying
a 2% payroll premium: an increase in real terms of $216.
We need only look one year beyond our 1994 date to see how much would be gained by implementing
a public health insurance program. In 1995, LEWIN/ICF predicts national health spending will increase
9.9%. Holding inflation to the NEW YORK HEALTH growth rate of 4.6%, would save $2,756 million
in one year alone. Even a higher NEW YORK HEALTH growth rate would still result in significant
savings. NEW YORK HEALTH will increase the ability of the State tofinanceother public services
and will enhance the competitive position of our state's business sector.
Public health insurance, by incorporating all health care costs under one budget, allows us to put a price
on our failure to control health care costs. Health care reform measures which leave much of health
spending in private hands, hide the insidious impact of inflation, but do little to solve underlying
problems of uncontrolled health spending and excessive administrative costs. Advocates of public
health insurance are put in the difficult position of admitting the need tofinancethe program with ever
high tax rates with each year that their proposals fail to become public policy. But those who criticize
are simply blaming the messenger, and ignoring the message. Until such time as we institute health
care reform that insures all Americans, eliminates administrative waste and sets global, health care
budgets, Americans will see their wealth and health gobbled up in ever bigger bites.
�NEW YORK HEALTH
PAGE 23
Endnotes
1. Himmelstein DU, Woolhandler S., A National Health Program for the United States: A physicians'
proposal. New England Journal of Medicine 1989;320:102-8.
2. Himmelstein D.U., Woolhandler S., Cost Without Benefit: Administrative Waste in U.S. Health
Care. New England Journal of Medicine 1986; 314:441-5.
3. Himmelstein D.U., Woolhandler S., The Deteriorating Administrative Efficiency of the U.S. Health
Care System. New England Journal of Medicine 1991;324:1253-1257.
4. Blendon R., Lehman R., Morrison I., Donelan K., Satisfaction With Health Systems in Ten Nations.
Health Affairs, Summer, 1990; 185-92.
5. Introductory Statement: The Problem of Rising Health Costs, Presented Before the Senate Finance
Committee, Richard Darman, Director, Executive Office of the President, Office of Management and
Budget, Washington, D.C, April 16,1991.
6. Health Insurance Association of America data, cited in: Towards an American Health Care Solution,
Service Employees International Union, Washington, D.C.
7. The Russo Universal Health Insurance Program of 1991 (HR-1300); The Health USA Act of 1991,
introduced by Senator Bob Kerry; The Universal Health Care Act of 1992, introduced by Senator Paul
Wellstone. State proposals have been introduced in many states, including: California, Ohio,
Washington, Missouri, Maine, Vermont, Illinois, Wisconsin, Massachusetts, Florida.
8. Grumbach K, Bodenheimer T, Himmelstein DU, Woolhandler S. Liberal Benefits, Conservative
Spending: The Physicians for a National Health Program Proposal, Journal of the American Medical
Society, May 15,1991;V265,No.l9;2549-54.
9. Emergency: Rising Health Costs in America, 1980-1990-2000, Families USA Foundation,
Washington, D.C, 1990.
10. Premiums Without Benefits: Administrative Waste in New York's Health Insurance Industry,
Public Policy and Education Fund of New York, Albany, NY, June 1991.
11. Employee Benefits: Survey Data from Benefit Year 1990. U.S. Chamber Research Center,
Washington, D.C, 1991.
12. Risking the Future: Low Income People in New York Without Health Insurance, Problems and
Proposed Solutions, Hospital Trustees of New York State, Albany, NY.
�NEW YORK HEALTH
PAGE 24
13. To the Rescue: Toward Solving American's Health Care Crisis, Families USA Foundation,
Washington, D.C, 1990.
14. Evans RG. Beyond the Medical Marketplace: Expenditures, utilization and pricing of insured
health in Canada, in National Health Insurance: Can We Learn from Canada?, ed. Andreopoulos S.,
John Wiley & Sons, New York, 1975.
15. Enterline PE, Slater V, McDonald AD, McDonald JC, The Distribution of Medical Services Before
and After "Free" Medical Care - The Quebec Experience. New England Journal of Medicine
1973;289:11748.
16. Newhouse JP, Manning WG, Morris CN, et al. Some Interim Results from a Controlled Trial of
Cost Sharing in Health Insurance. New England Journal of Medicine 1981;305:15017.
�Appendix A
NEW YORK HEALTH Fact Sheet
New York State Assembly, Office of Assemblyman Richard Gottfried
Revenue Calculations for NEW YORK HEALTH, 1990
Public Policy and Education Fund of New York
Local Government Savings Under NEW YORK HEALTH, 1990
Public Policy and Education Fund of New York
�New York Health (A.8912): Universal Health Coverage
What's Covered:
Most Everything
NEW YORK HEALTH covers all out-patient and inpatient health care including preventive, primary,
hospital, specialist, lab, dental, eye, prescription drugs,
mental health and treatment of drug and alcohol
addiction.
Who's Covered: All
New Yorkers
All residents of New York would be covered under one
health care plan. Your source of coverage is not
dependent on work, health, age or income.
What Do I Pay:
Nothing Out-ofPocket
There are no out-of-pocket costs. No co-payments,
deductibles or co-insurance. And no extra bills from
doctors or other providers.
What Does It Cost:
Less than We Spend
Now
NEW YORK HEALTH eliminates as much as $5
billion in administrative waste. The plan will control
costs by setting fees and rates so that we can increase
health care use and still reduce costs. Future cost
increases are tied to the growth of New Yorkers'
incomes.
How's It Paid For:
Through Current
Sources
Current Sources: Current spending from Medicaid
and Medicare, and other local and state health care
programs would be merged into the NEW YORK
HEALTH Trust Fund. So would Medicare "Part B"
premiums. (But there would be no more Medicare copayments, deductibles or extra charges).
And a Fair Health
Premium
The NEW YORK HEALTH Premium: Employers
who now provide health coverage would no longer
spend 10% to 12% for premiums. Instead, every
employer would pay a NEW YORK HEALTH
premium of 7.5% of payroll. This premium would
replace all private health insurance premiums and
workers' compensation health care costs. Employees
would pay 1.5% of payroll (which the employer could
pay as a job benefit). Self-employed people would pay
9% of earnings. There would be a premium paid by
people with high investment income.
...please turn over
�Where Do I Go for
Care: It's Up to You
Under NEW YORK HEALTH the patient will choose
his or her own doctor or other professional, hospital,
HMO, or health care center. The health care provider
will be paid direcdy by NEW YORK HEALTH.
How Do Health
Providers Get Paid:
Hospitals are on
Budgets
Hospitals and other institutions would be on global
budgets which include all operating costs. NEW
YORK HEALTH would provide steady funding,
eliminating the need to file claims case-by-case.
Expenditures for new buildings or equipment would be
approved separately.
Individual Health Care
Providers Choose
Doctors and other individual health care providers have
a choice of payment method. Most payments would be
fee-for-service, according to rates set by NEW YORK
HEALTH. Payment could also be on a set (capitated)
or salary basis, through an HMO, hospital or clinic.
W h a t ' s Left Out
NEW YORK HEALTH does not cover cosmetic
surgery (except reconstructive work following injury or
illness). Unfortunately, it does not cover long-term
care, although Medicaid coverage will continue. Within
five years the NEW YORK HEALTH Board of
Governors will develop a plan for long-term care.
H o w ' s It Run: By a
Board of Governors
The Board of Governors, made up of representatives of
consumers, business, labor, hospitals, doaors and nonphysician health care professionals, would manage the
health care system.
Who's Sponsoring
NEW YORK HEALTH
(Assembly Bill 8912)?
NEW YORK HEALTH has been introduced in the
New York State Legislature by Assembly Member
Richard N. Gottfried, Chair of the Assembly Committee
on Health, along with over 50 co-sponsorsfromall
around New York State. The bill number is A.8912.
Who Supports NEW
YORK HEALTH?
NEW YORK HEALTH is supported by the New York
Health Care Campaign, a broad coalition of
consumer, labor, community, health and other groups
committed to universal, affordable, quality health care
for all Americans.
For more information, please contact: The Health
Care Campaign, c/o Citizen Action, 94 Central Avenue,
Albany, NY 12206 (518)465-4600; or. Assembly
Member Richard N. Gottfried. 822 Legislative Office
building, Albany, NY 12248 (518)455-4941.
�R V N E CALCULATIONS F R N W Y R HEALTH
EEU
O E OK
All figures are billions of dollars for 1990.
EXPENDITURES
CRET
URN
NYHEALTH
Employer Based
Paid by Employer
Paid by Employee
11.4
2.9
17.6
3.5
6.2
0.7
Insurance Premiums (Individual/Self-Employed)
2.6
15
.
-1.1
Individuals - Out-of-pocket
7.2
Medicaid - State and Local
Medicaid - Federal
3.3
3.3
3.3
3.3
0.0
0.0
10.3
10.3
. 0.0
0.8
0.8
0.0
41.8
40.4
-1.4
Medicare
Other Public
TOTAL
Administrative Savings under NYHEALTH(12X)
Current Expenditures less Admin. Savings
Amount Available for Increased Utilization
Note:
-7.2
-5.1
36.7
3.7
Employees are currently assumed to pay an average of 20X of current health
care premiums. Actual data on employer/employee share not available.
Under NYHEALTH, employers assumed to pay 7.5X of payroll, while
employees pay 1.5X of payroll. Employees may pay less, as determined
either through collective bargaining, or at employer's discretion.
DT SUCS
AA ORE
Payroll Base
235.3 - N S Dept. of Labor, Division of Research and Statistics. 1989 total
Y
Wages and Salaries
wages and salaries increased by 6% to account for inflation.
Does not include agricultural or interstate railroad.
Self Employed
16.6 - Self-employed income was 7.8% of wages and salaries in 1987,
in N w York, according to the Office of Research and Statistics at
e
the Social Security Administration. 90% of self-employed wages
expected to be subject to the Medicare limit of $125,000.
Current State
Health Expenditures
- State health expenditure data from Lewin/ICF, Inc. ICF-Lewin data
includes long term care. Long-term care removed, assuming 11.6X of
state expenditures are on nursing home care (DOH). And that the
ratio of nursing home to home health care (2:1) for Medicaid (DSS)
is the same for non-Medicaid. Medicaid expenses on long term care are
deducted from a l l long term care (long term care is 37X of Medicaid, DSS).
Balance of long-term care is charged currently to individual, out-of-pocket.
Note: A separate analysis, using Stat. Abstract of the U.S., gave
very similar results.
Administrative Savings
- N w England Journal of Medicine, May 2, 1991. Study indicates that
e
14% of administrative costs can be reduced using health care
structure incorporated in NYHEALTH. 12% is conservative figure.
�E P O E H A T BENEFIT S V N S T N U Y R L C L G V R M N S U D R N W Y R H A T (A-8912), 1990
MLYE ELH
A I G O E OK O A O E N E T NE E OK E L H
L C L G V R M N (BY REGION)
OA OENET
TOTAL
PAYROLL
N W Y R HEALTH SAVINGS U D R
E OK
NE
CRET
URN
E P O E C S S N W Y R HEALTH
MLYE OT
E OK
HEALTH C S S
OT
NME O
UBR F
EMPLOYEES
N W Y R HEALTH
E OK
SAVINGS P R
E
EPOE
MLYE
$1,071
$1,051
$859
$1,653
$2,262
$450
$2,275
$985
$1,671
$183
$1,149
$2,491
$3,757
$2,546
$2,089
$1,289
$1,220
L N ISLAND
OG
Valley Stream U S
FD
Brentwood U S
FD
Island Trees U S
FD
Lynbrook Public Schools
Bellmore-Merrick C S
HD
Amityville U S
FD
Huntington U S
FD
East Rockaway U S
FD
Town of Babylon
Malverne U S
FD
Hicksville U S
FD
Elwood Public Schools
Town of North Hempstead
Town of Southampton
Southold Town
Plainview-Old Bethpage CS.D.
Carle Place Public Schools
$6,649,819
$68,678,251
$13,776,335
$15,071,908
$30,246,000
$19,299,978
$28,202,325
$7,168,263
$24,234,474
$11,093,391
$28,202,377
$11,501,191
$5,111,098
$14,059,636
$6,940,276
$30,185,313
$8,447,930
$798,619
$8,210,069
$1,582,626
$1,723,691
$4,095,084
$1,929,614
$4,077,196
$809,386
$3,753,571
$1,032,880
$3,410,010
$1,640,693
$3,079,508
$2,270,788
$1,126,686
$3,732,900
$1,049,978
$584,403
$6,003,957
$1,223,700
$1,145,240
$2,625,034
$1,693,566
$2,484,815
$632,079
$2,149,350
$978,083
$2,474,430
$1,017,882
$449,410
$1,252,261
$604,393
$2,701,586
$744,973
$214,216
$2,206,112
$358,926
$578,450
$1,470,050
$236,048
$1,592,381
$177,307
$1,604,221
$54,797
$935,580
$622,811
$2,630,098
$1,018,527
$522,293
$1,031,315
$305,005
200
2100
418
350
650
525
700
180
960
300
814
250
700
400
250
800
250
L W R H D O VALLEY
OE USN
Town of Clarkstown
Town of Stony Point
Haverstraw-Stony Point CS.D.
East Ramapo CS.D.
Ramapo CS.D.
Town of Orangetown
Nenuet U S
FD
Nyack U S
FD
Clarkstown CS.D
$19,357,958
$2,984,122
$39,331,575
$58,762,222
$24,460,770
$11,952,014
$10,565,904
$17,860,161
$50,564,529
$3,335,603
$367,909
$4,914,982
$7,300,266
$2,983,764
$1,817,568
$1,512,630
$1,769,610
$2,902,834
$1,714,735
$263,298
$3,449,119
$5,259,219
$2,138,198
$1,038,750
$923,519
$1,356,477
$4,411,454
$1,620,8^
$104,611
$1,465,862
$2,041,047
$845,566
$778,817
$589,111
$413,132
($1,508,620)
816
110
1036
1250
610
$1,986
$951
$1,415
$1,633
$1,386
278
425
411
$2,119
$972
($3,671)
CAPITAL DISTRICT
City of Saratoga Springs
Saratoga Springs CS.D.
Scotia-Glennville CS.D.
North Colonic CS.D.
City of Albany CS.D.
South Colonic CS.D.
Saratoga Warren Boces
City of Albany
Albany County
$8,605,992
$25,970,514
$10,612,596
$19,421,307
$40,112,108
$22,396,775
$9,711,953
$37,660,000
$74,763,631
$1,599,262
$3,380,850
$1,036,341
$1,572,972
$5,759,519
$2,491,626
$1,475,558
$6,658,298
$14,045,642
$769,976
$2,304,235
$941,579
$1,732,600
$3,529,427
$1,976,671
$867,781
$3,362,798
$6,667,157
$829,286
$1,076,614
$94,762
($159,629)
$2,230,092
$514,955
$607,777
$3,295,500
$7,378,485
300
800
387
750
1700
900
859
1600
3466
$2,764
$1,346
$245
($213)
$1,312
$572
$708
$2,060
$2,129
C N R L NW Y R
ETA E OK
Tioga CS.D.
Town of Newark Valley
Johnson City CS.D.
City of Syracuse
Syracuse CS.D.
Town of Vestal
Owego Apalachin CS.D
$4,297,249
$212,307
$11,270,039
$62,967,791
$104,782,055
$3,986,375
$10,565,872
$601,358
$32,503
$1,379,269
$9,817,989
$10,979,375
$713,058
$1,043,410
$383,399
$19,001
$1,004,270
$5,615,016
$9,347,266
$351,952
$932,966
$217,959
$13,502
$375,000
$4,202,973
$1,632,109
$361,106
$110,444
196
24
475
2500
3326
210
450
$1,112
$563
$789
$1,681
$491
$1,720
$245
W S E N NW Y R
ETR E OK
Erie 1 Boces
Erie County
City of Buffalo
Buffalo Board of Education
Tonawanda City Schools
$20,845,005
$264,476,000
$139,513,378
$155,745,954
$9,558,434
$1,755,913
$27,234,890
$15,985,938
$17,424,658
$814,680
$1,849,222
$23,587,590
$12,377,625
$13,890,189
$847,409
($93,308)
$3,647,300
$3,608,313
$3,534,469
($32,730)
700
($133)
6599
6500
275
$547
$544
($119)
$1,602,183,155
$197,031,571
$141,678,058
TOTALS
$55,353,513
46800
$1,183
�Appendix B
Estimated Sources of Personal Health Expenditures, 1990
LEWIN/ICF from, Emergency: Rising Health Costs in America, 1980-1990-2000,
Families USA Foundation, Washington, D.C. 1990.
National Health Expenditure Aggregate and Per Capita Amounts,
Percent Distribution, and Average Annual Growth Rate, by Source
of Funds: Selected Calendar Years 1965-2000
LEWIN/ICF
Health Insurance by Firm Size, United States, 1987
LEWIN/ICF: The Uninsured in New York State, 1989. New York State Department of Heal
�Table 3b
ESTIMATED SOURCES OF PAYMENT FOR PERSONAL HEALTH EXPENDITURES IN THE YEAR 1990 «/
(Dollatt I n t h o i m n d i )
STATE
ALABAMA
O U T OF P O C K E T b/
2,814.760
SPONSORED
2.012.389
STATE
FEDERAL
MEDICARE
TOTAL
PER
CAPITA
COST
183.013
425.482
1,932.843
1.655.817
9.522.402
2.286
80.380
80.360
60,357
231.034
1.242.929
2.367
MEDICAID
EMPLOYERNON GROUP
O T H F f l PRIVATE
101.765
24,057
OTHER PUBLIC
329.687
427,212
416.532
29.864
1.972.363
1.«9.372
2.379,617
240.666
137.174
222.669
367.632
1,367,192
1.'18,276
8,105,810
892.449
198.921
37,325
103.797
292.830
990.607
721,230
4,708.730
2.211
1.944
20.379.370
2.097.807
25.840,378
2,670.571
2.333.173
1.471.282
3.374.078
3.574.078
14.853,732
12.928.177
84.734.489
2.894
263.730
139.260
304,439
304.439
989.278
1.293.747
8.043.268
2.413
2.278.555
3.303.221
432.925
92.800
314.939
314,939
1,378,669
99.760
8,815.808
2.899
454.368
365.183
70.128
14.339
68.058
66.038
291,763
218.999
1.347,100
2.268
318.981
240.188
50.262
11,191
182.518
9.375.203
6.218.478
1,396.790
322.380
1.559,131
31,411.102
2.586
2.427
GEORGIA
3.964.313
3,041.590
124.588
952.179
48.022
102,084
106.251
2.301.978
•84,921
2.072
966.101
525.464
2.797.343
2.469
33.196
28.238
48,179
109,063
2.224.339
293.352
238.416
13.669,243
697.628
440.614
570.838
96.984
878.383
489,424
344.880
8.083.807
228.817
FLORIDA
182.516
1.125.484
S03.267
1.748.433
1,726
ILLINOIS
INDIANA
8.208.698
1,806.853
532,709
1,231.633
1.231.633
30,397.883
2.619
816.531
481,431
813,468
447.133
12.382.662
2.201
IOWA
1,834.062
2.218,841
228.318
115.314
6.719.023
2.204.733
319.434
3.382.637
10.348,102
3,988.394
247.922
355.293
49.288
6.613.478
2.351
KANSAS
KENTUCKY
1.772.719
2.218.333
1,418.857
413.790
220,379
220,379
2.548
234.106
399.438
1.233.785
190.889
1.229.672
6.426.779
270.882
100.840
67.343
1.345.939
1.287.848
7.021.823
1.873
LOUISIANA
2.547.782
352.995
96,280
345,188
608,634
9.343.113
2,183
149.985
29.898
2.173
484,561
99,774
284,450
341,404
2.687.926
2.178.431
1.938.060
MASSACHUSETTS
4,443,792
2.674.953
8.173.324
128.833
341,404
62.124
MARYLAND
689,728
3.169,204
1,741,608
460.731
2.030.597
MAINE
1,822,033
882.374
748,868
195,223
1,239.474
1.239.474
3.827.313
280.008
11.627,792
17,947,477
3.031
MICHIGAN
6.085.418
7.977.978
1,391.031
372,097
1.001.888
1.318.760
3.139.240
570.371
23.674,781
2.569
MINNESOTA
3.032.352
872.128
180,038
839,661
738.223
1.408.019
144.050
10.837.061
2.480
MISSISSIPPI
1,319.923
4.004.588
649.242
177.033
51,154
111.948
408.809
827.081
893.339
4.638.328
1,731
MISSOURI
MONTANA
3.643.361
4,398.101
643.312
224.843
333.821
347,738
3.033.308
302,638
13,373.361
2.388
383.463
438.346
37,203
112.948
241.279
336,283
1.841.223
2.059
1.132.890
1.361.739
48.228
283,541
23.273
NEBRASKA
70.028
128.325
171.137
668,770
113,011
3,933,640
2,452
807.751
1,033,308
96.602
38.825
71,392
71,392
488.336
487.008
3.115,213
2,757
370.939
3.501.694
48.364
2.238.858
1.981
283,989
17.368.763
2.224
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
D I S T R I C T OF C O L U M B I A
HAWAII
IDAHO
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
1,947,743
X
448.8I6
681.915
799.660
107.811
33.381
97.629
118,939
4.545,827
6,011.019
741.459
200.122
1,042.327
1.042.327
.
4.010.599
705.891
728.428
82.220
49.896
87,401
193.993
344.983
564.873
2.737.688
1.792
14.348.795
2.855.434
2.020.835
569.890
5.288.300
5.288.300
10,274,890
825,078
30.354,730
2.818
587.966
130.692
379,718
1,937.921
1.712.411
12.259.381
1.633
540.478
111.059
28.699
86,967
106,809
350.419
83.946
1,751,183
2.681
3.855.967
337.322
27,193.403
6.824.869
2,493
2.139
8.523.393
30.541.850
2.312
2.338
2.701.187
2.707
850.088
3.806,151
NORTH DAKOTA
442,809
6.966.974
8.754.357
1,643.671
2.028.346
1.379,606
286,712
429.028
76.027
1.244,280
294,947
1.739.803
400.683
1.278.850
1.081.298
207.895
1,597,413
110.855
383.577
171,843
1,248,011
274,849
1,833,583
986,919
7.749,007
1.106.938
331,829
OREGON
PENNSYLVANIA
1.657.140
7.993,087
RHODE ISLAND
SOUTH CAROLINA
704.349
833.313
133.007
30.383
173,308
1.809.718
1,401.609
269.561
63.523
160.028
223.809
428.154
• 69.323
332.487
108,789
31.119
107.733
3.284.049
2.365.982
341,451
804.337
2.183,966
11.992.115
8.477.215
1,095.590
493.952
1.355.624
30.642
110,304
463.330
1.143.083
1,320.646
80.021
31,732
65.019
172,449
6.384.239
318.164
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
2.438
11.740.861
NORTH CAROLINA
OHIO
OKLAHOMA
.
2.007.536
9.380.153
889.188
320.442
373.838
48.987
991,428
8 . 0 1 1,186
1,669
43,718
1,742.897
1.662.251
2.322
2.262
3.840,430
2.192
1,784
323.043
381.043
64.236
13.292
47.486
98.673
172.812
18.629
3.085.385
1.117.014
VIRGINIA
3.888.531
3,123.031
128.348
489,473
332.390
2.081.381
2.160,848
12.931,845
2.076
WASHINGTON
2,613.828
1.098.107
3,112,443
3.346.969
569.665
321.777
188.937
387,419
588.783
1.558,883
1.918.178
11,084,598
2.311
714.758
170,355
34,438
103.791
280,771
720,922
3.846,712
2.088
4.068.108
734.732
328,448
713.420
2.258.999
11,980,357
2.449
206.156
269.576
26.32B
166.623
13.994
743,573
379.384
19.865
19.865
107.370
158.705
821.858
1.736
$161,818^653
SI74J25J01
*27 063,851
»fl 3p8,703
t27.397.B85
$34,256,738
$116,277,024
$58,730,394
$605,978,347
$2,425
VERMONT
W E S T VIRGINIA
WISCONSIN
WYOMING
TOTAL
777,209
1
fU includes p e n o n a i health e*penditufes and admlni*trative co»1».
b/ Does not Include employee share of premiums for employer-sponsored insurance. These p«yments
SOURCE: Le*in/1CF estimates.
1
Included In the 'E mployer-Sponsofed' column.
323,181
11,328.956
37.330.724
1.956
�Tabla 1
.on«l haaltti axpandlcuraa aqqraqaca and par capita aaeuata. pareant dlacrlbutlon, and avaraqa annual parcant grotru,
by lourca of tundat Salaetad ealandar yaara 1965-2000
196S
1973
1980
National haalth axpandlturaa
Frlvata
Public
Fadaral
SLar.K and l o c a l
141.«
131.3
$10.3
$4.8
S.S
$132.9
$77.8
$33.1
$36.4
IS.7
$249.1
$143.9
$103.2
$72.0
33.2
U.S. population / I
204.0
224.7
233.3
Croat national product
$705
$1,398
$2,732
National haalth axpandlturaa
Frlvata
Public
Fadaral
3tata and l o c a l
$204
1S4
SO
24
27
$392
346
243
162
83
$1,039
612
447
306
141
National haalti. ax^«cdlturaa
Frlvata
Public
Fadaral
State and l o c a l
1JO.0
73.J
24.7
11.6
13.2
100.0
38.3
41.3
27.4
14.1
100.0
57.8
42.2
28.9
13.3
National haalth axpandlturaa
S.9
6.3
9.1
12.3
9.3
18.3
22.4
13.1
1.0
6.3
13.4
13.1
13.8
14.6
12.1
0.9
11.3
Xtaa
•onal haalta axpandltaraa
tvata
jblle
fadaral
Stata and l o c a l
U.S. population / I
Groaa natiooal product
1983
1989
1990
1991
1992
1993
2000
Aaount In b l l l l o n a
$809.0 $1,072.7 $1,613.9
$738.2
$604.1
$670.9
$457.4
$421.1
$.592.2
$330.9
$859.4
$389.3
$317.1 . $351.6
$480.5
$253.3
$281.6
$756.5
$215.7^ $236.6
$324.8
$174.4
$517.6
$192.2
155.7
78.6
101.4 ^ 112.6
238.8
69.4
n.s
Nuabar in a i l l l o n a
247.2
264.6
257.0
272.0
262.1
239.6
282.9
Aaount in b l l l l o n a
$7,284
$6,045
$4,013
$3,201
$3,463
$3,630
$9,665
Par capita aaount
$3,057
$3,944
$2,817
$1,699
$5,712
$2,583
$2,351
1729
2178
1607
3038
991
1300
1363
1767
1329
2674
708
1210
983
1085
1194
300
902
1830
823
679
741
387
426
372
M4
208
307
344
Percent dlatrlbutlon
100.0
100.0
100.0
100.0
100.0
100.0
loo. <•>
S3.2
56.5
53.2
37.0
38.3
58.1
58.0
44.8
46.6
41.7
43.5
43.0
41.9
42.0
30.3
32.0
29.3
29.4
29.2
28.9
28.7
14.6
14.5
13.9
12.3
13.7
13.1
13.3
Parcant of groaa national product
14.7
16.4
10.3
13.4
11.6
13.1
12.3
Avaraqa annual parcant growtb froa pravloua year mown
8.3
9.6
9.9
11.0
9.3
10.0
11.1
7.7
9.0
8.2
6.6
11.2
9.4
11.0
9.3
11.0
10.7
9.7
12.6
10.9
11.2
10.7
10.8
9.6
11.4
9.0
10.2
12.2
6.9
11.3
9.2
13.4
11.3
11.3
13.3
0.9
0.6
1.0
1.0
1.0
1.0
1.0
6.4
6.3
7.0
8.0
6.7
3.4
5.0
$420.1
$243.0
$173.1
$123.6
/ I July 1 aoclal aacurlty area population aatlaataa.
NOTT:Number• and parcenta aay not add to totala bacauaa ot rounding.
SOUKCZ:Haaltb Cara financing Adalnlatratlon, Office of taa Aetuaryi Data froa tha Offica of Satlonal Health Statlttlca.
�Table 15
Health Insurance Benefits by Firm Size,
United States, 1987 (Thousands)
Percent of
Workers In
Insuring
Firms
Percent oi
Workers In
Noninsurlng
Firms
Workers In
Insuring
Firms
Workers in
Noninsurlng
Firms
All
Workers
Under 10
10-24
25-99
5,248
7,S51
10,333
14,909
3,940
3,167
20,157
11,491
13,500
26.0
65.7
76.5
74.0
34.3
23.5
Under 100
23,132
22,016
45,148
51.2
48.8
100-499
Over 500
12,189
31,798
1,228
2,221
13,417
34,019
90.8
93.5
9.2
6.5
100 and Over
43,987
3,449
47,436
92.7
7.3
Total
67,119
25,465
92,584
72.7
27.5
Firm
Size
Source: Employer Health Insurance Survey developed by Lewin/ICF for the Small Business Administration,
Administration, 1986.
Taken From: The Unipsured i n New York S t a t e , 1989. New York S t a t e
Department o f H e a l t h , Page 46.
�ARIZONA STATE SENATE
Apr
TEL:1-602-542-3429
15,93
15:21
No .002
La Casa Margarita
Bottling Co.
3433 E. MILBER STREET
TUCSON, ARIZONA 85714
(602) 839-3995
DIVISION OF BILMAR BRANDS, INC.
4-13-93
Let me i n t r o d u c e myself please, My name i s C.W.
" B i l l " Gordon,
f a t h e r of Arizona S t a t e Senator and M i n o r i t y Leader, Cindy Resnick.
T have been i n the Wholesale L i q u o r business f o r Twenty Five Years
d e a l i n g w i t h many L i q u o r B o t t l e r s , AKA R e c t i f i e r s .
i n the e a r l y 80's and about the time MAAD became a r e a l i t y
I became q u i t e aware of h i g h proof l i q u o r s and the
d e v a s t a t i n g e f f e c t i t i s having on peoples h e a l t h , p l u s the
s l a u g h t e r on the roads of America.
I c r e a t e d a "Low C a l o r i e " or Reduced Proof t o 70 p r o o f . I t
was so s u c c e s s f u l we made a d r a s t i c drop from 70 proof t o
50 p r o o f . The 50 p r o o f proved t o us t o be a winner.
Three d r i n k s of 80 p r o o f s p i r i t s and you are o f f i c i a l l y
drunk. I t would take f i v e d r i n k s of 50 p r o o f t o do t h e
'same t h i n g .
T have an idea t o h e l p the drunk d r i v i n g problem.
Change the Law from a t a x a t i o n based on proof g a l l o n s t o
a set amount per case, such as 35 - 40 d o l l a r s a case
r e g a r d l e s s of p r o o f . The d i s t i l l e r . B o t t l e r or R e c t i f i e r
would then l o o k a t t h e cost per case and Just add water
t o double or t r i p l e h i s p r o d u c t i o n w i t h the same product
c o s t . This would have the e f f e c t i n my o p i n i o n of w e e i n g
the d r i n k e r s t o a reduced and more sensible-: d r i n k .
The Federal Government now takes i n t h e excess of Six B i l l i o n
D o l l a r s per year on the L i q u o r Tax. My t h e o r y would double,
or even t r i p l e , the t a x d o l l a r s . The Government now takes a
b e a t i n g on taxes j u s t from the m i l l i o n s of cases t h a t are s o l d
at 30-40-42-48-50-60-68 proof and up. The above p r o o f s are
mostly i n C o r d i a l s - Cream de Menthe - Peppermint Schnapps, Etc
The Beer and Wine i n d u s t r y should a l s o come under the reduced
proof w i t h a case or b a r r e l charge much g r e a t e r than what i s
taxed now.
i f you are l o o k i n g f o r b i l l i o n s , l o o k a t the Soda market
which s e l l g t w i c e the amount of gallonage as beer i n the US
I f a l l the above was Enacted, the d o l l a r s f o r H e a l t h Care
c o u l d be i n excess of 20 B i l l i o n D o l l a r s .
I would be happy t o appear i n person i f needed.
PHOTOCOPY
PRESERVATION
Thank you
for
listening.
P.02
�Tb figure oz. cost
Take b o t t l e cxjst - by equuvalent f l u i d ounces
U.S. Gallons x # of cases = Wine gallons
DEPARTMENT OF THE TREASURY
BUREAU OF ALCOHOL, TOBACCO AND RREARMS
DISTILLED SPIRITS
BOTTLE SIZE
EQUIVALEhfT
FLUID OUNCES
t.75
liters
59^ H.
too
iftdf S.
LITERS
BOTTLES
PEfl CASE PER CASE
U.S. GALLONS
PER CASE
10.50
2.773806
1/2
33.8 H. Oz/VcT-t
12
T2.00
3.170064
1 Quart^
milflfitors
25.4 R.
12
9.00
ZJ377548
4/5 Quarts
ministers
16.9 R. Oz.
24
12.00
3.170064
•roifHfitefs
SXF
6
1Z7 R. Oz.
24
9.00
2.377548
Oz/j&.l.
Qz/frtfX
, _ ,
'.VH.'-
^
^
•v
4/5 pwr I
i 200P miBlilers
6.8 R. Oz.
48
9.60
2.536051
100
miRiRtor^
3.4 R. Oz.
G
O
6.00
1.585032
1/4 Pint
50
miHiliteis
1.7 R. OzjlSMV
120
6.00
1.585032
1
Official Conversion Factor 1 Liter = 0.264172 U.S. Gallon.
Mandatoiy date for conversion: January 1, 1980.
ATF F 5100.10 (8^5)
, 1.6; a-fccjs*
J
o
•Jf A ^'
^
o
V
7c
PHOTOCOPY
PRESERVATION
�CITY OF WAS1LLA
290 K. HERN1NG AVK.
WASII.LA, ALASKA 99654-7091
PHONK: (907) 373-9050
KAX: (907) 373-9085
A p r i l 8,
1993
H i l l a r y Rodham C l i n t o n
F i r s t Lady
C h a i r , P r e s i d e n t s Task Force
on N a t i o n a l Health Reform
The White House
1600 Pennsylvania Avenue
Washington, D.C.
20500
Dear Mrs.
Clinton:
The Twenty-six W a s i l l a C i t y employees are concerned over the c o s t
and a v a i l a b i l i t y of h e a l t h c a r e f o r t h e i r neighbors and themselves.
As a group the employees asked Council to f o r m a l l y adopt t h e i r
r e s o l u t i o n on h e a l t h c a r e reform.
We support your e f f o r t s Oxi behalf of a l l Americans f o r e q u i t a b l e
and a f f o r d a b l e h e a l t h c a r e .
Sincerely,
/
J^)t«v C. S t e i n , Mayor
C i t y of W a s i l l a
il
H a r r i s , Employee
isentative
�CITY OF WASILLA
290 E HEKNING AVK
W A S I L I . A " , ALASKA 99654-7091
REQUESTED BY: COUNCILMAN HJELLEN
PREPARED BY:
MUNICIPAL SERVICES
PHONK: (907) 373-9050
KAX: (907) 373-9085
RESOLUTION NO. WR9&09
A RESOLUTION OF THE CITY OF WASILLA, ALASKA URGING LEGISLATIVE ACTION ON
REFORMING THE NATIONAL HEALTH CARE SYSTEM.
WHEREAS, Nationally, each succeeding year fewer and fewer citizens are able to financially
participate in employer insured health care systems; and
WHEREAS, Nationally, each succeeding year fewer and fewer under-employed, un-employed, and
self-employed citizens can afford health insurance premiums; and
WHEREAS, Nationally, health care providers are forced to raise rates to cover costs of care for
citizens who cannot or will not pay to the extent that an estimated 40% of premium costs to an employer
are used for this purpose;
NOW THEREFORE, BE IT RESOLVED, That the City of Wasilla recognizes that the problems
facing our health care system is not local or state based, but one of National Proportions; and
BE IT FURTHER RESOLVED, That the U.S. Congress and the new Clinton Administration is urged
to debate and act on the following:
1. Requiring all employers and self-employed persons to insure themselves or their
employees to some yet to be determined basic health standards on a National basis.
2. Completely restructure malpractice law accepting the fact that health care providers are
human institutions and will make mistakes and limit malpractice to gross negligence.
3. Limit malpractice awards to some Dollar limit unrelated to earning power.
4. Placing some rational limits and controls on the use of "High Tech", but very expensive
equipment
5. Placing more emphasis on Education and Preventative Health Care.
6. The regulation of the health care industry in some way to reduce the cost of health care.
I certify that a resolution in substantially the above form was passed by a majority of those voting
at a duly called and conducted meeting of the governing body of the City of Wasilla this
22 nd day
of March
1993.
ERliNG P.tfELSON,CMC
City Clerk
(SEAL)
JOHlTC. STEIN, Mayor
�HEALTH CARE TASK FORCE SORTING SHEET
CODER:
INPUT DATE:
GENERAL SORT:
POSTCARD 1
:
General mail
Personal stories
Other Health Providers
POSTCARD 2:
Offers to help/Employment
FORM L E T T E R :
Letterhead
REROUTE:
Casework
_Letter Campaign
Physicians
Scheduling
President
POTJ(^V AND PERSONAL STORIES:
O R G A N I Z A T I O N (I)
insurance premiums
insurance reform
insurance pools
boards and oversight
. C O V E R A G E (II)
working families
unemployed/low income
benefits
_providers
. I N F R A S T R U C T U R E / W O R K F O R C E (HI)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
manpower issues (training)
unnecessary procedures
GOVERNMENT PROGRAMS (IV)
medicare
medicaid
veterans
DoD
Indian health
COST ISSUES (VI)
drug prices
physician fees
hospital fees
jnedical equipment
fraud & abuse
.FINANCING (VII)
MENTAL H E A L T H (EX)
L O N G - T E R M C A R E (X)
PUBLIC HEALTH/
S P E C I A L POPULATIONS (XII)
prevention
AIDS
women's health
immunizations/children
rural
urban
OTHER
�i
-
BOB MILLER
Governor
STATE O F NEVADA
COMMISSION ON SUBSTANCE ABUSE EDUCATION,
PREVENTION, ENFORCEMENT AND TREATMENT
P.O. Box 2580
Elko, Nevada 89801
Commission
(702) 738-8004
Fax (702) 738-2625
Members:
JOHN CREAR. M.D.
Family P r a c t i c e a n d
Chemical Dependency
April 1, 1993
SUSAN DOCTOR
Program Coordinator
Washoe C o u n t y S c h o o l D i s t r i c t
PATRICIA C. HODGES
Principal
G e n e Ward Elementary School
ROGER
HUNT
Attorney
E d w a r d s H u n t Hale & Hansen
Mrs. Hillary Rodham Clinton
Presidential Task Force on National Health Reform
The White House
1600 Pennsylvania Avenue, N.W.
Washington, D.C. 20500
ELLEN JOHNSON
Adolescent Specialist
Teen Discovery
CHARLES LENZIE
C O B. <£ C . E . O .
Nevada Power C o m p a n y
R. T.
LOWRIE
Chief
B o u l d e r C i t y Police Dept.
Dear Mrs. Clinton:
DR. E A R L N1SSEN
Special Services Director
C h u r c h i l l County School District
BERNIE
ROMERO
Sheriff
W h i t e Pine C o u n t y
VINCE
SWINNEY
Sheriff
Washoe C o u n t y
MAR I LYNN TAYLOR
Program Director
St. Mary's Req M e d i c a l C e n t u r
LARRY W O O L F
C h a i r m a n / C . E . C.
M G M G r a n d Hotel. Inc.
Program
Coordinator:
MUIAHID RAMADAN
State Substance
Abuse
Ex Officio
FRANKIE
Attorney
Coordinator
Members:
SUE DEL
General
PAPA
IERRY
GRIEPENTROG
Director
D e p t . of H u m a n Resources
DR E U G E N E P A S L O V
Superintendent
D e p a r t m e m of E d u c a t i o n
IAMES P.
D:^c:cr
WELLER
First, I would like to commend you on your efforts to develop
a health care reform plan. In my capacity as Chairman of the
Drug Commission I am very adamant that a comprehensive
drug and alcohol treatment benefit be included in any
legislation for a national health care package.
It costs far more NOT to treat substance abuse than to treat it.
Treatment is far cheaper than incarceration and the potential
of salvaging a life and returning that person as a productive
member of society is a much more positive outcome. Treatment
for alcohol and drug abuse must achieve a parity with drug
education and drug enforcement, not only in real dollars but in
the level of importance in winning the drug war. Again, I
would urge you to include a comprehensive treatment benefit
for alcohol and drug dependency in any national health care
reform legislation.
DOROTHY B. NORTH
Commission
Chairman
�Mrs. Hillary Rodham Clinton
April 1, 1993
Page Two
Enclosed is a brochure distributed by the National Association
of Addiction Treatment Providers that makes cost comparisons
and shows the dollar for dollar benefit of substance abuse
treatment. Please take the time to peruse it.
If I can be of any further assistance to you, please don't
hesitate to contact me.
Sincerely,
Dorothy B. North
Chairman
DBN:hc
Enclosure
cc: File
�Finally...
T e Truth
h
Aot
bu
S bt n e
u sa c
A ue
bs
Te t e t
r am n
r
erhaps you've heard that
substance abuse treatment is
an expensive, overutilized
benefit. Perhaps you've read
that substance abuse
treatment is not effective. Perhaps
you've been led to believe that
substance abuse treatment providers
only offer 28 days of inpatient care.
And perhaps you are certain that
workers are able to access the health
care benefits their employers pay for.
Perhaps it's time you were told the
truth.
Examining the Myths and
Facts About Substance Abuse
Treatment
Myth: Health care purchasers spend
too much on substance abuse
treatment. More and more people
are getting this treatment and they
all stay in the hospital for 28 days at
around $1,000 per day.
Fact: Fewer and fewer people are
getting substance abuse treatment.
In 1989,3.4% of inpatient
admissions were for substance abuse
treatment (only 38 of payments).
-%
In 1990, inpatient substance abuse
admissions were down to only 2.7%
(2.9% of payments). In fact,
substance abuse admissions declined
3 % between 1987 and 1990.
6
Meanwhile, the average length of
stay is 18 days, not 28, and the
average price is $8,000 (about $450
per day).
S B T N E ABUSE A MS I N P R 1,000 C V R D LIVES
U SA C
D I SO S E
OEE
Substance abuse admissions bave declined 36% duri
period 1987 thru 1990
Source- MEDSTAT Siyem. Inc
S B T N E ABUSE I P TE T P Y E T P R CAPITA
U SA C
N A I N A M NS E
Substance abuse payments have declined 22% sin
Source. MEDSTAT S\Mems inc.
1989
1990
DISTRIBUTION O INPATIENT
F
ADMISSIONS F R 3.6 MILLION
O
C V R D LIVES
OEE
This pamphlet w s published by the National Association of
a
Addiction Treatment Providers (NAATP). For additional copies
of this pamphlet or a copy of "The Substance A ue Treatment
bs
Factboolr a 1 - a e booklet amplifying many of the points in
2p g
this brochure, please write to the facility listed above, or to
N A P 25201 P s o d Alicia, Suite 100, Laguna Hills, C
A T,
ae e
A
92653. Telephone: 714-837-3038.
1990
DISTRIBUTION O INPATIENT
F
M DC L P Y E T F R
E I A A M NS O
3.6 MILLION COVERED LIVES
Alcohol/Drug Treotment
2.74%
Alcohol/Drug Treatment
2.96%
All Ottier D g o e
i nss
a
97.26%
All Oh r Da n s s
t e i g oe
97.04%
Source. MEDSTAT Svstems. Inc
Source- MEDSTAT S^tems. Inc.
�Myth: There is no need for inpatient
treatment for substance abuse. Declining
inpatient admissions are justified due to
greater utilization of outpatient
treatment.
Fact: Inpatient treatment is a valuable
approach for those who need it. There is
a direct correlation between an
appropriate length-of-stay for inpatient
substance abuse treatment and a
diminished probability of readmission to
the hospital for substance abuse or for
any other reason. Meanwhile, while
outpatient programs are also effective for
those who need it, outpatient payments
are decreasing at several times that of
inpatient.
Myth: Substance abuse treatment is the
same as mental health treatment. It's
best to track them together as one
"mental and nervous" category.
Fact: Mental illness is assessed, treated
and consumes resources differently from
substance abuse. Combining these two
areas, as many benefits consulting or
utilization management concerns
inappropriately advise, yields misleading
infonnation to health care purchasers
and payors.
Myth: Managed care is doing what it is
supposed to do. Admissions and
payments for substance abuse treatment
are not being curtailed any differently
from any other area of health care.
Fact: In 1990, admissions for every area
of health care were down compared to
1989, except for pregnancy. Though
most areas were reduced between 1 and
%
7 , substance abuse admissions were
%
down a whopping 22.5%. Payments went
up in 1990 compared to 1989 in evensingle health care area except substance
abuse, which went down more than 20%.
PERCENTAGE OF READMISSIONS BY LENGTH OF STAY
The utilization data in this publication
Appropriate length of stay results in fewer readmissions was provided by MEDSTAT Systems, Inc.,
COMPARISON OF MENTAL HEALTH VS. SUBSTANCE ABUSE ADMISSIONS
an .Ann Arbor, Michigan-based health
care information company, subscribed to
by many of the nation's largest volume
health care purchasers.
MEDSTAT draws its data directly from the
health care claims of more than five
million workers and their dependents at
more than 60 companies. MEDSTAT does
not seek to amplify its own point of view
by merely surveying the opinions and
observations of carefully selected benefits
administrators; the charts and tables,
here, present the unadorned fads.
All Reodmissions
Substance A u e Readmissions
bs
Source M D T T S^lemv. inc.
E SA
OUTPATIENT SUBSTANCE ABUSE PAYMENTS
AS A % OF TOTAL OUTPATIENT PAYMENTS
Outpatient substance abuse payments
declined 33% in 1990
Total Payments
Substance Abuse 1989 Substance Abuse 1990
0.4%
0.6%
Conclusions:
• Utilization review agencies have singled
out both inpatient and outpatient
substance abuse treatment for benefit
reduction and elimination, despite proven
cost effectiveness.
• It costs more N T to treat substance
O
abuse than to treat it.
• Benefits administrators and health care
purchasers must make certain that:
-Their employees can access their
substance abuse treatment benefits
-The costs and utilization of
substance abuse treatment benefits
are tracked separately and apart from
mental illness and other health care
areas.
- Ulilization review agencies and
substance abuse treatment centers use
nationally recognized inpatient and
outpatient admission criteria for
substance abuse treatment, such as
the criteria of the American Society of
Addiction Medicine (ASAM).
18
99
19
90
Mental Health
18
99
Substance A u e
bs
Source- M D T T S^lerns. [nc
E SA
COMPARISON OF MENTAL HEALTH VS. SUBSTANCE ABUSE PAYMENTS
S5M
20 M
S0M
20 M
S5M
10 M
SO M
IOM
S0 M
5M
1989
1990
Mental Health
1989
1990
Substance A u e
bs
Source M D T T Systemj. Inc.
E SA
Source- M D T T S^ienu. Inc.
E SA
�^/iLne
Hillary
Rodham
The White
House
1600 Pennsylvania
Washington,
DC
Dear Mrs.
At3 562-4134
March 5,
1993
Clinton
Ave.
20006
Clinton:
We assume you have read our letter
of February
1, 1993
regarding
our concerns
about the announced
closing
of
Western
Massachusetts
Hospital.
Enclosed
is a copy of that letter
and some
news clippings
about reactions
to the hospital
's closing
for
your
review.
We feel
somewhat
encouraged
by those
who can make a difference.
confident
i f we could be assured
supporting
our
needs.
that
our concerns
are being
heard
However we would feel
more
that you are understanding
and
We feel
sad about the fact
that
attempt
to save our lives
as we have
lives
is at stake
and a unique health
eliminated.
We are
assistance.
anxious
Thank
to hear your
you for your
we need to play politics
known them.
The quality
care facility
may be
response
to our
attention.
request
for
Sincerely,
The Women 's Support
Group
Neuromuscular
Unit
istern
Mass
Hospital
'Ph'yllks
Mark?
Facilitator
PM:abz
Enclosures
Psy.D.
in
of
your
an
our
�9/ Sast^&witiun/SfteaJ,
SfafiAone
"tiitifteM
413
0/685
562-4131
January
30,
1993
Hillary
Rodman-Clinton
The White
House
1600 Pennsylvania
Ave.
Washington,
DC 20006
Dear
Mrs.
Clinton,
We, the women's
group on the Neuromuscular
Unit of
Western
Massachusetts
Hospital,
which is the only state
Departmen':
of
Public
Health
facility
in the western
part
of Massachusetts,
wan
o
congratulate
you on your appointment
to chair
the task fo: . - on
health
care policy.
We think
the President
made a wise
choice
because
of your experience
in advocating
for human
services.
Th-'s is why we are writing
to you.
We have Multiple
Sclerosis
and
Huntington's
Disease.
Because
of the extent
of our illnesses,
we
have been forced
to seek the kind of care Western
Massachusetts
Hospital
provides.
It is,
unfortunately
almost
impossible
to
find
the services
we need at other
hospitals.
We meet weekly
as a women's
group to support
each other
and
help
each other
deal with our lives
at the hospital.
We hope that
you,
as a woman of stature
and compassion
will
help us to let
Governor
William
Weld know that
this
hospital,
which provides
extensive
services
(without
running
a deficit
I) is crucial
to us and must
not
be
eliminated.
We have enclosed
so you can learn
some articles
more.
about
Western
Thank you very much for your time and
m your work and hope you will
try to
assist
Massachusetts
attention,
us.
Hospital
We wish
you
luck
Sincerely,
The Women's
Group
Neuromuscular
Unit
Western
Massachusetts
Hospital
West f i e l d ,
Massachusetts
PBM:abz
Fur
Insures
Phyllis
B. Mark,
Facilitator
Psy.D.
�«pitai
:
''.if
TV
,v*c-~i.-''' •••'*»>' , . ..i.^.".
^By CYNTHIA SIMISON 1;^:
WESTFIELD <The chief exec-""
utive officer . of Noble ..Hospital "
will tell a state Jiealth care''com-'"?
mittee Monday , he knows of 'n6
nursing horpe or aciite care'hdspi- tal in , the regiph'that 6an„ provide
the same quality j.eaife' as now
given to;patients at Western Massachusetts.^Hospital.
^'-ji '
"It is a very important conipo-"
nent of our entire, health care network in Western Massachusetts.. :
; I think it . would be a mistake to
; close it," George Roller said. . :
: v That opinion was echoed yester& $ ead of the National i
Multiple Sclerosis^'Societyr'who
pointed out the facility is one of
only two in the United S&tes that
provide specialized rehabilitative
services for young victims of multiple sclerosis.
-• • /"'"O, : ,..
• o'The state should be showcasing
the hospital, not seeking to close
it, Gloria Price, director of
health services for the National
™ Ple Sclerosis Society said
yesterday iify telephone interview-'
f'th ^e; AssociatedtPress"f^om '
her Atlanta office. "Those services "
just don't exist."
:
v
r
e
h
u
ultl
v
• • ^ r Unique services
-.
Price said that a Philadelphia
^h08pitali « .t|ie, only _other. facility
toififte>imlar^ervices;for miilti-;
. & P } m l 9 ^ $ f ! t a a s j .The. degen-''
' f ^ ^ ^ ^ ^ f t e n ^ r i k e s thoseT;;iniyieir 2ps;and,3p^,;who,may still
:
;
:
11;
L
PftK^jaMlteJlans^brteil the
- .v,^gislaUjr^. 'Joint;Cpmmittee on
Health Care at a public hearing
^t;Springfield, Technical Community College ^that' Noble' will fa6e
ScVP^Wems in^placing some of its
ii/ l^nj^yHaBd chronibally iii bari-flenls.if .^state-ruh public health :
hospital is closed as planned by
t
r
f
:
But state health officials said
:,they are convinced that if such
.se^ices are pot now available,
private miedical providers will be
: interested in creating them.
:jn;l-sJim,-.Hill, assistant state health
J.; commissioner, said that when the
state closed LakeyiUe. Hospital it
I was able ^tQiipersuade a private
• New. Bedford^provider to create a
special 50-bed uiiit for its patients
with muscular dystrophy.
i^Hillsaid^he.department was soliciting area providers in hopes of
interesting them, in creating specialized care units for coma, mul.
Continued on Page 4
�Praise heaped on WMass Hospital
Continued from Page 1
WMH patients. .., , • ii? r * m m ^"I._ain certain the bill will adKnapik said he views the move vance," Knapik said, adding that
as a "clear acknowledgement that the health care panel will likely
the equal or better care promised take action immediately after the
by the department does not exist hearing that is due to begin at 10
out there" for WMH's.78 patients, ..a.m. in Scibelli Hall,on the STCC
including those 'on •••ii^Ull^'^cam'pus.'-' - .*«:
;^
units for neurological 'diseases,
Hospital supporters remained
Alzheimer's and coma;.patieritg/j; cautiously optimistic..%
ing
"What I see happenin is people
'Department of Public Health are getting all "psyched up for
spokeswoman Kate McCormack Monday and Tuesday/ but what
. said, however, that the solicitation they have to realize is it's just
- bf such proposals has been part'of phase one," Richard Muskes, a sothe process used to place patients cial worker at the hospital and
from other hospitals closed by the
A ^ ^ ^ ^ ^ ^ M L T ^ ttnember of a steering committee
tiple sclerosis and Alzheimer's
Disease patients now at the hospital at the same time it was seeking individual placements.
? Along with the hearing on a bill
io delay the closing pending a
study of the plan's costs and benefits, Lt. Gov. Paul Cellucci and
Human Services Secretary Charles
Baker are due to visit the hospital
Tuesday, as requested by hospital
supporters who picketed the Statehouse two weeks ago.
;' More than 20,000 signatures
Tjave reportedly been collected on
petitions that will be presented to
Cellucci and Baker in favor of
" t w u ^ w i . ^ P ^ / ^ ^ m W ^ ^ m W g ^ g up to the
keeping the hospital open.
>£\:
\ •tJ-r-y ^/r%l^^$r \'5 \--.,KiAVcia's box, and we've^got a ways
v. Supporters of the hospital have ^ Knapik, a member of the Health ...-to go to make our way around the
also planned demonstrations today " Care Committee, saidt jie. expects ^ ball park,'\Muskes said. "We're
from 10 a.m. to 2 p.m. in West ^ scores of supporters 6r the;h6spi- Jg hot igoing ;to get an answer
Springfield and Northampton^ '.•f^Jal
representatives of|cpn- ^.Wednesday., It's. a long process,
v <w
:
u e n t
:
>
:
v
A
f :
The Republican legislator said /silent vigil outside the hospital
state Public Health Commissioner
David Mulligan to 'Secretary the hearing will beU'an integral while Cellucci and Baker tour the
Baker in which it is stated that the .*part of the process" but said there facility. 'Although .'Weld is due to
department will issue a request - l ^ j H ^ additional steps, including Xbe in the region'.Tuesday,-there
tor proposals from nursing homes
review by the Ways and: Means ^ .was no word yesterday on whether
and chronic hospitals to create ^committees of . the House and'Sen- he will include the hospital on his
specialized units for placement of " ate, before the bill is acted upon. ; -schedule.
:
t
-
3
�i-l
In Westfield, Thursday, February 25,1993 C?
- -1 - - T -
OPINlbN
our view
Western Mass.
i ;5
V:
deserves a better rate
1 a»|
5
CompassioB ahd taring — tluVW'w&a^'fflBJ^^^^TSe hospital staff has-cared for so ihany over •'• forwarding them to Gov. Weld.;.;
a hospital.
••;.-i»»iii.ij<-.-» 5fij"oi'e-jirtUrr. ^ ®.y! # >d. l t.' <V* y'it;i8 so'-jdiffidilt-tb-acThe letters came from health care profession-1
It is especitilly'trbe'm the^^e^of Western^" •*•»*•'.cept/that Gov; Wdd^Will close this facility this ^ als, former patients of We8teni;Mas8achusetts•/
Maasachiuetts' Hospita: The units-itor^Alzh^^^
He ^ p o t - ^ ^ f u n ^ fdr,the Kospi-;' flospital,.people wth family members who had
er's disease,;Pamative and hbspice Wcomas
^ ^ f , ^ ^ fiscal l994,budget,,hopmg to save
.. been served by the hospital, and others who
' and chraniciUness and. neuromuscular dege^oSllte?
? ? ^ u ^ ^ ' w ^ ' S ^ . ^ i .
• ^ ^ y ^ ^
Massachusetts needs _
ative diseases all provide very;specialicare^ ^ a a ^ , ^
^ ^ ^ ? ^ " ^ ^ ? theory is ^ ^ a f a c i h t ) ^ ..^.w;
^.^ , ,., ^
TU
-'u ^,
^ ^ ^ W ^ ^ ^ ^ ^ ^ S ' ^ , ^ i ' The letters teU of a ' ^ m ^ w h o s ^ ^ h ^ , ; ; ^ :
The staff m each unitjias h ^ * w y M ^ a f * a t e 8 " ™ # v ^
a malignant brain.tumor,sp^t:
fairies cope through^ difficult situation.a^J
v-Iirtheory; this flaay;seem.OK ,biit..in practice i
.
days inithe care of Western Massachu^
Watching and canngjor a f ^ y member who ^rt'-hurtai
It h^he^onw
displaced pa- , , e ts Hospital; of famiUes who believe the hos^'
I f ^ ^ ^ ^ f ^ ^ ^ ^ S ^ S R
'^ pital's gr^test; gifts are the compassion and -f
ness is a heart-breaking experiende^HbWiw^
what a fine
^dignity patients find there; of people whb w i f l ^
" iloo^you in thie.eye and,, without blinkihg^ay .[
Western Massachusetts Hospital provides;the. ,-,
that someone el^ec^res about a lov^d one . ^ - ^ o l ^
the^scnp^Te/^grain s ^ y l s - ^ ^ ^ ^ ^
? : s h o u l d j e m a m open.^^
makes the burden easier'to bear.
J ^ ^ ^ n o t e s asking that the hospital not dose.' W ^ r ^
.i" s4il,trT«6l.' Uiw: e-EsJ.e-ii.. <
.
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:
1 1 6
6
�WESTERN MASSACHUSETTS HOSPITAL FACT SHEET
The Weld a d m i n i s t r a t i o n believes t h a t the services provided by
Western Massachusetts H o s p i t a l can be d u p l i c a t e d i n "an equal or
s u p e r i o r " way i n t h e conununity.
The t r u t h i s t h a t Western
Massachusetts H o s p i t a l provides services which are not duplicated
elsewhere i n t h e s t a t e (and i n some cases, not even i n t h e
c o u n t r y ) . Western Massachusetts Hospital i s a s p e c i a l t y h o s p i t a l
w i t h a 107 bed c a p a c i t y and has a proud t r a d i t i o n o f serving
underserved and hard-to-serve residents o f Massachusetts.
For example. Western Massachusetts H o s p i t a l
coordinated
r e s p i t e care f o r 47 p a t i e n t s i n 1991 and 39 p a t i e n t s i n 1992.
Western Massachusetts H o s p i t a l f o s t e r s community/home-based care
f o r c h r o n i c a l l y i l l and d e b i l i t a t e d persons by o f f e r i n g an
i n c e n t i v e which helps a l l a y burnout; i . e . , caregivers can admit
t h e i r loved ones t o Western Massachusetts H o s p i t a l f o r a 1-2 week
p e r i o d so t h a t these caregivers can r e s t , regroup, recover from
h e a l t h problems, o r take a vacation.
Health care workers a t Western Massachusetts Hospital are
s p e c i a l l y educated t o create an "I'm okay, you're okay" m i l i e u f o r
p a t i e n t s , f a m i l i e s and s i g n i f i c a n t others. Family and s i g n i f i c a n t
others are an i n t e g r a l p a r t o f the care, e s p e c i a l l y when p a t i e n t s
w i t h c o g n i t i v e impairments are admitted.
E n d - o f - l i f e decision
making, informed consent, and s e l f - d e t e r m i n a t i o n are s e r i o u s l y
pursued.
Advanced medical d i r e c t i v e s are discussed w i t h t h e
p a t i e n t , f a m i l y and s i g n i f i c a n t others s t a r t i n g a t t h e time o f
i n i t i a l contact and c o n t i n u i n g throughout t h e p a t i e n t ' s stay.
Empowerment i s t h e g o a l .
The n e u r o l o g i c a l and communication d e f i c i t s seen i n these
p a t i e n t s make t h e d a i l y a v a i l a b i l i t y o f a h i g h l y s k i l l e d team
prudent. A n u r s i n g s t a f f o f 130, 5 physicians, s o c i a l workers,
physical
therapists,
respiratory
therapists,
occupational
therapists,
dieticians,
psychologists,
speech and hearing
p a t h o l o g i s t s , r e c r e a t i o n t h e r a p i s t s , pharmacists, p a s t o r a l care
s t a f f , v o l u n t e e r s , students, and d e n t i s t make up the p a t i e n t care
team. These p r o f e s s i o n a l s (as w e l l as the p a t i e n t s , f a m i l i e s and
s i g n i f i c a n t others themselves) r e a l i z e t h a t recovery i s u n l i k e l y a t
best. The team focuses i t s e f f o r t s on p r e v e n t i o n and maintenance.
Insurance c a r r i e r s and Medicaid do not reimburse nursing homes f o r
p r e v e n t i v e care.
Yet, t h e Commissioner o f P u b l i c Health, David
M u l l i g a n , and Lieutenant Governor Paul C e l l u c c i claim t h a t
prevention i s t h i s a d m i n i s t r a t i o n ' s theme.
A 40 bed, 21 day a l c o h o l and drug
treatment program f o r 20 head-injured
community) a r e housed on t h e h o s p i t a l
services a v a i l a b l e t o i n p a t i e n t s are
o u t p a t i e n t s per year.
treatment program and a day
persons (who reside i n t h e
campus. The eye and x-ray
u t i l i z e d by 350 a d d i t i o n a l
The Weld a d m i n i s t r a t i o n believes t h a t t h e same or b e t t e r
services are a v a i l a b l e i n the community by the p r i v a t e sector.
�-2Although long term care f a c i l i t i e s w i l l be forced t o admit these
patients, their quality of l i f e w i l l deteriorate.
The i n p a t i e n t programs a t Western Massachusetts H o s p i t a l
s e r v i c e f o u r (4) d i s t i n c t p o p u l a t i o n s :
1.
Neuromuscular Degenerative Diseaae Unit
Most o f t h e p a t i e n t s who r e s i d e on t h i s u n i t have MS
( M u l t i p l e S c l e r o s i s ) , HD (Huntington's Disease) or ALS (Amyotrophic
L a t e r a l S c l e r o s i s ) and are between the ages o f 30 and 50. This age
f a c t o r i n and o f i t s e l f makes these people i n a p p r o p r i a t e f o r a
g e r i a t r i c n u r s i n g home placement. Functional independence i s t h e
g o a l o f treatment whether i t be adaptive c h a i r c l i n i c s ; adaptive
u t e n s i l s f o r meals; wheelchair-accessible environment; handicap
vans; morning, a f t e r n o o n and evening a c t i v i t i e s ; pass p r i v i l e g e s ;
a i r c o n d i t i o n i n g ; o f f - s i t e recreation; residents' c o u n c i l ; etc.
This i s t h e only MS u n i t i n Massachusetts.
2.
Alzheimer's Unit
This u n i t houses p a t i e n t s w i t h Alzheimer's Disease, many
of whom have been r e j e c t e d by other f a c i l i t i e s because they e x h i b i t
troublesome (sometimes v i o l e n t ) behaviors.
The environment i s
t o t a l l y " c h i l d proofed" so t h a t these p a t i e n t s can wander f r e e l y .
I n a n u r s i n g home s e t t i n g , t h i s freedom i s not possible because i t
i s n o t safe.
Drugs and r e s t r a i n t s are f r e q u e n t l y used by other
facilities.
A c a r e f u l l y planned environment and r e c r e a t i o n are
used a t Western Massachusetts H o s p i t a l t o deal w i t h behaviors i n
t h e l e a s t r e s t r i c t i v e way.
3.
P a l l i a t i v e Unit
This i s t h e only i n p a t i e n t s e t t i n g which continues t h e
hospice care begun i n t h e home. I n FY 1992, 109 p a t i e n t s were
admitted t o t h i s u n i t .
They b e n e f i t e d from u n l i m i t e d v i s i t i n g
hours, p a i n management, and p a t i e n t , f a m i l y and s i g n i f i c a n t other
involvement i n treatment planning and care. People w i t h AIDS have
r e c e i v e d care w i t h o u t d i s c r i m i n a t i o n o r unnecessary precautions.
Dying w i t h d i g n i t y i s the g o a l .
4.
The Chronic Units
The Chronic U n i t s house p a t i e n t s whose c o n d i t i o n s r e q u i r e
s k i l l e d n u r s i n g care which nursing homes are only now beginning t o
tackle.
Many o f these p a t i e n t s have PVS ( p e r s i s t e n t v e g e t a t i v e
s t a t e ) . Many have t r a c h tubes and n u t r i t i o n a l support tubes. The
environment i s designed w i t h t r o l l e y s so t h a t even p a t i e n t s i n t h i s
coma-like s t a t e can shower. Extensive r e s p i r a t o r y care i s required
by many p a t i e n t s . This i s n o t p o s s i b l e i n most nursing homes.
F a m i l i e s and s i g n i f i c a n t others are educated about t h e
t r e a t m e n t options and are empowered t o make d i f f i c u l t e t h i c a l
decisions.
U n l i k e most s t a t e h o s p i t a l s , Western Massachusetts H o s p i t a l i s
self-supporting.
I n FY 1992, t h e t o t a l cash received was $12,073,665.
T o t a l h o s p i t a l costs i n FY 1992 were $11,715,620.
Western
operation.
Massachusetts
Hospital
is a
fiscally
solvent
�CODER:.
HEALTH CARE TASK FORCE SORTING SHEET
INPUT DATE:
GENERAL SORT:
POSTCARD 1:
General mail
Personal stories
Other Health Providers
.Letter Campaign
POSTCARD 2:
Offers to help/Employment
FORM LETTER-
Letterhead
_Policy
REROUTE:
Casework
.Scheduling
_Phy8icians
President
Other
POUCY AND PERSON AT J STORTES:
.ORGANIZATION (I)
insurance premiums
^insurance reform
insurance pools
boards and oversight
.COVERAGE (H)
working families
unemployed/low income
.benefits
.providers
.INFRASTRUCTURE/WORKFORCE (III)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
manpower issues (training)
unnecessary procedures
.GOVERNMENT PROGRAMS (IV)
medicare
medicaid
veterans
.DoD
Indian health
.COST ISSUES (VI)
drug prices
physician fees
hospital fees
medical equipment
fraud & abuse
.FINANCING (VII)
.MENTAL HEALTH (IX)
LONG-TERM CARE (X)
PUBLIC HEALTH/
SPECIAL POPULATIONS (XII)
prevention
AIDS
.women's health
.immunizations/children
.rural
urban
OTHER
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001a. letter
SUBJECT/TITLE
DATE
Zell Miller to Thomas Palmer [partial] (1 page)
2/26/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [4]
2006-0885-F
wr827
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information [(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA|
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRiVf. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�C ir=i=
STATE OF GEORGIA
OFFICE OF THE GOVERNOR
ATLANTA 30334-0900
Zell Miller
February 26, 1993
GOVERNOR
_o0l a]
Dear Mr. Palmer:
Thank you for your recent letter concerning the system you
have devised for detecting health care fraud. I am happy to
forward on to Mrs. Clinton the letter you had addressed to her.
I appreciate your sharing these thoughts with me.
With kindest regards, I remain
Sincerely,
Zell Miller
ZM:bs
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001b. letter
SUBJECT/TITLE
DATE
Thomas Palmer to Hillary Clinton [partial] (1 page)
2/12/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [4]
2006-0885-F
wr827
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
Pi National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) of the PRA)
P4 Release would disclose trade secrets or confidential commercial or
financial information |(a)(4) of the PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA)
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA)
b(l) National security classified information 1(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Thnmas E. Palmer
February 12,1993
Ms. Hilliary Rodham Clinton
White House
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Ms. Clinton:
00| b
Re: Health Care Fraud
First, let me introduce myself. I'm Tom Palmer, a Republican for many years who had had enough, and voted
for President Clinton, VP Gore, Wyche Folwer, and previously for Governor Zell Miller.
I know you're very busy, so I'll get right to the purpose of this letter. I'm a Computer Software programmer who
develops and markets Software to Medical and Chiropractic clinics. In this endeavor I have encountered many
cases of blatant fraud, and within the past year have reported cases to and worked with a Special Agent of the
Inspector General and Agents with the State of Georgia Ins. Fraud Investigation unit. Fraudulent activity is on
the rise quite dramatically, and it's disgusting.
Last fall, while working with the IG and State of Georgia Ins. Fraud unit, we were exposed to a situation which led
me to modify one of the features of my Software Program that could do in minutes what would normally take
countless hours, and numerous personnel to accomplish in spotting potential fraud. The System I developed is
called FRJSC, for fraud Besearch Investigation System Consultant. Briefly, the System can quickly find the
following types of potential violations:
1.
2.
3.
4.
5.
Excessive Lab Tests, especially to Medicare and Nursing Home Patients.
Excessive Injections and Prescription Drugs.
Excessive Examinations X-Rays, etc.
Excessive charges.
Improper procedures, tests, injections, and prescriptions being administered for a particular diagnosis.
FRISC can constantly monitor what's being done by Doctors and Chiropractors, and print a "flag" whenever a
violation is detected, thus quickly alerting Investigators. An Investigator can then quickly obtain a detailed analysis
ofthe activity by Doctor or Chiropractor in violation. Countless man-hours, and personnel expense can be saved,
and fraud can be spotted easier and dealt with quickly. Existing computers and personnel can be used to
implement FRISC, and when Doctors and Chiropractors realize that their activity is being monitored
by sophisticated Computers, the intimidation factor alone could start reducing fraudulent activity.
Supposedly, the Medicare Insurers', Blue Cross, £l. al., are making an attempt at dealing with fraud, but from what
I could determine, they dont come close, and I frankly don't think they want to, because the more they process,
the more they earn. And, the fact that fraud is so rampant and increasing so rapidly is evidence they're not being
even moderately successful in curtailing such activity.
I would welcome the opportunity to discuss how the FRISC System could assist your endeavors. There would
be no charge for the System, because I sincerely believe that it's time for everyone to contribute something
worthwhile to our Country and help get it out of the mess that has evolved, especially the Health Care System.
Sincerely,
Thomas E. Palmer
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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[Letters from Government Officials and Employees] [loose] [4]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
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Box 36
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
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Clinton Presidential Records: White House Staff and Office Files
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12092971
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https://clinton.presidentiallibraries.us/files/original/c3b6736175e1b6949e8bfafde052b843.pdf
5b2fa2dcef89b8c30e26028549ba8916
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Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1983
FolderlD:
Folder Title:
[Letters from Government Officials and Employees] [loose] [3]
Stack:
Row:
Section:
Shelf:
Position:
s
56
2
3
2
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. resume
Kathleen Lewinski DeBruhl [partial] (1 page)
n.d.
P6/b(6)
002a. letter
Constituent to Hillary Clinton, re: cancer (2 pages)
n.d.
P6/b(6)
002b, statement
From constituent, re: cancer (2 pages)
n.d.
P6/b(6)
003a. letter
Marian Van Landigham to Hillary Clinton [partial] (1 page)
4/7/1993
P6/b(6)
003b. letter
Constituent to Senator Joseph Gartlin, re: healthcare (2 pages)
2/12/1993
P6/b(6)
003c. letter
Joseph Gartlan to Constituent [partial] (1 page)
3/22/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [3]
2006-0885-F
wr826
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute ((a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) of the FOIAj
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy ((b)(6) of the F01A|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�EDM
SUPERVISOR THIRD DISTRICT
LOS A N G E L E S COUNTY
OFFICE
821 HALL OF A D M I N I S T R A T I O N
PHONE 9 7 4 - 1 0 3 3
�io-. ys^
farts
MEMBERS OF THE BOARD
GLORIA MOLINA
KENNETH HAHN
EDMUND 0. EDELMAN
DEANE DANA
MICHAEL D. ANTONOVICH
BOARD OF
SUPERVISORS
COUNTY OF LOS ANGELES
821
HALL
OF
ADMINISTRATION
/
LOS
ANGELES.
CALIFORNIA
E D M U N D D. E D E L M A N
SUPERVISOR. THIflD DISTRICT
974-3333
90012
November 27, 1992
Dear P r e s i d e n t - E l e c t C l i n t o n :
I have enclosed a copy o f t h e Los Angeles County H e a l t h
Access Report i n which you expressed an i n t e r e s t .
I f you have any q u e s t i o n s about t h e Task Force Report,
"Closing t h e Gap", I would be g l a d t o speak w i t h you o r
your N a t i o n a l H e a l t h P o l i c y T r a n s i t i o n team.
Best and warmest r e g a r d s .
EDMUND D. EDELMAN
Supervisor
Third D i s t r i c t
�TASK FORCE FOR HEALTH CARE ACCESS
IN LOS ANGELES COUNTY
"CLOSING THE GAP"
REPORT TO THE
LOS ANGELES COUNTY BOARD OF SUPERVISORS
NOVEMBER 2 4 , 1 9 9 2
�TABLE OF CONTENTS
ACKNOWLEDGMENTS/CONTRIBUTORS
HI
SECTION I.
INTRODUCTION AND BACKGROUND
SECTION II.
EXECUTIVE SUMMARY
SECTION III.
WHAT IS THE GAP?
11
SECTION IV.
GAP CLOSING APPROACHES
27
SECTION V.
IN THE GAP
31
SECTION VI.
CLOSING THE GAP
41
APPENDIX A.
BOARD OF SUPERVISORS RESOLUTION
59
APPENDIX B.
SUMMARY OF PUBLIC HEARINGS
67
APPENDIX C.
RESEARCH COMMITTEE REPORT
75
APPENDIX D.
SURVEY OF FREE AND COMMUNITY CLINICS
105
APPENDIX E.
TASK FORCE MEMBERS
113
APPENDIX F.
TASK FORCE STAFF
117
APPENDICES
�ACKNOWLEDGMENTS
It would have been impossible for the Task Force to have completed its tasks without the extraordinary
support that was received from a number of sources.
A major contribution was the superb support provided by staff of the National Health Foundation. Rita
Moya. President of the National Health Foundation, graciously undertook the role of chief of staff for
the Task Force and carried out her duties with extraordinary skfll. sensitivity and devotion. She was
more than ably supported by Ruel Berris, Mariene Larson and a wonderfully skilled office staff. All of
this support was provided firg bono and funded by the National Health Foundation.
Of critical importance was the excellent and highly professional support provided by staff of the Los
Angeles County Department of Health Services. Carl WOliams provided key coordination and was ably
assisted by Jonathan Freedman. Ron Hansen, Linda Dacon, Miya Iwataki and Bena Soohoo, among
others. Carmen Scott provided essential coordination with the Office of the CAO.
The Task Force was fortunate that Thaine Allison. Jr.. was avaflable to perform the essential research
on unmet need that is the centerpiece of our report. Our summer interns from USC, Brendan Kremer
and Felice Houston were responsible for carrying out the survey of our free and community clinics.
CONTRIBUTORS
The Task Force for Health Care Access in Los Angeles County was created as a public/private entity
without an appropriation of funds from the County Board of Supervisors. The work of the Task Force
has required considerable resources both in dollars and in-kind support. The Task Force wishes to
acknowledge the generous financial support of the following organizations who made possible this
report and the activities of the Working Group on the Aftermath, the Research Sub-Committee and the
Managed Care Working Group.
Blue Cross of California
Blue Shield of California
CareAmerica
HealthNet
James Irvine Foundation
Kaiser Permanente
PacifiCare Health Systems
Robert Wood Johnson Foundation
Rose Hills Association
Southern California Edison Company
in
�In-kind donations were also very important and included staff support, meeting space, research
assistance, graphics production, equipment, and supplies. The Task Force acknowledges with
appreciation in-kind support from:
Chinatown Service Center
City of Long Beach, Department of Health and Human Services
Clinica "Monsignor Oscar Romero"
COHR Connection
David Minning
East Los Angeles Community Center
Fairfax High School
Glendale Memorial Hospital and Health Center
Hospital Council of Southern California
Hubert H. Humphrey Comprehensive Health Center
Kaiser Permanente
Long Beach Children's Clinic
Long Beach Memorial Medical Center
Los Angeles County Department of Health Services
Los Angeles County Department of Internal Services - Urban Research
Los Angeles County Medical Association
Los Angeles Free Clinic
Martin Luther King Jr./Charles R. Drew Medical Center
National Health Foundation
Orthopaedic Hospital
Queen of Angels - Hollywood Presbyterian Medical Center
RAND Corporation
Saint Francis Medical Center
Southern California Edison
University of California, Los Angeles - School of Public Health
University of Southern California - School of Medicine
University of Southern California - School of Public Administration
Finally, the dedication and hard work of the members of the Task Force should not go unnoted. The
expansion of our tasks beyond the initial charge required extraordinary devotion and it was uniformly
forthcoming from the members. I am particularly grateful to Harry Douglas, III, D.P.A., and Corinne
Sanchez, J . D . , who so ably co-chaired the Task Force and co-chaired the Working Group on the
Aftermath with skill and dedication. The leadership that Jim Ludlam, Esq. and Edgar Carlson provided
for the Managed Care Working Group and its dedicated and creative members made a major
contribution to our product.
Robert E. Tranquada, M.D.
Chairman
IV
�SECTION I
INTRODUCTION AND BACKGROUND
On February 1 1 , 1992, on a motion by Supervisor Edelman, the Board of Supervisors created the Task
Force for Health Care Access in Los Angeles County. The Task Force was created as a result of the
Board's critical concern about the burgeoning problem of the uninsured and underinsured in the County
and the increasingly difficult challenge to provide and finance health care to the medically indigent
while maintaining quality care.
The Board further recognized that addressing the health care problems of the County will require the
cooperation, involvement and support of public and private providers, payors, and consumers.
Accordingly, the Task Force's membership is comprised of representatives of the public and private
health care sector, business, labor, medical and public health education and community groups.
The charge of the Task Force was to provide the Board, within 180 days of its first meeting:
•
A description of the critical unmet health needs of the medically uninsured/underinsured and
the current capacity of public and private resources to meet these needs.
•
Consensus on the principles essential to a health care reform strategy relevant to the needs
of the County of Los Angeles.
•
Ways consistent with the principles adopted by the Task Force to improve the health status
of underserved residents by adjusting the existing splintered patterns of access and care
through optimal utilization of existing resources.
1
�•
Consensus on elements essential to long term solutions requiring State and federal actions.
*
Examination of the impact of undocumented persons on the health care system.
The Task Force is jointly staffed by the Los Angeles County Department of Health Services and the
National Health Foundation, a non-profit entity.
�TASK FORCE FOR HEALTH CARE ACCESS
IN LOS ANGELES COUNTY
MEMBERS
Organization
Appointee
Small Business
Organized Labor
Managed Care Industry
Hospital Council of So. California
Chamber of Commerce
Commission on Insurance
Department of Health Services
Los Angeles County Medical Association
USC School of Medicine
UCLA School of Medicine
UCLA School of Public Health
Health Policy Research Consortium
RAND Corporation
Health Access Foundation
United Way
Supervisorial Appointee
Supervisorial Appointee
Supervisorial Appointee
Supervisorial Appointee
Supervisorial Appointee
Supervisorial Appointee
Supervisorial Appointee
Dennis C. Poulsen
Joseph Wetzler
Edgar T. Carlson
James E. Ludlam, Esq.
Jacque Sokolov, M.D.
Bill Press
Robert C. Gates
Richard W i g o d , M.D.
Ronald L. Kaufman, M.D., M.B.A.
Roy Young, M.D.
E. Richard B r o w n , Ph.D.
Robert Tranquada, M.D.
Arleen Leibowitz, Ph.D.
Michael Cousineau. D.P.H.
Harry Douglas, III, D.P.A.
David Chernof, M.D.
Hector Flores, M.D.
Sr. Elizabeth J . Keaveney, D.C.
Val Rodriguez
Corinne Sanchez, J.D.
Reed Tuckson, M.D.
Mimi West, M.S.W.
Chief of Staff
Rita Moya
�S E C T I O N II
EXECUTIVE SUMMARY
The Task Force for Health Care Access quickly focused on defining the gap between those identifiable
services now available in the County to the uninsured/underinsured population and an estimate of the
total need for such services. A decision was made to focus on ambulatory care, since inpatient hospital
care would require additional resources and there was not sufficient evidence to determine whether
a serious hospital inpatient care access problem exists.
The Task Force concluded early on that it is unlikely that state or national health care reforms sufficient
to provide definitive resolution of the access problems can be implemented in the near future. Equally
important, the Task Force believes that there in no realistic prospect for significant increases in
appropriations for direct health care services at local. State or federal levels in the near future.
Accordingly, the Task Force focused on those recommendations which can help alleviate the existing
access problem, short of national health care reform and without substantial increases in governmental
appropriations. At the same time, these recommendations will prove effective in the implementation
of health care reform and in directing the use of new resources as they become available. The work
of the Task Force can be summarized under several general themes:
The Gap
In 1990, there were 2,700,000 persons in Los Angeles County without health insurance. That
represents 33% of those under the age 65, and is substantially higher than the average percentage
of uninsured for the State of California (17%) or the nation (15%). Eighty-seven percent of the
uninsured are either employed or are the dependents of an employed person. Task Force research
�identified the need for ambulatory care visits for a population of 2.7 million, uninsured residents, at
between 12.5 and 19 million visits per year. The current resources available, even if generously
estimated, do not exceed 11 million visits a year, leaving a gap of unmet need between 1.5 and 7
million visits per year. It is noteworthy that these figures most likely do not include the needs of some
700,000 undocumented persons in the County. In concrete terms, the scope of resources required to
address this unmet need is equivalent to increasing County health services nearly three fold, increasing
the capacity of the free and community clinics by twelve fold, tripling the contribution of private
physicians, or some combination of all of these resources.
Basic Principles for Heallh Care Coverage Reform
The Task Force recognizes that the unmet need it has identified can only be addressed definitively by
the adoption of comprehensive health care reform that will provide universal access to health care.
Such legislation will, of necessity, originate at the State or federal level. The Task Force has developed
a number of recommendations which both have the potential to provide significant improvement in
health care access and which will serve as essential elements in the implementation of health care
reform and in the allocation of new resources as they become available. In order to achieve the most
rapid improvement in access, recommendations focus primarily on elements which can be implemented
with minimal additional funding.
Coordinated System of Comprehensive Care
A major focus of the Task Force's recommendations is on improvements in the current health care
delivery system that will promote efficiency and greater access for the uninsured. Current resources
consist of the extensive capabilities of the Department of Health Services and a substantial array of
private community and free clinics, hospitals and physicians who provide large amounts of care to the
�uninsured. The Task Force notes that presently, not only are the County operated services poorly
coordinated, but there is little, if any, coordination between public and private resources. The Task
Force strongly recommends that the Board of Supervisors instruct the Department of Health Services
to take leadership in the design and coordination of a single system of health care for the uninsured,
encompassing both public and private resources in a system capable of providing comprehensive care
utilizing the principles of managed care. Included in the system will be an electronic referral network
linking all the elements of the system and capable of improving the ability to refer patients for
appropriate care promptly and efficiently. Many characteristics of such a system are defined in the
recommendations and the Task Force has pledged to assist in obtaining the private resources that will
be required to implement the system. Such a system should be formally included in joint five year
plans, prepared by the Department of Health Services in consultation with the private providers and
community representatives and approved annually by the Board of Supervisors.
Mobilizing New Resources
In view of the enormous gap in resources it has identified, the Task Force recommends that the Board
of Supervisors use every means to maintain current levels of funding for the Department of Health
Services, provide stability in budgeting from year to year to make planning possible, and to make
improved funding of the Department of Health Services a very high priority for the future. Other
recommendations focus on mobilizing the private sector to assume a greater role in caring for the
uninsured/underinsured. The Task Force is committed to assisting in those tasks. A major
recommendation is the implementation of the Los Angeles Community Clinic Partners program. This
program involves linking voluntary resources from managed care organizations, group practices, private
hospitals and businesses with public or private clinics serving the medically indigent. The partnerships
will enhance the clinics capacity by helping to provide needed staffing support, equipment, supplies
and technical assistance.
�Promoting Preventive Services
The
Task
Force
recognized
that
over
time,
a
portion
of
the
need
for
services
uninsured/underinsured could be diminished if illness and disease could be prevented.
by
the
While it is
difficult to quantify the impact of all the preventive services that are recommended, it is accepted that
this approach is very cost effective in the areas recommended and should be a top priority when
resources are allocated.
Working Group on the Aftermath
Perhaps the most defining factor was the civil unrest that occurred shortly after the Task Force met
for the first time on April 2 9 , 1 9 9 2 . The creation of the Working Group on the A f t e r m a t h and the
resulting involvement of over 7 0 0 citizens in the Task Force's w o r k has had a profound effect on the
recommendations. With the creation of the Working Group on the A f t e r m a t h , the Task Force became
an action body and moved quickly to implement suggestions and ideas that could not wait for the
completion of a formal report. Chief among these was the creation of a number of Community Health
Councils in many areas of the County most impacted by problems of access to health care.
Community Health Councils
The Task Force is very proud of the Community Health Councils that have begun to organize
throughout Los Angeles County and places a great deal of emphasis on seeing that they are continued
and expanded as part of the Working Group on the Aftermath's agenda.
A s neighborhoods and
communities become involved in health care access issues, the needs of the uninsured and
underinsured will become much more clearly defined. The Community Health Councils will become
a key element in designing a system of providing services in Los Angeles County that
8
are
�geographically and culturally sensitive and address the unique needs of each local community.
Continued Commitment
In the spirit of public/private collaboration which created the Task Force, the members have agreed to
stay involved with the job of implementing the recommendations which will require the dedicated
efforts of the Department of Health Services, private health care providers, the philanthropic
community and citizens. The Task Force will continue to monitor progress on its recommendations,
serve as broker to attempt to mobilize private resources in support of its proposals and those of the
Community Health Councils, and give continuing consideration to issues not resolved in this report.
This report and the recommendations of the Task Force are only the first step in what will be a
continuing process to fill the gap in health care services for the 2.7 million people in Los Angeles
County without health care coverage.
�SECTION III
WHAT IS THE GAP?
Introduction
The Task Force for Health Care Access was created because it was recognized that there is a
substantial gap in access to health care for the uninsured and underinsured in Los Angeles County. The
purpose of this section is to define the gap in concrete terms and to serve as a basis for constructing
recommendations to close the gap and to measure progress of that effort.
The Task Force developed the following concept for defining the gap:
The Gap
The gap is defined as the difference between the defined need for health care by the uninsured in Los
Angeles County and the current supply of health resources accessible by the same population.
GAP = NEED - RESOURCES
The Need
In this case, need was calculated by estimating the number of people at risk (i.e. the uninsured in Los
Angeles County) and multiplying that number by an appropriate utilization standard. The standard
chosen was the utilization of ambulatory services by a population that is substantially equivalent to the
11
�characteristics of the uninsured.
The best estimate of the number of the uninsured population available is for March 1 9 9 0 . It was
obtained from the Current Population Survey, special analysis by E. Richard B r o w n , Ph.D., of the
University of California at Los Angeles, School of Public Health. The total estimate of uninsured in Los
Angeles County, for 1990, is 2 , 6 6 6 , 0 0 0 people under the age of 6 5 . There are an additional 4 2 , 0 0 0
uninsured aged 6 5 or older. The characteristics of those people will be examined below.
The method chosen to estimate the need was to utilize the rates of services used by other similar
populations. It was judged that the number of ambulatory visits per person utilized by the Medi-Cal
population in Los Angeles County, when those individuals had access to a managed care program,
would serve as an appropriate number of visits per person for the uninsured population. For this
analysis, outpatient utilization data was provided by a large non-profit health maintenance organization
(both private and Medi-Cal members) and by the LOS Angeles County Department of Health Services
Community Health Plan, a managed care plan run by the County for Medi-Cal recipients and some
medically indigent adults.
The differing utilization rates among the groups examined allowed the Task Force t o develop a range
estimate of the number of ambulatory visits needed to provide adequate care to the uninsured
population and also provided a check on the validity of the data. Using those actual utilization data and
multiplying them by the age and sex adjusted description of the uninsured resulted in the following
estimates of the number of visits needed:
Alternative Estimates of the Needs of the Uninsured
Estimate Based On
Number of visits needed
Private Pay HMO Patients
L.A. County DHS Community Health Plan
Medi-Cal HMO
12
12,516.699
16,201,000
18,928,957
�Thus it can be estimated that between 12.5 million and nearly 19 million ambulatory visits per year
would be required to serve the uninsured population of the County appropriately. Because of
considerations discussed in the report of the Research Committee (Appendix C), the Task Force
believes that approximately 15 million visits per year is a reasonable representation of the need.
The Resources
The uninsured population of Los Angeles County has several sources of ambulatory care. Providers
include the Los Angeles County Department of Health Services, the Pasadena and Long Beach City
Departments of Health, some 71 free and community clinics, outpatient departments of 104 private
hospitals, services provided w i t h o u t charge by private physicians and services purchased out-ofpocket. Using a variety of sources, staff was able to estimate the number of visits utilized by the
uninsured population f r o m these providers. Thus the resources are as follows:
E S T I M A T E S O F R E S O U R C E S PROVIDED T O THE UNINSURED
Source
Number of Visits in Last
Completely Recorded Year
Private Hospital Outpatient Clinic
Long Beach Health Department
Pasadena Health Department
71 Community and Free Clinics (# of uncompensated)
Los Angeles County Department of Health Services
Hospital Clinics
Comprehensive & Public Health Clinics
Private Physicians
Out of Pocket Services Purchased
Total Visits Provided
1,013,000
220,000
350,000
905,000
2,001,000
2,737.000
4.005,000
11.231.000
However, some estimates suggest that the number of physician visits provided to the uninsured
population may be considerably less than these estimates.
13
�The Gap
The currently unmet need, as defined by these figures, is between 1,500,000 and 7 , 0 0 0 , 0 0 0 visits
per year for the uninsured under the age of 65. It seems most probable that the actual unmet need is
approximately four million visits per year.
In another context, the unmet need represents what would be produced by doubling the County's
ambulatory resources, or increasing the free and community clinic visits by ten-fold, or increasing
private hospital uncompensated care by four-fold or by doubling the contributions of private physicians.
Since none of these appear to be achievable without major infusions of tax dollars, the Task Force
concentrated on recommendations which might take advantage of the potential in all of these sources.
It is important to note that the Task Force has not attempted to account for the needs of the
underinsured, for which there exist no accurate numbers. This group includes Medi-Cal recipients who
cannot always depend on private hospitals and private practitioners, those with pre-existing conditions
excluded by their current insurance, and those who have exhausted their insurance benefits or who
cannot meet their required co-payments or deductibles. One national estimate of the number of
underinsured suggests as many as 2 6 % of those under the age of 6 5 are underinsured.
THE SOCIAL CONTEXT OF THE GAP
It is misleading to consider the Gap simply as a cold number. It is made up of services that, under the
circumstances, are needed by actual human beings. To put a more human face on it, let us look at the
problems in terms of the social transformation underway in Los Angeles County.
14
�Significant Population Growth:
Over the past ten years, f r o m 1980 to 1990, the population of Los Angeles County has
increased f r o m 7.8 million to nearly 9 million, an increase of 1 9 % . All predictions call for a
continuation of this population increase into the 2 1 " century. By the year 2 0 0 0 , Los Angeles
County is expected to be home to more than 10 million residents.
A Growing Proportion of Children and Women of Reproductive Age:
Children and women of reproductive age are becoming a larger proportion of the population.
More than 2 5 % of the population is under the age of 18, a higher proportion than most of the
rest of the nation. This is a population that benefits most f r o m early interventions designed
to promote health and encourage positive health behaviors that can have a life-long impact.
Increasing Diversity:
The ethnic and racial composition of the County has changed dramatically in recent years. In
1 9 9 0 , about 4 1 % of County residents were Anglo, 3 7 % Latino, 1 1 % African-American, 1 0 %
Asian/Pacific Islander, and 0 . 5 % American Indians. Nearly one-third of the County's residents
were born in another country. Populations experiencing the greatest percentage increases over
the decade are Asian/Pacific Islanders ( 1 1 0 % increase) and Latinos ( 7 1 % increase).
One and a half million people have immigrated to Los Angeles over the past ten years. The vast
majority of documented immigration came from Asia and Latin America. In addition there are
believed to be approximately 7 0 0 . 0 0 0 undocumented persons in Los Angeles, and their
statistics are not included in any calculations of the unmet need. There is little or no
15
�information about their health insurance status, although it seems reasonable to assume that
the proportion of the undocumented without insurance is very high.
The number of languages spoken in Los Angeles County exceeds 100 and nearly half ( 4 5 % )
speak a primary tongue other than English. A b o u t 2.6 million L.A. County residents speak
Spanish and of these, while 7 0 0 , 0 0 0 speak an Asian language.
The cultural diversity of the population provides a real challenge to the delivery of health care
and the promotion of health. There will be an increased need to deliver health services in a
culturally relevant, linguistically appropriate manner, sensitive to the socio-economic and
lifestyle factors that influence health behavior.
Impact of the Undocumented Population:
Los Angeles County is believed to have the largest population of undocumented persons in the
nation. A s of January 1 , 1 9 9 2 the undocumented population was estimated to be 7 0 0 , 0 0 0 ,
not including amnesty persons (718,000) or recent legal immigrants ( 6 3 2 , 0 0 0 ) . Almost no
definitive information exists on the undocumented population w i t h regard to health insurance
coverage or personal health status. The Task Force was forced to rely upon anecdotal
information in assessing the health care needs of the undocumented and therefore their
statistics are not included in the preceding estimates of the uninsured population in Los
Angeles County. The recent passage of SB 4 8 5 , which establishes the criteria to be met in
order to qualify for Medi-Cal, may preclude Medi-Cal coverage for the undocumented w i t h the
exception of pregnancy related and emergency services.
It is assumed that large proportions of the undocumented population live in poverty (as it is
16
�federally defined) and that they are employed in low wage positions that are unlikely to include
health insurance as a benefit. The combination of poverty and lack of insurance discourages
the use of private providers without regard to residency status. Although undocumented
immigrants contribute to the economy through employment and by paying income tax, sales
tax, vehicle licensing fees and other forms of taxes, most face financial, language and cultural
barriers to access to needed health services. Another significant barrier to accessing services
is the widely perceived barrier that utilization of public facilities may lead to exposure and
deportation.
There is evidence that the incidence of communicable diseases, specifically measles,
tuberculosis, hepatitis and HIV/AIDS is significant in the undocumented population. The
absence of accessible public or private sources of detection, prevention and treatment impacts
the health of the entire community.
A logical conclusion is that the undocumented population is not likely to have normal access
to the health care system without one or more of the following interventions: I D Adoption of
a system of universal access to health care, (2) The rewriting of California's Medi-Cal eligibility
criteria, and (3) positive assurance that there is no risk of exposure and deportation through
use of health care providers, both public and private.
Beyond the important humane considerations of the absence of available and acceptable health
care for the undocumented population of the County, the public health implications are
significant. Such a significant reservoir of communicable disease should not be allowed to exist
beyond the reach of the public health system. County officials should continue to place this
issue high on their agenda as they participate in the formulation of state and national health
policy. Particularly relevant is recent information that there is a substantial net contribution of
17
�taxes to state and federal jurisdictions by the undocumented. It is critical that a portion of
these funds be returned to Los Angeles County to help alleviate significant health access
problems.
•
A Changing Workplace:
There is enormous economic potential in the Los Angeles County economy. However, the
recent recession, substantial decreases in defense spending, and urban unrest have led to
economic uncertainty. Most of the n e w jobs created over the past decade have occurred in the
service sector, a sector dominated by small business, current economic uncertainty and limited
linkages to health insurance benefits. Unemployment in Los Angeles County was 6 . 9 % in
1 9 8 1 , and is estimated to be 1 0 . 3 % for 1 9 9 2 . Job loss has also occurred, particularly in the
skilled positions most likely to be linked to health insurance benefits.
•
Persistent Poverty:
The number of people living in poverty in Los Angeles County has increased f r o m 9 8 0 , 0 0 0 in
1 9 8 0 t o 1 , 3 0 0 , 0 0 0 in 1990, an increase of 3 3 % . During the period, the total population of the
County increased only 1 9 % . The poverty population is projected to reach 1 , 6 0 0 , 0 0 0 by the
year 2 0 0 0 . The homeless population in the County at any given instance is estimated at
approximately 4 0 , 0 0 0 , and over the course of a year, as many as 2 0 0 , 0 0 0 become homeless
for a period of time.
Many of the problems associated with poverty are health problems not directly related to the
availability of health insurance. Such factors as unhealthy living conditions, inadequate diet, violence,
lack of transportation, and delays in receiving health care when it is unaffordable or inconvenient, all
18
�complicate access issues.
THE HEALTH O F L O S A N G E L E S RESIDENTS
While it is tempting to utilize averages and inclusive numbers in describing the problem of
access, cultural complexity brings with it social and cultural groupings that have disparate
needs. Moreover, health is a property of the individual and there is no "one size fits a i r
solution to the health care access problems.
•
African-Americans
The rate of infant death is twice as high among African-Americans as any other ethnic group
( 1 8 . 4 / 1 0 0 0 compared to 9 . 7 / 1 0 0 0 Countywide in 1 9 9 0 ) . Adult African-Americans have a
particularly high incidence of hypertension and related heart disease. African-Americans
experience the highest rate of low birth weight babies. The current incidence of AIDS/HIV
among African-Americans is 1.5 times that of Anglos. Homicide rates are three times higher
among African-Americans than the rest of the population.
•
American Indians
Los Angeles County is home to the largest urban concentration of American Indians in the
nation, comprised of 4 5 , 0 0 0 people (per 1 9 9 0 census) representing over 2 0 0 different tribes.
This population is widely dispersed throughout the County. The majority of the American Indian
population lives below the poverty line and many of the conditions experienced by this group
have strong associations with poverty (e.g. alcoholism and tuberculosis). Diabetes is also highly
prevalent.
19
�Anglos
Heart disease, cancer, and stroke are still the leading causes of death among Anglos.
Associated w i t h these chronic and disabling diseases are environmental factors, smoking and
alcohol consumption. HIV infection and AIDS were initially strongly concentrated among the
Anglo population. Anglo men represent 6 1 % of the accumulated AIDS cases over the history
of the epidemic. That disease is n o w seriously affecting other ethnic groups as well.
Asian/Pacific Islanders
The population group with the highest rate of g r o w t h in Los Angeles County, this group is
composed of over 2 0 different nationalities who speak more than 6 0 different languages and
dialects. Their overall health status tends to be better than average, although specific problems
exist within subgroups. For example, cancer, hypertension and diabetes affect JapaneseAmericans to a greater extent than other populations. Native Hawaiians have higher cancer
mortality rates than other Asian/Pacific Islanders or the general populations. Chinese elderly
have health problems related to hypertension, smoking, drug and alcohol use, and experience
a comparatively
high suicide rate. The incidence of tuberculosis, hepatitis B, parasitic
infestations and anemia is higher among those w h o are recent immigrants, especially those
coming f r o m China and Southeast Asia.
Latinos
The Latino population in Los Angeles County, which increased f r o m 2 million to over 3.35
million during the past ten years, constitutes the largest ethnic group in Los Angeles, at 3 7 %
of the population of the County, and will soon be the largest ethnic group in the County. While
20
�Latinos experience some of the lowest cancer and infant mortality rates in the County, the rate
of diabetes is nearly three times that found in the general population. Measles incidence is
highest among Latino children. In 1989, 68% of reported measles cases were in Latino children
under five years of age. Of those children with measles, 95% had not been immunized. There
has been a dramatic increase in the rate of reported AIDS cases in the Latino community, with
Latinos representing 26% of the reported cases in 1991, compared to only 15% of the
reported cases in 1988.
POPULATIONS AT RISK
At the beginning of this section it was identified that those without health care insurance are the ones
most at risk. To put this into context, the following facts should be considered:
In Los Angeles County:
•
1 in 3 persons under the age of 65 has no health insurance
•
1 in 6 depends on Medi-Cal for health coverage
•
1 in 7 lives in poverty
•
1 in 7 persons is on the Aid to Families with Dependent Children (AFDC)
program or Welfare program
•
1 in 20 persons over the age of 64 is without Medicare coverage
•
1 in 100 persons are considered medically uninsurable
The most striking thing about these populations is that the rate of increase, in recent years, has
significantly exceeded that of the population at large:
In the past ten years:
•
L.A. County population has increased by 19%
•
Those living in poverty has increased by 33%
21
�•
The number of uninsured has increased by more than 1 0 0 %
•
L.A. County, w i t h one-third of the State's population has nearly half of the
State's six million uninsured.
Children are disproportionately affected:
•
2 6 % of the County population is under the age of 18
•
3 2 % of the uninsured are children; a very high rate compared to that for the
State of California (23%) and the nation as a whole ( 1 7 % )
Employment is no guarantee of health insurance: More than two-thirds of Los Angeles County's
uninsured are either employed full time or dependents of full time employees. Nearly 6 0 % of the
County's uninsured w h o are under 6 5 are persons with incomes below 2 0 0 % of the federal guidelines
for poverty (currently just below $ 1 3 , 0 0 0 for a family of four). Conversely, 4 0 % of the uninsured have
incomes more than t w o times the federal poverty level. Anglos are no less immune than any other
ethnic group in terms of being uninsured. Latinos are the most severely affected (one in t w o Latinos
have no health insurance). One in four Asian/Pacific Islanders is uninsured. One in five Anglos and one
in six African-Americans, under the age of 6 5 , have no health insurance. The reality is that all people,
without respect to income, age or ethnicity can be at risk for having no health insurance coverage.
HEALTH C A R E R E S O U R C E S IN L O S ANGELES COUNTY
Public Sector Resources
The Los Angeles County Department of Health Services (DHS) is the largest local health services
department in the nation. A FY 1 9 9 1 - 9 2 budget of $ 2 . 2 billion sounds generous enough, but revenues
22
�to allow adequate care for the medically indigent are limited and the future uncertain. The Department,
greatly changed since its inauguration in 1 8 7 7 , operates six hospitals w i t h a total licensed bed capacity
of 4 , 3 3 2 and available beds of 3 , 2 7 7 , of which about 2 , 6 0 0 are acute medical/surgical beds. Three
of the County hospitals operate trauma centers.
In addition to the hospitals, the DHS system also includes six comprehensive health centers and 4 0
public health centers. The comprehensive health centers provide a variety of services for the treatment
of injury, illness and chronic diseases, and serve as hubs for the 4 0 health centers that provide public
health services such as communicable disease control, immunization, family planning, pre-natal care,
well baby and adult treatment services. In FY 1 9 9 1 - 9 2 , County hospitals provided more than 1 8 1 , 0 0 0
admissions, 3 0 0 , 0 0 0 emergency room visits and more than one million outpatient visits. The
comprehensive health centers and public health clinics provided more than 2.4 million visits.
Approximately 8 3 % of care provided in the clinic system is for persons w i t h o u t insurance and care for
others is supported by the Child Health and Disability Prevention Program (CHOP) and Medi-Cal.
Private Providers in LA County
Los Angeles has 2 2 , 7 0 0 licensed physicians and surgeons, 140 acute care hospitals w i t h over 3 4 , 0 0 0
licensed beds, of which 2 6 , 0 0 0 are staffed, and more than 7 0 free and community clinics (A survey
of the clinic capability
is included
in Appendix
D). In addition, 114 of the hospitals
offer
outpatient/emergency services which are accessible to the uninsured.
There are currently 8 5 licensed emergency departments at private hospitals, 10 of which are also
designated as Trauma Centers. Many people without insurance present themselves for care at
emergency rooms because such programs are required to evaluate patients w i t h o u t regard to ability
to pay. As a result, with the growing number of uninsured in the County, over 6 0 % of individuals
23
�treated in private hospital Trauma Centers receive care that is not compensated by either public or
private insurance. Needless to say, this has put an enormous strain on these centers, with the result
that the past ten years have seen a decline in private hospital emergency rooms from 103 to the
present number of 85, and a decline in designated Trauma Centers from 20 in about 1980 to a total
of 10 private centers today.
Tenuous Funding of the Health Care Safety Net
Over the past 14 years, a series of significant events have affected the County's ability to finance and
provide health care services:
•
Proposition 13 in 1978 severely limited the County property tax revenues that could
be devoted to health care, and made the County increasingly dependent on state
revenues to maintain its health care system.
•
In recognition of the limitations on County resources, AB-8 was enacted by the State
legislature in 1979 in order to replace some of the funds lost to the County health care
system as a result of Proposition 13.
•
The medically indigent adult population, originally included in Medi-Cal in the California
adoption of the 1965 Medicaid legislation, was removed from Medi-Cal eligibility in
1982, and responsibility was transferred back to the counties along with about 70%
of the funding previously provided for that category. This amounted to 250,000 people
statewide.
•
The Congress passed the Immigration Reform and Control Act in 1986, which among
other things, recognized the special burdens of regions with especially large
immigration burdens. Los Angeles County benefitted from that law with the receipt of
funds to support health care for recent immigrants in need.
24
�•
In 1988, Proposition 99, the Tobacco Tax Initiative was approved by the State's
voters. Funds derived from that source have proved invaluable in providing
compensation to private providers for the delivery of uncompensated care in hospital
emergency rooms. Until now, this has been a vital source which has prevented further
deterioration of the trauma system.
While these events have recorded the primary ups and downs in the availability of revenues to the
County to fund needed health services, in recent years there has been a dramatic erosion of both State
and federal funding for these purposes, placing an increasing strain on the ability of the County to
maintain adequate services. As a result, the County is heavily dependent on Medi-Cal revenues to keep
the system viable, and the decrease in other funds, particularly State funds, has created the need to
examine further reductions in County services. It is noteworthy that the proportions of County general
funds allocated to the Department of Health Services declined from 18% to 8% of general funds
between 1980 and 1992.
HEALTH IMPLICATIONS OF BEING UNINSURED
While it seems logical to assume that being uninsured has impact on personal health outcomes, it is
useful to review some of the findings of researches which have attempted to document the effects of
lack of health insurance. A study of adults who lost Medi-Cal benefits demonstrated that those with
such chronic diseases as high blood pressure and diabetes experienced significant worsening of control
of those diseases. Adults without health insurance are less likely to receive cancer and preventive
screenings. Several studies have demonstrated that uninsured women received substantially fewer
cervical screenings, breast examinations, blood pressure, and glaucoma screening examinations. The
uninsured have been shown to have "excessively high rates of admission for medical conditions that
often would not require hospitalization if adequate outpatient care was available." The same study
25
�demonstrated that the uninsured also have lower rates of access to needed elective surgical
procedures. It is noteworthy that the major incidence of death due to measles in Los Angeles County
was among Latino children, are among the least likely to be covered by health insurance in Los Angeles
County. Other studies demonstrate a significantly fewer doctor visits among the uninsured, and a much
higher level of out-of-pocket expenditures for health care than either publicly or privately insured
persons.
Lack of insurance is clearly a major impediment to access to needed and essential health care. There
are other barriers to access, as well. These include language and cultural barriers, transportation
problems and the general lack of accessible health care resources in economically deprived areas of
the County. Those issues require attention as well, if significant inroads into the health care access
problems of our County are to be made.
Two very recent studies confirm the observations noted above. One study showed that being
uninsured was the single determinant most closely associated with an increased number of adverse
events due to negligence during hospitalization. Neither race, sex, nor socio-economic status explained
the increased incidence of negligence associated with adverse events in the 3 0 , 0 0 0 hospitalizations
that were analyzed. In a study of patients hospitalized for conditions which usually do not require
hospitalization, it was shown that lack of insurance and Medicaid status had a strong association with
hospitalization that could have been prevented if early outpatient intervention had occurred.
26
�SECTION IV
GAP CLOSING APPROACHES
The Task Force for Health Care Access approached its charge in a variety of ways. The Task Force
initially focused on developing a basic understanding of the health care access problem in the County.
This was aided at the time of the Task Force's first meeting by a presentation by Dr. Kenneth Shine,
then Dean of the UCLA School of Medicine and now President of the Institute of Medicine of the
National Academy of Sciences.
Dr. Shine's lecture provided an overview of the uninsured and underinsured in the County, discussed
the scope of the problem, noted demographic trends, and suggested health status implications. The
central point in Dr. Shine's lecture was the recognition of the gap between the need for health care
among the uninsured and underinsured and the availability of health care resources to meet the need
in the County.
Subsequently, the Task Force adopted a time-phased workplan to guide its investigation into the size
and implications of the County health care access gap. The workplan outlined key areas required to
fulfill the Task Force's mission, including gathering specific data elements, guidance of staff research
and reports, and receipt of expert and lay testimony.
Organizationally, the Task Force formed three subcommittees:
•
Research Subcommittee -- This committee was comprised of Task Force members and staff.
It was charged with gathering and analyzing the data necessary for the Task Force to
27
�accomplish its fact finding and to support deliberations. The work of the Committee was
enhanced by a generous grant of $ 1 8 , 2 5 0 from the Southern California Edison Company to
support the data gathering and interpretation.
•
Managed Care Subcommittee
This committee was already in existence before the Task
Force had its first meeting. It was comprised of public and private managed care providers and
it examined proposals from managed care providers to increase access to health care for the
medically indigent.
•
Working Group on the Aftermath -- This committee was created to address the immediate
effect of the April 1992 civil unrest on health care resources within the impacted communities,
and to develop a plan for community-based solutions to health care access problems. The
Working Group is comprised of members of the Task Force and more than 7 0 0
other
interested community organizations and individuals. More background on the Working Group
on the Aftermath can be found in Section V.
The full Task Force met monthly or more often to gather testimony and receive input on the progress
of staff and subcommittees. All meetings were open to the public and were conducted in accordance
with the Brown Act requirements.
The Task Force also convened five public hearings in the month of August 1992 to obtain public input
on health care access problems in various communities. Those testifying at the public hearings were
asked to focus specifically on how public and private resources can be utilized more effectively to
provide better access to the uninsured. A total of 51 witnesses were heard. A summary of the public
hearings is provided in Appendix B.
28
�Throughout the progress of the Task Force, a large variety of proposals, ideas and concepts were
received from members of the Task Force, the Working Group on the Aftermath, staff, and those
providing testimony.
Staff compiled suggested items and the Task Force, after careful review,
accepted, modified, and/or deleted items via a two-step rank ordering process. These deliberations
occurred during regular public meetings of the Task Force. Subsequently, staff was instructed to
prepare the final report with input and review from the Task Force members.
29
�SECTION V.
IN THE GAP
Within a few hours after the Task Force adjourned its inaugural meeting on April 29, 1992, the civil
unrest following the acquittal of the four police officers in the Rodney King incident erupted and
continued for the next five days. More than one million people were directly affected in widely spread
areas of the County. As the implications for the health care access gap became apparent, consultations
were held with the Supervisorial offices and the County Department of Health Services. It was clear
that health care access in the affected communities had been adversely impacted and that the Task
Force was the appropriate body to take the lead in dealing with the immediate health care issues of
the aftermath. Accordingly, a special meeting of the Task Force was convened on May 8, 1992 and
a plan was devised to define that task.
The Task Force created the Working Group on the Aftermath and agreed that the Working Group would
be composed of Task Force members and other interested parties and would report back to the Task
Force. Additionally, the Task Force agreed to the following guidelines for the Working Group activities:
a) that solutions must be the product of the involvement of the affected communities, b) that different
communities would require different solutions, c) that a significant infusion of new resources into direct
health care services was unlikely, and d) that solutions must focus existing public and private resources
more effectively. Following the May 8th Task Force meeting, staff from the National Health Foundation
and the Department of Health Services identified community organizations in the impacted areas and
sent approximately 200 letters inviting representatives from these organizations to attend the first
meeting of the Working Group on the Aftermath. Thereafter, continual efforts were made to expand
the mailing list for future meeting notices.
31
�At the initial meeting of the Working Group on the Aftermath on May 15, 1992, held at the Los
Angeles Area Chamber of Commerce, Harry Douglas, III, DPA, was elected as its chair. Dr. Douglas
represents the United Way on the Task Force and is the Dean of the College of Allied Health at Charles
R. Drew University of Medicine and Science in Watts. In adopting the following objectives, the Working
Group focused its efforts to:
•
Provide a detailed description, by area, of the effects of the events of April 30 to May
4 on access to health care services in the involved areas of the County.
•
Identify and define a number of "communities of interest" in the involved areas, which
would represent populations of 50,000 or more and which could serve as the
geographical basis for the organization of Community Health Councils.
•
Bring together, beginning with two or three pilot areas. Community Health Councils
with broad representation from providers and consumers in each of the communities
of interest and assist them with staffing needs so that each could produce its own
agenda of priorities for improving access to health care.
•
Identify those public and private agencies, institutions, and organizations whose efforts
will be required to meet the needs identified by the Community Health Councils and
additionally identify potential public and private funding sources which could contribute
to these efforts.
•
To the extent necessary, provide standards to be met by each of the Community
Health Councils and provide ongoing assessment arid evaluation of all of the efforts.
32
�•
Provide a forum for the interchange of ideas and successful methods among the
leadership of the Community Health Councils.
Following that meeting, numerous additional community organizations were invited to join the Working
Group. At the first meeting of the expanded Working Group held at Drew University on May 29, 1992,
the objectives and organizational plan were accepted. It was agreed that work would proceed under
an action research format. Work was begun to define the geographic boundaries of the areas most
severely impacted by the civil unrest. A list of impacted "cluster" areas was developed:
•
Central City
•
Compton
•
Crenshaw
•
Inglewood
•
Long Beach
•
Mid-Wilshire/Koreatown
•
Pico/Union
•
Watts/Willowbrook
•
West Adams
•
East Los Angeles/San Gabriel Valley
•
Hollywood
•
Pomona
•
San Fernando Valley/Van Nuys/Lake View Terrace
•
Venice/West Los Angeles
These cluster areas became the focus for the major organizing efforts and the hubs for the Community
Health Councils.
33
�A t the June 3 0 , 1992 meeting of the Working Group held at the Los Angeles County Medical
Association offices, the participants were asked to divide into cluster groups based on the geographical
areas listed for the purpose of further defining the Community Health Councils. During this meeting,
Corinne Sanchez, J D , President and Chief Executive Officer of El Proyecto del Barrio, was elected CoChair of the Working Group.
Each cluster group was charged w i t h : a) appointing a convener, b) developing a statement of general
purpose and objectives, c) establishing guidelines for membership, d) identifying several immediate
projects, and e) developing a meeting schedule. Few groups were able to complete the ambitious
charge but the discussions provided the framework for further cluster group meetings. It was
anticipated that the cluster groups would serve as the springboard for the development of Community
Health Councils and that local communities would quickly organize themselves to participate directly
in the problem identification and solution process related to access to health care services.
By July it was recognized that in order to proceed further, the full time efforts of three community
organizers would be required to work with the volunteers in the cluster groups. Grant proposals were
prepared by the National Health Foundation to secure funding for the community organization effort.
Specific duties of the community organizers would include:
•
Extending outreach efforts to the greatest number of individuals within the target
communities and encouraging local citizen involvement in the Community
Health
Councils.
•
Finding key leaders (formal and informal) within each community w h o could provide
leadership for the Community Health Councils.
•
Encouraging the participation of medically needy and underserved populations that
have not traditionally been involved in health planning efforts.
34
�•
Developing a method for each Council to solicit input and prioritize the health care
needs of its community.
•
Involving participants in issues and projects that provide them with tangible outcomes.
•
Providing substantive and timely information to the Community Health Councils.
•
Providing technical assistance to the Councils for securing needed resources.
•
Assisting in the development of permanent funding sources for community organization
and programs.
The positions were advertised in several Hispanic, Asian/Pacific Islander and African-American
newspapers. Postings were also made at various universities.
On July 10, 1992, the conveners from each cluster group were invited to the first of several
conveners' meetings to discuss issues and concerns regarding the formation of Community Health
Councils and to review the job description for the community organizers.
The Working Group met again on July 29. 1992 at St. Francis Medical Center in Lynwood. The turnout
at the meeting was good, with more than 90 people representing various community organizations and
health care providers, several staff members of the Department of Health Services and the Task Force
for Health Care Access. Reports from each cluster group were given. Several of the clusters had
already held meetings and were focusing on health care issues in their area. The Crenshaw/West
Adams cluster had identified the need to inventory the public health hazards created by the debris left
from riot related fires. The East Los Angeles/San Gabriel Valley cluster was beginning to look at the
area's needs such as children's health services, prenatal care, diabetes, and health education. The
Pico/Union cluster reported on their efforts to begin a needs assessment and to recruit more
community representatives for their cluster.
35
�The conveners met again on August 17. 1992 to review and discuss a draft document outlining the
formation of a proposed Steering Committee for the Working Group which would replace the conveners
group. The following rationale set the stage for the discussion on its purpose and composition:
The Working Group on the Aftermath
has evolved into a loosely structured constellation of
community clusters. The clusters are tied together with a common agenda, namely, to address
health care access issues. They are also uniquely different in terms of geography,
composition,
health priorities, etc. A Steering Committee structure is proposed in order to provide a sense
of cohesion and consistency
for policy-making
Community
(CHC)
Health
recommendations
Councils
to
as well as provide a conduit for these
effectively
communicate
their
concerns
and
to the County Board of Supervisors.
The following purposes for the Steering Committee were recommended:
1)
Foster the development of a County-wide action agenda to address health care access
problems within specific communities.
2)
Assist in establishing community-based priorities.
3)
Provide a framework through which policy alternatives can be developed.
4)
Ensure that the community empowerment paradigm flows upward in the decision
channels.
5)
Safeguard the integrity of the Community Health Councils (CHC), and
6)
Provide a mechanism for County-wide leadership development and networking.
36
�The composition of the Steering Committee was recommended as follows:
1)
Eight members from the Task Force for Health Care Access:
Co-Chair
Harry Douglas III, D.P.A.
Co-Chair
Corinne Sanchez, J . D .
Members:
Val Rodriguez
Robert Tranquada, M.D.
Resource Members
Hospital Council of Southern California
Los Angeles County Medical Association
County Commission on Insurance
County Department of Health Services
21
One representative elected by each Community Health Council.
After much discussion, the proposed organizational structure was inverted so that the flow of
information went from the Community Health Councils down to the Working Group, and then to the
Task Force - a format consistent with the principle of empowerment for the Councils.
It was felt that the Steering Committee should meet on a regular basis (to be determined by the
Committee) and during these meetings establish the agenda for the Working Group meeting(s).
Recruitment of the Community Organizers occurred during August after grants were generously
provided by the James Irvine Foundation ($100,000) and the Robert Wood Johnson Foundation
($50,000).
A screening committee selected seven final candidates from among the applicants.
Members of the conveners group were invited to participate in the interview process. The Chair and
37
�Co-Chair of the Working Group, the Task Force Chief of Staff and representatives from the conveners
group comprised the interview panel. A multi-racial, multi-ethnic team of three Community Organizers
was selected and they were introduced at the August 28, 1992 Working Group meeting. The
community organizers officially began work on September 1, 1992.
Over 50 people attended the August 28, 1992 meeting of the Working Group. Reports were given
from each of the cluster groups. The proposed Steering Committee and organizational structure was
adopted as presented.
By September, the Working Group mailing list included over 700 representatives from community
organizations, health care provider organizations, members of the Task Force for Health Care A c c e s s
and the Department of Health Services. Approximately 50 individuals attended the September 2 5 ,
1992 Working Group meeting at Orthopaedic Hospital in Los Angeles. Several of the clusters reported
significant accomplishments: a) the launching of a health resources directory by the East Los Angeles
cluster, b) a special training program for community organization in the Pico/Union area related to
accessing services and recognizing post-traumatic stress symptoms, and c) the exploration of
public/private collaboration by the San Fernando Valley cluster. At this meeting. Dr. Raynard Kington,
from the Center of Health Care Access Research at the RAND Corporation presented a preliminary
proposal for doing a process evaluation of the activities of the Working Group which was well received
by the members.
In addition to reports from each cluster group, there was some discussion about the possible transition
of the Working Group on the Aftermath to Rebuild L.A.(RLA). During August, preliminary meetings
were held with RLA staff about merging the Working Group into RLA. At the first meeting of the RLA
Action Task Force on Health, Human Services and Youth in September, Dr. Tranquada, Chair of the
Task Force for Health Care A c c e s s , was appointed chair of the RLA Health Committee. At an October
38
�meeting of the RLA Health Committee, the idea of the merger of the Working Group on the Aftermath
and the Community Health Council Project with RLA was discussed in depth.
On October 30, 1992, at the Kaiser Permanente offices in Panorama City, a joint meeting of the
Working Group and the RLA Health Committee was held. It was discussed that the activities of the
Working Group could become part of the RLA structure and all unexpended grant monies for the
community organizing efforts would be transferred from the National Health Foundation to RLA.
39
�SECTION VI
CLOSING THE GAP
Task Force Recommendations
The members of the Task Force strongly and unanimously believe that the definitive solution to health
care access problems in Los Angeles County depends upon the enactment of federal or State health
care reform legislation that would provide universal coverage and access to health services. Members
recognized that these solutions may not be adopted in the immediate future, and that, even if enacted
soon, are likely to be implemented over several years. However, many problems in access and quality
of care can be addressed even before such reforms are adopted and will need to be implemented in
Los
Angeles
County
even
after
the
adoption
of
national
reforms.
Therefore
the
principal
recommendations are intended to provide a blueprint for change until definitive solutions can be
implemented.
In the near term, it is unlikely that there will be significant additional revenues f r o m federal. State or
local sources w i t h which to expand direct public health services. Therefore the recommendations
require minimal additional government funding, and focus on achieving greater efficiency
and
effectiveness in both public and private sources of health care for the medically indigent. Because
significant changes in hospital inpatient
care will require additional funding, the Task
Force
concentrated on ambulatory care as the principal unmet need. The Task Force did not give formal
consideration to the issues of access to mental health care.
Many of the recommendations ask the Department of Health Services to assume responsibility and a
leadership role. The recommendations may require staff time and other resources to implement. It is
the intent of the Task Force to work with DHS in prioritizing the various recommendations in regard
41
�to the level of attention and resources that should be focused on each.
The Task Force recommendations are organized into four groups:
•
Group I consists of recommendations which focus on increasing efficiency and
effectiveness of existing services by creating a coordinated public/private system of
health care service delivery for the uninsured and underinsured.
•
Group II addresses the need for expansion and effective use of resources.
•
Group III addresses the importance of attempting to decrease need for services by
increasing emphasis on preventive services.
•
Group IV includes longer range recommendations that will add to the attainment of a
permanent solution to close the gap. These recommendations include a set of "Basic
Principles for Health Care Coverage Reform". The Task Force recommends the
continued involvement of people who have become mobilized through the efforts of
the Working Group on the Aftermath.
42
�GROUP
RECOMMENDATIONS TO PROMOTE EFFICIENCY & SYSTEM IMPROVEMENTS
1.
The Board of Supervisors should instruct the Department of Health Services to design and
implement
an easily
accessible,
coordinated
system
of
comprehensive
care for
the
uninsured/underinsured including the goals of community oriented primary care. The system
should include fully coordinated DHS ambulatory, public health and hospital resources and be
formally linked to a network of free and community clinics, and private hospital clinics.
The system should emphasize a case management approach which would allow patients to
access the system at many places including DHS health centers. County and private hospital
emergency rooms, free and community clinics, and other health care providers. The system
should have a community oriented, geographically based focus that enhances accessibility.
This single coordinated system should be designed and piloted within one year w i t h full
implementation in t w o years. The cost of developing the computerized referral system should
be jointly shared by DHS (staff time) and private resources (which the Task Force will assist
in obtaining). A number of elements should be included in the system:
A.
A systematized method of communication, joint planning and coordination of programs
between DHS and the free and community clinics and other significant providers to the
uninsured must be initiated.
B.
The coordinated comprehensive care system should include an effort to provide a
common patient identifier and a coordinated, computer based referral network. The
43
�referral network should link DHS health centers. County and private emergency rooms
and clinics, the free and community clinics, and other private providers to provide
efficient and accurate access to needed referrals. This referral network should be
coupled with the development of a continuing program that will identify individual
physicians, clinics, and other care-givers who are willing to provide uncompensated
or reduced cost patient care. Such a database can provide referral sources for
uninsured patients seeking care in emergency rooms, urgent care centers, and free and
community clinics. The referral network will serve the dual purpose of relieving
overloaded facilities by appropriate redirection of patients and by assuring that referral
sources are not overloaded. It is anticipated that private funds will be sought to
establish and provide for the hardware and software for the network, and that DHS will
become responsible for its long term maintenance.
C.
DHS, working with the free and community clinics, the Los Angeles County Medical
Association, the Unified Medical Group Association, and the Managed Care SubCommittee of the Task Force should sponsor a system of recruiting volunteer
physicians, nurses and other health care personnel as resources to be shared in staffing
both private free and community clinics as well as currently unstaffed County facilities.
Particular attention should be paid to the availability of retired physicians, nurses and
other medical personnel as a source of volunteer staff in County and private clinics
serving the uninsured. DHS should take the lead in examining the need to provide
medical liability insurance coverage or subsidy as a means of encouraging volunteer
care-givers. Recruitment efforts should be coordinated with the implementation of the
"Los Angeles Community Clinic Partners" program.
D.
There should be continued exploration and utilization of opportunities to create specific
public/private partnerships for service delivery that address the needs of the
uninsured/underinsured. Such partnerships should be implemented only if there is a
44
�high probability that added value, in terms of increased efficiency and effectiveness,
can be achieved. Issues such as common formularies, purchasing agreements, shared
patient transportation services, and shared resources should also be pursued in regard
to public/private partnership opportunities.
E.
Throughout such a coordinated, community oriented system there should be increased
emphasis on case management, cost, and quality control. Here, case management
refers to the identification of primary sources of care for each patient in the system to
assure that there is full coordination of care, that necessary resources are made
available, and that unneeded resources are not utilized.
F.
DHS should be asked to work specifically with managed care organizations in
developing strategies for the implementation of capitated care programs for Medi-Cal
beneficiaries and for the uninsured/underinsured. Such capitated programs must have
appropriate quality control and patients enrolled in them must have the option to
disenroll and seek alternate sources of care.
2.
The Board of Supervisors should instruct DHS to continue to implement its current plans to
fully integrate its clinical, public health, and hospital based services. The objective should be
to provide care to County patients in a fully integrated system in which clinical resources are
shared from one clinical unit to another and which is capable of providing managed care to
patients and integrating regionally with those private free and community clinics which provide
significant services to the medically indigent. Responsibility to foster and achieve integration
at each level of DHS management should be included as part of individual personnel
evaluations for DHS managers.
3.
Working with groups such as the Los Angeles County Children's Planning Council, the State
Department of Health Services, the Children's Roundtable. the County Department of Childrens
45
�Services, and the 2 0 0 0 Partnership, the County Department of Health Services should develop
and implement as part of the comprehensive system of care, specific plans to address the
health care needs of uninsured/underinsured children. Programs must be family centered,
address the needs of pregnant women, and fully utilize available resources such as Child
Health and Disability Prevention (CHOP) Program and Women, Infant and Children's (WIC)
program. Whenever possible, family centered delivery of services should utilize school based
or other community based settings.
The plan should contain strategies for building upon the success attained in reducing infant
mortality and should emphasize the attainment of those Healthy Los Angeles 2 0 0 0 goals that
relate to children specifically. DHS should implement programs to meet the immunization
target of 9 0 % for all pre-school children within two years from the date this report is adopted.
4.
The Task Force recommends that the Department of Health Services be instructed to maintain
a current inventory of unused County ambulatory facility capability. Such an inventory can
serve as a planning basis for the expansion of DHS services, as a resource for free and
community clinics in need of additional space, and to locate sites for the development of
voluntarily staffed ambulatory clinics for County patients.
5.
In view of the reduction of Bielenson standards resulting from the recent state budget
legislation and the need to view all resources serving the indigent - both public and private as parts of a single system, the Task Force recommends that the Board of Supervisors
establish, annually review, and update five year objectives for the County Department of
Health Services, as part of the existing DHS strategic planning efforts. The objectives should
minimally include:
46
�A.
The scope and level of services to be provided by the Department of Health Services,
B.
Anticipated services to be provided by voluntary and private sources throughout the
County,
C.
Specific outcome and process measures to be monitored, with target objectives,
D.
The programs, resources, and system developments required to meet those objectives,
and,
E.
The revenue projections from all sources to be applied to those objectives, including
most probable, best, and worst case scenarios.
It is recommended that broad consultation with the voluntary and private sector, specifically
the Community Health Councils, be sought in order to establish these goals and objectives and
that the input be geographically and culturally representative of the County.
6.
The Task Force recommends that the Department of Health Services build on its existing
successful public/private integrated model for obstetrical services. The Task Force strongly
recommends that the Board instruct DHS to design, develop and implement a similar "early
warning and distribution system" in cooperation with the HIV Planning Council, the County
AIDS Commission and other related public/private organizations, for the HIV/AIDS epidemic.
While community participation is important, experts in care for the advanced stages of the
disease should be intimately involved with the definition of the attributes required for a
successful system. There is no question that without an effort at this time, the total burden
will be borne by the County. The present system is overwhelmed by the volume and
underfunding both in terms of personnel but more importantly adequate physical infrastructure.
Additionally, it is important to acknowledge that such an endeavor will challenge existing
practices, policies, procedures and applicable laws, therefore, appropriate resources must be
47
�made available, the involvement of HIV/AIDS affected communities and experts in HIV/AIDS
will be critical for the successful completion of this project.
The deliverables would include at least the following:
•
a definition of the goals and objectives of the program,
•
measurable indicators of performance,
•
estimates of expenses w i t h and w i t h o u t such an integrated program,
•
information system coordination,
•
provider coordination and community participation in the development of a system, and
•
a vehicle to assess effectiveness f r o m the professional, community and political
perspectives.
48
�GROUP II.
RECOMMENDATIONS IMPACTING RESOURCES AVAILABLE
TO THE HEALTH CARE SYSTEM
1.
The Task Force supports the efforts that have been made by the Board of Supervisors to limit
the effects of the current budget shortfall on the Department of Health Services. Under the
circumstances detailed in this report the members heartily approve such steps. The members
strongly recommend, until major changes in State or national health care policy and financing
occur, that the Board continue to fully support the ability of DHS to serve the medically
indigent and commit to increasing and stabilizing the County contributed portion of DHS'
budget to allow for meaningful improvements in the quantity and quality of services. The Task
Force urges County officials to work with State and federal legislators and with the State and
federal Departments of Health and Human Services to identify and to mobilize every possible
resource that can be applied to the maintenance or improvement of DHS capacity. With
respect to State, federal and other grant funded programs, the Board of Supervisors should
instruct CAO and DHS to ensure that staff positions are promptly filled and deployed.
2.
The Task Force recommends the full implementation of the "Los Angeles Community Clinic
Partners" program under the leadership of the Managed Care Sub-Committee, the continuing
participation of the National Health Foundation, the Hospital Council of Southern California,
the Los Angeles County Medical Association, the Unified Medical Group Association, and other
interested organizations. This will involve inviting all managed care institutions, group
practices, and private hospitals to identify one or more public and/or private clinics serving the
49
�medically indigent, with which it can form a partnership for the purpose of helping to fulfill
staffing, supply, equipment, accounting or other technical assistance needs. The program has
been designed to operate with support from the private sector.
3.
There is a need to provide more flexibility in the application of the various categorical funding
sources between inpatient, ambulatory, and primary care services. The Department of Health
Services should determine exactly which funding sources must be refocused. The Task Force
recognizes that federal and State categorical funding sources and priorities are critically
involved and that many avenues will need to be identified, advocated, and explored. A
comprehensive plan to enable DHS to reallocate revenues in order to improve levels of
ambulatory and primary care without diminishing its inpatient capabilities is requested within
six months from the adoption of this recommendation by the Board of Supervisors.
4.
The Board of Supervisors should facilitate the efforts of the schools of medicine in Los Angeles
County to increase their output of broadly trained specialists in the primary care disciplines of
family medicine, general internal medicine, and general pediatrics. To the extent that existing
relationships with those schools can be used to foster such an objective, such relationships
should be used. A County sponsored program leading to relief of educational debt burden for
physicians in exchange for specified years of service in primary care roles in County operated
or other properly qualified public or private programs should also be expanded and coordinated
with other efforts.
5.
The Board of Supervisors should direct the Department of Public Social Services and DHS to
develop an aggressive plan for increasing the identification and qualification of Medi-Cal
eligible residents. Emphasis should be placed on out-stationing eligibility workers at free and
community clinics, and community agencies, in compliance with federal guidelines, as well as
50
�expanding the current out-stationing programs. Attention should also be given to simplification
of the application form and process and to providing assistance to applicants in their native
languages in a culturally sensitive manner, when necessary.
6.
The Board of Supervisors should encourage DHS to work with the State Department of Health
Services, the Medical Board of California, and the State Legislature to determine whether a
role can be devised for unlicensed international medical graduates in closing the health care
access gap. Such an effort would require, minimally, a means of assessing their skills and
knowledge, the definition of their role in the medical team, the assurance of adequate medical
supervision, and the continuing assessment of competence, time limits to certification, and
methods of recertification. Their language skills and cultural sensitivity would be of great
assistance in many care settings.
7.
The Task Force recommends that DHS maximize collaboration, appropriate support and
utilization of any legitimate non-profit, community-based organization seeking to create
additional free and community clinics, or other resources whose mission is the care of the
medically indigent, and which would increase the supply of free and low-cost services to the
population in geographic areas were there is a lack of such services.
8.
In order to stabilize access to health care until insurance coverage is extended to all County
residents, the Task Force should explore all methods that would help reduce the financial
burden on private and community based high volume indigent care providers. That exploration
would include potential
new sources of revenue, sharing of patient
loads, and the
redistribution of the financial burden and resources for care of the uninsured among providers,
fiduciary intermediaries and payors. The Task Force has formed a sub-committee to undertake
a new objective to investigate and, if feasible, develop a proposal for action by the County.
51
�9.
The Task Force, recognizing the net positive tax contributions of Los Angeles County's
undocumented residents to State and federal entities, strongly urges the County Board of
Supervisors to continue aggressively to seek the return to the County from State and federal
sources of a greater portion of those taxes for the purposes of providing health care services
and other social services to this population. The Task Force recommends the sponsoring of
special legislation toward this end.
10.
The Task Force recommends the continued and expanded use of mid-level practitioners such
as physician assistants, nurse midwives and nurse practitioners. The Task Force recognizes
that appropriate use of mid-level practitioners is an excellent means for both public and private
health care providers to optimize valuable resources.
52
�GROUP III.
RECOMMENDATIONS TO DECREASE NEED BY
PROMOTING PREVENTIVE SERVICES
1.
The need for more information and education for consumers must be addressed by both public
and private health care providers. DHS must serve as the leader and involve community based
organizations in developing culturally sensitive education programs that assist in connecting
consumers to available resources, explaining the value of preventive health behaviors, and
empowering the consumers to participate in identifying and addressing their health care needs.
The fragmented, categorical sources of funding for consumer education programs must be
studied to determine h o w funds could be utilized more effectively by a coordinated effort.
2.
DHS and the providers that form partnerships with the County must plan and implement
appropriate programs w i t h increased emphasis on preventive services such as prenatal care,
reproductive care, immunizations, tuberculosis screening, sexually transmitted diseases,
mammography, HIV prevention, violence and injury prevention, and nutrition. The Board of
Supervisors must ensure that funding for public health and preventive services is a top priority.
3.
The Task Force recommends the continued support and encouragement of the ongoing
public/private HIV/AIDS planning groups in the design and implementation of strategies for the
prevention of transmission of HIV/AIDS. These strategies should focus on the development
of HIV/AIDS prevention in all communities, increased access to substance abuse treatment,
and explore the feasibility of adopting and evaluating new prevention strategies such as
53
�culturally sensitive and community controlled clean needle exchange programs. This planning
should be inclusive of agencies providing health care, social services, substance abuse
treatment, as well as schools, coalitions, churches and other institutions that work with people
at risk for HIV/AIDS transmission.
54
�GROUP IV.
LONG RANGE RECOMMENDATIONS
1.
The Task Force recommends that the support of the newly established Community Health
Councils be maintained after the completion of the report of the Task Force to the Board of
Supervisors. If the local communities are to have a mechanism to successfully involve citizens
in identifying and addressing their local health care needs, especially in the underserved areas,
the Community Health Councils must be maintained. It is recommended that the County
continue to support the Community Health Councils' organizing effort as an essential source
of community input for health access policy development and implementation. Further, that
the transfer of the Community Health Councils (CHC) funding to RLA occur at the earliest
practical time and that programmatic efforts continue under the administrative supervision of
the Steering Committee of the CHC.
2.
The Task Force recommends that the Board of Supervisors and the County of Los Angeles
work actively and assertively at the State and national levels for comprehensive health care
reform that would provide health care coverage to the entire population of Los Angeles County
and effectively control the g r o w t h of health care spending. The Task Force recommends that
legislation be supported to the extent that it is based on the principles in the Task Force's
"Basic Principles for Health Care Coverage Reform".
55
�B A S I C PRINCIPLES FOR HEALTH C A R E C O V E R A G E REFORM
It is essential that any health care coverage reform should address the following basic principles:
•
Provide health care coverage for all persons residing in the state of California, w i t h o u t
regard to immigration status.
Health care coverage may not be denied because of race, gender, ethnicity, sexual
orientation, prior medical conditions, or employment characteristics.
Public health clinics treating communicable diseases (i.e. TB, sexually transmitted
diseases, AIDS, and other communicable diseases) should be made available to all in
the interests of public health, regardless of residency.
In the short run, before all states provide for universal health care coverage, it may be
necessary to consider a residency test for insurance in order to prevent migration to
use health services.
However, funds must be provided to care for uninsured people w h o do not qualify for
insurance and w h o have urgent and immediate medical needs, w i t h a waiver of
residency requirements.
•
Encompass the full range of medically necessary services, including preventive, acute, and
continuing care for chronic disease.
Health care coverage and access to health services under any proposal must be
equitable and independent of financial means.
However, individuals may use their o w n funds to supplement the basic benefits.
56
�Control health care spending and the costs of care in any health care coverage plan by:
Reducing the costs of administering our health care system, including implementing tort
reform;
Designing a system for paying providers that encourages efficiency, improves quality,
and ensures equity regardless of the plan through which a patient is covered; and.
Carefully considering incentives that encourage appropriate use of the health care
system by patients.
Health care costs should be paid for fairly. The costs should be broadly distributed according
to ability to pay.
3.
The Board of Supervisors should approve the continuation of the Task Force for Health Care
A c c e s s in Los Angeles County for a period of one year following the delivery of its report to
the Board for the purpose of monitoring the progress of its recommendations and serving as
continuing recipient of additional recommendations which may positively affect the current
access situation. Note should be taken of the fact that no appropriation is requested for this
purpose.
4.
The Task Force has not examined the issue of access to mental health services and substance
abuse services, as these were not part of the charge. Nevertheless, as issues related to access
were reviewed, it was readily apparent that deficits in access to mental health services and
substance abuse services have a substantial negative effect on the health of the population,
especially in lower income groups and those without health insurance. The Task Force
therefore recommends that the Board of Supervisors appoint a suitable body, consisting of
providers, consumers, insurance industry, substance abuse service providers, business, labor,
57
�academic institutions, and the public, and charge it to examine the state of access to mental
health and substance abuse services and to bring its recommendations to the Board of
Supervisors within a prescribed period of time.
58
�APPENDIX A.
BOARD OF SUPERVISORS' RESOLUTION CREATING THE
TASK FORCE FOR HEALTH CARE A C C E S S
IN LOS ANGELES COUNTY
59
�MINUTES OF THE BOARD OF SUPERVISORS
COUNTY OF LOS ANGELES, STATE OF CALIFORNIA
Larry J . Monteilh, Executive Officer
Clerk of the Board of Supervisors
383 Hall of Administration
Los Angeles, California 90012
Chief Administrative officer
Director of Health Services
At i t s meeting held February 11, 1992, the Board took the
following action:
55
Supervisor Edelman made the following statement:
"Today, Los Angeles County leads the nation in
the number of medically uninsured persons. Nearly
one in three persons has no private. Medicare,
Medi-Cal, or other health care coverage. A
significant portion of these uninsured are
children, minorities, poor and indigent. Our
neighboring counties of Orange and San Diego rank
f i f t h and seventh in the United States with
uninsured rates of 22 and 20%, respectively.
Health care costs continue to increase in excess
of the general rate of inflation; the Health Care
Financing Administration indicates that in 1990
national health care expenditures exceeded $676
billion or 11% of the Gross National Product.
"With this continual escalation, which i s
fueled significantly by the burdens on the private
system to provide increasing amounts of
uncompensated care, businesses are finding i t
increasingly difficult to provide insurance for
their employees and i t i s becoming more d i f f i c u l t
for individuals (the public) to afford health
care. In the absence of insurance, these persons
are, in increasing numbers, looking to County
services as a safety net and provider of last
resort. With a l l of this, the effects of
Proposition 13 have removed the potential for
f l e x i b i l i t y from the County, and health care
matters have been profoundly influenced by
administrative and legislative actions by the
State and Federal governments.
(Continued on Page 2)
61
�Syn. 55
(Continued)
"State and Federal legislative bodies are also
currently reviewing several health insurance
reform proposals, including the establishment of
universal health insurance. We are faced with the
major challenge of how to provide and finance
access to health care for the uninsured and the
County-responsible patients while maintaining
quality care. To address this burgeoning problem,
Los Angeles County has been in the forefront and
has had to be innovative in i t s efforts.
"For example, Los Angeles County, in partnership
with private providers, has expanded access to
perinatal services by serving as a f i s c a l
intermediary for private providers in Medi-Cal
covered births and providing malpractice l i a b i l i t y
insurance for contract deliveries and perinatal
services. The County has also sponsored State
legislation that w i l l generate $1.2 billion in
inpatient care rate supplements for disproportionate
share providers, both public and private, statewide.
In the interest of our constituents, Los Angeles
County must be vigilant to maintain this position.
As these issues have attained a magnitude of
severity that no involved group can ignore,
individual efforts have been undertaken on the part
of consumers, employers, providers, insurers, labor
unions and others to seek workable solutions, in
the absence of State and/or Federal solutions.
"Therefore, a Task Force for Health Care Access
in Los Angeles County should be established to
examine the short and long range needs, financial,
insurance requirements and systems requirements
for adequate access to health care services for
a l l residents of the County. The purpose of the
Task Force, w i l l be to create a public/private
partnership to seek consensus on the principles
and actions essential to a health care reform
strategy relevant to our needs in Los Angeles
County. I t w i l l identify those issues that are
c r i t i c a l to consider in order to address solutions
to medical indigency, uncompensated care, cost
containment and access to c r i t i c a l l y needed care
for a l l residents of the County. In accomplishing
this, i t w i l l determine how other entities are
addressing these issues over the next ten years."
(Continued on Page 3)
62
�Syn. 55
(Continued)
Bob Tranquada and Rita Meyer addressed the Board.
After discussion. Supervisor Edelman made a motion that the
Board taXe the following actions:
1. Create the Task Force for Health Care Access
in Los Angeles County to consist of one
representative of each of the following
constituent groups:
- Small business (Los Angeles Chamber of
Commerce)
- Health Insurance Industry (State
Commissioner on Insurance)
- Labor Unions (Coalition of Unions)
- Managed Care Industry (California
Association of HMO's)
- Hospital Council of Southern California
- Los Angeles Chamber of Commerce
- Los Angeles County Commission on Insurance
- Los Angeles County Director of Health
Services
- Los Angeles County Medical Association
- USC School of Medicine
- UCLA School of Medicine
- UCLA School of Public Health
- Southern California Health Policy Research
Consortium
- The Rand Corporation Health Systems
Division;
2.
Instruct the Chief Administrative Officer and
the Director of Health Services to provide f u l l
cooperation and appropriate staff support to
the Task Force and request the National Health
Foundation, a non-profit foundation vhich has
previously collaborated with the County, to
provide additional staff support as an in-kind
contribution to the public/private
collaboration;
(Continued on Page 4)
63
�Syn. 55
3.
(Continued)
Provide for representation on the Task Force
by the following entities:
-
4.
conaunity group representatives: one
appointed by each Supervisor
Coamunity based ethnic/minority groups:
one appointed by each Supervisor
Health Access Foundation: one
representative
The United Way: one representative;
Charge the Task Force for Health Care Access
in Los Angeles County with:
a.
Providing a description of the present
circumstances in Los Angeles County with
regard to c r i t i c a l unmet health care
needs, the medically under- and uninsured,
the current capacity of public and private
resources to meet c r i t i c a l currently unmet
health care needs;
b.
Seeking a consensus on the principles
essential to a health care reform strategy
relevant to the needs of the County of Los
Angeles;
c.
Identifying a means of improving the
health status of underserved residents of
Los Angeles County looking to adjustments
in the existing splintered patterns of
access and care through the maximum
utilization of existing resources, as
immediate responses to the problem and
consistent with the-principles adopted by
this Task Force; and
d.
Seeking a consensus on those elements
which, over the longer term, w i l l require
action at the State or Federal level and
recommend actions to seek those
solutions, as well; and
(Continued on Page 5)
64
�Syn. 55
5.
(Continued)
Reporting back to this Board vith
recommendations within 180 days of
convening i t s f i r s t meeting.
Supervisor Antonovich offered an amendment to Supervisor
Edelman's motion, to request the Task Force to focus on the
impact of undocumented persons on the health care system.
Supervisor Edelman accepted Supervisor Antonovich's amendment.
On motion of Supervisor Edelman, seconded by Supervisor
Antonovich, unanimously carried, Supervisor Edelman's motion, as
amended, was adopted. In taking this action, the Board indicated
that the sub-committee of the County Commission on Insurance can
continue with their efforts in this area.
10211-6.com
Copies distributed:
Each Supervisor
County Counsel
Letters sent to:
State Commissioner on Insurance
Chairman, Coalition of Unions
Executive Director, California
Association of H O s
M'
President, Hospital Council of
Southern California
President, Los Angeles Chamber of
Commerce
Chairman, Los Angeles County
Commission on Insurance
President, Los Angeles County
Medical Association
Deem, USC School of Medicine
Dean, UCLA School of Public Health
Dean, UCLA School of Medicine
Executive Director, Southern California
Health Policy Research Consortium
President and Chief Executive Director,
The Rand Corporation Health
Systems Division
Executive Director, Health Access Foundation
President, The United Nay
65
�APPENDIX B.
SUMMARY OF PUBLIC HEARINGS
67
�TASK FORCE FOR HEALTH CARE ACCESS IN LOS ANGELES COUNTY
SUMMARY OF PUBLIC HEARINGS
During August 1992, the Task Force for Health Care Access in Los Angeles County undertook a series
of public hearings to gather testimony regarding how public and private resources can be made more
effective and provide better access to health care for the uninsured. Those testifying were asked to
specifically focus on short term solutions given the assumption that there is currently a lack of
adequate resources to meet the health care needs of the uninsured and that the federal and State
reforms which could solve this problem are unlikely to be implemented in the near term.
The hearings were all held in the evening from 6:00 P.M. to 9:00 P.M. The sites for the hearings were
geographically dispersed among the five supervisorial districts with hearings held in East Los Angeles,
Glendale, the Fairfax area of Los Angeles, Long Beach and South Central Los Angeles. Each of the
hearings was attended by a complement of Task Force members with never less than five members
in attendance and several hearings were attended by eight and nine members.
A total of 52 individuals testified at the five hearings. Those testifying represented 30 organizations
or agencies. Three of the presenters asked to be identified as private citizens not representing any
organized entity. Fifteen of those testifying represented free or community clinics and sixteen were
medical doctors. Five presenters represented hospitals. There were nine representatives of the County
Department of Health Services who provided testimony.
Although the ethnic and racial identity of each presenter was not specifically requested, from the
testimony it was determined that 15 Latinos, 5 African-Americans, 2 Asian/Pacific Islanders and 30
Anglos participated in the hearings. Thirty-one presenters were male and 21 were female.
There were 51 issues/recommendations collectively identified and presented in the testimonies. Many
of those testifying contributed multiple issues and recommendations. Although an attempt was made
to rank the inputs as primary or secondary, this proved too subjective and all inputs were given equal
weight for the purpose of this analysis.
What follows is a summary of the issues and
recommendations that were presented in order of frequency. Issues that were mentioned by only one
or two of the presenters are grouped together under topics only.
Summary of Issues/Recommendations from Public Hearings
(Frequency = number of presenters that included the issue or recommendation in their testimony.)
1.
Recommendation to place emphasis on preventive services and to shift away from current
focus on inpatient services.
Frequency = 1 9 .
Although none of the testimony detailed exactly what steps should be taken to accomplish this
recommendation, several presenters did focus on the need to restructure the financing system
that currently provides more revenues for inpatient services. Several of the presenters from
the Department of Health Services offered the OB Overflow contracting project with private
hospitals as an example of a value-added partnership that has been implemented.
69
�2.
Recommendation to create more value-added public/private partnerships to address the needs
of the uninsured in Los Angeles County.
Frequency = 1 6 .
Several of the testimonies provided examples of public/private partnerships that have been
successful in addressing the needs of the low-income residents of the county.
Many
presenters emphasized the need for a new approach to public/private collaboration that must
be worked out between the Department of Health Services and various private provider groups
including free and community clinics, volunteers and other community agencies.
3.
Recommendation to establish better coordination between comprehensive health centers,
private providers and County hospitals.
Frequency = 1 4 .
Many of the presenters from the community clinics in addition to representatives f r o m the
County Department of Health Services and private providers stressed the need for protocols
for transferring patients, specialty back-up arrangements and generally just more coordination
between the entities that n o w serve the indigent population. Examples of duplication and lack
of linkages were cited by several speakers. Olive View Medical Center and Mid-Valley
Comprehensive Health Center were mentioned as an example of where effective coordination
has begun.
4.
Recommendation for more education to consumers of health care services that would assist
them in accessing avaflable services, understanding the value of preventive behaviors and
empower them to participate in their own health care.
Frequency = 1 1 .
Nine of the eleven presenters w h o mentioned education as a key recommendation were Latino,
African-American or Asian/Pacific Islanders /Pacific Islander. These inputs correlate w i t h # 5 .
5.
Recommendation for more bMingual and culturally sensitive staff members in the health care
provider community.
Frequency = 1 1 .
A s w i t h the need for more education related to accessing health care services and information,
the need for more bi-lingual and culturally sensitive service providers was also mentioned by
a majority of non-Anglo presenters.
6.
Recommendation that public sector must assume the major responsibility for serving the
indigent and provide the leadership for public/private collaborative efforts.
Frequency = 1 1 .
While many of the presenters highlighted heroic efforts by private community based efforts to
serve the needs of the indigent, many stressed that the public sector must continue to carry
the major responsibility. Several of those testifying provided specific examples where the
public sector might attempt to foster more cooperation and encourage public/private
collaborative efforts.
70
�7.
Recommendation to shift away from costly care in emergency rooms to providing primary
health care services in more appropriate settings.
Frequency = 10.
W i t h many of the presenters recognizing h o w difficult the proposed shift might be to
accomplish, this recommendation was made by ten-presenters w h o felt it should be given
serious consideration.
8.
The need for universal access to health care was offered as the ultimate solution to the access
problem in Los Angeles County.
Frequency = 9.
While several of the speakers that made a plea for universal health care indicated they realized
it was beyond the scope of the Task Force's charge to address such an action, other
presenters asked for endorsement of specific universal access proposals. Both State and
federal proposals were mentioned.
9.
Recommendation that the Task Force look at access to preventive services as a special issue
and devote attention to tuberculosis screening, HIV testing, violence and injury prevention,
prenatal care, immunizations and nutrition.
Frequency = 9.
Many of the speakers addressed one or t w o specific preventive health measures that they felt
were key to controlling the spread of diseases and reducing the need for costly health services
among the indigent population. Unlike the comments that were tallied w i t h the first
recommendation (the need for more emphasis on preventive services and a shift away f r o m
inpatient services) these comments were focused on specific prevention related activities that
should be given priority by both public and private health care providers.
10.
Several of the providers mentioned the difficulty with Medi-Cal payments: both the inadequate
level of reimbursement and the delays in payment.
Frequency = 7.
Although the focus of the hearings was on the uninsured, those residents w i t h o u t private
health care coverage or public coverage under the Medi-Cal or Medicare programs, several of
the speakers did voice their frustration with the low reimbursement rates and long delays in
payment associated w i t h these programs.
11.
Recommendation to the private health care sector to share in the burden of caring for the
uninsured population with the thought that private providers must invest in the communities
(Los Angeles) in which they are operating.
Frequency = 7.
This recommendation was included in testimony from private providers, public representatives
and private organizations. Examples such as the Weingart Health Partners were highlighted
by the presenters. One idea that was proposed was the "Adopt-a-Clinic" program whereby
provider groups would link w i t h free and community clinics or County health clinics and provide
a coordinated volunteer assistance to help service the indigent patients.
71
�12.
Recommendation to make the Medi-Cal eligibOity process more accessible and to enroll a
greater number of the indigent that are Medi-Cal eligible.
Frequency = 7.
Several of the speakers addressed the difficulty of completing the Medi-Cal eligibility process
and mentioned that sometimes.it is easier to just treat a patient than to attempt to have the
patient obtain Medi-Cal. It was recommended that Medi-Cal intake workers be made available
to free and community clinics.
13.
Recommendation to adopt a managed care model for the delivery of heallh care services with
emphasis on cost control, quality and case management.
Frequency = 6.
Several of the presenters made a strong case for the adoption of managed care concepts in
dealing w i t h the indigent population. While f e w specifics were provided, the assignment of a
primary care physician to each patient was suggested by several speakers.
14.
Recommendation to shift emphasis in medical schools away from specialty training to focus
on family practice/primary care, especially at Los Angeles County's teaching hospitals.
Frequency = 6.
While some presenters recognized that the shift in emphasis at medical schools may be beyond
the scope of the Task Force, several strong recommendations were made and this was the sole
message delivered by several presenters.
15.
Recommendation that County health care services should be open non-traditional hours and
longer hours to create greater access to services and eliminate the long waiting periods at
many facDities.
Frequency = 6.
Most of the presenters who recommended the longer hours did not mention h o w the cost of
such a proposal could be accommodated in the current budget. One presenter did offer an
example of an evening program which will be piloted at the Azusa Health Center utilizing
volunteer physicians in the evening hours.
16.
Recommendation that the Task Force investigate the barriers to accessing health care services
that are unique to the undocumented population.
Frequency = 5.
Several presenters mentioned the lack of funds for services to the undocumented and also the
reluctance of undocumented persons to seek care at public and private facilities.
17.
Recommendation that retired physicians and other health care professionals be recruited to
volunteer in providing care to the indigent.
Frequency = 5.
The utilization of more volunteers in both public and private health care settings was
recommended by several presenters. Some of the testimonies highlighted projects where
volunteers were already participating. The issue of malpractice and other liability insurance
was raised and several examples of the County and others indemnifying volunteers were
offered.
72
�Issues and Recommendations with a Frequency of three or less.
*
Need for County Department of Health Services to substantially improve patient care
coordination between County public health clinics, comprehensive health centers and hospitals.
*
Emphasis on services to poor children including CHDP and WIC.
*
Emphasis on school linked services.
*
Funding for urgent care centers like the one proposed for El Monte.
*
Increase the dollars available to serve the indigent by eliminating the waste, fraud and
mismanagement in the health care system. Workers' compensation fraud was specifically
mentioned.
*
Increase access to advanced standards of care including access to the most advanced
pharmaceuticals to all AIDS patients regardless of insurance status.
*
Reform of the tort system particularly as it relates to malpractice insurance for volunteers, or
expand "Good Samaritan" law to volunteers.
*
Support for the creation of Community Health Councils as permanent bodies that would
influence the planning and delivery of health care services to the indigent.
*
Need for more mobile urgent care units.
*
Need for more mid-level practitioners, including a w a y to utilize foreign medical school
graduates.
*
The need to out-station Medi-Cal eligibility workers to do on-site eligibility intake.
*
The County Department of Health Services or another entity could assist the free and
community clinics w i t h group purchasing which would save money.
*
Attention to the particular barriers to accessing care for HIV/AIDS patients
transportation, cultural sensitivity and adequate public and private resources.
*
Utilization of an on-line integrated referral system to link health care providers serving the
indigent population to enhance the coordination of care and eliminate duplication.
*
Need for dental care among the indigent.
*
Need for mental health services for the indigent.
*
Need for substance abuse prevention and treatment especially for young people and pregnant
women.
*
Need for reforms in the health insurance system.
*
More funding for emergency and trauma services.
*
Need for the Task Force for Health Care Access to continue beyond November, 1 9 9 2 .
73
including
�APPENDIX C .
RESEARCH COMMITTEE REPORT
75
�RESEARCH REPORT SUMMARY
The best available estimate of the uninsured population in Los Angeles County is for March 1990. The
source is the Current Population Survey, special analyses by E. Richard Brown, Ph.D., University of
California Los Angeles, School of Public Health. The total estimate is 2,708,000. The largest group
is Latino with the vast majority in the primary working and child bearing years 15 - 44, (1,604,000).
The smallest group is less than one year of age.
One approach to estimating the "need" of the uninsured population is to utilize rates of services used
by other similar populations. Thus the number of visits per person in the Medi-Cal population could
be judged to be an appropriate number of visits per person for the uninsured population. For this
analysis data were collected from several sources, a large non-profit HMO, private and Medi-Cal
members, and Los Angeles County Community Health Plan, to estimate the number of visits needed
to provide care to the uninsured. These different utilization rates allowed the Task Force to provide
a range estimate of the number of visits needed to provide care to the uninsured population.
Estimates of Need, Current Resources and the Gap
Visits Needed
Current
Provider Type
per Year
Resources
The Gap
Private Pay HMO
12,516,699
11,230,805
1,285,894
L.A. County CHP
16,201,000
11,230,805
4,970,195
Medi-Cal HMO
18,928,957
11,230.805
7,698,152
The uninsured population of Los Angeles County has several sources of ambulatory care. Providers
include: community clinics, Los Angeles County Department of Health Services, Pasadena Department
of Health Services, Long Beach Department of Health Services, public and private hospitals and, private
physicians and clinics. Using a variety of sources, staff was able to estimate the number of visits that
were utilized by the uninsured population from these providers. Based on these various estimates there
were approximately 11.23 million visits being supplied to the uninsured population.
Currently the uninsured population is receiving about 4.2 visits per person per year. This amounts to
a rate deficit of between 1 and 3 visits per year per person depending on the utilization rate used for
comparison. Over all, the gap between need and resources is between 1.3 and 7.7 million visits per
year depending on the assumptions made about the need for visits. Based on these differences the
Task Force must determine a set of recommendations and a course of recommended action to attempt
to close the gap.
77
�Technical Report to the Task Force for Health Care Access
Introduction
The Task Force for Health Care Access gathered data and information from a variety of sources in
order to effectively assess the difference between the need (demand) for primary health services in Los
Angeles County and the ability of the system to meet that demand through a variety of independent
providers (supply). Providers include public sources (County and City), quasi private (public clinics and
non-profit hospitals) and, private for-profit hospitals, physicians and clinics. Each of these entities plays
a significant role in the provision of primary health care services to the uninsured population of Los
Angeles County.
This portion of the final report of the Task Force is based on an analysis of data that are available from
various public and private sources. These data sets are frequently inconsistent and have many
problems with compatibility. The staff has done its best to reconcile these differences and provide the
most accurate and consistent estimates possible under the circumstances.
Overview
There are five additional sections to this report. Section three describes the uninsured population of
Los Angeles County. Section four reports on the outpatient utilization rates of various managed care
systems in Los Angeles County based on experience of various providers. Based on these utilization
rates, demand estimates were calculated in section five. Section six provides estimates of supply from
public and private sectors. Section seven discusses the gap between supply and demand. Three
appendices are included at the end of the report.
Uninsured Population
Los Angeles has a diverse and in most estimates, a growing population. The characteristics and size
of this population is subject to debate given the difficulty of actually enumerating it during the 1990
census and the major social and economic changes that have occurred in the last two years. Given the
attendant problems of counting this population it is even more difficult to estimate the size and
characteristics of the uninsured population.
The best estimate available is for March 1990. The source is the Current Population Survey, special
analyses by E. Richard Brown, Ph.D.. University of California Los Angeles, School of Public Health.
Presented in Table 1 is an estimate of uninsured persons by age and ethnic group. The total estimate
is 2,708,000. The largest group is Latino with the vast majority in the primary working and child
bearing years 15 - 44, (1,604.000). The smallest group is less than one year of age. Table 2 presents
the percentage of uninsured population by age and ethnicity. The uninsured population is estimated
to be approximately 57% male and 4 3 % female.
79
�Table 1
Uninsured by Age and Ethnic Group
Los Angeles County, 1 9 9 0
Ethnicity
< 1
1-14
A g e Group
15-44
45 - 64
65 + *
Total
Latino
45,000
456,000
1,036,000
148,000
1,685,000
White
18,000
118,000
362,000
105,000
603,000
African-American
5,000
35,000
87,000
26,000
153,000
All Other
2,000
56,000
119,000
48,000
225,000
70,000
665,000
1,604.000
327,000
TOTAL
42,000
2,708,000
Source: March 1 9 9 0 Current Population Survey special tabulation by UCLA School of Public Health
* Cell size was too small to allocate by race.
Table 2
Uninsured by Age and Ethnic Group
Los Angeles County, 1 9 9 0
Ethnicity
< 1
Age Group
1-14
15-44
45 - 64
65 + *
Total
Latino
1.66
16.83
38.26
5.47
62.22
White
0.66
4.36
13.37
3.88
22.27
African-American
0.18
1.29
3.21
0.96
5.65
All Other
0.07
2.07
4.39
1.77
8.31
100.00
59.23
12.08
1.55
2.58
24.56
TOTAL
Source: March 1 9 9 0 Current Population Survey special tabulation by UCLA School of Public Health and USC School of Public
Administration
* Cell size w a s too small t o allocate by race.
Table 3 presents the population estimates by age and sex as well as ethnicity. Table 4 identifies the
percentages of the population by each cell. When the data were broken d o w n to this fine detail the
potential for error in the less than one year cells by male and female and ethnic group began to be too
large. In order to have a reasonable estimate therefore the less than one year group was combined w i t h
the one to fourteen category. Given that most infants are eligible for Medi-Cal benefits this is probably
an acceptable level of analysis and is certainly a prudent option. The rest of the analysis uses this
convention.
The population considered for analysis by the Task Force was all age groups. This decision was made
even though most people over 6 5 are eligible for Medicare. For the general population in most of the
State and for national estimates it can be reasonably assumed that all people over 6 5 are eligible for
Medicare. Less than one percent of hospital discharges for people over 6 5 are non-Medicare. Los
Angeles is somewhat unique w i t h its large and growing immigrant population (both documented and
undocumented). Since Medicare benefits are tied to a person's work history there are proportionally
more people in Los Angeles County that are over 6 5 and are ineligible for Medicare because they did
not work in the United States. Unfortunately, accurate data on the undocumented alien population do
not exist, and it is not possible to quantify this problem.
80
�Table 3
Uninsured by Age a n d Ethnic Qroup
Los Angeles C o u n t y . 1 9 9 0
Age Qroup
Ethnicity
45 - 64
65 + '
lass t h a n 15
IS • 44
Latino
247,000
588,000
72,000
907,000
White
67,000
207,000
55,000
329,000
African-Amencan
15,000
47,000
10,000
72,000
All Other
40,000
66,000
26,000
122,000
369,000
898,000
163,000
Latino
254,000
448,000
76,000
778,000
White
69,000
155,000
50,000
274.000
African-American
26,000
40.000
15,000
81,000
All Other
17,000
63,000
23,000
103,000
Total Female
366.000
706,000
164,000
22,000
1,258,000
TOTAL
735,000
1,604,000
327,000
42,000
2,708,000
65+•
Total
Total
Male
Total Male
20,0
1,450,000
Female
Source:
M a r c h 1 9 9 0 Currant Population Survey special t a b u l a t i o n by UCLA S c h o o l of Public H e a l t h
* Cell size w a s t o o small t o allocate by race.
Table 4
Uninsured by A g e a n d Ethnic Qroup
Los Angeles C o u n t y , 1 9 9 0
Age Qroup
less t h a n 1 5
15 - 4 4
45 - 64
Latino
17.03
40.55
4.97
62.55
White
4.62
14.28
3.79
22.69
African-American
1.03
3.24
0.69
4.97
All Other
2.76
3.86
1.79
8.41
Total Male by A g e
25.45
61.93
11.24
1.38
100.00
Percent Male
50.20
55.99
49.85
47.62
53.55
Latino
20.19
35.61
6.04
61.84
White
5.48
12.32
3.97
21.78
African-American
2.07
3.18
1.19
6.44
All Other
1.35
5.01
1.83
8.19
Total Female by A g e
29.09
56.12
13.04
1.75
100.00
Percent Female
49.80
44.01
50.15
52.38
46.45
Ethnicity
Male
Female
Source:
M a r c h 1 9 9 0 Current Population Survey special t a b u l a t i o n by UCLA S c h o o l o f Public H e a l t h
* Cell size w a s t o o small t o allocate by race.
81
�Utaization Rates
Access t o primary health care is sporadic at best and impossible at worst for the uninsured population.
Trying t o estimate the actual need for service for the uninsured population is complicated. Some
believe that the needs of this population is greater than those expressed by insured or Medi-Cal eligible
populations. From an economic stand point there are a variety of issues relative t o estimating the
number of visits that a population of this type requires. In a purely economic sense the number of visits
is determined by the willingness and ability to pay criteria.
One approach t o estimating the " n e e d " , as contrasted w i t h the demand, is t o utilize rates of services
used by other similar populations. Thus the number of visits per person in the Medi-Cal population
could be judged t o be an appropriate number of visits per person for the uninsured population. For this
analysis data were collected f r o m several sources (a large non-profit H M O , private and Medi-Cal
members, and LA County Community Health Plan) to estimate the number of visits needed t o provide
care t o the uninsured, based on different assumptions. These different utilization rates will allow the
Task Force to provide a range estimate of the number of visits needed to provide care to the uninsured
population.
Large Private H M O - The first set of utilization estimates were derived f r o m data supplied by
a large, private, non-profit H M O . Presented in Table 5 are the estimated number of members by source
of payment, age and sex. Patient visits by source of payment, age and sex are presented in Table 6.
Utilization rates were calculated based on age and sex, by total plan, Medi-Cal population and private
pay population and are presented in Table 7. Data are n o t available by race. One of the compromises
that w a s required in the analysis was to explore utilization by only age and sex and ignore the
ethnicity data available for the population. Private pay plan members utilize services at different rates
depending on the age and sex of the covered member. Private pay patients averaged 4 . 8 8 visits per
member. There are significant differences depending on the age group and the gender of the member.
The highest private pay users were females 4 5 - 6 4 years, at 7.18 visits per year. The male population
utilization rates are approximately 2 5 % lower than the female utilization rates.
Table 5
Patient Population By Age and Sex for H O Health Plan, Medi-Cal and Private Pay Patients
M
Age
Category
0 to 14
15 to 44
45 to 64
65+
Total
Male
Health Plan
Female
Total
566,196
289,350 276,846
507,781 566,063 1,073,844
481,654
232,609 249,045
87,810
99,881
187,691
1,117,550 1,191,835 2,309,385
Male
Medi-Cal
Female
9,114
2,173
343
731
12,361
8,802
11,336
1,014
1,921
23,073
Total
17,916
13,509
1,357
2,652
35,434
Male
Private Pay
Female
Total
280,236 268,044 548,280
505,608 554,727 1,060,335
232,266 248,031 480,297
88,541
101,802 190,343
1,106,651 1.172,604 2,279,255
Source: Derived from G A Input Data Information 1990, by Task Force for Health Care Access in L.A. County
HA
Table 6
Patient Population By Age and Sex for H O Health Plan, Medi-Cal and Private Pay Patients
M
Age
Category
Male
0 to 14
15 to 44
45 to 64
65+
Total
1,304,078
1,603,249
1,282,241
964,292
5,153,860
Health Plan
Female
Total
1,154,859 2,458,937
3,220,256 4,823,505
1,795,816 3,078,057
1,096,351 2,060,643
7,267,282 12,421,142
Male
49,949
12,121
3,473
11,861
77,404
Medi-Cal
Female
42,985
88,037
14,730
23,572
169,324
Total
92,934
100,158
18,203
35,433
246,728
Private Pay
Male
Female
1,254,129
1,591,128
1,278,768
952,431
5,076,456
Total
1,111,874 2,366,003
3,132,219 4,723,347
1,781,086 3,059,854
1,072,779 2,025,210
7,097,958 12,174,414
Source: Derived from G A Input Data Infonnation 1990, by Task Force for Health Care Access in L.A. County
HA
82
�Table 7
Ambulatory Utilization By Age and Sex for HMO Health Plan. Medi-Cal and Private Pay Patientt
Medi-Cal
Age
Private Pay
Health Plan
Female
Group
Male
Average
Average
Male
Female
Male
Female
4.88
5.19
4.51
4.34
4.48
4.15
0 - 14
4.17
5.48
3.16
5.58
7.77
7.41
3.15
5.65
15 - 44
5.69
4.49
14.53
13.41
5.51
7.18
45 - 64
5.51
6.39
10.13
7.21
10.94
10.95
65 +
10.98
10.98
16.23
12.27
13.36
10.98
6.89
5.63
4.07
5.64
6.45
4.05
TOTAL
5.65
4.88
Source: Derived from GHAA Input Data Information 1990, Task Force for Health Care Access
Average
4.32
4.45
6.37
10.95
4.86
Medi-Cal HMO - The large HMO has a small Medi-Cal based HMO program. These patients
have the same access to services as do the non-Medi-Cal patients. The Medi-Cal population utilizes
the HMO services at a much higher rate than does the private pay patient group. Overall the Medi-Cal
population utilizes services at about 25% higher rate. In some categories this is even higher. While
females utilize services at a much higher rate the Medi-Cal group in the 45 - 64 age group is almost
twice the private pay patients. According to the HMO spokesperson this Medi-Cal population is similar
in needs to all Medi-Cal patient populations. This higher utilization rate may reflect a lower health
status for the Medi-Cal population.
In general the Medi-Cal population in the 45 - 64 age group is primarily a disabled group with long term
disabilities. It is reasonable to assume that the disabled population in Los Angeles County has been
identified and therefore is not part of the uninsured population. The utilization rates for this age group
appear to be much higher than would be the case for the non-disabled uninsured population. In order
to develop a utilization rate that is more consistent with the perceived health status of the uninsured
population the utilization rates for this age group (45 - 64) were reduced to the same difference in
utilization that occurs in the private pay membership.
1
Community Health Plan - Data were supplied to the Task Force from the Los Angeles County
Community Health Plan (LACCHP). The LACCHP is a managed care system that serves approximately
10,278 members. Members are Medi-Cal eligibles, self selected Medically Indigent Adults (MIA),
sponsored by Los Angeles County and a few private pay enrollees. Table 8 lists the membership by
age and sex. The vast majority of the population (82.5%) is under 14 years of age. Membership is
slightly higher proportion of female than male (53 vs. 47%). Given that the vast majority of the
membership is children the male/female break down is not particularly important.
Members of the LACCHP utilized 48,166 visits as presented in Table 9.
Table 8
Population By Age and Sex for Community Health Plan. Medi-Cal Patients
Age
Community Health Plan
Category
Male
Female
Total
0 - 14
4,320
4,159
8,479
15-44
279
1,293
1,572
45 - 64
44
84
128
65+
41
58
99
TOTAL
4,684
5,594
10,278
Source: Derived from Community Health Plan 1991-92, by Task Force for Health Care Access
1
The utilization rate for the private pay group 45-64 was divided by the utilization rate for the 1544 group and this ratio was multiplied times the Medi-Cal group 15-44 utilization rates.
83
�Table 9
A m b u l a t o r y Utilization By A g e and Sex for Community Health Plan, Medi-Cal Patients
Health Plan Rate of Use
Age
Category
Male
Female
Total
19,229
16.680
35.909
1,139
554
8,674
1,204
9,813
1,758
254
21,176
0 - 14
432
26,990
686
48,166
15 - 4 4
45 - 64
65 +
TOTAL
Source: Derived f r o m Community Health Plan 1 9 9 1 - 9 2 , by Task Force for Health Care A c c e s s
Presented in Table 10 are the estimated visits per member of the LACCHP by age and sex. Overall the
members averaged 4.69 visits per member per year in 1990. It is interesting to note that the
population aged 45 and above (approximately 2% of the membership) experienced a utilization rate
that was more than twice the rate of the younger age group (10.77 per year). This may be a reflection
of the special population that is served by LACCHP in the older age groups.
Table 10
Ambulatory Utilization Rates, Visits per Capita, By A g e and
Sex for C o m m u n i t y Health Plan. Medi-Cal Patients
Age
Category
Male
Health Plan Rate of Use
Female
Total
0 - 14
4.45
4.01
4.24
15-44
4.08
6.71
6.24
45 - 64
12.59
14.33
13.73
65 +
6.20
7.45
6.93
TOTAL
4.52
4.82
4.69
Source: Derived f r o m Community Health Plan 1 9 9 1 - 9 2 . by Task Force for Health Care A c c e s s
Estimates of Need
Private HMO- Once utilization data were available it was a straight forward calculation to
estimate the number of outpatient visits that would be needed by the estimated uninsured population.
This is calculated by multiplying the number of visits per year times the population and is presented
in Table 11.
Private HMO Rate- The number of visits that the uninsured population would 'need' if it utilized
outpatient services at the same rate as the Private Pay HMO members would be 12,516.699 visits per
year. In contrast this is about four times as many visits as the Los Angeles County Department of
Health Services provides to all outpatients (includes hospital outpatient, free standing clinics and public
health visits in a given year.
Table 11
Ambulatory Utiliiation by Age and Sex for HMO Health Plan, Medi-Cal and private Pay Patients
Age
0 - 14
15 - 44
45 - 64
65 +
TOTAL
Male
Health Plan Rate of Usa
Female
Total
1.663,054
2,835.312
898,526
219.600
5,616,493
1,526,764
4,016,339
1,182,573
241,560
6,967,235
3,189,818
6,851.651
2,081,099
461,160
12,583,728
Male
Medi-Cal Rate of Use
Female
Total
2,022,293
5,009,046
1,650,434
324,600
9,006,374
1,787,379
5,482,897
2,382,367
269,940
9,922,583
3,809.672
10,491,944
4,032,801
594,540
18,928,957
Male
1,651,371
2,825,970
897,416
218,800
5,593,657
Source:
Denved from GHAA Input Data Information 1991, by Task Force for Health Cars Access
'Adjusted using the Private Pay rate change between age group 15-44 and 46-64 applied to 15-44 group
84
Private Pay Rate of Use
Female
Total
1,518,206
3,986,369
1,177,668
240,900
6,923,142
3,169,577
6,812,339
2,075,084
459,700
12,516,699
�Private Medi-Cal HMO Rate- if the uninsured population utilized services at the same rate as
the Medi-Cal HMO members then they would be expected to utilize 18,928,957 visits per year. This
difference reflects the relatively higher utilization rate of the Medi-Cal population but is age sex
adjusted.
Community Health Plan Rate- Table 12 presents estimates of the number of visits the
uninsured population would require if it used outpatient services at the same rate as the CHP
population. Based on the data presented the uninsured population would need 15,395,035 visits. This
estimate is very consistent with the 12.5 to 18.9 million visits estimated in Table 1 1 .
Table 1 2
Estimated Visits Needed t o Serve the Uninsured Population if
Patients Used Services at the Same Rate as Members of tha CHP
Age
Category
0 - 14
15-44
45 - 64
65 +
TOTAL
Health Plan Rate of Use
Male
Female
1,467,872
1,642,477
4,736,152
3,666,029
2,350,120
2,022,170
163,900
124,000
8,718,940
7.482,060
Total
3.110,349
8,402,180
4.402,290
287,900
16,201,000
Source: Derived f r o m C o m m u n i t y Health Plan 1 9 9 1 - 9 2 , by Task Force for Health Care A c c e s s
Community Clinics - The other data set that was available to the Task Force was the OSHPD
clinic survey. These data were used primarily to estimate the number of visits supplied to the uninsured
population. Some of these clinics serve a loyal following of patients over extended periods of time, yet
they do not serve a defined population as is the case in an HMO or managed care system. The 71
clinics that were identified for use in this study provide approximately 2.93 visits per year per patient.
If this rate of usage were applied to the 2.7 million uninsured in Los Angeles the population would
generate approximately 7.82 million visits for the uninsured population. This estimate appears quite
low when contrasted with the other estimates of utilization. This can partially be explained by the
inability to obtain utilization data by age and sex as in the other estimates and therefore this estimate
is not age sex adjusted. Another factor is the failure of the data collection system to capture visits by
this unsubscribed population to other providers such as private physicians, emergency rooms, hospital
out patient departments and other community clinics.
Estimates of Resources Currently Provided
The uninsured population of Los Angeles County has several sources of ambulatory care. Providers
include: community clinics, Los Angeles County Department of Health Services, Pasadena Department
of Health Services, Long Beach Department of Health Services, public and private hospitals and, private
physicians and clinics. Using a variety of sources, staff was able to estimate the number of visits that
were utilized by the uninsured population from these providers.
Community Clinics - Data for the licensed community clinics estimates were derived from the
Annual Report of Clinics which is submitted to the State of California, Office of Statewide Health
Planning and Development(OSHPD). These data are not audited but are carefully reviewed by the state
staff and checked for internal logic and consistency. Presented in table C l in Attachment C are the
summary statistics for 71 reporting free and community clinics for calendar year 1990.
85
�The 71 clinics that offer general medical services in the data set provided approximately 1,079,346
visits to 3 6 8 , 0 9 2 patients (2.93 visits per patient per year). Self pay and nonpaying patients accounted
for 349,556 patient visits that were not covered by some type of third party payor. It is unknown how
many of these visits were for patients that had insurance but were using services that were not
covered because the basic benefit had been used up or they had not yet reached their deductible limit.
Los Angeles County Department of Health Services - The Task Force staff has received an
estimate of approximately 4 million visits provided by the County DHS.
Pasadena Department of Health Services - These data are unavailable but it is believed relative
to the county wide total it is a small number of visits and will not affect the results.
Long Beach Department of Health Services - The staff at Long Beach Public Health Department
estimates that their clinics provide approximately 2 2 0 , 0 0 0 visits per year to the community, based
on discussions with the Director of Health Services it is not possible to separate out the number of
visits provided to uninsured patients.
Private Hospitals in Los Angeles County - Each hospital in California, except the Veterans
Administration and military hospitals, supplies data to the State of California, Office of Statewide
Health Planning and Development(OSHPD). The most applicable data for this project is their quarterly
data set. A set of the data for calendar year (by quarter) 1990 was obtained from OSHPD. This data
set includes 114 general acute care hospitals (including the LA County facilities).
Beginning with the first quarter 1992, data are broken down by several payor categories including selfpay and no-pay. In 1990, the number of outpatient visits were reported by only three categories of
payors. Medicare, Medi-Cal and Other. Using the 1992 first quarter percentages the number of visits
were estimated for the more detailed payor categories using the Other category in the 1990 data sets.
The results of these calculations show that in 1990 approximately 51,284 visits were paid for under
the County Medically Indigent Program and 9 6 1 , 9 1 7 visits were self pay patients in 108 private
hospitals (total visits 1,012,201).
Private Physicians - There are no estimates of the number of visits provided by private sector
physicians and clinics in Los Angeles County. One approach is to make an educated guess based on
a set of assumptions. Currently there are approximately 22,000 physicians licensed to practice
medicine in Los Angeles County. The research committee estimated that approximately 7 5 % of these
physicians are practicing outside of HMOs, County government, administrative positions and etc. Thus
16,500 physicians may be available to see uninsured patients. Of this physician pool, approximately
3 0 % are primary physicians (approximately 4,950) that are likely to see basic problems of the
uninsured. If each of these physicians sees 4 patients a week for 4 8 weeks per year then one would
anticipate approximately 9 5 0 , 0 0 0 free visits per year.
Data have been collected in a recent survey by the American Medical Association (Socioeconomic
Monitoring System). The results of this survey are of interest to the Task Force. In the survey 57.3
percent of physicians in the Pacific Region (Alaska, California, Hawaii, Oregon and Washington)
provided 3.2 hours of free care and administrative time to patients "due to the financial condition of
the patient". This 3.2 hours per week translates to approximately 153.6 hours per year. Assuming that
6 0 % of this time is devoted to patient care (therefore 4 0 % to administration) the net hours per year
would be 92.16. If physicians see 6 patients per hour this translates to 553 visits per year for 4 , 9 5 0
2
California Physician, October 1992 and Physician Marketplace Update, Volume 3 Number 1,
January 1992, American Medical Association, Chicago, III.
86
�primary physicians equal to approximately 2,737,000 visits.
Out-of-pocket Purchase of Visits
Many patients routinely purchase physician visits directly from their physician. Three sources were
available as an estimate of the number of visits purchased by the uninsured (2.7 million) population.
The first is unpublished data derived from the National Medical Insurance Survey (NMIS). These data
show approximately 1.2 visits per person per year paid out-of-pocket. If this rate was applied to the
uninsured population one would anticipate approximately 3.2 million visits purchased.
Uninsured members of the population are less likely to utilize medical services than insured persons.
Data from the National Medical Expenditure Survey show that in 1987, 8 7 . 3 % of the insured
population under 65 visited a physician or other provider during the year. This contrasts with only
6 3 . 7 % of uninsured people.
3
Uninsured persons pay a greater percentage of the costs than insured people. In 1987, uninsured
people under the age of 6 5 paid 7 7 % of the cost of care they received in contrast to those with
insurance that paid 5 1 % of the charges. People with public insurance (Medicaid and state and local
government) paid the least, averaging 1 7 % of charges.
Presented in Table 13 are estimates of the out-of pocket expenditures for care by insurance status and
race/ethnicity. The data are derived from the 1987 NMES and updated to account for the 3 6 %
increase in medical care prices between 1987 and 1 9 9 1 . The data in the table illustrates that the
uninsured population spent less on medical care out-of-pocket than did people with private health
insurance. This can be explained by the uninsured being less likely to use services and when they do,
they use fewer resources. The population covered by public insurance is probably more comparable
with the uninsured in terms of income and age. The uninsured use less care than the publicly insured
and spent more out-of-pocket and paid a much higher proportion of their own care.
4
Table 14 presents data for out-of-pocket expenditures for the total uninsured population. The estimates
are derived from Hahn and Lefkowitz, and inflated to 1991 dollars. The average uninsured person
spent $116 ($23 + $93) out-of-pocket on ambulatory care and $73 ($53 + $20) on inpatient hospital
and physician services. To estimate the number of visits paid for out-of-pocket by the uninsured, the
annual expenditure ($116) was divided by the average charge for a visit (including pharmacy) to a Los
Angeles free/community clinic ($92.23) (see Attachment C). This resulted in an estimate of 1.2 visits
per uninsured person per year. This estimate is consistent with another NMES estimate of an average
of 1.6 physician contacts per year for children under 17 who were uninsured all year.
6
8
3
Lefkowitz, D and A.Monheit, Health Insurance, Use of Health Services and Health Care
Expenditures (AHCPR Pub. No. 92-0017). National Medical Expenditure Survey Research Findings 12,
Agency for Health Care Policy and Research, Rockville, MD: Public Health Service, December 1991.
"Monthly Labor Review, p. 9 3 . Volume 115, No 5, May 1992
E
Hahn, Beth and Doris Lefkowitz. Annual Expenses and Source of Payment for Health Care
Services, National Medical Expenditures Survey Research Findings 14, Agency for Health Care Policy
and Research (1992, forthcoming)
"Monheit, Alan C . and Peter J . Cunningham, "Children Without Health Insurance" The Future of
Children (Fall, 1992).
87
�The second estimate of out-of-pocket visits is based on the National Health Interview Survey and was
derived by recent independent work of E. Richard Brown, Ph.D., at UCLA. This survey asked people
without health insurance that were under 200% of poverty and that had a private physician to
remember how many visits they had during the last year. Further examination of the data suggest that
this estimate should be reduced to the range of 1.8 to 1.6 visits per year. Using the adjusted rate and
applying it to the uninsured population the number of out-of-pocket visits was estimated to be 4.27
to 4.81 million visits.
Table 13
Out-of-pocket Expenditures by Insurance Status and Race/Ethnicity
11991 dollars)
Percent
Insurance Status
Expenditure
Percent Out
Using Care
Out-of-pocket
of Pocket
Private Insurance
White
89.0
535
53.0
Black
Hispanic
77.4
77.4
479
424
47.1
50.7
Public Insurance
White
87.2
310
21.7
Black
78.1
155
10.2
Hispanic
55.0
113
13.9
White
69.2
505
78.1
Black
53.2
446
68.0
Hispanic
55.0
350
81.0
Uninsured A l l Year
Source: Arleen Leibowitz, Ph.D.. RAND Corporation
Table 14
Average Out-of-pocket Expenditures by Insurance Status and Type of Service
(1991 dollars)
A n y Private
Type of Coverage
Public
Uninsured
Insurance
Insurance
All Year
Out-of-pocket Expenditure
Inpatient Hospital
52
104
53
Inpatient M D
25
5
20
112
52
93
37
14
23
226
175
189
Inpatient Hospital
37
402
224
Inpatient M D
14
140
44
Ambulatory M D
49
167
95
A m b u l a t o r y Non M D
14
33
22
114
742
385
Ambulatory M D
A m b u l a t o r y Non M D
Total Out-of-pocket
Public (non-Medicaid)
Charity and Bad Debt
Total Public/Charity
Note: Does not include dental, home health and other items included in Table 13.
88
�Table 15 summarizes the various dimensions of the uninsured population. The first part estimates the
total population by male and female. The next section provides estimates of demand based on the
various methods used. The third section provides the estimates of supply.
Table 15
Population to be Served, Estimates of Need and Estimates of Resources
Male
Female
Total
1,450,000
1,248,000
2,698,000
ESTIMATES OF NEED
Private Pay HMO
L.A. County CHP
Medi-Cal HMO
12,516,699
16,201,035
18,928,957
ESTIMATES OF RESOURCES
Private Hospital Outpatient Clinic
Self Pay
County Indigent
Long Beach Health Department
961,917
51,284
220,000
Pasadena Health Department
Free and Community Clinics
349,556
Los Angeles County Department of Health Services
Hospital
Self Pay
County Indigent
Clinics and Public Health
Self Pay
Pending CPSP/Medi-Cal
Unbilled
Private Physicians
45,262
860,221
870.973
29.592
1.100,000
2,737.000
Out-of-pocket Physician and Private Clinics
NIMS 3,204.000
NHIS
Median
high 4,272,000
low 4,806.000
4,005.000
TOTAL VISITS
11,230.805
Source: Tabulated by the Task Force for Health Care Access in Los Angeles County
89
�The Need vs. Resources Gap
To date, the staff of the Task Force has been able to account for approximately 11.23 million visits
supplied by various organizations to the uninsured population (see Table 15). This represents
approximately 1.2 to 7.7 million visit deficit if it were to receive services at the same rate as members
of a Medi-Cal HMO population. Table 16 presents the results of the Task Force's analysis to estimate
the gap based on differing need assumptions.
Table 16
Estimates of the Gap based on Alternative A s s u m p t i o n s for Demand Estimates
THE GAP
Private Pay HMO
1,375,894
Medi-Cal HMO
7,788,152
L.A. County CHP
4,254.230
Source: Tabulation by Task Force s t a f f , summarized f r o m report
Figure 1 compares the relative number of visits required to meet the needs of the uninsured population
depending on the assumptions made about the utilization rate of this population.
19
I
17
S
c
— 15
THE QAP
dc 13
£
>
ii
9
Private HMO
AEsot/neEs
LACCHP
Medi-Cal HMO
Figure 1. Millions of Visits Needed, Estimated Resources and the Estimated Gap
for the Uninsured Los Angeles County Uninsured Population Based
on Different Utilization Rate Assumptions
Sensitivity Analysis - Each of the estimates was tested for sensitivity to changes in magnitude
of the parameters. Over all, the four estimates for demand fall within a range of the 12 to 19 million
visits per year. Since all parameters are linear relationships, any change in the underlying parameter
leads to an equal proportional change in the total. Population data are stable in that they are based on
a national survey and applied to the local county circumstance.
The impact of the current recession is unknown. On the one hand, there are those that argue that
unemployment is higher and therefore the number of uninsured has increased. On the other hand, many
of those that have lost their jobs are already working in low pay jobs not covered by health insurance.
On balance there are probably more people without health insurance now than there yvere in 1990. but
the number is not as large as the increase in unemployment would suggest.
90
�Attachment A
List of 114 Hospitals Included in Data Set
91
�Table A l L i s t of 114 H o s p i t a l s Included i n Data S e t
FACILITY NAME
CITY
ALHAMBRA HOSPITAL
ANTELOPE VALLEY HOSPITAL MEDICAL CTR
AVALON MUNICIPAL HOSPITAL
BAY HARBOR HOSPITAL
BELLFLOWER DOCTOR'S HOSPITAL
BELLWOOD GENERAL HOSPITAL
BEVERLY HILLS MEDICAL CENTER
BEVERLY HOSPITAL
BROTMAN MEDICAL CENTER
CALIFORNIA HOSPITAL MEDICAL CENTER
CEDARS-SINAI MEDICAL CENTER
CENTINELA HOSPITAL MEDICAL CENTER
CENTURY CITY HOSPITAL
CHARTER COMMUNITY HOSPITAL
CHARTER SUBURBAN HOSPITAL
CHILDREN'S HOSPITAL OF LOS ANGELES
CITY OF HOPE NATIONAL MEDICAL CENTER
COAST PLAZA DOCTORS HOSPITAL
COMMUNITY & MISSION HOSPS-HTG PARK
COMMUNITY HOSPITAL OF GARDENA
COVINA VALLEY COMMUNITY HOSPITAL
DANIEL FREEMAN MARINA HOSPITAL
DANIEL FREEMAN MEMORIAL HOSPITAL
HSA
ALHAMBRA
LANCASTER
AVALON
HARBOR CIT
BELLFLOWER
BELLFLOWER
LOS ANGELES
MONTEBELLO
CULVER CIT
LOS ANGELES
LOS ANGELES
INGLEWOOD
LOS ANGELES
HAWAIIAN GARDENS
PARAMOUNT
LOS ANGELES
DUARTE
NORWALK
HUNTINGTON
GARDENA
WEST COVIN
MARINA DEL
INGLEWOOD
DOCTORS HOSP OF LAKEWOOD - NEW BEGINNINGLAKEWOOD
LAKEWOOD
DOCTORS HOSPITAL OF LAKEWOOD
WEST COVIN
DOCTORS HOSPITAL OF WEST COVINA
DOWNEY
DOWNEY COMMUNITY HOSPITAL
LOS ANGELES
EAST LOS ANGELES DOCTOR'S HOSPITAL
ENCINO
ENCINO HOSPITAL
LOS ANGELES
ESTELLE DOHENY EYE HOSPITAL
GLENDORA
FOOTHILL PRESBYTERIAN HOSPITAL
MONTEREY PARK
GARFIELD MEDICAL CENTER
GLENDALE ADVENTIST MED CT-WILSON TERRACEGLENDALE
GLENDALE MEMORIAL HOSP AND HEALTH CENTERGLENDALE
GLENDORA COMMUNITY HOSPITAL
GLENDORA
GRANADA HILLS COMMUNITY HOSPITAL
GRANADA HI
GREATER EL MONTE COMMUNITY HOSPITAL
SOUTH EL M
HAWTHORNE HOSPITAL
HAWTHORNE
VALENCIA
HENRY MAYO NEWHALL MEMORIAL HOSPITAL
LOS ANGELES
HOLLYWOOD COMMUNITY HOSPITAL
MISSION HI
HOLY CROSS MEDICAL CENTER
WEST HILLS
HUMANA HOSPITAL WEST HILLS
PASADENA
HUNTINGTON MEMORIAL HOSPITAL
COVINA
INTER-COMMUNITY MEDICAL CENTER
LOS ANGELES
KENNETH NORRIS JR. CANCER HOSPITAL
LANCASTER
LANCASTER COMMUNITY HOSPITAL
LOS ANGELES
LINCOLN HOSPITAL MEDICAL CENTER
TORRANCE
LITTLE COMPANY OF MARY HOSPITAL
LONG BEACH
LONG BEACH COMMUNITY HOSPITAL
LONG BEACH
LONG BEACH DOCTORS HOSPITAL
LONG BEACH
LONG BEACH MEMORIAL MEDICAL CENTER
LONG BEACH
LOS ALTOS HOSP & MENTAL HEALTH CENTER
LOS ANGELES
LOS ANGELES COMMUNITY HOSPITAL
LOS ANGELES
LOS ANGELES DOCTORS HOSPITAL
TARZANA
MEDICAL CENTER OF TARZANA
GARDENA
MEMORIAL HOSPITAL OF GARDENA
93
HFPA PEER TOC
913
901
933
933
921
921
927
919
927
925
925
929
927
921
921
925
913
921
923
929
915
927
929
933
933
915
921
925
905
925
915
913
909
909
915
903
913
929
903
925
903
905
911
915
925
901
925
931
933
933
933
933
925
925
905
929
4
4
6
4
4
5
3
3
3
3
2
3
4
4
4
18
12
4
5
5
5
4
3
9
4
5
4
5
4
5
5
3
3
3
4
4
5
5
4
5
4
3
3
3
5
5
5
3
3
5
2
5
5
4
4
4
1
5
4
1
2
2
2
1
2
1
1
1
2
2
2
1
1
2
2
2
2
1
1
2
2
2
1
2
2
1
1
2
1
1
2
1
2
2
2
2
1
2
1
1
1
2
2
1
1
2
1
2
2
2
2
2
�ARCADIA
METHODIST HOSPITAL OF SOUTHERN CALIF
LOS ANGELES
MIDWAY HOSPITAL MEDICAL CENTER
MONROVIA
MONROVIA COMMUNITY HOSPITAL
MONTEREY P
MONTEREY PARK HOSPITAL
NEWHALL
NEWHALL COMMUNITY HOSPITAL
NORTHRIDGE
NORTHRIDGE HOSPITAL MEDICAL CENTER
NORWALK
NORWALK COMMUNITY HOSPITAL
LOS ANGELES
ORTHOPAEDIC HOSPITAL
LOS ANGELES
PACIFIC ALLIANCE MEDICAL CENTER
LONG BEACH
PACIFIC HOSPITAL OF LONG BEACH
SUN VALLEY
PACIFICA HOSPITAL OF THE VALLEY
PINE GROVE HOSPITAL & MENTAL HEALTH CTR .CANOGA PAR
ARTESIA
PIONEER HOSPITAL
POMONA
POMONA VALLEY HOSPITAL MEDICAL CENTER
WHITTIER
PRESBYTERIAN INTERCOMMUNITY HOSPITAL
QUEEN OF ANGELS-HOLLYWOOD PRES MED CTR. LOS ANGELES
QUEEN OF THE VALLEY HOSP - WEST COVINA WEST COVIN
DOWNEY
RIO HONDO MEMORIAL HOSPITAL
HAWTHORNE
ROBERT F. KENNEDY MEDICAL CENTER
SAN DIMAS
SAN DIMAS COMMUNITY HOSPITAL
SAN GABRIE
SAN GABRIEL VALLEY MEDICAL CENTER
SAN PEDRO
SAN PEDRO PENNINSULA HOSPITAL
LOS ANGELES
SAN VICENTE HOSPITAL
LOS ANGELES
SANTA MARTA HOSPITAL
SANTA MONI
SANTA MONICA HOSPITAL MEDICAL CENTER
SHERMAN OA
SHERMAN OAKS HOSPITAL & HEALTH CENTER
LOS ANGELES
SHRINERS HOSPITAL - LOS ANGELES
REDONDO BE
SOUTH BAY HOSPITAL
LYNWOOD
ST. FRANCIS MEDICAL CENTER
SANTA MONI
ST. JOHN'S HOSPITAL AND HEALTH CENTER
BURBANK
ST. JOSEPH MEDICAL CENTER
PASADENA
ST. LUKE MEDICAL CENTER
LONG BEACH
ST. MARY MEDICAL CENTER
LOS ANGELES
ST. VINCENT MEDICAL CENTER
LOS ANGELES
TEMPLE COMMUNITY HOSPITAL
BALDWIN PA
TERRACE PLAZA MEDICAL CENTER
LOS ANGELES
THE HOSPITAL OF THE GOOD SAMARITAN
BURBANK
THOMPSON MEMORIAL MEDICAL CENTER
TORRANCE
TORRANCE MEMORIAL MEDICAL CENTER
LOS ANGELES
UCLA MEDICAL CENTER
LOS ANGELES
USC UNIVERSITY HOSPITAL
VAN NUYS
VALLEY PRESBYTERIAN HOSPITAL
LOS ANGELES
VENCOR HOSPITAL - LOS ANGELES
GLENDALE
VERDUGO HILLS HOSPITAL
CULVER CIT
WASHINGTON HOSPITAL
CANOGA PAR
WEST VALLEY HOSPITAL
WESTLAKE V
WESTLAKE MEDICAL CENTER
LOS ANGELES
WESTSIDE HOSPITAL
WHITTIER
WHITTIER HOSPITAL MEDICAL CENTER
LONG BEACH
WOODRUFF COMMUNITY HOSPITAL
Source:Complied from OSHPD Quarterly Data by Task Force S t a f f
94
913
925
913
913
903
905
921
925
925
933
907
905
921
917
919
925
915
921
929
917
913
933
925
925
927
905
925
931
923
927
907
911
933
925
925
915
925
907
931
927
925
905
929
937
927
905
905
925
919
933
3
3
5
5
5
3
5
23
4
4
4
5
5
3
3
3
4
4
4
5
4
3
5
5
3
4
22
4
3
3
3
4
3
3
4
5
3
5
3
1
3
3
5
4
5
4
4
5
4
5
1
2
2
2
2
1
2
1
2
1
2
2
2
1
1
1
1
2
1
2
1
1
2
1
1
1
1
2
1
1
1
2
1
1
2
2
1
2
1
1
2
1
2
1
2
1
2
2
2
2
�Attachment B
" »
°
f
» " i - .
95
X.eluaed
i o
D a t a
�Table Bl List of Clinics Included in Data Set
1330 S U H L N B A H BLVD
OT OG EC
AMERICAN INDIAN F E CLINIC INC
RE
CMTN
OPO
6000 N R H F G E O STREET
OT IURA
A R Y VISTA FAMILY HEALTH C N E
ROO
ETR
L S ANGELES
O
920 SO. R B R S N BLVD., #3 L S ANGELES
OETO
BEVERLY HILLS C M U I Y CLINIC
OMNT
O
1530 S U H OLIVE S R E
OT
TET
L S ANGELES
O
CALIFORNIA PEDIATRIC & FAMILY MEDICAL C N E
ETR
600 N R H B O D A
OT
RAWY
L S ANGELES
O
C I A O N SERVICE C N E FAMILY PLANNING CLINIC
HNTW
ETR
2675 W OLYMPIC B U E A D
.
OLVR
L S ANGELES
O
CLINICA ' S . O C R R M R '
MR SA OEO
14418 EAST PACIFIC A E U
VNE
BALDWIN P R
AK
C M U I Y HEALTH PROJECTS, INC. - BALDWIN P R
OMNT
AK
11043 VALLEY B U E A D
OLVR
EL M N E
OT
C M U I Y HEALTH PROJECTS, INC. • EL M N E
OMNT
OT
1175 U R H
NU
LA P E T
UNE
C M U I Y HEALTH PROJECTS, INC. LA P E T
OMNT
UNE
PSDN
AAEA
C M U I Y HEALTH PROJECTS, INC. P S D N
OMNT
AAEA
26 N R H R Y O D A E U
OT AMN VNE
PSDN
AAEA
C M U I Y HEALTH PROJECTS, INC. - P S D N
OMNT
AAEA
1724 E. W S I G O
AHNTN
PMN
OOA
C M U I Y HEALTH PROJECTS, INC. • P M N
OMNT
1050 W S G R Y
ET AE
OOA
PMN
OOA
354 E S ERVILLA S R E
AT
TET
C M U I Y HEALTH PROJECTS, INC. P M N
OMNT
OOA
W S COVINA
ET
120 N R H L N A E U
OT AG VNE
C M U I Y HEALTH PROJECTS, INC. • W S COVINA
OMNT
ET
C M U I Y HEALTH PROJECTS, INC. - W S COVINA
OMNT
336 1/2 S U H G E D R A E U W S COVINA
OT LNOA VNE ET
ET
WHITTIER
11738 VALLEY VIEW, SUITE B
C M U I Y HEALTH PROJECTS, INC. • WHITTIER
OMNT
W S COVINA
ET
1825 E. T E B R S R E
HLON TET
C M U I Y HEALTH PROJECTS W S COVINA
OMNT
ET
C L E CITY
UVR
4401 E E D S R E
LNA TET
C L E CITY Y U H H A T C N E
UVR
OT ELH ETR
L S ANGELES
O
630 SO. ST. LOUIS S R E
TET
E S L S ANGELES H A T T S F R E
AT O
E L H AK OC
W S COVINA
ET
E S VALLEY C M U I Y H A T CENTER, INC.
AT
OMNT ELH
420 S U H G E D R A E U
OT LNOA VNE
HLYOD
OLWO
1213 N R H HIGHLAND AVE
OT
E M N D E E M N HEALTH C N E
DUD . DLA
ETR
PACOIMA
13643 V N N Y B U E A D
A US OLVR
EL P O E T DEL BARRIO
RYCO
L S ANGELES
O
3945 WHITTIER B V
LD
EL IAS CHICO FAMILY HEALTH C N E
ETR
S U HG T
OT AE
FAMILY PLANNING C R O G E T R L A - O T G T W M 4382 T E D B U E A D
T F RAE ..SUH AE O
WEY OLVR
VENICE
FAMILY PLANNING O G E T R L.A., INC.-VENICE CL. 1501 PACIFIC A E U
F RAE
VNE
L S ANGELES
O
FRANCISCAN HEALTH C N E
ETR
2859 GLASSELL S R E
TET
SAN P D O
ER
H R O F E CLINIC
ABR RE
P O B X 429
.. O
L S ANGELES
O
H L Y O D S N E F E CLINIC
OLWO UST RE
3324 S N E B V
UST LD
L S ANGELES
O
I G E O D FAMILY C R C N E
NLWO
AE ETR
10519 SO. W S E N A E U
ETR VNE
L S ANGELES
O
KNIGHTS O MALTA F E CLINIC - L S ANGELES
F
RE
O
2222 W O E N I W
. CAVE
L S ANGELES
O
K R O HEALTH FOUNDATION
OY
3544 W S OLYMPIC B U E A D
ET
OLVR
LOS ANGELES
LA CLINICA - S N L DRIVE
UO
133 N R H S N L DRIVE
OT UO
L S ANGELES
O
L S ANGELES F E CLINIC, INC.
O
RE
8405 BEVERLY B U E A D
OLVR
SEPULVEDA
MISSION CITY C M U I Y N T O K INC.
OMNT
EWR,
15206 PARTHENIA S R E
TET
L S ANGELES
O
N W W T S HEALTH C N E
E AT
ETR
10300 S U H C M T N A E U
OT OPO
VNE
LOS ANGELES
N R H A T C M U I Y CLINIC
OTES OMNT
5809 N R H F G E O STREET
OT IURA
SAN F R A D
ENNO
N R H A T VALLEY HEALTH C R . - ' E V N
OTES
OP
11133 O M L E Y A E U
'EVN VNE
OMLEY
PACOIMA
N R H A T VALLEY HEALTH C R . -PACOIMA
OTES
OP
12756 V N N Y B U E A D
A US OLVR
SAN F R A D
ENNO
N R H A T VALLEY HEALTH C R . -SAN F R A D R A 1600 S N F R A D R A
OTES
OP
A ENNO OD
ENNO OD
PSDN
AAEA
P S D N PLANNED P R N H O
AAEA
AETOD
1045 N R H LAKE A E
OT
V
L S ANGELES
O
P A N D P R N H O A O R HILLS
LNE AETOD GUA
1920 M R N O S R E
AEG
TET
L S ANGELES
O
P A N D P R N H O BIXBY C N E
LNE AETOD
ETR
1920 M R N O S R E
AEG TET
L S ANGELES
O
PAND PRNHO SNA MNC
LNE AETOD AT
OIA
1920 M R N O S R E
AEG
TET
L S ANGELES
O
P A N D P R N H O W R D POPULATION L.A. C N G 1920 M R N O S R E
L N E AETOD OL
AEG
TET
AOA
L S ANGELES
O
P A N D P R N H O W R D POPULATION L.A. EL M N 1920 M R N O S R E
LNE AETOD OL
AEG
TET
OT
L S ANGELES
O
P A N D P R N H O W R D POPULATION L.A. L K W O 1920 M R N O S R E
L N E AETOD OL
AEO
AEG
TET
L S ANGELES
O
PLANNED P R N H O W R D POPULATION L.A. P M N 1920 M R N O S R E
AETOD OL
OOA
AEG
TET
L S ANGELES
O
P A N D P R N H O W R D POPULATION L.A. S E M N 1920 M R N O S R E
L N E AETOD OL
HRA
AEG
TET
LOS ANGELES
PAND PRNHO - MDON
LNE AETOD
ITW
1920 M R N O S R E
AEG
TET
L S ANGELES
O
PLAZA C M U I Y C N E CLINIC
OMNT ETR
P O B X 23248
.. O
L S ANGELES
O
S N A M R A FAMILY C R C N E
AT AT
AE ETR
353 N R H H M H E
OT
UPRY
PICO RIVERA
S A S N PLAZA MEDICAL G O P
LUO
RU
9436 E S S A S N
AT LUO
RDNO BAH
EOD
EC
S U H B Y CHILDRENS HEALTH C N E
OT A
ETR
410 S U H CAMINO R A
OT
EL
GREA
ADN
S U H B Y F E CLINIC - G R E A
OT A RE
ADN
742 W S G R E A B U E A D
ET ADN OLVR
S U H B Y F E CLINIC - M N A T N B A H
OT A RE
AHTA
EC
MNATN BAH
AHTA
EC
1807 M N A T N B A H BLVD
AHTA EC
S U H CENTRAL FAMILY HEALTH C N E
OT
ETR
L S ANGELES
O
4524 S N P D O P A E
A ER
LC
ST. J H ' W L CHILD C N E
ONS EL
ETR
L S ANGELES
O
514 W S A A S B U E A D
ET DM
OLVR
THE CHILDRENS CLINIC
LN BAH
OG EC
P O B X 1428
.. O
THE F R E FOUNDATION
OT
US
7543 W O L Y AVENUE, SUITE 200VAN N Y
OOE
UHR
LD O
T.H.E. CLINIC F R W M N A A T HELP E E Y O A CLI 3860 W MARTIN L T E KING B V L S ANGELES
O OE K O
VRWMN
LOS ANGELES
TET
U L S H O O NURSING H A T C N E - S N E ST. 1203 SO. SANTEE S R E
CA COL F
ELH ETR
ATE
L S ANGELES
O
OT
TET
U L S H O O NURSING H A T C N E - SO. MAIN 226 S U H MAIN S R E
CA COL F
ELH ETR
CMTN
OPO
4200 C M T N B U E A D
OPO
OLVR
UNITED HEALTH PLAN MEDICAL C N E - C M T N
ETR
OPO
5648 VINELAND A E U
VNE
NRH HLYOD
OT
OLWO
VALLEY C M U I Y CLINIC
OMNT
VENICE FAMILY CLINIC
604 R S A E U
OE VNE
VENICE
97
�UATTS HEALTH F U D T O - O S O U U U
ONAINHUE F HR
W T S J R A S H O - A E HEALTH CLINIC
AT/ODN COLBSD
WESTSIDE FAMILY Y C
MA
WESTSIDE N I H O H O CLINIC INC
EGBROD
WESTSIDE W M N S HEALTH C N E
OE'
ETR
WILMINGTON C M U I Y F E CLINIC
OMNT RE
W M N S CLINIC
OE'
8005 S U H FIGUEROA STREET
OT
2265 E S 103RD STREET
AT
11311 L G A G AVE
A RNE
H36 W S 23RD S R E
ET
TET
1711 O E N P R BLVD
CA AK
1459 N R H A A O B U E A D
OT V L N OLVR
9012 W S OLYMPIC B U E A D
ET
OLVR
SourceiCompiLed from O H D f i l e by Task Force Staff
SP
98
L S ANGELES
O
L S ANGELES
O
L S ANGELES
O
LN BAH
OG EC
S N A MONICA
AT
WILMINGTON
BEVERLY HILLS
�Attachment C
Summary Elements From t h e OSHPD C l i n i c Survey
99
�Table Cl Summary Elements of Seventy Two Los Angeles C l i n i c s
Units
Data
Element
Data D e s c r i p t i o n
2.19.1
2.19.2
Total Patients
Total Visits
V i s i t s per P a t i e n t
abortions
number
operating
rooms
number
O p e r a t i o n s p e r Room
O p e r a t i n g Room Minutes
Minutes per O p e r a t i o n
P a t i e n t s Non E n g l i s h Speakers
Patients
under 1
children
1-12
teen
13-19
young a d u l t
a d u l t s 20-44
m i d d l e age
a d u l t s 45-64
older adults
a d u l t s 65+
Sex
female
male
Indian
Race
of
A/P I s l e d
Black
Latino
Patient
Chinese
white
other
a l l other
Gen Med
Mat&Child
Types
FP
of
Dental
STDs
Service
Substance
Mental H e a l t h
Rehab
Dialysis
Surgical
Abortion
Other
Sources o f Revenues
Revenues
Medicare
Patients
Visits
Revenues
Medi-Cal
Patients
Visits
Revenues
2.25.1
2.26.1
2.27.1
2.28.1
4.5.1
4.12.1
4.13.1
4.14.1
4.15.1
4.16.1
4.17.1
4.18. 1
4.19.1
4.20.1
4.21.1
4.22.1
4.23.1
4.24.1
4.25.1
4.26.1
4.27.1
4.41.1
4.42.1
4.43.1
4.44.1
4.45.1
4.46.1
4.47.1
4.48.1
4.49.1
4.50.1
4.51.1
4.52.1
5.1.1
5.1.2
5.1.3
5.2.1
5.2.2
5.2.3
5.4.1
Percent
369,743
1,080,997
2.92
3,229
5
1,720
344
102,720
59.72
178,061
25,985
53,051
49,023
170,109
38,799
13,423
225,737
111,236
3,858
14,495
48,118
183,726
2,736
79,347
1,296
3,398
84,970
65,186
80,372
24,682
22,966
9,867
12,240
4,806
0
1,069
2,610
6,757
2,086,094
6,757
20,104
10,087,677
49,945
150,040
3,427,061
Source:Tabulated From OSHPD Annual C l i n i c Data by Task Force S t a f f
101
48.16
7.03
14.35
13.26
46.01
10.49
3.63
61.05
30.08
1.04
3.92
13.01
49.69
0.74
21.46
0.35
0.92
22.98
17.63
21.74
6.68
6.21
2.67
3.31
1.30
0.00
0.29
0.71
1.83
3.99
1.83
2.36
19.27
13.51
17.59
6.55
�Table Cl(Continued) Summary Elements of Seventy Two Los Angeles C l i n i c s
Data
Element
5.4.2
5.4.3
5.5.1
5.5.2
5.5.3
5.7.1
5.7.2
5.7.3
5.8.1
5.8.2
5.8.3
5.9.1
5.9.2
5.9.3
5.10.1
5.10.2
5.10.3
5.11.1
5.11.2
5.11.3
5.12.1
5.12.2
5.12.3
5.13.1
5.13.2
5.13.3
5.19.1
5.19.2
5.19.3
5.20. 1
5.21.1
5.23.1
5.24.1
5.27. 1
5.28.1
5.29. 1
5.30. 1
5.31. 1
5.39.1
5.40.1
5.41. 1
5.42.1
5.50.1
6.1.1
6.2.1
6.3.1
6.4.1
6.5.1
6.6.1
6.7.1
Data
Description
Units
SLIAG
17,588
41,719
2,846,284
14,421
42,615
222,384
1,246
3,021
109,017
4,859
6,688
8,841,586
21,346
114,930
10,141,454
75,708
246,243
6,382,044
40,569
103,601
5,412,121
45,901
99,742
2,789,717
19,366
44,435
52,345,439
290,949
853,034
394,543
3,813,496
499,830
639,719
0
1,501,739
655,903
6,568,243
2,355,798
15,640,185
52,345,439
15,640,185
36,705,254
52,345,439
45,129,736
1,732,984
5,993,922
2,227,661
1,407,889
23,032,671
79,524,863
Patients
Visits
Revenues
CHDP
Patients
Visits
Revenues
CMSP
Patients
Visits
Revenues
Patients
Other County
Visits
Revenues
Private Insurance Patients
Visits
Revenues
Patients
S e l f Pay
Visits
Revenues
Patients
Non-Paying
Visits
Revenues
Other Payor
Patients
Visits
Revenues
P r o p o s i t i o n 99
Patients
Visits
Revenues
Total
Patients
Visits
Deductions from Medicare
Medi-CAL
Revenue
SLIAG
CHDP
Other County
Insurance
Bad D e b t s
C h a r i t y Care
Other
T o t a l Deductions
Revenue
Deductions
N e t P a t i e n t Revenue
T o t a l P a t i e n t Revenue
Salaries
Supplies-Office
Supplies-Medical
Rent/Mortgage
Utilities
Other
T o t a l O p e r a t i n g Expense
Percent
4.76
4.89
5.44
3.90
5.00
0.42
0.34
0.35
0.21
1.31
0.78
16.89
5.77
13.47
19.37
20.48
28.87
12.19
10.97
12.15
10.34
12.41
11.69
5.33
5.24
5.21
100.00
78. 69
100.00
Source:Tabulated From OSHPD Annual C l i n i c Data by Task Force S t a f f
102
�Table Cl(Continued) Summary Elements of Seventy Two Los Angeles C l i n i c s
Data
Element
Data Description
6.10.3
6.12.1
6.12.2
6.12.3
6.13.1
6.13.2
6.13.3
6.14.1
6.14.2
6.14.3
6.15.1
6.15.2
6.15.3
6.16.1
6.16.2
6.16.3
6.17.3
6.20.1
6.20.2
6.20.3
6.21.3
6.22.3
I n s t i t u t i o n a l Support
Federal
Federal
Federal
State
State
State
County
County
County
Local
Local
Local
Private
Private
Private
Units
Revenue
Contract
Grant
Total
Contract
Grant
Total
Contract
Grant
Total
Contract
Grant
Total
Contract
Grant
Total
Donations
Tot Op Rev C o n t r a c t
Tot Op Rev Grant
Tot Op Rev Revenues
O p e r a t i n g Expense
Net From
Operations
Percent
36,705,254
2,060,348
12,271,075
14,331,423
11,835,451
4,407,611
16,243,062
3,270,016
3,951,952
7,221,968
597,184
808,141
1,405,325
1,876,452
2,942,914
4,819,366
5,746,108
19,639,451
24,381,693
86,472,506
79,524,863
6,947,643
Source:Tabulated From OSHPD Annual C l i n i c Data by Task Force S t a f f
103
�APPENDIX D.
SURVEY OF FREE AND COMMUNITY CLINICS
105
�T A S K FORCE FOR HEALTH C A R E A C C E S S
S U R V E Y ON FREE AND COMMUNITY CLINICS
In order to determine the existing health resources in Los Angeles County, a survey was conducted
on the status of the free and community clinics. Since the clinics play a vital role in supplying access
for the uninsured, the survey examines the current operation of the clinics, their needs, and resources.
The results are broken d o w n into four categories; general overview of reporting clinics, service
breakdown, clinic needs, and effects of the civil unrest. The last section is a recent addition that is
intended to assist the Working Group on The Aftermath in determining the effects of the civil unrest
on the health care access equation.
Methodology
To collect the information, a t w o part questionnaire was administered over a t w o month period. The
surveyed group consisted of 120 clinics based on OSHPD data. The list was modified to exclude any
duplications. The first part of the survey was a skip-pattern telephone questionnaire that examined
the effects of the unrest. The survey specifically examined physical damage, interrupted services,
patient reaction, and medical needs. The second part of the survey was a mail-in questionnaire that
examined the normal operating status of the clinics. The telephone survey had a 4 5 % response rate
while the mail-in survey had a 4 0 % response rate.
Results
I. General Overview of the Free and Community Clinics
Services Provided:
On a whole, the surveyed clinics offered an extensive list of medical services. Forty percent of the
surveyed clinics offered some type of general medical care while 4 2 % offered family planning services
and 3 7 % provided OBIGYN. Other common services included pediatrics ( 4 0 % ) , social services ( 3 5 % ) ,
pharmaceutical ( 2 3 % ) , and dental ( 2 3 % ) . A high response rate was received from the county's mental
health clinics as 4 9 % of the respondents offered some type of mental services. Surprisingly, a lack
of emergency care was noted as only 2 % of the responding clinics claimed to offer emergency
services.
Community Outreach Programs:
A second vital function of the clinics is to offer community services and contacts. The clinics
responded that more than half offer some type of outreach and education program. Other services
noted were community nutrition ( 2 3 % ) , language translation ( 2 1 % ) , vocational training ( 1 2 % ) , child
care ( 7 % ) , and legal services ( 5 % ) .
Patient Utilization:
The surveyed clinics reported a large variation in the number and type of patients seen in each area.
On a whole, the clinics reported a large average daily census of 73 patients. This number varied
depending on the size and type of clinic. The range of the information was from a l o w of 5 patients
a day for a counseling center to a high of 4 5 0 for a pediatric clinic.
The utilization of clinics also varied greatly in ethnicity, age, and sex. The respondents reported that
a majority of the patients were between the ages of 18 and 3 0 as on the average 2 9 % of the clinics'
patients were in this age group. The 3 1 to 6 4 age group was second highest w i t h 2 3 % followed by
107
�5 to 14 ( 1 2 % ) , 1 to 4 ( 1 1 % ) , and 15 to 17 ( 1 0 % ) . Surprisingly, respondents reported that only 8 %
of their patients were above the age of 6 5 .
Respondents also reported that the majority of their patients were of Latino descent. The clinics
reported that on the average, 4 1 % of their patients were Latino, 3 4 % were A n g l o , 1 1 % were
Asian/Pacific Islanders, and 9 % were of African-American descent. The clinics also reported that 1 %
of their patients were American Indian and 4 % were from other ethnic backgrounds.
Lastly, the respondents noted that a majority of their patients were female. The clinics reported that
6 4 % of their clientele were female while only 3 6 % were male.
Paver Mix:
Though many of the clinics do not bill their patients directly, the type of payment varies greatly. The
reporting clinics noted that on the average 2 6 % of the primary source of payment comes f r o m the
patients themselves. The next highest payer is Medi-Cal which supplies on the average 1 8 % . Other
government funding includes Medicare (6%) and the Child Health Disability Program ( 5 % ) while 1 6 %
comes f r o m other government sources. Public and private donations are also a major f o r m of funding
for the clinics as an average of 1 7 % of the clinic's income comes f r o m grants and donations. A small
amount of the care is covered by private insurance (4%) while other services are uncompensated
entirely.
Personnel Utilization:
When asked about physician staffing, the respondents replied that a majority of the clinical work is
provided by paid physicians. Most of these physicians, however, work only on a part-time basis. Of
the responding clinics, 3 7 % reported that they use paid physicians to perform primary care medicine.
Others reported that they use paid physicians for pediatric care (28%), OB/GYN (26%). family planning
(19%), and mental health (12%). Most of these physicians are on a part time schedule at the clinic.
The respondents noted that 8 2 % of the OB/GYN physicians are part time while all of the family
planning and 6 7 % of the pediatric physicians are part time. Surprisingly, the clinics reported that they
do not utilize very many volunteer physicians. Three clinics reported using volunteer physicians for
primary care while only two clinics reported using volunteers for mental health counseling or pediatrics.
The lack of volunteer physicians is a major issue for the clinics as they noted volunteer physicians as
one of their priority needs (see section III).
The clinics also utilize ancillary volunteers extensively. The mental health clinics were the largest users
of volunteers as 4 7 % of their ancillary personnel were unpaid. Again, the clinics noted that volunteers
were a priority need for continuation of services.
II. Breakdown by Specialty
To determine the current status of clinics by specialty, the respondents were divided into four groups.
The first group is made up of clinics that offered general medicine as their primary f u n c t i o n , the second
group consists of mental health clinics, the third group is composed of family and pediatric clinics and
the last group is a combination of specialty clinics and rehabilitation facilities. The grouping allows for
analysis based on the type of care given at the clinic. The groups were not separated by patient type
as children's clinics and senior centers that offered primary care as their emphasis were included in the
general medicine group. Also, children's counselling centers were included in the mental health group
as mental services were their primary function.
There was a lack of information for the
specialty/rehabilitation group and their results have not been included in the analysis.
With the division, the clinics can be compared on utilization, patient type, and budgeting. A s expected,
the clinics w i t h the largest amount of utilization were the general medical clinics. On the average, the
108
�primary care facilities had a daily census of 100.5 patients. This was above the average of the family
clinics which had a daily census of 91.55. The family clinics statistics were skewed slightly as one
clinic had a daily census of 4 5 0 patients. This was far above the normal range for the other family
clinics which fell between 30 and 90. Removal of the 4 5 0 figure from the data set resulted in an
average daily census of 4 6 . 7 5 . a number that better represents the range. The range of the general
medical clinics is much closer to their average census as removal of the highest and lowest figures in
the data set result in only a small change in the average. The mental health clinics also had a smaller
range with a daily census average of 32.5 patients. The utilization of the clinics thus shows that
general medical clinics by far offer the most amount of care on a daily basis.
Using the average of the percentages supplied by the clinics, patient demographics can be determined.
The general medical clinics reported that a majority of their patients are of Latino descent (62%). The
mental health and family clinics however, report that most of their patients are Anglo (42% and 5 4 %
respectively), while Latino is the second largest group (39% and 18%). The general medical clinics
also report a large number of Asian/Pacific Islanders patients (16%). All three clinic types report that
African-American patients make up about 1 0 % of their clientele. The clinics also report that women
use the clinics more than men, a fact that is especially true in the family clinics. General medicine and
family clinics report that most patients fall between the ages of 18 and 3 0 while family clinics report
the majority of their clientele to be between the ages of 31 and 64.
The budget of the clinic types vary greatly. Using the average of the clinic operating budgets, the
general medical clinics are the highest funded clinics. The average funding for a general medical clinic
is $ 2 , 1 4 2 , 6 7 7 . The mental health clinics are the second highest funded group with an average
operating budget of $1,231,818.
The family clinics are much smaller with an average of only
$ 7 9 8 , 8 8 2 . Of the three types of clinics, the family health facilities service the most clientele for the
operating budget. When the operating budget is divided by the yearly patient census, the family health
clinics average $57.90 per patient. Mental health clinics offer slightly higher numbers as they average
$64.61 per patient. The general medical clinics spend the most as they average $ 6 8 . 0 0 per patient.
The values point to the cost of the various care and how much additional funding may have to be used
to increase the number of patients served.
It is interesting to note that both the mental health clinics and the general medical clinics receive the
majority of their funding from self paying patients while family clinics receive their money from
government sources. The family clinics only receive 8% of their funding from the patients while 4 1 %
comes from the government and 5% comes from private grants.
III. Clinical Needs
The respondents were asked two final questions to identify the needs of their clinic and community.
The first question asked for a listing and priority ranking of clinical needs other than funding. The
second part asked for identification of any additional needs of the clinic or community.
Priority Needs:
The clinics were asked to list their needs and then rank them with one being the most important. The
answers were recorded and tabulated with a first priority given three points, a second priority two
points, and three and below was given one point each. The results are listed in order below:
•Space (points: 63)
A majority of the clinics noted the need for space, land, and physical plant. Some
pointed out that they had the staff to offer more care but they were limited by the
facility.
109
�•Volunteer Physicians (points: 50)
The respondents stated that they were in great need of volunteer physicians to assist
in the performing of services. Some suggested a county referral n e t w o r k through which
physicians could be placed w i t h clinics. The physicians could w o r k to pay off
government medical loans or gain experience.
•Other Personnel (points: 41)
Many of the clinics noted that they were in need of other personnel including nurses,
technicians, counsellors, administrative workers, clerical, and volunteers. Few clinics
stated that they had the resources to fund the extra personnel. Some respondents
suggested a referral network similar to the one suggested for the volunteer physicians.
•Equipment (points: 30)
Clinics often stated that they were in need of medical and office equipment. Only one
clinic noted that it had lost equipment during the civil unrest.
Other priority needs that were noted:
•Pharmaceutical Supplies
•Bilingual Workers
•Publicity
• N e w Facilities
•Board members
•Expanded Dental
•Laboratory
•Malpractice Insurance
•Specialty Referral Panel
(16 points)
(13 points)
(11 points)
(5 points)
(2 points)
(1 point)
(1 point)
(1 point)
(1 point)
Community and Clinical Needs:
The respondents noted many additional needs for the community and the clinics. The results are listed
in order of frequency:
•Funding (frequency: 22)
Almost all of the respondents noted a lack of funding for the clinics. Though f e w had
suggestions in light of the proposed budget cuts, some suggested increased contracting
w i t h County agencies and increased income f r o m the " s i n " taxes (smoking, alcohol,
snacks).
•Preventive Care (frequency: 19)
The clinics reported that a lot of their w o r k could be easily accomplished if more
preventive care was attempted. Some suggested more Health Fairs to be run as a
group project w i t h the County, clinics, and medical supply companies. A f e w clinics
noted that the need for preventive care was heightened by the civil unrest as some
doctors' offices that formerly supplied such care had burned d o w n .
•Care for Undocumented Aliens (frequency: 7)
Many clinics stated that they were uncompensated for care to undocumented aliens.
The respondents were concerned that the care for these patients would continue to
deteriorate if the government decides to further restrict funding for such care.
110
�•Barriers t o Care (frequency: 5)
Some clinics noted that there were major barriers to giving care to the patients w h o
needed it. Respondents pointed to language and cultural barriers as a major problem
in supplying care. T w o clinics suggested a referral network for bilingual nurses to allow
for better care in multi-cultural areas.
•Contracting w i t h HMOs Instead of Clinics (frequency: 3)
Three respondents stated that they were concerned with the proposed idea to contract
with Health Maintenance Organizations to provide care for Medi-Cal patients. The
respondents felt that compensated patients were being removed from the clinics
leaving the respondents w i t h only uncompensated clientele. As one respondent stated
"It seems as if [The Clinics] are good enough to give free care but not good enough to
be contracted w i t h . "
•Social Service Integration (frequency: 3)
A f e w clinics noted that the health centers are becoming more than just medical
suppliers. With the current economic times, the clinics have become social service
centers as well. To assist in supplying social care, the clinics have suggested extra
funding, personnel, and integration of DPSS into the Clinic arena.
Other needs that were addressed:
•
•
•
•
•
•
•
Additional physicians
Grants for dental care
Increase in patients w i t h life threatening needs. Patients are waiting until
problems are bad enough to require emergency care as they cannot afford to
pay for any services.
Need for care for victims of riots
Need for mental health counselling resources
No access to specialty clinics
The Westside of L.A. needs funding like the other areas of L.A.
IV. Effects of Civfl Unrest
Of the free and community clinics surveyed, 4 7 % reported no effects of the civil unrest in Los Angeles.
Fifty-three percent, however, reported effects including physical damage, changes in walk-in patients,
interrupted services, and cancellations.
One clinic reported physical damage to their facility. The damage included destruction of computer
equipment and medical supplies. The clinic has been able to replace much of the damaged equipment.
A majority of the respondents reported that they closed their facility for one day or more due to the
inability of staff and patients to come to the clinic. Ninety percent of the clinics that reported effects
of the unrest stated that they faced some type of service interruption during the first week.
Many clinics reported a change in the number of patients seen during the unrest and in the four weeks
following. Clinics reported that during the first four days, f e w patients came to the clinics. Following
the first week, clinics experienced different reactions by patients. Fifteen percent of the respondents
noted an increase in the number of walk-in patients in the first week. The number rose to 1 9 % by the
second week. In contrast, some clinics reported extensive decreases in the normal number of walk-in
111
�patients. Thirty percent of the respondents noted a decrease in the walk-ins in the first week, dropping
slightly to 2 7 % in the second week. Many clinics also reported cancellations of appointments and no
shows. Fifty-four percent of the clinics reported an increase in the first week but the number fell
sharply to 3 5 % by the second week.
The clinics reported that they expect a rise in the number of patients requiring service in the months
following the unrest. Due to the loss of resources, (physicians' offices, homes, etc.) and waiting by
some patients to seek care, the respondents noted that there may be a large increase in the demand
for care. The clinics noted that they may not be equipped to handle the increase and may need some
assistance if the demand rises.
112
�APPENDIX E.
TASK FORCE MEMBERS
113
�T A S K FORCE MEMBERS
E. Richard Brown, Ph.D.
Professor
U.C.L.A. - School of Public Health
Edgar T. Carlson
Vice President, Regional Hospital Administrator
Kaiser Permanente
David Chernof, M.D.
Sr. Vice President & Corporate Medical Director
Blue Cross of California
Michael Cousineau, D.P.H.
Executive Director
Homeless Health Care Los Angeles
Harry Douglas, III, D.P.A.
Dean
College of Allied Health, Charles Drew University
Hector Flores, M.D.
Private Practice Physician
Robert C. Gates
Director
Los Angeles County Dept. of Health Services
Ronald L. Kaufman, M.D., M.B.A.
Asso. Chief of Staff & A s s o . Professor
LAC + USC Medical Center, School of Medicine
Sr. Elizabeth J . Keaveney. D.C.
President, Chief Executive Officer
Saint Francis Medical Center
Arleen Leibowitz, Ph.D.
Sr. Economist & A s s o . Head, Health Programs
RAND Corporation
James E. Ludlam, Esq.
Partner
Musick, Peeler & Garrett
Dennis C. Poulsen
President & Chief Executive Officer
Rose Hills Company
Bill Press
Chair, L.A. County Commission on Insurance
Political Commentator - KCOP TV & KFI Radio
Val Rodriguez
Community Organizer
Health Promotions Council
Corinne Sanchez, J.D.
President & Chief Executive Officer
El Proyecto del Barrio
Jacque Sokolov, M.D.
President
Sokolov Strategic Alliance
115
�Robert Tranquada, M.D.
Norman Topping/National Medical Enterprises
Professor of Medicine & Public Policy
School of Public Adm., Univ. of S o . California
Reed Tuckson, M.D.
President
Charles R. Drew University
Mimi West, M.S.W.
Community Volunteer
Commission on Narcotics and Dangerous Drugs
Joseph Wetzler
President
Local 501
Richard Wigod, M.D.
Immediate Past President
Los Angeles County Medical Association
Roy Young. M.D.
Professor
School of Medicine, University of California, L.A.
116
�APPENDIX F.
TASK FORCE STAFF
117
�TASK FORCE STAFF
Chief Administrative Office
Carmen Scott
L. A. County Department of Health Services
Linda Dacon
Jonathan Freedman
Ron Hansen
Miya Iwataki
Elena Soohoo
Carl Williams
National Health Foundation
Ruel Berris
Linda Estrada
Mariene Larson
Rita Moya
Research Committee
Thaine Allison. Jr.
Felice Houston
Brendan Kremer
Community Organizers
Chestine Haddad
Miguel Sandoval
Julie Solis
Alan Wu
119
�STATE OF
OFFICE
LOUISIANA
OF THE LIEUTENANT GOVERNOR
•!• MELINDA SCMWEGMANfJ;;
LICUTCNANT
GOVERNOR
-;;>!. P. o. BOX *.5fi>3
J
^BATON
ROUGE, LOUISIANA^!
A N D
( S O * ) 3*2-'70'09"*'~
COMMISSIONER
DEPARTMENT
RECREATION
OF
CULTURE.
AND
FAX ( B O * ) 3 * 2 - 1 9 4 9
TOURISM
March 10, 1993
Ms. Hillary Rodham Clinton
Office of the First Lady
Room 100 - The White House
Washington, D.C. 20050
Dear Hillary:
As you work with the new administration in seeking new ideas and new approaches to
healing the nation's medical/health care problems, I would like to recommend Ms. Kathleen
Lewinski DeBruhl as a candidate for a position on the Health Reform Team. Anything you
can do will be greatly appreciated by me personally. If you need any additional information,
please let me know.
With best wishes,
•s* MELINDA S
Xieufenaht Governor
MS:js
attachment
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. resume
SIIBJECITTITLE
DATE
Kathleen Lewinski DeBruhl [partial] (1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [3]
2006-0885-F
wr826
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. S52(b)|
PI National Security Classified Information [(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PKA|
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIAj
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIAj
b(3) Release would violate a Federal statute 1(b)(3) of the FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIAj
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIAj
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�CURRICULUM VITAE
OF
KATHLEEN LEWINSKI DeBBUHL
, ADDRESS
EDUCATION
Yeahiva University - Benjamin N. Cardoza School cf Law
- New York, New York - J J ) . 1981
State University of New York at Binghamtan - Binghamton, New York
R A . - 1976 Political Science/History
WORK EXPERIENCE
January. 1992 - Present: SHAREHOLDER, USKOW & LEWIS, A PROFESSIONAL CORPORATION,
One Shell Square, 50th Floor, New Orleans, Louisiana, 70139, (504) 581-7979. Ms. DeBruhl was
requested to relocate her corporate health care practice and become a shareholder of Liskow & Lewis in
1992. liskow & Lewis is one of the ten largest law firms in New Orleans with over 85 attorneys. Ms.
DeBruhl is the head of the corporate health care section which serves as general counsel to acute-care and
rehabilitation hospitals throughout Louisiana. Ms. DeBruhTs clients include health care providers of all
disciplines including multiple physician specialties, medical staffs, home health agencies, ambulatory
surgical facilities and clinical laboratories. Client representation focuses on federal and state regulatory
issues including Medicare and Medicaid certification and reimbursement, physidan recruitment and
contracting, medical staff issues, managed care, compliance with COBRA emergency requirements,
Medicare fraud and abuse including enforcement and compliance issues, as well as insurance industry
compliance and fraud.
November. 1990 - December. 1991: WOOTAN & STAKELUM, A PROFESSIONAL CORPORATION,
1515 Poydraa Street, Suite 2200, New Orleans, Louisiana, 70112. Merger of Kathleen L . DeBruhl's
Professional Law Corporation with Wootan & Stakelum, P.C. Continuation of practice of corporate and
health care law, including general counsel representation to hospital boards, home health agencies,
physician joint venturing, and regulatory issues under Title XVm of the Social Security Act, including
reimbursement and Medicare fraud and abuse.
February 1986 - October. 1990: INDEPENDENT PRACTITIONER -KATHLEEN L . DeBRUHL, A
PROFESSIONAL LAW CORPORATION, 3900 N. Causeway Boulevard, Suite 1430, Metairie, Louisiana
70002. Practice includes general law with special practice of corporate and health law.
August 1984 - February 1986: CORPORATE COUNSEL - HEALTH SERVICES DEVELOPMENT
CORPORATION, Metairie, Louisiana. Responsibilities included general corporate formation and
dissolution; stock and asset acquisitions; mergers and reorganizations. Preparation and negotiation for
construction of new hospital facilities. Preparation and negotiation of ground leases; management leases
and commercial leases. Health law including Title XVin,XIX,and Section 1122 regulatory work; medical
staffrepresentation; general counsel representation for hospital boards. Civil and administrative litigation,
both state and federal.
�Kathleen Lewinski DeBruhl
Page -2-
November 1981 - August 1984: ASSOCIATE ATTORNEY - WYLLIE & FRAICHE, A Partnership of
Professional Law Corporations, Metairie, Louisiana. Responsibilities included corporate formation;
acquisition; reorganization and merger. Health law including Medicare and Medicaid reimbursement;
general counsel for hospitals and other healthcare facilities; Title XVIII, XIX, and Section 1122 regulatory
work. Civil and administrative litigation, both state and federal.
ADMITTED TO PRACTICE
Supreme Court, State of Louisiana - 1982
Supreme Court, State of New York - 1982
U.S. District Court - Eastern District of Louisiana - 1982
U . S. District Court - Western District of Louisiana - 1983
U . S. District Court - Middle District of Louisiana - 1983
PROFESSIONAL ORGANIZATIONS
1982 to Present - Louisiana State Bar Association
1982 to Present - New York State Bar Association
1982 to Present - American Academy of Hospital Attorneys of the American Hospital Association
1982 to Present - National Health Lawyers Association
1986 to Present - Louisiana Society of Hospital Attorneys of the Louisiana Hospital Association
1991 - 1992 - Louisiana State Bar Association - Appointment to Medical/Legal Interprofessional
Committee (A Joint Committee of the Louisiana Medical Society and Louisiana State
Bar Association) - Subcommittee on Law and Medical Students
LECTURES
1981 - 1984
St. Charles General Hospital Nurse Orientation Program(s) - "Nursing Liability"
New Orleans, Louisiana
1983
-
Louisiana Nursing Association - "Nursing Liability"
New Orleans, Louisiana
1984
-
Louisiana Nursing Association of OB-GYN Nurses - "Nursing Liability"
New Orleans, Louisiana
1986
-
Doctor's Hospital of Jefferson Medical Staff - "Informed Consent"
Metairie, Louisiana
�Kathleen Lewinski DeBruhl
Page -3-
1989
-
Louisiana Association of Home Health Agencies - "Physician Joint Ventvu-es and Medicare
Fraud & Abuse - New Orleans, Louisiana
1989
-
Doctor's Hospital of Jefferson - Nursing Staff - "Legal Issues in Nursing"
Metairie, Louisiana
1989
-
New Orleans Professional Office Affiliates Association (Elmwood Medical Center) "Overview of Legal Issues" - Jefferson, Louisiana
1990
-
Louisiana Hospital Association - Society for Hospital Attorneys - "Health Care Quality
Improvement Act" - New Orleans, Louisiana
1990
-
Louisiana Hospital Association - Louisiana Society for Healthcare Administrative Support
Personnel - "Overview of Current Legal Issues Affecting Hospitals"
New Orleans, Louisiana
1990
-
Louisiana Hospital Association Healthcare Administrators - "Health Care Quality
Improvement Act" - (New Orleans, Baton Rouge, Lafayette, Alexandria, Monroe,
Shreveport and Lake Charles, Louisiana)
1990
-
Eye, Ear, Nose & Throat Hospital Medical Staff - "Healthcare Quality Improvement Act"
New Orleans, Louisiana
1990
-
Louisiana Hospital Association - Organization of Nurse Executives - "Legal Issues in
Nursing" - Shreveport, Louisiana
1990
-
Louisiana Hospital Association - Louisiana Society for Hospital Social Work Managers in
Health Care - "Overview of Current Legal Issue Affecting Hospitals" - Lafayette, Louisiana
1990
-
Louisiana Hospital Association - Louisiana Society for Healthcare Administrative Support
Personnel - "Overview of Current Legal Issues Affecting Hospitals" - Baton Rouge,
Louisiana
1991
-
Louisiana Hospital Association - Louisiana Society for Hospital Social Work Managers in
Healthcare - "Overview of Current Legal Issues Affecting Hospitals - Lafayette, Louisiana
1991
-
Louisiana Hospital Association - Louisiana Society of Hospital Attorneys - Winter Health
Law Update, - "National Practitioner Data Bank", Alexandria, Louisiana
1991
-
Willis-Knighton Medical Center - Legal Factors Affecting Nursing Management,
Shreveport, Louisiana
1991
-
Wootan & Stakelum, APC CUent Seminar - 1991 Legislative Changes - What Affects You
as an Employer?
1992
-
Louisiana Hospital Association - Annual Spring Meeting - "Confidentiality in the Hospital
Workplace"
1992
-
Louisiana Hospital Association - Hospital Administrators - "Fraud and Abuse Enforcement in the 90's", Baton Rouge and Shreveport, Louisiana
�Kathleen Lewinski DeBruhl
Page -4-
1992
Louisiana Hospital Association - Louisiana Society of Hospital Attorneys - Winter Health
Law Update - "Managed Care Contract Issues", New Orleans, Louisiana
1992
Liskow & Lewis Physician Seminar, "Business Issues Affecting Physicians in the 1990's",
New Orleans, Louisiana
1993
Doctor's Hospital of Jefferson - Nursing Staff - "Withdrawal of Life Support and Do Not
Resuscitate Policies", Metairie, Louisiana
PUBLICATIONS
March, 1990
-
Louisiana Hospital Association - Legal Brief - Health Care Quality Improvement
Act
April, 1992
Louisiana Hospital Association - Legal Brief - "Informed Consent for Vaccine
Administration"
February, 1993 -
Editor, Contributing Author, Liskow & Lewis' "Health Law Alert" - Compilation
of federal and state regulatory, legislative, and judicial developments in health
care
OTHER APPEARANCES
1991
Cox Cable - "It's the Law" Television Show with Judge Steven Plotkin - "Medico-Legal
Issues"
�CODER.
HEALTH CARE TASK FORCE SORTING SHEET
INPUT DATE:
OEWRRAL SORT:
POSTCARD 1:
Personal stories
.General mail
.Letter Campaign
Other Health Providers
POSTCARD 2:
.Offers to help/Employment
.Physicians
FORM LETTER:
Letterhead
.Policy
REROUTE:
Casework
.Scheduling
POLICY AND PERSONAL
President
Other
SS:
.ORGANIZATION (I)
insurance premiums
insurance reform
insurance pools
boards and oversight
.COVERAGE (H)
working families
unemployed/low income
benefits
providers
.INFRASTRUCTURE/WORKFORCE (III)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
manpower issues (training)
.unnecessary procedures
.GOVERNMENT PROGRAMS (IV)
medicare
medicaid
veterans
DoD
Indian health
.COST ISSUES (VI)
drug prices
physician fees
hospital fees
medical equipment
fraud & abuse
FINANCING (VH)
MENTAL HEALTH (IX)
LONG-TERM CARE (X)
PUBLIC HEALTH/
SPECIAL POPULATIONS (XH)
prevention
AIDS
.women's health
Jmmunizations/children
jrural
urban
OTHER
�J
^
�^ientexxmxt (Snterrtor
Leo McCarthy
Hntz of <2IaItf0tTtta
•
STATE CAPITOL
R O O M 1114
S A C R A M E N T O . CA 95814
19161 4 4 5 - 8 9 9 4
Q
4 5 5 G O L D E N GATE A V E N U E
SUITE 2218
SAN FRANCISCO. CA 94103
1415) 5 5 7 - 2 6 6 2
•
5 7 7 7 WEST CENTURY BOULEVARD
SUITE 1650
L O S A N G E L E S . CA 9 0 0 4 5 - 5 6 3 1
1310) 4 1 2 - 6 1 1 8
February 23, 1993
First Lady Hillary Rodham Clinton
The White House
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mrs. Clinton:
Thank you for taking on the formidable task of health care reform. I believe you will succeed
in getting a comprehensive plan through Congress.
As we build a government that looks like America, we need a health care system that takes
care of America. The long-standing disparity in health status between minorities -- African
Americans, Asian Pacific Americans, Latinos and Native Americans - and most nonminorities, must be successfully addressed in your effort.
I would like to share with you information from my work on minority health access issues,
including childhood immunization. Over three years ago, I targeted minority health access
as an issue that needed aggressive attention in California. I began working with leaders in
the minority communities to assess the problem and develop strategies to connect community
initiatives with legislative responses.
Our work produced four major results:
o Elevating the visibility of little-known statistics exposing the gap between the health
status of minorities and most non-minorities;
o The convening of first-ever community/legislative hearings on Asian Pacific American
health access issues;
o A report based on the proceedings of the Asian Pacific American health hearings, which
is still the nation's only comprehensive community testimony regarding health issues in
these communities;
o The convening of a statewide task force to bring the issue of childhood immunizations
in minority communities to priority status.
to
�Given the common misperception of Asian Pacific Americans as "model minorities" who are
all successful academically and financially, the myriad troubles facing these diverse
communities, including health access, are often misunderstood or overlooked.
There are members of the Asian Pacific American community who are experts in the health
care field, particularly in the area of linguistic and cultural issues. I have developed, in
partnership with a coalition of community, legislative and business leaders, including Sherry
Hirota of Asian Health Services, Lauren Mayeno of the Association of Asian Pacific Health
Organizations and Tessie Guillermo of the national Asian American Health Forum, a report
based on public hearings, entitled, Asian Health Issues in the 1990s. I believe it would be
important to include such experts in the discussion when your task force addresses the issue
of access.
Linguistic access is an issue of concern for all non-English speaking communities, but one that
is experienced with particular acuity in the Asian Pacific American community. In California,
where Asian Pacific Americans are the fastest growing minority community and comprise
approximately 10% of our total population in the state, they are also the most diverse. The
failure to have culturally competent services available to hospitals and clinics causes frequent
access and treatment problems. Individual case samples in this report are from California,
but are similar to experiences throughout the nation. Language and cultural barriers affect
millions of Americans who are monolingual or limited English speaking. Lack of access to
quality health care for our multicultural and multilingual eligible residents proves to be costly
both in work productivity and government cost.
It is common for many in the Chinese American community to ignore early cancer warning
signs, delay seeking care or avoid treatment all together, mostly because of cultural and
linguistic obstacles. The incidence of liver cancer among Chinese males is seven and a half
times that of their white counterparts. Lung cancer incidence and deaths in Chinese and
Hawaiian women are recorded as the highest in the nation. These rates indicate many face
sizable barriers to treatment with advanced technology and primary prevention and early
detection methods. During the measles epidemic of 1990, over 50% of the deaths were
Asian Pacific American children. The efforts to prevent the outbreak were hindered by the
lack of language and cultural competency by community health workers and medical providers
to those communities most at risk.
The President's proposal to provide free immunization to all children in the United States is
a welcome response to a public health emergency we have felt severely in California. In 1992
I created a Statewide Immunization Task Force. I directed the Immunization Task Force,
in conjunction with the University of California at Berkeley's Children and Youth Policy
Project, to produce a report, "Immunizing California's Children," to provide policy makers,
elected officials, health providers, parents and advocates, with a blueprint on how to fully
immunize our children. While economic accessibility presents one of the greatest obstacles
to full immunization, I know you are aware there are many other barriers, such as those
related to outreach and cultural familiarity. I am sending several copies of the report. I hope
you and your staff will find them useful.
-2-
�While our efforts have focused on researching woefully underexamined issues in the Asian
Pacific American communities, our findings are indicative of the well-documented health and
access problems facing many in all minority communities in the United States.
In the African American community, babies are 95% more likely to die than their white
counterparts; African American women have a 40% greater chance of dying from breast
cancer than their white counterparts and African American men have a 60% greater chance
of death and disability due to hypertension than their white counterparts. I have worked in
collaboration with the California Black Health Network and Dr. Clyde Oden, President of the
Watts Health Foundation in Los Angeles, to develop initiatives to address these disturbing
numbers.
The Latino community in California, which provides proportionally more participants in the
labor force than any other racial/ethnic group, is one of the most uninsured and underserved.
The Native American population in California is culturally diverse and geographically
widespread. Califomians who use the National Indian Health Service have unacceptably high
rates of late prenatal care, unintentional injury, accidental death, diabetes, STD's and
alcoholism.
The California House delegation and Senators Dianne Feinstein and Barbara Boxer will be
very supportive of your efforts. Additionally, leaders in minority communities will offer their
aid. In particular, California-based Asian Pacific American leaders and health care
professionals are poised to network with their counterparts in other states in the area of
minority access to help get health care reforms enacted. New York, Texas, Hawaii,
Massachusetts and Illinois, for example, have strong community leadership in the matter of
minority health access and would be critical in building a national consensus for your health
care reform plan.
You have my good wishes and active support. It takes courage and commitment to accept
the job of major health care reform. My office and I are available to help.
Warm regards,
Leo McCarthy
LM: sk
Enclosures
cc: Senator Dianne Feinstein
Senator Barbara Boxer
Congresswoman Nancy Pelosi
Congressman Pete Stark
�CITY OF GREER
106 SOUTH M A I N
STREET
GREER, SOUTH CAROLINA 29650
February 5, 1993
Mrs. H i l l a r y C l i n t o n
The White House
16 00 P e n n s y l v a n i a Avenue
Washington, DC 20500-0001
Dear Mrs. C l i n t o n :
I would l i k e t o b r i e f l y share w i t h you my p o i n t o f view as an
independent r e t a i l pharmacist as you undertake t h e monumental t a s k
of i m p r o v i n g our h e a l t h - c a r e d e l i v e r y system and c o n t r o l l i n g c o s t .
I am u n c e r t a i n as t o t h e degree p h a r m a c e u t i c a l
services
contribute
t o t h e problem,
b u t I have seen c o s t s
rise
d i s p r o p o r t i o n a t e l y t o t h e r a t e o f i n f l a t i o n over t h e p a s t s e v e r a l
y e a r s , due almost e n t i r e l y t o manufacturers' p r i c e i n c r e a s e s . I t
would seem t h a t drug p r i c e i n c r e a s e s should somehow be l i m i t e d t o
i n c r e a s e s i n t h e consumer p r i c e index.
Another p r a c t i c e by drug manufacturers' t h a t c o n t r i b u t e t o t h e
o v e r a l l problem i s t h e d i f f e r e n c e i n a c q u i s i t i o n c o s t t o p r o v i d e r s .
D i f f e r e n t p r i c e s a r e charged t o p r o v i d e r s i n t h e U n i t e d S t a t e s ,
Canada, and Mexico.
A l s o , d i f f e r e n t p r i c e s a r e charged t o
h o s p i t a l s , m a i l o r d e r pharmacies, d o c t o r s ' o f f i c e s t h a t d i s p e n s e ,
and r e t a i l pharmacies.
This p r a c t i c e u l t i m a t e l y s h i f t s t o many
consumers and i n s u r a n c e companies an u n f a i r share o f o v e r a l l c o s t s .
I a l s o have a s e r i o u s concern about t h e f u t u r e o f independent
r e t a i l pharmacies ( a p p r o x i m a t e l y 40,000) and our a b i l i t y t o s u r v i v e
i f we a r e n o t a l l o w e d t o purchase pharmaceuticals a t c o m p e t i t i v e
p r i c e s and be a l l o w e d t o p a r t i c i p a t e i n h e a l t h plans as l o n g as we
are w i l l i n g t o meet c o m p e t i t o r s ' p r i c e s f o r d e l i v e r y o f pharmacy
services.
As a l o n g t i m e c i v i l s e r v a n t , an o b s e r v a t i o n o f mine over t h e
past t w e n t y years o r so i s t h a t s m a l l business owners a r e much more
i n v o l v e d i n s u p p o r t i n g t h e i r communities t h a n a r e employees o f
l a r g e c o r p o r a t i o n s . The m a j o r i t y o f c o n t r i b u t o r s and v o l u n t e e r s i n
t h i s c i t y a r e members o f t h e s m a l l business community. I hope t h e
c u r r e n t a d m i n i s t r a t i o n i s c o g n i z a n t o f t h e f a c t t h a t t h i s segment
o f o u r economy needs some p r o t e c t i o n . The l a s t two a d m i n i s t r a t i o n s
d e f i n i t e l y d i d n o t seem t o understand t h i s f a c t .
�Mrs. H i l l a r y C l i n t o n
February 5, 1993
Page 2
I w i s h you w e l l i n a l l your e f f o r t s . I f ever I o r t h e C i t y o f
Greer can be o f a s s i s t a n c e , I o f f e r our s e r v i c e s i n advance.
With regards,
CITY OF GREER
C. Don W a l l
Mayoj
CDW/jl
�WALTER J. HICKEL/GOVERNOR
State of Alaska
GOVERNOR'S COUNCIL ON DISABILITIES AND SPECIAL EDUCATION
P.O. Box 240249 • Anchorage, Alaska 99524-0249 • Phone: 907-563-5355 • Fax: 907-563-5357
March 5, 1993
Mrs. Hillary Rodham Clinton
Chair, National Health Care Task Force
The White House
1600 Pennsylvania Avenue N.W.
Washington, D.C. 20500
Dear Mrs. Clinton:
Thank you for your leadership in health care issues. In order to keep the
needs of people with disabilities in the debate over health care reforms,
we want to provide you with information about Alaskans.
Health care coverage is offered by employers, the Indian Health Service,
and through CHAMPUS. As many as 70% of Alaskan adults with disabilities
use Medicaid as their primary health insurance. However, nearly 20% of
all Alaskans lack health care coverage.
Children with developmental disabilities and their families experience a
unique problem. The children can not be covered by health insurance
because they have pre-existing conditions. Children with disabilities
living at home with their natural parents can't receive Medicaid funding if
the family's income is too high. Since they refuse to place their children
in the state's custody or in an institution, a significant number of Alaskan
families live impoverished by medical bills.
The Alaska State Legislature created a task force to develop a strategy to
provide health coverage and contain rising cost. Additionally, the
Governor's Council on Disabilities, the Older Alaskans Commission and the
state Medicaid agency collaborated to explore options for financing long
term care. For your review, a copy of these reports is enclosed.
Again, thank you for giving health care a national focus. Should you have
any questions, please call me.
Sincerely,
David Ttfaltman
Executive Director
�t
i n
COMMITTEE ASSIGNMENTS:
JOHN REEVES
Dislncl 72
Conslilution. Vice Chairman
Hinds Counly
AgricLillurc
555 Tombigboe Street. Suite 107
Appiopnalions
Jackson. Mississippi
Judiciary A
39201
Rules
February 9, 1993
H i l l a r y C l i n t o n , Esquire
D i r e c t o r , H e a l t h Care Task Force
The White House
1600 Pennsylvania Avenue, N.W.
Washington, D.C. 20500
Dear Mrs. C l i n t o n :
I r e a l l y a p p r e c i a t e your banning smoking i n t h e White House.
I am s u r p r i s e d t h a t i t has n o t been done b e f o r e now. Your a c t i o n s
set a w o n d e r f u l example f o r m i l l i o n s o f Americans.
I have i n t r o d u c e d no-smoking b i l l s i n t h e l e g i s l a t u r e f o r s e v e r a l
years now and h o p e f u l l y I w i l l be s u c c e s s f u l . Smoking, of course,
k i l l s t h e smoker e v e n t u a l l y , b u t i t a l s o can k i l l t h e non-smoker.
That i s why we need t o have smoke-free b u i l d i n g s .
I am a Republican and I have admired your stamina. My w i f e has
an M.B.A. and i s t h e p e r s o n n e l manager f o r a major l i f e i n s u r a n c e company,
We have one c h i l d and one on t h e way, b u t I have never suggested t h a t
she p u t her career a s i d e . I have encouraged her career I t h i n k t h a t
your example encourages many women t o seek t h e i r f u l l p o t e n t i a l p r o f e s s i o n a l l y and s t i l l m a i n t a i n s t r o n g f a m i l y t i e s and commitments.
With best r e g a r d s , I remain
nceMely,
hn R. Reeves
JRR/j f j
�V I R G I N I A M.
THOMAS
LEGISLATIVE OFFICE
VICE CHAIRMAN
ENVIRONMENTAL MATTERS COMMITTEE
LOWE OFFICE BLDG., ROOM 2t9-C
ANNAPOLIS, MARYLAND 21401-1991
TELEPHONE (410) 841-3205
TOLL FREE: I -BOO-492-7122
JOINT COMMITTEE ON ADMINISTRATIVE,
EXECUTIVE AND LEGISLATIVE REVIEW
DISTRICT OFFICE:
CHILD CARE ADVISORY COUNCIL
6153 FORTY WINKS WAY
COLUMBIA. MARYLAND 2I04E-4313
TELEPHONE: (410) 730-0485
TTY (410) 841-3814
SELECT COMMITTEE ON DRUG AND ALCOHOL ABUSE
JOINT HEALTH CARE COST CONTAINMENT COMMITTEE
ON LONG TERM CARE
GOVERNOR'S ADVISORY BOARD ON RESIDENTIAL
PROGRAMS FOR ELDERLY AND DISABLED ADULTS
GOVERNOR'S TASK FORCE ON NON-TIDAL WETLANDS
HOUSE OF DELEGATES
ANNAPOLIS, MARYLAND 21401-1991
JOINT MEDICAID OVERSIGHT COMMITTEE
H O W A R D COUNTY - DISTRICT 1 3A
April 6, 1993
Ms. Hillary Rodham Clinton
The White House
1600 Pennsylvania Avenue
Washington, D C 20500
..
Dear Ms. Clinton:
Attached are some Health Care Reform Ideas I received from a constituent,
them to be very impressive and would greatly appreciate your giving them
your attention.
Sincerely,
hrgima
Delegate
VMTrrjp
"homas
I found
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002a. letter
SUBJECT/TITLE
DATE
Constituent to Hillary Clinton, re: cancer (2 pages)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [3]
2006-0885-F
wr826
RESTRICTION CODES
Presidential Records Act - (44 U.S.C. 2204(a)|
Freedom or Inrormation Act - (5 U.S.C. 552(b)|
PI National Security Classified Inrormation 1(a)(1) or the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIAj
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the F01A|
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIAj
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002b. statement
SUBJECT/TITLE
DATE
n.d.
From constituent, re: cancer (2 pages)
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [3]
2006-0885-F
wr826
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA]
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA|
b(3) Release would violate a Federal statute [(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the F01A|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIAJ
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIAj
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�<7>
February 4,1993
(
Dear Mrs. Clinton:
I would like to take this opportunity to bring to your attention the
enclosed invitation from the Women Against Rape/Child Watch group,
requesting your presence at the their 20th Anniversary Celebration in October.
I wanted to join Joan McKenna in urging you to attend. I know that the
State of New Jersey and the Women Against Rape association would be most
honored to have you present. Your attendance would truly make this event a
momentous occasion. If you choose to attend the 20th Anniversary celebration, I
can assure you that you will have an avid and appreciative audience.
We in New Jersey are looking forward to four years of growth and
success garnered by the Clinton/Gore Administration. Your presence at this
annual event will only serve to spur New Jersey towards a better future for
generations to come.
Please accept my and New Jersey's sincerest best wishes for a
promising new era. We are looking forward to a kinder and gentler United States.
Sincerity,
JUW.FLORIO
fovernor
JJF:adh
Hillary Rodham Clinton, First Lady
The White House
West Wing #8
Washington, DC 20500
�HELPING ASSAULT VICTIMS' EMERGENCY NEEDS
WOMEN AGAINST RAPE
COUNTIES SERVED:
Camden
Burl.-Glouc.
P.O. BOX 346
COLLINGSWOOD, NJ 08108
(609) 858-7800
(609) 858-7063 FAX
Joan McKenna, President & CEO
BOARD OF DIRECTORS
Officers
WAR'S
Mickey Garrett, Chairperson
Or. Mary Previty, 1st Vice Chair
Terry Bonzella, 2nd Vice Chair
Kale McNally Sec./Treas.
Trustees
Barbara Mayock
Joy Bantivoglio
Gmny Flowers
February
John Lewis, Chairperson
Judd Booker
Police Chiel. Pine Hill
Bill Youse
Local #439
Jim Kehoe
Local #322
Tony Nicim
Lieut. Sherill's Ollice
Joanne Annacone
Public Relations
Tom Paparone
Paparone Housing
Sarah Dawling
Public Relations
Jim Killough
Central Jersey Bank
Jackie Gehring
Chair, VGA
Anna Mullen
Mayor, Gloucester Twp.
Shirley Williams
CEO, Group Homes
Kelly Law
Attorney al Law
la Starr
AM Philadelphia
Pal Ambrosius
Womens Way
Clem Carney
Social Services
Bill Hanna
Jane Cahill
SOLICITOR
Michael J McKenna
Attorney Al Law
ChenyHill
HAVEN
1993
Hi I l a r y Rodham Cl i n t o n
The Wh i t e House
West Wing, #8
W a s h i n g t o n , D.C. 20500
Dea r
ADVISORY BOARD
1,
Hillary:
The
v o l u n t e e r s and s t a f f o f Women A g a i n s t
R a p e / C h i l d Watch were e x c i t e d t o v i e w t h e r e c e n t
i n a u g u r a l a c t i v i t i e s and w i s h you and P r e s i d e n t
C l i n t o n much s u c c e s s .
We a r e c o n f i d e n t
that
under t h e C l i n t o n A d m i n i s t r a t i o n , 1993 w i l l usher
in a new e r a o f g r o w t h , u n d e r s t a n d i n g , c o m p a s s i o n
and h uma n i t y f o r o u r n a t i o n .
For t h e members o f WAR, 1993 a l s o r e p r e s e n t s
our 2 0 t h a n n i v e r s a r y as a n o n - p r o f i t r a p e - c r i s i s
center.
WAR's
anniversary
c e l e b r a t i o n is
scheduled
f o r O c t o b e r and i t w o u l d be g r e a t l y
appreciated
i f we c o u l d
honor
you f o r your
advocacy on b e h a l f o f women and c h i l d r e n .
With
your d e d i c a t i o n , c o n c e r n and f i r m commitment t o
children's
issues,
there
could
be no b e t t e r
c h o i c e as t h e e v e n i n g ' s h o n o r e d g u e s t .
G o v e r n o r T i m F l o r i o , a s t r o n g champion and
f r i e n d of our o r g a n i z a t i o n s i n c e i t s i n c e p t i o n i n
1973, has g r a c i o u s l y a g r e e d t o s e r v e as h o n o r a r y
chairperson of the event.
Women A g a i n s t Rape has a s s i s t e d more than
2.5,000 v i c t i m s - b o t h a d u l t s and c h i l d r e n - o f
s e x u a l a b u s e , i n c e s t and r a p e .
We have p r o v i d e d
cr i m e - p r e v e n t i o n programs f o r more than 200,000
p a r t i c i p a n t s r a n g i n g f r om p r e - s c h o o l c h i l d r e n t o
senior c i t i z e n s .
WAR
spent
i t s first
seven
years
as a
non-funded
volunteer
organization
until
then
Congressman F l o r i o h e l p e d t o g a i n f e d e r a l Ccmrunity
Solicitor. Board of Directors & Advisory Board Members are not compensated.
A United Way Member Agency
�WAR (Women A g a i n s t
Rape)
February
1,
1993
Development B l o c k G r a n t f u n d s .
We have e n j o y e d
relationships with
the late Michael
Landon as
w e l l as John Walsh t h e f o u n d e r o f t h e C e n t e r f o r
Missing Children.
B o t h have w o r k e d w i t h us a t
fundraisers
and
through
a
public
service
announcement.
In f a c t ,
Mr. Landon's p u b l i c
service
announcement
inspired
an
astounding
r e s p o n s e f r o m young men and boys who were v i c t i m s
of s e x u a l a s s a u l t .
Thanks t o t h e t e n a c i t y and s t r e n g t h o f t h e
p e o p l e o f New J e r s e y , WAR has c o n t i n u e d as one o f
the
oldest rape-crisis centers
in the country
providing
i rrme d i a t e ,
confidential
and
free
2'+-hour s e r v i c e s . Ours i s one o f t h e few c e n t e r s
to
provide
shelter
specifically
f o r sexually
abused women and c h i l d r e n .
WAR's
volunteers,
staff
and Board o f
D i r e c t o r s w o u l d be h o n o r e d i f you w o u l d a c c e p t
our i n v i t a t i o n .
Wh i Ie WAR's a n n i v e r s a r y i s i n
October.
we w o u l d
be happy
t o arrange our
c a l e n d a r t o a cconrmoda__Le_y ou r busy s c h e d u l g .
Ttfte
G o v e r n o r ' s s t a f f has a l s o a g r e e d t o w a i t u n t i l we
hear f r om you b e f o r e s e t t i n g a f i n a l d a t e .
May God b l e s s y o u , t h e P r e s i d e n t and C h e l s e a
as you embark upon t h i s i m p o r t a n t t i m e i n your
life
and g r a n t you c o n t i n u e d good h e a l t h and
happiness.
I look f o r w a r d t o h e a r i n g f r o m y o u .
W i t h t h a n k s f o r your k i n d c o n s i d e r a t i o n , I remain
ce r e I y
roan McKenna
'res i den t /CEO
JMcK/rmu
�P S ^OUERNOP'3 OFFICE
lG
TEL :684-633-2269
fipr 22*93
15:45 Ho .070 P.01
GOVERNOR'S OFFICE
(Amencan Samoa Government)
FAX TRANSMITTAL
SHEET
Date
TO:
fflgS.
U-rlUo'u
f^Unftn
•
Fax #:
FROM
MESSAGE: 0£jt<j/K*4>
SENDER: Q L
Fax
ftrii^
^
DATE:
FOUJOU>
No. of pages i n c l u d i n g t r a n s m i t t a l s h e e t :
&>±(
6 33- 2 - ^ ^
&<-f r^kt
I^^(^ %
-
TIME:
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3',3.0
^
(IF YOU FAIL TO RECEIVE LIGIBLE COPIES " F ALL PAGES, OR ARE MISSING
O
ANY PAGES, PLEASE CALL (684) 633-4116, AND ASK FOR THE SENDER).
THANK YOU.
�flSG. GOVERNOR ' S OFFICE
TEL : 684-633-2269
Apr 22'93
15:46 No. 070 P.02
OFFICE OF THE GOVERNOR
American Samoa Government
Pago Pago, American Samoa 96799
A.P. Lutali, Governor
Tauese P. Sunia. LL Governor
Tefephone: (684) 633-4116
Roc (664) 633-2269
A p r i l 22, 1993
Serial:
601
Mrs. HillsLry Rodham Clinton
The F i r s t Lady
The White House
Washington, D.C.
Dear Mrs. Clinton:
I greatly appreciate the recent opportunity to present American
Samoa's views on the proposed National Health Care Reform Program.
However, i t i s extremely d i f f i c u l t to adequately describe by l e t t e r
and form the e n t i r e l y unique health care issues that face the
health systems of isolated island j u r i s d i c t i o n s such as American
Samoa, Guam, and the Commonwealth of the Northern Marianas. Not
only are our health systems very different, but the s o c i a l ,
economic, and p o l i t i c a l environments which shape and influence the
nature of our health systems are not duplicated anywhere i n the
continental U.S. Because of t h i s , I am certain you can understand
why I am greatly concerned that the major changes being proposed
under the National Health Care Reform Program could potentially
have a major negative impact on our f r a g i l e health system. Since
i t w i l l take careful analysis of the components of the f i n a l reform
program to determine the impact on American Samoa, I am most
urgently seeking the inclusion now of s u f f i c i e n t f l e x i b i l i t y and
broad waiver provisions which w i l l allow us to l a t e r design a l o c a l
reform program which accomplishes the desired end through l o c a l l y
appropriate mechanisms.
I understand that Congressman De Lugo has suggested the p o s s i b i l i t y
of a meeting of the Governors of American Samoa, Guam, and the
Commonwealth of the Northern Marianas with you to discuss the
potential impact of the National Health Care Reform Program on our
respective j u r i s d i c t i o n s . I n l i g h t of the above general overview,
and the more detailed information and concerns transmitted to your
o f f i c e previously, I would welcome such an opportunity, i f i t could
be arranged during the period i n which we would a l l be present i n
Washington for budget hearings, preferably the afternoon of May 3rd
or May 4th. Given the present f i n a n c i a l situation of the American
Samoa Government, i t would be d i f f i c u l t for myself and my Health
Advisor to t r a v e l the great distance to Washington s p e c i f i c a l l y for
such a meeting a t another time.
�flSG GOVERNOR'S OFFICE
TEL:684-633-2269
Apr 22*93
15 = 46 Mo.070 P.03
BILIARY CLINTON
Page 2
4/22/93
Please be assured that your extraordinary e f f o r t s to help shape a
more r a t i o n a l and equitable health care system f o r our nation are
deeply appreciated by those of us who are working toward the same
goal.
A. P. Lutalj
Governor of American Samoa
cc. Mr. John Hart
Deputy Assistant to the President for
Intergovernmental A f f a i r s
The White House
Washington, D.C.
�Columliusi
43215
February 23, 1993
F i r s t Lady H i l l a r y Rodham C l i n t o n
The White House
1600 Pennsylvania Avenue
Washington, DC
Dear Mrs. C l i n t o n :
C o n g r a t u l a t i o n s on t a c k l i n g a tough i s s u e . I n case you're
i n t e r e s t e d i n a R e p u b l i c a n * p e r s p e c t i v e on h e a l t h c a r e , I ' v e
enclosed something I w r o t e i n 1991. The more ideas you have t h e
b e t t e r o f f you a r e . There i s one t h i n g I d i d n ' t address i n t h e
r e p o r t , and t h a t ' s p h a r m a c e u t i c a l c o s t s .
Everybody's c o m p l a i n i n g about t h e huge d i f f e r e n c e between
the c o s t o f drugs i n America verses everywhere e l s e . I t i s n ' t t o o
d i f f i c u l t t o f i g u r e o u t what's happening and what t h e answer i s .
American drug companies spend enormous sums on r e s e a r c h &
development. That i s a n e c e s s i t y i n o r d e r t o produce t h e new
m i r a c l e drugs. I f drug companies weren't p e r m i t t e d t o r e c o v e r
t h e i r R & D c o s t s , t h e r e would be any new drugs. Witness t h e l a c k
o f new drugs i n Canada.
F o r e i g n c o u n t r i e s s t a n d on t h e s i d e l i n e s and watch American
companies spend b i l l i o n s t o develop new drugs. Once developed, t h e
f o r e i g n governments l i m i t t h e drug's p r i c e , l e a v i n g t h e drug makers
no c h o i c e b u t t o r e c o v e r a l l o f t h e i r R & D c o s t s from American
consumers. American consumers a r e p a y i n g a l l o f t h e r e s e a r c h and
development c o s t s ( a l o n g w i t h t h e p r o f i t s ) f o r drugs w i t h w o r l d
wide markets. A p o l i t i c a l l y p o p u l a r s o l u t i o n would be t o s i m p l y
l i m i t t h e drugs' p r i c e i n t h e U.S., which, o f course, would be
sheer f o l l y . That would r e s u l t i n no r e s e a r c h and development and
no new l i f e s a v i n g drugs.
A more e l e g a n t s o l u t i o n would be t o r e q u i r e drug companies t o
s e l l t h e i r products i n t h e United States a t t h e lowest p r i c e they
charge any o t h e r c o u n t r y i n t h e w o r l d . Exempted from t h i s
r e q u i r e m e n t would be any c o u n t r y t h a t l i f t s t h e i r p r i c e c o n t r o l s .
I n v e r y s h o r t o r d e r , American companies would be t e l l i n g t h e p r i c e
c o n t r o l c o u n t r i e s t h a t t h e y can no l o n g e r s e l l them t h e i r drugs.
�The reason i s t h a t American companies c o u l d n o t a f f o r d t o
lower t h e i r p r i c e s i n t h e U.S. t o such a low l e v e l .
Eventually,
f o r e i g n governments would have no c h o i c e b u t t o l i f t t h e i r p r i c e
c o n t r o l s , and a l l consumers, n o t j u s t American, would be s h a r i n g i n
the R & D
costs.
The r e s u l t would be s u b s t a n t i a l l y lower drug
p r i c e s f o r American consumers. To those f o r e i g n powers who impose
p r i c e c o n t r o l s , a l l Congress need do i s " j u s t say no".
Good Luck.
Sincerely,
L o u i s W. B l e s s i n g , J r .
Ohio S t a t e R e p r e s e n t a t i v e
LWB/hms
End.
An h o n e s t , " L e t ' s n o t k i c k "em i n t h e b u t t q u i t e y e t " m i n o r i t y
p a r t y approach t o h e a l t h c a r e .
�r
\ ^
John Hall, Chairman
Pam Reed, Commissioner
Peggy Garner, Commissioner
i^^A^^^
£
TEXAS WATER COMMISSION
I'Komawc n:xA,\s' IHALTII AND sAmr HYPRFVUNTING AND
March
11,
6ft
HF.DUCING POLLUTION
1993
H i l l a r y Rodham C l i n t o n , Chair
N a t i o n a l H e a l t h Care Task Force
The White House
Washington, DC 20500
Dear Chairman C l i n t o n :
I have been honored t o serve as Commissioner under t h e appointment
of Texas' Governor Ann Richards t o t h e Texas Water Commission. I
a l s o serve as a v o l u n t e e r on t h e Board o f t h e Permian Basin
R e g i o n a l C o u n c i l on A l c o h o l and Drug Abuse (PBRCADA). The C o u n c i l
c u r r e n t l y serves 17 c o u n t i e s i n West Texas.
My purpose i n w r i t i n g t o you i s t o r e s p e c t f u l l y r e q u e s t t h a t
a l c o h o l and drug t r e a t m e n t b e n e f i t s be i n c l u d e d as p a r t o f any
h e a l t h care r e f o r m package.
I s t r o n g l y support cost e f f e c t i v e
treatment
f o r alcoholics,
drug-dependent persons and t h e i r
families.
I n my v o l u n t e e r c a p a c i t y w i t h t h e PBRCADA, I have seen t h e expense
of a l c o h o l and drug a d d i c t i o n t r e a t m e n t and r e a l i z e t h e importance
of s p e c i a l i z e d t r e a t m e n t programs and f a c i l i t i e s .
I hope t h a t
H e a l t h Care Reform w i l l d e a l e f f e c t i v e l y w i t h t h i s i s s u e .
Sincerely,
Peggy/ Garnjer, Commissioner
Texas Water Commission
PG/av
cc:
Pamela Bowerman, PBRCADA, 3641 N. D i x i e , Odessa, TX 79762
C h r i s t i n e L u b i n s k i , N a t i o n a l C o u n c i l on A l c o h o l i s m & Drug
Dependence, 1511 K S t r e e t , NW, S t e . 926, Washington, DC 20005
P.O. Rox 13087 • 1700 North Congress Avenue • Austin, Texas 78711-3087 • 512/463-7830
PRINTED ON RECYCLED PAPER
�CODER:.
HEALTH CARE TASK FORCE SORTING S
INPUT DATE:
GENERAL SORT:
POSTCARD 1:
.Personal stories
General mail
Letter Campaign
Other Health Providers
POSTCARD 2:
.Offers to help/Employment
FORM LETTER:
Letterhead
REROUTE:
Casework
POTJCY AND PERSONAL
.Policy
.Physicians
Scheduling
President
Other
£S:
.ORGANIZATION (I)
insurance premiums
insurance reform
insurance pools
boards and oversight
.COVERAGE (H)
working families
unemployed/low income
.benefits
_providers
INFRASTRUCTURE/WORKFORCE (III)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
manpower issues (training)
^unnecessary procedures
.GOVERNMENT PROGRAMS (IV)
medicare
^medicaid
veterans
DoD
Indian health
.COST ISSUES (VI)
drug prices
physician fees
hospital fees
medical equipment
fraud & abuse
FINANCING (VH)
MENTAL HEALTH (IX)
LONG-TERM CARE (X)
PUBLIC HEALTH/
SPECIAL POPULATIONS (XII)
prevention
_AIDS
women's health
immunizations/children
rural
urban
OTHER
�VIP
qf
iiouae of SEpreBEntattUEB
&tat£ of ^outir (Carolina
William S. Houck, Jr., M.D.
District No. 63 - Florence County
701 Brockington Lane
Florence, SC 29501
3 1 4
C
B l a t t
B u i l d , n
Columbia, SC
g
29211
Tel. (803) 734-3004
Committee:
Medical, Military, Public and
Municipal Affairs
March 18,
1993
Mrs. H i l l a r y Rodham C l i n t o n
The White House
1600 Pennsylvania Avenue
Washington, DC 20500
Dear H i l l a r y :
The task of reforming the health care system of our country i s c e r t a i n l y not
an easy one. With a l l the special i n t e r e s t groups p u l l i n g and tugging a t you, I'm
sure that any system you devise w i l l be looked upon by some as bad. The sooner we
a l l r e a l i z e t h a t we are a l l consumers, the b e t t e r we can accept any change. I
congratulate you on your e f f o r t s and look forward to your s o l u t i o n .
My purpose i n w r i t i n g you i s not to give you any e a r t h - s h a t t e r i n g reform
package, but to emphasize to you some of my thoughts along these l i n e s .
Your
advisors are f a r more aware of the economic impact that any h e a l t h care reform
package w i l l e f f e c t .
I do f e e l that cost containment throughout the system i s
mandatory. To encourage p a r t i c i p a t i o n by the business community, cost containment
has to be the centerpiece of any plan. I introduced such a plan l a s t year i n South
Carolina. The cost of health care i n my plan was pushed back two years to encourage
p a r t i c i p a t i o n by the business community. Much to my regret, the Hospital Association
of South Carolina lobbied my plan very vigorously, and I was unable to f i n a l i z e my
efforts.
We hear much about those parts of the health care system t h a t are i n the
s p o t l i g h t and as the cause f o r the problem. Let me remind you that to remedy the
system, we must remember those so-called i n s i g n i f i c a n t systems that t r u l y " s l i p by".
These are the so-called second-line agencies or defenses that a c t u a l l y syphon o f f
great funds from the system.
We hear much about the a d m i n i s t r a t i v e cost i n the
insurance business, but also there i s tremendous administrative cost i n the h o s p i t a l
administrative systems. Home health agencies syphon o f f tremendous d o l l a r s from the
�March 18, 1993
Page Two
system, and t h i s i s true o f the health care equipment agencies, the physiot h e r a p i s t s , the chiropractors and other systems t h a t must be addressed i n any major
reform.
Probably the biggest worry o f state budgets i s t h a t o f the Medicaid system.
This i s p a r t i c u l a r l y true i n South Carolina. Medicaid costs w i l l c e r t a i n l y continue
to r i s e and w i t h the c l o s i n g o f the Charleston Naval Base, we can expect reduction
i n state monies. This w i l l only s t r a i n the state budget more.
I n some states steps have been taken t o remedy the Medicaid problems. One o f
the most a t t r a c t i v e solutions i s t h a t o f p r i v a t i z a t i o n o f the Medicaid system. This
is not yjithout i t s shortcomings but by introducing the voucher system i n the Medicaid
system, the p a r t i c i p a n t s w i l l have some incentive not t o abuse and over-spend i n the
system. I n d i v i d u a l s i n the Medicaid system w i l l be rewarded by conserving Medicaid
funds. Those funds t h a t remain can be d i s t r i b u t e d i n an equitable way among the
Medicaid r e c i p i e n t s as reward f o r not abusing and over-spending i n the system.
Any change i n the Medicaid system w i l l require federal waivers. I would l i k e
very much your input and suggestions along these l i n e s . I have discussed t h i s w i t h
those members o f the health and human services on the state l e v e l , but would
c e r t a i n l y welcome any type suggestion or input on the federal l e v e l .
I look forward t o your f i n a l plan f o r h e a l t h care reform i n t h i s country,
because I am sure i t w i l l be an imaginative one and also one t h a t w i l l a f f o r d
everyone access t o health care.
Yours very t r u l y ,
William S. Houck, J r .
WSHJr/whg/100H-12,13
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003a. letter
SUBJECT/TITLE
DATE
Marian Van Landigham to Hillary Clinton [partial] (1 page)
4/7/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [3]
2006-0885-F
wr826
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b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions |(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA)
Release would violate a Federal statute 1(a)(3) of the PRA|
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financial information 1(a)(4) of the PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�COMMONWEALTH
HOUSE
OF
OF
VIRGINIA
DELEGATES
RICHMOND
MARIAN V A N L A N D I N G H A M
CITY HALL
301 KING STREET
ALEXANDRIA, VIRGINIA 2 2 3 1 4
April
7, 199 3
COMMITTEE ASSIGNMENTS:
PRIVILEGES AND ELECTIONS
EDUCATION
APPROPRIATIONS
FORTY-FIFTH D I S T R I C T
Mrs. H i l l a r y Rodham C l i n t o n
The White House
Washington, D. C. 20500
Dear Mrs. C l i n t o n :
I r e c e i v e d t h e p a t h e t i c attached l e t t e r from one o f my
c o n s t i t u e n t s who cannot g e t assistance f o r her Cerebral Palsy
a f f l i c t e d c h i l d and keep t h i s c h i l d , because o f insurance
problems.
I t i s y e t one more example o f problems w i t h our present
h e a l t h d e l i v e r y system.
Sincerely,
Marian-'Van L a i ^ i n g h a m
MVL/hcc
cc:
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003b. letter
SUBJECT/TITLE
DATE
Constituent to Senator Joseph Gartlin, re: healthcare (2 pages)
2/12/1993
RESTRICTION
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COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [3]
2006-0885-F
WT826
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
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b(2) Release would disclose internal personnel rules and practices of
an agency |(b)(2) of the FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA|
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office [(a)(2) of the PRA|
Release would violate a Federal statute 1(a)(3) of the PRA)
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
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SUBJECT/TITLE
DATE
Joseph Gartlan to Constituent [partial] (1 page)
3/22/1993
RESTRICTION
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COLLECTJON:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [3]
2006-0885-F
wr826
RESTRICTION CODES
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P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the F O l \ |
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA|
b(3) Release would violate a Federal statute [(b)(3) of the FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOI A]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�SENATE
OF
VIRGINIA
J O S E P H V. O ART LAN. J R .
C C M M I T T t E ASSIGNMENTS:
MTH S N T RA DIITRICT
E AO I L
FAtRFAX C O U N T Y ,
ftOUTHCASTERN
P R I V I L E G E t AND E L E C T I O N S , CHAIRMAN
C O U R T S OF i U S T i C S
PAST
FINANCE
MAftON N E C K , V i n Q I N I A 1 2 0 7 0
REHABILITATION
AND S O C I A L S E R V I C E S
RULES
March 22, 1993
Dear Ms.
I apologize that I have not responded to your letter before
now. I sympathize deeply with the d i f f i c u l t situation you and your
daughter find themselves i n . I am very hopeful that President
Clinton's task force on Heath Care Reform w i l l be successful in
addressing and solving the kind of problem that you find yourself
in.
Because you l i v e i n Delegate Marion Van Landingham's d i s t r i c t ,
I have forwarded your letter to her. I am sure she w i l l be happy to
see i f anything can be done on the state level to help you.
Very truly yours,
^pseph V. Gartlan, J r .
�THE ASSEMBLY
^
5
5
STATE OF NEW YORK
ALBANY
5^
CHAIRMAN
Committee on Alcoholism
and Drug Abuse
JOHN BRIAN MURTAUGH
Assemblyman 72nd District
May 3, 1993
Mrs. Hillary Rodham Clinton
The White House
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mrs. Clinton:
As Chairperson of the New York State Assembly Committee on Alcoholism and
Drug Abuse, I have three concerns which I feel must be an integral part of any
meaningful and truly effective national health care policy.
First, it is increasingly evident that addiction, be it to alcohol, drugs or tobacco,
underlies or is interwoven with a considerable portion of the nation's incident rates for
multiple illnesses. Health care cannot possibly get a handle on costs without addressing
our nation's growing problem with abuse of a dependence upon these substances.
Addiction, in addition to causing health problems directly, is also closely correlated with
illness as it is a primary factor in many of our nation's social ills - family violence,
parental neglect, accidents at work and on the road, crime, sexual and physical abuse.
These social problems, in turn, contribute to health difficulties in creating more illness
in a vicious circle and unending cycle. I believe with Joseph Califano that addiction is
America's foremost health problem.
Second, it is clear that the recent rise in AIDS and TB. are directly related to the
IV drug abusing population and the sexual partners of the IV drug users. Therefore, you
cannot address diseases like AIDS and drug resistant TB. without addressing addiction.
Ironically, our drug treatment system gives us an excellent vehicle for treating this
population. Addicts do not function well within the traditional health care system. They
do respond to the drug treatment system where HIV prevention and drug resistant TB.
treatment can be most easily added.
Third, I firmly believe that the resources to address our addiction problem could
take a quantum leap forward, if we reversed the present 70%-30% Federal spending ratio
of law enforcement vs treatment and prevention. The best way to reduce demand is to
get people well. Study after study has demonstrated that treatment works, provided there
is an extensive continuum of care matched to the stage of the addict's illness and
recovery.
Room 627. Legislative Office Building, Albany, New York 12248, (518) 455-5807
COMMUNITY OFFICE: 656 West 204th Street, Suite 4, New York, New York 10034, (212) 304-2090
�/
Mrs. Hillary Rodham Clinton
May 3, 1993
Page 2
We cannot leave the problem of addiction out of health care reform. We have an
opportunity to make a large segment of our population well, who are destined, if their
illness progresses, to be the sickest and most costly users of the system. Alcohol abuse
in particular seems to be ignored by the Washington establishment. Ironically, alcohol
abuse, particularly among women can best be identified in an appropriate hospital
setting. People who are hospitalized or receive emergency room treatment where
alcoholism/substance abuse is probably a major contributor should be evaluated and
referred to treatment where necessary. New York State has experienced some excellent
success among women in a Hospital Alcoholic Intervention Project. I am enclosing a
Report on that New York State Hospital Alcohol Intervention Project for your convenience.
I am deeply afraid the great promise and hope the nation has as you take up this
issue will be dampened and may even ultimately fail, if you do not give the issue of
addiction full attention.
Sincerely,
JOHN BRIAN MURTAUGH
Chairman, NYS Assembly
Committee on Alcoholism
& Drug Abuse
JBM/bws
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March 18,
1993
H i l l a r y Rodham C l i n t o n
Old E x e c u t i v e O f f i c e B u i l d i n
1600 P e n n s y l v a n i a Avenue
W a s h i n g t o n , D.C.
20500
Dear Mrs. Rodham C l i n t o n :
As s t a t e l e g i s l a t o r s c o m m i t t e d s t r o n g l y t o b o t h a c c e s s and c o s t c o n t r o l
i n h e a l t h c a r e , we t h a n k y o u f o r y o u r w o r k .
We u r g e you t o t a k e b o l d
a c t i o n i n t h e i n t e r e s t s o f consumers and t h e economy, r a t h e r t h a n s p e c i a l
i n t e r e s t groups.
We
hope t h a t y o u r p r o p o s a l w i l l :
- b r e a k t h e l i n k o f employment, and i n s u r a n c e , w h i c h c r e a t e s w a s t e f u l
a d m i n i s t r a t i o n , l i m i t s a c c e s s , and c a u s e s p r o b l e m s o f t r a n s i t i o n
between j o b s .
- l i n k c o s t c o n t r o l and a c c e s s .
Evidence from every i n d u s t r i a l c o u n t r y
shows t h a t i t i s i m p o s s i b l e t o p r o v i d e one w i t h o u t t h e o t h e r .
- c o n t r o l c o s t s w i t h i n a f i x e d budget.
We c a n n o t c o u n t on managed
c o m p e t i t i o n t o s l o w i n c r e a s e s t o an a p p r o p r i a t e l e v e l .
We b e l i e v e a f u n d i n g s y s t e m based on b r o a d - b a s e d t a x e s i s f a i r e s t t o b o t h
consumers and e m p l o y e r s .
We b e l i e v e a d e l i v e r y s y s t e m w i t h c a p i t a t i o n
payments and g l o b a l b u d g e t s i s t h e b e s t way t o a s s u r e b o t h a c c e s s and
cost c o n t r o l .
We u r g e t h e a d o p t i o n o f a s i n g l e - p a y e r p l a n on a n a t i o n a l l e v e l .
I f this
i s n o t p o s s i b l e , p l e a s e c r e a t e i n c e n t i v e s and c l e a r away i m p e d i m e n t s ,
a l l o w i n g s t a t e s t o e x p e r i m e n t w i t h b o t h f i n a n c i n g and d e l i v e r y i n ways
w h i c h enhance a c c e s s , e q u i t y , and c o s t c o n t r o l .
Best wishes f o r your
success.
Sincere!y,
P a t r i c i a D. J e h l e n , 3 0 t h M i d d l e s e x
John E. McDonough, 1 2 t h S u f f o l k
John A. B u s i n g e r , 1 5 t h N o r f o l k
Mary Jane Simmons, 4 t h W o r c e s t e r
B a r b a r a E. G r a y , 6 t h M i d d l e s e x
J . James M a r z i l l i , 2 5 t h M i d d l e s e x
E l l e n S t o r y , 3 r d Hampshire
John S t e f a n i n i , 7 t h MiddlesexSusan S c h u r , 1 2 t h M i d d l e s e x
C a r o l A. Donovan, 3 3 r d M i d d l e s e x
Anne M. P a u l s e n , 26t.h M i d d l e s e x
Janet O'Brien, 5 t h Plymouth
Barbara Gardner, 8 t h Middlesex
John R o g e r s , 1 2 t h N o r f o l k
�A R 14 '93 13:47 684 6334828 G V R O S OFFICE
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GOVERNOR'S OFFICE
(American Samoa Goverrmnemt)
FAX TRANSMITTAL
SHEET
Date:
4/f f / 13
Fax #
TO: Mir?, tillla/lj
UHitr Ko^nF
Fax #:
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RM
MESSAGE: Q ^ y
SENDER:
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ANY PAGES j PLEASE CALL (684) 633-1+116, AND ASK FOR THE SENDER).
THANK YOU.
�fiPR 14 '93 13:47 684 6334828 GOVERNORS OFFICE
1
P.2
r
April
13,
1993
Serial:
571
Mrs. H i l l a r y Rodham C l i n t o n
P r e s i d e n t i a l Task Force on Health Care Reforin
The White House
Washington, D.C.
Dear Mrs. C l i n t o n :
American Samoa i s f u l l y committed t o h e a l t h care reform which w i l l
c o n t r i b u t e t o t h e attainment of n a t i o n a l goals and o b j e c t i v e s .
However, i t must be recognized t h a t t h e s p e c i a l circumstances
e x i s t i n g i n t h i s small i s o l a t e d i s l a n d T e r r i t o r y , as i n many other
r u r a l communities across the n a t i o n , make many of t h e elements o f
the proposed n a t i o n a l h e a l t h care reform program i n a p p r o p r i a t e or
u n f e a s i b l e l o c a l l y . Given s u f f i c i e n t f l e x i b i l i t y , American Samoa
should, nevertheless, be able t o adopt some elements o f t h e
n a t i o n a l program, adapt o t h e r s , and i n c o r p o r a t e c e r t a i n components
unique t o our l o c a l circumstances which would, when i n t e g r a t e d i n t o
an acceptable comprehensive program, achieve t h e d e s i r e d r e s u l t
l o c a l l y w h i l e meeting t h e i n t e n t o f t h e n a t i o n a l program.
The t o t a l p o p u l a t i o n of American Samoa i s 51,000 persons and i s
growing a t the r a t e o f 3.6% per year. The T e r r i t o r y i s an i s o l a t e d
i s l a n d community which l i e s 2400 sea miles from access t o t h e
nearest r e g i o n a l source o f s o p h i s t i c a t e d secondary and t e r t i a r y
medical care. Over 58% o f t h e p o p u l a t i o n have incomes below t h e
poverty l e v e l . The h e a l t h care system i s e n t i r e l y government owned
and operated and i s d e f i c i e n t i n s p e c i a l i s t medical manpower,
e s s e n t i a l medical equipment,, and drugs and s u p p l i e s . Health care
f a c i l i t i e s are i n urgent need of r e n o v a t i o n , expansion, o r
replacement. However, fundamental h e a l t h system changes d i r e c t e d
at t h e u n d e r l y i n g d e f i c i e n c i e s o f t h e system, are planned. When
implemented, these changes are expected t o s i g n i f i c a n t l y improve
the capacity o f t h e l o c a l h e a l t h care system t o make e s s e n t i a l
h e a l t h care s e r v i c e s accessible t o a l l a t a reasonable cost.
S p e c i f i c d e s c r i p t i o n s o f these unique circumstances and t h e i r
r e l a t i o n s h i p t o t h e elements o f t h e proposed n a t i o n a l h e a l t h care
reform program have been t r a n s m i t t e d t o Mr. John Hart, Deputy
�A R 14 '93 13:48 684 6334828 G V R O S OFFICE
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A s s i s t a n t t o t h e President f o r Intergovernmental A f f a i r s , Mr.
Raymond Scheppach, N a t i o n a l Governor's A s s o c i a t i o n , and t h e
Honorable Ron De Lugo's Special Task Force on I n s u l a r Areas f o r
Health Care Reform.
The f o l l o w i n g issues are o f g r e a t e s t
importance, and are presented here f o r your i n f o r m a t i o n and
consideration:
1. Recognizing t h e s p e c i a l circumstances e x i s t i n g i n American
Samoa, s u f f i c i e n t f l e x i b i l i t y and broad waiver a u t h o r i t y
should be i n c o r p o r a t e d i n t o t h e f i n a l n a t i o n a l h e a l t h care
reform program t o enable American Samoa t o p l a n and implement
a l o c a l h e a l t h care reform program which meets t h e i n t e n t and
purposes o f t h e n a t i o n a l program through means t h a t are
a p p r o p r i a t e and f e a s i b l e w i t h i n t h e c o n t e x t o f i t s unique
s o c i a l , p o l i t i c a l , and economic environments. The precedent
f o r such f l e x i b i l i t y was e s t a b l i s h e d w i t h the amendment t o t h e
Social S e c u r i t y Act making American Samoa e l i g i b l e f o r Federal
Medicaid assistance.
2. American Samoa w i l l r e q u i r e considerable f i n a n c i a l support and
t e c h n i c a l assistance i n order t o develop the c a p a c i t y of i t s
l o c a l h e a l t h care d e l i v e r y system t o meet minimum standards
expected by the n a t i o n a l h e a l t h care reform program. The l o c a l
system must be developed as a sub-system o f a broader r e g i o n a l
h e a l t h care system. American Samoa's h e a l t h care system
i n t e r a c t s w i t h , and i s dependent upon, t h e h e a l t h care system
of t h e State o f Hawaii, the nearest center where a l l t e r t i a r y
medical care and much secondary care, can be accessed.
3. Remove t h e cap on American Samoa's Medicaid Program.
Underfinancing i s the g r e a t e s t b a r r i e r t o the development o f an
acceptable h e a l t h care system i n t h i s T e r r i t o r y . The
government cannot provide s u f f i c i e n t funds t o support t h e
system; g e n e r a l l y low f a m i l y income precludes the generation o f
s i g n i f i c a n t h e a l t h revenues from the p r i v a t e s e c t o r ; and t h e
cap on t h e Medicaid Program prevents American Samoa from
r e c e i v i n g adequate Federal assistance t o help s u b s i d i z e t h e
cost o f p r o v i d i n g h e a l t h s e r v i c e s t o the poor.
Thank you very rauch f o r t h e o p p o r t u n i t y t o provide t h e above
information.
I n l i g h t o f t h e p o t e n t i a l impact o f t h e n a t i o n a l
program on our f r a g i l e i s l a n d h e a l t h care system, I u r g e n t l y
request t h a t t h e recommendations presented above be given serious
c o n s i d e r a t i o n i n t h e d r a f t i n g o f t h e f i n a l h e a l t h care reform
program.
�P R 14 '93 13:49 684 6334828 G V R O S OFFICE
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4/13/93
I have designated Mr. Charles R. McCijddin, Special A s s i s t a n t
f o r Health, as t h e contact person i n my o f f i c e f o r a l l h e a l t h
care reform matters. You may contact him f o r a d d i t i o n a l
i n f o r m a t i o n a t telephone: (684) 633-4116, or FAX: (684) 6332269.
I wish you success i n t h i s most important endeavor.
Sincerely,
A.p. L u t a l i
Governor o f American Samoa
�SCOn E. HUTCHINSON, MEMBER
H U E P S OFFICE B X 128
OS OT
O
MAIN CAPITOL BUILDING
HARRISBURG, PA 17120-0028
PHONE; (717) 783-8188
tgfe
COMMITTEES
viiLiiSSSSSOflF
rffirj^iiSfB^r^^—
V
CX '
FEDERAL-STATE RELATIONS
FINANCE
430 13TH STREET
FRANKLIN, PA 16323
PHONE: (814) 437-2110
206 SENECA STREET
IHOILSC
of ^Representatives
J
OIL CITY PA 16301
PHONE: (814) 677-6363
1-800-645-0281
1
COMMONWEALTH OF PENNSYLVANIA
HARRISBURG
March 12,
1993
Ms. Hillary Clinton
First Lady of the United States
1600 Pennsylvania Avenue
AciSuj
Luii DC
2 vii Ob
Dear Ms. C l i n t o n :
I am the State Representative f o r the 64th L e g i s l a t i v e D i s t r i c t of
Pennsylvania, and I would l i k e t o inform you of f i n a n c i n g problems
a f f l i c t i n g r u r a l h o s p i t a l s i n Pennsylvania and across the country.
S p e c i f i c a l l y , I am w r i t i n g t o you on behalf of a group t h a t i s
f i g h t i n g t o preserve c r i t i c a l care services a t the O i l C i t y
Hospital.
The people Qf our community are f r i g h t e n e d about the loss of acute
care services because of f i n a n c i a l problems which threaten t o close
O i l C i t y H o s p i t a l . O i l C i t y has a large Medicare population, and
because i t i s located i n a county that i s not l i s t e d on the urban
MSA l i s t , they receive 30-40% less f o r every medical procedure they
perform, as opposed t o h o s p i t a l s located i n urban MSA counties.
What i s p a r t i c u l a r l y perplexing i s that h o s p i t a l s i n s i m i l a r
communities ( f o r example, Greenville and Corry, PA) receive the
urban Medicare reimbursements. I f a i l t o see the r a t i o n a l e . There
i s nothing f a i r about t h i s .
In Pennsylvania we've continued t o compound t h i s d i s p r o p o r t i o n a t e
paymenL problem by reimbursing auto accident care a t 110% of the
Medicare r a t e . Also, our state's worker's compensation system w i l l
soon be t i e d t o Medicare rates.
Meanwhile, President C l i n t o n i s t a l k i n g about c u t t i n g payments
given t o h o s p i t a l s by Medicare, and Governor Casey has proposed
c u t t i n g Medicaid payments t o h o s p i t a l s .
O i l C i t y H o s p i t a l has an extremely high Medicaid p a t i e n t load.
Almost 31% of t h e i r p a t i e n t s over the past several years have been
Medicaid p a t i e n t s . When you look at the d i s p r o p o r t i o n a t e payments
that O i l C i t y has t o l i v e w i t h , t h e i r high Medicare and Medicaid
population, and more payment cuts promised by the President and the
Governor, the f u t u r e looks bleak.
The O i l C i t y Hospital's current c r i s i s i s j u s t the t i p of a much
�COMMITTEES
SCOn E. HUTCHINSON, MEMBER
HOUSE POST OFFICE BOX 128
MAIN CAPITOL BUILDING
HARRISBURG, PA 17120-0028
PHONE; (717) 783-8188
FEDERAL-STATE RELATIONS
FINANCE
430 13TH STREET
FRANKUN, PA 16323
PHONE: (814) 437-2110
206 SENECA STREET
OIL CITY PA 16301
PHONE: (814) 677-6363
1-800-645-0281
iHotise of Representatives
COMMONWEALTH OF PENNSYLVANIA
HARRISBURG
l a r g e r iceberg. We need your help t o stop the c l o s i n g of t h i s and
many other r u r a l h o s p i t a l s .
Thank you f o r your cooperation and assistance i n t h i s matter.
Sincerely,
Scott E. Hutchinson
^
State Representative
64th D i s t r i c t
206 Seneca Street
O i l C i t y PA 16301
rs
cc
President B i l l C l i n t o n
Governor Robert Casey
Senator H a r r i s Wofford
Senator Arlen Specter
�COMMITTEES
Representative
JIM
HOLLAND
VICE-CHAIRMAN
Public Transportation
ROUTE 1
KNOBEL. AKKANSAS 72435-9801
S T A T E
O F
A R K A N cS A c
A S
DISTRICT 84
Clay County
Part of Greene County
Part of Randolph County
y
MEMBER
Insurance and Commerce
Joint Committee on Energy
Joint Performance Review
A p r i l 29, 1993
F i r s t Lady H i l l a r y Rodham C l i n t o n
O f f i c e o f the F i r s t Lady
Old Executive O f f i c e B u i l d i n g
Room 100
Washington DC 20500
Dear Mrs. C l i n t o n :
Enclosed i s some information which I s t r o n g l y believe could be
b e n e f i c i a l t o our n a t i o n a l healthcare problems. I have spent more
than a week discussing the pros and cons o f t h i s plan w i t h Mary
W i l l i s , who i s a l i a i s o n t o Dr. W i l l i s .
I t has been a long time since I had the p r i v i l e g e o f co-sponsoring
the Q u a l i t y Education o f Arkansas. I f e l t as s t r o n g l y about t h a t as
I do about the n a t i o n a l healthcare problems today.
Congratulations on the f i n e j o b you are doing. You have an awesome
task i n f r o n t o f you and I hope t h i s i n f o r m a t i o n w i l l be o f some
help t o you. Please f e e l f r e e t o contact Dr. W i l l t o discuss any
aspect o f t h i s plan.
Sincerely,
rim H o l l a n d
/State Representative
D i s t r i c t 84
JH:mas
Enc.
�4^
THE UNITED STATES VIRGIN ISLANDS
OFFICE OF THE GOVERNOR
GOVERNMENT HOUSE
Charlotte Amalie, V.I. 00802
809-774-0001
March
30,
1993
Mrs. H i l l a r y Rodham C l i n t o n
The P r e s i d e n t ' s Task Force
on H e a l t h Care Reform
The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500
Dear Mrs. C l i n t o n :
Should t h e pre-eminent r e f o r m o f t h e C l i n t o n Presidency
encompass t h e h e a l t h care o f a l l U.S. c i t i z e n s ? Of course.
How can i t not?
And y e t I understand American c i t i z e n s i n
t h e T e r r i t o r i e s may be l e f t o u t , w h i l e non-Americans l i v i n g
i n t h e U n i t e d S t a t e s would be i n c l u d e d .
I am t h e Governor o f 100,000 c i t i z e n s o f t h e V i r g i n
I s l a n d s , a l l o f whom a r e c i t i z e n s o f t h e U n i t e d S t a t e s .
Because we r e s i d e i n a t e r r i t o r y , t h e C o n s t i t u t i o n does n o t
p e r m i t us t o v o t e f o r p r e s i d e n t , n o r a l l o w our Delegate t o
Congress t o v o t e on f i n a l passage o f t h e laws t h a t a f f e c t us.
But t h e Congress has f o u g h t hard t o i n c l u d e us when t h e
exclusionary p o l i c i e s
of previous
A d m i n i s t r a t i o n s has
d i s c r i m i n a t e d a g a i n s t us.
The p a s s i o n f o r change, f o r f a i r n e s s , f o r r e f o r m — t h a t
i s so c l e a r l y t h e h a l l m a r k o f B i l l C l i n t o n — s u r e l y means,
a t t h e v e r y l e a s t , an end t o d i s c r i m i n a t i o n a g a i n s t t h e
territories.
Mrs. C l i n t o n , please send t h e s i g n a l t h a t t h e
t i m e s have changed: i n c l u d e t h e t e r r i t o r i e s i n t h e n a t i o n a l
h e a l t h care r e f o r m package.
Cordially,
Alexander A. F a r r e i :
Governor
�CODER:_
HEALTH CARE TASK FORCE SORTING SHEET
INPUT DATE:
GENERAL SORT:
POSTCARD 1:
General mail
Personal stories
Other Health Providers
POSTCARD 2:
Offers to help/Employment
FORM LETTER;
Letterhead
REROUTE:
Casework
.Letter Campaign
_Policy
.Physicians
Scheduling
President
Other
POLICY AND PERSONAL STORIES:
.ORGANIZATION (I)
insurance premiums
insurance reform
insurance pools
boards and oversight
.COVERAGE (H)
working families
unemployed/low income
benefits
_providers
.INFRASTRUCTURE/WORKFORCE (HI)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
manpower issues (training)
unnecessary procedures
.GOVERNMENT PROGRAMS (IV)
medicare
medicaid
veterans
DoD
Indian health
_COST ISSUES (VI)
drug prices
physician fees
.hospital fees
_medical equipment
fraud & abuse
.FINANCING (VH)
.MENTAL HEALTH (EX)
.LONG-TERM CARE (X)
PUBLIC HEALTH/
SPECIAL POPULATIONS (XH)
prevention
_AIDS
women's health
immunizations/children
rural
urban
OTHER
�CAPITOL OFFICE
ROBERT W. O'DONNELL
STATE REPRESENTATIVE
ROOM 109, EAST WING
MAIN CAPITOL BUILDING
HARRISBURG, PENNSYLVANIA
717-787-5860
COMMONWEALTH OF PENNSYLVANIA
HARRISBURG
April 30, 1993
Mrs. Hillary Rodham Clinton, Chair
The Presidential Task Force on National Health Care Reform
The White House
Old Executve Office Building
Washington, DC 20500
Dear Hillary:
Enclosed is a summary description of a system which could be extremely
useful in cost containment of Medicare and Medicaid. I have also enclosed a brief biography
of its creator, Rocco Martino, a truly brilliant man.
I have tried to submit this through DNC but have been unable to get a return
call.
I would appreciate it if someone in your health care effort would review this
and let me know if there is any interest in hearing further from Dr. Martino.
Donna enjoyed getting your recent letter and she sends her best.
Cordially, ^,
Robert W. O'Donnell
RWO/ss
�THE
ASSEMBLY
STATE O F NEW YORK*\S
ALBANY
SUSAN JOHN
Assemblymember 131st District
•
•
COMMITTEES
Education
Energy
Corporations. Authorities & Commissions
Judiciary
Governmental Operations
REPLY TO:
DISTRICT OFFICE
792 South Clinton Avenue
Rochester, New York 14620
(716) 244-5255
ALBANY OFFICE
Room 833
Legislative Office Building
Albany, New York 12248
(518) 455-4527
February 19, 1993
H i l l a r y Rodham C l i n t o n
The White House
Washington, D.C.
20500-0001
Re:
Health
Care Reform
Dear Ms. Rodham C l i n t o n :
Enclosed f o r r e v i e w by y o u r Task Force i s
r e g a r d i n g t h e u n i v e r s a l h e a l t h system i n A u s t r a l i a .
information
Among o t h e r i n t e r e s t i n g f e a t u r e s o f t h e i r system i s t h a t
A u s t r a l i a spends o n l y 8 p e r c e n t o f i t s GDP on h e a l t h c a r e and has
t h r e e g e n e r a l p r a c t i t i o n e r s f o r every s p e c i a l i s t r a t h e r t h a n t h e
r e v e r s e r a t i o i n t h i s n a t i o n . The A u s t r a l i a n system r e t a i n s b o t h
p r i v a t e i n s u r a n c e f o r t h o s e who want a d d i t i o n a l f e a t u r e s ( p r i v a t e
room i n a h o s p i t a l , f o r example) and freedom t o choose one's care
provider.
These a r e some o f t h e reasons I f e l t a r e v i e w o f t h e i r
system i n y o u r process would be e n l i g h t e n i n g .
I n c o n c l u s i o n , as a r e p r e s e n t a t i v e i n t h e s t a t e l e g i s l a t u r e
from Rochester ( o f t e n c i t e d by P r e s i d e n t C l i n t o n ) and as t h e l e a d
d e l e g a t e f o r New York's 30th C o n g r e s s i o n a l D i s t r i c t i n t h e 1992
campaign, I would be p l e a s e d t o work w i t h anyone on t h e Task Force
s t a f f t o p r o v i d e any o t h e r i n f o r m a t i o n o r a s s i s t a n c e .
Good l u c k i n t h i s c h a l l e n g i n g
endeavor.
V e r y \ t r u l y yours,
Susan
Member o f Assembly
SVJ:pp
Printed on recycled paper.
�CODER: " • U ^ -
H E A L T H C A R E TASK F O R C E SORTING S H E E T
INPUT DATE:
3^:^
GENERAL SORT:
P O S T C A R D 1:
.Personal stories
.General mail
.Letter Campaign
Other Health Providers
POSTCARD 2:
.Offers to help/Employment
.Physicians
FORM L E T T E R :
Letterhead
.Policy
REROUTE:
Casework
.Scheduling
President
Other
PQUCY AND PERSONAL STORIES:
.ORGANIZATION (I)
insurance premiums
^insurance reform
insurance pools
boards and oversight
. C O V E R A G E (II)
working families
unemployed/low income
^benefits
providers
. I N F R A S T R U C T U R E / W O R K F O R C E (III)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
manpower issues (training)
.unnecessary procedures
. G O V E R N M E N T PROGRAMS (IV)
medicare
medicaid
veterans
DoD
Indian health
COST I S S U E S (VI)
( / d r u g prices
physician fees
hospital fees
.medical equipment
fraud & abuse
FINANCING (VII)
MENTAL H E A L T H (IX)
. L O N G - T E R M C A R E (X)
PUBLIC HEALTH/
S P E C I A L POPULATIONS (XH)
prevention
AIDS
women's health
immunizations/children
rural
urban
OTHER
�Ohio Developmental
DISABILITIES
^
^
Planning Council
g^fjK
Voi,,ovich
8 East Long Strom, 6th Floor
Columbus, 01110 43266-0415
614-466-520.5 Voice
614-644-5530 TDD
614-466-0298 FAX
February
12, 1993
H i l l a r y Rodham C l i n t o n , Chair
Task Force on N a t i o n a l H e a l t h Care Reform
The White House
Washington, DC 20510
Dear Ms. Rodham C l i n t o n :
Sincere b e s t wishes t o you, t h e P r e s i d e n t , and your Task Force
l e a d e r s h i p and s t a f f as you t a c k l e t h e h e a l t h care problems t h a t
plague our n a t i o n . I was asked by S t a t e Senator Ben Espy's o f f i c e
t o h e l p i d e n t i f y people who would j o i n you on the podium f o r your
h e a l t h care r a l l y here i n Columbus as your bus caravan l e f t the
c o n v e n t i o n . I and those you met t h a t day c o u l d n o t be more pleased
t h a t we were able t o h e l p , and t h a t you are moving so d e l i b e r a t e l y
toward h e a l t h care r e f o r m .
I w r i t e w i t h t h e hope t h a t I and my o r g a n i z a t i o n can be a f u r t h e r
r e s o u r c e from a d i s a b i l i t y p e r s p e c t i v e . Evidence o f our p r i o r
involvement i n c l u d e s t h e f o l l o w i n g :
o
The enclosed P o s i t i o n Paper has been c r e d i t e d n a t i o n a l l y as a
s u c c i n c t and c r e d i b l e a n a l y s i s o f h e a l t h care i s s u e s , l e a d i n g
t o r e q u e s t s f o r t e s t i m o n y from t h e N a t i o n a l C o u n c i l on
D i s a b i l i t y , as w e l l as many s t a t e and l o c a l o r g a n i z a t i o n s .
While i t i n c l u d e s a s i n g l e payer recommendation (which we
accept as beyond o p t i o n s you w i l l c o n s i d e r ) , I hope t h a t i t
a l s o r e v e a l s a t e c h n i c a l grasp o f d i s a b i l i t i e s i s s u e s t h a t
would need t o be c o n s i d e r e d i n any r e f o r m l e g i s l a t i o n t h a t i s
prepared.
o
My o r g a n i z a t i o n and I have had a l e a d r o l e i n Ohio i n organi z i n g e x p e r t t e s t i m o n y ( c i t i z e n and p r o f e s s i o n a l ) r e l a t e d t o
h e a l t h care and o t h e r d i s a b i l i t y r e l a t e d i s s u e s . L o c a l
h e a l t h care forums (one example a t t a c h e d ) have been designed
t o educate p u b l i c p o l i c y makers about t h e h e a l t h care issues
f a c i n g persons w i t h d i s a b i l i t i e s . I was a l s o t h e Ohio
resource which a s s i s t e d t h e N a t i o n a l C o u n c i l on D i s a b i l i t y
when i t o r g a n i z e d t e s t i m o n y d u r i n g h e a r i n g s on t h e Americans
w i t h D i s a b i l i t i e s Act i n C l e v e l a n d , Ohio i n 1991.
�H i l l a r y Rodham C l i n t o n
Page 2
February 12, 1993
I would a p p r e c i a t e any i n f o r m a t i o n you might p r o v i d e about the
Task Force sub-groups t h a t are being developed. I f we can be o f
h e l p , we would be most honored t o p r o v i d e any t e c h n i c a l a s s i s t a n c e
t h a t might a s s i s t your work. I n f a c t , may we i n v i t e t h e Task
Force back t o Columbus, where your h e a l t h care theme made such a
s t r o n g e a r l y impression?
Again, b e s t wishes as you pursue t h i s venture o f h i s t o r i c a l
s i g n i f i c a n c e . Please do n o t h e s i t a t e t o c a l l i f you f e e l we can
play a part.
Sincerely,
mcereiy,
*
Richard V. S k e l l e y , Ph.D.
H e a l t h Care A n a l y s t
Government A f f a i r s C o o r d i n a t o r
RS:a j
Enclosures
�REPLY JO:
COMMITTEES
43RD
DISTRICT
M I C H A E L M. D A W I D A
SENATE
THE
POST
STATE
HARRISBURG.
(717)
FINANCE. MAJORITY
OFFICE
CAPITOL
PA
CHAIRPERSON
BANKING AND INSURANCE
C O M M U N I C A T I O N S A N D HIGH
17120-0030
TECHNOLOGY
787-7683
PUBLIC HEALTH AND WELFARE
URBAN AFFAIRS A N D HOUSING
314
EAST
EIGHTH
HOMESTEAD.
(412)
AVENUE
VETERANS AFFAIRS AND
PA 1 5 1 2 0
EMERGENCY
PREPAREDNESS
461-1126
DEMOCRATIC POLICY
BIRMINGHAM
2IST
•
COMMITTEE
T O W E R S . S U I T E 110
AND WHARTON
P I T T S B U R G H . PA
(412)
STREETS
15203
488-6111
Senate of ^cnnegltonm
February 24, 1993
F i r s t Lady H i l l a r y Rodham C l i n t o n
F i r s t Lady o f t h e U n i t e d S t a t e s
The White House
1600 Pennsylvania Avenue, N
W
Washington, DC 20500
Dear Ms. C l i n t o n :
As a l o n g t i m e advocate o f t h e c i g a r e t t e t a x , I am w r i t i n g t o express my
support f o r a major c i g a r e t t e t a x i n c r e a s e o f a t l e a s t $2.00 per pack. T h i s t a x
would be a c r u c i a l s t e p t h a t our n a t i o n should t a k e t o p r o t e c t our c h i l d r e n from
a d d i c t i o n t o tobacco and t o lower h e a l t h care c o s t s .
S t r o n g s u p p o r t f o r r e d u c i n g tobacco consumption a l r e a d y e x i s t s among t h e
American people, i n c l u d i n g many smokers. T h i s support w i l l o n l y grow i f your
A d m i n i s t r a t i o n f o r c e f u l l y a r t i c u l a t e s the health r a t i o n a l e f o r t a k i n g t h i s step.
T h i s s u p p o r t i s e v i d e n t i n Pennsylvania as I was a b l e t o pass t h e "Clean Indoor
A i r A c t " i n 1988. Since t h e n , more and more people have expressed t h e i r concern
over t h e h e a l t h aspects r e l a t e d t o tobacco use.
The h e a l t h b e n e f i t s o f h i g h e r tobacco taxes a r e n o t t h e o r e t i c a l , t h e y a r e
proven. Every o t h e r major i n d u s t r i a l i z e d n a t i o n , i n c l u d i n g Canada, t a x e s tobacco
at a much h i g h e r l e v e l than does t h e U n i t e d S t a t e s . Canada has reduced tobacco
use among youth by t w o - t h i r d s s i n c e 1980, p r i m a r i l y t h r o u g h tobacco t a x
increases.
The American Cancer S o c i e t y , American Heart A s s o c i a t i o n and t h e American
Lung A s o o c i a t i c n have e s t i m a t e d t h a t a $2.00 per pack t a x i n c r e a s e , m a i n t a i n e d
i n r e a l terms, would r a i s e about $35 b i l l i o n d o l l a r s per year and would save
about two m i l l i o n American l i v e s over t i m e . S u r e l y t h e r e can be no b e t t e r way
t o r a i s e revenue i n t h i s t i m e o f need t h a n t o impose a t a x t h a t w i l l p r o t e c t o u r
c h i l d r e n , improve o u r economy and save c o u n t l e s s l i v e s .
I am h o p e f u l t h a t you w i l l t a k e t h i s long overdue s t e p f o r t h e h e a l t h o f
t h e American f a m i l y .
Sincerely,
Michael M. Dawida
43rd S e n a t o r i a l D i s t r i c t
MMD/BVR:bvr
�dalifornia §emur iCEgtsIature
STATE OF CALIFORNIA
CALIFORNIA SENIOR
LEGISLATURE
California Senior Legislature
SENIOR ASSEMBLYWOMAN
GENEVIEVE (JENNIE) DULANY
1387 LICHTVIEW STREET
MONTEREY PARK, CA 91754
(213) 264-3342
11111119
February 1, 1993
REPRESENTING OLDER CALIFORNIANS IN
LOS ANGELES COUNTY
First Lady Hillary Cl inton
White House
-
- •
•
- —
•
Washington, D C 20510
..
Dear Mrs. Clinton:
Congratulations to you on your appointment to Chair the Task Force for
revising the American Health Care System. The successful solution to this
problem is an essential key in solving our social and economic problems. Your
appointment and the task force that you chair is a clear signal that the
matter will receive the serious attention that is required to overcome the
obstacles that impede the corrections needed.
Our $839 billion health care system has collapsed under the weight of the
apparatus that has been uncontrolled for many years. N system in any other
o
developed country is burdened by nearly as much waste as is a part of our
health care system, and that waste is now the source of our problem with the
system.
Without question the greatest source of wasted dollars in the system is the
role of the insurance industry. 1500 companies, with different programs and
claim forms, have added a cost to the system that is estimated to be
approximately 25% of the money spent on the system, while, at the same time
we have managed to provide the same functions for our senior population
through the Medicare system for approximately 5 of the money spent.
%
As a start in your task of revising our system, please establish a uniform
health care program for everyone and administer i t in approximately the same
way that Medicare is administered, with a single payer.
There are too many people in this country who have no health benefits, and the
time has long past when something must be done about i t . Our present health
system is so inadequate.
Please do not hesitate to contact me, i f there is any way in which I can help.
Sincerely,
Genevieve Dulany
Senior Assembywoman
California Senior Legislature
�WESTERN LEGISLATIVE CONFERENCE
121 SECOND ST.
4 TH FL.
THE COUNCIL OF STATE GOVERNMENTS
SAN FRANCISCO. CA 94105
25 January, 1993
Mrs. Hilary Clinton
Task Force on Health Reform
Office of the First Lady
1600 Pennsylvania Ave., N.W.
Washington, D.C. 20500
WESTERN STATES
ALASKA
PHONE (415) 974-6422
FAX (4 1 5) 974-1747
4
9<
Dear Mrs. Clinton:
COLORADO
On November 15, at the 1992 Annual Meeting of the Western Legislative
Conference (WLC), legislators representing 13 western states and three Pacific
island governments formally adopted the enclosed resolutions as official WLC
positions. Resolution No. 92-5 addresses the states' desire for the Clinton
Administration and Congress to involve the states and U.S. insular areas in the
formation of any national health care policies and programs. Your careful
consideration of this resolution is strongly encouraged.
HAWAII
Thank you for your consideration of this issue. We eagerly await your response.
IDAHO
Sincerely yours,
ARIZONA
CALIFORNIA
MONTANA
NEVADA
NEW MEXICO
Senator Andrew Levin (HI)
Chair, Health Care Task Force of
the Health & Education Committee
Western Legislative Conference
OREGON
dp:hc
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEALTH OF THE
NORTHERN MARIANA
' ISLANDS
GUAM
�' JAMES AK?
PRESIDENT
®I]e Senate
MILTON HOLT
VICE PRESIDENT
©fye J^euenteentl] Jlegtslature
RICHARD M. MATSUURA
MAJORITY LEADER
nf tl]c
D O N N A R. IKEDA
MAJORITY FLOOR LEADER
BERTRAND KOBAYASHI
MAJORITY POLICY LEADER
ANDREW LEVIN
MAJORITY CAUCUS LEADER
STATE CAPITOL
HONOLULU, HAWAII 96813
MIKE MCCARTNEY
MAJORITY WHIP
MARY GEORGE
February 4, 1993
MINORITY LEADER
RICK REED
MINORITY FLOOR LEADER
FIRST DISTRICT
MALAMA SOLOMON
S E C O N D DISTRICT
RICHARD M. MATSUURA
THIRD DISTRICT
ANDREW LEVIN
FOURTH DISTRICT
RUSSELL BLAIR
FIFTH DISTRICT
JOE TANAKA
Ms. H i l a r y Rodham C l i n t o n
Task Force on Health Reform
O f f i c e of the F i r s t Lady
1600 Pennsylvania Ave., N W
..
Washington, D.C. 20500
Dear Ms. C l i n t o n :
SIXTH DISTRICT
RICK REED
SEVENTH DISTRICT
LEHUA FERNANDES SALLING
EIGHTH DISTRICT
DONNA R. IKEDA
NINTH DISTRICT
MATT MATSUNAGA
TENTH DISTRICT
BERTRAND KOBAYASHI
ELEVENTH DISTRICT
ANN KOBAYASHI
TWELFTH DISTRICT
CAROLFUKUNAGA
THIRTEENTH DISTRICT
ANTHONY K. U. CHANG
FOURTEENTH DISTRICT
MILTON HOLT
FIFTEENTH DISTRICT
NORMAN MIZUGUCHI
SIXTEENTH DISTRICT
REY GRAULTY
SEVENTEENTH DISTRICT
ELOISE YAMASHITA
TUNGPALAN
EIGHTEENTH DISTRICT
RANDYIWASE
NINETEENTH DISTRICT
DENNIS M. NAKASATO
TWENTIETH DISTRICT
BRIAN KANNO
TWENTY-FIRST DISTRICT
JAMES AKI
TWENTY-SECOND DISTRICT
GERALD T. HAGINO
TWENTY-THIRD DISTRICT
MIKE
MCCARTNEY
TWENTY-FOURTH DISTRICT
STANLEY T. KOKI
TWENTY-FIFTH DISTRICT
MARY GEORGE
CHIEF CLERK
T. DAVID WOO. JR.
On behalf of the Western L e g i s l a t i v e Conference,
a consortium of 13 western states and three P a c i f i c
i s l a n d governments, I would l i k e t o ask t h a t you
allow us "a seat a t the t a b l e " as you work on n a t i o n a l
health care reform.
The enclosed l e t t e r and r e s o l u t i o n were mailed t o you
by our San Francisco o f f i c e on January 25, 1993.
I enclose i t again f o r your easy reference.
I have been Chair of the Health Committee i n the Hawaii
State Senate, and c u r r e n t l y serve as Chair of the Health
Care Task Force of the Western L e g i s l a t i v e Conference.
I also serve as Vice Chair of the Health Committee of
the National Conference of State Legislatures. I n those
c a p a c i t i e s , I have become p a r t i c u l a r l y f a m i l i a r w i t h the
e f f o r t s of Hawaii t o provide u n i v e r s a l health care f o r
our residents, and the e f f o r t s of many other states t o
meet the health care needs of t h e i r populations.
I believe t h a t the states have a great deal t o o f f e r i n
the n a t i o n a l discussion on health care reform, and I know
t h a t you are aware of how much innovation i s possible
at the state l e v e l a f t e r your work i n Arkansas. There
i s apprehension t h a t much of the e f f o r t put f o r t h by the
various states w i l l be undermined by the n a t i o n a l government as we move toward t r y i n g t o solve the health care
c r i s i s . I t would be a shame t o lose the good works done
already, or on the drawing boards, i n our struggle t o
find a national solution.
I n your capacity as Chair of the Task Force on Health
Reform, you are i n a p o s i t i o n t o include many voices
�jStntr nf JH.-ttu.'iii
Ms. H i l a r y Rodham Clinton.
Page 2
February 4, 1993
which might not otherwise be heard. I f there i s a way
i n which you can allow the states t o p a r t i c i p a t e i n
your d e l i b e r a t i o n s , we believe t h a t we can add t o the
dialogue and p o s i t i v e l y c o n t r i b u t e t o the u l t i m a t e
s o l u t i o n . There are any number of people who could
i n d i v i d u a l l y f i l l the r o l e of representing the states'
i n t e r e s t s , but we would need your blessing i f we are
to be allowed t o p a r t i c i p a t e i n any meaningful way.
We know t h a t you have an enormous task before you, and
dozens of i n t e r e s t s p u l l i n g you i n a multitude of
d i r e c t i o n s . I f we can help rather than hinder you
i n your noble e f f o r t t o resolve t h i s i n t r a c t a b l e problem,
I hope you w i l l c a l l on us.
Thank you f o r your
consideration.
Very t r u l y yours.
ANDREW LEVIN
Senator, Third
AL:CSY
District
�SENATOR ANDREW LEVIN
£ t a t t of Hafoait
r
STATE OFFICE TOWER
235 S. BERETANIA ST.
HONOLULU. HAWAII 96813
\
Ff 8 4 9
-*3
u i
y
.-•MEits
" • H . - 6(5328-22
--A-'
MRS. HILARY RODHAM CLINTON
TASK FORCE ON HEALTH REFORM
OFFICE OF THE FIRST LADY
16 00 PENNSYLVANIA AVE., N W
..
WASHINGTON, D.C.
20500
�{Eljs (Ununrtl
CITY OF
DAVID
A.
BUFFALO
COLLINS
MASTEN DISTRICT COUNCIL-MEMBER
1414
CITY
BUFFALO.
N.
HALL
Y.
14202
April
13,
1993
The H o n o r a b l e D a n i e l P. Moynihan
United States Senator
S u i t e 203, G u a r a n t y B u i l d i n g
28 Church S t r e e t
B u f f a l o , NY
14202
Dear S e n a t o r
Moynihan:
I have taken the n e c e s s i t y to a t t a c h a copy of a r e s o l u t i o n
which was unanimously approved by the B u f f a l o Common C o u n c i l
January 19, 1993.
T h i s r e s o l u t i o n endorsed a U n i v e r s a l S i n g l e Payer H e a l t h Care P l a n .
I n the course of c u r r e n t d i s c u s s i o n s r e g a r d i n g t h i s n a t i o n a l
h e a l t h c a r e dilemma, i t i s our b e l i e f t h a t t h i s p l a n p r o v i d e s
t h e b e s t o p p o r t u n i t y f o r good m e d i c a l c a r e f o r A m e r i c a n s .
We hope t h a t you w i l l t a k e t h i s i n f o r m a t i o n i n t o c o n s i d e r a t i o n
d u r i n g your d e l i b e r a t i o n s .
S h o u l d you need a d d i t i o n a l
i n f o r m a t i o n , do n o t h e s i t a t e t o c o n t a c t me a t ( 7 1 6 ) 8 5 1 - 5 1 4 5 .
Collins
Hasten D i s t r i c t Councilmember
DAC/db
Attachment
cc
A r l e t t e SlachmuyIder, C i t i z e n Action
Mrs. H i l l a r y C l i n t o n , C h a i r p e r s o n , N a t i o n a l H e a l t h Care Task
Mr. I r a M a g a z i n e r , C h i e f S t a f f P e r s o n , N a t i o n a l H e a l t h Care
Task F o r c e
Force
�CITY C L E R K ' S O F F I C E
CITY
HALL
BUFFALO,.
April 14, 199.6
.19-
To Whom It May Concern:
3 iff rriuj Cllf rtifg. That at a Session of the Common Council of the City of Buffalo, held
19th
j
r
January
in the City Hall, on the
day of
19 21, a resolution was adopted ^ f
following is a true copy:
0
No. 160
BY: MR. PITTS
SUPPORT FOR A NATIONAL HEALTH CARE PLAN
WHEREAS:
The United Slates shares with South Africa
the distinction ol being the only industrialized country without a
national health care program; and
WHEREAS:
37 million uninsured and 68 million [
underinsured Americans made their needs known during the 1992 j
elections causing heallh care to be a key issue addressed by all of j
the candidates; and
WHEREAS:
It is a tragic fact that one million Americans are
denied needed medical care every year; and
WHEREAS:
Heallh care costs continue to grow at an
alarming rate of two to three times the rate of inflation, and are a
driving force in Ihe skyrocketing of the national debt; and
WHEREAS:
The Government AccounUng Office (GAO)
has concluded that if the universal coverage and single payer
features of the Canadian system were appliad in the U.S., lh«»
savings In administrative costs alone (estimated at $67 billion per
year in the short run) would be more than enough to provide
comprehensive coverage for all Amoiicans; and
WHEREAS:
Consumer Reports has backed single-payer
as the best plan, both lor the quality and comprehensiveness of
care and for cost containment; and
WHEREAS:
It has been shown, using figures (rom the City
of Buffalo Comptroller's office,, that adopting a national single- !
payer health care system could save the City over $5 million j
annually: and
WHEREAS:
The
Buffalo Common
Council had
recommended in the past the adoption ol a single payer system
(Item 206 C.C.P. September 17, 1991 - "National Health Care
Policy" and Item 176 C.C.P. March 17, 1992 -"Support
NYHEALTH); and
WHEREAS:
A national campaign has been organized to
send one million postcards to President-elect Clinton supporting a
single-payer health care system that includes the following six
principles:
1)
Make health care a right," NOT lied to employment;
2)
Cover everyone under a single, fairly financed plan;
3)
Provide comprehensive benefits from preventive to longterm care;
4)
Get rid of out-of-pocket costs like co-payments and
deductibility:
5)
Cut administrative waste and set budgets lo lower
medical costs;
'i)
Let consumers choose theii' own health professionals
without having to pay more.
NOW.THEREFORE BE IT RESOLVED THAT:
The Buffalo Common Council urges President-elect Clinton and
the U.S. Congress to make reform ol tho health care system a top
priority; and
BE IT FURTHER RESOLVEDTHAT:
The Buffalo Common Council endorses the efforts of Ihe WNY
Health Care Campaign in its drive to send 10,000 postcards to
President-elect Clinion; and
BE IT FURTHER RESOLVEDTHAT:
.
In order to insure universal, comprehensive care and at lhe same
time control spiralling heallh care costs this Council urges
President-elect .Clinton and the U.S. Congress to adopt a •ST
single-payer, progressively financed, national health care plan; and
BE IT FINALLY RESOLVED THAT:
This Common Council directs lhe City Clerk to send a certified
copy of this resolution to President-elect Clinion and to the
membei s ol the Western Now York Congressional delegation.
ADOPTED.
Ciry Clerk.
�ADMINISTRATIVE BUILDING
111 WASHINGTON STREET - WHITEVILLE, NORTH CAROLINA 28472 - PHONE 919-642-5700
COMMISSIONERS
C.W. Williams
Zone 1
March 17, 1993
Ed Worley
Zone 2
Sammie Jacobs
Zone 3
A. Dial Gray, HI
Zone 4
L y n w o o d Norris
Zone 5
Samuel G. Koonce
Zone ft
Mike Richardson
Zone 7
James E. H i l l , Jr.
County Attorney
The F i r s t Lady
Mrs. C l i n t o n
The White House
Washington, D. C. 20000
Dear Mrs. C l i n t o n :
On b e h a l f o f t h e Columbus County Board o f Commissioners, I
r e s p e c t f u l l y e n c l o s e a R e s o l u t i o n unanimously adopted by t h e
Board i n s u p p o r t o f t h e tobacco i n d u s t r y and e s p e c i a l l y t h e
tobacco farms o f Columbus County, N o r t h C a r o l i n a .
Any c o n s i d e r a t i o n g i v e n t h i s R e s o l u t i o n i s g r e a t l y a p p r e c i a t e d .
Sincerely,
Roy L. Lowe
Administrator
Ida L. Smith
Clerk to Board
Roy L . Lowe
/
County A d m i n i s t r a t o r
RLL:Id
End.
�R E S O L U T I O N
THE BOARD OF COUNTY COMMISSIONERS
of Columbus
County,
North
Carolina,
at their
regular
meeting
on the 15th day of
March,
1993,
at Whiteville,
Columbus
County,
North
Carolina,
unanimously
adopted
the following
Resolution.
W I T N E S S E T H :
WHEREAS,
a critical
situation
is
now developing
Washington
over
e f f o r t s to increase
excise
taxes
on tobacco;
proposed
increase
which
would
increase
the
24-cents
per
federal
excise
tax by as much as two-dollars
per pack;
and
WHEREAS, tobacco
taxes
have
increased
taxes;
in
just
eleven
(11)
years
taxes
and
other
tripled;
than
taxes
faster
than
on tobacco
WHEREAS, less
taxes
are being
placed
on tobacco
tobacco
grown in the United
States
and i f additional
are needed,
the imports
should
be increased;
and
WHEREAS, a tobacco
in the loss
of 231,000
dollars;
and
result
billion
production
income
of
generate
taxes;
a severe
the major
tax increase
of this
jobs
with a payroll
WHEREAS,
Columbus
County
is
in the State
of North
Carolina
$40 million
dollars;
and
WHEREAS,
$333,270,000
and
the
tobacco
in
tax
WHEREAS, the proposed
impact
on the farmers
income
crop.
in
a
pack
imports
tobacco
magnitude
would
loss
of over
5.5
ranked
#4 in
with
an annual
acreage
in Columbus
money,
excluding
sales
increase
in tobacco
of Columbus
County
any
have
tobacco
tobacco
county
and
will
local
taxes
will
as tobacco
have
is
NOW, THEREFORE, BE IT RESOLVED by the Columbus
County
Board
of Commissioners
that
the Board requests
the North
Carolina
General
Assembly
and
the
United
States
Congress
for
special
consideration
to be given
the tobacco
farmers
of Columbus
County
and the State
of North
Carolina
when additional
taxes
are
being
considered
to reduce
the d e f i c i t .
BE IT FURTHER RESOLVED,
that
the Columbus
County
of Commissioners
unanimously
supports
the tobacco
farmer,
markets,
tobacco
warehouses
and all agri-businesses
associated
tobacco
in Columbus
County.
Board
tobacco
with
COLUMBUS COUNTY BOARD OF
COMMISSIONERS
BY:
Samuel
ATT
Roy
L:
e,
Administrator
G. Koonce,
Chairman
�CODER.
HEALTH CAKE TASK FORCE SORTING SHEET
INPUT DATE:
GENERAL SORT:
POSTCARD 2:
General mail
.Personal stories
Other Health Providers
POSTCARD 1:
.Letter Campaign
.Offers to help/Employment
Physicians
FORM LETTER:
Letterhead
.Policy
REROUTE:
Casework
.Scheduling
President
Other
POLICY AND PERSONAL STORIES:
ORGANIZATION (I)
.insurance premiums
.insurance reform
..insurance pools
boards and oversight
.COVERAGE (H)
working families
unemployed/low income
benefits
providers
.INFRASTRUCTURE/WORKFORCE (IH)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
manpower issues (training)
unnecessary procedures
.GOVERNMENT PROGRAMS (IV)
medicare
medicaid
veterans
DoD
Indian health
.COST ISSUES (VI)
drug prices
physician fees
hospital fees
medical equipment
fraud & abuse
FINANCING (VH)
MENTAL HEALTH (IX)
LONG-TERM CARE (X)
.PUBLIC HEALTH/
SPECIAL POPULATIONS (XH)
prevention
AIDS
women's health
immunizations/children
rural
urban
OTHER
�JOHN C. LEWIN. M.D.
JOHN WAIHEE
G O V E R N O R OF
D I R E C T O R OF
HAWAII
STATE
OF
HEALTH
HAWAII
DEPARTMENT O F HEALTH
P. O. BOX 3378
HONOLULU. HAWAII 96801
March 9,
In
reply,
please
refer
File:
1993
Ms. H i l l a r y Rodham C l i n t o n
C h a i r , P r e s i d e n t ' s H e a l t h Care Task F o r c e
Executive Office of the President
1600 P e n n s y l v a n i a Avenue, N.W.
W a s h i n g t o n , D.C.
20500
Dear Ms.
Clinton:
I n m i d - J a n u a r y , you r e c e i v e d an i n v i t a t i o n f r o m b o a r d
member, D o u g l a s S. McNish, t o be t h e k e y n o t e s p e a k e r a t t h e
n a t i o n a l A s s o c i a t i o n o f F a m i l y and C o n c i l i a t i o n C o u r t s a n n u a l
m e e t i n g i n May o f 1994 on t h e H a w a i i a n I s l a n d o f Maui.
One o f t h e t h e i r p r i m a r y c o n c e r n s i s t h e need f o r b e t t e r
a d v o c a t i o n f o r t h e needs o f c h i l d r e n who s u f f e r a t t h e hand o f
family discord.
V a r i o u s p r o g r a m s t h a t have made a d i f f e r e n c e
w i l l be h i g h l i g h t e d i n an e f f o r t t o b u i l d on t h e theme c a p t u r e d
i n t h e H a w a i i a n s a y i n g "Ho'oponopono Eha," t r a n s l a t e d a s , "Making
Right the Pain."
D e a l i n g w i t h such f u n d a m e n t a l f a m i l y d i s c o r d i s
c e n t r a l t o t h e w e l l - b e i n g o f A m e r i c a n f a m i l i e s and n e i g h b o r h o o d s .
P e r h a p s , b o t h t i m i n g and y o u r p e r s o n a l i n t e r e s t s may o v e r l a p
s u f f i c i e n t l y f o r your being able t o accept t h e i n v i t a t i o n ; I
believe the conference w i l l a f f o r d outstanding o p p o r t u n i t i e s f o r
action.
yours,
JOHN C. LEWIN, M.D.
Director of Health
to:
�TOWN OF
LONGBOAT KEY
Incorporated November 14, 1955
501 Bay Isles Road
Longboat Key, Florida 34228
(813) 383-3721
FAX 383-7231
January 26, 1993
Mrs. H i l l a r y Rodham C l i n t o n
The White House
1600 P e n n s y l v a n i a Avenue
H e a l t h Care O f f i c e - West Wing
Washington, DC
20500
Dear Mrs. C l i n t o n :
I am tremendously encouraged by your appointment t o head
t h e a d m i n i s t r a t i o n ' s e f f o r t t o develop a n a t i o n a l h e a l t h
c a r e program.
I f anyone can achieve p r o g r e s s on t h i s
c r i t i c a l i s s u e , i t i s you.
I have some i d e a s I t h i n k would be o f v a l u e t o you, b u t I
know t h e chances o f your ever r e a d i n g t h i s a r e a thousand
t o one. T h e r e f o r e , I am g o i n g t o make t h r e e q u i c k
s u g g e s t i o n s t o t r y and a t t r a c t your a t t e n t i o n :
1) S e l e c t one s t a t e t o be a p i l o t p r o j e c t f o r
whatever you p l a n t o do. (And make t h a t s t a t e
F l o r i d a s i n c e , because o f Medicare, we a l r e a d y
have major, major i n f r a s t r u c t u r e i n p l a c e . )
2) Use r e l i e f from t h e t e r r i b l y e x c e s s i v e c o s t s o f
malpractice insurance t o b r i n g doctors, h o s p i t a l s
and o t h e r h e a l t h c a r e p r o v i d e r s i n t o l i n e .
3) While u s i n g t h a t s i n g l e s t a t e p i l o t program f o r
t h e o v e r a l l p r o j e c t , a t t a c k t h e c o s t s o f drurjs on
a n a t i o n a l b a s i s . T h i s i s do-able — do-able
almost i n s t a n t l y — and would g i v e immediate
reasonable f u l f i l l m e n t t o P r e s i d e n t C l i n t o n ' s
campaign promise.
As you p r o b a b l y have guessed, I have d e t a i l e d i d e a s
worked o u t on these and o t h e r f a c e t s o f t h e e n t i r e
program — ideas t h a t a r e p r a c t i c a l and can be made t o
work i n a reasonable t i m e f r a m e . I f you would l i k e t o
see them, j u s t l e t me know. But I have no d e s i r e t o
s i m p l y p i l e up waste paper f o r some t h i r d a s s i s t a n t t o
your f o u r t h u n d e r s e c r e t a r y t o acknowledge and t h r o w
away.
�Mrs. H i l l a r y Rodham C l i n t o n
January 26, 1993
Page: 2
Please, i n c i d e n t a l l y , DO NOT bother t o send a form
l e t t e r "Thank You" t o €His l e t t e r , unless you are r e a l l y
i n t e r e s t e d i n having someone of s i g n i f i c a n c e look a t my
ideas.
I s h a l l send copies of t h i s l e t t e r as noted below. I f
you wish a reference as t o whether I am a r e l i a b l e
c i t i z e n or crackpot, check them.
Sincerely,
Tames P. (Jim) Brown
Mayor, Town of Longboat Key
CC: Congressman Porter Goss
Senator Bob Graham
Senator Connie Mack
pa
�TOWN OF
LONGBOAT KEY
501 BAY ISLES ROAD • LONGBOAT KEY, FLORIDA 34228
Mrs. H i l l a r y Rodham C l i n t o n
The White House
1600 Pennsylvania Avenue^
Health Care O f f i c e - West Wing
Washington, DC
20500
!ni:!!iHHM;ii;::Hn:::!i.i
�HEALTH CARE TASK FORCE SORTING SHEET
CODER:.
INPUT DATE:
GENERAL SORT:
POSTCARD 1:
.General mail
.Personal stories
Other Health Providers
_Letter Campaign
POSTCARD 2:
Offers to help/Employment
FORM LETTER:
Letterhead
_Policy
REROUTE:
Casework
.Scheduling
Physicians
President
Other
POLICY AND PERSONAL STORIES:
ORGANIZATION (I)
.insurance premiums
..insurance reform
..insurance pools
.boards and oversight
.COVERAGE (H)
working families
unemployed/low income
benefits
providers
.INFRASTRUCTURE/WORKFORCE (III)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
manpower issues (training)
unnecessary procedures
.GOVERNMENT PROGRAMS (IV)
medicare
medicaid
veterans
DoD
Indian health
_COST ISSUES (VI)
drug prices
physician fees
hospital fees
medical equipment
fraud & abuse
FINANCING (VII)
MENTAL HEALTH (IX)
.LONG-TERM CARE (X)
.PUBLIC HEALTH/
SPECIAL POPULATIONS (XII)
prevention
AIDS
women's health
immunizations/children
rural
urban
OTHER
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Letters from Government Officials and Employees] [loose] [3]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-017-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/ba623271bb8edea1d05725ceaa442ecc.pdf
f3d78e59b5528f481aa3d2e45c273658
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1983
OA/ID Number:
FolderlD:
Folder Title:
[Letters from Government Officials and Employees] [loose] [2]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
2
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECmTTLE
DATE
RESTRICTION
001. letter
Buddy Childers to Hillary Clinton [partial] (1 page)
4/15/1993
P6/b(6)
002a. letter
To Senator Madison Mayre, re: hospital bill (2 pages)
2/1/1993
P6/b(6)
002b. bill
Blue Cross Blue Shield Claims (2 pages)
11/3/1992
P6/b(6)
003. note
From Dolores Peters [partial] (1 page)
n.d.
P6/b(6)
004. letter
Dolores Peters to William Herwig (2 pages)
3/23/1993
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [2]
2006-0885-F
wr825
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�WESTERN LEGISLA TIVE CONFERENCE
121 SECOND ST.
4 TH FL.
THE COUNCIL OF STA TE GOVERNMENT
SAN FRANCISCO. CA p-'JOf
PHONE <- ?5) i7--5-22
'AX .•-'r
'
APPROVED RESOLUTION NO. 92-1
PRESIDENTIAL ELECTIONS
(Remaining on Daylight Savings Time i n Mountain and P a c i f i c Time
Zones Through Election Day)
WESTERNSTATES
ALASKA
ARIZONA
CALIFORNIA
(Introduced by the Executive Committee)
'
COLORADO
HA WA II
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
WHEREAS, the practice of the media to project winners of
presidential elections sometimes before polls close i n the East,
but always before they close i n the West, detracts from voter
turnout i n the West; and
WHEREAS, the practice i s an affront to Westerners even i f i t did
hot affect turnout; and
WHEREAS, numerous ideas have been suggested to deal with t h i s
problem, some of which are unworkable and some even interfering
with freedom of the press; and
'fHEREAS, a very simple idea that w i l l improve the situation for
Westerners i s to leave daylight savings time i n effect for the
Mountain and P a c i f i c time zones; and
WHEREAS, extended daylight savings time w i l l of i t s e l f add to voter
^urnout because of an additional hour of daylight at the end of
most workdays when many people vote;
N W THEREFORE BE IT RESOLVED by the Western L e g i s l a t i v e Conference
O,
that i n presidential election years, the Mountain and P a c i f i c time
ones remain on daylight savings time at l e a s t through election
ay, thus decreasing the time between poll closings i n those areas
nd those i n the East by one hour; and
COMMONWEAL TH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
3E IT FURTHER RESOLVED that t h i s resolution be forwarded to a l l
appropriate members, o f f i c e r s and committees of Congress and that
i t be given prominent distribution i n the regional and national
nedia.
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
92EX1-1A
®
�WESTERN LEGISLATIVE CONFERENCE
121 SECOND ST.
4 TH FL
THE COUNCIL OF STA i E GOVERNMENT,
SAN FRANCISCO CA 94105
PHONE
:5- ?~--6-22
-AX •- :5
'
APPROVED RESOLUTION NO. 92-2
PACIFIC STATES AND ISLANDS OCEAN GOVERNANCE
(Calling Upon the Western Legislative Conference to Actively
Pursue Cooperative Studies on Ocean Governance)
WESTERN STATES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
(Introduced by the Ocean Resources Committee)
WHEREAS, the P a c i f i c states of Alaska, C a l i f o r n i a , Hawaii, Idaho,
Oregon, and Washington and the P a c i f i c Islands of American Samoa,
Guam and the Commonwealth of the Northern Marianas share a common
resource, the P a c i f i c Ocean; and
WHEREAS, the economy of the P a c i f i c states and island governments
depends on the renewable resources of the P a c i f i c Ocean; and
WHEREAS, i t i s the goal of the P a c i f i c states and island
governments to conserve the long-term values, benefits and natural
resources of the ocean both within the boundaries of each state or
t e r r i t o r y and beyond by giving clear p r i o r i t y to the proper
management and protection of renewable resources over nonrenewable
resources; and
WHEREAS, the March 10, 1983 Presidential Proclamation of the
Exclusive Economic Zone (EEZ), extending the sovereign right of the
U.S. 200 miles off a l l U.S. state and t e r r i t o r i a l lands, was th
largest resource acquisition i n U.S. history - an area more than
one and one half times greater than the continental U.S.; and
WASHING TON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEAL TH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
WHEREAS, the December 27, 1988 Presidential Proclamation extending
the seaward l i m i t of United States t e r r i t o r i a l waters from 3 to 12
nautical miles provides an opportunity for a l l coastal states to
more f u l l y exercise and assert their r e s p o n s i b i l i t i e s pertaining to
the protection, conservation, and development of ocean resources;
and
WHEREAS, i n the f a l l of 1985, the Western L e g i s l a t i v e Conference
created an Ocean Resources Committee, comprised of the s i x P a c i f i c
states and three U.S. P a c i f i c islands, and i n December 1985,
l e g i s l a t o r s from a l l nine j u r i s d i c t i o n s began meeting to discuss
t h e i r respective coastal and ocean concerns; and
WHEREAS, i n January 1988, the WLC Ocean Resources Committee
published a report, "A Leadership Agenda: State Management of Ocean
Resources", including five recommendations for action and the
®
�APPROVED RESOLUTION NO. 92-2
Page 2
conclusion that i n l i g h t of the current federal policy vacuum, the
P a c i f i c states have an unusual opportunity to lead the nation as
effective stewards of ocean resources; and
WHEREAS, the WLC Ocean Resources Committee has been a c t i v e l y
investigating issues of ocean governance, which need to be
addressed i f the P a c i f i c states and islands are to f u l l y r e a l i z e
the potential of t h e i r offshore resources while providing adequate
protection for the marine environment; and
WHEREAS, the WLC Ocean Resources Committee developed the P a c i f i c
Ocean Resources Compact, the f i r s t interstate compact to address
issues of mutual o i l s p i l l prevention and response, and while the
committee w i l l not be pursuing enabling state l e g i s l a t i o n at the
present time, the members are interested i n continuing work on
innovative ocean governance structures; and
WHEREAS, the members of the WLC Ocean Resources Committee agree
there i s a need for some governance structure for the integrated
comprehensive management of ocean resources, and that the structure
w i l l require both state and federal involvement; and
WHEREAS, i t w i l l require regional cooperation, planning, and action
to achieve the ocean conservation and management goals of the
P a c i f i c states and islands; and
WHEREAS, the Western Governors' Association passed a resolution on
June 23, 1992 c a l l i n g for the P a c i f i c states and American flag
P a c i f i c islands to inventory t h e i r own ocean management e f f o r t s ;
N W THEREFORE BE IT RESOLVED that the Western L e g i s l a t i v e
O
Conference of the Council of State Governments supports the e f f o r t s
of the WLC Ocean Resources Committee to pursue better planning and
governance of ocean resources, i n order to insure t h e i r continued
contribution to the economies of the P a c i f i c states and islands;
and
BE IT FURTHER RESOLVED that the WLC Ocean Resources Committee work
with the Western Governors Association, the Ocean Governance Study
Group and the Coastal States Organization i n cooperative e f f o r t s on
ocean governance; and
BE IT FURTHER RESOLVED that the Ocean Resources Committee of the
Western L e g i s l a t i v e Conference, i n consultation with the
�APPROVED RESOLUTION NO. 92-2
Page 3
aforementioned organizations, prepare an Action Plan, t o include an
inventory of t h e separate s t a t e and i s l a n d ocean management
a c t i v i t i e s , f o r cooperative e f f o r t s i n t h i s area.
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
920R1-1A
�WESTERN LEGISLATIVE CONFERENCE
121 SECOND ST
i TH FL
1
THE COUNCIL OF STA TE GOVERNMEN ,
SAN FHANCISCO. CA 9-' 105
PHONE ••-:?
:
--.A . - - r
APPROVED RESOLUTION NO. 92-3
MANAGEMENT OF THE EXCLUSIVE ECONOMIC ZONES OF AMERICAN SAMOA, THE
COMMONWEALTH OF THE NORTHERN MARIANAS ISLANDS AND GUAM
WESTERN STATES
(Recognizing the Right of American Samoa, Guam and the
Commonwealth of the Northern Marianas Islands to J u r i s d i c t i o n and
Control Over Their Respective Exclusive Economic Zones (EEZs))
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
(Introduced
by the Ocean Resources Committee)
WHEREAS, the t e r r i t o r i e s of American Samoa and Guam and th
Commonwealth of the Northern Marianas Islands (Flag Islands) are
unique p o l i t i c a l e n t i t i e s within the U.S. p o l i t i c a l system, with a
different legal and h i s t o r i c a l basis for t h e i r right to
j u r i s d i c t i o n and control over their respective Exclusive Economic
Zones (EEZs); and
WHEREAS, a l l Flag Islands have h i s t o r i c a l l y and t r a d i t i o n a l l y made
use of t h e i r offshore ocean resources and are vested with the
inherent right to explpre, exploit, control and manage t h e i r EEZ
resources
as recognized through customs and convention of
international law as well as duly enacted statutes and covenants;
and
OREGON
UTAH
WASHINGTON
WHEREAS, the federal government has not recognized the legitimate
rights of the Flag Islands to their respective EEZs and that t h i s
posture i s i n c o n f l i c t with established international conventions
respecting the ocean resource integrity of non-self-governing
t e r r i t o r i e s under administering powers; and
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEALTH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
WHEREAS, any federal attempt to subvert the rights of the people
of the Flag Islands to control their Exclusive Economic Zones does
not duly take into account the traditional, legal and international
conventions which vest the people of the Flag Islands with inherent
rights to j u r i s d i c t i o n over their Exclusive Economic Zones; and
WHEREAS, the peoples of the Flag Islands have no Constitutional
process available to them to consent to the decisions of th
federal government and as such u n i l a t e r a l federal determinations
regarding the Flag Islands EEZs i s inherently undemocratic; and
WHEREAS, the National Governor's Conference has adopted i n i t
policy on the Exclusive Economic Zone a recognition of the unique
rights of the Flag Islands to j u r i s d i c t i o n and control over t h e i r
EEZs;
®
�APPROVED RESOLUTION NO. 92-3
Page 2
NOW, THEREFORE BE IT RESOLVED t h a t t h e Western L e g i s l a t i v e
Conference of the Council of State Governments recognizes the r i g h t
of American Samoa, Guam and t h e Commonwealth of the Northern
Marianas Islands t o j u r i s d i c t i o n and c o n t r o l over t h e i r r e s p e c t i v e
Exclusive Economic Zones; and
BE IT FURTHER RESOLVED t h a t copies o f t h i s r e s o l u t i o n be
t r a n s m i t t e d t o t h e President o f t h e United States; t o t h
President-Elect of the United States; t o t h e Speaker o f t h e U.S.
House of Representatives; t o the President o f the U.S. Senate; t o
the Secretary o f the U.S. Department o f State; t o the Secretary o f
the U.S. Department of I n t e r i o r ; t o t h e Governors o f t h e Flag
Islands; and t o the Executive D i r e c t o r of t h e Council o f State
Governments.
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
920R3-1A
�WESTERN LEGISLATIVE CONFERENCE
12-SECOND ST.
- TH FL.
THE COUNCIL OF STATE GOVERNMzN i S
SAN FRANCISCO. CA 9-105
FHONE .-'5 9T--6-22
-A.V --r
r---~-~
PROPOSED RESOLUTION NO. 92-4
TRANS-PACIFIC SHIPMENT OF PLUTONIUM
(Opposing the Transportation of Hazardous and Radioactive
Materials i n the P a c i f i c Ocean Unless They Can Be Transported
Safely)
WESTERN STATES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
•
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
(Introduced by the Ocean Resources Committee)
WHEREAS, shipments of plutonium i n oxide powder form from France
for use i n Japan's breeder reactor program are expected to commence
in the f a l l of 1992; and
WHEREAS, Japan's plans c a l l for three to five shipments per year
for an indefinite period, following one of several 17,000-mile
trans-oceanic routes; and
WHEREAS, the plutonium i n question i s recovered from spent reactor
fuel of U.S. origin and the U.S. has rights of prior consent under
the Atomic Energy Act: for the use and transportation of the
plutonium; and
WHEREAS, the transportation plan currently i s under review by U.S.
federal agencies, with the State Department i n the lead, and i s not
available to the public due to security concerns; and
WHEREAS, i t i s not known i f trans-Pacific routes w i l l enter U.S.
waters, or whether Hawaii or any of the American flag islands are
designated as emergency ports; and
WHEREAS, there are no known protocols for notification of local
jurisdictions or management plans involving local j u r i s d i c t i o n s i n
the event of an incident i n port or at sea; and
WHEREAS, plutonium i s one of the most toxic substances known to
man, has a h a l f - l i f e of over 24,000 years, and has been
demonstrated to migrate up the food chain; and
COMMONWEAL TH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
WHEREAS, shipment of plutonium by sea has unique environmental
conditions and r i s k s , with standards for shipment by land not
providing adequate protection i n marine accidents or allowing for
post-accident cask recovery and environmental cleanup;
NW
O , THEREFORE BE IT RESOLVED that the Western Legislative
Conference (WLC) of the Council of State Governments supports the
©
�APPROVED RESOLUTION NO. 92-4
Page 2
t r a n s p o r t of hazardous and r a d i o a c t i v e m a t e r i a l s
method t e c h n o l o g i c a l l y a v a i l a b l e ;
by t h e safest
BE IT FURTHER RESOLVED t h a t t h e WLC supports t h e Resolution
introduced by the Asian P a c i f i c Parliamentarians' Union a t i t s 51st
(1992) council meeting and the Resolution adopted by the 21st Guam
L e g i s l a t u r e on July 10, 1992, expressing concerns over the maritime
t r a n s p o r t o f plutonium and urging both Japan and t h e United States
of American t o take a l l steps t o ensure safe t r a n s p o r t , i n c l u d i n g
adequate s e c u r i t y measures; and
BE IT FURTHER RESOLVED t h a t the U.S. Congress reconsider and adopt
Rep. N e i l Abercrombie's amendment r e q u i r i n g independent e v a l u a t i o n
of the t r a n s p o r t o f the cask containing t h e plutonium p r i o r t o
entry i n t o any U.S. p o r t ; and
BE I T FURTHER RESOLVED t h a t t r a n s p o r t vessel and shipment casks
should meet independently v e r i f i a b l e standards t o withstand
maritime accidents, i n c l u d i n g c o l l i s i o n , f i r e and s i n k i n g ; and
BE IT FURTHER RESOLVED t h a t t h e WLC urges t h a t t h e protocols
supported by western governors f o r land t r a n s p o r t a t i o n o f
r a d i o a c t i v e materials must be applied s t r i n g e n t l y t o ocean
t r a n s p o r t a t i o n , w i t h special consideration
given t o marine
conditions and r i s k s .
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
920R2-1A
�WESTERN
LEGISLA
i 21 SECOND ST.
TIVE CONFERENCE
J TH FL
SAN FRANCISCO. CA
THE COUNCIL
OF S TA TE GOVERNMEN
RHONE •-:f • F'-S-i:
-AX
TS
-':
APPROVED RESOLUTION NO. 92-5
STATE INVOLVEMENT IN NATIONAL HEALTH CARE POLICIES
(Urging the Clinton Administration and the Congress to Involve
the States and U.S. Insular Areas i n the Formation of any
National Health Care Policies and Programs)
WESTERN STATES
ALASKA
(Introduced by the Health and Education Committee)
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
WYOMING
WHEREAS, health care i s recognized as a c r i t i c a l l y important public
policy issue i n the United States; and
WHEREAS, the importance of health care was a focal point of the
recently concluded presidential election campaign; and
WHEREAS, a new national administration has placed a high p r i o r i t y
on addressing health care issues, including the p o s s i b i l i t y of some
form of national health insurance; and
WHEREAS, the states and the U.S. insular areas have a great deal of
expertise i n the health' care area, having been on the front lines
of health care delivery and therefore would be valuable
participants i n development of health care p o l i c i e s ; and
WHEREAS, the states and the U.S. insular areas have a v i t a l
interest i n the scope and the financing of any national health
insurance program; and
WHEREAS, there are major concerns about placing unreasonable
mandates on the states and the U.S. insular areas i n the
development of national health care p o l i c i e s ; and
PACIFIC ISLANDS
AMERICAN SAMOA
WHEREAS, any national health care policy must allow for individual
states and U.S. insular areas to meet the special needs of their
populations; and
COMMONWEALTH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
WHEREAS, the f l e x i b i l i t y of state approaches to health care issues
could be pre-empted without the involvement of states and U.S.
insular areas i n the planning process; and
WHEREAS, states and U.S. insular areas have been pioneers i n
developing innovative models for the delivery of health care; and
WHEREAS, the federal government should encourage the continuing
development of innovative health care models by states and U.S.
insular areas; and
®
�APPROVED RESOLUTION NO. 92-5
Page 2
WHEREAS, i t i s i n the best i n t e r e s t o f c i t i z e n s t h a t the states and
U.S. i n s u l a r areas be a strong partner w i t h the f e d e r a l government
i n the formation o f any n a t i o n a l health care plan;
NOW, THEREFORE BE IT RESOLVED t h a t t h e Western L e g i s l a t i v e
Conference of the Council of State Governments i s encouraged by t h e
p r i o r i t y t h a t President-elect C l i n t o n has placed on addressing
health care issues; and
BE IT FURTHER RESOLVED t h a t the C l i n t o n A d m i n i s t r a t i o n and t h e
Congress are urged t o involve t h e states and U.S. i n s u l a r areas,
i n c l u d i n g the Western L e g i s l a t i v e Conference o f t h e Council o f
State Governments, i n the decision making process o f any n a t i o n a l
health care proposals t h a t are placed before t h e Congress and t h e
American people.
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
92HE1-1A
�WESTERN LEGISLATIVE CONFERENCE
121 SECONDS'
4THFI.
THE COUNCIL OF STATE GOVERNMEN:
SAN FRANCISCO C A & C f
-HONE
9T--r-22
FAX - ' r
APPROVED RESOLUTION NO. 92-6
REPRESENTATIVE JUNE LEONARD OF WASHINGTON STATE
(Conveying Best Wishes For a F u l l Recovery From Her Recent
Illness)
WESTERN STATES
ALASKA
(Introduced by the Health and Education Committee)
ARIZONA
.CALIFORNIA
WHEREAS, a recent i l l n e s s has prevented State Representative June
Leonard from participating i n the 1992 annual meeting of the
Western Legislative Conference; and
COLORADO
HAWAII
WHEREAS, this absence has deprived the Western Legislative
Conference of her valued leadership as chair of the Health and
Education Committee;
IDAHO
MONTANA
NEVADA
NEW MEXICO
NW
O , THEREFORE BE IT RESOLVED that the Western Legislative
Conference of the Council of State Governments conveys i t s best
wishes to State Representative June Leonard of Washington State for
a speedy recovery to f u l l and vigorous health so that she soon i s
able to resume her active participation i n regional policy
development through the Western Legislative Conference.
OREGON
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEALTH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
®
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
92HE2-1A
�WESTERN LEGISLATIVE CONFERENCE
121 SECOND ST.
- TH FL.
THE COUNCIL OF STA TE G O V E R N M c N l
SAN FRANCISCO. CA W G :
PHONE I-:5I ?:--v-22
- A:•: • - 'E A'--'"
APPROVED RESOLUTION NO. 92-7
JAPAN/U.S. HEALTH CARE EXCHANGE
(To Japan f o r Hosting Delegation)
WESTERN STATES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
(Introduced by the Health and Education Committee)
WHEREAS, t h e Council o f State Governments and t h e Japan
Foundation's Center f o r Global Partnership have organized an
exchange between leading h e a l t h p o l i c y experts i n the United States
and Japan; and
WHEREAS, t h i s delegation w i l l t r a v e l t o Japan t o meet w i t h
physicians, h e a l t h and welfare m i n i s t r y o f f i c i a l s , academic
researchers and j o u r n a l i s t s ; and
WHEREAS, the delegation's goals are t o f u r t h e r debate r e l a t e d t o
h e a l t h care cost containment, q u a l i t y and access p r e s e n t l y being
debated on a domestic l e v e l ; and
WHEREAS, t h i s exchange w i l l provide valuable i n s i g h t r e l a t i n g t o
h e a l t h care d e l i v e r y and deeper c r o s s - c u l t u r a l understanding o f
health care systems;
NOW, THEREFORE BE IT RESOLVED t h a t t h e Western L e g i s l a t i v e
Conference wishes t o express most sincere thanks t o Japan f o r
hosting the delegation and p r o v i d i n g the o p p o r t u n i t y t o l e a r n about
Japan's h e a l t h care system.
WYOMING
PACIFIC ISLANDS
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
AMERICAN SAMOA
92HE3-1A
COMMONWEALTH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
®
�WESTERN LEGISLATIVE CONFERENCE
121 SECOND ST.
- TH FL
THE COUNCIL OF STA TE GOVERNMEN'
SAN FRANCISCO. CA 9-1 OF
FHONE'-'5 . " - - r - ' J
r
- U ' • - r f r"--""
APPROVED RESOLUTION NO. 92-8 EXTENDED
(90-14 One-Year Extension, Expires i n '93)
COORDINATION OF GUIDANCE AND PREVENTION SERVICES FOR FAMILIES
(Urging a C a l l to Action by the Public and Private Sectors)
WESTERN STATES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
(Introduced by the Health and Education Committee)
WHEREAS, the family i s the core of society and therein l i e s the
root of both social problems and solutions; and
WHEREAS, the American family i s undergoing transition because of
the number of single-parent families, children without families and
families without homes and familial roots; and
WHEREAS, economics are having a dramatic effect on families who
need two incomes to maintain an average or even substandard
l i f e s t y l e ; and
WHEREAS, there are special needs associated with increasing numbers
of minorities and minority language users; and
WHEREAS, the high rate of family mobility leaves children with
fewer extended family members from whom they might receive support;
and
UTAH
WASHINGTON
WHEREAS, the number of teenage mothers has more than t r i p l e d from
what i t was 25 years ago; and
WYOMING
WHEREAS, child abuse and neglect have risen s i g n i f i c a n t l y ; and
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEALTH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
®
WHEREAS, nearly one million children drop out of school each year;
over 64 percent of those dropouts who have jobs receive minimum
wages; 60 percent of prison inmates are school dropouts;
and
WHEREAS, approximately 37 million Americans used an i l l e g a l drug
l a s t year, almost one i n every ten Americans uses an i l l e g a l drug
in an average month; and more than $200 b i l l i o n i s l o s t i n the U.S.
each year i n the economic and social drain from substance abuse, i n
unemployment, lost productivity, chronic i l l n e s s , crime, family
abuse and deaths; between 3,600 and 10,000 babies are born each
year with f e t a l alcohol syndrome; i t i s estimated that nearly
375,000 newborns each year have been exposed to i l l e g a l drugs,
frequently cocaine; and
�APPROVED RESOLUTION NO. 92-8 EXTENDED
Page 2
WHEREAS, each day i n the U.S., approximately 1,000 adolescents
attempt suicide, and 18 are completed; suicide i s the third leading
cause of death among teens after accidents and homicides; half of
teen suicide victims come from single-parent families, and family
c o n f l i c t and abuse are common factors leading to suicide; and
WHEREAS, mental i l l n e s s represented the t h i r d most c o s t l y c l a s s of
health care expenditures i n the U.S. i n 1980, not including
indirect costs of l o s t productivity and related factors; and
WHEREAS, AIDS i s rapidly emerging as a major health threat to
infants and children; and
WHEREAS, many Americans have inadequate or no health insurance (an
estimated 36.8 million Americans have no health insurance); a
greater proportion of the uninsured l i v e i n the western and
southern U.S.; uninsured persons under age 65, including the
employed uninsured, the unemployed uninsured, the underinsured, and
the uninsurable or "high r i s k " population; and
WHEREAS, medical indigency i s the number one health issue on state
l e g i s l a t i v e agenda; uncompensated care costs the states almost $12
b i l l i o n i n 1987; uninsured persons are less l i k e l y to seek needed
medical care; t h i s lack of primary and preventive care often leads
to more costly care i n the future; and
WHEREAS, quality, affordable child care i s often lacking for
working parents, leaving "latch-key" children at home alone or to
fend for themselves; and school-age children need acceptable c h i l d
care before and after school; and
WHEREAS, there i s an increasing number of families in AFDC programs
causing
a heavier
caseload
for already
understaffed and
undertrained caseworkers; and
WHEREAS, there i s a need for increased
restructuring i n the AFDC programs; and
accountability and
WHEREAS, there i s a growing need for early childhood
including early intervention strategies;
education,
NW
O , THEREFORE, BE IT RESOLVED that the Western L e g i s l a t i v e
Conference of the Council of State Governments c a l l s upon the
National Governors' Association to form a task force to provide
guidance to the public and private sectors, including consideration
of appropriate tax credits and f i s c a l incentives for educational
and preventive services to families, with the goal to maintain
�APPROVED RESOLUTION NO. 92-8 EXTENDED
Page 3
f a m i l y u n i t y , t o r e s t o r e the d i g n i t y of the f a m i l y , and t o develop
responsible c i t i z e n s f o r America; and
BE IT FURTHER RESOLVED t h a t t h i s r e s o l u t i o n be t r a n s m i t t e d t o t h e
current chairman and appropriate s t a f f o f t h e National Governors'
Association, and t o t h e Congressional delegations of t h e Western
States and t o other o f f i c i a l s i n accordance w i t h the bylaws and t h e
r u l e s of t h e Western L e g i s l a t i v e Conference.
(RESOLUTION APPROVED BY THE CONFERENCE AT ITS
1990 ANNUAL MEETING ON SEPTEMBER 26 IN ANCHORAGE, ALASKA.)
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
92HE4-1A
�WESTERN LEGISLA TIVE CONFERENCE
i2i SECONDS'.
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THE COUNCIL OF STA TE GOVERNMEN'
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APPROVED RESOLUTION NO. 92-9 EXTENDED
(90-13 One-Year Extension, Expires '93)
REDUCING DEMAND FOR ILLEGAL DRUGS
(Urging the President and Congress to Emphasize Demand Reduction
Strategies)
WESTERN STATES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
.'.-ION TANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
(Introduced by the Health and Education Committee)
WHEREAS, i l l e g a l drug abuse continues to be i d e n t i f i e d by the
American people as a serious social problem; and
WHEREAS, abuse of i l l e g a l drugs costs b i l l i o n s of dollars to the
public through increased health care costs, higher crime rates,
lost workers' productivity, environmental damage and medical
trauma; and
WHEREAS, inadequate financial resources are available for public
education programs or treatment of the victims of i l l e g a l drug
abuse; and
WHEREAS, eliminating drugs from the workplace may be one of the
more effective strategies states can pursue; and
WHEREAS, reducing the demand for i l l e g a l drugs has great potential
for addressing this social problem; and
WHEREAS, the President and Congress are negotiating passage of a
package of demand-reducing strategies i n our nation's "war against
i l l e g a l drugs";
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
NW
O , THEREFORE, BE IT RESOLVED that the Western L e g i s l a t i v e
Conference of the Council of State Governments urge the President
and the Congress of the United States to emphasize demand-reduction
strategies; and
BE IT FURTHER RESOLVED that the Western L e g i s l a t i v e Conference of
the Council of State Governments a s s i s t state l e g i s l a t o r s to
identify their state needs for additional demand-reducing
strategies, to identify those a c t i v i t i e s that work best within
their state, especially i l l e g a l drug-use prevention programs i n
COMMONWEALTH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
®
�APPROVED RESOLUTION NO. 92-9 EXTENDED
Page 2
K-12 school classrooms and the workplace, and t o design ways t o
share those a c t i v i t i e s w i t h l e g i s l a t o r s from other s t a t e s .
(RESOLUTION APPROVED BY THE CONFERENCE AT ITS 1990 ANNUAL MEETING
ON SEPTEMBER 26 IN ANCHORAGE, ALASKA.)
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
92HE5-1A
�WESTERN LEGISLATIVE CONFERENCE
;2i SECONDS'
i TH -£..
THE COUNCIL OF STA TE GOVERNMtzN; S
SAN FRANCISCO. CA =- :C-
APPROVED RESOLUTION NO. 92-10
SAFE DRINKING WATER ACT IMPLEMENTATION
WESTERN STATES
ALASKA
(Urging Congress and the U.S. Environmental Protection Agency to
Provide Adequate Funding and Maximum F l e x i b i l i t y to the States i n
Implementing the Federal Safe Drinking Water Act)
(Introduced by the Water Policy Committee)
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
WHEREAS, to protect the public from health hazards resulting from
contamination of drinking water, i n 1974, Congress passed the
federal Safe Drinking Water Act; and
WHEREAS, the Safe Drinking Water Act amendments of 1986 directed
the U.S. Environmental Protection Agency (EPA) to accelerate the
federal effort to develop regulations for the safe drinking water
program; and
WHEREAS, one of the key mechanisms through which the goals of the
Safe Drinking Water Act amendments are achieved i s through state
primacy agreements; and
WHEREAS, state and public water supply systems have made
substantial progress i n protecting drinking water and American has
the safest drinking water i n the world; and
WHEREAS, current federal funding assistance to the states i s not
commensurate with the costs to states and water supply systems for
implementing the regulations of the Safe Drinking Water Act; and
WHEREAS, some drinking water requirements are not j u s t i f i e d based
on the r i s k s posed to the public and the costs to implement these
requirements sometimes outweigh their benefits; and
AMERICAN SAMOA
COMMONWEAL TH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
WHEREAS, the U.S. EPA regulations address the water pollution
problems that result from industrial sources i n populated areas i n
the eastern U.S. without looking at the unique conditions of the
West; and
WHEREAS, the National Governors' Association has adopted an eightpoint plan for improving the nation's drinking water program that
recommends statutory changes, improving program efficiency and
increasing the a v a i l a b i l i t y of resources; and
WHEREAS, the Western Governors' Association and the Governors'
Forum on Environmental Management have endorsed similar plans; and
®
�APPROVED RESOLUTION NO. 92-10
Page 2
WHEREAS, t h e U.S. EPA has established a National Implementatior
Work Group t o review Phases I , I I and V o f t h e f e d e r a l d r i n k i n g
water r u l e s .
NOW, THEREFORE BE IT RESOLVED t h a t t h e Western L e g i s l a t i v e
Conference of The Council of State Governments urges Congress t o
e x p e d i t i o u s l y pursue r e a u t h o r i z a t i o n of the Safe D r i n k i n g Water Act
to provide f l e x i b i l i t y t o states and p u b l i c water supply systems t o
provide a safe, dependable d r i n k i n g water supply; and
BE I T FURTHER RESOLVED t h a t as p a r t o f t h e process o f
r e a u t h o r i z a t i o n , the U.S. EPA be required t o conduct a study and
prepare a r e p o r t t o Congress and t h e states addressing t h e
f o l l o w i n g issues:
(1) updated costs t o the states of implementing the Act r e g u l a t i o n s
and a determination of adequate federal f i n a n c i a l assistance l e v e l s
f o r implementation o f the Act;
(2) consideration of a requirement t h a t t h e l i s t o f contaminants
pursuant t o Section 1412 of the Act take i n t o account whether t h e
contaminant a c t u a l l y causes a s i g n i f i c a n t adverse e f f e c t on human
h e a l t h , or other r i s k or safety f a c t o r s , o r i s known or a n t i c i p a t e d
to be found i n p u b l i c water systems;
(3) a determination o f whether compliance deadlines can be r e v i s e d
to provide states w i t h more f l e x i b i l i t y i n implementing f e d e r a l
regulations without jeopardizing the p u b l i c h e a l t h ; and
BE IT FURTHER RESOLVED t h a t the Western L e g i s l a t i v e Conference
urges Congress t o appropriate $100 m i l l i o n t o help states meet
mandated regulatory costs and t o provide 75% o f the costs f o r any
a d d i t i o n a l new requirements, while s t a t e and l o c a l e n t i t i e s o f
governments should commit themselves t o seeking a d d i t i o n a l
resources t o close the remaining resource gap; and
BE IT FURTHER RESOLVED t h a t t h e Western L e g i s l a t i v e Conference
supports the National Implementation Work Group i n i t s e f f o r t s t o
examine and recommend changes t o the Safe D r i n k i n g Water Act and
encourages the U.S. EPA t o develop c l e a r and simple d r i n k i n g water
standards and regulations t h a t provide maximum f l e x i b i l i t y t o
states as the regulations are implemented.
RESOLUTION RENEWED FOR ONE YEAR BY THE CONFERENCE AT ITS
1992 ANNUAL MEETING ON NOVEMBER 18 IN AGANA GUAM
92WA1-1A
�WESTERN LEGISLATIVE CONFERENCE
121SECQNDST
4 TH FL.
THE COUNCIL OF STA TE
SAN FRANCISCO. CA 9^05
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APPROVED RESOLUTION NO. 92-11
PROTECTING GROUND WATER QUALITY
WESTERN STATES
(Urging the U.S. Environmental Protection Agency to Modify i t s
Ground Water Strategy to Reflect Current Statutory Authority and
to Provide Adequate Funding)
ALASKA
ARIZONA
(Introduced by the Water Policy Committee)
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
WHEREAS, ground water i s a c r i t i c a l l y important natural resource,
especially i n the arid West; and
WHEREAS, ground water management - the protection of i t s quality
and i t s orderly, rational allocation and withdrawal for beneficial
use - requires cooperation among a l l levels of government; and
WHEREAS, states recognize the importance and role of comprehensive
ground water planning overall water management; and
NEVADA
NEW MEXICO
WHEREAS, the federal government has a longstanding policy of
deferring to the states to develop and implement ground water
management and protection programs; and
OREGON
UTAH
WHEREAS, western states have legal systems to allocate ground water
rights and further have the responsibility for ground water quality
protection; and
WASHINGTON
WYOMING
PACIFIC ISLANDS
WHEREAS, the U.S. Environmental Protection Agency (EPA) has
prepared i t s f i n a l report, "Protecting the Nation's Ground Water:
EPA's Strategy for the 1990's", which establishes ground water
policy direction for the agency; and
WHEREAS, the policy direction would require states to develop
comprehensive ground water protection plans, the content and
COMMONWEALTH OF THE substance of which would be subject to review and approval by the
NORTHERN MARIANA
U.S. EPA, i n c o n f l i c t with the traditional deference by the federal
ISLANDS
government to states' authority i n the administration of ground
water quality and quantity regulation; and
GUAM
AMERICAN SAMOA
WHEREAS, the U.S. EPA i s formulating funding allocation p o l i c i e s ,
p a r t i c u l a r l y with respect to the "set-aside" of certain Clean Water
Act Section 106 monies, that also indicate a s h i f t away from the
traditional federal role of deference to state authority i n ground
water management; and
®
�APPROVED RESOLUTION NO. 92-11
Page 2
WHEREAS, the U.S. EPA lacks statutory authority to impose ground
water program requirements on states, as the approvals and
sanctions i n the strategy contemplate; and
WHEREAS, the U.S. EPA's strategy and draft guidance document do not
adequately address the changes within the agency and other federal
agencies necessary to coordinate federal ground water programs;
NW
O , THEREFORE BE IT RESOLVED that the Western L e g i s l a t i v e
Conference of the Council of State Governments urges the U.S. EPA
to modify i t s ground water strategy to r e f l e c t a true state-federal
partnership, consistent with i t s current statutory authority, and
supported by an adequate level of grant funding for states that
does not simply re-direct funds that would otherwise be available
to state water pollution control programs.
92WA2-1A
�WESTERN LEGISLA TIVE CONFERENCE
THE COUNCIL OF S TA i t GO VtRNMzN
•21 SECOND ST.
APPROVED RESOLUTION NO. 92-12
REAUTHORIZATION OF THE ENDANGERED SPECIES ACT
WESTERN STATES
(Urging Congress to Consider the Rights of the Western States i n
Developing Their Water Resources When Considering Reauthorization
of the Endangered Species Act)
(Introduced by the Water Policy Committee)
WHEREAS, the federal Endangered Species Act has been used by some
parties to obstruct western water projects; and
WHEREAS, the Endangered Species Act does not adequately take the
costs and benefits of implementation of the Act into account; and
WHEREAS, implementation of the Endangered Species Act c o n f l i c t s
with the administration of western states water rights, i n the
development of water supplies;
NW
O , THEREFORE BE IT RESOLVED that the Western Legislative
Conference of the Council of State Governments urges Congress to
use every means possible i n the reauthorization of the Endangered
Species Act so that the Act w i l l not be used as a means to obstruct
the development of water resources i n the western states.
92WA3-1A
PACIFIC ISLANDS
•
AMERICAN SAMOA
COMMONWEALTH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
®
�WESTERN LEGISLATIVE CONFERENCE
THE COUNCIL
121 S E C O N D S ' .
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APPROVED RESOLUTION NO. 92-13 EXTENDED
(90-17 One-Year Extension, E x p i r e s '93)
STATE PRIMACY IN WETLANDS MANAGEMENT
WESTERN STATES
(Urging the States to Maintain Primacy i n the Management of
Wetlands)
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEAL TH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
(Introduced by the Water Policy Committee)
WHEREAS, wetlands contribute toward food, habitat, quality water
and water storage for humans, f i s h , livestock and w i l d l i f e , enhance
recreational, environmental and aesthetic values, and a s s i s t i n
erosion control, flood attenuation, nutrient recycling, aquifer
recharge and a myriad of other values; and
WHEREAS, the Western States are sensitive to society's desire to
protect wetlands so that these values are perpetuated for future
generations; and
WHEREAS, the Western States have created and enhanced wetlands
through the development of i r r i g a t i o n systems, elevation of water
tables, recharging of aquifers, creation of cropland and pasture as
sources of water, food and cover, and s o i l and water conservation;
and
WHEREAS, the Western States consider the issue of wetlands
management to be driven by and predicated upon the fundamental
issue of water management and the states' prerogatives to manage
and administer water within their borders; and
WHEREAS, the governments of the Western States understand better
than the federal government the dramatic impacts of wetland
p o l i c i e s on state lands, natural resources, people, l i f e s t y l e s ,
environment, constitutional rights, and economies; and
WHEREAS, current wetland p o l i c i e s of federal agencies include
definitions, j u r i s d i c t i o n s , and regulations that are inconsistent,
uncoordinated, u n r e a l i s t i c , r e s t r i c t i v e , and inconsiderate of local
and state resource problems and needs; and
WHEREAS, these federal policies were developed without formal input
from the states and i n apparent disregard for state water policies
and water law and private property rights and have thereby created
c o n f l i c t , confusion, disorganization and discontent; and
WHEREAS, current federal definitions and inventories often do not
®
�APPROVED RESOLUTION NO. 92-13 EXTENDED
Page 2
distinguish between naturally-occurring and manmade wetlands,
creating
further
confusion,
conflict,
disorganization
and
discontent; and
WHEREAS, federal wetlands p o l i c i e s do not address vector-borne
disease or animal and human health and safety hazards; and
WHEREAS, each area of the U.S. i s uniquely d i f f e r e n t i n r a i n f a l l ,
surface waters, s o i l type and vegetation; and
WHEREAS, each Western State possesses the r e s p o n s i b i l i t y , authority
and a b i l i t y to accurately assess and develop a consistent,
coordinated and r e a l i s t i c wetlands policy that w i l l enhance t h e i r
wetlands, natural resources and environment and that w i l l involve
state management and administration of water within t h e i r borders
and that w i l l reconcile public p o l i c i e s encouraging sound
conservation while f u l f i l l i n g the individual needs of the people,
c i t i e s , towns and counties within each state;
NOW, THEREFORE, BE IT RESOLVED that the Western L e g i s l a t i v e
Conference of the Council of State Governments believes that states
should exercise primacy i n establishing and administering wetlands
p o l i c i e s and programs for t h e i r states; and
BE IT FURTHER RESOLVED that the Conference encourages President
Clinton to instruct executive agencies with authority over wetlands
to develop, with each state, exact definitions of wetlands to be
used for a l l federal agencies.
(RESOLUTION APPROVED BY THE CONFERENCE AT ITS
1990 ANNUAL MEETING ON SEPTEMBER 26 IN ANCHORAGE, ALASKA.)
92WA4-1A
�WESTERN LEGISLATIVE CONFERENCE
V2. SECOND ST
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J TH FL
THE COUNCIL O STA / =
GOVERNMLN
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SAN 'FANCISCO. CA
APPROVED RESOLUTION NO. 92-14
MARKET DEVELOPMENT AND GOVERNMENT PROCUREMENT OF RECYCLED
MATERIALS
WESTERN STATES
(Urging Public and Private Agencies to E s t a b l i s h Programs to
Develop Markets for Recycled Materials and to Favor Purchases of
Recycled Products)
ALASKA
(Introduced by the Environment and Resource Management Committee)
ARIZONA
WHEREAS, the a v a i l a b i l i t y of markets for recycled products i s
essential to the success of recycling and i s an element of any
comprehensive approach to s o l i d waste management and resource and
energy conservation; and
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEAL TH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
WHEREAS, state and local government purchasing represents a
significant percentage of the gross national product (GNP) and
therefore, can have a s i g n i f i c a n t effect on the demand for
secondary materials by purchasing and using recycled products; and
WHEREAS, state and local agencies can influence private purchase
of recycled products by setting an example through purchasing,
testing products and establishing standards and specifications
that can be replicated by private agencies; and
WHEREAS, the federal government, whose purchases represent seven
to eight percent of the GNP, i s implementing Section 6002 of the
Resource Conservation and Recovery Act, requiring agencies using
federal funds to favor recycled products; and
WHEREAS, recycled products are generally competitive with v i r g i n
products i n price and quality and are becoming more available as
more manufacturers and vendors enter the marketplace and as the
supply of secondary materials increases dramatically; and
WHEREAS, by working together, state and local
increase the use of recycled products; and
governments can
WHEREAS, the success of recycling depends on the manufacture of
recovered materials into useful products that reenter the economy;
and
WHEREAS, there are s i g n i f i c a n t tax advantages granted to the
production of v i r g i n materials that may act as a disincentive to
the use of recycled materials; and
WHEREAS, the c o l l e c t i v e effort of the Western States to
consolidate economic power through the establishment
of a
®
�APPROVED RESOLUTION NO.
Page 2
recyclable materials
fluctuations;
92-14
commodities market would s t a b i l i z e market
NOW,
THEREFORE, BE IT RESOLVED that the Western L e g i s l a t i v e
Conference of the Council of State Governments urges that public
and private agencies and organizations e s t a b l i s h programs to favor
purchases of recycled products, including:
1.
l e g i s l a t i v e , executive
buying recycled products;
and
administrative
commitment to
2.
using standard specifications, d e f i n i t i o n s and minimum
content standards (such as those established by the
U.S.
Environmental Protection Agency (EPA) under RCRA or the Northeast
Recycling Council) to allow manufacturers to make a standard
product and reduce unit costs;
3.
eliminating prohibitions or limitations against recycled
products and
including recovered materials content i n bid
specifications;
4.
cooperative purchasing programs among the s t a t e s , l o c a l
governments, regional authorities and private organizations to
increase the volume of purchases and decrease unit costs;
5.
providing incentives, as needed, for buying recycled products
(including price preferences and l i f e - c y c l e costing);
6.
cooperation between vendors and users to ensure that vendors
can s e l l recycled products and that users are aware of recycled
products on the market;
7.
keeping good records on recycled purchasing programs
publicize efforts and share information with other users; and
to
8.
purchasing a variety of recycled products, including products
for which EPA guidelines have been established (paper, o i l , t i r e s ,
building insulation, concrete); products from the materials being
collected for recycling; products from the O f f i c i a l Recycled
Products Guide; and other products including, but not limited to,
p l a s t i c , auto parts, compost aggregate, asphalt, solvents, rubber
and construction materials;
BE IT FURTHER RESOLVED that the Conference believes market
development programs must be made an integral part of recycling
collection i n i t i a t i v e s and that i n promoting markets for recovered
materials,
economic
development,
waste
management
and
environmental protection, authorities must work with private firms
�APPROVED RESOLUTION NO. 92-14
Page 3
to select, to Insure f u l l funding and to implement the most
appropriate and cost-effective market development instruments from
among the following available p o l i c i e s :
1.
material processing
facilities;
2.
contracts between suppliers and manufacturers;
3.
economic development programs (including f i n a n c i a l assistance
and assistance with f a c i l i t y s i t i n g and permit review);
4.
regional cooperative brokerage and transportation management
programs;
5.
preferential procurement of recycled products;
6. information and research programs (information clearinghouses
and public, private and university research and development
consortia) to develop new recycled products and expand the use of
recovered materials i n existing products;
7.
investments i n transportation infrastructure and marketing
programs to increase ciomestic and foreign use of recovered
materials;
8.
reassess standards and specifications for products and
secondary materials, and education programs for consumers and
businesses to expand demand for recycled products;
9.
revisions i n the tax codes, including d i f f e r e n t i a l packaging
or materials taxes that favor recycled materials;
10.
improved current-cash
materials; and
and futures
markets
for recycled
11.
additional market development instruments when required by
innovation and change within the recycling industry; and
BE IT FURTHER RESOLVED that the Conference urges Congress to enact
l e g i s l a t i o n that eliminates the disparity between tax advantages
granted to recycled products and v i r g i n materials; and
BE IT FURTHER RESOLVED that the Conference supports establishment
of regional recyclable materials commodities markets which w i l l
foster recyclable materials market development a c t i v i t i e s and work
toward s t a b i l i z a t i o n of these markets both i n terms of quality and
price.
92RM1-1A
�WESTERN LEGISLATIVE CONFERENCE
',21 SECOND ST.
* TH FL
THE COUNCIL OF 5 i A TE G O V t R N M E N
SAN FHANC:SCC CA 9- •CF-
—ONE---: 9'--~-22
'-A - ' r r"- •
APPROVED RESOLUTION NO. 92-15
BALANCED APPROACH TO FEDERAL ENVIRONMENTAL INITIATIVES
(Urging the New Administration t o Proceed Cautiously w i t h New
Environmental Programs)
WESTERN STA TES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEALTH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
®
(Introduced by the Environment and Resource Management Committee)
WHEREAS, environmental q u a l i t y i s e s s e n t i a l t o the f u t u r e of t h i s
n a t i o n ; and
WHEREAS, our new n a t i o n a l Administration has declared the need f o r
emphasizing environmental p r o t e c t i o n as one of i t s main o b j e c t i v e s ;
and
WHEREAS, the economies of many states are s u f f e r i n g the e f f e c t s of
recession, w i t h many jobs l o s t ; and
WHEREAS, t h e n a t i o n a l and s t a t e economies
assistance i n developing growth and jobs;
need
a l l possible
NOW, THEREFORE BE IT RESOLVED t h a t t h e Western L e g i s l a t i v e
Conference of the Council State Governments urges the new n a t i o n a l
A d m i n i s t r a t i o n t o maintain a balanced approach t o environmental
p r o t e c t i o n l e g i s l a t i o n and a d m i n i s t r a t i o n i n which the economic
impact
of environmental
protection
i s given
significant
consideration, w i t h an emphasis on a cautious approach t o new
environmental p r o t e c t i o n programs u n t i l such time as the n a t i o n a l
and s t a t e economies recover t h e i r health.
92RM3-1A
�WESTERN LEGISLA TIVE CONFERENCE
•21 SECOND ST
-THFL.
THE COUNCIL 0 F STATE GOVERNMENTS
SAN FRANCISCO. CA r-'.'::"
C
.H'0V5
APPROVED RESOLUTION NO. 92-16
UNFUNDED ENVIRONMENTAL MANDATES
(Urging Congress to Establish a Commission on the Implementation
of Environmental Protection)
WESTERN STATES
ALASKA
(Introduced by the Environment and Resource Management Committee)
ARIZONA
WHEREAS, the Congress has numerous laws imposing environmental
r e s t r i c t i o n s on the states; and
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEAL TH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
®
WHEREAS, the Congress has i n i t i a l l y funded substantial programs to
implement the mandates imposed by Congress; and
WHEREAS, i n recent years federal f i n a n c i a l constraints have caused
Congress to reduce the funding for the implementation of these
mandates; and
WHEREAS, State Governments and P a c i f i c Island Governments face
similar f i n a n c i a l constraints and are not f u l l y capable of
implementing the mandates from Congress; and
WHEREAS, there i s no mechanism available for reducing the
obligation
presented i n those mandates due to f i n a n c i a l
constraints; and
NW
O , THEREFORE BE IT RESOLVED that the Western L e g i s l a t i v e
Conference of the Council of State Governments c a l l s upon the
Congress to established a national Commission on the Implementation
of Environmental Protection composed of members of Congress and an
equal number of elected representatives of state and P a c i f i c island
governments and local governments to develop a new national program
which establishes fundamental levels of environmental protection
which must be implemented despite f i n a n c i a l constraints and
alternative levels of environmental protection which s h a l l be
implemented only to the extent that they are f u l l y funded by the
federal government.
92RM2-1A
�WESTERN LEGISLA TIVE CONFERENCE
12'SECOND ST,
-THFL
THE COUNCIL OF S TA TE GO VERNMEN'
SAN FRANCISCO CA 94 ;05
RHONE
9~-v-~S
-"-:.V •-•5
APPROVED RESOLUTION NO. 92-17
AMENDING THE COASTWISE SHIPPING ACT OF 1916 AND THE MERCHANT
MARINE ACTS OF 1920, 1928 AND 1936
WESTERN STATES
ALASKA
ARIZONA
Relative t o Requesting the U.S. Congress t o Review Certain
Provisions o f the Coastwise Shipping Act o f 1916 and the Merchant
Marine Acts o f 1920, 1928 and 1936 (As Amended) as they Apply t o
Member States and I s l a n d Governments of the Western L e g i s l a t i v e
Conference
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
• UTAH
WASHINGTON
WYOMING
(Introduced by the Economic Development and I n t e r n a t i o n a l Trade
Committee)
WHEREAS, since the o r i g i n a l passage by the U.S. Congress of the
Coastwise Shipping Act of 1916 and the Merchant Marine Acts of
1920, 1928 and 1936 (as amended) — c o l l e c t i v e l y known as the Jones
Act -- s i g n i f i c a n t trade r e l a t i o n s h i p s have been established
d i r e c t l y and between member states and i s l a n d governments of t h e
Western L e g i s l a t i v e Conference and P a c i f i c Rim c o u n t r i e s ; and
WHEREAS, i t i s believed t h a t t h e cost of e s s e n t i a l commodities
purchased by residents of states and i s l a n d governments has
increased s i g n i f i c a n t l y because of the lack o f competition i n the
shipping of goods; and
WHEREAS, i t i s believed t h a t the a p p l i c a t i o n of the Jones Act also
c o n t r i b u t e s t o the increase i n the p r i c e o f goods manufactured by
United States corporations i n WLC member s t a t e s and i s l a n d
governments thereby decreasing the competitiveness of United States
producers;
PACIFIC ISLANDS
NOW, THEREFORE BE IT RESOLVED t h a t t h e Western L e g i s l a t i v e
Conference of the Council of State Governments hereby requests th
AMERICAN SAMOA
United States Congress t o review those provisions o f the Coastwise
COMMONWEAL TH QF THE Shipping Act of 1916 and the Merchant Marine Acts o f 1920, 1928 and
NORTHERN MARIANA
1936 (as amended) which p r o h i b i t or r e s t r i c t open competition i n
ISLANDS
the shipping trade between and among t h e coastal p o r t s of t h e
mainland United States and the i s l a n d t e r r i t o r y o f Guam.
GUAM
92ED2-1A
®
�WESTERN LEGISLA TIVE CONFERENCE
SECOND ST.
SAN FRANCISCO
THE COUNCIL Or S IA / E GOVERNMcN: S
CA 94 W5
APPROVED RESOLUTION NO. 92-18
GENERAL AGREEMENT ON TRADE AND TARIFFS APPROVAL
WLC Urging the Administration to Come to Agreement on the General
Agreement on Trade and T a r i f f s
WESTERN STATES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEAL TH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
®
(Introduced by the Economic Development and International Trade
Committee)
WHEREAS, the Uruguay round of the General Agreement on Trade and
T a r i f f negotiations which has taken place over the l a s t five years
addresses thousands of items; and
WHEREAS, the negotiating parties are i n agreement upon the vast
majority of these items; and
WHEREAS, the few remaining areas of contention are agricultural
concerns which impact small growers i n several countries; and
WHEREAS, the f a i l u r e to agree upon international trade and t a r i f f
standards w i l l result in policies of protectionism and r e t a l i a t i o n ;
and
WHEREAS, passage of the accord w i l l bring about greater economic
prosperity; and
WHEREAS, such prosperity results i n the overall good of society;
NW
O , THEREFORE BE IT RESOLVED that the Western Legislative
Conference of the Council of State Governments urges the
Administration to come to agreement on the General Agreement on
Trade and T a r i f f s for the benefit of the United States and other
countries of the world.
92ED3-1A
�WESTERN LEGISLATIVE CONFERENCE
12-'SECONDS!.
-THFL
THE COUNCIL OF STATE GOVERNMEN'
SAN FRANCISCO. CA ^ ; C 5
-HONE -:.-
-"^
APPROVED RESOLUTION NO. 92-19
NORTH AMERICAN FREE TRADE AGREEMENT APPROVAL
Resolution Urging Congress to Approve North American Free Trade
Agreement
WESTERN STATES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
(Introduced by the Economic Development and International Trade
Committee)
WHEREAS, the North American Free Trade Agreement was signed i n
October of 1992 and the United States, Canada and Mexico w i l l
create a free trade area with over 360 million inhabitants and $8
t r i l l i o n gross output; and
WHEREAS, the agreement should promote economic development i n th
region and therefore benefit each of the states; and
WHEREAS, as particular areas of importance to states are
considered. Congress i s requested
to consult with
state
legislatures during the hearings on r a t i f i c a t i o n of the agreement;
and
WHEREAS, upon r a t i f i c a t i o n adequate federal funding for retraining
programs for U.S. workers who w i l l be dislocated as a r e s u l t of the
treaty; and
WHEREAS, upon r a t i f i c a t i o n labor standards, wage
workplace standards should be s t r i c t l y enforced; and
levels and
WHEREAS, upon r a t i f i c a t i o n urgent effort should be made to maintain
high levels of environmental protection and no support of efforts
to reduce standards should be made; and
WHEREAS, upon r a t i f i c a t i o n the Western L e g i s l a t i v e Conference
supports adequate federal funding by the United States and Mexico
COMMONWEAL TH OF THE
to clean up existing pollution along the U.S. - Mexico border;
AMERICAN SAMOA
NORTHERN MARIANA
ISLANDS
GUAM
NW
O , THEREFORE BE IT RESOLVED that the Western L e g i s l a t i v e
Conference of the Council of State Governments urges Congress to
r a t i f y the North American Free Trade Agreement i n a timely manner.
92ED1-1A
®
�WESTERN LEGISLA TIVE CONFERENCE
;2i SECOND ST
THE COUNCIL OF S TA / E G O V t R N M t N •
SAX FRANCIoCO C-
APPROVED RESOLUTION NO. 92-20
APPRECIATION OF THE GUAM HOST PACIFIC ISLAND GOVERNMENT
(Introduced by the Resolutions Committee)
WESTERN STATES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
HAWAII
IDAHO
MONTANA
NEVADA
NEW MEXICO
OREGON
•
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEALTH OF THE
NORTHERN MARIANA
ISLANDS
GUAM
®
WHEREAS, t h e 1992 Annual Meeting o f t h e Western L e g i s l a t i v e
Conference of the Council o f State Governments has been held i n
Guam; and
WHEREAS, the Guam Host Committee and the Guam L e g i s l a t u r e and s t a f f
have expended extraordinary amounts o f e f f o r t and time t o create
the 1992 Western L e g i s l a t i v e Conference Annual Meeting being an
e x c e l l e n t event; and
WHEREAS, the Annual Meeting program support provided by the Host
State enabled a l l attendees t o come away w i t h invaluable i n s i g h t s
i n t o the f u t u r e of Western s t a t e government and c o n t r i b u t e d t o th
c o n s t r u c t i v e tone of the meeting;
NOW, THEREFORE BE IT RESOLVED t h a t t h e Western L e g i s l a t i v e
Conference of the Council of State Governments, assembled i n Annual
Meeting, thanks the Guam Host Committee, the L e g i s l a t u r e and s t a f f ,
the many p r i v a t e sector p a r t i c i p a n t s and h o t e l f a c i l i t i e s f o r t h e i r
generous h o s p i t a l i t y and a l l t h e i r hard work and c o n t r i b u t i o n s t o
the success of t h i s Annual Meeting.
92RS1-1A
�/ JAMES AK!
f _
PRESIDENT
MILTONHOLT
VC P E I E T
I E R SD N
RICHARD M MATSUURA
M J RT L A E
AO I Y E D R
Of tlfE
DONNA R. IKEDA
M J RT FO R L A E
AO I Y L O E D R
BERTRAND KOBAYASHI
M J RT P LC L A E
AO I Y O I Y E D R
ANDREW LEVIN
M J RT C U U L A E
AO I Y A C S E D R
J&tate of P a f a a i i
STATE CAPITOL
HONOLULU. HAWAII 96813
MIKE MCCARTNEY
M J RT W I
A O I Y HP
M R GEORGE
AY
MN RT L A E
I O IY EDR
RICK REED
MN RT F O R L A E
I O IY L O EDR
FIRST DISTRICT
MLM S L M N
A A A OO O
SECOND DISTRICT
RC A D M. M T U R
IHR
AS U A
THIRD DISTRICT
A D E LEVIN
N RW
FOURTH DISTRICT
R S E L B AR
USL LI
FIFTH DISTRICT
JOE T N K
A AA
SIXTH DISTRICT
RC R E
I K ED
SEVENTH DISTRICT
L H A F R A D S S LI G
E U E N N E A LN
EIGHTH DISTRICT
D N A R. I E A
ON
KD
NINTH DISTRICT
MT MTU A A
AT AS N G
TENTH DISTRICT
B RR N K B Y S I
ETAD OAAH
ELEVENTH DISTRICT
ANN K B Y S I
OAAH
TWELFTH DISTRICT
CR L F K NG
A O UU A A
THIRTEENTH DISTRICT
A T O Y K. U. C A G
NH N
HN
FOURTEENTH DISTRICT
ML O H L
I T N OT
FIFTEENTH DISTRICT
N R A WZ G C I
O MN IU U H
SIXTEENTH DISTRICT
RY G A LY
E R UT
SEVENTEENTH DISTRICT
E OS Y M S I A T N P L N
L I E A A H U G AA
T
EIGHTEENTH DISTRICT
RN Y I AE
AD WS
NINETEENTH DISTRICT
D N I M. N K S T
E NS
A A AO
TWENTIETH DISTRICT
B I N K NN
RA A O
TWENTY-FIRST DISTRICT
JAMES AKI
TWENTY -SECOND DISTRICT
GERALD T. HAGINO
TWENTY.THIRD DISTRICT
MIKE MCCARTNEY
TWENTY-FOURTH DISTRICT
STANLEY T. KOKI
February 4, 1993
Ms. H i l a r y Rodham C l i n t o n
Task Force on Health Reform
O f f i c e of the F i r s t Lady
1600 Pennsylvania Ave., N.W.
Washington, D.C. 20500
Dear Ms. C l i n t o n :
On behalf of the Western L e g i s l a t i v e Conference,
a consortium of 13 western s t a t e s and three P a c i f i c
i s l a n d governments, I would l i k e t o ask t h a t you
allow us "a seat a t the t a b l e " as you work on n a t i o n a l
h e a l t h care reform.
The enclosed l e t t e r and r e s o l u t i o n were mailed t o you
by our San Francisco o f f i c e on January 25, 1993.
I enclosa i t again f o r your easy reference.
I have been Chair of the Health Committee i n the Hawaii
State Senate, and c u r r e n t l y serve as Chair of the Health
Care Task Force of the Western L e g i s l a t i v e Conference.
I also serve as Vice Chair of the Health Committee of
the N a t i o n a l Conference of State L e g i s l a t u r e s . I n those
c a p a c i t i e s , I have become p a r t i c u l a r l y f a m i l i a r w i t h the
e f f o r t s o f Hawaii t o provide u n i v e r s a l health care f o r
our r e s i d e n t s , and the e f f o r t s o f many other states t o
meet the h e a l t h care needs of t h e i r populations.
I b e l i e v e t h a t the states have a g r e a t deal t o o f f e r i n
the n a t i o n a l discussion on h e a l t h care reform, and I know
t h a t you are aware of how much i n n o v a t i o n i s possible
at the s t a t e l e v e l a f t e r your work i n Arkansas. There
i s apprehension t h a t much of the e f f o r t put f o r t h by the
various s t a t e s w i l l be undermined by the n a t i o n a l government as we move toward t r y i n g t o solve the health care
c r i s i s . I t would be a shame t o lose the good works done
already, or on the drawing boards, i n our struggle t o
find a national solution.
TWENTY-FIFTH DISTRICT
MARY GEORGE
CHIEF CLERK
T. DAVID WOO. JR.
I n your c a p a c i t y as Chair of the Task Force on Health
Reform, you are i n a p o s i t i o n t o i n c l u d e many voices
�i
,*tntr of IHotnoii
^cufiitfiuitlj liieyisliitiui'
Senate
Ms.
Hilary Rodham Clinton
Page 2
February 4, 1993
which might not otherwise be heard. I f there i s a way
in which you can allow the states to participate in
your deliberations, we believe that we can add to the
dialogue and positively contribute to the ultimate
solution. There are any number of people who could
individually f i l l the role of representing the states'
i n t e r e s t s , but we would need your blessing i f we are
to be allowed to participate i n any meaningful way.
We know that you have an enormous task before you, and
dozens of interests pulling you in a multitude of
directions. I f we can help rather than hinder you
in your noble effort to resolve t h i s intractable problem,
I hope you w i l l c a l l on us.
Thank you for your
consideration.
Very t r u l y yours,
ANDREW LEVIN
Senator, Third D i s t r i c t
AL:CSY
�'
WESTERN
LEGISLATIVE
121 SECOND ST
4 TH FL.
CONFERENCE
THE COUNCIL
SAN FRANCISCO. CA 94105
OF STA TE
PHONE (415) 974-6422
GOVERNMENTS
FAX (415) 974-1747
25 January, 1993
Mrs. Hilary Clinton
Task Force on Health Reform
Office of the First Lady
1600 Pennsylvania Ave., N.W.
Washington, D.C. 20500
WESTERN STATES
ALASKA
ARIZONA
CALIFORNIA
COLORADO
Dear Mrs. Clinton:
On November 15, at the 1992 Annual Meeting of the Western Legislative
Conference (WLC), legislators representing 13 western states and three Pacific
island governments formally adopted the enclosed resolutions as official WLC
positions. Resolution No. 92-5 addresses the states' desire for the Clinton
Administration and Congress to involve the states and U.S. insular areas in the
formation of any national health care policies and programs. Your careful
consideration of this resolution is strongly encouraged.
HAWAII
Thank you for your consideration of this issue. We eagerly await your response.
IDAHO
Sincerely yours,
MONTANA
NEVADA
NEW MEXICO
Senator Andrew Levin (HI)
Chair, Health Care Task Force of
the Health & Education Committee
Western Legislative Conference
OREGON
dp.hc
UTAH
WASHINGTON
WYOMING
PACIFIC ISLANDS
AMERICAN SAMOA
COMMONWEAL TH OF
NORTHERN MARIANA
ISLANDS
JUAM
�Ohio Developmental
Dis ABILITIES
Planning Council
George V. Voinovich
Governor
8 East Long Street, 6th Floor
Columbus, Ohio 43266-0415
614-466-5205 Voice
614-644-5530 TDD
614-466-0298 FAX
February 12, 1993
H i l l a r y Rodham C l i n t o n , Chair
Task Force on N a t i o n a l Health Care Reform
The White House
Washington, DC 20510
Dear Ms. Rodham C l i n t o n :
Sincere best wishes t o you, the President, and your Task Force
leadership and s t a f f as you t a c k l e the health care problems that
plague our n a t i o n . I was asked by State Senator Ben Espy's o f f i c e
to help i d e n t i f y people who would j o i n you on the podium f o r your
health care r a l l y here i n Columbus as your bus caravan l e f t the
convention. I and those you met t h a t day could not be more pleased
t h a t we were able t o help, and t h a t you are moving so d e l i b e r a t e l y
toward health care reform.
I w r i t e w i t h the hope that I and my o r g a n i z a t i o n can be a f u r t h e r
resource from a d i s a b i l i t y perspective. Evidence of our p r i o r
involvement includes the f o l l o w i n g :
o
The enclosed P o s i t i o n Paper has been c r e d i t e d n a t i o n a l l y as a
succinct and c r e d i b l e analysis of health care issues, leading
to requests f o r testimony from the National Council on
D i s a b i l i t y , as w e l l as many s t a t e and l o c a l o r g a n i z a t i o n s .
While i t includes a single payer recommendation (which we
accept as beyond options you w i l l c o n s i d e r ) , I hope that i t
also reveals a t e c h n i c a l grasp o f d i s a b i l i t i e s issues t h a t
would need t o be considered i n any reform l e g i s l a t i o n that i s
prepared.
o
My o r g a n i z a t i o n and I have had a lead r o l e i n Ohio i n organi z i n g expert testimony ( c i t i z e n and p r o f e s s i o n a l ) r e l a t e d t o
health care and other d i s a b i l i t y r e l a t e d issues. Local
health care forums (one example attached) have been designed
to educate p u b l i c p o l i c y makers about the h e a l t h care issues
facing persons w i t h d i s a b i l i t i e s . I was also the Ohio
resource which assisted the N a t i o n a l Council on D i s a b i l i t y
when i t organized testimony during hearings on the Americans
w i t h D i s a b i l i t i e s Act i n Cleveland, Ohio i n 1991.
�/
H i l l a r y Rodham C l i n t o n
Page 2
February 12, 1993
I would appreciate any information you might provide about the
Task Force sub-groups t h a t are being developed. I f we can be of
help, we would be most honored to provide any t e c h n i c a l assistance
t h a t might assist your work. I n f a c t , may we i n v i t e the Task
Force back t o Columbus, where your h e a l t h care theme made such a
strong early impression?
Again, best wishes as you pursue t h i s venture of h i s t o r i c a l
s i g n i f i c a n c e . Please do not h e s i t a t e t o c a l l i f you f e e l we can
play a p a r t .
Sincerely,
incerely,
J
Richard V. Skelley, Ph.D.
Health Care Analyst
Government A f f a i r s Coordinator
RS :a j
Enclosures
�Community Forum
on the
Health Insurance
Show your support by attending on
J u l y 17, 1 9 9 1 from 7:00 - 9:00
p.m.
Columbus City Council Chambers
90 West broad Street, 2ncl Tloor
Columbus, Ohio
To learn more about...
o how people are alTected by shortcomings
in health care coverage
O a proposed model for implementing a
publicly administered single payer system ,
o action you can take to make change
happen!
Testimony will be presented by consumers, health care providers and representatives of the business community to a
panel of state and local policy makers.
^ Reception and chance to speak with
policy makers to follow.
Because...
America has lost its S.H.I.R.T !
on health insurance
^ Parking available on Gay Street behind City Ilall and in front of the police
station.
n
n'
n
3
&
Accessible entrance to City Hall
Lhroiuih the Gay Street entrance.
Sponsored by:
• The Ohio Developmental Disabilities Planning Council
• Central Ohio Heahh Insurance Planning Croup
O
�Start
Health
Community
Insurance
Forum on the Health
Reform
Insurance
Today
Crisis
July 17,1991
7:00-9:00 p.m.
Columbus City Council Chambers
Diane Lardie
Presiding
Executive Director, Northeast Ohio Coalition for National Health Care
Beverly Rackett
Moderator
Executive Director, MOBILE Independent Living Center
Invited Panelists
Richard Cordray, Ohio House of Representatives, 33rd District
Susan Craig, Governmental Relations Specialist, Ohio Nurses Association
Ben Espy, Columbus City Council, candidate for mayor
Bill Faith, Executive Director, Ohio Coalition for the Homeless
Marc Guthrie, Ohio House of Representatives, 67th District
Virginia Jones, M.D., Physician
Nelson Kraus, M.D., Physician, WCMH-TV
Greg Lashutka, Attorney, candidate for mayor
John Leibold, Attorney
William Myers, Commissioner, Columbus Health Department
Richard Pfeiffer, Ohio Senate, 15th District
Patti Ruble, Social Worker, Columbus Legal Aid Society
Presenters
Karla Lortz, Executive Secretary, Governor's Council for People with Disabilities
Ann Gazelle, Consultant on Accessibility in the Arts and Business
Eric Handler, Medical Director, Nisonger Center, Ohio State University
Nina Bruns, former small business owner
Mike Schroeder, Manager of Community Services Development, Ohio
Department of Mental Health
Cerita Cain, Parent of a child with spina bifida
Bill Lintz, Director, Central Ohio Amputee Support Team
Claudia Bergquist, Vice Chair, Rehabilitation Services Commission;
Counselor, Columbus State Community College, Handicapped Student Services
Gary L. Johnson, Executive Director, Newark Resident Homes
Mary Mooney-Biel, Program Director, Central Ohio Easter Seals Rehabilitation
Center, parent of a child who is medically fragile
David T. Williams, Consultant, Disability Resource Group
Sue Willis, Owner, McGuire-Willis, a graphics design firm
Reception sponsored by the Easter Seal Society of Central Ohio
�Clinton Presidential Records
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marker by the William J. Clinton Presidential Library Staff.
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Publications have not been scanned in their entirety for the purpose
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�:
r
J
•r
INSURING HEALTH CARE
FOR
PEOPLE WITH
DISABILITIES
1
If
POSITION PAPER
SI-:
a:
ft
Si-:
Health Insurance Task Force
of the
Ohio Developmental Disabilities
Planning Council
�HEALTH CARE TASK FORCE SORTING SHEET
CODER:
/
TYPE QF MATERIAL:
General mail
Personal stories
\A&ierB to help
- / Letterhead
Employment
.Advocacy
i/frolicy
Letter Campaign
_CaseworiE
.Requests:
-speech
-meeting
Other
Explanation:
ADVISORY PANEL?
physician
large employers
r.n.
/ o t h e r health provider
small business
.seniors
other consumers
Explanation:
PRIMARY INTEREST:
COST ISSUES
Drug Prices
Physician Fees
Hospital Fees
Unnecessary Procedures
Medical Equipment
Fraud and Abuse
_ P U B L I C HEALTH/SPECIAL POPULATIONS
Prevention
AIDS
Women's Health
Immunizations
Rural
Urban
\XGOVERNMENT PROGRAMS
Medicare
Medicaid
Veterans
DoD
COVERAGE
Working Families
Unemployed/Low Income
Benefits
Providers
ORGANIZATION
Insurance Premiums
Insurance Reform
Insurance Pools
Boards and Oversight
INFRASTRUCTURE/WORKFORCE
Quality Assurance (Guidelines)
Administration, Reimbursement
& Patient Information Systems
Malpractice & Tort Reform
Manpower Issues (Training)
LONG-TERM CARE
MENTAL HEALTH
X
FINANCING
Explanation:
P/S/hfii
OTHER
it 11 £Z
PTAN PREFERENCE: (Support = +; Oppose = -)
CP
SP
OP
Clinton Plan
Single Payer
Other Plan
MC
PP
CV
Managed Competition
Pay or Play
Credits, Vouchers,
Medical Savings Accts.
CA
BR
GE
Canadian
British
German
�E M. (BUDDY) CHILDERS
REPRESENTATIVE, DISTRICT I?
28 SURREY TRAIL
ROME, GEORGIA 30161
(404)656-5141(0)
(706) 291-8203 (H)
ttoiise of Representatives
*
STATE CAPITOL
HOUSE MEZZANINE
ATLANTA. GEORGIA 30334
(404)656-5141
STANDING
COMMITTEES:
APPROPRIATIONS
HEALTH & ECOLOGY. CHAIRMAN
UNIVERSITY' SYSTEM OF GEORGIA
A p r i l 15, 1993
Mrs. H i l l a r y Rodham C l i n t o n
White House H e a l t h Care Reform Task Force
1600 Pennsylvania Avenue
Washington, D.C.
20500
Dear H i l l a r y :
I have c h a i r e d t h e H e a l t h and Ecology Committee i n t h e
s t a t e o f Georgia f o r t h e l a s t t e n years and am f a m i l i a r w i t h
t h e many i s s u e s d e a l i n g w i t h h e a l t h care.
I j u s t wanted t o
share w i t h you some o f my t h o u g h t s as you e x p l o r e t h e many
avenues i n d e a l i n g w i t h t h e r i s i n g c o s t s o f h e a l t h c a r e .
There a r e s e v e r a l d i r e c t i o n s t h a t you can p o i n t t o i n
seeking t h e cause o f r i s i n g , as w e l l as f i n d i n g t h e s o l u t i o n
t o c o n t r o l l i n g , h e a l t h care c o s t s .
C o n t r i b u t i n g t o t h e increase
o f h e a l t h care c o s t s i s a c o m b i n a t i o n
of issues.
The blame
has t o be shared by a v a r i e t y o f groups.
These groups a r e
consumers, by o v e r - u t i l i z a t i o n ; h o s p i t a l s , p a r t i c u l a r l y those
who p r o v i d e s e r v i c e s f o r p r o f i t ; l e g a l c o s t s ; d r u g companies;
t h e i n s u r a n c e i n d u s t r y ; and p h y s i c i a n s ' f e e s .
I n seeking a s o l u t i o n , you have t o be c a u t i o u s i n c o r r e c t i n g
t h e problem and n o t d e s t r o y t h e g r e a t e s t h e a l t h care system
i n t h i s universe.
For example, w h i l e some p h y s i c i a n s '
fees
are over p r i c e d , o t h e r s a r e r e a s o n a b l e .
I n correcting the
problem, p h y s i c i a n s ' fees have t o remain r e a s o n a b l e , o t h e r w i s e ,
i n d i v i d u a l s w i l l n o t go i n t o t h e p r a c t i c e o f m e d i c i n e .
As you d e a l w i t h t h i s i s s u e , you must be c a r e f u l n o t t o
destroy
t h e pharmaceutical
industry i n t h i s country.
Quite
h o n e s t l y , I am concerned t h a t you may be a d v e r s e l y
affecting
t h i s i n d u s t r y t h a t has b r o u g h t t o t h e market, t h r o u g h
their
r e s e a r c h , some remarkable drugs t h a t have i n f a c t h e l d down
h e a l t h care c o s t s .
While t h e r e a r e areas t h a t t h i s i n d u s t r y
needs t o improve i n , p l e a s e be c a r e f u l and n o t d e s t r o y t h e
m e d i c a l i n n o v a t i o n t h a t has been brought about i n t h i s c o u n t r y .
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
Buddy Childers to Hillary Clinton [partial] (1 page)
4/15/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [2]
2006-0885-F
wr825
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information |(b)(l) of the FOIAj
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) of the FOIA)
b(3) Release would violate a Federal statute |(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) of the FOIA)
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the KOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIA)
National Security Classified Information |(a)(l) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA|
Release would violate a Federal statute [(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy [(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Mrs. H i l l a r y Rodham C l i n t o n
Page 2
A p r i l 15, 1993
O v e r r e a c t i n g about drug p r i c e s w i l l be hazardous t o our
collective
health.
I t may
prompt
government
officials,
l e g i s l a t o r s , and policymakers t o s l a p p r i c e c o n t r o l s o r other
d i s i n c e n t i v e s on medical i n n o v a t i o n . This would be d i s a s t r o u s
to f u t u r e g e n e r a t i o n s .
We t a k e medical i n n o v a t i o n f o r granted.
When a c h i l d
has s t r e p t h r o a t , we go t o t h e d o c t o r and get a p r e s c r i p t i o n
f o r an a n t i b i o t i c .
I n a couple of days, t h e c h i l d i s back
i n school.
W i t h i n my l i f e t i m e , c h i l d r e n who g o t s t r e p were
l i k e l y t o develop rheumatic f e v e r l e a v i n g them w i t h permanent
damage and some even d i e d .
A more r e c e n t i n n o v a t i o n i s a vaccine t h a t has l e d t o
a 90 percent d e c l i n e i n a disease t h a t o f t e n leads t o m e n i n g i t i s
i n c h i l d r e n under f i v e .
Without t h e vaccine an e s t i m a t e d 9,000
c h i l d r e n would have developed m e n i n g i t i s i n 1991 and more than
2,000 would have s u f f e r e d permanent b r a i n damage, a c c o r d i n g
t o t h e J o u r n a l o f t h e American Medical A s s o c i a t i o n .
Even people who applaud medical progress sometimes say
we can't a f f o r d i t . Just t h e o p p o s i t e i s t r u e — w e can not
a f f o r d n o t t o make medical p r o g r e s s .
Just look a t t h e two
above examples.
An a n t i b i o t i c f o r a c h i l d may cost $15 t o $20. This i s
a small p r i c e t o pay f o r a l l o w i n g a parent t o r e t u r n t o w o r k — n o t
t o mention t h e t r e a t m e n t costs f o r t h e c o m p l i c a t i o n s t h a t might
develop w i t h o u t t h e drug.
For t h e vaccine, t h e savings are
much more d r a m a t i c .
President C l i n t o n , i n a February 12 press
conference,
c i t e d t h e case o f a F l o r i d a c h i l d named Rodney
M i l l e r who developed m e n i n g i t i s . According t o t h e P r e s i d e n t ,
the c h i l d ' s h o s p i t a l b i l l was a l r e a d y more than $46,000, w h i l e
the vaccine t h a t could have prevented t h e t r a g i c disease cost
only $21.
Measures, such as r e s t r i c t e d l i s t s of p r e s c r i p t i o n medicines
t h a t w i l l be a v a i l a b l e t o s t a t e Medicaid r e c i p i e n t s and p r i o r
a u t h o r i z a t i o n a r e now being proposed by t h e N a t i o n a l Health
Care F i n a n c i n g A d m i n i s t r a t i o n and t h e United States House and
Senate Committees. This e f f o r t t o " c o n t a i n h e a l t h care c o s t s "
simply w i l l n o t work.
Such p o l i c i e s w i l l increase costs as
patients get sicker requiring h o s p i t a l i z a t i o n .
�Mrs. H i l l a r y Rodham
Page 3
A p r i l 15, 1993
Clinton
If
t h e r e s e a r c h programs b e i n g b r o u g h t about
by t h e
pharmaceutical
industries
who
compete
on an open
market
d i m i n i s h e s , n o t o n l y w i l l t h e c o s t s o f h e a l t h care e s c a l a t e
but
l i v e s w i l l be l o s t as w e l l .
According t o the B a t t e l l e
Memorial I n s t i t u t e , i n n o v a t i v e new drugs w i l l save more t h a n
f i v e m i l l i o n l i v e s over t h e n e x t 25 y e a r s f o r f i v e d i s e a s e s
a l o n e : h e a r t d i s e a s e , s t r o k e , c o l o n cancer, l u n g cancer, and
leukemia.
Rather t h a n encouraging t h i s r e s e a r c h , we a r e c a s t i n g
drug companies who come up w i t h these i n n o v a t i o n s as v i l l a i n s .
Government o f f i c i a l s
introduce b i l l s
to strip
away
their
i n c e n t i v e s t o c o n t i n u e r e s e a r c h and d e v e l o p b e t t e r t r e a t m e n t s
as t h e y h o l d p r i c e c o n t r o l s over t h e i r heads.
Unfortunately,
t h i s t h r e a t extends t o p a t i e n t s whose v e r y l i v e s depend on
the proven e f f e c t i v e n e s s o f these m e d i c i n e s .
The e f f o r t t o "demonize" t h e d r u g companies i s b e g i n n i n g
to take i t s t o l l .
Drug s t o c k s have gone down d r a s t i c a l l y and
there are r e p o r t s of downsizing i n the pharmaceutical i n d u s t r y .
That w i l l mean l e s s i n v e s t m e n t i n drug development and u l t i m a t e l y
fewer b r e a k t h r o u g h m e d i c i n e s .
A v a c c i n e f o r AIDS may become
a "might have been" i n s t e a d o f a r e a l p o s s i b i l i t y as m i g h t
a cure f o r A l z h e i m e r ' s d i s e a s e .
W i l l t h i s save money?
Maybe i n t h e s h o r t r u n , b u t i n
the l o n g r u n i t w i l l c o s t t h i s c o u n t r y . I n s t e a d o f p r e v e n t i n g
AIDS, w e ' l l have t o spend money t o t r e a t i t s v i c t i m s .
Instead
of c u r i n g A l z h e i m e r ' s w e ' l l have t o pay t o warehouse A l z h e i m e r ' s
patients i n i n s t i t u t i o n a l settings.
Rather t h a n bashing t h e d r u g companies, we ought t o s i t
down and a t t e m p t t o work some o f t h e s e i s s u e s o u t . There i s
a r e a l need t o make drugs a f f o r d a b l e , b u t we can n o t do i t
at the r i s k of f u t u r e i n n o v a t i o n .
There i s g o i n g t o have t o be a f e e e s t a b l i s h e d f o r some
p r o v i d e r s e r v i c e s , as w e l l as l e g a l s e r v i c e s .
Establishing
what would be r e a s o n a b l e fees can be o b t a i n e d w i t h t h e h e l p
of
those competent people i n t h e P r e s i d e n t ' s a d m i n i s t r a t i o n
who have e x p e r t i s e i n these f i e l d s .
F i g u r e d i n t o t h e c o s t s of h e a l t h care i s t h e a d m i n i s t r a t i v e
c o s t s o f thousands o f people i n t h e i n s u r a n c e i n d u s t r y .
Reducing
the
h i g h a d m i n i s t r a t i v e c o s t s w i l l have t o occur i n o r d e r t o
b r i n g h e a l t h care c o s t s down.
�Mrs. H i l l a r y Rodham C l i n t o n
Page 4
A p r i l 15, 1993
F i n a l l y , every i n d i v i d u a l i s going t o have t o pay f o r
health services.
Those employers who do n o t p r o v i d e
health
care coverage a r e s h i f t i n g t h e costs t o o t h e r s as t h e i r employees
get s i c k and have t o e n t e r t h e h e a l t h care system. A l l employers
and employees a r e g o i n g t o have t o pay a share o f t h e expense
of p r o v i d i n g h e a l t h care t o t h e c i t i z e n s o f o u r c o u n t r y .
I applaud you f o r your e f f o r t s i n a d d r e s s i n g t h i s
very
complex i s s u e .
I n c l o s i n g , please be c a u t i o u s and do n o t damage
the g r e a t h e a l t h care d e l i v e r y system t h a t we have l i k e we
d i d i n d i s m a n t l i n g t h e AT&T communication system d u r i n g t h e
Reagan a d m i n i s t r a t i o n .
Sincerely,
Aw
Buddy C h i l d e r s , Chairman
H e a l t h and Ecology Committee
BC:Imb
�SENATE
M A D I S O N
E.
39TH SEN»TO»i*L
SOUTHERN
BOX
COMMITTEE
SMYTH.
CHAIRMAN
AGRICULTURE. CONSERVATION
*ART.
AND
NATURAL
FINANCE
PART
P R I V I L E G E S AND
37
SHAWSViLLE. VIRGINIA
ASSIGNMENTS:
G E N E R A L LAWS.
DISTRICT
GALAX. CARROLL. N O R T H E R N
P 0
VIRGINIA
M A R Y E
MONTGOMtRV. GRAv»ON.
PULASM.
OF
ELECTIONS
RULES
34*02
April
Mrs. H i l l a r y
White House
9, 1993
Clinton
Washington, D. C.
20515
Dear Mrs. C l i n t o n :
I am forwarding to you the attached l e t t e r from Mrs. Lewis P.
Kirk of E l k Creek, V i r g i n i a . I t r u s t that during your committee's
d e l i b e r a t i o n s on our nation's h e a l t h care problems s i t u a t i o n s such
as those confronting the Kirk Family can be eliminated.
Thank you f o r p e r m i t t i n g me
your a t t e n t i o n .
t o b r i n g Mrs. K i r k ' s
With kind personal regards, I am.
Sincerely,
Madison E. Marye
MEM/1bp
Enclosure
/
l e t t e r to
RESOURCES
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002a. letter
SUBJECT/TITLE
DATE
To Senator Madison Mayre, re: hospital bill (2 pages)
2/1/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [2]
2006-0885-F
wr825
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office |(a)(2) of the PRA]
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA|
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002b. bill
SUBJECT/TITLE
DATE
11/3/1992
Blue Cross Blue Shield Claims (2 pages)
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1983
FOLDER TITLE:
[Letters from Government Officials and Employees] [loose] [2]
2006-0885-F
wr825
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204<a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA]
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information ((b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) of the FOIA)
b(3) Release would violate a Federal statute 1(b)(3) of the FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�SENATE
OF VIRGINIA
COMMITTEE ASSIGNMENTS:
MADISON E. M A R Y E
3 9 T M 9 C N A T O R I AL
MONTGOMCRV.
GflAYSON.
GALAX. CARROLL.
BOX
NATURAL
RESOURCES
FINANCE
PART.
P R I V I L E G E S AND
PART
ELECTIONS
RULES
37
SHAWSVILLE. VIRGINIA
CHAIRMAN
A G R I C U L T U R E . C O N S E R V A T I O N AND
SMYTH.
N O R T H I R N
PUIASKI. SOUTHCRN
P.O
G E N E R A L LAWS.
OIBTRICT
24162
A p r i l 9, 1993
Mrs. H i l l a r y C l i n t o n
White House
Washington, D. C. 20515
Dear Mrs. Clinton.P e r m i t me t o b r i n g the a t t a c h e d l e t t e r from Mrs. Dolores S.
P e t e r s o f F l o y d , V i r g i n i a t o your a t t e n t i o n .
T h i s i s t h e type o f
t h i n g t h a t o l d e r people
f i n d extremely f r u s t r a t i n g .
While
b e a u r a c r a t i c h a s s e l i n g and r e d tape c o n f r o n t us a l l , i t i s
p a r t i c u l a r l y t r y i n g f o r a person o f Mrs. Peter's age. I t h o u g h t
t h a t somewhere i n your d e l i b e r a t i o n s on h e a l t h care you might want
to c o n s i d e r the p l i g h t o f Mrs. P e t e r s and many e l d e r l y c i t i z e n s who
f i n d themselves i n t h e same s i t u a t i o n .
Thank you f o r p e r m i t t i n g
attention.
me t o b r i n g
this
W i t h k i n d p e r s o n a l r e g a r d s , I am.
Sincerely,
Madison E. Maryaf
MEM/1bp
cc: Mrs. Dolores S. Peters
Enclosure
problem
t o your
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�T W ^ O ^ MdtAs ^U^f^u
^£u*e. ^
[*0
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Dolores Peters to William Herwig (2 pages)
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COLLECTION:
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personal privacy [(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIAj
b(3) Release would violate a Federal statute [(b)(3) of the FOIAj
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIAj
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIAj
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIAj
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
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RR. Document will be reviewed upon request.
�C l m u;
ou b s
43215
February 23,
1993
F i r s t Lady H i l l a r y Rodham C l i n t o n
The White House
1600 Pennsylvania Avenue
Washington, DC
Dear Mrs. C l i n t o n :
Congratulations on t a c k l i n g a tough issue. I n case you're
i n t e r e s t e d i n a Republican* perspective on h e a l t h care, I've
enclosed something I wrote i n 1991. The more ideas you have the
b e t t e r o f f you are. There i s one t h i n g I d i d n ' t address i n the
r e p o r t , and t h a t ' s pharmaceutical costs.
Everybody's complaining about the huge d i f f e r e n c e between
the cost of drugs i n America verses everywhere else. I t i s n ' t too
d i f f i c u l t t o f i g u r e out what's happening and what the answer i s .
American drug companies spend enormous sums on research &
development. That i s a necessity i n order t o produce the new
miracle drugs. I f drug companies weren't p e r m i t t e d t o recover
their R&D
costs, t h e r e would be any new drugs. Witness the lack
of new drugs i n Canada.
Foreign c o u n t r i e s stand on the s i d e l i n e s and watch American
companies spend b i l l i o n s t o develop new drugs. Once developed, the
f o r e i g n governments l i m i t the drug's p r i c e , l e a v i n g the drug makers
no choice but t o recover a l l of t h e i r R & D
costs from American
consumers. American consumers are paying a l l of the research and
development costs (along w i t h the p r o f i t s ) f o r drugs w i t h world
wide markets. A p o l i t i c a l l y popular s o l u t i o n would be t o simply
l i m i t the drugs' p r i c e i n the U.S., which, of course, would be
sheer f o l l y . That would r e s u l t i n no research and development and
no new l i f e saving drugs.
A more elegant s o l u t i o n would be t o r e q u i r e drug companies t o
s e l l t h e i r products i n the United States a t the lowest p r i c e they
charge any other country i n the world. Exempted from t h i s
requirement would be any country t h a t l i f t s t h e i r p r i c e c o n t r o l s .
I n very short order, American companies would be t e l l i n g the p r i c e
c o n t r o l c o u n t r i e s t h a t they can no longer s e l l them t h e i r drugs.
�f
The reason i s t h a t American companies could not a f f o r d t o
lower t h e i r p r i c e s i n t h e U.S. t o such a low l e v e l .
Eventually,
f o r e i g n governments would have no choice but t o l i f t t h e i r p r i c e
c o n t r o l s , and a l l consumers, not j u s t American, would be sharing i n
the R & D costs. The r e s u l t would be s u b s t a n t i a l l y lower drug
p r i c e s f o r American consumers. To those f o r e i g n powers who impose
p r i c e c o n t r o l s , a l l Congress need do i s " j u s t say no".
Good Luck.
Sincerely,
Louis W. Blessing, J r .
Ohio State Representative
LWB/hms
End.
An honest, "Let's not k i c k "em i n the b u t t q u i t e y e t " m i n o r i t y
p a r t y approach t o h e a l t h care.
�^
0
M
\
Columbus
43215
HEALTH CARE COSTS
9/28/91
I n order t o understand what i s d r i v i n g medical costs, we need
t o look a t the h i s t o r y of health care. Not too many years ago,
t h i s century, as a matter of f a c t , h e a l t h care was a home delivered
product. Serious problems r e s u l t e d i n a h o s p i t a l stay. Health
care was not u n l i k e car care. Most people took care of t h e i r own
car, but serious problems brought the car t o a garage. There was
competition and n a t u r a l cost c o n t r o l s , p a r t l y because there was no
insurance. I f a doctor or h o s p i t a l charged too much, people simply
would go elsewhere or take care of themselves. The f i g u r e s bear
t h i s out. Attached i s graph #4, which p r e t t y w e l l shows what
happened t o h e a l t h care costs i n t h i s country.
Prior to the late 1960'a, health care costs never exceeded 1%
of the GNP.
By the year 2000, health care costs w i l l account for
18% of GNP.
I n 1965, a major p a r t of Lyndon Johnson's "Great Society"
became h e a l t h care s e c u r i t y . People were " e n t i t l e d " t o h e a l t h care
and the "government" would pay the tab. The f i r s t major piece of
l e g i s l a t i o n was the Medicare/Medicaid Act of 1965. A cursory
glance a t Graph #4 shows what happened t o h e a l t h care costs s h o r t l y
a f t e r enactment of Medicare l e g i s l a t i o n . The AMA o r i g i n a l l y
opposed Medicare t o o t h & n a i l . By 1970, v i r t u a l l y a l l physicians
thought Medicare was the best t h i n g since s l i c e d bread. Why? They
had customers who d i d n ' t care so much about cost or u t i l i z a t i o n ,
because the "government" was f o o t i n g the b i l l . No one complained
about fees except the r e g u l a t i n g agency.
Consumers, the only people with the power to control costs i n
a free market, were now squeezed out of the equation.
The best example of why the only e f f e c t i v e r e g u l a t o r of costs
i s the u l t i m a t e consumer can be shown through the h i s t o r y of
Medicare. Once the government set fees, they created an a r t i f i c i a l
f l o o r below which no provider would charge. Why should they charge
less i f the government was t e l l i n g them t h a t they would be
�reimbursed a t a h i g h e r l e v e l ?
The b e s t analogy would be t o a p p l y
the medicare example t o a g r o c e r y s t o r e . I f t h e government
reimbursed t h e s t o r e s a t t h e r a t e o f $1.99 p e r g a l l o n o f m i l k , t h e
g r o c e r would never reduce h i s p r i c e below $1.99, u n l e s s he had t h e
m o r a l i t y o f Mother Theresa. Each succeeding year, t h e n e g o t i a t e d
p r i c e would r i s e a t l e a s t as much as t h e r a t e o f i n f l a t i o n , and
most o f t h e t i m e more t h a n t h a t , due t o some e x p e r t l o b b y i n g by t h e
p r o v i d e r s about t h e h i g h c o s t o f t e c h n o l o g y , e d u c a t i o n , e t c . . .
The e n t i t l e m e n t mind s e t a l s o produced a c o s t problem w i t h
h e a l t h care r e s e a r c h & development. The u s u a l R & D e q u a t i o n i s t o
produce a b e t t e r p r o d u c t a t t h e same p r i c e , o r an e q u i v a l e n t
p r o d u c t a t a l e s s e r p r i c e . The c o s t f a c t o r i s ever p r e s e n t i n f r e e
e n t e r p r i s e r e s e a r c h & development. Companies would n o t develop
p r o d u c t s t h a t were u n a f f o r d a b l e . That c o s t r e s t r a i n t was removed
from h e a l t h care R & D , because people f e l t e n t i t l e d t o t h e maximum
h e a l t h c a r e a v a i l a b l e , r e g a r d l e s s o f c o s t . Governments and
i n s u r a n c e companies were b e g i n n i n g t o cover more and more s e r v i c e s .
The drug companies and medical equipment m a n u f a c t u r e r s responded
w i t h some f a b u l o u s new p r o d u c t s . T h i s h e a l t h care environment
spawned t h e f a t a l f l a w i n t h e i r r e s e a r c h and development.
Cost r e s t r a i n t i s non-existent i n h e a l t h care r e s e a r c h ,
l e a v i n g us with astronomically p r i c e d and therefore unusable
products f o r most Americans.
Because o f t h e e n t i t l e m e n t mind s e t and government mandates,
new p r o d u c t s a r e purchased and used no m a t t e r what t h e i r c o s t .
H e a l t h care companies p l a c e no r e s t r i c t i o n s on t h e i r r e s e a r c h e r s
r e g a r d i n g t h e u l t i m a t e c o s t o f t h e new p r o d u c t . That i s c r u e l and
unusual punishment f o r t h e s i c k and i n j u r e d who need these p r o d u c t s
b u t cannot a f f o r d them. AZT i s a prime example. The v e r y r i c h
have t h e b e s t h e a l t h care a v a i l a b l e , and, f o r a t i m e , so d i d
w e l f a r e r e c i p i e n t s . That i s changing because t h e i n s u r e r s and
governments can no l o n g e r a f f o r d t o pay f o r these t e c h n o l o g i e s . As
the p r i c e s s k y r o c k e t and fewer people can absorb t h e c o s t o f t h e
new t e c h n o l o g i e s , t h e market s h r i n k s g e o m e t r i c a l l y . The
r e s e a r c h e r s w i l l e v e n t u a l l y work on l o w e r i n g t h e p r o d u c t i o n c o s t t o
i n c r e a s e t h e i r market.
That i s b e g i n n i n g t o happen now, b u t i t i s
almost t o o l a t e .
The t y p i c a l p r o d u c t l i f e i n a f r e e market i s one o f h i g h
p r i c e s , t h e n new developments t o t a k e i n a l a r g e r market.
That i s
p r e c i s e l y what happened w i t h computers and c a l c u l a t o r s . Only t h e
w e a l t h y c o u l d a f f o r d a $3,000.00 c a l c u l a t o r i n t h e e a r l y 70*5; now
t h e y c o s t $10.00. The o n l y f i e l d where t h a t has n o t happened i s
h e a l t h c a r e . That i s so because we e s s e n t i a l l y t o o k t h e f r e e
market o u t o f medicine i n 1965. A t t h e pace we a r e g o i n g , t h e r e
won't be s u f f i c i e n t funds a v a i l a b l e t o p r o v i d e maximum h e a l t h care
f o r every American.
�Health care research & development must be d i r e c t e d a t cost as
w e l l as e f f i c a c y .
Two areas t h a t should be addressed are p a t e n t law and FDA
a p p r o v a l procedures.
Approval should be e x p e d i t e d f o r any drug or
t e c h n o l o g y t h a t i s c o s t e f f e c t i v e . That would i n c e n t t h e companies
to include a cost v a r i a b l e i n t h e i r research.
Patent law should be
changed t o a l l o w a guaranteed r e t u r n o f c o s t s and p r o f i t s f o r drugs
and t e c h n o l o g i e s i n r e t u r n f o r lower c o s t s t o consumers. R i g h t
now, companies are l u c k y t o g e t t h e i r p r o d u c t approved p r i o r t o t h e
e x p i r a t i o n o f t h e 17 year p a t e n t . Companies t r y t o recoup a l l o f
their R&D
c o s t s i n a s h o r t t i m e . The FDA s h o u l d be empowered t o
extend p a t e n t s i n r e t u r n f o r lower c o s t s on necessary drugs.
The l a c k o f a f r e e market has skewed p r o f e s s i o n a l fees as w e l l
as drugs and machinery. S u r g e r i e s t h a t were 7 hour a f f a i r s 2 5
years ago are now 30 minute o u t p a t i e n t l a s e r s u r g e r i e s .
Despite
t h a t , s u r g e o n s fees f o r those o p e r a t i o n s have n o t gone down, t h e y
have e s c a l a t e d a l o n g w i t h e v e r y t h i n g e l s e i n t h e h e a l t h care f i e l d .
Again, t h a t i s because t h e r e i s no c o m p e t i t i o n and t h e consumer has
no knowledge or a b i l i t y t o make choices t h a t would impact c o s t s .
1
Insurance has been h i s t o r i c a l l y d e f i n e d t o guard a g a i n s t
unusual r i s k s .
Premiums are pooled t o cover a c t u a r i a l l y p r e d i c t e d
l o s s e s . For example, 100 companies buy f i r e i n s u r a n c e a t $1,100.00
per year.
One company has a f i r e and t h e l o s s i s $100,000.00.
The
premiums cover t h e l o s s p l u s $10,000.00 p r o f i t and overhead f o r t h e
insurer.
What happens i f t h e i n s u r e r c a l c u l a t e s t h a t a l l one hundred
businesses w i l l have a f i r e i n a premium year? The i n s u r e r s
p r o b a b l y wouldn't w r i t e t h e p o l i c i e s , b u t i f t h e y d i d , t h e y would
charge $110,000.00 f o r t h e premium. F r a n k l y , t h e i n s u r e r s would
have no c h o i c e . Businesses would be p r e t t y s t u p i d t o buy such a
p o l i c y , s i n c e t h e premium expense would exceed t h e i r l o s s . They
are b e t t e r o f f s e l f - i n s u r i n g a g a i n s t a sure l o s s , because t h e y
would save t h e p r o f i t and expense o f a t h i r d p a r t y i n s u r e r . No one
i n t h e i r r i g h t mind would i n s u r e a g a i n s t l o s s e s t h a t were c e r t a i n
t o occur, now would they? Guess a g a i n .
We do not have health insurance i n t h i s country.
pre-paid medical c o s t s .
We
have
By and l a r g e , premiums f o r h e a l t h insurance cover a c t u a r i a l l y
known l o s s e s f o r t h e average American f a m i l y . That i s a f a r c r y
from t h e u s u a l insurance s i t u a t i o n where many s m a l l premiums cover
a few l a r g e l o s s e s . I n a d d i t i o n , those f a m i l i e s are p a y i n g , v i a
t h e i r premiums, an e x t r a c o s t t o an a d m i n i s t r a t o r t o pay t h e i r
medical b i l l s f o r them. The f i r s t t h i n g s e l f i n s u r a n c e w i l l do f o r
middle c l a s s Americans i s t o save them much o f t h e overhead. What
�we should be doing i s i n s u r i n g against unusual h e a l t h care costs,
not every minor p r e s c r i p t i o n t h a t comes down the pike.
We have a system where a $15.00 p r e s c r i p t i o n w i t h a $10.00
co-pay r e s u l t s i n a $5.00 insurance claim. That $5.00 claim costs
the provider and insurer about $20.00 i n postage and processing
costs. So a p r e s c r i p t i o n t h a t would cost the consumer $15.00,
a c t u a l l y costs him $35.00. And the consumer i s paying the extra
costs through h i s premiums. That's what I mean when I say we don't
have h e a l t h insurance, we have pre-paid medical costs. I s i t any
wonder h e a l t h care costs are so high?
What happens i n the h e a l t h care system today? There i s a
mumbo jumbo o f co-pays, deductibles, and negotiated fees. The
bottom l i n e i s t h a t the u l t i m a t e insured consumer doesn't know what
he i s being charged and doesn't care. The best example i s a
co-payment p r o v i s i o n . Many plans r e q u i r e a $10.00 co-payment f o r
each o f f i c e v i s i t . The theory i s t h a t co-pays hold down costs
because the consumer pays p a r t of the cost. That i s a myth. The
consumer doesn't care i f the o f f i c e v i s i t costs $35.00 or $100.00,
because a l l he i s paying i s $10.00 i n e i t h e r case. Co-pays do
nothing t o hold down p r i c e s . They a c t u a l l y increase costs i f the
consumer has a choice. The consumer w i l l go t o the highest p r i c e d
physician based upon the commonly held assumption t h a t higher
p r i c e s mean b e t t e r q u a l i t y .
The same can be said f o r nominal d o l l a r amount deductibles.
People w i t h , say, $250.00/year/family deductibles don't care what
something costs because they know they're going t o pay a t l e a s t
$250.00 anyway, and a f t e r t h a t , they have insurance. Think about
PPO's and HMO's. These concepts are r e a l l y b i z a r r e . I n a PPO, the
consumer i s reimbursed a t , f o r example, 90% o f the costs f o r a
provider i n the PPO, and 70% f o r a non-plan provider. I f Dr. "A"
charges $50.00 f o r an o f f i c e v i s i t , and Dr. "B" only charges
$20.00, the consumer w i l l obviously choose Dr. "B". Wrong!
The PPO concept has reversed the usual free market forces. Dr.
"B" won't charge $20.00 f o r very long. He w i l l r a i s e h i s rates
because he won't lose any customers. Dr. "A" w i l l soon be a t the
low end o f the totem pole and w i l l successfully negotiate an
a r t i f i c i a l increase i n h i s r a t e s . HMO's are even worse i n t h a t
there i s no choice whatsoever. PPO's and HMO's have not only
f a i l e d t o stem the r i s i n g t i d e o f health care costs, they have been
a major cause o f cost e s c a l a t i o n .
The s o l u t i o n i s t o give the consumer a d i r e c t f i n a n c i a l stake
i n the process. That was the system p r i o r t o 1965, and h e a l t h care
costs increased p r e t t y much w i t h i n f l a t i o n then. That i s the only
way t h a t the market system w i l l work. They are any number o f ways
to do t h i s , and the f o l l o w i n g example i s j u s t one idea.
�Have a p o l i c y o f insurance t h a t covers 50% o f t h e f i r s t
$2,000.00 o f h e a l t h care c o s t s . A f t e r $2,000.00, you can p r e t t y
w e l l assume t h a t some unusual problems o c c u r r e d , and t h e n k i c k i n a
p r o v i s i o n c o v e r i n g maybe 80% o f t h e c o s t s up t o , say, $15,000.00.
A f t e r $15,000.00, a c a t a s t r o p h i c p r o v i s i o n would k i c k i n c o v e r i n g
any a d d i t i o n a l c o s t s f u l l y . A f t e r payment o f t h e i n s u r a n c e
premium, t h e maximum o u t - o f - p o c k e t expense p e r year would be about
$3,600.00 f o r any f a m i l y .
The premium f o r such a p o l i c y would be
l e s s t h a n $100.00/month. The t o t a l c o s t would be l e s s t h a n
$4,800.00 p e r year, which i s what t h e average h e a l t h i n s u r a n c e
premiums and d e d u c t i b l e s c o s t a f a m i l y these days. Under t h i s
system, you don't need t o worry about d e s i g n a t i n g a group o f
p r o v i d e r s . No consumer i s g o i n g t o go t o a d o c t o r who charges
$100.00 f o r an o f f i c e v i s i t .
They w i l l shop around. I f t h e y
d o n ' t , t h a t ' s t h e i r c h o i c e , and t h e y w i l l pay a c c o r d i n g l y .
A d m i n i s t r a t i v e c o s t s w i l l a l s o be reduced s i g n i f i c a n t l y .
There won't be a need t o review medical n e c e s s i t y o r determine i f
t h e c o s t i s reasonable, a t l e a s t f o r t h e f i r s t $2,000.00. The
consumer w i l l t a k e care o f t h a t b e t t e r t h a n any b u r e a u c r a t .
P h y s i c i a n s won't have t o worry about t h e r i d i c u l o u s amount o f
paperwork t h e y have now. P h y s i c i a n s * overhead w i l l be lower.
The c r i t i c a l element under a consumer d r i v e n system i s n o t t h e
f a c t t h a t h e a l t h insurance premiums w i l l be lower, even though t h a t
i s i m p o r t a n t , and would i n f a c t happen. The c r i t i c a l element i s
t h a t consumer awareness and p r i c e shopping w i l l lower t h e c o s t s f o r
everybody. The v a s t m a j o r i t y o f h e a l t h care consumers a r e i n s u r e d ,
middle c l a s s f a m i l i e s . They dominate t h e market. That dominance
w i l l a l s o cause t h e average c o s t o f s e r v i c e s t o be lower f o r
w e l f a r e r e c i p i e n t s w i t h medical cards. No p r o v i d e r w i l l s t a y i n
business v e r y l o n g by c h a r g i n g h i g h e r t h a n market f e e s .
I r o n i c a l l y , a t t h e v e r y t i m e when t h e Supreme Court was
t h r o w i n g o u t f e e schedules f o r l a w y e r s , we were a d o p t i n g f e e
schedules f o r h e a l t h care p r o v i d e r s . Since t h a t t i m e (1970), l e g a l
fees have i n c r e a s e d a t a l e s s e r r a t e t h a n i n f l a t i o n , w h i l e h e a l t h
care c o s t s have gone t h r o u g h t h e r o o f . What does t h i s t e l l us?
These p r i n c i p l e s can be extended. There a r e many o t h e r
s i t u a t i o n s where t h i s w i l l work, p a r t i c u l a r l y i n t h e p h y s i c i a n
s p e c i a l t i e s , where t h e c o s t s a r e s p i r a l i n g .
These p o l i c i e s c o u l d
be " t i e r e d " f o r h o s p i t a l s t a y s o r expensive s u r g e r i e s . For
example, t h e percentage o f payment can be a d j u s t e d based upon t h e
consumers' income o r w e a l t h . To a person making $25,000.00, a
medical charge o f $500.00 might have t h e same impact as a $2,000.00
charge has f o r a person making $50,000.00. Perhaps we c o u l d
develop p o l i c i e s where t h e lower income consumers pay 25% i n s t e a d
of 50%.
By way o f t a x p o l i c y o r o t h e r w i s e , we c o u l d peg t h e
percentage d e d u c t i b l e t o t h e consumer's f i n a n c i a l s i t u a t i o n .
�There are many o t h e r methods o f d o i n g t h i s , and t h e r e are many
o t h e r c o n s i d e r a t i o n s t h a t I haven't mentioned. One example would
be t h e f a c t t h a t t r u e emergency procedures would n e c e s s a r i l y be
exempted, s i n c e t h e consumer would have no chance t o shop, and
s h o u l d n ' t be r e q u i r e d t o do so. I n a d d i t i o n , p r e v e n t i v e care
s h o u l d be f u l l y covered.
For t h e l i f e o f me, I do n o t understand
why h e a l t h i n s u r e r s do n o t spend a few d o l l a r s on p r e v e n t i v e care
now i n o r d e r t o save m i l l i o n s l a t e r .
I guess t h e y have t h e same
mind s e t as Congress: J u s t worry about t h e n e x t e l e c t i o n o r
p r o f i t a b i l i t y review and f o r g e t about t h e f u t u r e .
We s h o u l d a b s o l u t e l y e l i m i n a t e C e r t i f i c a t e o f Need. I f a
h o s p i t a l o r n u r s i n g home wants t o add 5,000 beds, t h a t ' s t h e i r
business.
The S t a t e o f Ohio s h o u l d n ' t pay f o r them, though. A l l
CON does i s guarantee p r o f i t s and h i g h c o s t s . Once new beds are i n
t h e reimbursement e q u a t i o n , however, c o s t s r i s e d r a m a t i c a l l y .
W i t h o u t r e i t e r a t i n g t h e e n t i r e economic argument, s i m p l y t u r n t h e
consumers loose and l e t t h e marketplace reward t h e e f f i c i e n t and
punish the i n e f f i c i e n t .
I f we do t h a t , we won't see any new beds
b u i l t u n l e s s t h e y are needed. We won't see n u r s i n g homes b u i l t on
prime r e a l e s t a t e w i t h t h e S t a t e p i c k i n g up t h e c o s t . What we w i l l
see a r e v e r y c o s t e f f i c i e n t n u r s i n g homes, a l l o w i n g more o f our
p o o r e r c i t i z e n s b e i n g a b l e t o a f f o r d n u r s i n g home c a r e . A bonus
c o s t r e d u c t i o n would be t h e e l i m i n a t i o n o f t h e CON
bureaucracy.
T h i n k o f what f r e e market f o r c e s would do i n t h e area o f
medical t e c h n o l o g y usage. R i g h t now t h e r e are more MRI u n i t s i n
H a m i l t o n County t h a n e x i s t i n t h e e n t i r e c o u n t r y o f Canada. They
are p r o b a b l y used 6 hours/day. I f t h e f r e e market pushed f o r t h e
l e a s t expensive MRI exam, t h e p r o v i d e r s would i n s u r e a system where
maybe 3 u n i t s would be o p e r a t i n g 24 hours/day, a t a tremendous c o s t
savings t o t h e consumer.
Perhaps t h e e a s i e s t o f a l l t o areas t o reduce c o s t s are i n
p r e s c r i p t i o n drugs.
Ask any i n s u r e d consumer what t h e c o s t o f
t h e i r p r e s c r i p t i o n i s b e f o r e t h e y buy i t , and 95% o f them wouldn't
have a c l u e , u n l e s s i t was a renewal.
Ohio's p l a n f o r S t a t e
Employees has a $10.00 co-pay. For reasons c i t e d b e f o r e , s t a t e
employees c o u l d care l e s s whether t h e p r e s c r i p t i o n c o s t s $10.00 o r
$100.00, because t h e y pay $10.00 i n e i t h e r case. As an a s i d e , I
might t e l l you t h a t Ohio employees are r e q u i r e d t o renew t h e i r
p r e s c r i p t i o n s by m a i l t h r o u g h a Pennsylvania drug company. Some
p r e s c r i p t i o n drugs v a r y i n p r i c e by as much as 4 0% among drug
s t o r e s w i t h i n one m i l e o f each o t h e r . I'm t a l k i n g about i d e n t i c a l
drugs, n o t s i m i l a r drugs. What does t h i s t e l l us?
Again, i f p r e s c r i p t i o n s were based upon a 50% p r i n c i p l e , where
t h e consumer had a f i n a n c i a l s t a k e , t h e r e would be some
c o m p e t i t i o n . One o t h e r measure would need t o be adopted: Require
�pharmacists t o p u b l i s h t h e i r p r i c e s f o r p r e s c r i p t i o n drugs.
There's an obvious reason t h e y don't p u b l i s h p r i c e s now.
Pharmacies m i g h t o b j e c t , b u t t h e y s h o u l d be p a r t o f t h e f r e e
e n t e r p r i s e system j u s t l i k e t h e r e s t o f us. I would b e t t h e ranch
t h a t p r e s c r i p t i o n c o s t s would d e c l i n e s i g n i f i c a n t l y a f t e r one year
of t h i s .
S t a t i s t i c a l f a c t : 30% o f a l l p r e s c r i p t i o n drugs a r e
consumed by persons 65 y e a r s o f age o r over. I f t h e r e was ever a
group t h a t would p r i c e shop, i t i s s e n i o r c i t i z e n s . They have been
t h r o u g h t h e tough economic t i m e s .
I would hope such a system would work o u t as f o l l o w s :
We need t o c o n v i n c e t h e h e a l t h i n s u r e r s t o o f f e r consumer
d r i v e n p l a n s f o r s a l e , and make sure t h e Department o f I n s u r a n c e
g i v e s them a p p r o v a l . I b e l i e v e these p l a n s would be v e r y
m a r k e t a b l e because t h e y would a c t u a r i a l l y c o s t t h e i n s u r e r s l e s s
t h a n c u r r e n t p l a n s i n a c t u a l reimbursements, and t h e i r
a d m i n i s t r a t i v e c o s t s would be l o w e r . I a l s o expect consumers t o
buy t h e s e p l a n s f o r t h e same reason. On t h e f a c e o f i t , one might
t h i n k consumers would b a l k a t p a y i n g annual o u t o f p o c k e t h e a l t h
care expenses o f $4,800.00. That i s n ' t t h e case, however. Some o f
t h e s e people a r e p a y i n g $500.00+/month now f o r h e a l t h i n s u r a n c e .
I f t h e consumer d r i v e n p l a n s s o l d f o r $100.00/month, n e a r l y
everyone would jump a t t h e coverage. The annual c o s t i s t h e same
even i f t h e y needed c o s t l y c a r e . I n a d d i t i o n , t h e y have t h e
o p p o r t u n i t y t o save some money. And t h e y would save money; f o r
themselves and t h e i n s u r e r s . I n s t e a d o f a n t a g o n i s t s , t h e i n s u r a n c e
companies and consumers would be a l l i e s .
F r a n k l y , a p l a n where t h e f i r s t $2,000.00 i s p a i d t o t a l l y by
t h e consumer would be even b e t t e r . On t h e s u r f a c e t h i s would seem
u n f a i r , b u t keep i n mind t h e s e same people are p a y i n g i n excess o f
$6,000.00/year i n premiums. I would b e t t h e i r premiums would be
reduced by more t h a n t h e $2,000.00, and would save money.
A l t h o u g h i t i s d i f f i c u l t t o a p p l y t h i s approach t o w e l f a r e
r e c i p i e n t s , i t can be done by u s i n g t h e c a r r o t i n s t e a d o f t h e
s t i c k . A p l a n c o u l d be d e v i s e d where r e c i p i e n t s are g i v e n
f i n a n c i a l i n c e n t i v e s t o p r o p e r l y u t i l i z e h e a l t h care s e r v i c e s .
We
must be c a r e f u l n o t t o encourage u n d e r u t i l i z a t i o n , p a r t i c u l a r l y a t
t h e expense o f t h e c h i l d r e n . That would be a t r a g e d y .
I c o u l d be wrong, b u t I expect t h i s program t o do a l l o f t h e
following:
1)
2)
Cause a r e d u c t i o n i n r e a l terms i n t h e p r i c e s f o r h e a l t h
care s e r v i c e s ;
Cause a r e d u c t i o n i n h e a l t h care c o s t s t h r o u g h overhead
reduction;
�3)
4)
5)
Not c o s t t h e consumer any more t h a n he i s p a y i n g now, and
a c t u a l l y cause savings t o many consumers; those who don't
o v e r u t i l i z e t h e system.
Give t h e consumer s e c u r i t y a g a i n s t a r e a l c a t a s t r o p h e .
Curb t h e s p i r a l i n government spending f o r h e a l t h care a t
a l l levels.
The premise o f t h i s idea i s t h a t m i l l i o n s o f consumers f o r c i n g
market d e c i s i o n s every minute o f t h e day a r e a f a r more p o w e r f u l
f o r c e i n h o l d i n g p r i c e s down t h a n some b u r e a u c r a t o r HMO employee
n e g o t i a t i n g p r i c e s f o r them once a year.
11
Health care "cost c o n t r o l today i s no d i f f e r e n t than the
old planned economies of the Soviet Union.
The "government" s e t p r i c e s j u s t l i k e n e g o t i a t o r s f o r HMO's do
f o r t h e u l t i m a t e consumer. That d i d n ' t work i n t h e S o v i e t Union,
b u t we c l i n g t o t h e idea t h a t we can make i t work i n t h e h e a l t h
care f i e l d .
Why do we t h i n k we can make d e c i s i o n s b e t t e r t h a n t h e
u l t i m a t e consumer?
The numbers and examples used h e r e i n a r e j u s t t h a t : Examples.
I'm sure o t h e r people can come up w i t h some b e t t e r i d e a s . I t w i l l
n o t serve t h e medical community w e l l t o s i m p l y oppose every
p r o p o s a l t h a t i s i n t r o d u c e d . They need t o g i v e us some i d e a s .
L e t ' s t a l k about h o s p i t a l s . A t y p i c a l s u r g i c a l s i t u a t i o n
i n v o l v e s a surgeon who has " p r i v i l e g e s " a t t h e h o s p i t a l . The
p a t i e n t p r o b a b l y has never met t h e a n e s t h e s i o l o g i s t , t h e nurses,
t h e a s s i s t i n g p h y s i c i a n , r a d i o l o g i s t o r anyone e l s e i n v o l v e d i n t h e
s u r g e r y . The p a t i e n t a l s o doesn't have t h e f o g g i e s t n o t i o n o f what
a l l these persons' fees a r e o r w i l l be. T h i s i s a c l a s s i c
u n r e g u l a t e d monopoly. I f I am a t r u e p a t i e n t consumer, I w i l l
search o u t t h e b e s t v a l u e f o r a surgeon o r o t h e r s p e c i a l t y . My
problem i s t h a t my c h o i c e o f a s u r g e r y team may n o t be a l l o w e d t o
p e r f o r m s u r g e r y i n a h o s p i t a l , p a r t i c u l a r l y i f t h e i r fees a r e l e s s
t h a n what t h e h o s p i t a l ' s board l i k e s . That's c r a z y . I f I choose a
surgeon who i s l i c e n s e d by t h e s t a t e , t h a t surgeon ought t o be
a l l o w e d t o use a s t a t e l i c e n s e d h o s p i t a l t o p e r f o r m h i s s u r g e r y .
The t r a d i t i o n a l approach t o h o l d i n g down c o s t s i s t o l i m i t
a d m i t t i n g p r i v i l e g e s . A l l we a r e d o i n g i s l i m i t i n g t h e people who
can p e r f o r m s u r g e r i e s t o a s e l e c t group o f h i g h p r i c e d , p r e approved and a n o i n t e d surgeons. No wonder s p e c i a l t y s u r g i c a l
procedures a r e so h i g h .
I would l i k e t o see a system where t h e p a t i e n t goes t o h i s
f a m i l y p h y s i c i a n , and, t h r o u g h r e f e r r a l o r o t h e r w i s e , i t i s
determined t h a t a s u r g i c a l procedure i s needed. The p a t i e n t t h e n
�shops around f o r a surgeon o r s u r g i c a l team, and g e t s a t o t a l p r i c e
e s t i m a t e up f r o n t ; t h a t i n c l u d e s e v e r y t h i n g : The h o s p i t a l ,
surgeon, a l l p e r s o n e l l , drugs, a n e s t h e s i a , e v e r y t h i n g . The surgeon
i s t h e n bound t o t h a t e s t i m a t e , w i t h c e r t a i n u n f o r e s e e a b i l i t y
exceptions.
I f we do t h a t , t h e surgeon w i l l be n e g o t i a t i n g w i t h
t h e v a r i o u s h o s p i t a l s f o r c o s t s . That w i l l r e v e r s e t h e i d e a o f t h e
h o s p i t a l s c o n t r o l l i n g physicians. I t w i l l also solve the
" u n b u n d l i n g " problem a s s o c i a t e d w i t h h o s p i t a l s . Consumers can't
p r i c e shop i f t h e y don't know what t h e t o t a l p r i c e i s . I view t h e
surgeon as s i m i l a r t o t h e g e n e r a l c o n t r a c t o r , w i t h t h e h o s p i t a l and
a l l o t h e r a s s o c i a t e d p r o v i d e r s as b e i n g t h e s u b c o n t r a c t o r s .
T h i s v e r y system i s i n p l a c e i n C i n c i n n a t i f o r a t l e a s t one
s p e c i a l t y t h a t i s n o t covered by i n s u r a n c e . T h i s s p e c i a l t y i s
o f f e r i n g a t o t a l p r i c e , i n c l u d i n g meds, f o r s u r g i c a l procedures,
and t h e p r i c e has gone down. The reason i s t h a t t h e p r o v i d e r s must
d e a l w i t h t h e u l t i m a t e consumer, n o t an i n s u r e r . What does t h i s
t e l l us?
We require t h i s very system i n car r e p a i r s . We don't get a
separate b i l l from the mechanic, the garage, the p a r t s s u p p l i e r ,
e t c . . . A l l s t a t e s a l s o require that an estimate be given p r i o r to
any work being done. I r e a l i z e that surgery i s n ' t the same as
r e p a i r i n g a car, but i s i t that d i f f e r e n t i n p r i n c i p l e ?
J u s t a q u i c k t h o u g h t on m a l p r a c t i c e c o s t s . I can t e l l you t h e
most d i f f i c u l t case t o prove and t r y i s m a l p r a c t i c e . We have a l s o
passed v i r t u a l l y every b i t o f t o r t r e f o r m and m a l p r a c t i c e r e f o r m
r e q u e s t e d by t h e OSMA. Despite t h a t , t h e premiums c o l l e c t e d i n
t h i s s t a t e o u t s t r i p t h e payouts and c l a i m c o s t s g e o m e t r i c a l l y .
Somebody ought t o t a k e a hard l o o k a t t h i s s i t u a t i o n .
I believe
t h e g i v e n reason, t h e " l o n g t a i l " a s s o c i a t e d w i t h c h i l d r e n , i s a
myth. I t i s a k i n t o a pyramid scheme, because a f t e r 18 y e a r s , t h e
t a i l has been covered.
The c u r r e n t system o n l y covers t h e
insurers' t a i l .
I n c o n c l u s i o n , government p r i c e s e t t i n g has never worked i n
any area t o reduce c o s t s . U n f o r t u n a t e l y , however, t h a t i s what t h e
c u r r e n t system i s a l l about.
U n t i l we change i t t o a consumer
d r i v e n system, t h e c o s t s w i l l remain o u t o f c o n t r o l .
�Graph 4
National Health Care Expenditures
Expenditures in Billions
Percent of GNP
$1800,
m
S1500 -
^ 15%
$1200 -
J
1 2%
$900 $600
$300 -
1965
1970
1980
1985
1990
Source: Health Care Financing Admi;:istration
1995
Projected
- 0%
2000
�KENTUCKY COMMISSION O N WOMEN
Brereton Clones
Governor
614 A SHELBY STREET
F R A N K F O R T , KY. 40601
(502) 564-6643
MarshaC.Weinstein
Executive Director
February 9, 1993
Hillary Clinton, Chair
National Health Care-Reform Taskforce
1600 Pennsylvania Avenue
Washington, DC 20500
Dear Ms. Clinton:
On behalf of the Kentucky Commission on Women, I would like to congratulate you on
your appointment as head of the taskforce on health-care reform. We applaud your
efforts to create an inclusive agenda, which reflects America's diverse composition.
Since Governor Brereton Jones has proposed health-care reform in this state, we
have been studying a multitude of health-care issues. As the only woman on the
designated taskforce, however, I have generally focused my efforts on helping draft
legislation that addresses women's needs.
In an effort to educate the public about women's health care, my office has published
a newsletter, as well as spoken to several organizations about women's specific needs
in this area. In an attempt to provide health-care providers with current research, we
have been actively serving on the planning committee for the Helen B. Fraser
Conference, which will exclusively focus on women's health-care. This conference
will be held September 29 - October 1 in Louisville, KY. I have included a list of topics
and potential speakers.
As the Commission becomes more involved in this issue, we find ourselves relying on
research gathered by the Campaign for Women's Health for national statistics and
ideas from other states. We completely endorse their agenda and hope that you will
seriously consider their suggestions when drafting model legislation. We would be
pleased to provide you with any information and statistics about women in this state or
assist you in any manner.
Additionally, I encourage you to push for the reestablishment of a National
Commission on Women, similar to the one created under the Kennedy administration.
This would illuminate further the gender inequities of our public policies.
�Realizing that you are a committed feminist and children's advocate, we are confident
you will remember women's concerns as you strive to create a more equitable healthcare system. This reform offers an excellent opportunity to help alleviate some of the
injustices women currently suffer under the present health-care system.
Once again, we appreciate your efforts to transform the current system, so that it
meets the needs of a broader base of citizens. Do not hesitate to contact us if we can
be of any service.
Sincerely,
Marsha Weinstein
Executive Director
Enclosure
It
�General Sessions
Liz Curtis Higgs
* Choosing to Change
Dr. Anne Kasper
Women's Health Care
Carolyn Curry
*Miclfife - A Time for Celebration
Dr. Rice Leach
Kentucky Health Care Reform
Dr. Leah Dickstein
Women's Health; The Holistic Approach (the
connection between mind and body)
* These sessions already have actual titles
Breakout Sessions
1.
2.
3.
4.
5.
6.
8.
9.
Hormone Replacement Therapy (includes osteoporosis)
Contraceptive Choices
Substance Abuse
(To include prenatal issues in addiction to
recognizing and assisting the "hidden" female
abuses. Alcohol and tobacco will be addressed in
separate sessions)
Smoking and Women
(impact and cessation of)
Preconceptional Health/Folic Acid
Adolescent women" Growing up in the 90's
(The adolescent as a health consumer/adolescent
primary care issues.)
Women & HIV
(To include update on how women present difference
symptoms than men, women are diagnosed in later
stages and how self esteem issues affect women's
risk)
Domestic Violence
(Recognizing and making new referrals, New
Legislation)
Adult Survivors of Child Sexual Abuse
(How to recognize, be sensitive to and refer for
treatment)
�10.
11.
12.
13.
14.
15.
16.
Overcoming Barriers to Health Services: Bridging the Gap.
Challenges of Caring for a Child with Special Needs
Cholesterol and Heart Disease in Women
Take Care of Ourselves
Prescription Drug Abuse and Women
(To include presentations from a physician and
pharmacist. Information on how women become
addicted, how they"work the system," and how they
can be helped. Also, to look at the prescribing
practices of physicians.)
Depression
Women and Alcoholism
�
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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[Letters from Government Officials and Employees] [loose] [2]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
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Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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3/16/2015
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42-t-12092971-20060885F-Seg3-035-016-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/73040645e6c29d570661137cb7826c0b.pdf
4a8c4e952b5cf82a267430ab0bf70dd7
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1983
FolderlD:
Folder Title:
[Letters from Government Officials and Employees] [loose] [1]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
2
�JOAN KINNEY, GOVERNOR OF THE
STATE OF
K A N S A S D E P A R T M E N T OF
AND
REHABILITATION
KANSAS
SOCIAL
SERVICES
D O N N A W H I T E M A N, SECRETARY
February
19,
1993
H i l l a r y Rodham C l i n t o n
Chairperson
Task Force on N a t i o n a l H e a l t h Care Reform
1600 Pennsylvania Avenue
Washington, D.C.
20500
Dear Ms. Rodham C l i n t o n :
I would l i k e t o t a k e t h i s o p p o r t u n i t y t o c o n g r a t u l a t e you on your new p o s i t i o n
as C h a i r p e r s o n f o r t h e Task Force on N a t i o n a l H e a l t h Care Reform. I am sure
t h i s j o b w i l l prove t o be v e r y c h a l l e n g i n g and, a t t i m e s , overwhelming.
As t h e
S e c r e t a r y f o r t h e Kansas Department o f S o c i a l and R e h a b i l i t a t i o n S e r v i c e s ,
Kansas' M e d i c a i d agency, I have a g r e a t i n t e r e s t i n t h e work which you are
d o i n g . As you and t h e P r e s i d e n t know, i n c r e a s e s t o t h e c o s t o f M e d i c a i d over
t h e p a s t s e v e r a l years have caused f i s c a l p a n i c f o r many s t a t e s which wonder how
l o n g t h e y can a f f o r d t o f u n d t h i s program.
T h i s agency welcomes your appointment and t h e e s t a b l i s h m e n t o f t h e Task Force as
t h e f i r s t upward s t e p i n a l o n g c l i m b t o b u i l d e q u i t a b l e h e a l t h care d e l i v e r y
and payment systems f o r t h i s c o u n t r y . Since t h e s t a t e Medicaid agencies have
e x p e r t i s e i n a d m i n i s t e r i n g m e d i c a l programs and i n p r o c e s s i n g c l a i m s f o r a much
broader p o p u l a t i o n t h a n has t h e f e d e r a l government ( f o r Medicare r e c i p i e n t s ) , I
b e l i e v e t h a t we can be o f i n v a l u a b l e a s s i s t a n c e t o you as you p l a n and prepare
f o r h e a l t h c a r e r e f o r m . An a r t i c l e i n t h e January 28, 1993, Community H e a l t h
Funding Report s t a t e d " P r e s i d e n t C l i n t o n asks Americans t o send t h e i r w r i t t e n
s u g g e s t i o n s t o t h e Task Force. . . . "
We p l a n t o t a k e f u l l advantage o f t h a t
i n v i t a t i o n t o keep you a p p r i s e d o f t h e changes we f e e l are necessary t o ensure
t h a t n a t i o n a l h e a l t h care r e f o r m i s w e l l - p l a n n e d , a f f o r d a b l e , s u c c e s s f u l , and,
most i m p o r t a n t l y f o r us, guarantees access t o m e d i c a l l y necessary q u a l i t y care
f o r our c l i e n t s .
To b e g i n t h i s d i a l o g u e , I encourage you t o share t h e enclosed a r t i c l e from t h e
November 19, 1992, Washington Post w i t h your c o l l e a g u e s on t h e Task Force.
This
i s one o f t h e b e s t w r i t t e n , s u c c i n c t p i e c e s I have read about one p a t h t h i s
c o u n t r y c o u l d t a k e i n i t s quest t o r e f o r m h e a l t h c a r e . The a u t h o r Marcia
A n g e l l , as e x e c u t i v e e d i t o r o f t h e New England J o u r n a l o f M e d i c i n e , i s o b v i o u s l y
no s t r a n g e r t o our h e a l t h care systems.
She has s o r t e d t h r o u g h t h e myriad o f
p r o p o s a l s and p r o p o s i t i o n s and has a p l a n which c l e a r l y d e f i n e s a need f o r : (1)
a n a t i o n a l l i m i t on h e a l t h care spending, (2) a s i n g l e payor ( n o t a s i n g l e
d e l i v e r y ) system, and (3) sound h e a l t h care management p r a c t i c e s based not on
t h e d e s i r e f o r more money b u t on t h e d e s i r e t o serve humanity.
915
SW
HARRISON
STREET, T O P E K A , K A N S A S 6
6612
�H i l l a r y Rodham C l i n t o n
February 19, 19 93
Page 2
I hope t h a t you f i n d Ms. Angell's a r t i c l e h e l p f u l as you begin the Task Force on
National Health Care Reform. This agency w i l l continue t o watch and read what
i s being said i n the media about reform and t o share our ideas and opinions w i t h
you.
Thank you very much f o r g i v i n g us the opportunity t o be involved i n what w i l l
probably be the most important task between now and the year 2000. I f we may be
of any assistance t o you i n t h i s process, please do not h e s i t a t e t o c a l l on us.
Rebecca Mize, Management Services, has been e s p e c i a l l y assigned t o research and
educate t h i s agency on health care reform. Please c a l l her at (913) 296-4723 i f
you have any questions.
/1
Sincerely/
Donna L. Whiteman
Secretary
DLW:RLW:JJG:RHM:rm
Enclosure
cc:
Governor Joan Finney
Robert Epps
Joyce Sugrue
�Marcia Angell
Three Steps to Universal Health Care
President-elect Clinton will now have
to make good on his campaign promise
to reform our failed health care system.
He will find-it hard going. To expand
access to health care without increasing
costs will require an overhaul both in the
way health care is paid for and in the
way it is delivered. We need to make
three fundamental changes.
First, we need a national cap on spending for health care. This should be set by
Congress, perhaps as a percentage of
GNP. Otherwise health care will continue
to absorb a growing fraction of our resources, since it is relatively immune to
ordinary consumer pressures. Most people are not disposed to shop for bargains
in health care, and when they are sick
they are unable to do so. Their doctors,
who determine what care is needed, are
rewarded in our fee-for-service system
for doing more rather than less.
Second, we need a single payer. Our
multiple profit-making insurance companies add greatly to costs. They compete
not by lowering costs but by insuring
6nly the most healthy, limiting the coverage of those they do insure, resisting
claims and doing everything possible to
shift costs. All of this is expensive.
The most efficient and fair way to pay
for health care is through the income
tax. In this way, there would be only one
collector (and a very experienced one, at
that), and the wealthiest would pay the
'most. The federal government might
then allocate the funds to the states,
according to relevant demographic feaitures, and the states would distribute
the funds to the health care institutions
and provider groups. Please note that
this is not "socialized medicine" or government-controlled health care. The
federal government would merely collect the money. Play-or-pay proposals
are more complicated and less satisfactory; they burden American -businesses
with the failings of the health care
system at a time when businesses have
serious problems of their own.
Third, health care should be deliveredby groups of providers paid a set amount
for each patient enrolled (capitation),
with individual providers receiving a
salary (some specialists would consult
for several groups on a fee-for-service
basis). Needless to say, doctors should
earn good salaries. Primary care physicians should probably eam more than
their current average; many specialists
should eam less and some far less. The
provider groups would be managed by
boards of enrollees and providers. They
would compete for enrollees on the basis
of quality, by which I mean not only
medical quality, but also through such
courtesies as short waiting times and
attentiveness. The groups should not
compete on the basis of price. Provider
groups trying to cut their price would be
tempted to stint on providing necessary
care. For the same reason, any funds left
at the end of the year should be rebated
to the enrollees or go toward amenities
for the organization. They should not be
returned to individual providers.
After the establishment of such a
system, we would need to prevent the
development of a private, parallel feefor-service system that would produce
two tiers of health care, with a consequent tendency to underfund the national system. One method would be to
require government employees, even at
the highest levels, to remain in the
capitation system. This restriction
would dissuade those responsible for the
system from underfunding it.
That is the system I propose. Now
let's look at three airguments that will be
made against it. First, it will be argued
that universal coverage will increase
costs. On the contrary, the system I am
advocating would almost certainly lower
total expenditures. Let's look at just one
area of savings. About 25 percent of the
$800 billion we now spend on health
care each year goes for administrative
costs. These would be cut drastically in
the system I am proposing. If they were
lowered to 10 percent of expendi-
tures—the percentage in Canada—we
would save $120 billion. This is what it
would cost to provide health care for the
nearly 40 million uninsured, assuming a
cost of $3,000 each (what we now
spend, on average). Furthermore, the
costs per capita would probably be lower
without the incentives of our present
fee-for-service system to do unnecessary procedures.
Second, it will be said that a universal
health care system paid for out of general revenues would lead to long waits for
care, as in Canada. This argument is
specious. The reason for waits in Canada (and they a.-e not nearly so long as
we often hear) is that the Canadians
spend considerably less than we do on
health care—about $2,000 for each citizen. But waits are not inherent to their
system. If the Canadians spent as much
as we do, there would be no waits.
Finally, it will be argued that the free
market is the best way to limit costs. This
is the most fallacious of all the misconceptions. Let's look at an analogy. When the
big three automobile companies compete
with each other, they may indeed lower
the costs of each car, but only with the
aim of expanding their share of the market, that is, of selling more cars. And
insofar as they are successful, the total
effect is to expand the whole industry.
The same is true of hospitals or doctors
competing with one another. Competition
in a free market is not intended to limit an
industry but to expand it.
It's time to stop imagining that health
care is a commodity that patients buy if
the price is right. It is instead a social
good that all citizens require at some time
in their lives. The challenge is to deliver it
efficiently and equitably. The proposal I
have outlined would meet this challenge.
The writer is executive editor of the
New England Journal of Medicine.
�4TH
DISTRICT
COMMITTEES
A L L Y S O N Y. SCHWARTZ
THE
STATE
CAPITOL
H A R R I S B U R G . PA
(717)
FAX
27
7 8 7 1 4 2 7
(717)
EAST
772-2756
DURHAM
PHILADELPHIA.
(215)
STATE OOVERNMEKTr. CHAIR
AQINO A NO YOUTH
APPROPRIATIONS
COMMUNITY AND ECONOMIC DEVELOPMENT
EDUCATION
POLICY
PUBLIC HEALTH AND WELFARE
URBAN AFFAIRS AND HOUSING
CAPITOL PRESERVATION COMMITTEE. MEMBER
17120-0030
STREET
PA 1 9 1 1 9
242-9710
FAX (215)
550-6906
REPLY T O :
•
HARRISBURG
•
PHILADELPHIA
enate of Itannsulbama
March 8, 1993
Hillary Rodham Clinton, Esq.
Office of the First Lady
The White House
1600 Pennsylvania Avenue, NW
Washington, D.C. 20500
Dear Ms. Clinton:
I recently sent you a copy of my briefing book on the Women's
Health Security Act which I have introduced in the Pennsylvania State
Senate.
Before winning my seat in the Pennsylvania State Senate, I worked
for thirteen years as the executive director of the Elizabeth Blackwell
Health Center i n Philadelphia, a women's health center which is a national
model for providing health care to women. I have enclosed my biography
for your information and background on the kind of work I have done i n
Pennsylvania.
From my perspective, the starting point f o r discussion of health
care reform must be the definition of a standard package of benefits. I t
will be the key to cost containment and improved health status.
The standard package is critical because i t will define whether the
system is intended to cover all essential services or be a barebones
minimum. I t will define whether we expect most people to be satisfied with
the standard or whether it will encourage as many as possible to look
elsewhere. I have sought to define such a benefits package f o r women with
the legislation I introduced i n Pennsylvania.
I contacted your office a few days before you were scheduled to
come to Pennsylvania on February 11th to see i f you would have an
opportunity to meet briefly. While that was not possible, I would be
delighted to meet with you i n Washington or work with your health care
team on incorporating a women's health perspective.
I was thrilled to learn of your recent meeting with the Women's
Congressional Caucus focusing on health care for women. I have
personally been in touch with the Philadelphia area delegation as well as
�-2-
national health organizations including the Campaign for Women's Health,
the National Women's Law Center and the Breast Cancer Coalition. We are
all very much in agreement in perspective and direction.
I have enclosed a copy of our briefing book as well as testimony I
presented at Governor Casey's Managed Health Care hearings held recently
in Philadelphia. As someone actively involved in health care reform on the
State level, I am deeply committed to improving the health status of all
Americans as our ultimate goal while reducing costs and improving access.
It is an awesome task. Please know that your role in this effort is
much appreciated. I would be honored to have the opportunity to
participate in some way in this process on the national level.
Sincerely,
Allyson Y . Schwartz
State Senator - 4th District
Enclosures
cc: Patti Solis
�Serving the 4th Senatorial District and the people of Pennsylvania
State Senator
ALLYSON Y. SCHWARTZ
After two decades of working in health and human services for families and children in
Philadelphia, on November 6,1990, Allyson Schwartz became one of the few women in
Pennsylvania history to be elected to the State Senate. She represents the 4th Senatorial District.
Sen. Schwartz was the prime sponsor of the Mammography Quality Assurance Act which was
signed into law on July 9,1992. This bill guarantees all mammography facilities in the state meet
quality standards consistent with the American College of Radiology's accreditation program.
Sen. Schwartz serves as the Majority Chair of the Senate State Government Committee. She is also a
member of the Senate Aging and Youth, Appropriations, Community and Economic Development,
Education, Policy, Public Health and Welfare, and Urban Affairs and Housing Committees. She
serves as a member of the Joint State Government Commission Task Force on Children and Youth,
the Capitol Preservation Committee, the Governor's Children's Service Task Force and the Advisory
Committee to the Pew Charitable Trust Children's Initiative.
A leading pro-choice advocate, Sen. Schwartz was the only representative from Pennsylvania and
one of only two State Legislators appointed to NARAL's National Commission on America after Roe.
Sen. Schwartz was a key negotiator in the Senate for the Children's Health Partnership Act,
legislation passed in November, 1992, to provide health coverage for thousands of uninsured
children in Pennsylvania.
Sen. Schwartz has been at the forefront of legislative efforts to enact a Family and Medical Leave
Law, to pass a responsible "living will" act, to expand opportunities for workplace child care, to
require schools to provide kindergarten, to ban the sale of deadly assault weapons, and to mandate
insurance companies provide preventive care for diseases specific to women.
Sen. Schwartz has stood up for public transportation by supporting the creation of a dedicated
funding source for SEPTA, for the elderly by assuring sound funding for the PACE program, for
public education by being a strong voice against school vouchers, and for the environment by
proposing legislation to help small businesses come into compliance with the Clean Air Act.
In the fiscal year 1992-93 state budget. Sen. Schwartz fought for and secured $5 million for the
development of innovative programs to serve medically dependent children.
Sen. Schwartz was appointed to the National Democratic Platform Committee.
Sen. Schwartz currently serves on the board of directors of Philadelphia Health Management
Corporation; the Philadelphia Ranger Corps; Aliens Lane Art Center; and the Center for Responsible
Funding. She also serves on the Temple University Comprehensive Breast Center Consumer
Advisory Board; the National Women's Network of the National Conference of State Legislators;
Women Legislators' Lobby, PA State Chair; Center for Policy Alternative, Policy Alternative Leader;
Montgomery County Commission for Women and Families Leadership Committee; and Families of
Murder Victims.
more
�Schwartz has served on numerous other boards and commissions including, the Governor's Task
Force on Health Care Cost Containment, the Delaware Valley Child Care Council, PA Citizens
Crime Commission Task Force on Juvenile Justice, and the Mayor's Task Force on Homelessness.
Sen. Schwartz holds various memberships, including the American Jewish Congress, Joint Action
Committee, NOW, NARAL, AAUW, League of Women Voters and the American Israel Public
Affairs Committee.
Sen. Schwartz is a founding member of Women's Way, the most successful women's funding
federation in the nation and currently serves on the Advisory Council.
From 1972 to 1975, Schwartz served as an assistant unit director of the Philadelphia Health Plan,
one of Philadelphia's first health maintenance organizations.
In 1975, at the age of 27, Schwartz founded the Elizabeth Blackwell Health Center, a national model
in the provision of health services for women, where she served as executive director for 13 years.
In April, 1988, Schwartz joined city government, first as Philadelphia's Deputy Managing Ehrector
for Health and Human Services and later as acting commissioner and first deputy commissioner of
the Department of Human Services.
Sen. Schwartz received a bachelors degree from Simmons College and a master of social services
from Bryn Mawr College.
Sen. Schwartz is married and has two sons, 17 and 14, who attend public schools in Philadelphia.
1/93
�Clinton Presidential Records
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��COMMONWEALTH
OF
KENTUCKY
O F F I C E O F T H E GOVERNOR
B R E R E T O N C.
JONES
THE
GOVERNOR
C .prTOL
700 CAPITAL
FRANKFORT
(502)
1993
Mrs. H i l l a r y Rodham C l i n t o n
The White House
Washington, D.C. 20500
Dear H i l l a r y :
We are working hard t o reform the h e a l t h care system i n
Kentucky. Our goals are t o c o n t a i n t h e r a p i d l y r i s i n g costs
of h e a l t h care and t o provide h e a l t h care coverage f o r a l l
Kentuckians.
Recently we unveiled our plan t o meet these goals. I have
enclosed a copy of t h e plan f o r your review. The b a t t l e f o r
meaningful h e a l t h care reform i s one of the toughest I have
ever experienced. Please know how e x c i t e d we are about t h e
progress you are making on the f e d e r a l l e v e l .
We look forward t o working w i t h you d u r i n g the months ahead.
Please do not h e s i t a t e t o c a l l i f we can be o f assistance.
With best regards, I am
Since^erky,
ones
BCJ/sh
AN
EQUAL
OPPORTUNITY
EMPLOYER
M/RH
40601
5 6 4 - 2 6 11
0March 18,
AVENUE
�COMMONWEALTH OF KENTUCKY
OFFICE OFTHE GOVERNOR
B R E P E T O . ^ C.
! H E ••-Atl-nTiL
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AvENiJE
P.Si.NK^OPT 4 O 6 0 1
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EMBARGOED UNTIL 1:30 P.M. EST MONDAY, MARCH 1 , 1993
KentucXy Health c a r e Reform
Executive Summary
GOALS: To c o n t r o l the skyrocketing c o s t s of h e a l t h care and to
provide coverage f o r every Kentuckian r e g a r d l e s s of
p r e - e x i s t i n g conditions.
The major elements o f t h e Governor B r e r e t o n Jones' h e a l t h care
r e f o r m p r o p o s a l s focus on f i v e areas: c o s t c o n t a i n m e n t , u n i v e r s a l
access, h e a l t h care d e l i v e r y r e f o r m s , q u a l i t y assurance, and
f i n a n c i n g . F o l l o w i n g a r e t h e major p o i n t s i n c l u d e d i n each area.
C o a t CorifcairnHanfc
** A five-member H e a l t h Care A u t h o r i t y would be e s t a b l i s h e d ,
w i t h f o u r o f t h e members a p p o i n t e d by t h e Governor and c o n f i r m e d by
t h e Senate. The S e c r e t a r y o f Human Resources would serve as c h a i r .
The A u t h o r i t y would be empowered t o s e t r a t e s t o c o n t r o l t h e
c o s t o f h e a l t h i n s u r a n c e premiums and payments made t o h e a l t h care
providers.
The A u t h o r i t y would r e g u l a t e a l l aspects o f t h e h e a l t h care
i n d u s t r y and would r e v i e w t h e minimum h e a l t h c a r e b e n e f i t package
t h r o u g h which a l l Kentuckians would have an o p p o r t u n i t y t o o b t a i n
coverage. The r o l e o f t h e A u t h o r i t y would extend t o v i r t u a l l y a l l
areas o f t h e h e a l t h c a r e r e f o r m program.
** The c r e a t i o n o f a mega p o o l would be a key element o f c o s t
c o n t r o l . T h i s p o o l , r e p r e s e n t i n g more t h a n one m i l l i o n K e n t u c k i a n s ,
would g i v e t h e s t a t e t h e necessary l e v e r a g e t o n e g o t i a t e t h e best
and l o w e s t - c o s t coverage f o r i t s p a r t i c i p a n t s .
The A u t h o r i t y would n e g o t i a t e c o n t r a c t s f o r t h e p o o l , and t h e
c o n t r a c t s c o u l d be e s t a b l i s h e d on a s t a t e w i d e o r r e g i o n a l b a s t s .
The p o o l would
i n c l u d e t h e f o l l o w i n g groups:
public
employees, M e d i c a i d r e c i p i e n t s , uninsured/unemployed
persons;
employees of- businesses choosing t o p a r t i c i p a t e ; i n d i v i d u a l s o r
f a m i l i e s c h o o s i n g t o p a r t i c i p a t e ; wards o f t h e s t a t e ; and workers'
AN
EQUAL
OPPORTUNITY
EMPLOYER
M/RH
�compensation h e a l t h care b e n e f i c i a r i e s choosing t o p a r t i c i p a t e .
The coverage plans o f f e r e d t h r o u g h t h e mega p o o l c o u l d vary
for
each group.
But every p l a n would use "managed c a r e "
principles.
Under managed c a r e , p a t i e n t s must choose a s i n g l e
p r i m a r y care p h y s i c i a n who must approve a l l r e f e r r a l s t o
s p e c i a l i s t s and arrange f o r non-emergency h o s p i t a l i z a t i o n .
A reasonably p r i c e d insurance plan t h a t includes c a t a s t r o p h i c
coverage would be a v a i l a b l e t h r o u g h t h e p o o l . The c o s t o f t h i s
p l a n , based on a c t u a r i a l a n a l y s i s , would be $116 p e r person per
month f o r 1994.
S e r v i c e s p r o v i d e d t o M e d i c a i d r e c i p i e n t s would n o t be changed,
but steps would be t a k e n t o c o n t r o l c o s t s .
The s t a t e would seek a w a i v e r from t h e f e d e r a l government t c
i n c l u d e t h e Medicare program i n t h e mega p o o l .
However, t h e r e
would be no r e d u c t i o n i n s e r v i c e s o r i n c r e a s e i n c o s t s f o r Medicare
recipients.
** C o n s i d e r a b l e s a v i n g s a l s o would be r e a l i z e d t h r o u g h changes
i n t h e w o r k e r s ' compensation system.
I t would be m o d i f i e d t o
r e q u i r e t h e use o f a p p r o p r i a t e managed care p r a c t i c e s i n t h e
d e l i v e r y o f h e a l t h care f o r i n d u s t r i a l i n j u r i e s and o c c u p a t i o n a l
diseases.
E f f e c t i v e J u l y 1 o f t h i s year, workers compensation i n s u r a n c e
r a t e s f o r t h e v o l u n t a r y market and t h e assigned r i s k p o o l f o r npnc o a l i n d u s t r i e s would be reduced by 5 p e r c e n t from t h e l e v e l i n
e f f e c t as o f February 1. The lower r a t e s would t h e n be f r o z e n f o r
two y e a r s . Rates f o r t h e assigned r i s k p o o l f o r t h e c o a l i n d u s t r y
i n f i s c a l year 1992-93 would be reduced by 5 p e r c e n t e f f e c t i v e J u l y
1 and t h e n f r o z e n f o r t v o y e a r s .
** S t a n d a r d i z i n g t h e forms used f o r i n s u r a n c e c l a i m s and
a p p l i c a t i o n s and p r o v i d e r payments would a l s o r e s u l t i n c o s t
savings.
Insurance c a r r i e r s who f a i l e d t o comply w i t h t h i s
r e q u i r e m e n t would l o s e t h e i r l i c e n s e and be s u b j e c t t o f i n e s .
** Reforms i n l o n g - t e r m care would focus on c a r i n g f o r t h e
e l d e r l y and t h e s e v e r e l y d i s a b l e d i n t h e l e a s t
restrictive
environment
possible.
This
would
include the possible
e s t a b l i s h m e n t o f a F o s t e r Care f o r t h e E l d e r l y program and an
expansion o f A d u l t Day Care and Home Care s e r v i c e s as a l t e r n a t i v e s
t o more expensive n u r s i n g home care.
** Another area o f c o s t c o n t r o l would be medical l i a b i l i t y
r e f o r m , s t a t e law would r e q u i r e t h a t medical m a l p r a c t i c e d i s p u t e s
be heard f i r s t by m e d i a t i o n panels b e f o r e b e i n g f i l e d i n c o u r t
( u n l e s s a l l p a r t i e s i n v o l v e d waive m e d i a t i o n ) .
U n i v e r s a l Access
** A l l Kentuckians would have a t l e a s t a minimum h e a l t h
i n s u r a n c e b e n e f i t p l a n f o r themselves and t h e i r dependents by
January 1, 1994. The p l a n would be a v a i l a b l e i n a number o f ways,
r a n g i n g from s t a t e - p r o v i d e d coverage f o r low-income o r unemployed
K e n t u c k i a n s t o e m p l o y e r - p r o v i d e d coverage f o r w o r k i n g K e n t u c k i a n s .
�Employers who p r o v i d e coverage f o r a l l f u l l - t i m e employees
would n o t be s u b j e c t t o a 16 p e r c e n t p a y r o l l t a x t h a t would be
assessed i f t h e y do n o t p r o v i d e t h e coverage.
i n addition,
employers would pay a p r o - r a t a share o f t h e i r p a r t - t i m e employees
insurance c o s t s based on a 4 0-hour work week. The c o s t o f f u l l t i m e coverage f o r t h e b a s i c b e n e f i t p l a n would be $116 p e r person
per month. Costs f o r p a r t - t i m e workers would be c a l c u l a t e d on a
pro-rata basis.
I f p a r t - t i m e employees a r e e l i g i b l e f o r f u l l coverage under
another p l a n , employers would be exempt from paying f o r t h e
coverage.
A s t a t e subsidy would h e l p businesses who p r o v i d e i n s u r a n c e
f o r t h e i r employees and have a n e t income o f l e s s t h a n $50,000 p e r
year and an annual p a y r o l l o f l e s s t h a n $200,000.
The subsidy
would pay a percentage o f t h e i n s u r a n c e c o s t s f o r such f i r m s on a
s l i d i n g s c a l e depending on an employee's e a r n i n g s .
** Employers would be r e q u i r e d t o o f f e r , b u t n o t pay f o r , a
f a m i l y p l a n f o r t h e i r employees. These p l a n s , o f f e r e d t h r o u g h t h e
mega p o o l , would cost $393 p e r month i n 1994 ($116 p a i d by t h e
employer and $277 c o n t r i b u t e d by t h e employee).
** Workers w i t h incomes below 100 p e r c e n t o f p o v e r t y would
r e c e i v e a s u b s i d y from t h e s t a t e t o supplement t h e premium payment
made by t h e i r employer.
T h i s would a l l o w low-income a d u l t s ' t o
r e c e i v e an enhanced b e n e f i t p l a n . Premium payments f o r p a r t - t i m e
workers w i t h incomes below 100 p e r c e n t o f p o v e r t y would be f u l l y
s u b s i d i z e d by t h e s t a t e . P a r t - t i m e workers w i t h incomes under 200
p e r c e n t o f p o v e r t y would be e l i g i b l e f o r a s t a t e s u b s i d y f o r t h e i r
i n s u r a n c e c o s t s which a r e beyond t h e amount c o n t r i b u t e d by t h e i r
employer.
** S t a t e government would f u l l y s u b s i d i z e unemployed a d u l t s
w i t h household incomes below 100 p e r c e n t o f p o v e r t y . Those w i t h
incomes between 100 and 200 p e r c e n t o f p o v e r t y would r e c e i v e
p a r t i a l s u b s i d i e s from t h e s t a t e .
**
The reforms
would p r o v i d e b a s i c m e d i c a l
care f o r
i n d i v i d u a l s who a r e d i s a b l e d and choose t o work.
Currently,
d i s a b l e d persons who choose t o work l o s e t h e i r Medicare o r Medicaid
b e n e f i t s and a r e o f t e n unable t o o b t a i n p r i v a t e insurance coverage.
** The reforms would p r o v i d e an a l t e r n a t i v e t o i n c a r c e r a t i o n
f o r i n d i v i d u a l s w i t h m e n t a l i l l n e s s who a r e undergoing i n v o l u n t a r y
h o s p i t a l i z a t i o n procedures.
As t h e p l a n p r o v i d e s h o s p i t a l i z a t i o n
and o u t p a t i e n t s e r v i c e s f o r t h e m e n t a l l y i l l , t h e s e i n d i v i d u a l s
c o u l d be d i v e r t e d from j a i l and e v a l u a t e d immediately upon t h e
r e q u e s t o f l o c a l mental h e a l t h p r o f e s s i o n a l s .
** H e a l t h care b e n e f i t s p r o v i d e d by t h e s t a t e would be
a v a i l a b l e o n l y t o people who have r e s i d e d i n t h e Commonwealth f o r
a p e r i o d o f one year.
�** A l l h e a l t h i n s u r a n c e u n d e r w r i t e r s would be r e q u i r e d t o
o f f e r t h e minimum b e n e f i t p l a n by January 1, 1994 as a c o n d i t i o n of
l i c e n s u r e . A l l such p l a n s would i n c l u d e a h e a l t h exam, a s s o c i a t e d
l a b t e s t s and immunizations each year as a p p r o p r i a t e t o age, gender
and p h y s i c a l c o n d i t i o n . None o f t h e s e procedures would be s u b j e c t
t o c o - i n s u r a n c e payments o r d e d u c t i b l e s .
A l l h e a l t h p l a n s w r i t t e n i n Kentucky must be community r a t e d
r e g a r d l e s s o f age, gender, p h y s i c a l c o n d i t i o n or o c c u p a t i o n .
E x c l u s i o n s f o r p r e - e x i s t i n g c o n d i t i o n s would be p r o h i b i t e d i n
h e a l t h i n s u r a n c e p l a n s w r i t t e n i n Kentucky.
Health Care D e l i v e r y Reforms
** P r i m a r y care s e r v i c e s would be t h e f o u n d a t i o n o f t h e h e a l t h
care d e l i v e r y system i n Kentucky, and t h e c u r r i c u l a i n t h e s t a t e ' s
medical s c h o o l s would be changed t o emphasize p r i m a r y care w i t h an
o r i e n t a t i o n on p r e v e n t i o n .
Under t h e s u p e r v i s i o n o f t h e H e a l t h Care A u t h o r i t y , t h e Human
Resources C a b i n e t would e s t a b l i s h t a r g e t s f o r t h e d i s t r i b u t i o n o f
h e a l t h p r o f e s s i o n a l s t o address t h e needs of underserved areas of
Kentucky.
Grant and l o a n programs would be e s t a b l i s h e d t o
encourage p h y s i c i a n s and m e d i c a l p r o f e s s i o n a l s t o l o c a t e i n
underserved a r e a s .
** The U n i v e r s i t y o f Kentucky would expand nurse m i d w i f e r y ,
nurse p r a c t i t i o n e r
and p h y s i c i a n a s s i s t a n t programs.
The
U n i v e r s i t y o f L o u i s v i l l e would e s t a b l i s h programs i n no fewer than
two o f t h e s e areas. P h y s i c i a n a s s i s t a n t s and nurse p r a c t i t i o n e r s
would be a b l e t o w r i t e p r e s c r i p t i o n s i f t h e y were p r a c t i c i n g under
the d i r e c t supervision of physicians i n organized s e t t i n g s .
** The r e f o r m s would c h a l l e n g e p r o v i d e r s s e r v i n g d i f f e r e n t
r e g i o n s o f Kentucky t o o f f e r p r o p o s a l s on e s t a b l i s h i n g s e r v i c e
d e l i v e r y n e t w o r k s , i f t h e p r o v i d e r s f a i l t o do so, t h e H e a l t h Care
A u t h o r i t y would be empowered t o c r e a t e t h e networks t o address t h e
needs o f t h e e n t i r e Commonwealth.
A t l e a s t one f u l l - s e r v i c e
h o s p i t a l would be i n c l u d e d i n each s e r v i c e d e l i v e r y area as would
s e v e r a l l i m i t e d - s e r v i c e community h e a l t h f a c i l i t i e s t h a t o f f e r
q u i c k access t o p a t i e n t s i n need o f p r i m a r y or trauma c a r e . H e a l t h
departments would be expanded i n underserved areas t o p r o v i d e b a s i c
care t o r e s i d e n t s .
Quality
Assurance
** B e g i n n i n g January 1, 1994,
implement p r a c t i c e g u i d e l i n e s f o r
define appropriate standards of
treating patients.
Working w i t h
develop outcome measures t h a t
evaluations of providers.
t h e H e a l t h Care A u t h o r i t y w i l l
a l l medical p r o f e s s i o n a l s t h a t
c a r e which s h o u l d be used i n
p r o v i d e r s , t h e A u t h o r i t y would
would be used
for periodic
�** Using i n f o r m a t i o n compiled from the mega p o o l and p r i v a t e
i n s u r e r s , t h e A u t h o r i t y would implement p r o v i d e r p r o f i l e s t h a t
would be made a v a i l a b l e t o the p u b l i c .
** These
of e v a l u a t i n g
and i n s u r e r s
e f f e c t i v e and
measures c o u l d g i v e p r o v i d e r s and consumers a means
p r o v i d e r s ' performance. They would enable consumers
t o determine which p r o v i d e r s c o n s i s t e n t l y d e l i v e r
c o s t - e f f i c i e n t services.
Financing
** The a d d i t i o n a l money needed t o pay f o r t h e p l a n would be
o b t a i n e d from t h e savings r e a l i z e d t h r o u g h implementing
the
r e f o r m s . These savings i n c l u d e :
—
$8 m i l l i o n a n n u a l l y t h a t c o u l d be r e d i r e c t e d from
s h o r t - t e r m m e n t a l h e a l t h s e r v i c e s p r o v i d e d t h r o u g h s t a t e mental
h o s p i t a l s and comprehensive care c e n t e r s t o buy h e a l t h care f o r t h e
uninsured.
Coverage would be p r o v i d e d f o r t h e m e n t a l l y i l l under
t h e minimum b e n e f i t package.
— $10 m i l l i o n a n n u a l l y from s e r v i c e s p r o v i d e d t h r o u g h
county h e a l t h departments f o r t h e m e d i c a l l y i n d i g e n t . The reforms
would p r o v i d e coverage f o r these Kentuckians.
— The H o s p i t a l i n d i g e n t Care Program (HICAP) would be
l i m i t e d o n l y t o those h o s p i t a l s t h a t serve t h e l a r g e s t share" of
Medicaid r e c i p i e n t s , t h u s e l i m i n a t i n g t h e need t o f u l l y u n d e r w r i t e
t h e c o s t of uncompensated care t h r o u g h HICAP.
— $13 m i l l i o n c o u l d be r e d i r e c t e d from t h e Q u a l i t y and
C h a r i t y Care T r u s t Agreement w i t h t h e U n i v e r s i t y of L o u i s v i l l e
H o s p i t a l (Humana) s i n c e t h e care f o r t h e i n d i g e n t these funds had
f i n a n c e d c o u l d be p r o v i d e d under t h e r e f o r m p l a n .
— The use of managed care p r i n c i p l e s f o r t h e i n s u r a n c e
coverage o f f e r e d s t a t e employees and t e a c h e r s would reduce c o s t s by
a p p r o x i m a t e l y $62 m i l l i o n a year.
—
The r e f o r m p l a n would b r i n g t h e p r i s o n and
jail
p o p u l a t i o n s i n t o t h e mega p o o l , r e s u l t i n g i n a $3.5 m i l l i o n annual
savings.
—
The p r o v i d e r t a x program would be r e s t r u c t u r e d t o
comply w i t h new f e d e r a l mandates, s u p p l y i n g t h e Medicaid program
w i t h $240 m i l l i o n a n n u a l l y .
** An expansion i n t h e number of Medicaid r e c i p i e n t s would
i n c r e a s e t h e t o t a l program c o s t by $352 m i l l i o n a year, i n c l u d i n g
$102.5 m i l l i o n i n s t a t e funds.
The r e m a i n i n g funds would be
p r o v i d e d by t h e f e d e r a l government.
A d d i t i o n a l Reforms
** Seat b e l t
passengers.
use
would be
mandated f o r a l l m o t o r i s t s
and
** H e a l t h e d u c a t i o n w i l l be i n t e g r a t e d i n t o t h e c u r r i c u l a f o r
a l l Kentucky c h i l d r e n grades K-12.
��THE A S S E M B L Y
STATE OF NEW
YORK
A L B A N Y
COMMITTEES
Aging
Housing
Labor
Local Government
Small Business
JOAN K. CHRISTENSEN
Assemblywoman 119th District
Onondaga County
March 12, 1993
H i l l a r y Rodham C l i n t o n
Task Force on National Health Care Reform
The White House
Washington, DC 20500
Dear Mrs. C l i n t o n :
I n your r o l e as head o f t h e Health Care Reform Task Force, I
am c e r t a i n t h a t you have been faced w i t h t h e many h e a l t h care
problems facing t h i s country. Access t o adequate h e a l t h care f o r
a l l members o f society, n u t r i t i o n , and h e a l t h education are a small
p a r t o f t h e complete h e a l t h care p i c t u r e .
However, these issues
have combined t o create a much bigger h e a l t h care problem, t h a t of
infant mortality.
I n 1987, a study done by t h e Children's Defense Fund o f 56
c i t i e s found Syracuse t o rank number one i n African-American i n f a n t
m o r t a l i t y . C u r r e n t l y i n the C i t y o f Syracuse, t h e i n f a n t m o r t a l i t y
r a t e among a l l races i s 12.8 deaths per 1000 l i v e b i r t h s . The
African-American i n f a n t m o r t a l i t y r a t e i s 19.2 deaths per 1000 l i v e
births.
These s t a t i s t i c s are s t a r t l i n g i n and o f themselves.
Since I am a State Assemblywoman representing areas o f high i n f a n t
m o r t a l i t y i n t h e c i t y and am also a mother, these s t a t i s t i c s are
more alarming.
Both the c i t y and Onondaga County have attempted t o use s t a t e
and f e d e r a l money t o combat the problem o f i n f a n t m o r t a l i t y . The
County Health Department has formed an i n f a n t m o r t a l i t y review
board, funded by the s t a t e , t o study cases i n order t o f i n d
p e r t i n e n t p u b l i c h e a l t h issues.
The studies which have been
researched over t h e past three years are h e l p f u l , b u t i n dealing
w i t h a problem such as high i n f a n t m o r t a l i t y , d i r e c t a c t i o n i s o f
primary importance.
This i s why I b r i n g t o your a t t e n t i o n an o r g a n i z a t i o n t h a t i s
-having a p o s i t i v e , d i r e c t e f f e c t on lowering the i n f a n t m o r t a l i t y
r a t e i n Syracuse and throughout t h e County. Just For Babies was
founded i n August 1991 f o r the purpose of supplying pregnant women
and t h e i r f a m i l i e s w i t h any services t h a t are needed - from an
appointment w i t h an o b s t e t r i c i a n , t o a c r i b , t o baby formula. The
agency i s run day-to-day on a l i m i t e d budget, which c o n s i s t s of
• Room 502. Legislative Office Building. Albany. New York 12248. (518) 455-5383. FAX (518) 455-5417
G 4317 E. Genesee Street. Room 103. Syracuse. New York 13214. (315) 449-9536. FAX (315) 449-0712
�H i l l a r y Rodham Clinton
p.2
donations from the public and the pocket of i t s director, Nessa
Vercillo-DeGirolamo.
Ms. Vercillo-DeGirolamo implemented her
program by using s t a t i s t i c s and information that she gained while
she sat on the infant mortality review board of the Onondaga County
Health Department.
In the 19 months since i t was founded, Just For Babies has
helped 725 families, providing pregnant women and t h e i r newborns
with supplies and services which are integral to t h e i r s u r v i v a l .
Just For Babies has saved these babies from becoming s t a t i s t i c s .
This organization has a d i r e c t impact on lowering the infant
mortality rates in my d i s t r i c t . The program i s so successful that
i t i s being duplicated i n other Central New York c i t i e s - Albany,
Binghamton, Rochester, and Utica.
I am enclosing information about Just For Babies to better
acquaint you with the organization. As you continue to research
ways to end the health care c r i s i s in the United States, I urge you
to come to Syracuse and see an organization that i s making a change
in the health care system of Syracuse.
I f the Just For Babies
model can work for other c i t i e s i n Central New York, i t may be able
to work i n other c i t i e s throughout the country.
I appreciate your attention to t h i s issue, and I t r u l y hope
that you w i l l be able to include Just For Babies i n your agenda.
Sincerely,
Joan K. Christensen
Member of the Assembly
JKC/dfm
�March 1-7,1993
bolvay-Comillus Edition
Kiwanis M m es
e br
D n t Cribs
o ae
A special project of the local
Kiwanis Clubs in Onondaga County
is the "Just for Babies" program, a
service for low income mothers in
need of basic baby necessities. The
Kiwanians have been collecting
cribs, baby furniture, clothing and
other baby supplies that can be
cleaned and refurbished and then
provided to these mothers.
Kiwanians feel the program is a key
element in reducing infant mortality-
in the Greater Syracuse area.
Pictured is Mark Relkes, manager of customer service for Taylor
Rental Company, receiving a check
from Mrs. Donna Curtin of the
Solvay-Gedes Club for 16 baby cribs
to be used in the "Just for Babies"
program. Taylor Rental provided the
cribs at a favorable price to assist
the Kiwanians in this program.The
Kiwanians goal is 75 cribs.
�ID
101
Babies •
Nessa Vercillo-DeGirolamo
Director
(315) 47-44656
"Just f o r Babies" i s a n o t - f o r - p r o f i t o r g a n i z a t i o n t h a t opened
i t s doors t o t h e improverished women, f a m i l i e s and bab ies o f t h i s
community i n August o f 1991. Our m i s s i o n i s t o p r o v i d e t h e
a b s o l u t e n e c e s s i t i e s of l i f e f o r t h e i r newborn or soon -to-be born
infants.
These items may i n c l u d e , c r i b s ,
clothing , blankets,
bedding,
b o t t l e s , s t r o l l e r s , car seats,
emergenc y d i a p e r s ,
formula and baby f o o d .
We g i v e these
b a s i c s t o them a t
a b s o l u t e l y no c o s t .
We a l s o r e f e r them t o other community
s e r v i c e s and programs, such as WIC, Pregnancy Care , Onondaga"
County Health Dept., S a l v a t i o n Army Teen P a r e n t i n g pr ogram, j u s t
to name a few.
The items are presented t o t h e mom or dad i n h i g h q u a l i t y used
c o n d i t i o n or nev. Nothing i s g i v e n t o t h e f a m i l y i n need w i t h
s t a i n s , r i p s or o t h e r i m p e r f e c t i o n s . We b e l i e v e t h a t , a l t h o u g h
the f a m i l i e s may n o t be i n t h e g r e a t e s t shape f i n a n c i a l l y , t h i s
should n o t be r e f l e c t e d i n t h e way t h a t t h e y a r e t r e a t e d . Their
self-esteem
i s one of t h e most i m p o r t a n t components of t h e
program, other than t h e p r o v i s i o n o f t h e items themselves. We do
not ask f o r f i n a n c i a l d i s c l o s u r e of any k i n d f o r t h i s reason
alone. We f e e l t h a t i f they have found us and expressed a need
for these fundamental pieces of t h e i r babies l i v e s , t h e y indeed
must be r e q u i r e d .
We b e l i e v e t h a t we are d i r e c t l y a f f e c t i n g t h e i n f a n t m o r t a l i t y
f i g u r e s , by s u p p l y i n g t h i s much needed s e r v i c e t o members o f t h i s
community and t h e h e a l t h and human s e r v i c e s agencies t h a t r e q u i r e
a s s i s t a n c e i n t h e i r ongoing e f f o r t s t o do t h e same.
Please make no m i s t a k e , t h e needs c o n t i n u e t o grow r e g a r d l e s s of
what we consider t o be a l a r g e number of c l i e n t s a l r e a d y served.
While we r e a l i z e t h a t JFB i s not t h e be a l l and end a l l of
programs, we K O t h a t we have made a s i g n i f i c a n t d i f f e r e n c e i n
NW
the l i v e s of those who have u t i l i z e d our program, and made t h e
jobs of many s o c i a l s e r v i c e workers, h e a l t h care
p r o v i d e r s , and
p r e v e n t i v e workers a l i t t l e b i t e a s i e r , and most I m p o r t a n t , we
have made t h e l i v e s o f t h e innocent c h i l d r e n s a f e r by p r o v i d i n g a
warm place t o s l e e p , a f u l l tummy and a d r y bottom.
v e r c i l l o . Director
JUST FOR BABIES, I n c .
Mill Pond Landing ° 327 West Fayette Street« Syracuse, New York 13202
�ti)
ID
lor
able
Nessa Vercillo-OeGiroJamo
Director
(315) 474-1656
March 2, 1993
Mrs. Joan Christensen
Assemblywoman 119th
4317 E. Genesee St.
DeWitt, New York
13224
Dear Joan,
The following is some data that I thought you would be interested
i n f o r background information.
This list includes most of the agencies and social service programs
that make referrals to Just f o r Babies, I n c . on a daily and weekly
basis.
A l l of whom are formally f u n d e d .
Salvation Army - Emergency Assistance
For Diapers, food and Formula
Salvation Army - Teen Parenting Program f o r e v e r y t h i n g from c r i b s ,
to health and hygiene items f o r baby.
Onon. Cty Health Dept - ( p u b l i c health nurses, public health social
w o r k , pregnancy care, W . I . C . )
- Emergency Assistance f o r diapers,
food, and formula
- Clothing, cribs and other equipment
Onon. Cty Dept of Social Services (CMCM, Infant Mortality Outreach,
P. A . C T . {parents & children t o g e t h e r } ,
Adult and Family Services - emergency
diapers/formula
Onon. Cty Children's Protective Division, Purchase Preventive
Onon. Cty Dept. of Corrections (Jamesville Penitentiary) we
c u r r e n t l y have clothing, an infant seat, a car seat,
a dressing table, a bassinet, toys, mobile and other
s u n d r y items i n the prison f o r women inmates with
c h i l d r e n , but the COUNTY CANNOT PROVIDE FOR THEM.
They t u r n to us f o r assistance.
Mill Pond Landing ° 327 West Fayette Street ° Syracuse, New York 13202
�The following refer for the basics for their clients and
newborn needs. They usually need EVERYTHING.
their
Headstart Programs all of them
Vincent House
Vera House
A.NCLA (association for the advancement of latinos of the community)
Spanish Action League
St. Joseph's Hospital and Maternal & Child Health Center
Upstate Medical Center OBGYN Clinic (out patient)
Upstate Medical Center Pediatric Clinic (out Patient)
Perinatal Center
\
Grouse Irving Memorial Social Work Dept.
^
a/^t
Grouse Irving Memorial Obstetrical Floors and Labor & Delivery
sJP%
Consortium for Children's Services
jfl^^mfl ^
Syracuse Women's Commission - Family Ties
^
W . I . C . (Women, Infants and Children) EMERGENCY F O R M U L A ^ ^
Lullaby League
Catholic Charities
Cooperative Extension
Visiting Nurses Association
Syracuse Community Health Center
West Side Clinic
Huntington Family Center
Brighton Family Center
South West Community Center
Volunteer Center
Churches all around Syracuse
Birthright
Support
There are more, not to mention word of mouth. As you can see, we
are a very viable program and helping all of those who have
funding. I don't get i t . I will be happy at any time to show you
and your staff any information about my program.
As usual, Joan, I can't thank you enough for your encouragement,
time and ACTIVE SUPPORT.
I also am very impressed with and
grateful to Davida of your office. She is bright, intelligent and
down to earth, a wonderful asset to your office as I am sure you
are aware.
Please let me know i f there is any additional information that I
can provide you with.
With warmest regards, I remain
Sincerely,
Nessa Vercillo
Director
Just for Babies, Inc.
�CLIENT INTAKE INFORMATION SHEET
JFB #
DATE:
SS#
NAME:
PHONE:
ADDRESS:
ZIP
MOM'S DOB:
OTHER
CONTACT:
_INVOLVED: Y/N_
FOB DOB
MOM'S EDC:
BABY'S
OTHER
BABY'S NAME
SEX:
BDOB:
BABY'S WT.
BABY'S LENGTH:
CHILDREN AND AGES:
ENTITLEMENT PROGRAMS: WIC
PA
MA
SSI
AFDC
HEALTH AND HUMAN SERVICE AGENCIES INVOLVED
PRENATAL CARE PROVIDER:
PEDIATRIC
CARE PROVIDER:
WORKER:
AGENCY:
PHONE
BABY'S NEEDS:
SIZE
ADDITIONAL INFORMATION:
INTAKE DONE B Y :
APPOINTMENT DATE:
TO BE PICKED UP B Y :
DATE PUT ON CRIB LIST:
DATE PUT ON COMPUTER:
REFERRALS MADE:
ADDITIONAL
DATE:
TIME:
TIME:
MADE B Y :
BY:_
" BY:
COMMENTS:
INITIALED BY:
DATE
�11
"Just for Babies
327 West Fayette Street
Syracuse, New York 13202
474-1656
REFERRAL TO JUST FOR BABIES. INC.
DATE :
/
/
CLIENT'S NAME:
DOB:
/
/
SS#
PHONE:
OTHER CONTACT:
ADDRESS:
# OF CHILDREN:
AGES/SEX:
FAMILY CIRCUMSTANCES:
ITEMS REQUESTED
BOY
GIRL
BABY ' S DOB
SIZE OF CLOTHING
SEX UNKNOWN
WT,
M M S EDC (due date).
O'
/ /.
1.
2.
3.
4.
5.
6.
REFERRING AGENCY INFORMATION
DATE REFERRAL CALLED I N : /
/
GIVEN TO:
JUST FOR BABIES, INC,
AGENCY MAKING REFERRAL:
PHONE:
ADDITIONAL COMMENTS:
WORKER & TITLE:
�received from "Just f o r Babies",
I,.
the following items.
I have asked for these items and accept
f u l l responsibility for their application and dispensing.
I will
not hold "Just for Babies" liable for anything relating to its
use or provision. I further understand that these items are
provided to me by "Just for Babies" on a loaned basis only, and
when I am no longer in need of these items, I will return them to
"Just for Babies. "
ITEMS:
I have further received from, "Just for Babies", referrals to
AGENCY:
NAME:
•
and will follow-up on my own behalf.
While we understand that there will be normal wear on these items
from the
child's use, we ask that you keep these items clean and
in good condition so that others may benefit from their use in
future.
i :
i
Date:
Referred by:
Assisted by:_
Client:
Date:
"Just for Babies"
�Cifg of IRandcuilk
CITY COUNCIL
PAUL R; SPITZFADEN
MAYOR
DENIS P. BECHAC
•THE HEART OF THE OZONE BELTLINDA BARNETT
MAYOR PRO TEU
SECRETAHY/TAX COUECTOR
JACK B. McGUIRE
AT-LAROE
EDWARD J. PRICE III
DISTRICT I
ADELAIDE BOETTNER
DISTRICT II
JAMES J. GLEASON III
DISTRICT III
March 16,1993
Mrs. H i l l a r y Rodham C l i n t o n
The White House
Washington, D. C. 20006
Dear Mrs. C l i n t o n :
I am enclosing an a r t i c l e which i n d i c a t e s t h a t a New Orleans
h o s p i t a l t h a t l i m i t e d i t s services t o low-income chemical dependency
p a t i e n t s was able t o manipulate the Medicaid "disproportionate"
payments t o reap a 36% p r o f i t margin f o r i t s stockholders i n the
f o r - p r o f i t e n t e r p r i s e . This type o f s i t u a t i o n may be one o f the t h i n g s
t h a t should be addressed by the h e a l t h care task f o r c e .
I wish you and the President w e l l i n your endeavors. I have been
a supporter o f the President since I f i r s t had the pleasure o f meeting
him i n Baton Rouge, i n A p r i l o f 1991 when we inaugurated the Louisiana
Chapter o f the DLC. I knew then who my candidate f o r President was,
and I continued t o express my support through p a r t i c i p a t i o n i n fundr a i s e r s a t Lindy Boggs home i n New Orleans and a t the DLC Annual
Conference and f o r the two campaign v i s i t s t o New Orleans, as w e l l as
through service on our r e g i o n a l and l o c a l campaign committees.
1
I t ' s great to be able t o be proud t o be a Democrat again!
With warmest good wishes.
Sincerely,
Jack B. McGuire
Councilman-at-Large
JBMcGihs
3101 EAST CAUSEWAY APPROACH
MANDEVILLE, LOUISIANA 70448
PHONE (504) 626-3144
FAX (504) 626-7929
�NEW ORLEANS CITYBUSINESS
MARCH 15-21, 1993
Caring for the poor proves lucrative for local hospital
BY STEPHANIE RIEGEL
New Orleans General Hospital isn't your typical profit center. Perched on the edge of the St.
Thomas public housing complex, the small facility offers only a handful of medical services to
a largely poor clientele.
But New Orleans General is about as profitable as hospitals get. Last year, the hospital
made $17.2 million on $49.6 million in revenues
that come primarily from Medicaid. Local hospital administrators say the resulting 36 percent
profit margin is unheard of in their business.
"It's far and above what you would expect
hospitals to make," says one local hospital
CEO, whose for-profit facility enjcys a profit
margin of 7 percent in a good year.
Behind the financial success of New Orleans
General is a Medicaid program called
disproportionate share, which pays additional
Medicaid money to hospitals that treat a
disproportionately high number of Medicaid patients. Because almost 100 percent of New Orleans General's patients are Medicaid, the hos- New Orleans General Hospital had a 36 percent profit margin last year, thanks to the
pital has been able to reap millions in dispropor- Medicaid disproportionate share program.
tionate, or "dispro," money.
The situation may seem ironic in light of the push for national
Those measures enabled the hospital to
health care reform. The Clinton administration is planning an
keep a lid on costs, says Donald West, adoverhaul of the nation's health care system because costs are spiral- ministrator of New Orleans General. By no
ing out of control. But national and state heahh care officials say they longer having a surgery unit, the hospital
see nothing wrong with for-profit institutions like New Orleans
didn't have to spend money on high-tech
General making a mint off Medicaid.
medical equipment or malpractice insurance.
"Under the Medicaid rules, you can't pick and choose which hosAnd by offering primarily chemical
pitals can benefit from it," says Chris Pilley, secretary of the state
dependency rehab services — which are typDepartment of Health and Hospitals. "We couldn't set up one set of
ically low-budget services — the hospital
rules for the public non-profits and another set of rules for the prididn't have to staff highly skilled medical
vately owned hospitals.''
personnel or operate a costly intensive care
Things haven't always been so good for the 136-bed hospital.
unit.
Formerly Sarah Mayo Hospital, New Orleans General was purchasSimmons pumped between $4 million and
ed in 1986 by Gateway Medical Systems Inc., an Atlanta company
$5 million into the hospital in the form of new
which tried unsuccessfully in the mid-1980s to develop a chain of equipment, rercatrons and landscaping. As.
inner-city hospitals. Gateway mismanaged most of its facilities, faila result, occupancy climbed from 50 percent
ing to fund their maintenance and upkeep, and New Orleans General
in 1990 to more than 71 percent last year,
was no exception.
slightly better than the market average.
In 1987, a local physician videotaped conditions at the hospital:
While the changes helped New Orleans
stained mattresses, clogged toilets and examples of rodent infestaGeneral, what really made the hospital suction. The video was distributed to local television stations and
cessful was the disproportionate share proprompted the Department of Health and Hospitals to threaten to
gram. Though created by Congress in 1981
close down the facility. Though a cleanup followed, problems conas a way to encourage private hospitals to
tinued at the hospital throughout most of the 1980s.
treat poor people, it wasn't until the late
In February 1989, a Gateway executive,
1980s that most states began to develop forOpelousas businessman Nolan Simmons,
mulas that enabled them to take advantage of
formed his own company and purchased the
the program. Louisiana was particularly aglocal hospital from Gateway. The price of the
gressive, devising a formula in 1989 that
sale came to around $10 million, including
made it easy for hospitals, both public and
the assumption of about $4 million in debt,
private, to qualify for dispro money.
says Douglas Habig, an attorney for Medical
Here's how the program works. Under the
Heritage, the corporate entity that owns the
state's Medicaid regulations, any hospital
hospital. Simmons declined to be interviewwhich has a Medicaid or low-income patient
ed.
base of more than 25 percent qualifies for
Simmons had been a "troubleshooter" for
dispro money. At New Orleans General that
Gateway, advising the company on how to
figure is about 95 percent, which means 70
turn around its troubled holdings, explains
percent of the hospital's patients are used by
Habig. (The attorney says Simmons did not
the state »o calculate the hospital's so-called
have any control over Gateway's
dispro formula.
mismanagement of the local facility.) SimThe dispro formula is determined by
mons also had considerable experience in
multiplying that percentage — which in the
health care — he formerly worked for
case of New Orleans General is 70 — by
Humana Inc. — and he owns several
three, which means New Orleans General has
businesses, including the state's second-laa dispro factor of 210 percent. That percentrgest hog breeding facility in Port Barre, La.,
age is then multiplied by the amount it costs
and a country-western bar in Missouri.
the hospital to treat a Medicaid patient. If an
When Simmons bought New Orleans Genaverage Medicaid case costs $1,500 — which
eral, he made two key changes that helped
is typical at New Orleans General, according
improve the cost efficiency of the hospital.
to figures from DHH — the hospital would
He closed New Orleans General's surgery
receive $3,150 in disproportionate share
department, which was underutilized, and
funding. The hospital also would receive the
converted all but about 25 of the hospital's
basic $1,500 cost of treating the patient,
beds into a chemical dependency treatment
bringing its total Medicaid reimbursement on
unit. Some of the beds in that unit are run by
the case to $4,650.
the hospital, others are leased out to a sepaFor New Orleans General, the dispro sysrate chemical dependency treatment program
tem has worked well. Last year, the hospital
called Reality Treatment Center, which is
generated $19.7 million in total revenues beowned by Stale Rep. Sherman Copelin.
�fore dispro money, according to Health Care
Investment Analysts (HCIA), a Baltimore
firm that compiles hospital data. But $29.9
million in "other income," most of which
was disproportionate share money according
to Habig, enabled the hospital to realize a
profit of $17.2 million — despite operating
expenses of $32.4 million.
To some national health care experts, those
numbers appear high. When told of the
amount of "other income" reported by New
Orleans General, Chuck Bradford, a partner
in the Phoenix office of the public accounting
firm Arthur Andersen, was stunned. "That's
the most disproportionate share of
disproportionate share money I've ever heard
of," says Bradford, who specializes in health
care.
Nev/ Orleans Genera! officials are candid
about the way in which dispro money has
worked to their advantage. "Without
disproportionate share money we couldn't
stay open," says Juadon Norton, corporate
controller for Medical Heritage. "When we
came here in 1989, it was right after
disproportionate share started. If it hadn't
been for that, we wouldn't have been able to
do the things we've done.''
The growth in the hospital's profits has
been impressive. In 1988, under Gateway's
ownership, New Orleans General lost $3.3
million on revenues of $3.6 million. By 1991,
the hospital reported $4.2 million in profits
on revenues of $12.2 million, according to
HCIA.
While it may appear the hospital is taking
advantage of the system, state officials say
New Orleans General isn't doing anything
wrong. "It seems like a loophole," says
David Hood, an analyst in the state's Legislative Fiscal Office. "But it's perfectly legal."
Medicaid officials also defend the way the
hospital is doing business. "Congress intended that hcspitii's that serve a disproportionate share of Medicaid patients receive a
disproportionate share of money for doing
it," says Debbie Ciirrie, an accountant in the
Medicaid division of the regional office of the
Health Care Financing Authority in Dallas.
They also point out that New Orleans General isn't alone. Some 17 Louisiana hospitals
receive dispro money, including United
Medical Center, Children's Hospital, Tulane
University Medical Center and the Medical
Center of Louisiana locally. Louisiana hospitals receive so much dispro money that the
state ranks fifth in terms of the amount of
disproportionate share dollars it gets from
Medicaid.
"It's one of the highest in the country and
the second-highest in the region behind
Texas," Currie says. In 1992, Louisiana received some $1 billion in disproportionate
share dollars. Only New York, California,
Texas and New Jersey received more.
One of the main reasons Louisiana does so
we)! under the d'sproportionate share program is because the state has a charity hospital system, which is unique to Louisiana and
Hawaii. Most of the patients at the state's
charity hospitals are either Medicaid patients
or indigent, which enables the state-owned
system — like New Orleans General — to
make a large profit from the program. State
officials, for instance, intend to use dispro
money to fund the recent $58.5 million purchase of the former Hotel Dieu hospital.
What makes New Orleans General different from the other hospitals in the area that
receive dispro money, however, are two factors: It's a for-profit institution and it provides medical services that, for the most part,
are inexpensive to provide. At non-profit
Children's Hospital, by comparison, where
more than 60 percent of the patients are
Medicaid, dispro dollars are needed to cover
the costs of high-tech medical procedures,
says hospital CEO Steve Worley.
United Medical Center is the only other
for-profit facility locally receiving dispro
money. But unlike New Orleans General,
United Medical Center provides costly services like emergency room treatment and
surgery. Also unlike New Orleans General,
United Medical Center does not have such an
unusually high percentage of Medicaid patients.
Some local hospital administrators question the propriety of New Orleans General
reaping such big profits. "There is nothing
illegal," says one local hospital CEO, "but
clearly the intent of disproportionate share
was not for it to line the pockets of stockholders."
The flood of disproportionate share dollars
may soon slow to a trickle, however. Last
year Congress put a cap on the amount of
dispro money states can receive. DHH officials have recently rewritten the formula
and DHH Secretary Pilley says that could
mean less money for hospitals like New Orleans General.
In the meantime, officials at the local hospital are taking steps to enlarge their patient
base to include more than Medicaid cases.
Later this year, New Orleans General will
reopen its surgery unit. The hospital also recently opened a primary care clinic in the
former emergency room, the Good Neighbor
Clinic Internationale, and is trying to market
the ciinic io a broader paiier.i base,
specifically the Hispanic community.
"We're expanding the business to more of
a commercial market," says Habig.
Hospital officials are realistic, however, in
their goal. New Orleans General has no intention of trying to compete with the city's
large specialty hospitals. "Our market isn't
competing with Ochsner or even Touro,"
says Habig. "But there are niches that are
available to this hospital." Those niches are
primarily among the city's black and
Hispanic communities, he says.
Hospital officials are concerned about the
effect changes in the disproportionate share
program and in health care in general will
have on the hospital. But Habig says the hospital will change with the times. "Obviously
reimbursement will change and who knows
what kind of health care system we'll end up
with," he says. "But we'll be keeping a close
eye on it and will try to tie into the markets
that are there the best we can.''
•
�^
HEALTH CARE TASK FORCE SORTING SHEET
CODER: (>^3
INPUT DATE:
GENERAL SORT:
POSTCARD 1:
General mail
.Personal stories
Letter Campaign
Other Health Providers
POSTCARD 2:
Offers to help/Employment
FORM LETTER:
Letterhead
_Policy
REROUTE:
Casework
.Scheduling
.Physicians
President
POUCY AND PERSONA!J STORTES:
.ORGANIZATION (I)
insurance premiums
insurance reform
insurance pools
boards and oversight
.COVERAGE (II)
working families
unemployed/low income
benefits
providers
.INFRASTRUCTURE/WORKFORCE (III)
quality assurance (guidelines)
administration, reimbursement
& information systems
malpractice & tort reform
manpower issues (training)
unnecessary procedures
GOVERNMENT PROGRAMS (IV)
medicare
medicaid
veterans
DoD
Indian health
.COST ISSUES (VI)
drug prices
physician fees
hospital fees
.medical equipment
fraud & abuse
FINANCING (VII)
MENTAL HEALTH (IX)
LONG-TERM CARE (X)
PUBLIC HEALTH/
SPECIAL POPULATIONS (XH)
prevention
AIDS
.women's health
.immunizations/children
rural
urban
OTHER
�THE ASSEMBLY
S T A T E
O F
^
r
l
N E W Y O R K
Tw n r v
>
,
c
v
v
A L B A N Y
WILLIAM BIANCHI
Assemblyman 3rd District
CHAIRMAN
Task Force on
Food, Farm & Nutrition Policy
COMMITTEES
Aging
Commerce
Transporation
Veterans
March 24, 1993
Mrs. Hillary Rodham Clinton
The White House
Washington, DC 20500
Dear Mrs. Clinton:
Your work on behalf of children in this country has been an inspiration to us all. As
Chairman of the NYS Assembly Task Force on Food, Farm and Nutrition Policy, I share
your interest and my legislative focus for this year is school meal programs. I have
introduced legislation to expand school breakfast programs to all the "severe need" schools
in our state.
My research into the value of school breakfast programs for the educational process,
especially for low-income children, convinced me of the need to require more of our schools
to offer it. It is cost effective for schools to participate because of the generous federal
reimbursements. New York is one of the few states to supplement the federal funding with
reimbursements of our own.
In order to win approval of my proposalfromthe Legislature and the Governor we
need all the support we can get. Many hunger, education and even some agricultural
advocacy groups are supporting this issue but we can always use more backing. I expect that
you would appreciate a proposal to aid children's nutrition and education and if you could
provide support it would be of great value to our effort. If you need more information or
would, like to discuss the issue please let me know.
Good luck with your work and thank you in advance for any help you can provide.
Sincerely,
I. William Bianchi
Member of Assembly
WB:RS/p
Room 734, Legislative Oflice Building, Albany, New York 12248, (518) 455-4901
228 Waverly Avenue, Patchogue. New York 11772. (516) 447-5393
�^ 7
WAYNE W. WOOD
State Representative
Home:
2429 Rockpon Road
Janesville, WI 53545
(608) 752-5485
44th Assembly District
COMMITTEE ASSIGNMENTS
Assembly Chair, Criminal Justice &
Public Safety
Assembly Vice-Chair, Ways & Means
Member, State Affairs, Securities &
Corporate Policy
iacmtsm legislature
March 24,
1993
Office:
112 A West, State Capitol
P.O. Box 8953
Madison, WI 53708
(608) 266-7503
Ms. H i l l a r y Rodham C l i n t o n
The White House
1600 Pennsylvania Avenue NW
Washington, D.C. 20006
Dear Ms. C l i n t o n :
I am very pleased t h a t you are working on the development of a n a t i o n a l
h e a l t h proposal f o r the President. This i s an issue t h a t has been of r e a l
concern t o me during my seventeen years i n the Wisconsin L e g i s l a t u r e .
I n connection w i t h your r e s p o n s i b i l i t i e s , I thought you might be i n t e r e s t e d
i n a plan t h a t I developed here i n Wisconsin several years ago. I t was based on
i n f o r m a t i o n that i s enclosed along w i t h t h i s note. Please note t h a t t h i s i s a
rough o u t l i n e only -- the e s s e n t i a l component of the plan would be t h a t one
insurance pool would serve a l l e l i g i b l e p a r t i c i p a n t s .
I t was stated a t the time t h a t t h i s plan would have cost $89 m i l l i o n . The
same year the plan was presented, Wisconsin h o s p i t a l s wrote o f f $95 m i l l i o n i n
f r e e care or bad debt. Therefore, I f e e l t h a t t h i s plan could have e a s i l y been
funded by r e - d i r e c t i n g h e a l t h care costs.
I hope t h a t t h i s i n f o r m a t i o n i s of some help t o you as you seek t o develop
a n a t i o n a l plan. At any r a t e , I wish you good luck i n t h i s endeavor. I f i r m l y
believe t h a t both you and the President are correct i n i n s i s t i n g that access t o
q u a l i t y , a f f o r d a b l e h e a l t h care f o r a l l c i t i z e n s should be a primary goal of our
f e d e r a l government.
Sincerely,
WO
OD
Representative
44th Assembly D i s t r i c t
WW:db
Enclosure
Legislative Hotline: toll-free message service 1-800-362-9696
�A
P. s.
SamDle Health Insurance Rates
for Male, Female, & 2 Children
i n 3 rate areas i n Wisconsin
at various ages
Company:
Time Insurance Company of Milwaukee, WI
Plan:
24 Karat Form 556 (see brochure f o r p r o v i s i o n s )
(rates rounded per month and do r e f l e c t 15% "non-smoker" discount))
(Most Areas i n Wisconsin)
Age
Male
Female
25
$51
$64
35
54
45
75
Children
(SE Wisconsin Area)
( C i t y of Milwaukee)
2
Children
Male
Female
$ 72
$67
$ 68
$ 85
$79
61
84
67
72
99
79
85
102
67
100
120
79
Male
Female
$59
$58
74
59
90
59
prepared September 25, 1989
Children
�JiARAt
If you're looking for quality health insurance for you and
your family, then consider the 24 Karat Major Medical
Plan from Time Insurance.
• Time has been a stable provider of health insurance
for more than 90 years.
• Time is one of a handful of companies who have
earned an A + Superior rating from the A.M. Best
Company (insurance industry analysts) for ten consecutive years.
• During 1987, Time paid 90% of all individual medical
claims within one week of receipt or less.
The 24 Karat Major Medical plan offers the best value
for your premium dollar. While many policies may look
affordable upfront, the long-term picture shows that your
total cost includes premiums plus unpaid expenses. Time's
24 Karat Plan provides quality coverage upfront and later
on when it really counts.
• Freedom to select the doctor and hospital of your
choice.
• 52,000,000 lifetime benefit
• Semi-private room benefit regardless of where you are
hospitalized
• Intensive care with no limit on the number of days
• Outpatient treatment
• X-rays and lab costs
• Organ transplants for donors as well as recipients
• Optional Prescription Drug Card, Accidental Medical
Expense, and Maternity Coverage.
CHOICE OF DEDUCTIBLE
HERE'S HOW IT WORKS
OTHER FEATURES
OF THE 24 KARAT PLAN
This rate of payment applies to each person every calendar year (January 1 through December 31).
Each calendar year, each insured person
must satisfy the deductible selected.
After the deductible, Time pays 80% of the
first $5,000 of all covered charges.
Time pays 100% of the remaining covered
charges incurred during the calendar year.
4
Each covered person has a lifetime maximum benefit of $2,000,000.
Choose betweenfivecalendar year deductible amounts —
$100, $250, $500, $1,000 and $2,500. Once selected, each
insured person must satisfy that deductible only once during the calendar year, and not for each accident or illness.
Carryover Deductible: Charges you incur during the last
three months of the year which satisfy the deductible for
the current year, will also satisfy the deductible for the
upcoming calendar year.
Maximum Family Deductible: Three individual deductibles will satisfy the deductible requirement for all
covered persons in a family during the calendar year.
Family Capping Maximum: The maximum out-of-pocket
expense for your family for covered charges will not exceed the amount listed for each calendar year (amount
varies by the deductible you choose). Once the family cap
is reached, additional covered charges for you and your
family are paid at 100% for the remainder of the calendar year.
Family Capping
Maximum
Deductible
•
52,500
S 10
0
. 2,500 •..
250.
•••3,000 . 500 "
•
4,000 :••
1,000
8,000 •-•
• 2,500 • - :
Conversion Privilege: A spouse or dependent whose
coverage expires is eligible for a similar plan without
evidence of insurability.
Non-Smoker's Discount: A 15% discount applies to all
adult insureds who have not smoked cigarettes or used
tobacco in any form in the past 12 months.
Hospital Self Audit: It pays to take a close look at your
hospital bills. If you find an error of $25 or more, Time
will give you 50% of our savings, up to $500 per hospital
stay.
�r
i
MAJOR MEDICAL PLAN 556
OUTLINE OF COVERAGE
r
This outline of coverage provides a very brief description of the imponant features of your policy. Due to different state regulations, requirements and mandated
benefits, certain policy provisions may vary from this
general description. This is not the insurance contract and
only the actual policy provisions will apply. The policy
itself sets forth in detail the rights and obligations of both
you and Time Insurance Company.
Maximum Benefit: S2 million lifetime benefit for each
covered person.
Deducdble Amount Per Calendar Year: S100, S250, S500,
51,000 or 52,500. A basic deductible applies to each
covered person during each calendar year. A maximum
of 3 times the deductible will be required for each family
in each calendar year. There is a family capping maximum
which limits the out of pocket expenses incurred in a
calendar year. If there is any other health insurance plan
which provides benefits (in excess of the basic deductible) for covered expenses, the amount of benefits paid
under the other plan will be deducted from total covered
expenses in lieu of the basic deductible.
Rate of Payment: The rate of payment for each covered
person each calendar year after the deductible is 80% of
the first 55,000 of all covered expenses and then 100%
thereafter. If benefits paid by another health plan are used
as the deductible, benefits will be paid at 100%, but not
to exceed the benefit payable in the absence of other
coverage. Cenain types of Covered Expenses are not subject to the Deductible or the 80% Rate of Payment.
Covered Expenses: Charges must be usual, customary and
necessary.
The following are Covered Expenses:
a) Hospital room and board charges up to the semiprivate room rate.
b) Charges for cardiac care or other intensive care
services.
c) Other hospital services including any service performed in a hospital's outpatient department or in a
freestanding surgical facility.
d) Physician services, including second surgical opinions;
anesthesia service.
e) X-ray, radioactive treatment and lab charges.
0 Ambulance for one trip to the hospital per injury or
sickness.
g) Drugs which require a written prescription of a physician. (If optional rider is attached, drugs covered
under the rider are not covered under the policy).
h) Permanent anificial members or eyes, oxygen, casts
and onhopedic braces.
i) Rental of a wheelchair or hospital-type bed (up to the
amount of purchase price).
j) Charges by a nurse when medically necessary and required by the attending physician. The nurse cannot
be a member of your family.
k) Nursing home or extended care facility charges
following a hospital confinement. Covered expense
for daily charges will not exceed 50% of the semiprivate room charge at the hospital where last confined. This benefit is limited to 30 days. You must
be admitted within 14 days of discharge from the
hospital.
1) Mental illness, alcoholism, drug addiction, or
chemical dependency. Expense must be incurred while
confined in a hospital. This benefit is subject to a
maximum of S2,500 per calendar year for a covered
person.
m) Expense due to a congenital problem of a child of the
insured born while the policy is in force. Benefits are
the same as for any other sickness or injury'.
n) Expense incurred by you, your spouse or dependent
child due to complications of pregnancy. Complications include nephrosis, cardiac decompensation,
missed abonion, non-elective caesarean section, and
ectopic pregnancy which is ended.
o) Home health service performed by a licensed home
health agency which a physician has prescribed in lieu
of hospital confinement, provided the hospital service would have been covered.
p) Sterilization charges. The covered person must be insured for at least two years before the expense is incurred. (Not covered in IA and T X ) .
q) Hospice care.
r) Human organ/tissue transplant or replacement:
Covered expense incurred for the following
transplants will be paid on the same basis as any other
sickness: a) artery or vein; b) cornea; c) kidney; d)
joint replacements; e) heart valve replacements; f) implantable prosthetic bypass or replacement vessels; g)
bone marrow; h) heart and i) liver. Expenses incurred
�c
for surgery, storage and/or transportation sen-ice
related to donor organ acquisition are also covered,
up to a maximum benefit of 510,000 per covered
procedure.
The Policy does not cover:
a) Intentionally self-inflicted injury; suicide or attempt
thereat.
b) Mental illness except as provided in the Mental Illness
provision.
c) Use of any government hospital or medical care unless
legally required to pay or any expense which is covered
by a health insurance plan under federal, state or other
government law, except Medicaid.
d) Injury or sickness covered by Worker's Compensation or Occupational Disease Laws.
e) War or act of war; injury or sickness while in the
military' service.
0 Cosmetic surgery', except reconstructive surgery required by trauma, infection or disease, or congenital
disease or anomaly of a covered dependent child, born
while this policy is in force, resulting in a functional
defect.
g) Eye exams, glasses, contact lenses, eye surgery for correction of refraction error, or hearing aids.
h) Dental x-rays and treatment except for injury to
whole, natural teeth. Expense must be incurred within
6 months of the injury.
i) Treatment or removal of tonsils or adenoids during
the first six months of coverage, except for
emergencies.
j) Normal pregnancy or childbirth, unless Maternity
Rider is added.
k) Treatment of temporomandibular joint disorders.
(TMJ)
1) Treatment for infertility, artificial insemination or
reversal of sterilization.
m) Pre-Existing Conditions: Pre-Existing Conditions are
sicknesses or injuries that: a) were diagnosed by a
physician within two years prior to the policy date,
or b) were such that a prudent person would have
sought treatment within two years before the policy
date. Pre-existing conditions will be covered two years
after the policy date unless specifically excluded at the
time of issue. Conditions fully disclosed on the application and not excluded by Time Insurance are not
considered pre-existing.
n) There is a 15-day waiting period after the policy date
for sickness. Sickness commencing during the 15-day
period will be considered the same as a pre-existing
condition.
o) In a few states, a limitation for the treatment of Acquired Immune Deficiency Syndrome (AIDS), or Aids
Related Complex (ARC) may apply. See your state
specific outline.
Renewability Provisions: Time will not renew this policy
after you reach age 65 or become eligible for Medicare.
Otherwise, Time can refuse to renew this policy only: 1)
if all policies issued on this form are non-renewed in your
state of residence; 2) in the event of fraud in applying
for this policy or in filing a claim for policy benefits; or
3) if there is other health insurance in force which would
result in over-insurance.
Dependent Coverage: Dependents can be included
on an application through age 20. They can remain on
a policy until they reach age 21, or 25 if a full-time
student.
ABOUT
TIME INSURANCE COMPANY . . .
Time Insurance consistently receives an A + Superior
rating from A . M . Best Company, insurance industry
analysts. Established in 1892, Time currently ranks 12th
in individual health premium out of 1,100 companies and
has more than S800 million dollars in assets. Time is a
wholly owned subsidiary of AMEV Holdings, Inc., New
York City.
�THE ASSEMBLY
S T A T E O F NEW
YORK
ALBANY
PAUL HARENBERG
Assemblyman 5th District
Room 724
Legislative Office Building
Albany, New York 12248
(518) 455-5937
CHAIRMAN
Committee for the Aging
W ^ , _ „ K
M a r C H
OA
2 4 ,
-I a n i
1 9 9 S
COMMITTEES
Mental Health
Veterans Affairs
Ways & Means
85 Middle Road
Say ville, New York 11782
(516) 589-8685
State Office Building
Veterans Memorial Highway
Hauppauge, New York 11788
(516) 366-1404
Ms. H i l l a r y Rodham Clinton
The White House
Washington, DC 20500
Dear Ms. Rodham Clinton:
As Chair of the New York State Assembly Committee on Aging, I
accept your invitation to share my thoughts on health care reform
with you.
The following areas must be included i n any plan i n order to
meet the goals of universal access and cost containment. Many of
the following points are key features of the NEW YORK HEALTH
l e g i s l a t i o n that was approved l a s t year by the New York State
Assembly.
*Universal Coverage, regardless of age, income, health or work
status to include the entire population i n a s i n g l e system
creating market power to negotiate r e a l price controls with
providers. Employer based coverage would leave m i l l i o n s
without coverage and would reduce market bargaining power.
^Comprehensive coverage. including a l l medical and health
s e r v i c e s from pre-natal care to long-term care. Long term
care coverage at home and i n a nursing home must be included
for a t r u l y comprehensive program meeting the needs of our
society.
*Emphasis on primary and preventive care to prevent i l l n e s s e s
before they a r i s e and to s t a r t treatment at the e a r l i e s t
possible stages. Your recent proposal ensuring the
immunization of a l l children i s an excellent step i n t h i s
direction.
*A single paver system eliminating the role of private
insurers i s needed to remove the tremendous administrative
waste of insurance companies that prevails under the current
multi-payor system.
�*Cost containment measures that cap the amounts providers
can charge for services. To achieve cost control, before
prices skyrocket, caps can prevent the need for "rationing"
health care. Cost containment should also include control
over prescription drug costs that continue to r i s e at
incredibly sharp rates.
*No co-insurance, deductibles or co-payments that would
discourage people from promptly seeking care when they need
it.
*Freedom of choice for consumers in the selection of providers
to ensure patients' autonomy over t h e i r own care.
•Progressive financing by payroll and corporate income taxes
that would save money for government and private employers on
t h e i r health costs by replacing the high private insurance
premiums now being used to fund incomplete, i n e f f i c i e n t and
costly insurance plans.
The proposed managed competition approach i s getting much
attention i n Washington. Managed competition would not eliminate
the administrative waste of insurance companies' bureaucracies. I t
would l i m i t the consumers' choice of providers. Managed competition
relying on competing networks of providers simply w i l l not work in
areas of the country where there i s a s c a r c i t y of providers.
The health care c r i s i s facing our nation requires the
innovative approach that a single payer system provides and not an
extension of managed care which has not met the needs for
individual choice and affordable, quality health care.
Thank you for giving me the opportunity to share my ideas.
I believe they represent the views of the majority of older New
Yorkers.
Sin94re Ly,
(
/
Paul Harenberg
Chairman
Assembly Committee onf Health
�TOWN OF
LONGBOAT KEY
Incorporated November 14,1955
501 Bay Isles Road
Longboat Key, Florida 34228
(813) 383-3721
FAX 383-7231
January 26, 1993
Mrs. H i l l a r y Rodham C l i n t o n
The White House
1600 Pennsylvania Avenue
Health Care O f f i c e - West Wing
Washington, DC
20500
Dear Mrs. C l i n t o n :
I am tremendously encouraged by your appointment t o head
the a d m i n i s t r a t i o n ' s e f f o r t t o develop a n a t i o n a l health
care program. I f anyone can achieve progress on t h i s
c r i t i c a l issue, i t i s you.
I have some ideas I t h i n k would be o f value t o you, but I
know the chances o f your ever reading t h i s are a thousand
t o one. Therefore, I am going t o make three quick
suggestions t o t r y and a t t r a c t your a t t e n t i o n :
1) Select one s t a t e t o be a p i l o t p r o j e c t f o r
whatever you plan t o do. (And make t h a t s t a t e
F l o r i d a since, because o f Medicare, we already
have major, major i n f r a s t r u c t u r e i n place.)
2) Use r e l i e f from the t e r r i b l y excessive costs of
malpractice insurance t o b r i n g doctors, h o s p i t a l s
and other h e a l t h care providers i n t o l i n e .
3) While using t h a t s i n g l e s t a t e p i l o t program f o r
the o v e r a l l p r o j e c t , a t t a c k t h e costs o f drugs on
a n a t i o n a l basis. This i s do-able — do-able
almost i n s t a n t l y — and would give immediate
reasonable f u l f i l l m e n t t o President C l i n t o n ' s
campaign promise.
As you probably have guessed, I have d e t a i l e d ideas
worked out on these and other f a c e t s o f t h e e n t i r e
program — ideas t h a t are p r a c t i c a l and can be made t o
work i n a reasonable timeframe. I f you would l i k e t o
see them, j u s t l e t me know. But I have no d e s i r e t o
simply p i l e up waste paper f o r some t h i r d a s s i s t a n t t o
your f o u r t h undersecretary t o acknowledge and throw
away.
�Mrs. H i l l a r y Rodham Clinton
January 26, 1993
Page: 2
Please, incidentally, DO NOT bother to send a form
l e t t e r "Thank You" to f E i s l e t t e r , unless you are r e a l l y
interested i n having someone of significance look at my
ideas.
I s h a l l send copies of t h i s l e t t e r as noted below. I f
you wish a reference as to whether I am a r e l i a b l e
c i t i z e n or crackpot, check them.
Sincerely,
Fames P. (Jim) Brown
Mayor, Town of Longboat Key
CC: Congressman Porter Goss
Senator Bob Graham
Senator Connie Mack
pa
�THE ASSEMBLY
S T A T E O F NEW
YORK
CHAIR
Subcommittee on High Speed Rail
and Magnetic Levitation
ALBANY
SAM HOYT
Assemblymember 144th District
COMMITTEES
Transportation
Energy
Children and Families
Tourism, Arts & Sports Development
Alcoholism & Drug Abuse
Room 656
Legislative Office Building
Albany. New York 12248
(518) 455-4886
FAX (518) 455-4890
General Donovan State Office Building
125 Main Street
Buffalo. New York 14203
(716)852-2795
FAX (716) 852-2799
MEMBER
March 24,
1993
Task Force on Women's Issues
Office of
State-Federal Relations
HONORARY MEMBER
Puerto Rican/Hispanic Task Force
Mrs. H i l l a r y Rodham-Clinton
The White House
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mrs. Rodham-Clinton:
I would l i k e to congratulate you and your husband on your
outstanding v i c t o r y l a s t November.
I am writing to inform you of a position that was taken l a s t
June i n New York State concerning health care reform. The New York
State Assembly
ui passed a b i l l c a l l NYHEALTH by a vote of 91-53.
This
l e g i s l a t i o n c a l l e d for the implementation of a single-payer health
care system.
One of the most c r i t i c a l reasons for backing a health reform
plan of single-payer health care was based on the f i n a n c i a l
benefits. We were able to fund a comprehensive, universal health
care plan f o r New York State at a net savings of health care
d o l l a r s . Our financing plan c a l l e d for replacing private premiums
with a 2% personal payroll tax and 8% employer payroll tax. As
most employers are expected to spend an average of 12% to 13% of
t h e i r p a y r o l l on health care i n 1994, t h i s would have been a 33%
savings for employers. Local governments would have saved more
than $1 b i l l i o n since they too spend well over 8% of t h e i r
government p a y r o l l on health care benefits. In E r i e County, which
includes part of my d i s t r i c t , i t was found our county would save
$3.6 m i l l i o n of payroll costs and that a small manufacturer i n
Orleans County, also i n Western New York, would save $1100 per
employee. The l e g i s l a t i o n also c a l l e d for health care i n f l a t i o n to
be held to no more than 20% of general i n f l a t i o n , guaranteeing that
the payroll premium would not have to increase to keep up with
health spending.
These savings were able to be achieved by eliminating $5
b i l l i o n of administrative waste i n our health care system.
We
currently have 4 00 different insurance companies i n New York State.
Printed on recycled paper.
�Mrs. Rodham-Clinton
-2-
March 24, 1993
and the d u p l i c i t y and i n e f f i c i e n c y i s wasting our health care
d o l l a r s . Elimination of t h i s waste would have allowed us to
implement a plan of comprehensive coverage to our c i t i z e n s ,
including eye care, dental care and prescription drugs, at savings
to individuals and businesses. Certainly a p o l i t i c a l l y viable plan
to s e l l to most constituents.
We did have the problem of addressing the issue of people in
the health insurance industry losing jobs. Therefore, we included
provisions i n the b i l l for a job retraining program to help those
individuals. I t i s important to note too that we estimated that a
large number of these positions would simply be transferred to
administration of the "single-payer administration" whether i t be
a government agency or a non-profit, such as Blue Cross/Blue
Shield.
A single-payer plan on the state l e v e l eliminated enough
i n e f f i c i e n c y in our system to allow the funding of a comprehensive
plan a t no additional cost.
The support of constituents was
overwhelming, which i s why the b i l l passed the New York State
Assembly at a vote of 91-53 within i t s f i r s t year of introduction.
A national single-payer plan has been shown to have even greater
savings.
I have enclosed the financing document of t h i s plan as well as
further information.
I c e r t a i n l y hope you take a close look a t
t h i s solution. In E r i e County, the Medicaid portion of our budget
i s r i s i n g a t an alarming rate, causing many budgetary b a t t l e s and
cuts that would be unnecessary with the adoption of a single-payer
plan. We must have r e l i e f of t h i s f i s c a l problem.
I urge you to carefully consider t h i s plan. We must have a
solution that w i l l provide r e l i e f to our l o c a l governments,
businesses and a quality system for the American people.
I f you have any questions, I can be contacted at the New York
State Assembly, Legislative Office Building, Room 656, Albany, NY
12248, (518) 455-4886.
Thank you for your consideration.
Si
fSM
'A
MEMBER OF ASSEMBLY
SH:mp
cc:
Hon. Daniel Patrick Moynihan
Enclosure
�Health Care For All — The Only Kind We Can Afford
America has the finest health care in the world. But millions are effectively cut off from it, because they don't have
health coverage. And businesses that provide coverage for
their employees are being crippled by the cost.
We need what almost every other country in the world has
— a universal health plan. Opinion polls show that most
Americans agree. And until Congress acts, the states should.
That's why I have introduced the "N.Y. Health" bill, with
over 60 co-sponsors from all parts of the State.
The U.S. spends a higher percentage of its gross national
product on health care than almost any country. But some of
our health statistics would embarrass many underdeveloped
countries — from infant mortality to life expectancy.
Over 30 million Americans — over 2 million New Yorkers
— have no health coverage. They don't have it at work, can't
afford it on their own, and aren't poor enough for Medicaid or
old enough for Medicare. Millions more have inadequate
coverage.
As head of the Assembly's Health Committee, almost
every problem I deal with is made worse by the large and
growing number of uninsured New Yorkers.
Employers that provide coverage may spend about 15% of
payroll to do it. They often see premiums go up over 20% a
year. Small businesses have the hardest time finding affordable policies. More and more, employers are cutting back or
dropping coverage or shifting more of the cost to their workers.
Insurance companies seek out "low risk" customers. Those
who get labeled "high risk" are hit with exorbitant premiums
or rejected entirely. Even Blue Cross is trying to get approval
to set rates like that.
Those who have coverage have problems, too. Deductibles, co-payments, insurers arbitrarilyrefusingto pay part of
the bill or rejecting the claim.
It seems that everyone — with coverage or not — has a
health insurance horror story. (As a state employee, I have a
good health plan, but my wife and I still have problems with
our health insurance!)
Hospitals and doctors waste dme and money doing paperwork for hundreds of different health plans. Insurance companies spend enormous amounts on marketing, deciding risk
levels of customers, monitoring deductibles and co-payments, and deciding whether to reject claims. The unnecessary spending caused by the current system is over $5 billion
a year in New York.
No health insurer has the power to effecdvely control
health care costs, so they keep skyrocketing.
The "N.Y. Health" bill, A. 8912, is supported by a broad
coalition of community and health advocacy groups, labor
unions, and groups representing women, senior citizens,
people with AIDS and other health conditions, etc. It is similar to the bill in Congress, H.R. 1300, sponsored by Rep.
Marty Russo.
'W.K Health" - How It Would Work
Under N.Y. Health, every New Yorker would be covered automatically, regardless of where you work,
whether you work, your health condition, age, etc.
The coverage is comprehensive — inpatient hospital
care, primary and preventive care, specialists, prescription
drugs, dental and eye care, labs, mental health, etc. N.Y.
Health pays the bill — no deductibles, co-payments, or
extra charges from providers.
You would choose your own doctors, hospitals and
other practitioners and providers. They get paid by N.Y.
Health, not by the patient. Hospitals would be paid on an
annual budget, negotiated with N.Y. Health. Instead of the
wasted work and cost of billing and collecting, they would
get steady funding from the plan. Docton and other providers would be paid fees set by the plan. Practitioners
could choose to work for a hospital, neighborhood clinic
or H.M.O., which could be paid a set rate.
Employers who now provide coverage would no longer
have to pay as much as 15% of payroll for premiums. N.Y.
Health would be financed mainly by a 7.5% premium paid
by all employers, plus 1.5% paid by employees (which the
employer could pick up as a job benefit). Self-employed
would pay 9% of their earnings (up to the PICA income
level). The funding of existing government health programs (including Medicaid and Medicare) would be
merged into the N.Y. Health Trust Fund.
Senior citizens would continue to pay "Pan B" premiums to N.Y. Health, but would no longer face co-payments, extra charges, or Medigap premiums.
The planregrettablydoes not cover long-term care, although it directs N.Y. Health's board to develop a proposal. Existing Medicare and Medicaid long-term care provisions would continue.
N.Y. Health would be run by a broad-based board. Its
revenue and spending would be separate from the State
budget process.
Many are skeptical about whether government can do
the job. But under N.Y. Health, government won't be practicing medicine it will be processing payments. And the
present system is a nightmare.
The numbers work because we'll save about $5 billion
in administrative and paperwork spending by hospitals,
practitioners and insurers. Also, the N.Y. Health plan will,
for the first time, have comprehensive power to contain
health care costs. Premiums will be lower because all employers pay a fair share. And finally, universal access to
primary and preventive care will keep New Yorkers healthier and keep costs down.
It's not magic. N.Y. Health is just common sense.
Assembly Member
Dick Gottfried
Community Office
242 West 27th Street
New York, NY 10001
Tel.: 807-7900
�N W YORK STATE ASSEMBLY
E
MEMORANDUM IN SUPPORT OF LEGISLATION
B i l l No. Assembly 8912
Senate
x M m on Original B i l l
eo
M m on Amended B i l l
eo
Introduced by: Member of Assembly Gottfried, et a l Senate
T i t l e ; AN ACT t o amend t h e p u b l i c h e a l t h law, the s t a t e
f i n a n c e law, and t h e t a x law, i n r e l a t i o n t o t h e establishment o f
the New York Health Plan.
Purpose; To e s t a b l i s h a comprehensive system of u n i v e r s a l
access t o h e a l t h insurance by a l l r e s i d e n t s o f New York State,
access t o and choice o f h e a l t h care p r o v i d e r s , c o n t r o l s on h e a l t h
care c o s t s , development o f h e a l t h care services, and a mechanism
f o r f i n a n c i n g of t h e program.
Summary? Section 1 amends t h e Public Health Law by adding a
new A r t i c l e 51 e s t a b l i s h i n g the New York Health Plan. A r t i c l e 51
s e t s f o r t h t h e a d m i n i s t r a t i v e s t r u c t u r e of t h e New York Health
Plan, t h e powers and d u t i e s of t h e governing board, the scope o f
b e n e f i t s , payment mechanisms and cost c o n t r o l s .
Section 2 amends t h e State Finance Law by adding a new
s e c t i o n 97-mm e s t a b l i s h i n g t h e New York Health Trust Fund.
Monies i n the fund would be used t o finance the New York Health
Plan. Sources include: f e d e r a l , s t a t e and l o c a l expenditures f o r
the Medicare and Medicaid programs; premium payment revenues paid
by employers and employees; funds p r e v i o u s l y appropriated f o r
s e r v i c e s t h a t would now be covered by t h e New York Health Plan.
Section 3 amends t h e Tax Law by adding a new A r t i c l e 35
e s t a b l i s h i n g a mechanism t o c o l l e c t New York Health Plan premium
payments. A 7.5% employer and 1.5% employee p a y r o l l premium ( t h e
employer may pay t h e employee's s h a r e ) , and a 9% premium payment
on self-employment income would be l e v i e d . Premium payments
would a l s o be l e v i e d on unearned income i n instances where such
income exceeds 50% o f an i n d i v i d u a l ' s t o t a l income, a d d i t i o n a l
revenues include premium payments by o u t - o f - s t a t e employers.
Section 4 provides f o r an e f f e c t i v e date on the f i r s t day o f
January f o l l o w i n g enactment i n t o law, and also establishes t h e
f o l l o w i n g t i m e t a b l e f o r implementation:
o by February 28 t h e Governor s h a l l make t h e i n i t i a l appointments t o t h e New York Health Board o f Governors;
o by March 31, t h e Department o f Social Services i s d i r e c t e d
t o apply f o r necessary f e d e r a l waivers t o allow f o r t h e
p a r t i c i p a t i o n of Medicare and Medicaid i n t h e New York
Health Plan;
o by December 31 t h e Board o f Governors and t h e Department
of Social Services s h a l l develop a procedure f o r the deposit
�premiums, or going without
expenses, lack of coverage
discriminatory underwriting
to the erosion of coverage
care s e r v i c e s .
coverage. Rising out-of-pocket
for pre-existing conditions, and
practices are a l l factors that lead
and a lack of access to needed health
The New York Health Plan seeks to address the needs of that
portion of the population lacking health insurance coverage, as
well as the needs of the growing number of New Yorkers who are
frustrated with the coverage they have. Through establishment of
a uniform and u n i v e r s a l benefit plan coverage could be extended
to a l l New Yorkers while also reducing expenditures and controlling health care c o s t s .
The New York H e a l t h Plan achieves savings through t h e
c o n s o l i d a t i o n of h e a l t h care expenditures under a s i n g l e , p u b l i c a l l y financed, insurance program. Such a program e l i m i n a t e s more
than $5 b i l l i o n i n a d m i n i s t r a t i v e waste, i n c l u d i n g excess i n s u r ance company a d m i n i s t r a t i o n and costs of b i l l i n g and c o l l e c t i n g
f o r h o s p i t a l s , p h y s i c i a n s and other h e a l t h care p r o v i d e r s . I t
also provides s t a b i l i t y t o New York's h o s p i t a l s , f r e e i n g up
resources f o r p a t i e n t care.
The savings would be used t o finance increased h e a l t h care
coverage f o r the 2 m i l l i o n New Yorkers l a c k i n g coverage, and the
many m i l l i o n more w i t h inadequate coverage. Funds c o u l d thus be
t a r g e t e d f o r primary and p r e v e n t i v e s e r v i c e s , t r a i n i n g of h e a l t h
care workers, and t o enable physicians t o set up p r a c t i c e s i n
inner c i t y and r u r a l communities.
P r i o r L e g i s l a t i v e H i s t o r y : New b i l l .
A.5275 of 1970,
introduced by Assemblymember Al Blumenthal, was the l a s t u n i v e r s a l h e a l t h insurance proposal introduced i n New York S t a t e .
F i s c a l I m p l i c a t i o n s : No new costs t o s t a t e and l o c a l
government. Current governmental expenditures f o r t h e p r o v i s i o n
of h e a l t h care s e r v i c e s , such as Medicaid, would be u t i l i z e d t o
support coverage under the New York Health Plan, c o s t c o n t r o l and
q u a l i t y assurance mechanisms under the plan w i l l r e s t r a i n h e a l t h
care cost increases otherwise experienced by governmental payors.
I n a d d i t i o n , as an employer, s t a t e and l o c a l government - l i k e
a l l employers p r o v i d i n g h e a l t h b e n e f i t s - w i l l r e a l i z e a reduct i o n i n t h e i r expenditures f o r employer-provided h e a l t h insurance
coverage by paying t h e lower New York Health Plan premium payment .
E f f e c t i v e Date: The f i r s t day of January f o l l o w i n g enactment.
�THEASSEMBLY
-
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STATE OF NEW YORK
I
ALBANY
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SAM HOYT
Assemblymember 144th District
HAh?4'Si
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Room 656
Legislative Oflice Bldg.
Albany, New York 12248
Mrs. H i l l a r y Rodham-Clinton^,.
The White House
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1600 P e n n s y l v a n i a Avenue^
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Washington, D.C. 20500 V""
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�LINDA TALIAFERRO
FRED RADOSEVICH
Phone 273-57 14
875-3312
Chairman
Phnnr-; 362 394?
LARRY CALLER
" \ P h o n e 362-7772
BOARD OF COUNTY COMMISSIONI
SWEETWATER COUNTY, WYOMING
P.O. Box 730
Green Rivet. Wvommq 82935
February
12,
Gre
en R ver Phone
875 9360
Ext. 210
1993
Hillary Clinton
F i r s t Lady
The White House;
Washington, D.C.
Dear Mrs. C l i n t o n :
C o n g r a t u l a t i o n s on y o u r appointment t o lead t h e s p e c i a l
t a s k f o r c e t o h e l p s o l v e t h e n a t i o n ' s h e a l t h care c r i s i s !
As a
member o f t h e DLC, I a l s o share some o f t h e s e same concerns w i t h
you and t h e P r e s i d e n t .
As a county commissioner, I see f i r s t hand some o f t h e
problems c a u s i n g t h e r a p i d l y i n c r e a s i n g h e a l t h c o s t s .
While s i t t i n g on our l o c a l h o s p i t a l board f o r s e v e r a l y e a r s , I
n o t i c e d an i n t e r e s t i n g c h a i n o f events.
The board r a i s e d
h o s p i t a l r a t e s whenever n e i g h b o r i n g h o s p i t a l s r a i s e d t h e i r s .
Competative p r i c e s were never c o n s i d e r e d b u t r a t h e r a d e s i r e t o
keep Medicare r a t e s r i s i n g f o r a l l concerned because t h o s e
payments were never "enough."
M e d i c a l d o c t o r s t e l l me t h e y a r e s m a l l businessmen and wish
t o remain a p a r t o f our f r e e e n t e r p r i s e system.
Nothing could
be f u r t h e r f r o m t h e t r u t h .
When was t h e l a s t t i m e you o r I g o t
a c o m p e t a t i v e b i d on our d o c t o r ' s services'? We d o n ' t .
The
medical p r o f e s s i o n i s p r e s e n t l y i n a p o s i t i o n t o t a k e advantage
of i t s customers and t h e i r i n s u r a n c e companys, and i t does.
The m e d i c a l i n d u s t r y i s no d i f f e r e n t t h a n e l e c t r i c u t i l i t i e s and
needs t o be p r i c e r e g u l a t e d .
The most i m p r e s s i v e method I ' v e seen t o p r o v i d e u n i v e r s a l
coverage f o r a l l c i t i z e n s , r i c h and poor a l i k e , i s t h e Oregon
p l a n . P r i o r i t i s i n g each m e d i c a l p r o c e d u r e from one t o 500,
d e t e r m i n i n g what l e v e l o f f u n d i n g we as a n a t i o n can a f f o r d , and
p r o v i d e everone b a s i c m e d i c a l care.
Those v/ho wish c o u l d
purchase p r i v a t e medical i n s u r a n c e f o r a d d i t i o n a l coverage o f
t h o s e items n o t covered.
�Hillary Clinton
February 12, 1993
PAGE 2
P r o v i d i n g h e a l t h c a r e f o r a l l i s a c o m p l i c a t e d problem b u t
I'm c o n v i n c e d i t i s s o l v e a b l e problem and I would be happy t o
h e l p i n any way I c o u l d . With b e s t r e g a r d s , I am,
truly
^ourj
Larrjr Caller
Commissioner
�REPLY ^O:
COMMITTEES
4SRD DISTRICT
M I C H A E L M. DAWIDA
FINANCE. MAJORITY CHAIRPERSON
BANKING AND INSURANCE
COMMUNICATIONS AND HIGH
TECHNOLOGY
PUBLIC HEALTH AND WELFARE
URBAN AFFAIRS AND HOUSING
VETERANS AFFAIRS AND
EMERGENCY PREPAREDNESS
SENATE POST OFFICE
THE STATE C A P I T O L
H A R R I S B U R G . PA 1 7 1 2 0 - 0 0 3 0
(717) 7 8 7 - 7 6 8 3
•
314 E A S T E I G H T H AVENUE
H O M E S T E A D . PA 1 5 1 2 0
(412) 461-1126
DEMOCRATIC POLICY COMMITTEE
•
B I R M I N G H A M T O W E R S , S U I T E 1IO
21ST A N D W H A R T O N S T R E E T S
P I T T S B U R G H . PA 1 S 2 0 3
(412) 488-6111
Senate of ^eratsylUania
F e b r u a r y 24, 1993
F i r s t Lady H i l l a r y Rodham C l i n t o n
F i r s t Lady o f t h e U n i t e d S t a t e s
The W h i t e House
1600 P e n n s y l v a n i a Avenue, NW
Washington, DC 20500
Dear Ms. C l i n t o n :
As a l o n g t i m e advocate o f t h e c i g a r e t t e t a x , I am w r i t i n g t o e x p r e s s my
s u p p o r t f o r a major c i g a r e t t e t a x i n c r e a s e o f a t l e a s t $2.00 p e r pack. T h i s t a x
would be a c r u c i a l s t e p t h a t o u r n a t i o n s h o u l d t a k e t o p r o t e c t o u r c h i l d r e n from
a d d i c t i o n t o tobacco and t o lower h e a l t h c a r e c o s t s .
S t r o n g s u p p o r t f o r r e d u c i n g t o b a c c o consumption a l r e a d y e x i s t s among t h e
American p e o p l e , i n c l u d i n g many smokers. T h i s s u p p o r t w i l l o n l y grow i f your
A d m i n i s t r a t i o n f o r c e f u l l y a r t i c u l a t e s t h e h e a l t h r a t i o n a l e f o r t a k i n g t h i s step.
T h i s s u p p o r t i s e v i d e n t i n Pennsylvania as I was a b l e t o pass t h e "Clean I n d o o r
A i r A c t " i n 1988. Since t h e n , more and more p e o p l e have expressed t h e i r c o n c e r n
over t h e h e a l t h aspects r e l a t e d t o t o b a c c o use.
The h e a l t h b e n e f i t s o f h i g h e r t o b a c c o t a x e s a r e n o t t h e o r e t i c a l , t h e y a r e
proven. Every o t h e r major i n d u s t r i a l i z e d n a t i o n , i n c l u d i n g Canada, t a x e s tobacco
at a much h i g h e r l e v e l t h a n does t h e U n i t e d S t a t e s . Canada has reduced t o b a c c o
use among y o u t h by t w o - t h i r d s s i n c e 1980, p r i m a r i l y t h r o u g h t o b a c c o t a x
increases.
The American Cancer S o c i e t y , American Heart A s s o c i a t i o n and t h e American
Lung / V s c c c i a t i c n have e s t i m a t e d t h a t a $2.00 p e r pack t a x i n c r e a s e , m a i n t a i n e d
i n r e a l t e r m s , would r a i s e about $35 b i l l i o n d o l l a r s p e r year and would save
about two m i l l i o n American l i v e s over t i m e . S u r e l y t h e r e can be no b e t t e r way
t o r a i s e revenue i n t h i s t i m e o f need t h a n t o impose a t a x t h a t w i l l p r o t e c t o u r
c h i l d r e n , improve o u r economy and save c o u n t l e s s l i v e s .
I am h o p e f u l t h a t you w i l l t a k e t h i s l o n g overdue s t e p f o r t h e h e a l t h o f
t h e American f a m i l y .
Sincerely,
M i c h a e l M. Dawida
43rd S e n a t o r i a l D i s t r i c t
MMD/BVR:bvr
�t
ROSCOE DIXON
CHAIRMAN
REPRESENTATIVE
HEALTH AND HUMAN RESOURCES
LEGISLATIVE OFFICE:
ROOM 17, LEGISLATIVE PLAZA
NASHVILLE, TENNESSEE 37243-0187
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87TH
COMMITTEE MEMBERSHIP:
EDUCATION
CALENDAR AND RULES
FISCAL REVIEW
LEGISLATIVE DISTRICT
March 22, 1993
Mrs. Hillary Clinton
The White House
1600 Pennslyvania Avenue
Washington, D C 20500
..
Dear Mrs. Clinton:
I wish to congratulate the Clinton/Gore Administration for its concern
and vision that all citizens receive quality health care in the United
States and m state of Tennessee. I wish you well in this challenging
y
opportunity and look forward to the realization of your goal.
However, I want to stress the continuing life-threatening problems of
alcohol and drug abuse. I f substance abuse is excluded from the
National Health Insurance Reform Act, which is scheduled for May 1993,
coverage of approximately three (3) million victims of substance abuse
could be affected. I t is essential that comprehensive coverage for
substance abuse prevention and treatment services be mandatory as the
core benefit in any national health care reform legislation.
The costs of untreated alcohol and other drug problems are enormous. A
Department of Health and Human Services Report, entitled "The Economic
Costs of Alcohol and Drug Abuse and Mental Illness", noted that in 1988
the cost of alcohol and other drug problems was $144.1 b i l l i o n .
Prevention and treatment will save lives, families, and money. A
University of California study found that every one dollar ($1) spent
on alcohol and other drug treatment saves $11.54 in health care and
criminal justice costs, and lost productivity for business. Providing
prevention, early intervention and treatment coverage for alcohol and
other drug problems is cost effective and helps to reduce illnesses and
deaths from a myriad of related diseases as well as accidents and
physical abuse.
�r
Mrs. Hillary Clinton
March 22, 1993
Page 2
If there is anything that I can do to assist you, please do not
hesitate to call.
Suicerely,
Roscoe Dixon
RD:db
cc:
Mrs. Tipper Gore
Senator Jim Sasser
Representative Bob Clement
Dr. Elaine Johnson
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Letters from Government Officials and Employees] [loose] [1]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-015-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/08977a0d4c277ca500a029ad2c4d0dec.pdf
51edcf518616fcb7077ddfa8f8ad2c0d
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1981
FolderlD:
Folder Title:
[The Journal of American Health Policy] [loose]
Stack:
Row:
Section:
Shelf:
Position:
s
56
2
2
3
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�THE JOURNAL OF
AMERICAN
HEALTH POLICY
The Facts, People, and Ideas Shaping Health Care in the United Slates
March/April 1993
Vol.3/No.2
A Decade of Medicare's Prospective Payment System: Success or Failure?
Stuart H. Altman and Donald A. Young
Competition and Prospective Payment: A New Way to Control Health Costs
Richard F. Averill and Michael J. Kalison
The ABCs of HIPCs
Elliot K. Wicks, Richard E. Curtis, and Kevin Haugh
A National AIDS Czar:
We Need One
No We Don't
Daniel T. Bross
J. Roy Rowland
Paying for Long Term Care Without Breaking the Bank
Mark R. Meiners
Reality Ignored: Health Reform and People With Disabilities
Sara D. Watson
DEPARTMENTS I
FrontLine: White House task force gears up for
health reform battle; Lobbying groups gird for fullscale assault
PowerLine: Real-world view guides AIDS policy expert
Mark Smith.
FineLine: 24-Hour coverage benefits employers and
workers.
StateLine: Certificate-of-need laws back in style; Florida
pushes managed competition; Minnesota takes first steps
to universal coverage.
FAULKNER & GRAY
d
THOMSON PROFESSIONAL PUBLISHING
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[The Journal of American Health Policy] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-014-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/c5b643d4d1b5a19c21c201e97a958a19.pdf
4e3fe06b4c6165cab4beee1cc0154598
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1337
FolderlD:
Folder Title:
[Institute of Living Letter] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
6
1
�NDU-03-1993
14=36
mm
FROM
TO
THi<:
iNS^rrrmE
OF
LIVliNC
FAX TRANSMITTAL
ip .
0
Ira Magaziner
FAX: (202) 456-7739
From:
Patricia Rehmeo RN, M N
S
Director, Partial Hospital Service
Number o f pages i n c l u d i n g t h i s page
Remarks
^_
9-2024567739
P.01
�NOU-03-1993
14:36
TO
FROM
9-2024567739
P.02
HIE
NSTITUTE
OF
IJVTNG
November 3, 1993
Ira Magaziner/Mrs. Clinton
The White House
Washington, DC 20500
Dear I r a Magaziner/Mrs. Clinton:
As Director of the Partial Hospital Service at The Institute
of Living and as a mental health clinician, I cannot emphasize
strongly enough the importance of partial hospitalization in the
continuum of mental health services, and the significant Impact
this level of care has had on avoiding and reducing inpatient
hospitalizations. Partial hospital has proven to be both a
c l i n i c a l l y appropriate and cost-effective means of providing
mental health care. I t allows patients to live in the community
with their families while providing supportive, therapeutic
treatment.
At the present time, approximately 300 patients are
receiving care through The Institute's nine partial hospital
programs. A significant number of these patients would
not be able to maintain their current level of functioning
through traditional outpatient treatment. Eliminating
partial hospitalization as a treatment alternative would be
therapeutically harmful for these patients and many would likely
require inpatient hospitalization after a short period of time.
Therefore, i t i s essential that partial hospitalization be
made available as part of the mental health benefit package of
a l l accountable health plans. I urge you to correct this error
before the final legislation i s released to Congress.
Sincerely,
Patricia Rehmer, RN, MSN
Director, Partial Hospital service
400 Washington Street
Hartford. Connecticut 06106
(203)241-8000
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Institute of Living Letter] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-013-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/428a671b7b2fac50c5cd98c595964f76.pdf
c1f145be78e569d75be659dc5847af3f
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1975
FolderlD:
Folder Title:
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�HEALTH POLICY INSTITUTE
GRADUATE SCHOOL OF PUBLIC HEALTH
UNIVERSITY OF PITTSBURGH
PITTSBURGH, PA 15261
�HEALTH POLICY INSTITUTE
r'
GRADUAtE SCHOOL OF PUBLIC HEALTH
UNIVERSITY OF PITTSBURGH
PITTSBURGH, PA 15261
�University of Pittsburgh
Health Policy Institute
Graduate School of Public Health
^
TeTeT^™
Fx 4 26 4 3146
a 1-2
September 27, 1993
Hillary Rodham Clinton
Chair, White House Interagency Task Force
on Health
c/o: Capricia Marshall
Special Assistant to the First Lady
Room 204 East Wing
The White House
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mrs. Clinton:
Enclosed please find a recently published Health Policy Institute report, A
New Health Care System for Southwestern Pennsylvania: Vision, Decision, and
Strategy. Though the work of your Task Force in recommending health care
system reforms to the President appears to be near completion, you may find the
work of our Project Team of interest as the Administration seeks congressional
approval for its reform plan.
As with all Health Policy Institute projects, this one was guided by a team
of experts and decision makers all of whom held a stake in the outcome and
recommendations of the project. In this case, the project set out to define an
ideal health care system for this region (which includes Pittsburgh and the
surrounding ten counties) and to make recommendations for how to achieve that
ideal. You will note that the thinking of the project team was substantially
influenced by the national health policy debate that was triggered by the election
of Pennsylvania Senator Harris Wofford and that continued through the 1992
presidential campaign and the first months of the Clinton Administration.
The key point of this report with regard to national health care reforms
and their relationship to the health care needs of people at the regional level is
discussed under the subtitle "Rationale for Regional Action" (pages 32 through
40) and summarized on Exhibit 2 (pages 36 and 37). This point is that there are
certain aspects of needed health care reforms that can best be accomplished at
the federal level, including financing, access to health services, and assurance of
quality and appropriateness of care. Conversely, there are other aspects of reform
that will require careful attention and strong public-private support at the state
and local levels, including monitoring of populations' health status and service
needs, planning for the dissemination of technologies, and promoting ethical and
cultural sensitivity in patient care. This report recommends one way to pursue the
latter set of objectives.
"
�[
Hillary Rodham Clinton
Page 2
The project team believed that its regional level reform plan was fully
consistent with the proposals for federal level reforms as these were known at the
time of its work. The project team also believed that this regional level reform
plan would begin to create the structural foundation as well as the mechanism for
public input that would allow a federal reform plan based on a managed
competition model to succeed. The "regional health alliance" recommended here
would be made up of persons who understood the distinguishing characteristics of
the regional health care system as well as the important health service needs of its
population. The mission of this organization as recommended is sufficiently broad
to include efforts to educate the population about the need for health care
reform, the efficient use of health benefits and services, and the best choices for
healthy behaviors.
The project team members, as well as I, have been strongly supportive of
the Clinton Administration's effort to reform the nation's health care financing
and delivery systems. We have been particularly impressed with the way in which
you conducted the work of the Task Force — with inclusiveness, sensitivity to
political realities, and attention to scholarship. We wish to see the national
reform plan succeed and believe that this likelihood would be enhanced by
encouraging regional activity of the kind described in this Health Policy Institute
report.
Thank you for your attention,
ery truly yotfrSx
Margaret A. Potter, J.D.
Associate Director and
Project Team Leader
Enclosure
cc:
Senator Harris Wofford
Ira Magaziner
�Health Policy I n s t i t u t e
Graduate School o f P u b l i c H e a l t h , U n i v e r s i t y o f P i t t s b u r g h
Summary o f t h e Executive Summary
PLAN FOR REFORM:
1.
f e d e r a l / s t a t e r e f o r m would enhance r e g i o n a l r e f o r m , b u t n o t
r e q u i red
2.
U n i v e r s a l access ( b a s i c care)
3.
I n s . premium n o t based on d i f f e r e n t i a l r a t i n g
4.
Regional H e a l t h A l l i a n c e (new o r g a n i z a t i o n )
- m o n i t o r s p o p u l a t i o n h e a l t h and needs, estab. b a s i c care
pkg., s e t s t d s . f o r h e a l t h care
- assure coverage f o r u n i n s u r e d u s i n g funds from member
f e e s , gov't progs., p h i l a n t h r o p y
5.
Primary care networks - e i t h e r HMOs, o r p r o v i d e r s
c o n t r a c t i n g w/3rd p a r t y o r g a n i z a t i o n s f o r f i n a n c i n g f u n c t i o n s ;
network c o n t a i n s or c o n t r a c t s t o p r o v i d e s e c o n d a r y / t e r t i a r y care
- p e r i o d i c open e n r o l l m e n t s f o r i n d i v i d u a l s
6.
Fund f l o w same as now ( i . e . 3 r d p a r t i e s , employers, g o v t ,
i n d i v i d u a l s t o p r o v i d e r s ) + new ways
- RHA pays f o r u n i n s u r e d
- employers d e a l w/ins.co. or d i r e c t l y w/network
- i n d i v i d u a l s d e a l w/ins.co. o r d i r e c t l y w/network
7.
M e d i c a i d , Workers' Comp. i n v i t e d t o purchase b a s i c pkg.
d i r e c t l y from networks
8.
P r i c e f o r non-network s e r v i c e s ( a v a i l a b l e t o i n d i v i d . , 3 r d
p a r t i e s ) above t h a t f o r b a s i c - c a r e pkg.
9.
RHA i n f l u e n c e s spending t h r o u g h s t d - s e t t i n g , c e r t i f i c a t i o n
- d e f i n e s b a s i c pkg., determines p r i c e parameters
OTHER:
1.
RHA members: those t h a t i n f l u e n c e / i n f l u e n c e d by h.c. system
2.
t e c h n i c a l support f o r r e f o r m i m p l e m e n t a t i o n on v o l u n t a r y or
contractual basis
3.
i m p l e m e n t a t i o n f i n a n c e d by govt and p r i v a t e sources
4.
r a i s e p u b l i c awareness, s t i m u l a t e p u b l i c involvement i n
h e a l t h reforms
HIGHLIGHTS OF REGIONAL PLAN COMPARED TO NAT'L PLAN:
1.
a t t n . t o r a t i o n a l i z i n g c a p i t a l spending
2.
m o b i l i z i n g p u b l i c awareness and p e r s o n a l r e s p o n s i b i l i t y
3.
co-ord. d e l i v e r y o f h e a l t h and s o c i a l s e r v i c e s
4.
enhancing e t h i c a l / c u l t u r a l s e n s i t i v i t y
�Report of a study
A NEW HEALTH CARE SYSTEM
FOR SOUTHWESTERN PENNSYLVANIA:
VISION, DECISION, AND STRATEGY
HEALTH POLICY INSTITUTE
Graduate School of Public Health
University of Pittsburgh
Pittsburgh, PA 15261
HPI Policy Series #18-B
June 1993
�Health Policy Institute
The public and private policies and decisions that guide the health care system are
crucial since the delivery of health care services directly affects the quality of life and
economic well-being of the community. In recognition of this, the Health Policy Institute
(HPI) was established in 1980 to pursue the following mission: to enhance health by
improving the policies and decisions that influence health care in Southwestern
Pennsylvania and, by extension, the Commonwealth of Pennsylvania and the nation. The
Institute's mission is pursued through three core activities: 1) analysis of and research on the
policies and decisions that affect health care; 2) education of present and future health care
decision makers; and 3) direct participation in organizations whose policies and decisions
influence health care.
Located in the Department of Health Services Administration, Graduate School of
Public Health, University of Pittsburgh, the Institute is guided by an Advisory Council and is
supported financially by a broadly based set of health care organizations, business firms, and
foundations.
This study was approved by the Institute's Advisory Council and Margaret A. Potter,
J.D. has served as Project Team Leader, with overall responsibility for the study's conduct.
This is the second part of a two-part study. The first part, A New Health Care System for
Southwestern Pennsylvania: Focus Group Interviews, was published in March of 1992. It
provided some of the basic insights that were the foundation of the work reported here. The
project team, whose members are listed at pages vii - viii, have met and worked for over a
year on the ideas presented here. Their primary and immediate purpose was to design a new
health care system, based on a consensus vision of what the current system could and should
become. Their task was to determine whether individuals of diverse backgrounds and
affiliations could agree on a vision for health care delivery and financing and then further
agree on a plan and a strategy for actualizing that vision. As this report details, they have
done so and now offer their consensus for consideration and implementation by the larger
community of this region's health care decision makers.
Beaufort B. Longest Jr., Ph.D.
Director, Health Policy Institute
in
�Acknowledgements
For contributions to this work, many thanks are in order. Members of the project
team are the coauthors of this report. All of them are experts and leaders in the health care
delivery and human service systems that affect Southwestern Pennsylvania. They gave
fourteen months of their time to this work, striving to reach consensus on issues that have
stalemated the federal and state governments for years.
While each member brought unique perspectives and important ideas to this project, a
number of them made special contributions. Bob Haigh and his associate Carol Ranck of the
Pennsylvania Department of Public Welfare were frequently asked for data and explanations
about the state's Medical Assistance program, and they always responded with a prompt
willingness that belied their heavy schedules. Kathy Cline of Blue Cross of Western
Pennsylvania contributed her own analyses of high-technology utilization patterns and costs,
and some of the exhibits in Appendix A are the result of work that she did or directed.
Charlie Pruitt, who leads not only the Presbyterian SeniorCare System but also the
Southwestern Pennsylvania Partnership on Aging, gave us the benefit of the latter group's
recommendations for reform in relation to long term care. George Yeckel, representing both
the South Hills Health System and The Hospital Council of Western Pennsylvania, was
among the most active members of the team, someone whose vision and energy inspired and
sustained us. Charlotte Jefferies, partner in the lawfirm of Horty, Springer, and Mattem,
often attended project team meetings as John Horty's alternate and invariably made a
valuable contribution to our discussions.
Taking stock of the health care system's status quo and trends was a focus of this
work in its early months, and the Blue Cross and Blue Shield organizations of this
commonwealth made substantial contributions. From Blue Cross of Western Pennsylvania
came much valuable information, advice, and historical perspectives with inputs from Cindy
Bryce, Tony Bugel, Dean Eckenrode (also a project team member), Don Falkinburg, Steve
Fisher, Neil Hollander, George Kruth, Eamie Robinson, and Wanda Young. Blue Shield of
Pennsylvania in the person of Gene Rosetti gave data, analyses, and much thoughtful time including travel from Camp Hill to attend project team meetings. Independence Blue Cross,
through Gene Carelli, also supplied data and analyses. Though not all of their contributions
appear in this final report, the project team and the Institute's staff benefited nevertheless
from their efforts.
Professor Judith Lave, in her customary collegial manner, contributed insightful
comments and probing questions on the first draft of this report. She thereafter attended
meetings, where she offered an economic "reality check" on the ideas of the project team and
staff. While she deserves much credit for the strengthening of this report that resulted from
her help, any remaining shortcomings are not hers but ours.
I
I
Two Health Policy Fellows contributed to this work, both students in the Master of
Health Administration program at the time. Sherrie Settle performed months of analysis on
data about the regional health care system, and many of the exhibits in Appendix A are her
work. Carol Frederick worked on background issues, including organizational structures and
primary care alternatives - icebergs of work with only the tips shown here. She can be
�confident that her contributions will continue to help us, even as she leaves for her new life
as a hospital manager.
Among colleagues and staff of the Health Policy Institute, Lily Maskew and Elly
Poster deserve thanks for their high standards, attention to detail, and unflagging patience.
Sharon Zucconi, as a project team member and epidemiologist, kept us focused on the real
purpose of this work - meeting people's health care needs. Beaufort Longest was, as
always, the organizational and intellectual leader whose style was to stand back and give
others credit when things went well but to step up and straighten things out when the going
got tough.
My sincerest thanks to all.
Margaret A. Potter, J.D.
Associate Director and Project Team Leader
vi
1
I
�Project Team Members
Gilbert Friday, M.D.
Chief, Clinical Services
Asthma & Allergic Disease Center
Children's Hospital of Pittsburgh, and
Board Chairman of Pennsylvania Blue
Shield
Alan A. Axelson, M.D.
Medical Director and
Chief Executive Officer
Intercare
Southwood Psychiatric Hospital
Michael Blackwood, M.P.H.
President and CEO
Health America
Thomas Gessner, M.D.
Associate Medical Director and
Chief of Pediatrics
Latrobe Area Hospital
John A. Burkholder, M.D.
President, Allegheny County Medical
Society (1992)
Robert Haigh
Director of Policy, Planning and
Regulatory Commission
Department of Public Welfare
Commonwealth of Pennsylvania
Kathryn Cline
Corporate Health Strategist
Blue Cross of Western Pennsylvania
The Honorable William Coyne
Member, U.S. House of Representatives
Leon L. Haley, Ph.D.
President
Urban League of Pittsburgh, Inc.
David Dietly
Vice President, Employee Health
Programs
Michael Herman
Executive Director
Three Rivers Area Labor-Management
Committee
PNC Financial Corporation
Dean Eckenrode
Vice President, Provider Reimbursement
Blue Cross of Western Pennsylvania
Helen S. Faison, Ed.D.
Deputy Superintendent
Board of Education
Pittsburgh Public Schools
John J. Horty, Esq.
Horty, Springer, & Mattem, P.C.
Carol L. Frederick
Fellow
Health Policy Institute (1992-93)
Theresa A. Laver
Executive Director
Allegheny County Alliance on Aging
William Hughey, Jr.
Executive Director
Pittsburgh/Allegheny County Chapter
American Red Cross
vii
�Beaufort B. Longest, Jr., Ph.D.
Director
Health Policy Institute
Sherrie Settle
Fellow
Health Policy Institute (1991-92)
The Honorable Frank Mascara
Chairman, Washington County (PA)
Board of Commissioners
Richard Steinman, M.D., Ph.D.
Assistant Professor of Medicine
University of Pittsburgh
School of Medicine and
Pittsburgh Cancer Institute
Presbyterian University Hospital
Mr. Lou Pappalardo
President, American Federation of
Teachers Local 2067
Eugenia Chambers Stoner, Esq.
Director
Federal Government Relations
University of Pittsburgh Medical Center
Wilford Payne
Executive Director
Primary Health Care Services
Alma Illery Medical Center
George Yeckel
Vice President, Board of Directors
South Hills Health System
Chairman, Hospital Council of Western
Pennsylvania
Margaret A. Potter, J.D.
Associate Director and
Project Team Leader
Health Policy Institute
Charles W. Pruitt, Jr.
President and CEO
Presbyterian SeniorCare System
Sharon Zucconi, Ph.D.
Policy Analyst and Research
Assistant Professor
Health Policy Institute
Joseph Ricci, M.D.
Vice President, Medical Affairs
Pennsylvania Blue Shield
N. Mark Richards, M.D.
Senior Program Officer
The Jewish Healthcare Foundation
of Pittsburgh
P. Richard Rittelmann, F.A.I.A.
Senior Vice President
Burt Hill Kosar Rittelmann Associates
Helen Romano, Ph.D.
Vice President for Patient
Care Services
Washington Hospital
viu
�Table of Contents
Page
The Health Policy Institute
iii
Acknowledgements
v
Project Team Members
vii
Table of Contents
ix
List of Exhibits
xi
Executive Summary
xiii
A NEW HEALTH CARE SYSTEM FOR SOUTHWESTERN PENNSYLVANIA:
VISION, DECISION, AND STRATEGY
1
Section 1:
Introduction
3
Section 2:
Vision: Mission and Objectives for a
Regional Health Care System
Section 3:
9
19
A.
The Reform Plan
21
B.
Rationale for Regional Action
32
C.
Section 4:
Decision: A Plan for Regional Reform
Unresolved Issues
40
Strategy: Recommendations for Implementation
References
57
65
Appendices
A.
Status Quo and Present Trends
Al
B.
"Ethical Principles to Guide Health Care Reforms"
by Beaufort B. Longest, Jr., Ph.D
Bl
ix
�List of Exhibits
Page
1.
Regional Reform Plan
2.
Comparison of Federal, Pennsylvania, and S.W. Pennsylvania Regional
Reform Plans: Do They Meet Regional Reform Objectives?
Special Programs Offering Financial Assistance for
36-37
Health Care Services
51-52
3.
23
4.
Major Payor Coverage of Selected Health Care Services
A6
5.
Characteristics of the Uninsured, Pennsylvania, 1987
A8
6.
Unmet Health Care Needs: What Kind of Care was Needed
but not Obtained
Relative Proportions of Elderly and Nonelderly Age Cohorts in
Allegheny County, 1970 to 1990
7.
8.
9.
10.
A10
A12
Hospital Discharge Rate Changes in Elderly and
Nonelderly Populations of Southwestern Pennsylvania Counties,
1980 to 1990
A13
Distribution of Primary Care Clinics in
Southwestern Pennsylvania Counties, 1992
A15
Primary Care Specialty MDs Per Capital in
Southwestern Pennsylvania Counties, 1989
A16
11.
Health Manpower Shortage Areas in Southwestern Pennsylvania, 1990
A18
12.
Percent Change in Family/General Practice Physicians,
1975 to 1986
Non-physician Care Providers Residing in
Southwestern Pennsylvania Counties, 1991
A19
13.
14.
Comparison of 1965 and 1985 Health Expenses by Business,
Governments, and Households
xi
A20
A22
�List of Exhibits
(continued)
15.
16.
17.
Page
Inflation Rates of Consumer Prices for All Items and for
Medical Care in the Pittsburgh Area, 1981 to 1990
A23
Comparison of Hospital Expenses in 1982 and 1990 for
Six Southwestern Pennsylvania Counties
A24
MRI Services Provided by Pennsylvania Blue Shield
Hospital vs. Nonhospital Settings
A26
18.
HMO Enrollments in Southwestern Pennsylvania, 1980 to 1990
A27
19.
Mean Operating Margins and Mean Total Revenue Margins in
Southwestern Pennsylvania Hospitals, FY 1983 to FY 1991
Medical Assistance Intermediate Care Patient Days as a
Percentage of Total Intermediate Care Patient Days in
Southwestern Pennsylvania Nursing Homes, 1989
20.
xn
A30
A31
�EXECUTIVE SUMMARY
It has been said, "There is little that is meaningful about health care which is
national." But if what is meaningful about health care is indeed local, then health care
reforms currently being shaped by the federal and state governments might bear some close
scrutiny by people at the local level.
1
The purpose of this project was to consider the health care system of Southwestern
Pennsylvania in terms of what should be changed, what should stay the same, and what
should drive future policies and decisions. In the course of answering these questions, the
project team envisioned a regional system that would meet the most important needs of
people in this region, decided on a plan for such a system, and recommended a strategy to
implement it.
Vision: Mission and Objectives for a Regional Health Care System
At its most essential, the project team agreed that the health care system should focus
on the health of the people who depend upon it. Or, as the project team put it, the mission
of the health care system should be:
To maximize the present and future health of all residents of
Southwestern Pennsylvania by rationalizing and coordinating the
delivery of efficient, high-quality health services, and by
providing health education, with due respect for the life-stage,
moral, cultural, and economic diversities of this population.
Pursuit of this mission should be done through eight objectives, which can be viewed
as benchmarks for progress applicable to any health care reform plan ~ regional, statewide,
or national. They are:
1.
Identify and monitor the health status and the health service needs of the
population.
2.
Assure universal access to basic health care services.
3.
Assure payment for health care services that is fair and reasonable to both
payors and providers.
4.
Rationalize the dissemination of health care technologies.
5.
Encourage personal responsibility in the use of health services and the exercise
of sound personal health habits.
'Goldsmith, J., "A Radical Prescription for Hospitals," Harvard Business Review May-June: 104-111 (1989).
xiii
�6.
Improve coordination of services within the health care system and between
health and other social services.
7.
Maintain and enhance the quality of care and the administrative aspects of its
delivery.
8.
Promote ethical and cultural sensitivity toward patients and their families.
Decision: A Plan for Regional Reform
During the course of its deliberations, the project team considered how to direct its
recommendations for changes in health care at the regional level, in light of evolving stateand national-level reform plans. Their decision was to do more than merely advise those
efforts. Instead, the project team articulated a regional reform plan that was capable of
implementation here - one that could be enhanced by, but that would not necessarily require,
concurrent state or federal action.
This plan rejects the idea that "patching" the existing system would suffice and
instead embraces the alternative of whole system change. The change is intended to redirect
spending for health care to assure that all are provided with basic care. An underlying
premise is that this can be achieved by reallocating existing resources, which means that
some may get less than they do at present but all will have access to what is most needed and
important to good health. The plan proposed here provides a structure for health care
planning, financing, and delivery that is flexible enough to adapt to change over time and to
serve the special needs of subpopulations within the region.
At the regional level, the project team believed that a new organization should be
created to bear responsibility for pursuing the stated mission and objectives. Called a
Regional Health Alliance (RHA), it would be accountable to the people of this region and
have unrestrained access to appropriate information from providers and payors. The RHA
would influence decision makers in arriving at global, strategic decisions about the region's
health care system, focusing on values rather than on specific operational decisions. It would
neither render care directly, nor engage in micromanaging operational decisions of health
care providers, nor take the place of health insurers.
The RHA is to be made up of members of the public among its governing body and
committees, which would also include health care providers and payors including third-party
organizations, public programs, and employers. Key features of the regional reform plan
are:
•
The RHA, a decision-making body, would monitor the population's health,
establish a basic care package, and set standards for health care. It would
assure that unsponsored (uninsured) persons have coverage using funds derived
from a variety of sources including membership fees, government programs,
and philanthropy.
xiv
�•
The basic care package would be those health care services deemed essential.
It would be made available to all residents, constituting a "floor" of health
care below which no one would be allowed to fall. The premium paid for this
package would not be subject to differential rating based on a person's health
status or risk factors.
•
Primary care networks would be organized to deliver the basic care package.
They would either be integrated financing and delivery systems (like HMOs)
or providers that contract with third party organizations to perform financing
and underwriting functions. Each network would either contain or contract to
obtain secondary and tertiary care providers, thus enabling the network to
provide all services covered by the basic care package.
•
The flow of funds to purchase health care would run, as it does now, from
payors (including third parties, employers, government, and individuals) to
providers. The RHA would pay only for the basic care package on behalf of
the otherwise unsponsored. Employers could, if they so desire, buy the basic
care package for their employees through third party organizations (insurers);
employers could also deal directly with one or more primary care networks.
Similarly, individuals could purchase the basic care package either directly or
through third parties.
•
Government programs, including Medical Assistance (Pennsylvania's Medicaid
program) and Workers Compensation, should be invited to purchase the basic
care package directly from the networks.
•
Individuals and third parties would retain the ability to purchase health care
services from non-network providers; however, the price for such care, either
in direct fees or insurance premiums, would be in addition to the price of the
basic care package.
Though the RHA would have no direct control over most of the health care dollars in
this system, it would influence spending through standards-setting and certification activities.
First, the RHA would define the basic care package and help to determine its pricing
parameters to assure comparability among providers, thus enhancing market-based
competition. Next, it would certify networks both for their financial responsibility and for
their meeting quality standards. Payors and consumers could select among networks using
this certification as a guide, and networks could compete on the degree to which each would
exceed the minimal certification standards. Periodic open enrollments would allow for
change of network membership and would encourage inter-network competition on the bases
of quality and price.
This overview shows that the reform plan would redefine existing relationships within
the region's health care system and would redirect spending to give a high priority to basic
care and to ensure universal coverage in the population. However, an important question is:
What is the value of a regional health care system reform initiative, at a time when
similar reform plans are pending at both the federal and Pennsylvania levels? The
xv
�answer is found by evaluating proposals at all three levels based on the eight objectives
(listed above) which the project team established. The features of a likely federal plan are
based on the work of the so-called Jackson Hole Group as well as on press reports
concerning the work of the White House Interagency Health Care Task Force. A health care
reform plan has been proposed for Pennsylvania by the Governor's Economic Development
Partnership. Comparing among these plans and the regional proposal given here is at present
a speculative exercise, since none of them has yet been subjected to the political-legislative
process in which adjustment and alteration are inevitable. Nevertheless, comparison even at
this state of the plans' development reveals their most obvious similarities and dissimilarities
as well as their respective strengths and weaknesses.
In many ways, both the federal and the Pennsylvania proposals mirror recommendations by the project team. However, neither of these plans is designed as fully to meet all
the stated objectives as is the regional reform plan. The regional plan addresses all eight
objectives; but the federal plan has no provision that encourages personal responsibility
(Objective 5), and the Pennsylvania plan makes no mention of ethical and cultural concerns
(Objective 8). Neither the federal nor the state plan is focused on the health needs of people
(Objective 1) as is the regional plan.
Overall, the strengths and weaknesses of the federal and state plans complement those
of the regional plan. The federal plan stands the best chance (theoretically, if not politically)
of creating systemwide assurance of universal coverage and of effective cost containment.
Its major weakness is the potential to create rigid or bureaucratic responses to problems that
are shifting, dynamic, and idiosyncratic - such as a population's health care needs, the
development of new health care technologies, and local culture and mores. The Pennsylvania
plan could be important in the absence of or pending definitive federal action; it could gamer
statewide resources better than the regional plan. Compared with the state and federal plans,
the regional plan's focus on the health status and needs of people translates into closer
attention to rationalizing capital spending, mobilizing public awareness and personal
responsibility, coordinating the delivery of health and other social services, and enhancing
the ethical and cultural sensitivity of the system. Its major weakness is its lack of direct
control over the overall framework of health care financing.
Thus, the ideal way to achieve the health care system envisioned by the project team
would be to implement the regional reform plan together with comprehensive reform at the
federal and/or state levels as outlined above. Coordination of regional activity with federal
and state reforms is essential.
The regional reform plan described here, while addressing the fundamental
requirements of the project team's vision, nevertheless leaves many issues unresolved. These
include:
•
Sources of authority and accountability for the RHA;
•
Geographic scale of regional reform;
•
The need for regulation in addition to competition to control cost growth;
xvi
�The definition of basic health care;
The inclusion of long term care;
Coverage for out-of-network or "non-basic" care;
Problems of rural and underserved areas;
Payment for education and reserach; and
The need for federal and state program waivers.
This is a formidable list of highly important issues. However, resolution of these
issues in the context of this project was neither practical nor immediately desirable, given the
necessarily limited scope of the project and the continuing uncertainty about what federal
and/or state health care reforms will be. Ultimately, resolution of these issues will depend
on a combination of factors, including the content of relevant state and federal legislation,
further technical study and analysis, and further discussion and consensus-building among
stakeholders in the health care system.
Strategy: Recommendations for Implementation
The character of the project team's recommendations for regional health care reform
is structural and global, rather than policy-oriented and narrowly focused. The project
team's task was to determine what structural framework could best support desirable health
care reforms in the Southwestern Pennsylvania region and to recommend how this framework
could be put into place. Within this context, the project team made the following six
recommendations:
1.
Regional leaders should assume responsibility for implementing the reform
Plan.
2.
Membership in the RHA should be broadly inclusive of all constituencies that
influence, and are influenced by, the health care system.
3.
The formation of the RHA should leverage all available forms of governmental
legitimation.
4.
Technical support for implementing the reform plan should be drawn from
organizations with relevant expertise on a voluntary or contractual basis.
5.
Implementation should be financed through government and private sources.
6.
A program to raise public awareness of and stimulate public involvement in
health system reforms should be conceived and implemented.
xvn
�A NEW HEALTH CARE SYSTEM FOR SOUTHWESTERN PENNSYLVANIA:
VISION, DECISION, AND STRATEGY
�Section 1
INTRODUCTION
�Only a short time ago, it was predicted that a few huge, vertically integrated
organizations would soon dominate the American health care system. Since then several
national corporations have acquired and then divested many hospitals, having found
economies of scale elusive and local affiliates often intractable. Goldsmith explained why the
predictions had failed to come true by saying, "there is little that is meaningful about health
care which is national. Health services are a neighborhood business, beginning and ending
with a doctor and a patient" (1989).
His observation is worth revisiting today, as the nation stands on a threshold of major
reforms in health care financing and delivery, led there by federal policy makers. The
failures of many serious efforts during the past two decades to control the costs of health
care and to eliminate disparities of access to services have forced attention to the need for
major, structural reform. The election in November of 1992 of a president and a
congressional majority of the same political party raised the potential that such federal
reforms could be enacted. Few informed observers now seriously question that national
priorities for health spending must be rationalized, that structural dysfunctions in the major
public-sector health programs must be repaired, and that reliance on employment-based
private insurance must be reexamined. These are crucial influences on cost, availability,
quality, and effectiveness of health care that demand federal attention. National health care
reform may indeed go much further, perhaps creating new mandatory programs and benefits,
new financial and insurance regulations, and even new organizational forms for health
service contracting and oversight.
But the fact remains that health care is essentially a local matter, even though its
failures and inequities have seemed for so many years to need a comprehensive, national
overhaul. The time is right to consider that what is most "meaningful" about health care
may be its responsiveness to the needs of local populations. Considering that people tend to
stay close to home when seeking and using health services, it should not be surprising that
pluralism is a hallmark of American health care. In this, Southwestern Pennsylvania is
typical of the nation, with its vigorously heterogeneous local communities. Here, culture,
environment, geography, history, lifestyle, demographics, and many other factors should be
considered in determining what health services are desirable and necessary.
In the present context of federally-led reform, communities should be developing a
sense of direction about change for themselves. Do their employers, their health care
managers and providers, and - most importantly - their people know what characteristics
�and attributes they want to define their health care systems? Can they overcome competing
self-interests to move the larger system in desirable directions? Now, localities and regions
would do well to identify their own needs and preferences and to direct their advocacy and
decision making toward reforms that best suit them. Local people should decide which
among the set of federal and state reform alternatives are most compatible with local needs
and resources.
Moreover, local and regional innovation should be undertaken to add to and improve
the pool of options. Experimentation and model-building can yield concrete information that
federal policy makers can and should use.
It was for these purposes of locally providing a sense of direction and contributing to
the reform process that this project was undertaken. With it, the Health Policy Institute has
served as a convener of Southwestern Pennsylvania's health care constituencies in a threestep, consensus-building process:
•
First, to define a vision: agree on a direction for the region's health care
system over the next decade, so to have a clear sense of what reforms will
serve best the health of residents.
•
Second, to reach a decision: formulate a specific plan for the envisioned
regional health care system to serve as a framework for advocating reforms
here as well as at the state and national levels.
•
Third, to articulate a strategy: recommend the necessary steps to bring about
health care system changes that are consistent with the vision.
The Health Policy Institute's approach to this project was to build consensus among
the diverse interest groups that would be needed to initiate reform. While the Institute's staff
provided technical support and policy expertise, they relied on representatives of many
constituencies of the regional health care system to assess alternatives, to make value
judgments, and ultimately to shape recommendations. These representatives, the project
team listed on pages vii to viii, first met in March of 1992. They began by reviewing the
results of focus group interviews about regional health care system reform, which had been
conducted by the Institute during the preceding year (Health Policy Institute, 1992). While
informed by the focus groups' opinions and ideas, the project team members went on to
�went on to formulate their own. Next, they reviewed the status quo ~ the present conditions
and trends of health care in the region. This review is presented here as Appendix A.
Finally, they developed a consensus about a specific mission and objectives for the region's
health care system and proposed a plan of action.
This report is the result of long and careful consideration. It represents a consensus
among project team members with very different economic interests and philosophical
viewpoints. In the course of their discussions, profound questions were raised about whether
major change in health care delivery is either desirable or feasible. For example, endorsing
a "right" to health care was agreed to be very desirable but almost impossible to actualize
financially; cost control was considered an essential feature of reform but ~ given that every
patient wants the best possible care - an extremely elusive one; and though there was
criticism of the existing employment-based system of health insurance, enthusiasm for
eliminating it was lacking. On these and many other issues, project team members sought
positions on which all could agree. Often such positions were not those which individuals
would separately have taken nor those which would have best served the interests of their
affiliated organizations. Thus, this report is very much the product of compromise and
consensus.
It is also a pragmatic document. The conclusions reached and presented here reflect
the sense of many project team members that no "vision" should be embraced unless capable
of accomplishment, but that a vision must be defined first, with barriers to accomplishment
faced thereafter. This is the spirit and intent of the plan and recommendations given in the
following report: the vision is what could be agreed upon within the context of political and
economic realities, but many hurdles still stand between the vision and its actualization. The
project team believes they are surmountable.
�Section 2
VISION: MISSION AND OBJECTIVES FOR
A REGIONAL HEALTH CARE SYSTEM
�The vision for Southwestern Pennsylvania's health care system begins with a
statement of mission: the fundamental purpose that should drive all decision making. The
vision is further articulated through a set of objectives, derived from the mission statement.
In this section, a mission statement developed by the project team is set out and its premises
explained. Next, eight objectives are stated along with the underlying rationales and
motivations for each.
The purpose of having a stated mission and objectives is to provide the foundation for
designing health care system reforms. In developing this mission and objectives, the project
team expressed a wide range of concerns, terminologies, and even philosophies. Thus, their
work product represents a blending and an attempt to harmonize these many divergent
viewpoints.
MISSION STATEMENT
A well-conceived mission should be the starting point for health care system reform.
The project team approached the task of drafting a mission statement by discussing why the
need for reform is now so great. Two sets of reasons were articulated. The first set was
economic and financial. Health care cost escalation is so intense and so enduring that it is
blamed as a factor in the country's decline in domestic living standards and global
competitiveness. The second set of reasons was social and moral. Because costs are so
high, the number of people who can afford needed care is shrinking, and many people have
growing concerns about the effect of extremefinancialpressures on the quality of health care
in the immediate future. As indicators of the need for reform, both the financial/economic
and the social/moral concerns support the need to redirect health care delivery away from the
technology-centered, reimbursement-driven patterns of the present and toward a new focus on
the needs of people.
Three important ideas are related to this. First, the project team believed that while
health service delivery occurs in an economic context that cannot be ignored, the
fundamental social nature of health care is paramount. For years, policy makers have
debated whether health care should be considered a social or an economic good (Yoder
1986). Social goods are those that should be assured for all regardless of profitability, those
that are by definition "community" services devoted to humanitarian goals. Economic goods
are those made available according to the rules of the marketplace. The differences between
11
�these views have fueled arguments about whether providers' behavior should be more
altruistic or more businesslike; whether payment for services should be tax-based or private;
and whether and to what extent government should intervene in the distribution of services.
These are and will remain issues to be balanced, rather than resolved fully one way or the
other. The project team nevertheless concluded that the weight of evaluation should favor
the concept of health care as a social good. One very practical implication of this social
good emphasis is the idea that research and education should be as much a part of the health
care system as are financing and delivery of care.
Second, the needs of people are the health care system's central reason for being and
therefore its primary concern. The system should strive to improve people's health in
practical and meaningful ways. Delivery systems should be designed to broaden access
among the population and to put a high priority on the services that are of greatest benefit to
the most people. Those aspects of health care that should receive greater resources and
attention are disease prevention, primary care, and health promotion.
Third, ethical principles should guide health care decision making at the levels of
systemwide policy, institutional management, and individual patient care. The project team
recognized this ethical imperative by emphasizing that no one's access to basic health care
should depend upon ability to pay, and everyone should contribute fairly to assure that all are
included. The system's design should reflect the social and economic realities of the region,
with its many racial and ethnic groups and its changing industrial base. Services should be
delivered in a manner that preserves patients' dignity as human beings. One project team
member - Beaufort B. Longest, Jr., Ph.D. - articulated a set of principles to guide health
care reforms (Appendix B), which can and should be applied at any level whether national,
statewide, or regional.
Reflecting all these considerations, the project team adopted the following mission
statement for the health care system of Southwestern Pennsylvania:
To maximize the present andfiiturehealth of all residents of
Southwestern Pennsylvania by rationalizing and coordinating the
delivery of efficient, high-quality health services, and by
providing health education, with due respect for the life-stage,
moral, cultural, and economic diversities of this population.
12
�OBJECTIVES
Eight objectives, derived from the mission statement, represent the project team's
collaborative thinking. They are intended as benchmarks for progress toward improvements
and can be applied to any health care reform plan, whether regional, statewide, or national.
Much background for these objectives is given in Appendix A, a review of present conditions
and future trends for the region's health care system. The objectives were established to
meet the worst and most difficult shortcomings of the status quo: inadequate access to care,
intolerable cost growth, and threats to continued quality. Importantly, these objectives
should stimulate further discussion and debate. They are not endpoints; in fact, if they are
truly to guide decisions and actions, each objective must be translated into a set of specific
goals, each of which is capable of measurement and evaluation.
Objective 1: Identify and monitor the health status and the health service
needs of the population.
If the health care system is indeed intended "to maximize the present and future health
of all residents of Southwestern Pennsylvania," then ways to identify and monitor health
status must be created and implemented. Certainly, the definition of "basic" health benefits
(as stated in Objective 2) requires knowledge about the overriding health problems off-'the
region, amenable intervention strategies, and meaningful ways to measure unmetrhealthrcare 'O
"need!. Improvement of people's health through evaluation and prioritization of unmet needs,
allocation of health care resources to address problems, and development of targeted
programs and policies are central to pursuit of the mission.
Objective 2: Assure universal access to basic health care services.
Universal access does not mean access to all possible services for everyone at all
times; it does mean having a "floor" of services below which no one is allowed to fall.
Deciding on these basic services suitable for the population of Southwestern Pennsylvania
should be based on the following principles:
•
All cost-effective, drsease-preventive services should be included. *
13
�•
All necessary acute and chronic care should be included.^
•
Expensive, high-tech care should be included only to the extent that it meets^
the "value-added" test of contributing to the individual's qualify of life.<i?
Assuring access to needed services implies eliminating the use of services that are
unnecessary, duplicative, or futile. Services should be universally provided and financed
when their quality and outcomes can be measured against a standard of improving health
status. Other services, which might be subject to exclusion from universal coverage (such as
purely cosmetic or amenity-enhanced services) could remain available for those who desire
and can pay for them on an individual basis. More difficult decisions would include whether
to assure (or, if not, how to limit) diagnostic procedures that add nothing to a treatment plan
but are ordered to insulate the physician from malpractice liability or to satisfy the patient's
desire for state-of-the-art technology. Another limitation could focus on the relative
convenience of service delivery modes, such as mental health day treatment instead of
inpatient care, which would impose greater burden and responsibility on patients and their
families while helping to conserve health care dollars. When seeking to limit heroic
measures to extend briefly the life of a dying patient, profoundly sensitive and important
ethical and moral judgments will be necessary.
Objective 3: Assure-paymfent for health care services that is fair and
reasonablOoIboth payors and providers.
The excellence of the region's health care system should not be jeopardized, and its
importance in the regional economy should not be overlooked. Nevertheless, a commitment
to assuring universal access requires making further difficult decisions about how best to
allocate scarce resources. Thus, limits on what is universally financed are inevitable.
Additionally, some real costs must be taken out of the system -- including those, arising from.duplicatioh7"excessive~ec6nbmic self-ihterest, and' administrative bufeaucraeies. - -There=should_
be greater parity -of payment-structures and-rates among. all-public and private, thirdspartypayors. Reforms should simplify both benefits and reimbursement - a potentially effective
vehicle for large-scale cost-containment, since this could yield savings of administrative
costs. The premium for the basic benefits should be the same regardless of a person's health
status and risks.
14
�Objective 4: Rationalize the dissemination of health care technolfgies.
A commitment to universal access further requires better controls on capital
expenditures for health care technology and facilities than now exist. To achieve this, it is
necessary to reinstitute voluntary planning and to use new ways of planning: the system
1
0
needs discipline, but not necessarily gdvemn^ht-mMdated planning orhHvierre^lation.
Health care decision making should take place through real dialogue among key
constituencies. Those who pay for health care services need a forum in which to discuss
health care issues and educate its members, who should be involved in planning through this
mechanism. The fact that virtually all hospitals in this region are nonprofit charitieS'Should
make them particularly amenable to voluntary planning. Their trustees are by law committed
to serving the best interests of the community as a whole, and such planning can be a vehicle
to determine their respective institutions' most useful roles.
The dissemination of new technologies into health care delivery should be
rationalized. Not only equipment but also procedures and programs (like bone marrow
transplantation) should be included. Cost growth can be limited through the building of a
consensus about what should be the appropriate maximum investment in health care services
and new technology. In other words, conscious decisions should be made about how muchp
where, and for what usesjiigh-technology equipment and procedures are needetf. The
community should establish investment benchmarks to limit growth. Medical services in the
region should be consolidated, and tertiary service proliferation among so many hospitals
should be halted. Ideally, the interest of cost-control should be balanced with the value of
assuring that well-established and proven treatments are appropriately available throughout
the region.
Objective 5: Encourage personal responsibility in the use of health
services and the exercise of sound personal health habits.
Without public understanding and support, health system reform will be difficult and,
most likely, unsuccessful. The message should be delivered to the public that cost-effective
health care is everyone's responsibility, including that of patients. People must learn not to
misuse health care financing systems, whether private or public. Financial incentives should
encourage patients to use and providers to render care appropriately - for example, to have
primary care services at the office instead of the emergency room. Consumers need better
15
�education about the system, enabling them to use wisely the resources available to them.
The perspective that favors first-dollar insurance coverage, and that considers unlimited
choice to be the sine qua non of high-quality health care, must be reevaluated.
Good health is also a personal responsibility, and individuals should take care of their
own health and lifestyle as well as participate in treatment decision making. Providers of
health care should treat patients not only with medications but also with education for
enhancing skills in living and for improving home support systems. Though it is important
for providers to make the system "user-friendly" for patients, providers are also responsible
for deciding what are meaningful indicators of quality. For example, while amenities like
attractive interior design and furnishing might suggest quality to a patient, superb infection
control might be more meaningful if the patient knew about and understood it. Providers
should participate in educating patients accordingly.
Objective 6: Improve coordination of services within the health care
system and between health and other social services.
A pluralistic health care system is desirable; poorly coordinated care is not. The
system should have multiple, coordinated entry points, which permit access to acute, longterm, and community-based care. Certain functions could be centralized - notably case
management - to improve coordination. Resources should be shared among providers,
including hospitals, personal care and nursing homes, in-home service organizations, and
community-based programs. Long term care should be better integrated with acute care.
There should be better communication and collaboration among doctors, nurses,
paraprofessionals, support staff, patients, and families in making treatment decisions and in
carrying them out. This implies physicians who are more willing to relinquish some of their
traditional autonomy in patient care decision making and to collaborate with others in the
patient care team.
Services should be coordinated across a spectrum of human needs. It is unrealistic to
separate health, psychosocial, and economic systems, so the idea of a health care system
should be broad enough to include both institutional providers and neighborhood hubs like
schools and churches. Human problems are more likely to yield to approaches that deal
comprehensively with social and economic environments. Thus, communities should be
16
�empowered to monitor health status, articulate health care needs, and to eliminate
environmental and worksite health hazards. Communities should have centers of care, and
there should be alliances and coalitions among providers and their communities. This means
that health care leaders must participate in the social service partnerships that have made the
Pittsburgh area so successful in addressing human needs, such as supported housing for the
homeless.
Objective 7: Maintain and enhance the quality of care and the
administrative aspects of its delivery.
Quality of care should be seen in terms of the best achievable health of communities.
Two ways to maximize health care quality are to improve medical practice and to improve
the management of health care delivery.
Outcomes research, particularly its primary care component, should drive
improvements in medical practice. Physicians should be guided by practice parameters or
treatment protocols, which should be established by physicians on the basis of better studies
of efficacy and outcomes for alternative treatments. Providers should be more accountable
for medical necessity. Care should be "rationed" not according to a patient's age or
diagnosis but according to whether it will enhance his or her quality of life. The public
should be better educated about "low-tech" interventions and conservative treatments that are
recognized medically as yielding successful outcomes.
Health care financing, too, should be guided by efficacy and outcome studies:
decisions about what to pay for should be based on what treatments work. High quality care
should be rewarded with increased patient loads, and poor-outcome care should be penalized.
"Continuous quality improvement" techniques, as well as quality assurance, should be
practiced throughout the health care sector. There should be a systems approach to track
what actually happens to patients, including feedback loops to provide information to make
better decisions. Health care institutions should become more flexible, able to adapt to rapid
changes in technology, reimbursement, and patients' needs.
17
�Objective 8: Promote cultural and ethical sensitivity toward patients and
their families.
More is needed than merely payment system and delivery structure reforms. A
change in style and sensitivity on the part of providers is needed, too. The system must be
made not only more affordable but also more humane, less impersonal, and less intimidating.
Cultural and ethnic diversity exists among patients, which providers should recognize
and accommodate. This means that access, especially to primary care, should be
multicentered and pluralistic. To the extent that some health care needs can be addressed in
the context of the many informal networks of neighborhood, school, and church, the
rendering of service is more likely to be consistent with the shared values, customs, and
cultures of smaller homogeneous communities. This is particularly true of rural
communities, where attracting health care providers who are comfortable with and committed
to the local lifestyle is essential.
The system should be consumer-oriented, and consumers should articulate their needs
to providers and government. Consumers should communicate their real needs and
preferences to providers, and they should seek empowerment to enhance their ability to affect
public policy making on their behalf. The aging of society is a demographic reality; and
since so many women are caregivers to aged relatives as well as the longer-lived of marital
partners, women especially need empowerment and advocacy in health care decision-making.
Health care delivery should incorporate values about life and death that transcend
financial and organizational considerations. An effort should be made to resolve, or at least
to rationalize, the sometimes conflicting considerations of advancing health care technologies,
patient choice issues, and medical ethics.
18
�Section 3
DECISION: A PLAN FOR REGIONAL REFORM
�During the course of its deliberations, the project team considered how to direct its
recommendations for changes in health care at the regional level, in light of evolving stateand national-level reform plans. Their decision was that they should do more than merely
advise those efforts. Instead, the project team decided to articulate a regional reform plan
that was capable of implementation here - one that could be enhanced by but that would not
necessarily require concurrent state or federal action.
A vision for a better, more effective health care system was presented in the
preceding section. In this section, a specific plan for how that vision might be actualized is
described and explained. This plan is compared and contrasted with pending reform plans of
the Clinton Administration and Pennsylvania's Governor. Finally some important,
unresolved issues are explored, and alternative resolutions are identified.
THE REFORM PLAN
The plan that follows is based on a rejection of the notion of "patching" the existing
system, as has been attempted in the past. This proposal embraces whole system change.
The change is intended to redirect spending for health care to assure that all are provided
with basic care. An underlying premise is that this can be achieved by reallocating existing
resources, which means that some may get less than they do at present but all will have
access to what is most needed and important to good health. The plan proposed here begins
to define basic care, to which all are entitled, as that which meets the real needs of people
within the available dollars. The plan provides a simple, basic structure for health care
planning, financing, and delivery that is flexible enough to adapt to change over time and to
serve the special needs of subpopulations within the region.
This description is organized to present first an overview of the reform plan. This is
followed by detailed descriptions of its major elements: a Regional Health Alliance, primary
care networks, and payors. Finally, some special reform capabilities of this plan are noted
and discussed.
21
�Overview
An overview of the Southwestern Pennsylvania reform plan is presented in Exhibit 1.
It begins with the creation of a new organization, since leadership for health care reform
must be independent of any single interest group. Thus, this plan proposes the formation of
a Regional Health Alliance (RHA) to serve as a locus of responsibility and accountability for
implementing reforms. The RHA would be accountable to the people of this region. It
should have unrestrained access to appropriate information from providers and payors. Its
responsibilities should be well-defined and consistent with pursuit of the mission statement
and achievement of the objectives described in the preceding Section 2. The RHA should
influence decision makers in arriving at global, strategic decisions about the region's health
care system, focusing on values rather than on specific operational decisions. It should
neither render care directly, nor engage in micromanaging the operational decisions of health
care providers, nor take the place of health insurance.
The RHA is to have members of the public among its governing body and
committees, which would also include health care providers and payors including third-party
organizations, public programs, and employers.
Exhibit 1 illustrates the important relationships among these members. RHA would
serve as a decision-making body, one which monitors the population's health, establishes a
basic care package, and sets standards of care. Exhibit 1 shows these standards-setting and
certification functions of RHA as dashed lines running toward both payors and providers.
RHA would also assure that unsponsored (uninsured) persons have coverage using funds
derived from a variety of sources including membership fees, as well as government
programs and philanthropy. Exhibit 1 shows the flow of membership fees from both payors
and providers as a solid line running toward the RHA.
Under this plan, the flow of funds to purchase health care would run, as it does now,
from payors (including third parties, employers, government, and individuals) to providers.
On Exhibit 1, these flows of payment are shown as shaded paths. The RHA would pay only
for the basic care package on behalf of the otherwise unsponsored. Employers could, if they
so desire, buy the basic care package for their workers through third party organizations
(insurers); employers could also deal directly with one or more primary care networks.
Similarly, individuals could purchase the basic care package either directly or through third
parties. (The role of third parties in organizing and financing the delivery of basic care is
22
�Exhibit 1
Regional Reform Plan
Primary Care
Networks
Secondary
and Tertiary
Providers
Membership/Fees
Payment for Services
Standards/Certification
23
�discussed further below.) Government programs, including Medical Assistance
(Pennsylvania's Medicaid program) and Workers Compensation, should be invited to
purchase the basic care package directly from the networks. Though inclusion of the
Medicare program for the elderly and disabled is desirable, this is probably not feasible in
the immediate future.
Primary care networks would either be integrated financing and delivery systems (like
HMOs) or they would be providers that contract with third party organizations to perform
financing and underwriting functions. Each network would either contain or contract with
secondary and tertiary care providers, thus enabling the network to provide all services
covered by the basic care package. The relationship between networks and the secondarytertiary tier of providers is shown on Exhibit 1 as a shaded box, indicating payment for
services through salary, fee, capitation contract, or other arrangement.
Under this proposal, individuals and third parties would retain the ability to purchase
health care services from non-network providers; however, the price for such care, either in
direct fees or insurance premiums, would be in addition to the price of the basic care
package.
Though the RHA would have no direct control over most of the health care dollars in
this system, it would influence spending through standards-setting and certification activities.
First, the RHA would define the basic care package and help to determine pricing parameters
for the basic care package to assure comparability among providers and thus to enhance
market-based competition. Next, it would certify networks both for financial responsibility
and for meeting quality of care standards. Payors and consumers could select among
networks using this certification as a guide, and networks could compete on the degree to
which each exceeds the minimal certification standards. Periodic open enrollments would
allow for change of network membership and would encourage inter-network competition on
the bases of quality and price.
This overview shows that the reform plan would redefine existing relationships within
the region's health care system and would redirect spending to give a high priority to basic
care and to ensure universal coverage in the population. Following is a more detailed
description of the plan's major elements.
24
�Regional Health Alliance (RHA)
This new organization must be broadly representative of all key decision-making
constituencies of the health care system as well as of the diverse communities within the
region. This is important for two reasons. First, the kinds of decisions which the RHA will
make require technical understanding and frank discussion and compromise among the health
care system's various constituencies. Second, the objectives that address understanding of
real health needs (Objective 1) and promoting cultural and ethical sensitivity (Objective 8)
require the direct input of the people who receive health care. Thus, the RHA should strive
to involve health care consumers, providers, payors, government, business, labor, educators,
private funders, and religious leaders.
Though broadly representative, the RHA should be administratively lean. It should
contract as necessary with experts in research, law, accounting, finance, and other fields to
support its activities, rather than hire a large, permanent staff.
Membership means participation in RHA's governance and decision making. RHA's
most important areas of decision making are:
•
To monitor the health status and determine the health care needs of the
region's people;
•
To establish a basic care package of services, consistent with and adjusted to
meet those health care needs;
•
To help control health service costs by advocating a balanced set of marketbased and regulatory approaches, within the context of eventual state and/or
federal health care reforms.
•
To negotiate an affordable level of region-wide investment in new health care
technologies and capital assets;
•
To certify participating health care delivery networks for financial
responsibility and quality of care;
25
�•
To develop a financial base of support to provide coverage for residents who
are otherwise unsponsored; and
•
To support the development of health care personnel and facilities in
underserved areas.
Each of these areas of decision making would be represented within the RHA
structure by a standing committee. In addition, there would be a Governing Board and a
Policy Committee. The Governing Board should have relatively few members; however, the
committees should include both Governing Board members and other participants to assure
broad-based geographic and interest-group participation in decisions. The eight standing
committees and their functions are as follows:
The Benefits Committee would develop a list of services that would constitute the
basic care package. This committee would also evaluate and adjust the package over
time, based on improved information about health status and needs of the population,
medical practice outcomes, and utilization patterns of network enrollees.
The Cost Committee would monitor health care spending, including amounts for
personal health care services and products and for systemwide capital assets and
equipment. It would recommend a per-person level of spending that would ensure
access to the basic care package, as defined by the Benefits Committee.
The Education Committee would be concerned with both professional and public
education concerning the mission, objectives, and specific activities of the RHA. It
would recommend health and wellness educational goals and priorities for schools,
workplaces, neighborhoods. It would develop educational programs and materials for
public education purposes. It would serve as RHA's liaison with the news media.
This committee would also recommend subspecialty training caps to medical schools
and otherwise monitor the needs for health care professionals for the use of training
programs throughout the region.
The Finance Committee would monitor the flow of dollars within the reformed health
care system and assure the adequacy of financial participation of government
programs (Medicare, Medical Assistance, and others), private payment, and RHA
membership fees. It would oversee the processes of obtaining government waivers
26
�and procuring care for unsponsored patients. It would also seek grants and
contributions for unsponsored care and special programs or innovations. It would
establish criteria for financial responsibility that would be applied in certifying
primary care networks.
The Health Status/Needs Assessment Committee would monitor health status, identify
problems and unmet needs, and suggest appropriate strategies for intervention. Its
recommendations would assist the Benefits Committee in defining needed care, the
Cost Committee in making resource-allocation decisions and in identifying
deficiencies of health manpower and services, the Research Committee in defining
studies to be done and evaluations to be conducted, and the Quality Standards
Committee in determining data to be collected from the certified networks.
The Policy Committee would prepare reports and make recommendations to the
Governing Board in all areas of RHA's mission and objectives. It would recommend
goals and objectives, evaluate program performance, prepare reports to the
community, and recommend changes and innovations.
The Quality Standards Committee would monitor both research on quality of care and
actual provision of care in the networks. It would serve as a conduit for research
information on quality of both medical practice and service administration for the
benefit of network providers. It would establish criteria for quality and outcomes of
care that would be applied in certifying primary care networks.
The Research Committee would contract with research organizations for utilization
analyses, outcome studies, policy analyses, and health needs evaluations. It would
recommend data needs and systems to benefit decision making by all the RHA
committees and Governing Board.
It is obvious that the concerns of these committees overlap. Their work and thinking
must be shared and brought together for decision-making by the Governing Board. Such
coordination could be achieved through interlocking membership among the committees and
particularly through representation of each standing committee on the Policy Committee.
27
�Primary Care Networks
These are integrated delivery systems that directly provide health care to an enrolled
population. They would bid for enrollment contracts from third parties, self-insured
employers, possibly individuals, and the RHA (for the otherwise unsponsored). The
contracts would obligate the networks to provide the full basic care package for a fixed price
per year per enrollee. This price should be "community-rated" - the same for all enrollees
regardless of health status or risk factors. However, with the goal of preventing selective
enrollment of healthier groups and individuals, prices should be adjusted for a risk factor
such as age that is a fair predictor of utilization.
Networks would be formed by and around physician group practices, hospitals,
HMOs, community health centers, and other primary care providers. The hub organization
of each network would contract with other providers for specialty care. By making the
network financially responsible for the total basic care of every enrollee, better coordination
of primary care, specialty care, and necessary social service support is likely to result. The
focus on primary care is key: the new system must reverse the status quo and shift funding
and decision-making power to primary care providers. If networks were organized by and
around tertiary care services, the shift of emphasis toward preventive and primary care
deemed necessary and desirable would be less likely to occur.
These networks must be designed to bear the financial risk of coverage for providing
the basic care package with the revenues made up of the total annual per-person payments
received from enrollees. They must be able to bear the risk of unexpected or exceptionally
costly care that might be needed by enrollees in a given year. Not all networks will be able
to do this on their own. They may lack not only the equity resources needed in case of
heavy losses but also the underwriting expertise needed to project and to plan adequately for
these. Therefore, third party organizations (including both insurers and HMOs) could supply
reinsurance by contract to individual networks.
Networks would be certified by the RHA as meeting minimum standards of quality
and financial responsibility. They would provide information and feedback to RHA
regarding utilization and the health status and needs of their enrollees. The RHA should
encourage networks to be flexible, innovative, and efficient with carefully conceived financial
incentives.
28
�People would choose a network through their enrollment sponsor (employer,
government, or RHA), with annual open enrollment periods. The sponsor might offer the
choice of two or more geographically suitable networks, perhaps including alternatives like
an HMO and a physician group practice. An individual's sponsor could be made transparent
to the provider of care, thus avoiding the potential stigma of welfare (for those who are statesponsored) or charity (for those who are RHA-sponsored).
Payors
This reform plan would leave in place the present roles of employers, third party
organizations, government, and individuals as payors for health care services; but the plan
would eventually modify their activities and interrelationships.
Employers. As already noted, employers could continue either to self-insure or to
purchase health benefits through third parties; they could offer their workers only the basic
benefits package, or they could offer this along with additional benefits for additional
payment. Employers' and employees' respective contributions to the price of benefits would
be subject to policy making within the employer organization or to negotiation between
employers and labor. However, employers could rely on RHA certifications and standards,
as well as its definition of basic care, to minimize or relinquish their present burden of
evaluating, selecting, and monitoring health plans and alternatives. Employees could use this
same information to select among the networks offered by their employers. To the extent
that price differentials among networks existed (say, the difference between an open,
insurance-model plan and a closed-panel HMO), both employers and employees could make
more informed decisions about how to spend their health care dollars.
Government. Governments are major purchasers of health care and their participation
in the reform plan is essential to assure adequate volume of enrollments as well as to
encourage private payors' confidence and participation. However, given the highly regulated
and specialized payment systems currently existing in the Medicare program, as well as the
federal bureaucracy associated with it, short-term inclusion of it in the reform plan is
unlikely. More probable is the incorporation of the state Medical Assistance program, which
is based largely on fee-for-service payment at present and which is widely perceived as
needing fundamental reform. Medical Assistance clients could be offered a choice of
networks in suitable geographic areas. They might be permitted periodic opportunities to
29
�change networks, corresponding to open enrollment periods for other people. The Medical
Assistance program should pay a per-client annual fee for enrollment that is the same as that
paid for other enrollees.
Workers Compensation is another government program that could be incorporated
into the newly reformed health care system. It is now a state-regulated program that is
financed through employers' premiums paid typically to private insurance carriers. It
provides payment for lost wages and medical expenses due to work-related injuries. If the
basic care package defined by the RHA were deemed adequate and if a fair and reasonable
additional payment could assure provision of care for workplace injuries, then Workers
Compensation could be included in the care provided by networks, resulting in "twenty-four
hour" coverage for workers. The wage component could continue to be financed separately.
The present cost-growth crisis of the Pennsylvania Workers Compensation system is one
reason in favor of this unified coverage; the managed care orientation of networks, based on
oversight and referral by a primary care physician, is another. Nevertheless, many technical
and political problems are likely to delay implementation of twenty-four hour coverage for
some time (Baker and Cantor 1993).
Individuals and the Unsponsored. Most people in this region will continue to have
health care coverage under a private employment-based plan, the federal Medicare program,
or the state and federal Medical Assistance program. Still, a sizable number, perhaps
hundreds of thousands, will be either employed where coverage is unavailable or unemployed
and financially unqualified for Medical Assistance. Some of these persons, perhaps 20%
(see Health Policy Institute 1988; and Appendix A, Exhibit 5), would have sufficient
personal income to afford the basic benefit package. These are individuals who could
purchase directly from a primary care network.
But the regional health care system should include all residents: this is a moral
imperative as well as an operational objective. Achieving this on the regional level is
difficult; achieving it without taxing authority is probably impossible. Ultimately, it is the
responsibility of government at the state and/or federal levels to assure payment for health
care coverage for all citizens. In light of past experience and political realities, a full
assumption of this responsibility may be years away. Therefore, the RHA should
immediately exercise its influence and mobilize financial resources toward achieving
universal coverage as soon as possible.
30
�Because of the limitations of RHA's authority and financial resources, coverage for
the otherwise unsponsored will have to be phased in over time. Financing for inclusion of
the unsponsored could be available in part from RHA membership fees paid by networks and
payors. Because the RHA is intended to help curtail the growth of health care costs, payors'
spending for basic health care coverage could be lower, and their membership fees could be
drawn from the savings. Because RHA's standards and procedures should enhance
efficiency, membership fees from networks could be drawn from their net cost reductions. A
major incentive for such participation should be the desire to overcome the present system's
inequity; a minor consolation could be the understanding that it is temporary, meant only to
curb the inequity while a comprehensive governmental solution is operationalized. It is
nevertheless clear that payment of these fees would represent a formalized "cost-shift,"
temporarily institutionalizing that which exists unquantified and informally in the present
health care system. Cost-shifting under this plan would only exist to pay for otherwise
unsponsored patients. It should not exist to relieve any payor of its fair share of the cost of
basic care.
Because of the large numbers of unsponsored residents, membership fees alone could
not meet the entire need for coverage. Other sources of support including public programs,
private philanthropy, and charity care will be needed. Furthermore, employers should be
encouraged at least to maintain their present levels of coverage and indeed to expand it to
those employees currently lacking it. Individuals should be encouraged to participate in
group plans to the extent they have both opportunity and financial ability to do so.
Eventually, state or federal law should require participation in health care plans by all
individuals.
1
Special Reform Capabilities of the RHA
The structure, functions, and relationships built into the RHA give it the capacity to
achieve important objectives and improvements. Some of these are essential to the vision
articulated in Section 2 of this report; others are not essential but are nevertheless desirable
in the long term.
'This recommendation was made by the Health Policy Institute in its report titled Health Care for the Medically Indigent in
Southwestern Pennsylvania (1988).
31
�Among the essential capabilities of the RHA are immediate attention to the problem
of access to care for the unsponsored of the region, pending a comprehensive federal or state
program to address this concern. Through local planning, the RHA could provide rational
control over health care and technology spending by providing a forum for region-wide
discussion and consensus. Through benefit design, it could force a shift of health spending
toward the areas of most important and common need: prevention and primary care. By
doing this, it can indirectly stimulate the creation of new primary care sites in underserved
areas and neighborhoods by expanding thefinancialresources available. By identifying
patients only according to their network enrollment, the RHA can reduce the payor class
discrimination feared or experienced by patients.
Given success and credibility in its major undertakings, the RHA could direct its
attention to additional health care delivery improvements. It could stimulate the use of case
management to coordinate care and social services using the best available models. It could
also provide a conduit for philanthropy, directing it to support unsponsored care, necessary
research, and pilot testing of innovative programs and policies.
A major benefit of RHA and its healthcare delivery networks could be to simplify the
multiple layers of bureaucracy and the demands of numerous different payors, all of which
create expensive administrative complexity for hospitals, physicians, and other providers.
The project team discussed the benefits of establishing a single set of claim forms to be used
by anyfinancingorganization in the region. An added benefit could be a centralized data
processing service, not organizationally connected to any payor, that could provide uniform
reports and feedback to meet the RHA's needs as well as the needs of consumers, payors,
and providers.
RATIONALE FOR REGIONAL ACTION
As of this writing, comprehensive health care reform plans are being shaped at both
the federal and the Pennsylvania levels of government. The Clinton Administration's White
House Interagency Health Care Task Force is working toward a self-imposed late summer or
early fall, 1993 deadline to make a reform proposal to Congress. This proposal will likely
contain major elements of the Jackson Hole Group's managed competition plan (Ellwood
1991; Ellwood and Etheredge 1991; and Enthoven 1991). The Casey Administration in
Pennsylvania is drafting legislation to enact elements of a reform plan developed by the
32
�Health Committee of the Governor's Economic Development Partnership (George and Tolson
1992; Casey 1993). These emerging federal and state plans share many elements in common
and, indeed, have strong similarities to the regional reform plan offered in this report.
With this apparent imminence of substantial government-mandated health care reform
that is at least consistent with what the project team believes to be best for the region, what
need is there for any initiative at the regional level at this time? The answer can be found in
an evaluation of all three plans using the project team's eight objectives (described in Section
2) as criteria. However, before making this side-by-side comparison, a brief overview of the
federal and state reform plans is useful.
The Federal Plan. Since the Clinton Administration has not yet unveiled a health care
reform plan in all its detail, this description is based on the Jackson Hole Group's writings
endorsed by the President during his campaign, as well as on press reports concerning the
work of the White House Interagency Task Force.
This plan is based on a concept called "managed competition" that has been described
by its principal architects, Paul Ellwood, Lynn Etheredge, and Alain Enthoven (1991) for the
so-called Jackson Hole Group. Its most important features are accountable health plans
(AHPs), health insurance purchasing corporations (HIPCs; more recently dubbed "Health
Alliances"), a National Health Board, and a trio of private oversight boards. AHPs could be
registered under one of two models: (1) a health care service provider that also serves as a
financing system, as does an HMO; or (2) the coupling of an underwriting organization and a
health care service provider. Each AHP would offer a standard set of health care services,
and any number of them would compete for enrollees within a given geographic area. AHPs
would be "accountable" to the public to produce favorable patient outcomes and to slow cost
increases.
HIPCs would purchase health care from AHPs on behalf of small employers and
individuals, who would thereby pool their purchasing power. Though large employers could
purchase health benefits directly from AHPs, they would nevertheless benefit from the
HIPCs' provision of standardized information about price, quality, and enrollee satisfaction
to assist in choosing among AHPs. The HIPC in a given state or region would contract with
with AHPs to conduct periodic open enrollments. It would also contract with participating
employers, and none could be excluded because of employees' health status or risks. In
33
�effect, the HIPC would take the place of an employer's health benefits department by
fulfilling the responsibilities of evaluating and selecting from among competing AHPs,
monitoring AHPs, and providing information about their relative quality.
This managed competition model includes the establishment of three private-sector
standards boards and one quasi-public policy board. The private boards include an Outcomes
Management Standards Board to provide the evaluation criteria for AHPs, a Health Standards
Board to establish "uniform effective health benefits" to be provided by AHPs, and a Health
Insurance Standards Board to establish underwriting practices. The quasi-public National
Health Board, modelled on the Securities and Exchange Commission, would be advised by
and provide oversight to the private standards boards. Subsidiary boards at state or regional
levels are contemplated in addition to the national-level boards.
Two elements of the Jackson Hole Group's plan are viewed as highly important.
First, to induce price sensitivity for health benefits and thereby enhance competition among
AHPs, the federal tax code would be changed to limit the tax exemption for employerprovided health benefits to an amount equivalent to the price of the lowest-cost AHP in a
region. Second, to assure competition based on price rather than extent of coverage, AHPs
would be exempt from compliance with states' mandated benefits laws that might be
inconsistent with the uniform effective health benefits package. It is not sure that there is
sufficient political support for these elements to guarantee their inclusion in the federal
reform package. In particular a segment of the Clinton Administration's health policymaking team favors "global budgeting" rather than purely market-based competition to limit
spending and thereby to assure cost-containment. Others in the Administration oppose such
regulation, as do some influential members of Congress. Thus, whether price controls will
exist in the eventual federal plan is uncertain.
The Pennsylvania Plan. The Pennsylvania Governor's Economic Development
Partnership recently issued the recommendations of its Health Care Committee (George and
Tolson 1992). This plan is also based on the managed competition model, though it
combines some functions of HIPCs and the national boards into a single statewide Health
Policy Board. The state plan would establish managed care networks (MCNs), which are
similar to AHPs. MCNs would offer community rating and open enrollment, be paid by
capitation, and report on and be accountable for costs and outcomes. Though not calling
specifically for HIPC-type organizations, the state plan does recommend that small employers
34
�create pools for the purpose of buying health care plans. The Health Policy Board would
establish a basic health care package, certify and monitor MCNs providing that package, set
a capitation structure for payment of the package, and oversee a bidding process to establish
MCNs' rates.
Like the Jackson Hole Group plan, the Pennsylvania plan would attenuate or break
the present strong link between the availability of health care coverage and the workplace.
Employers could have a lesser role than now in designing benefits packages. However,
unlike the federal plan, Pennsylvania's does not call for or depend on a federal tax code
change to enhance price competition among MCNs by limiting the exemption for employers'
health benefit costs. The Pennsylvania plan does not recommend a global budget or any
other regulatory price controls.
The Pennsylvania plan was given further specificity in a legislative proposal by the
governor (Casey 1993). New features included there were for a Clinical Advisory Council
to assist the Health Policy Board in defining the guaranteed benefit package and in raising
medical quality issues and for Community Health Care Partnerships to help the Board
identify local health care needs. Both the council and these partnerships appear to be
advisory only, since the proposal has no provision for decentralizing any of the Board's
important areas of decision making.
Meeting the Project Team's Objectives. In many ways, both the federal and the
Pennsylvania proposals mirror recommendations by the project team. However, neither of
these plans is designed as fully to meet all the objectives stated in Section 2 as is the regional
reform plan. Comparing among these plans is at present a speculative exercise, since none
of them has yet been subjected to the political-legislative process in which adjustment and
alteration are inevitable. With this caveat in mind, Exhibit 2 helps to illustrate the
comparative strengths and weaknesses of the three plans on the basis of features relevant to
each of the eight project team objectives.
Objective 1 is to identify and monitor the health status and service needs of the
population. Although both the federal and state plans offer ways to monitor the outcomes
and quality of patient care, neither calls for any attention to the health status or needs of the
much larger population of all enrollees. The regional plan does focus on this larger
population through continuing monitoring and evaluation and deliberate attention to
35
�Exhibit 2
Comparison of Federal, Pennsylvania, and Southwestern Pennsylvania Regional Reform Plans:
Do They Meet Regional Reform Objectives?
: p;Rejgionai' p
Objective ; •
:
:
llllFeiJerar f 0 §
Clinton Administration
1
Pennsylvania
Casey Administration
2
S.W. Pennsylvania
HPI Project Team
1. Identify and monitor the: health status: : Qualified Yes: AHPs to be judged on
and health service needs of the
standard health outcomes — including
population
clinical status, function, and
well-being - of patients (not
necessarily of enrolled or community
population)
Qualified Yes: MCNs required to
report medical outcomes to HPB on
patients; relevant, advisory role for
community health care partnerships
Yes: RHA to monitor health status and
needs of regional population
2. Assure universal access to basic
health care services
Yes: employer mandate; new tax
revenues & cost savings to pay for
unemployed; maintain or incorporate
Medicare & Medicaid
Yes: employer mandate; new Pa. tax
for children's coverage; incorporate
Medicaid & Worker's Compensation;
tighter requirements for charity care;
maintain Medicare
Yes: rely on state or federal employer
mandate and new Pa. children's
coverage; fold in Medicaid; maintain
Medicare; target charity care;
temporary institutionalized cost-shift
for unemployed
3. Assure payment for health services
that is fair & reasonable to both
payors & providers
Yes: Enhanced market-competition
through elimination of unlimited tax
exclusion for employment health
benefits; pooling of small group
purchasers; bidding by providers for
enrollees based on price; possible
"global budget" or other spending cap
Qualified Yes: reliance on enhanced
competition through expansion of
Multiple Employer Trusts; bidding by
providers for enrollees with guidelines
for capitation rates & limitations on
annual increases. Also, see Objective
#4, below
Yes: Negotiated per-person annual
payment for basic benefits package;
competition by providers based on
quality, location, amenities; RHA
over-sight of costs & revenues
4. Exercise control, over the
:•: dissemination of health care W\
technologies
Indirectly: through enhanced market
pressures for efficiency; possible
inclusion of limits on capital spending
through a "global budget"
Indirectly: through enhanced market
pressures for efficiency; optimizing
competitiveness through use of
HCCCC data; remove incentive to
over-utilize technology through tort
reform. NOTE: stronger Pa. CON law
passed,' which may enhance this
objective.
Directly: RHA to negotiate and
recommend regional limits on capital
spending and regional plans for
technology distribution, thus creating a
stronger foundation for CON decisions
:
ON
:
�Exhibit 2 (continued)
Regional
Objective
Clinton Administration'
Pennsylvania
Casey Administration
2
S.W. Pennsylvania
HPI Project Team
S. Encourage personal responsibility
in the use of health services and the
; exercise of sound personal health
habits
No explicit provision
Qualified Yes: employers to promote
wellness & prevention; insurers to
detect & mitigate fraud; no provision
directed toward individuals
Yes: including health promotion,
education, and awareness of social
burden of health benefits abuse
6. Improve coordination of services
within the health care system and
? between health & other social
sery ices: ||;: ;f
Indirectly: Uniform effective health
benefits to be delivered through AHPs,
which integrate services; no provision
as between health & other social
services
Indirectly: basic benefit package to be
delivered through MCNs, which
integrate services; no provision as
between health & other social services
Indirectly & directly: basic benefits
package to be delivered through
primary care networks, which contract
with & monitor secondary & tertiary
services; RHA to promote &
coordinate practice standards among
all the health professions and to
facilitate conduit between health &
other social services
Yes: quality to be monitored by three
national standards boards on medical
outcomes, technology and treatment
effectiveness, and insurance
underwriting practices
Qualified Yes: through optimal use of
cost & quality data produced by
HCCCC by purchasers of care, but
lacking administrative quality oversight
Yes: RHA to serve as conduct
between medical & administrative
quality researcher and primary care
networks by setting standards for
certification of networks
No written provision, but White House
Task Force has working group on
ethical implications of reform
No provision
Yes: through emphasis on local
primary care provider networks and
representation of local interests on
RHA & its committees
:
3
;
; 7. Maintain and enhance the quality of
care and the administrative aspects
of its delivery
:
8. Promote ethical & cultural
:: sensitivity toward patients and their
families : •
NOTES:
1.
As described by Ellwood (1991), Ellwood and Etheredge (1991), and
Enthoven (1991), aU for the "Jackson Hole Group"; and refined by statements
from members of the White House Interagency Health Care Task Force and
its staff.
2.
George and Tolson (1992).
3.
Pennsylvania Certificate of Need authority was renewed and broadened under
Act 179 of 1992.
Acronyms
Accountable Health Partnership (federal)
AHP
Certificate of Need; see note 3
CON
HCCCC Pennsylvania's Health Care Cost Containment Council, created in 1986
to collect data and report on providers' cost and quality performance
Managed Care Network (Pennsylvania)
MCN
Regional Health Alliance (regional)
RHA
�special-needs subpopulations. A system and process for doing this is presented in a
forthcoming Health Policy Institute study (1993).
Objective 2 calls for universal access to basic health care services. Among the three
plans, the federal (as stated by the Jackson Hole Group) offers the most realistic and
immediate action: to increase tax revenues so that anyone not covered by an employer's or a
government program can obtain the uniform effective health benefits directly through a
HIPC, which would be paid by federal subsidy. Both the Pennsylvania and the regional
plans rely heavily on existing programs and projected future savings to allow coverage of the
unsponsored; neither calls for new tax subsidies. Nevertheless, it appears that the very
feature of the federal plan that would make it most effective in covering the unsponsored - a
new tax ~ is its greatest potential barrier to immediate enactment. Congress may eventually
authorize this taxation, but a period of phase-in may well be used to soften its impact.
Meanwhile, the unsponsored will be denied access to basic care. Under this likely scenario,
the responsibility of the RHA to raise and then to channel funds from a variety of sources for
coverage of the unsponsored is especially important. The regional plan calls for a
commitment to this process, the feasibility of which would be enhanced if coordinated with
the implementation of Pennsylvania Act 113, the Children's Health Care Act. This new law
will help to pay for the health insurance of children who are ineligible for Medical
Assistance but who live in uninsured low- to moderate-income families. Using state funds,
coverage will be made available either free, at 50% of cost, or at cost.
2
Objectives 3 and 4 address the need for cost control, respectively through payment for
health services and spending for capital resources of health care. For controlling the price of
health services, all three plans depend heavily on enhanced competition among health care
providers. However, a recent study by the Congressional Budget Office questions the ability
of managed competition, without regulatory price controls, to slow the growth of national
health spending in the foreseeable future (Reischauer 1993). The federal plan, with its
explicit call for change in the federal tax code and its ability to impose a global budget on
health spending, probably has the greatest potential for cost containment among the three
plans. How strong it will be depends on Congress. The Pennsylvania plan offers no
2
Coverage under Act 113 will be free to the youngest (up to age 6) and poorest children (up to 185% of the federal poverty
line), and to older children (up to age 16, after a five-year phase-in) with family income up to the poverty line. Half-price
subsidized insurance will be available to children under age 6 with family income up to 235% of the poverty line. Coverage at cost
will be available to children who meet the age and income guidelines for free or subsidized insurance when the program's funds
are insufficient for them. Benefits will include immunizations; well-child and other office visits; outpatient, emergency, and
inpatient hospital care; prescriptions with a $5 copayment; and dental, vision, and hearing care.
38
�enhancement to market-based competition to achieve cost containment for health services.
However, the Commonwealth's newly broadened certificate of need (CON) law may enhance
the market's ability to discipline capital spending. The regional reform plan, which leaves
open the question of external price controls, would build upon the CON law by requiring
voluntary planning as the basis to determine the best allocation of capital resources to meet
health care needs.
Objective 5 is to encourage personal responsibility in the use of health services and
the exercise of sound personal health habits. For this, the federal plan makes no explicit
provision, and the Pennsylvania plan relies on the voluntary activities of employers and
insurers. The regional plan vests responsibility for educating the public in the RHA, which
must be accountable for this as for all its other functions.
Objective 6 requires improved coordination of services within the health care system
and between health and other social services. All three plans would indirectly address
coordination within the health system by requiring the single, accountable entity to provide a
full range of basic health benefits. The vertical integration of provider activities within such
an entity would tend to enhance continuity and comprehensiveness of care. Neither the
federal nor the Pennsylvania plan makes provision for coordination between health and other
social services; but, under the regional plan, the RHA is well-situated to address this.
Because of its broad representation of community leaders and its high visibility as an
accountable entity, the RHA is in an excellent position to access and be accessed by both
public- and private-sector social service providers. Thus, comprehensive solutions to social
problems with health aspects and implications can be developed, coordinating social with
medical interventions and community-based with institutional resources.
Objective 7 calls for the maintenance and enhancement of the quality of care and the
administrative aspects of its delivery. All three plans provide ways to monitor the clinical
quality of services, but only the regional plan explicitly addresses the administrative quality
of healthcare delivery by using the RHA as a conduit between researchers and healthcare
providers. There is no inherent reason why the federal and state plans cannot incorporate a
similar function in one of the health boards. Alternatively, private health care accreditation,
like that of the Joint Commission on Accreditation of Healthcare Organizations, can adapt
present "total quality improvement" standards to federal AHPs or Pennsylvania MCNs or
regional primary care networks.
39
�Objective 8 is to promote ethical and cultural sensitivity toward patients and their
families. At the federal level, the Jackson Hole Group plan is silent on this issue, although
the White House Interagency Task Force is known to have a working group on the ethical
implications of health care reform. Nor does the Pennsylvania plan speak to this objective.
The regional plan, however, is again well-suited to addressing these subjective aspects of
health care quality through broad representation of communities in the decision-making
agenda and processes of the RHA.
In summary, the similarities of the federal, Pennsylvania, and regional reform plans
mask substantial disparities in how each would address the eight objectives deemed by the
project team to be essential in pursuing the mission of the region's health care system. The
regional plan addresses all eight objectives; but the federal plan has no provision for
encouraging personal responsibility, and the Pennsylvania Plan makes no mention of ethical
and cultural concerns.
Overall, the strengths and weaknesses of the federal and state plans complement those
of the regional plan. The federal plan stands the best chance (theoretically, if not politically)
of creating systemwide assurance of universal coverage and of effective cost containment.
Its major weakness is the potential to create rigid or bureaucratic responses to problems that
are shifting, dynamic, and idiosyncratic - such as a population's health care needs, the
development of new health care technologies, and local culture and mores. The Pennsylvania
Plan could be important in the absence of or pending definitive federal action; it could gamer
statewide resources better than the regional plan. Compared with the state and federal plans,
the regional plan's focus on the health status and needs of people translates into closer
attention to rationalizing capital spending, mobilizing public awareness and personal
responsibility, coordinating the delivery of health and other social services, and enhancing
the ethical and cultural sensitivity of the system. Its major weakness is its lack of direct
control over the overall framework of health care financing.
Thus the ideal way to achieve the health care system envisioned by the project team
would be to implement the regional reform plan together with comprehensive reform at the
federal and/or state levels as outlined above. Coordination of regional activity with federal
and state reforms is essential.
40
�UNRESOLVED ISSUES
The regional reform plan described above, while addressing the fundamental
requirements of the project team's vision, nevertheless leaves many issues unresolved. These
include sources of authority and accountability for the RHA, geographic scale of regional
reform, the need for legislation in addition to competition to control cost growth, the
definition of basic health care, the inclusion of long term care, coverage for out-of-network
care, problems of rural and other underserved areas, payment for education and research,
and the need for federal and state program waivers. This is a formidable list of highly
important issues, but their resolution by the project team in the context of this project is
neither practical nor immediately desirable. First, the charge to this project team was limited
to defining a vision for health care reform in this region, establishing a structural framework
for the vision, and outlining actions necessary to put the framework into place. Thus, the
members did not focus on the resolution of the issues presented here, but only flagged them
as important for future attention. Second, many of the issues can be resolved only with
reference to pending state or federal health care reforms. Thus, an attempt by the project
team to answer them now would be impractical and, at best, academic.
In the discussion that follows, these unresolved issues are analyzed, and some
alternatives for their resolution are identified. While each of them is discussed separately,
many are interrelated. Their solutions will depend on the outcome of federal or state reform
legislation, on further technical study and analysis, and on further discussion and consensusbuilding.
Sources of Authority and Accountability
The RHA is conceived as an administrative, rather than an operating, agency
reflecting its mission, the leanness of its staffing, and its organizational structure. It appears
in this report as a purely voluntary agency, made up of participants who join due to a
combination of community-interest and self-interest. Thus, it may seem that such an
organization has insufficient influence over policy and decision making to accomplish its very
ambitious purposes. Furthermore, the RHA is envisioned as being the locus of
accountability to the region for its health care system. It must be true to the values and
needs of the people. Unfortunately, accountability to the community interest, as against the
41
�many individual constituent interests which RHA will face, may be difficult for a purely
voluntary agency.
The project team considered what sources of authority and accountability might be
tapped to strengthen the RHA. According to the classic definitions of French and Raven
(1959), organizational power or influence can be classed into five types: legitimate (i.e.,
legal or hierarchical), reward-based, coercion-based, expert-based, and referent (designated
to a natural or charismatic leader). Accountability follows from the source of authority: the
organization must answer in effectiveness to those who legitimate it through law, financial
investment, or otherwise. The process of selecting representatives is also a means of
accountability, which should therefore depend upon the eventual derivation of the RHA's
authority.
The RHA could exercise reward- and coercion-based influence through its
certification and standards-setting activities. It could also employ appropriate experts to help
resolve problems arising in the contexts of health status monitoring, coverage for the
unsponsored, benefits pricing, technology utilization and dispersion, and the medical and
administrative quality of services. To the extent that RHA serves as a financial funnel for
the purchase of health care for the otherwise unsponsored, it would be accountable to those
who contribute funds for this purpose. To the extent that RHA exercises influence using
rewards, penalties, and expert authority, it would be accountable to the constituencies that
are represented on its Governing Board and committees.
The RHA could rely upon referent power as an organization formed and sustained by
consensus of community leaders and health care decision makers of the region. Through its
individual and organizational members, the RHA could influence many constituencies
through consensus building and recommendations to urge the region's health care system in
the desirable directions. Of course, the ability of the RHA to influence decision making
depends heavily upon the willingness of decision makers to be influenced - that is, to give
up some autonomy. Whether and to what extent the health care system's constituents are
willing to relinquish decision making autonomy in the pursuit of the stated mission and
objectives are unknown.
More problematic than the other potential sources of authority and accountability for
the RHA is that type called "legitimate." It could be conferred on the RHA by federal or
state government and would carry the quid pro quo of public accountability. Thus,
42
�governmental legitimation for the RHA is highly desirable; the problem is in identifying a
feasible route for obtaining it. Several alternative sources for legitimation are apparent.
First, the newly strengthened certificate of need law in Pennsylvania (Act 179 of 1992)
provides for regional planning boards, and this is a role that the RHA could play. However,
the precise role of such boards has yet to be defined through the regulatory process, and it is
unclear whether the RHA would qualify as one. Second, the Governor's health care reform
plan as currently conceived does not call for a regional policy-making body (George and
Tolson 1992; Casey 1993). Certainly, regional leaders would want to be represented on both
the Health Policy Board and the Clinical Advisory Council, and the RHA's leadership could
fulfill such roles. Additionally, the RHA and/or its participants could fulfill the role of the
proposed Community Health Care Partnerships. Finally, the Jackson Hole Group plan and
the Clinton Administration's apparent leanings support HIPCs or Health Alliances at either a
state or a regional level, though at present it is unclear how much authority and responsibility
these would have. For a state like Pennsylvania, which encompasses geographically and
demographically diverse regions, designation of a several HIPCs rather than a single
statewide one seems to be a reasonable proposition. Given the purposes and functions of a
HIPC by the Jackson Hole Group (Enthoven 1991), it is conceivable that the RHA could
serve such a role.
Thus, none of the alternatives for governmental legitimation is a certainty at this time,
and the other sources of authority and accountability for the RHA ~ though necessary and
important - are weaker. A full resolution of this problem must await and take advantage of
opportunities that arise during the process of implementation, including the actions that may
eventually be taken by the federal and the state governments.
Geographic Scale of Regional Reform
An unanswered question is what geographic area should come under the RHA's
influence. Project team members represented organizations whose spheres of activity ranged
from as small as municipalities to as large as the state of Pennsylvania. It is useful to
consider this question in terms of the system's scale - its size relative to the various
functions and constituencies. The RHA has been described in the preceding pages as
influencing a single health care system. In reality, it would work among a set of subsystems.
While the ten-county Southwestern Pennsylvania area should be the initial target for
43
�implementing the RHA, attention should be paid to whether different geographic areas would
better accommodate the various subsystems.
For example, there is concern that smaller geographic and ethnic or racial
communities within the region have important needs that might be overlooked if priority
setting took place only at the regional level; even more so if such decisions were made at the
federal or state levels. Certain subpopulations of the region are known to have more serious
and complex health problems than others: the high mortality rate of infants in AfricanAmerican communities is an example. Thus, the content of the basic benefit package might
be better tailored to areas such as suburbs versus the inner city. In contrast, some
"subsystems" are arguably larger in scale than the ten counties. The market for tertiary
services provided in this region crosses state boundaries and, for some, extends nationally.
This region is also considered a net exporter of health care professionals, making the market
for this region's medical, nursing, and allied health education also statewide and multistate.
The implementation of this reform plan should be sensitive to this question of scale.
For some purposes, the region could be subdivided similarly to the internal division of the
old Health Systems Agency Region 6. Or, local subsidiaries of the RHA, analogous to
school boards, could be created to allow local communities some decision-making autonomy
over service configuration and spending priorities. When the scale of a subsystem is larger
than the region, the RHA should seek coordination with state regulators and licensing boards
and with state and national professional societies, advocacy groups, and trade associations.
In all of these subsystems the RHA should strive to maintain full and fair representations of
all constituencies of health care financing and delivery.
Although there are good reasons to provide for local autonomy (i.e., subregions) and
to create linkages with agencies and organizations outside of the region, both kinds of efforts
could tend to weaken the RHA. For example, if each local community could establish a
priority for targeting its own health service need (say, childhood accidental injury)
independently of all other communities in the region, then providing resources and expertise
for all these priorities could dilute the RHA's strengths and create administrative complexity.
Similarly, the RHA would not want any of its objectives to become the captive of interprofessional disputes or interest group politics. One of the problems for implementation will
be to balance the values of local autonomy and external connections with these potential
dangers.
44
�Competition versus Regulation to Control Cost Growth
The project team reached no consensus on the need for regulation in addition to
competition to control cost growth in the health care system. Many members of the project
team were doubtful that market-based competition among health plans would alone be
sufficient for this purpose, and these members believed that the RHA should serve as a
forum for negotiating and setting a fixed price for the basic care package. In the view of
these members, networks would compete not on price but on the bases of quality of care,
convenience of location and hours, optional coverage of non-basic services, and various
amenities. Initially, the RHA would have to make determinations about the level of spending
for the basic care package on the bases of estimates and a provider bidding process. In
subsequent years, better data about service quality and cost growth would permit more
precise adjustments. From year to year, spending limits could incorporate rate-of-growth
factors to allow for maintenance and improvement as well as inflation and changes in the
nature and extent of health care needs in the population. However this approach was
fundamentally different from the basis for competition envisioned by either the Jackson Hole
Group or the Pennsylvania plan, and the project team did not universally endorse it. Some
members were opposed to an explicitly regulatory role for the RHA, preferring instead the
market-based reform models. Still other members advocated a much stronger role for
government or the RHA in the form of a single-payor plan.
This lack of agreement mirrors the current debate within the Clinton Administration
and among members of Congress. It transcends political and ideological boundaries,
reflecting concern not only for the effectiveness of cost-controls but also for the affordability
(and thus attainability) of universal coverage. A federal resolution of this problem favoring
either the so-called "global budget" or the single payor model would effectively determine it
for the state and regional systems: both of these alternatives vest nearly full control at the
federal level. On the other hand, a policy allowing individual states flexibility in this matter,
is at least as likely an outcome of the federal debate (Havighurst 1993). State-level
determination of price-control policy suggests important roles for the region: the RHA could
provide advice to state-level decision makers and a model for replication elsewhere in the
state. Further regional debate and consensus-building around this problem are very much
needed but must be done with more certainty about federal health care reform policy than
now exists.
45
�The Definition of Basic Health Care
There are many problems surrounding need to define a package of basic benefits,
which would be made universally available under any of the three (federal, state, and
regional) reform plans. Among them: what should be included as basic care; who should be
permitted to make this decision; and how is it possible to assure that the guarantee of
universal basic health care is in fact affordable? In developing the regional reform plan, the
project team addressed all these questions together. Attempts are now underway to answer
these questions in the context of federal health care reform, and this is another issue on
which a resolution at that level would preclude any significant decision making at the state or
the regional level. However, resolution by federal legislation is nowhere near a certainty.
The very complexity of health care and the variability of people's needs over time calls for a
more flexible approach, one which turns over the definition to regulatory boards and agencies
and which can be decentralized in favor of state and regional autonomy. For this reason, it
is important for the problem of defining basic benefits to continue to receive close and
careful attention at the state and regional levels.
There has been some public debate about whether to call that package of services
which is included in a universal financing system "basic" or "standard." The difference lies
in the implication that basic care is a minimum and that standard care is richer - that which
people who currently have coverage would want to continue. In favoring "basic care," the
project team relied on the principle that care which is guaranteed to everyone must be within
the system's financial reach. In other words, if the financial constraints on the system would
mean that everyone could not have a rich "standard" benefits package, then the better choice
is to guarantee only a "basic" benefits package so that everyone is included. Thus, basic
services should be those that constitute a "floor" of care, below which no one is permitted to
fall. This principle surely leads to some form of rationing, but a commitment to universal
access, in the context of finite resources makes it inevitable.
The project team's decision to require that universal access should be guaranteed to
only that care which is basic raises important practical problems. First, a lean basic care
package for the region may be less coverage than is now mandatory for the Medical
Assistance and Workers Compensation programs; and, the leaner the basic care package, the
less likely it will be that those sponsored groups can be effectively folded into the regional
delivery system of certified primary care networks. This concern is relevant to the
discussion (below) about federal and state program waivers. Second, a leaner basic care
46
�package means that more "out-of-network" coverage will be sought by those who can afford
to pay for it. This implies that, even with the regional reform plan, a large and vigorous
health insurance market for richer coverage will exist. The disparities in quantity and quality
of health care between rich and poor, which account for much of the moral shortcoming of
the present health care system, are thus likely to persist. Thus, the process of defining basic
care, even though constrained by concern for universal affordability, must also be broadened
by the need to avoid multiple "tiers" of health care benefits.
Many organizations have in recent years developed lists of services that should
constitute basic health care, and any regional decision makers would have these to refer to
(State of Oregon for its Medicaid Program; Medicare standards for Medigap policies; the
Henry Ford Hospital recommendations; the Midwest Business Group on Health, 1993; the
federal HMO Act; and others). The project team believes that these lists should be
instructive but that none is acceptable as an end-product without first engaging in a process
of consensus-building.
The project team's approach to defining the basic care package is process-oriented,
rather than outcome-oriented. It requires attention both to who is involved in the process and
to what its framework for decision making should be. As to who should be involved, the
project team believes that physicians and other providers, payors, and consumers should
participate in a process of consensus-building. The interests and expertise of each of these
groups would balance and inform those of the others. Medical treatment decisions are
fundamentally based on the doctor-patient relationship. However, on a systemwide basis, the
question of who is entitled to what specific services and for what reasons cannot be answered
by unrestricted medical judgment and patient demand. Such decision making would be too
unpredictable and too expensive to finance on a universal basis. There also is concern that a
system of benefits designed entirely and exclusively by health care professionals would be
too expensive because the professionals would tend to seek an "ideal" level and quality of
service. Inclusion in the process of those with purchasing sophistication would help limit
spending. Inclusion of those who consume health services would assure rational trade-offs of
price, quantity, and quality of service for the highest priority needs.
As to the framework for decision making, the project team proposed a process that
begins with a macro-allocation decision at the systemwide level and then moves to microallocation decisions at the doctor-patient level. The macro-allocation question is: what
proportion of total resources should be devoted to (1) prevention and primary care,
47
�(2) curative and rehabilitative care, and (3) custodial and palliative care? The allocations
made initially would be subject to change based on the health status needs of the population
over time.
The micro-allocation decisions focus on who is entitled to what specific services and
for what reasons. These decisions should be made in the context of the individual patient's
quality of life and to the limitation of resources within the larger health care system. Much
research and innovation is currently being done to enhance this kind of decision making.
Outcomes research is being conducted on a wide scale nationally to yield better information
for doctors on how well various treatment protocols work in relation to alternative protocols
for the same diagnosis, and greater attention is being given to recognizing the patient's role
in making treatment choices (Wennberg 1992; Fortune 1992).
Given the RHA's mission and primary objective of serving the health needs of the
population, the process of identifying a basic care package should seek advice and expertise
from epidemiology and other public health disciplines. A detailed model for monitoring the
health service needs of populations, and for feeding appropriate information into resource
allocation decision-making, is provided in a forthcoming Health Policy Institute report
(1993).
Inclusion of Long Term Care
The population of Southwestern Pennsylvania includes a higher proportion of elderly
than that of the state or the nation. The growth rate of its very old cohort (those over 85) is
as high as anywhere in the country. While the elderly are by no means the only population
group that consumes long term health care services, they are the largest single group that
does so. For these reasons, inclusion of such services as extended institutional nursing care,
home care, and personal care living arrangements in the basic care package is a major
concern of advocates for the elderly among project team members. The obvious problem
with this is its expense.
A course of action within the context of systemwide healthcare reform has been
considered by a regional organization, the Southwestern Pennsylvania Partnership for Aging
(SWPPA), whose members include individuals, organizations, health care providers, and
government agencies who are concerned for the well-being of older persons. Its
48
�recommendations affirm that the major priorities of reform should be to achieve universal
access, cost control, and an emphasis on preventive care, with an expansion of the
"continuum of care" beyond traditional health benefits packages (SWPPA 1993).
Nevertheless, it recognized that:
It is clear that in a time of limited resources, all of our goals cannot be
met simultaneously. ... [rjhe three [major] priorities must take precedence in
health care reform over expanding payment for a broad array of long-term
care services. We do, however, believe that in many cases, the cause of cost
control will be best served by allowing flexible access to alternatives to acute
care. We also believe that restructured delivery systems on a State and
Regional level can demonstrate models of service which can later be included
universally.
The project team did not resolve this issue. Their recommendation is that every
health care service, including long term care, should be "on the table" for evaluation and
negotiation in the design of the basic care package. The concern should be to provide
needed care for the elderly as well as for others within the limit of available financial
resources.
Out-of-Network Health Care
Implementation of the regional reform plan needs to address two, mutually exclusive
and very different kinds of health care delivery that would remain outside its framework:
private purchase of non-basic benefit services and coordination with existing programs of
supplemental health care delivery and financing. Final resolution for both kinds of out-ofnetwork care will again depend largely on policies enacted at the federal level.
The reform plan permits individuals and third parties to buy health care services that
are not within the basic care package. The alternatives to this are probably untenable: either
(1) to effectively socialize the system, having government ownership and control of health
care resources, or (2) to prohibit providers from offering additional care for fees from
individual patients. Americans are unlikely to accept either of these. However, there is
concern that retaining the fee-for-service market for non-network health care services could
undercut the reform effort. Providers competing for the "extra" dollars of affluent patients
could perpetuate both the present inflationary race for technology and amenities and the
present disparities of health care available to the poor compared to the wealthy. Minimizing
49
�the impact of these problems could involve the pricing of non-network health care to make it
less affordable and therefore less desirable. There should be no subsidy for such care
through either RHA membership fees or, to the extent universal coverage is eventually
financed publicly, tax revenues.
Beyond the large-scale public and private programs that cover the health benefits of
most people, there is a vast system of supplementary health programs that have grown up
over the years to fill the present system's gaps in eligibility and benefits. A partial, but
important list of such programs, detailing their eligible target populations and the benefits
they offer, is shown at Exhibit 3. The total funding for health services available through
these various programs is not known, and they unquestionably serve health care needs that
would otherwise be unmet. However, they operate as bits and pieces rather than in a
comprehensive manner. Patients who benefit from these programs often do so without the
oversight of primary care physicians. To the extent that these programs provide services that
would fall within the defined basic benefits package, the RHA should attempt to incorporate
their resources within its networks. This could improve the quality of care available to
program patients as well as add to the RHA's financial support for otherwise uninsured
patients.
Problems of Rural and Other Underserved Areas
The managed competition model has been criticized for being unworkable in rural
areas, where fewer health service providers are available to compete (Kent 1993). This same
criticism is applicable to the regional reform model proposed here, since the ten counties of
Southwestern Pennsylvania include urban, suburban, and rural areas among which the
availability of health care providers varies widely. If the price or price range of a basic care
package were uniform throughout the region, then the regional reform plan might make rural
and otherwise underserved areas more attractive to providers. Furthermore, the regional
reform plan avoids a mandate that all approved networks be managed care organizations,
thus allowing rural primary care providers maximum latitude in forming relationships with
secondary and tertiary providers. Nevertheless, providing an adequate supply of primary
care professionals and facilities to all the areas currently underserved is a long-term task,
which will require coordination of payment, resource allocation, and educational policies at
all levels of authority and decision making.
50
�Exhibit 3
SPECIAL PROGRAMS OFFERING FINANCIAL ASSISTANCE
FOR HEALTH CARE SERVICES
ALLEGHENY COUNTY HEALTH DEPARTMENT, WOMEN, INFANTS & CHILDREN (WIC)
FOOD/NUTRITION CLINICS
Eligibility: Low income and medically high risk pregnant women, nursing mothers, and children less than 5 years of
age. Services: Nutrition counseling and vouchers for specified nutritious foods (13 sites).
DEPARTMENT OF PUBLIC WELFARE, MEDICAL ASSISTANCE/MEDICAID
Eligibility: Recipients of public assistance money grants or SSI payments. Other low income persons may be eligible
for services excluding dental care, prescription drugs, and medical equipment, supplies and prostheses under
"medically needy" designation. Services: Inpatient and outpatient hospital care, clinic care, medical equipment and
supplies, prescribed drugs, prostheses, and remedial eye care.
BLUE CROSS OF WESTERN PENNSYLVANIA/BLUE SHIELD, CARING PROGRAM FOR CHILDREN
Eligibility: Unmarried children from birth to age 19 of families with annua] income at or below 100% of federal
poverty guidelines and who are ineligible for Medical Assistance coverage. School-aged children must remain fulltime students through the 12th grade. Program covers Western Pa. residents. Services: Free primary health care
benefits. Includes emergency care, pediatric care, outpatient surgery, office visits, diagnostic and lab work,
immunizations. Enrollment: Program has served 17,000 children since its inception in 1985. Current enrollment is
approximately 6,000.
BLUE CROSS SPECIAL CARE PROGRAM
Eligibility: Income guidelines. Must not be eligible for Medical Assistance coverage.
EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)
Eligibility: Anyone under the age of 21 and eligible for Medical Assistance. Serivces: Physical exams, hearing and
vision testing, immunizations, growth and developmental assessments, dental exams, routine lab tests, help with
scheduling doctor appointments, and transportation assistance. Free follow-up care also includes free eyeglasses, free
hearing aids, and free braces.
HEALTHY START
Eligibility: There are no eligiblity requirements. There are currently six target areas being served; North Side,
Center City, East End, South Side, West End, and Duquesne/Braddock, however services provided are not limited
residents in only those areas. Services: Medical care focusing on prenatal and postnatal care, social services, and
referral services.
PACE PROGRAM
Eligibility: PA resident status for 90 days, age 65 or older, income below $13,000 for single person or $16,200 for
married couple. Must be ineligible for prescription benefits under Medical Assistance. Services: Assists with
payments for prescriptions, medications, insulin, syringes, and needles.
Rx COUNCIL OF WESTERN PENNSYLVANIA
Eligibility: Income limited to 150% of federal poverty guidelines. Must be ineligible for PACE, Medical Assistance,
or third party prescription benefits. Services: Vouchers for prescription drugs. Limited to immediate needs and
short-term assistance. Controlled substances are not covered. Program serves approximately 250 clients per year.
RYAN WHITE CARE FUND
Provides funds to persons with AIDS for a variety of expenses including medical services, prescriptions,
transportation, etc. The Pittsburgh AIDS Task Force provides limited emergency funds to persons with AIDS for
non-medical expenses.
51
�Exhibit 3 (continued)
ASSISTANCE WITH PRESCRIPTION DRUGS FOR SPECIFIC DISEASES
American Cancer Society - limited voucher program; American Kidney Fund -financialassistance with medications,
transportation and dietary needs; Leukemia Society of America, Inc. - up to $750/yr for anti-leukemic drugs, crossmatching and transfusion of blood, and transportation to and from treatment center; Myasthenia Gravis Association of
W. Pa., Inc. - provides medications at discount through Drug Bank Program.
IMMUNIZATION PROGRAMS
CDC Childhood Vaccine Program - provides childhood immunizations to children age 0-6 years, with emphasis on
age-appropriateness of vaccination; Allegheny County Health Department Influenza Vaccine Program - targets those
55 years and older and nursing home residents, with 21,500 doses given in 1992 by the Health Department and
78,000 doses that year for the Medicare Effectiveness Study; Travel, Allegheny County Health Department - provides
services for travelers in need of immunization at little above cost.
PENNSYLVANIA MENTAL HEALTH/MENTAL RETARDATION SYSTEM
Under the MH/MR Act of 1966, state funding is administered through counties for mental health services. Services
include inpatient, outpatient, and some community outreach.
52
�Education and Research
At present, much of the financing for the education of health care professionals
(primarily physicians) and for biomedical research comes from the federal government,
whose policies therefore dominate those efforts. Surprisingly little has been written about the
effects of health care reform on these financing systems, but it is reasonable to expect that
the federal government will continue both funding and policy making. Regionally, the
project team recommends that federal policy making should address all the health-related
professions in a coordinated fashion. Especially important are questions concerning the
proper roles of physicians and physician extenders in providing primary care in rural and
other underserved areas.
Recently, the Pew Health Professions Commission (1993) considered the problem that
the current educational system for health service professionals is "out of sync with the needs
of the health care system that is emerging" (p. 1). A number of its recommendations are
particularly relevant to the regional reform plan offered here:
Review the current policies of funding graduate medical education
through the Health Care Financing Administration, and develop a plan to
ensure that at least 50 percent of the nation's residency positions are in
primary care areas and expanded primary care training in other
relevant disciplines (p. 23).
* * *
Encourage experimentation of health care delivery models at the state
level by streamlining the waiver process for variance from Medicaid and
Medicare guidelines (p. 23).
* * *
Create statewide coalitions to assess the long-term health care needs of
the population and relate those needs to the states' investment in health
professions education. The coalitions should be comprised of high-level
representatives drawn from all relevant constituencies. These should be linked
to ongoing efforts to reform state health policy (p. 24).
The project team agrees that the financing of biomedical research and health
professional education must be rethought in light of health care reforms. In particular, the
members believe that educational institutions should not passively await governmental
53
�incentives or mandates but should be proactive in helping to achieve appropriate ratios of
primary care and specialty providers.
Need for Federal and State Program Waivers
Restructuring the regional health care system as is proposed here will require the
participation of employers who buy health care plans as well as of existing governmentsponsored health care programs. The latter include the federal Medicare program, the
federal-state Medical Assistance program, and the state Workers Compensation program.
Bringing these payors into the new system is problematic.
At present, many employers in Southwestern Pennsylvania do not participate in
private health insurance plans which are designed, marketed, and administered by
organizations licensed and overseen by the state. Rather, these employers either provide no
health benefits to their employees or they self-insure their own health benefit plans. Noninsuring employers tend to have small workforces, but together they employ a large and
growing percentage of all the region's workers. Self-insured employers tend to have many
employees, not all of them residing locally. Self-insurance is a growing trend among large
employers as insurance premiums continue their relentless inflation.
Implementation of the regional reform plan depends on participation of many if not all
of these employers. If the Pennsylvania plan were fully enacted, all employers in the state
would be required to offer health benefits. However, current federal law would probably
prevent enforcement of this mandate on self-insured employers, whose benefits packages
might differ significantly from the "basic" package. The federal Employee Retirement
Income Security Act (ERISA) exempts self-insuring employers from state-mandated insurance
coverage. Thus, without either a federal ERISA waiver or a mandate for employersponsored health plans enacted by federal law, private employer participation in the regional
reform plan may fall short of universal.
There is also a problem with government participation. Among the government
payors, participation of the Medicaid program, is perhaps the most crucial, at least at the
early stages of implementation. The Pennsylvania Medicaid or Medical Assistance (MA)
program has benefits and eligibility standards that are in part the result of federal mandate
and in part the result of state regulation. To the extent that the RHA's basic care package
54
�were leaner than the package of MA mandated benefits, its coverage would be out of
compliance and its providers could not receive MA reimbursement.
Furthermore, MA uses largely a fee-for-service payment model. Pennsylvania
currently has authority to experiment with capitated payment, and some MA recipients are
covered by managed care organizations. However, there is still the potential for substantial
disparity in available MA payment and RHA's basic benefits package. At present, MA pays
managed care organizations individually negotiated, monthly capitation fees that currently
approximate 90% of the average MA recipient's total monthly fee-for-service charges. If the
basic benefits package were defined to include services that MA either limits or excludes
(such as substance abuse treatment and certain mental health services), payment from the
state on behalf of MA recipients could be inadequate.
Therefore, the enrollment of MA recipients into the RHA system would probably
require negotiation with both federal and state authorities leading to waivers of various
Medicaid program requirements. To have the participation of Medicare beneficiaries, similar
problems concerning mandated program benefits would require negotiation with federal
authorities and additional waivers.
Other Issues
The foregoing unresolved issues are largely matters amenable to resolution through
the political process, technical study and analysis, or RHA-sponsored negotiation and
compromise. The project team was concerned also about a group of issues that are important
but perhaps more difficult to resolve and perhaps even beyond the scope of any initial reform
plan. Among such issues were:
•
How and whether to pool responsibility within the region or other geographic
areas for the capital debt burden of the present health care system that may be
created by the down-sizing of institutions.
•
How to deal with health care job losses resulting from shifts in financing and
service delivery patterns and priorities within the system.
55
�•
How to restructure specialty referral systems in a way that clarifies the role of
tertiary providers and assures their continued vitality.
These issues may defy resolution solely at the regional level. However, the project
team believes that sensitivity to them should influence the process of implementing health
care reform here as elsewhere.
56
�Section 4
STRATEGY: RECOMMENDATIONS FOR IMPLEMENTATION
�The preceding two sections of this report offered a vision - a mission and set of
objectives for the regional health care system ~ and a decision -- a plan that embodies the
vision. This section discusses a strategy for translating the plan into action. The six
recommendations presented here can be seen as a blueprint for regional leadership to begin
building toward reform. The character of these recommendations is structural and global for
the regional health care system, rather than policy-oriented or narrowly focused.
Throughout this report, the project team's judgments and consensus opinions are
stated about important policy matters. These are found especially in the discussions of
objectives (Section 2) and unresolved issues (Section 3). The members intend for these
opinions and judgements, weighted by the fact that they were reached through long and
careful consideration, to influence the process of implementing reforms. Nevertheless, these
ideas are not presented here as recommendations. The project team's given task was to
determine what structural framework could best support desirable health care reforms in the
Southwestern Pennsylvania region and to recommend how this framework can be put into
place.
Thus, it is strictly within a narrowly defined task that the project team makes these
six recommendations. The first five are addressed to decision makers in business, labor,
health care, and philanthropy. The final recommendation is addressed to these leaders and
also to the people of this region who are, and should be, the ultimate decision makers about
their health care system.
Recommendation 1:
Regional leaders should assume responsibility for implementing the reform plan.
The reform plan presented in this report includes the formation of a Regional Health
Alliance (RHA) and the organization of primary care networks. But even before such a plan
can be implemented, it must be examined and endorsed by regional leaders. These should
include individuals and organizations whose authority in the region derives from their
economic dominance, financial resources, electoral support, or health policy expertise.
Southwestern Pennsylvania has a long and successful history of this kind of leadership by
partnership, and the present crisis in health care warrants it now.
59
�The implementation strategy that such a leadership group should pursue is presented
here in the next five recommendations which concern legitimation of the RHA, technical
support, financing, and public education and involvement.
Recommendation 2:
Membership in the RHA should be broadly inclusive of all constituencies
that influence, and are influenced by, the health care system.
The nature and scope of activities envisioned for the RHA require that it has
considerable influence over health care decision makers, including doctors and institutions,
third parties, employers, and the public at large. In a sense, the project team has negotiated
a consensus about regional health care reform, and its members are representative of many of
these same decision makers. To some extent, each project team member may have an ability
to influence his or her own constituency to cooperate in the implementation and operation of
the reform plan. But that ability is limited. Each constituency is large and diverse, and no
single person can speak for it. Any constituency confronted with this plan will see
challenges to its economic, cultural, and/or professional interests; and any could withhold its
support and participation.
The key to implementing this or any other reform plan is the willingness of decision
makers to be influenced -- that is, to give up some decision-making autonomy in the interest
of achieving the consensus vision. Without this willingness and agreement, reforms will be
illusory. Every constituency will retain some ability to "game the system" to its own
advantage, regardless of how the system is structured. That is not only unavoidable it is,
given a pluralistic system, in many ways desirable. However, the emphasis must be on each
constituency being able to see its own advantage in terms of the good of the whole system.
In the earliest stages of implementation, as well as in constituting the RHA's
Governing Board and standing committees, the following constituencies should be sought out
and represented:
Community Organizations
Educators (health & professional)
Government (elected & appointed)
Labor
Payors
Religious Leaders
60
Consumers
Employers
Health Care Providers
Media
Philanthropies
�Recommendation 3:
The formation of the RHA should leverage all available forms of
governmental legitimation.
The RHA will be most likely to succeed if it has govemmentally sanctioned
legitimacy. A number of models could confer this, including legislation (state or federal),
regulation (such as will be promulgated under the amended Pennsylvania Certificate of Need
statute), and judicial. None of these models should be foreclosed, and all should be
explored. This type of legitimacy is particularly important and desirable because it clearly is
given with ties of accountability. An RHA that has governmental authority will necessarily
have to answer for its efficiency and success in achieving stated goals. In fact, a state or
federal "managed competition" reform model would create Health Standards Boards or
Health Insurance Purchasing Cooperatives (see Section 3, above) whose functions apparently
mirror those proposed for the RHA. Under such a reform model, the RHA could take on
the regional level functions of such boards or cooperatives.
Lack of government sponsorship or sanction in the short term should not, however,
be viewed as fatal to the regional reform plan. The dynamics of reform at the state and
federal levels are likely to offer many opportunities for the regional effort, including sources
of authority for the RHA that are not now apparent.
Recommendation 4:
Technical support for implementing the reform plan should be drawn
from organizations with relevant expertise on a voluntary or contractual
basis.
As noted in Section 3, numerous technical issues and policy problems will require
attention and resolution if the reform plan is to be implemented. Nevertheless, there is
concern that, both in implementation and eventual operation, the reforms should not create
new bureaucracies. In order to have both the necessary expertise and administrative
leanness, the reform plan's initiators should recognize and call upon this region's
professional, educational, and research organizations for assistance on a voluntary or
contractual basis. Additionally, many federal, state, and local initiatives for health care
61
�reform are currently underway elsewhere and are facing the same or similar issues and
problems. Drawing upon that accumulated expertise should be done through consultantships.
Recommendation 5:
Implementation should be Financed through government and private
sources.
The process of implementing the reform plan will require financial support, including
for organization, administration, and technical problem solving. Operation of the RHA may
require start-up funding for a time prior to when membership fees are sufficient to sustain it
and to provide coverage for the uninsured. Many financial sources could be tapped, for
these purposes. Federal and state health care reform initiatives might offer funding for a
local pilot project like the RHA. Major national philanthropies have in the past and may
continue in the future to offer similar pilot project support. Locally-based philanthropies and
corporations have a direct interest in implementing the reform plan proposed here; they
should become involved both as financial supporters and decision makers in the earliest
stages of implementation.
Recommendation 6:
A program to raise public awareness of and stimulate public involvement
in health system reforms should be conceived and implemented.
None of the foregoing parts of an implementation strategy are more important than
educating the public about the need for health care reforms and involving the public in
refining this reform plan and putting it into place. Creating a regional reform model such as
this will require acceptance of new patterns of health care delivery and superficially
undesirable limitations on health benefits. It is not at all certain that much of the public
living in this region yet recognizes that change of this magnitude is needed. Without such
understanding, and the support that would flow from it, implementing reforms - regional,
statewide, or national ~ cannot be done. National surveys indicate that, while the public
wants health care reforms, it does not know enough to choose among alternative reform
plans. According to one veteran public opinion surveyor, Americans seem now to focus on
waste, fraud, and abuse in the present health care system as its only major flaws as a way to
avoid facing up to deeper problems (Yankelovich 1992). This view was confirmed by a
62
�study of the Public Agenda Foundation (Immerwahr, Johnson, and Keman-Schloss 1992),
which went on to recommend that:
Leaders should not expect quick solutions. Americans' current
attitudes took years to develop, and, in many ways, they are an accurate
reflection of what leaders have explicitly or implicitly told them for decades.
Change in their deeply-held values will come only gradually.
The public education that is needed in the immediate short-term can begin in a
number of ways. Advocates for reform in the region should meet with community leaders
and their constituencies to explain why it is needed and what economic and personal costs it
will require. Involvement of the media in this educational effort is important, particularly
the print media. Participation of recognized community and corporate leaders in the early,
formative stages of the RHA would allow these leaders to help in the process of educating
their constituencies and in molding the reform plan to the needs and desires of those
constituencies.
63
�REFERENCES
�Baker, L.C., and A.B. Krueger, "Twenty-Four-Hour Coverage and Workers' Compensation
Insurance," Health Affairs Supplement: 271-281 (1993).
Casey R.P., Pennsylvania Health Security Act. Governor Robert P. Casey's proposal to
reform the state's health care system and provide real health security to all Pennsylvanians.
Harrisburgh, PA: May 19, 1993.
Ellwood, P., for the Jackson Hole Group, "The 21st Century American Health System,
Uniform Effective Health Benefits," Policy Document #3 of 4, September 4, 1991.
Ellwood, P., and L. Etheredge, for the Jackson Hole Group, "The 21st Century American
Health System, Overview and Accountable Health Partnerships," Policy Document #1 of 4,
September 3, 1991.
Enthoven, A., for the Jackson Hole Group, "The 21st Century American Health System,
Market Reform and Universal Coverage," Policy Document #2 of 4, September 4, 1991.
Fortune, "Let's Really Cure the Health System," pp. 47-58, March 23, 1992.
French, J.R.P., and B.H. Raven, "The Basis of Social Power" in Studies of Social Power,
edited by D. Cartwright, pp. 150-167. Institute for Social Research, Ann Arbor, MI: 1959.
George, W.M., and J.H. Tolson (co-chairmen), Managed Competition: A Health Care
System for Pennsylvania. A report of the Pennsylvania Economic Development Partnership
Health Care Committee, Harrisburg, PA: November 1992.
Goldsmith, J., "A Radical Prescription for Hospitals," Harvard Business Review May-June:
104-111 (1989).
Havighurst, C , "Clinton and Congress: "Satisficing" Their Way to Health Reform,"
Medicine & Health, Perspectives. Healthcare Information Center, Faulkner & Gray,
Washington, DC, May 10, 1993.
Health Policy Institute, Health Care for the Medically Indigent in Southwestern Pennsylvania,
HPI Policy Series #16. University of Pittsburgh, Pittsburgh, PA: 1988.
Health Policy Institute, A New Health Care System for Southwestern Pennsylvania: Part A Focus Group Interviews, HPI Policy Series #18-A. University of Pittsburgh, Pittsburgh, PA:
1992.
Health Policy Institute, Health Care Needs of the Community: Implications for Health Care
Reform, HPI Policy Series #19. University of Pittsburgh, Pittsburgh, PA: 1993
(forthcoming).
Immerwahr, J., J. Johnson, and A. Keman-Schloss, Faulty Diagnosis. Public Misconceptions About Health Care Reform. Public Agenda Foundation, New York, NY: 1992.
67
�Kent, C, "Managed Competition in Rural Areas: Will the Seed Take?" Medicine & Health,
Perspectives. Healthcare Information Center, Faulkner & Gray, Washington, DC: March
15, 1993.
Midwest Business Group on Health, "MBGH Meets with Jackson Hole Group," Bulletin:
January-February 1993.
Reischauer, R.D., "Statement of Robert D. Reischauer, Director, Congressional Budget
Office, before the Subcommittee on Health, Committee on Ways and Means, U.S. House of
Representatives," February 2, 1993.
Southwestern Pennsylvania Partnership for Aging, "Position Paper, Health Care Reform,"
Warrendale, PA (undated; unpublished).
Pew Health Professions Commission, Health Professions Education for the Future: Schools
in Service to the Nation. USCF Center For the Health Professions, University of California,
San Francisco: February 1993.
Wennberg, J.A., "AHCPR and the Strategy for Health Care Reform," Health Affairs 11 (4):
67-71 (1992).
Yankelovich, D., "How Public Opinion Really Works," Fortune, October 5, 1992.
Yoder, S.G., "Profits and Health Care: An Introduction to the Issues," chapter 1 in ForProfit Enterprise in Health Care, Committee on Implications of For-Profit Enterprise in
Health Care (B.H. Gray, ed.). National Academy Press, Washington, DC: 1986.
68
�Appendix A
STATUS QUO AND PRESENT TRENDS
�The preceding report offers a plan to reform the health care system of
Southwestern Pennsylvania; this Appendix provides background to explain why reform is
needed. In many ways, the health care resources of Southwestern Pennsylvania are
outstanding. Hospitals are large, well-equipped, and staffed with highly trained and
motivated professionals. Physician supply is as good or better than anywhere in the
country. Biomedical research conducted here is world class. Absent are such problems
characteristic of other localities as "dumping" uninsured patients and overcrowding of
emergency departments. By these standards, health care here works very well indeed.
Nevertheless, this region's system has serious problems. It is seen as too
concerned with its own vitality and too little concerned with the needs of people.
Providers' resources are typically not allocated according to rational, health-related
objectives but rather in response to reimbursement incentives. Further, the components
of the present health care system are seen as disconnected and insulated from each other,
resulting in patient care that lacks continuity. Health care is also delivered without
sufficient regard for broader social and economic problems, which often have profound
implications for people's health. Technical quality is one of the highlights of American and of Southwestern Pennsylvanian ~ health care. But this has created a negative
tendency toward rendering care in an impersonal and administratively top-heavy manner.
Two fundamental and mutually aggravating problems are characteristic of this
region's health care system: many people are uninsured or otherwise unable to pay for
the care they need, and the cost of care is escalating relentlessly. These are of course the
same two fundamental problems plaguing the national health care system. In the
following pages, the regional specifics of these problems are defined and analyzed.
DECLINING ACCESS TO HEALTH CARE
Barriers to essential health care are affecting ever greater numbers of people in
Southwestern Pennsylvania, as elsewhere in the state and nation. Though individuals of
any age, family status, or place of residence may have difficulty in accessing needed
services from time to time, at least three groups now experience structural access
problems. The elderly as a group depend on Medicare coverage, but that program has no
prescription drug or long-term nursing care benefits. Low-income families, especially
single mothers and their children, face difficulties in finding both primary and specialty
A3
�care for a combination of reasons including low and slow Medicaid payments to providers
and cultural dissonance between themselves and providers. Rural residents face
geographic barriers to health services, in addition to these others.
Explaining the barriers faced by the regional population can be done in terms of
four major problems and trends: failure to define "basic" health care; lack of adequate
financial coverage; an increasingly elderly population; and a chronic undersupply of
services in rural areas. Each of these is addressed in turn.
"Basic" Health Care
It is generally agreed that preventing illness and maintaining optimal health makes
sense by tending to avoid more expensive curative care later on. But the concept of
favoring prevention and primary care has never been translated into a practical list of
basic health services that everyone should have to guarantee optimal health. Without
this, spending priorities have not been established that reflect the common wisdom.
In part, this failure is due to the way in which health services have usually been
financed: through insurance. From a purely economic standpoint, insurance is best
suited to paying for low-frequency, high-cost services like hospital care; by comparison,
insurance is a wasteful way to pay for high-frequency (i.e., predictable), low-cost (i.e.,
relatively affordable) services like office visits. Therefore, traditional insurance has
paid for the latter and not for the former.
1
Because of this, insurance benefits almost by definition allocate health care dollars
in ways that do not correspond to the most common, ordinary health care needs of
people. And as the most ordinary health care services become increasingly expensive,
even people having health care coverage face limitations on their access to much-needed
care. Some examples are exclusions of coverage (such as prescrptions and intermediate
nursing care by Medicare), limitations of coverage (such as outpatient mental health or
substance abuse treatment by private plans and Medicaid), and cost-sharing (deductibles
and copayments). Attempts by Pennsylvania, as by virtually all state governments, to
'Feldstein, P.J., Heallh Economics. John Wiley & Sons, New York: 1988, pp. 114-122.
A4
�remedy this problem with mandated coverage for high-frequency service needs are
blamed for making insurance benefits more expensive.
Typical employer- or government-sponsored health benefits nevertheless remain
concentrated in acute care. Exhibit 4 shows selected health care services and their
coverage by the major payors, including Medicare, Medicaid ("Medical Assistance" or
MA in Pennsylvania), Blue Cross-Blue Shield with major medical, and typical health
maintenence organization (HMO) benefits. Services are divided broadly into three
categories: preventive/primary, acute, and chronic/long term. Clearly, the most
uniformly covered category of benefits is acute, where all of the services listed are
covered by all payor types. Less fully covered but still addressed at least in part by all
payor types are services in the chronic/long term category. Least covered of all services
are those in the preventive/primary category. Among the payors, Medicare covers almost
no such services; Medicaid and the Blues cover some, often with significant limitations;
and HMO-type plans tend to cover most of them.
The fact that preventive and primary care are typically not paid for by insurance
plans leads to their being undervalued and deemphasized by health care providers. The
traditional training and interests of physicians, whose decision-making dominates health
care delivery, compound this shortcoming. Since prevention is not their primary focus,
access to preventive care is often problematic. Conversely, since physician training and
interest emphasize technology-intensive acute care, access to such expensive services is
for many patients easier. Other factors also contribute to poor access to preventive
services. For example, the tort liability system is perceived to have had a negative effect
on the availability of vaccines for children, since product liability insurance premiums
paid by vaccine manufacturers drives up their costs.
Some major health problems in this region have causes that, though complex, may
be grounded in poor access to primary care. Among these, the mortality rate of AfricanAmerican infants is a prime example. According to the Allegheny County Health
Department in 1990, 24 per 1,000 of Pittsburgh's black children had died before their
first birthday, a rate more than four times that of white children. Studies, both national
and local, have failed to explain definitively this disproportionate death rate; however, the
A5
�Exhibit 4
Major Payor Coverage of Selected Health Care Services
Medicare
Medicaid
The Blues/
Major Med.
Dental
No
Limited
Limited
Limited
Education
No
No
No**
Yes
Prenatal
N/A
Yes
Yes
Yes
Rx drugs
No*
Limited
Limited
Limited
Screening
No
Yes
Limited
Yes
Well-child
No
Yes
Yes
Yes
Vaccines
Limited
Yes
Yes
Yes
Vision
No
Limited
Limited
Limited
Diagnostics
Yes
Yes
Yes
Yes
Emergency
Yes
Yes
Yes
Yes
Inpatient
Yes
Yes
Yes
Yes
Outpatient
Yes
Yes
Yes
Yes
Home health care
Yes
Yes
Yes
Yes
Hospice
Yes
Limited
Yes
Yes
Mental health
Yes
Yes
Yes
Yes
--skilled
Yes
Yes
Yes
Yes
-intermediate
No
Yes
No
No
Personal care homes
No
No
No
No
Rehabilitation
Yes
Yes
Yes
Yes
Service
HMQ/PPQ
Preventive/primary:
Acute
Chronic/Long Term:
Nursing
*
Except inpatient-prescribed drugs, which are covered.
Except by special employer-group contract.
A6
�fact that many of these black infant deaths occurred within three months of birth points to
poor maternal health and inadequate prenatal care as important causative factors.
2
Rational prioritizing of health care services should depend on detailed, up-to-date
information about the health status and health risk factors in the regional population.
Available data suggest that many frequent causes of morbidity and mortality in the
regional population are preventable, though such data do not provide a full or complete
picture of the population's health status and needs. For example, trends of certain
diseases suggest that treatment and prevention are especially needed for high regional
incidences of breast cancer, lung cancer, measles, AIDS, tuberculosis, suicides and
homicides. However, data describing the frequency of nonreportable diseases are not
readily available, and health risk factors are not measured at the regional or county level.
3
Without reforms, the tendency to spend disproportionately on acute care is likely
to persist. The public sector will continue to target assistance to crises and to those most
in need (including the elderly and the very poor), with the unintended result of giving low
budgetary priority to prevention efforts.
Uninsuranee and Underinsurance
A study conducted in 1987 revealed that Southwestern Pennsylvania had the state's
highest proportion of uninsured residents. As shown in Exhibit 5, 10.9% were
uninsured here, compared to 8.6% in the state as a whole. The four-county metropolitan
area of Pittsburgh had an even higher rate: 14.6%. Nearly one-third of the state's 1.02
million uninsured lived in the southwestern region.
4
Since then some private insurers, notably Blue Cross of Western Pennsylvania,
have developed and offered plans targeted to low-income families and children. The
Commonwealth of Pennnsylvania has recently enacted a Children's Health Insurance
Jewish Healthcare Foundation of Pittsburgh, Ear to the Ground. A Study of Black Infant Mortality in the Greater Pittsburgh
Area. Pittaburgh, PA: March 1992.
'Health Policy Institute, Health Care Needs of the Community: Implications for Health Care Reform, HPI Policy Series
University of Pittsburgh, PitUburgh, PA: 1993 (forthcoming).
* Lewin & Associates, Health Care for the Medically Indigent in Pennsylvania, Analytic Report prepared for the Pennsylvania
Health Care Cost Containment Council, Harrisburg, PA: June 1988.
A7
�Exhibit 5
Characteristics of the Uninsured,
Pennsylvania, 1987
Number of uninsured:
1,020,000
Proportion of population:
Statewide
S.W. region*
Pittsburgh PMSA**
8.6%
10.9%
14.6%
Geographic distribution:
S.W. region*
Pittsburgh PMSA**
333,000 (32.6%)
240,720 (23.6%)
Income distribution of uninsured:
Less than 100% of FPL***
Between 100% and 150% of FPL
Between 15% and 200% of FPL
More than 200% of FPL
46.6%
23.7%
8.0%
21.7%
Uninsurance rates of racial subpopulations:
White
Black
Other
7.8%
15.0%
13.7%
Employment status of uninsured adults:
Full-time
Part-time
Unemployed
Retired or dependent
33.6%
18.6%
19.7%
28.1%
Age distribution of uninsured:
Less than 6
Between 6 and 17
Between 18 and 64
Over 64
12.6%
16.1%
68.5%
2.8%
*
***
Includes Somerset County, as well as 10 S.W. Counties
Includes Allegheny, Fayette, Washington, & Westmoreland
Counties
Federal poverty line
Source: Lewin & Associates for PA Health Care
Cost Containment Council, June 1988
A8
�Plan, offering comprehensive coverage (see text at page 35). Nevertheless the numbers
of uninsured and underinsured in this region are likely to grow and their problems to
accelerate, due to the interrelated problems of increasingly expensive health insurance,
higher copayments and deductibles, higher employees' shares of premiums, and
decreasing availability of employer-based coverage. To the extent that health care
institutions are called upon to provide free care for the poor and uninsured, they will
have more limited resources with which to do so. Competition and entrepreneurialism
tend to exert a downward pressure on the availability of indigent patient care, because
service to these nonpaying patients results in a shifting of costs that raises prices to
paying patients.
As shown in Exhibit 6, the region's low-income uninsured seem able to access
hospital-based services, at least when they seek such care; however, they find it much
more difficult to access primary care services, particularly dental care, prescription drugs
& devices, and gynecologic cancer screenings. This is due at least in part to the
perception that doing without preventive, primary, and chronic maintenance services
poses no immediate threat to life. But avoiding these relatively low-cost preventive and
primary services tends to prioritize the use of more expensive acute care services.
5
Furthermore, technological advances are permitting a shift of many services from
within institutions to outpatient settings and even to patients' homes. Traditionally,
"charity" care has been delivered in inpatient and hospital clinic settings. To the extent
that health care moves out of these traditional settings, the availability of care for
indigents may be further jeopardized.
Medical limitations of health insurance coverage also exist in this region. Socalled "job lock" (fear that changing employment might lead to loss or limitation of
coverage) is another aspect of the insurance problem. This should not be construed as a
problem created solely by the health insurance market. While some people are indeed
reluctant to change jobs for fear of losing health benefits, many face limited alternative
job opportunities due to a prolonged economic recession. Nevertheless, as long as health
care coverage remains strongly linked to employment, job lock will remain a concern that
should be addressed through insurance market reform.
i
Health Policy Institute, Health Care for the Medically Indigent in Southwestern Pennsylvania, HPI Policy Series It 16.
University of Pittsburgh, PitUburgh, PA: 1988.
A9
�Exhibit 6
Unmet Health C a r e N e e d s
What kind of c a r e w a s n e e d e d but not o b t a i n e d ?
Other (5%)
Outpatient/Ambulatory surgery (4%
npatient care ( 4 % ) *
E m e r g e n c y care ( 5 % ) *
Breast e x a m / P a p s m e a r
(13%)
>
o
Prescriptions (13%)
Dental (55%)
•Indicates hospital-based care
Source: Health Policy Institute, 1988.
�Personal responsibility, or lack of it, also affects the rate of insurance in the
population. Some individuals do not buy health insurance even though they are not poor.
A study of the uninsured in this region showed that 20% had incomes exceeding 200% of
the federal poverty line. For some of these people, insurance may be unaffordable
because their employers do not offer group plans; for others, health insurance may simply
be a low priority. Another group of uninsured are those who qualify for Medicaid but
refuse to apply for it. Some of these have justified their refusal with a desire to avoid
welfare-dependency. Nevertheless, those who choose to go without private coverage
they can afford or public programs for which they qualify contribute unnecessarily to the
burden that providers bear and limit the amount of charity care that would otherwise be
available.
6
7
The Elderly
Growth of the over-65 population cohort in this region already exceeds the
national rate, showing a 49% increase in twenty years from 477,401 in 1970 to 709,525
in 1990. As shown in Exhibit 7, in 1970 the elderly of Allegheny County made up 11 %
of the population; in 1990, their proportion had grown to 17%.
8
Even if this disproportion of elderly in the region's population is temporary, as
demographic trends indicate, their demand for health care services in the short term will
be extraordinary. For example, the elderly use many health services at higher rates than
the general population, and this is evident with their use of expensive inpatient hospital
care. Exhibit 8 illustrates that between 1980 and 1990, the hospital discharge rate among
the nonelderly of this region fell sharply; however, this rate among the elderly for the
same period either rose (as in Allegheny County and the rural counties) or fell only
slightly (as in the metropolitan counties).
9
"Health Policy Institute (1988).
'Health Policy Institute (1988).
'Pennsylvania State Health Data Center, using U.S. Bureau of the Census statistics derived from the 1990 census, unpublished
data from Summary Tape File 1 made available by request in 1992.
'Hospital Council of Western Pennsylvania, Populations of Western Pennsylvania. A Population Analysis. Warrendale, PA:
1992.
All
�Exhibit 7
Relative Proportions of Elderly and Nonelderly Age Cohorts
in Allegheny County, 1970 to 1990
1970
1980
1990
1.61 million
1.37 million
1.34 million
78.2%
72.
77.8%
7.1%
>
<55
.3%
13.3%
10.9%
55-64
65-74
Source: PA State Health Data Center and U.S. Bureau of the Census
10.6%
> = 75
�Exhibit 8
Hospital Discharge Rate Changes in Elderly and Nonelderly
Populations of S.W. PA Counties, 1980 to 1990
% CHANGE, 1980 - 1990
ALLEGHENY CO.
METRO
Elderly
RURAL
Nonelderly
�The elderly are also much more likely than the general population to require
institutional nursing care. Already, long term care providers express concern about an
inadequate supply of long term care beds, strain among family caregivers, and difficulty
in recruiting nurses ~ who are underpaid in long term relative to acute facilities.
These factors have obviously negative implications for future access to, as well as quality
of, care in nursing homes.
10
Rural Locations
11
Rural populations face geographic barriers to access, which add to those of
poverty, uninsurace, and age. Although there is at least one full-service hospital in each
of the region's ten counties, many rural areas have a very limited supply of primary care
providers and facilities.
Exhibit 9 illustrates the maldistribution of primary care clinics throughout the
region. Such clinics can be sponsored by health departments, community health centers,
hospitals, schools, and other kinds of nonprofit groups. However, very few primary care
clinics operate in the region's rural areas. Lawrence County has no such clinics. While
the other rural counties all have health department clinics, these may offer a very limited
range of services. There are community health centers in Armstrong, Fayette, and
Greene counties. A review during 1992 by the Health Policy Institute discovered no
hospitals, schools, or other social service organizations to be sponsoring primary care
clinics in any Southwestern Pennsylvania county outside of Allegheny.
The problem of physician shortage in this region is particularly severe in the rural
areas. Exhibit 10 shows that in every Southwestern Pennsylvania county except
Allegheny, the number of primary care physicians is below an "acceptable" federal
standard of 56 per 100,000 residents. Within many of these counties there are pockets of
'"Health Policy Institute, A New Health Care System for Southwestern Pennsylvania: Part A - Focus Group
Interviews, HPI Policy Series #18-A. University of Pittsburgh, Pittsburgh, PA: 1992, at Appendix G.
"Unless otherwise specified in this discussion, the rural counties include Armstrong, Butler, Greene, Indiana,
and Lawrence; the metropolitan counties include Beaver, Fayette, Washington, and Westmoreland. These are
designations made by the U.S. Bureau of the Census. The metropolitan counties, despite this formal classification
for census purposes, have areas with sparse population that are distant in travel time from the metropolitan center
of Pittsburgh. Therefore, such areas share many characteristics and problems of the rural counties.
A14
�Exhibit 9
Distribution of Primary Care Clinics in S.W. PA Counties, 1992
OTHER
NFP
CLINICS
WMNS
OE'/
REPRODUCTIVE
HEALTH
SERVICES
SHO
COL
HEALTH
PARTNERSHIPS
HOMELESS/
RNWY
UAA
10
5
14
4
3(3)
0
0
0
? 1
0
1
0
0
0
?
1
4
0
0
0
0
?
5
2
7
0
0
0
7
Armstrong
3
2
0
0
0
0
?
Fayette
4
1
0
0
0
0
?
Greene
1
3
0
0
0
0
?
Indiana
1
0
0
0
0
0
?
Lawrence
?
0
0
0
0
0
?
CMUIY
OMNT
HEALTH
CENTERS
HOSPITALBASED
CLINICS
44
10
21
Beaver
7
0
Butler
4
Washington
Westmoreland
1 CUT
ONY
HEALTH
DEPT.
CLINICS '
0
Allegheny
(2>
MTO
ER:
>
RURAL:
(1) S m sites limited to specific services, such as immunizations or child health services.
oe
(2) 1 geriatric
(3) 1 geriatric; 1 mental health
Sources:
Health Policy Institute; Jewish Healthcare Foundation, 1992;
Pennsylvania Forum for Primary Health Care, 1986
P Department of Health Clinic Listing
A
|
1
�Exhibit 10
Primary Care Specialty MDs* Per Capita
in SW PA Counties, 1989
MDi per 100.000 population
160
140
120
100
Ideal**
83/100,000
>
Acceptable**
56/100,000
ON
SO
Q-
60
-B
a
(=@
* = — * -
-B-
-B
B
-*
B
*
—*—
B
•
*
40
NHSC Standard**
29/100,000
160
AlKabtsr
-e-
-Q-
:!§!
2 0
54
41
68
B«aT.r
Far*tt*
Waiblngtoa
84
47
• 44;:
53
46
46
W'land
Armitrong
Batlci
Cr»»n»
Indiana
Lawt*ne*
SW PA Countlei
•Includes family and general practice, internal medicine, pediatrics, and obstetrics/gynecology.
""•Physician supply standards are suggested by the U.S. Department of Health & Human Services. The lowest standard
shown qualifies an area for National Health Service Corps (NHSC) physicians.
Source: Pennsylvania Medical Society, 1989
�even worse physician shortage. According to statistics published in 1992 by the federal
Department of Health and Human Services and shown in Exhibit 11, so-called "health
manpower shortage areas" exist within Allegheny, Armstrong, Beaver, Butler, Fayette,
Greene, Indiana, and Westmoreland counties. While this official designation qualifies an
area for assignment of National Health Service Corps physicians, there are not enough to
meet the need; and these areas remain chronically deprived of permanent resident medical
professionals. In all but three of the ten counties, the supply of family and general
practice physicians fell between 1975 and 1986 (see Exhibit 12), and this trend is
probably true of other primary care specialties (such as pediatrics, internal medicine, and
obstetrics-gynecology) as well.
What is true of physician supply in the rural areas is also true of other health
professionals. The rural and metropolitan counties have few health professionals, even
considering their lower population distribution compared to Allegheny County. As of
1990, Allegheny County had half the population of the ten counties; the rural counties
had about one-sixth of the total. However, as shown in Exhibit 13, thefiverural
counties shared among them only 9 (37 of 426) of the region's certified registered
%
nurse practitioners (CRNPs); 13% (31 of 243) of the physician assistants; and 1 % (245
1
of 2,227) of the dentists. There were no midwives in the rural counties.
A recent national study of medically underserved areas flagged Pennsylvania's
problems, many of which are concentrated in rural counties of the southwestern
region. Butler County was 47th among America's largest rural counties that were
medically underserved, and Lawrence was 90th. Among America's one hundred most atrisk counties as determined by having both low physician-to-population ratios and high
indicators of poor health status, Fayette County ranked 13th, Beaver County ranked 18th,
Butler County ranked 43rd, and Lawrence County ranked 55th.
12
12
Hawkms, D.R., Jr., and S. Rosenbaum, Lives in the Balance. A National, State and County Profile of
America's Medically Underserved. National Association of Community Health Centers, March 1992.
A17
�Exhibit 11
Health Manpower Shortage Areas* in Southwestern Pennsylvania (1990)
Degree of
County/Service Area
>
Shortage**
Allegheny County
Arlington Heights/St. Clair
1
East Liberty (Medicaid population)
1
Homewood Brushton
2
McKees Rocks - Stowe
3
Metro Counties
Beaver County/East Liverpool (Georgetown & Glascow Boros., Greene Twp., & Hookstown & Ohioville Boros.)
3
Fayette County/Connellsville (Bullskin Twp., Connellsville City & Twp., Dawson Boro, Dunbar Twp. & Boro.
Everson Boro., Lower Tyrone Twp., S. Connellsville Boro., Saltlick, Springfield & Upper Tyrone Twps. & Vanderfouilt Boro.)
4
Fayette County/Greensboro (German Twp., Masontown Boro, Nicholson Twp., Point Marion Boro., Springhill Twp.)
2
Fayette County/Markleysburg (Henry Clay, Steward & Wharton Twps., and Markleysburg and Ohiopyle Boros.)
2
Westmoreland County/Connellsville (E. Huntingdon Twp., Mt. Pleasant Twp., Mt. Pleasant Boro., S. Huntingdon Twp.,
Scottsdale Boro. and Smithton Boro.)
4
Westmoreland County/Kiski Valley (Allegheny, Bell & Washington Twps. & Avonmore, E. Vandergrift, Hyde Park,
Oklahoma, Vandergrift & W. Leechburg Boros.)
2
Rural Counties
Armstrong County /Day ton Rural Valley (Atwood Boro., Cowanshannock Twp., Dayton
Boro., Redbank Twp., Rural Valley Boro., and Wayne Twp.)
4
Armstrong County/Kiski Valley (Apollo Boro, Bethel, Burrel, Gilpen, & Kiskiminetas Twps., Leechburg &
N. Apollo Boros, and Parks & South Bend Twps.)
2
Armstrong County /Northeast Butler (Hovey Twp., Parker City)
3
Butler County/Northeast Butler (Allegheny, Concord, Donegal, Fairview, Parker, Venango & Washington Twps.
and Bruin, Cherry Valley, Chicora, Eau Claire, Fairview, Karns City, & Petrolia Boros.)
3
Armstrong County/Punxsutawney (Redbank Twp.)
3
Greene County/Clay/Batelle (Aleppo, Freeport, Gilmore, Jackson & Springhill Twps.)
2
Greene County/Greensboro (Dunkard, Greene, & Monogahela Twps. and Greensboro Boro.)
2
Indiana County/Mahaffey (Banks Twp., and Glen Campbell Boro.)
1
Indiana County/Punxsutawney (Banks Twp., Canoe Twp., Northern Mahoning, Smicksburg Boro, and W. Mahoning)
3
*
HMSA designation is based on (1) geographic area "rational" for the delivery of health services; (2) population-to-physician ratio of (generally)
3500:1 or more; (3) inaccessibility of health care resources in contiguous areas. A population group within a region which has specific barriers to
access may also qualify as HMSA with a population-to-physician ratio of 3000:1 or more.
**
Degree of shortage is based on population-to-practitioner ratio as well as other indicators of need, with Group 1 having the highest degree of
shortage.
�Exhibit 12
Percent Change in Family/General
Practice Physicians, 1975-1986
% Change
40%
30%
20%
13%
10% -
0%
>
C
o
-10% -12%
-15%
-16%
-20% -
-19%
-24%
-30% -
-29%
_l_
-40%
Allaghanr
Bcavar
Fay*!!*
Waihlnglon
W'land
Armitrong
SW PA Counties
Source: Pennsylvania Medical Society, 1987
Batlcr
Gracn*
Indiana
Lawranci
�Exhibit 13
Non-Physician Care Providers Residing in
S.W. PA Counties, 1991
Allegheny County
172
Rural Counties
37
Rural Counties
31
Allegheny County
Metro Counties
87
Metro Counties
Nurse Practitioners (N-426)
40
Physician Assistants (N-243)
Rural Counties
>
ro
o
Metro Counties
Population
Allegheny County
1407
Allegheny County
11
Rural Counties
245
Metro Counties
3
Midwives (N-14)
Source: PA Bureau of Professional and Occupational Affairs, Department of State.
Metro Counties
676
D e n t i s t s (N-2227)
�COST ESCALATION
No matter what national-level health care reforms are enacted, there will always
be limited funds available for health care relative to potential demand for services. Costcontainment will always be necessary ~ and very difficult to achieve, but under present
conditions it is virtually unattainable. The high priority given to individual choices of
provider and financing drives up costs. Accountability for cost of care is so widely
dispersed among payors, providers, employers, patients, etc. that no one takes
responsible action on behalf of the entire system. Health care delivery is inefficient. The
health industry lacks real competition over quality and price.
At the current rate of increase, family health coverage can be expected to continue
and grow as an intolerable financial burden by the end of the decade. Cost-containment
approaches used now only make the system more complex and less effective for patients;
without really holding down costs. The key concern is that cost escalation of health care
services is continuing without a concomitant improvement in people's health.
According to national figures shown in Exhibit 14, health expenses between 1965
and 1989 grew for businesses, governments, and households. Business's health expenses
as a share of fringe benefits more than doubled and as a share of after-tax profits
increased more than sixfold. The federal government's spending on health as a
percentage of revenues more tripled. State and local government's health expenses as a
percentage of their revenues increased by 92%. By comparison with these, the
substantial 34.1% increase in household spending on health as a percentage of income
appears modest.
There is no reason to think that this growth trend is less for business, government,
or households in Southwestern Pennsylvania. Throughout the last decade, medical care
cost inflation exceeded general inflation in the Pittsburgh area by 150% to 200%
(Exhibit 15). Total hospital expenses, as shown in Exhibit 16, rose 87.2% between 1982
and 1990, with outpatient expense growth more than doubling the total expense growth at
180.8%. Some of this increase can be attributed to rising personnel costs; some to
intensity of services due to serving older, sicker patients; and some to increasingly
expensive and frequently utilized technology.
A21
�Exhibit 14
COMPARISON OF 1965 AND 1985 HEALTH
GOVERNMENTS, AND HOUSEHOLDS
Source: U.S. Health Care Financing Administration
EXPENSES
1965
1989
22.4%
14.0
46.1 %
100.5
BY
BUSINESS,
Percent change
Business health expense as
a percentage of:
Fringe benefits
After-tax profits
105.8%
617.8
Federal health expense as a
percentage of federal
revenues
3.5
15.1
331.4
State and local health
expense as a percentage of
state and local revenues
7.5
14.4
92.0
Household health expense
as a percentage of
household income
4.1
5.5
34.1
A22
�Exhibit 15
Inflation Rates* of Consumer Prices for All Items
and for Medical Care in the Pittsburgh Area,
1981 to 1990
Percent inflation
1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
All items
Medical care
• I n f l a t i o n r a t e s s h o w n are not a d j u s t e d for CPI Index
by U.S. D e p t . of L a b o r b e t w e e n 1987 and 1 9 8 8 .
Source:
change
PA State H e a l t h Data C e n t e r and U.S. Bureau of t h e
A23
Census
�Exhibit 16
COMPARISON OF HOSPITAL EXPENSES IN 1982 AND 1990
FOR SIX SOUTHWESTERN PENNSYLVANIA COUNTIES
1982
Audited
Total Hospital Expense
Total Capital
Total Medical Education
1990
Budgeted
1,489,098,467
2,787,768,814
87.2
110,809,152
319,863,861
188.7
43,417,533
107,310,119
147.2
2,232,151,829
72.9
555,616,985
180.8
Percent
Change
5
Total Inpatient Expense
Total Outpatient Expense
1,291,209,210
197,889,257
*The figures are totals for the six-county region of Allegheny and its surrounding counties (Armstrong,
Beaver, Butler, Washington and Westmoreland).
Source: Blue Cross of Western PA
�Technology
The hallmark of excellence in the regional health care system - its technological
advancement ~ is viewed as a major factor in the system's persistent and pervasive
medical cost inflation. An example is the use of magnetic resonance imaging (MRI)
services. Introduced in the mid-1980s, this diagnostic technology was available in more
than half of the hospitals and in many freestanding facilities throughout the region by
1989. Despite a price of $1200 or more per procedure, utilization of MRI shot up
between 1986 and 1990, with the highest growth rate occurring in the latest year and that
in settings other than hospital exceeding that in hospitals (Exhibit 17).
Many question whether all this use of technology is necessary. People seem to
expect access to "miracle" technologies, especially at the end of life. The legal system
encourages overtreatment by threatening liability for physicians who do not try every
treatment possible. Unnecessary, expensive procedures continue to be done - like bypass
surgery on the very elderly, and MRI in addition to cheaper X-ray. Physicians order
expensive tests, and their patients insist on having them, for even routine diagnoses, even
when the test result will not affect the treatment plan.
Managed care systems are believed to have the ability to control unnecessary
utilization of expensive technologies and thereby to achieve lower overall health care
costs for their enrollees. In this region, managed care plans have not been as successful
in competing with traditional insurance plans as elsewhere. For example, health
maintenance organization (HMO) enrollments here lag behind the national and state rates.
In 1990, 13.5% of the national population and 11.5% of the Pennsylvania population
were enrolled in pure HMOs. Exhibit 18 shows that in Southwestern Pennsylvania,
HMO enrollments grew rapidly during the 1980s; nevertheless, total enrollments in 1990
were still only 9.4% of the population.
13
Reasons often given for this resistance to HMOs and other types of managed care
plans here and elsewhere are that they limit patients' freedom of choice among doctors
and hospitals; that they fail to use effective incentives to curtail overutilization; and that
"Kraus, N., M. Porter, and P. Bell, Managed Care: A Decade in Review 1980-1990. Interstudy, Excelsior,
MN: 1991.
A25
�Exhibit 17
MRI S e r v i c e s Provided in Six
Southwestern Pennsylvania Counties
in Hospital vs. Non-Hospital Settings
Number of S e r v i c e s (Thousands)
1990
1986
Hospital Setting
Source:
Non-Hospital Setting
Blue Cross of Western Pennsylvania analysis of
Pennsylvania Blue Shield claims.
A26
�Exhibit 18
HMO Enrollments in Southwestern Pennsylvania,
1980 to 1990
Persons Enrolled
(Thousands)
300
1980
1985
Source: Kraus, Porter, and Bell (InterStudy 1991).
A27
1990
�they interpose a complex bureaucracy between the doctor and the patient without being
sufficiently accountable for poor outcomes of care.
Reimbursement Regulation
Providers are preoccupied with reimbursement incentives - even in making patient
care decisions. There is no payment for keeping people healthy. Present payment
policies are perceived to encourage alternatively the premature termination of needed care
or the continuation of care that is unlikely to improve the patient's outcome. Fee-forservice reimbursement encourages providers to do more, so as to get paid more. Even
the highly regulated Medicare payment system embodies a "retail" rather than a
"wholesale" approach, - that is, purchasing on a per-unit of service basis rather than by
volume of services.
Detailed, complex reimbursement regulations create administrative red tape,
expense, and unintended consequences. For example, federal reimbursement regulations
in the early 1980s created an incentive for hospitals to maximize Medicare payments by
placing assets in separate affiliated corporations. The corporate restructuring that resulted
in this region as elsewhere expended millions and led to hospitals' diversification into
new business activities. Some of these were unrelated to patient care or other health
motives. At the time, such spending appeared to make good business sense. In
retrospect, restructuring and diversification probably did little to enhance the quality or to
control the costs of health care.
Government payors, who because of the huge volume of their sponsored patients
can dictate the prices they will pay for care, often pay less than the cost of care.
Notably, the federal Prospective Payment Assessment Commission has reported that the
gap between Medicare payments and hospitals' costs is widening, with only 43 percent of
hospitals having their costs covered by prospective payment. Medicaid payment is
also notoriously low and, because of new federal regulations restricting how states raise
funds for their Medicaid programs, is likely to become even less adequate in the near
future. In Pennsylvania, the Governor's 1993-94 budget proposal would substantially
14
4
' Altman, S.H., (Chairman), Report and Recommendations to the Congress, March 1, 1993. Prospective
Payment Assessment Commission, Washington, DC, at p. 3.
A28
�reduce revenues designated for Medicaid payment. The result of underpayment by
government payors is typically a shift of costs and increased prices to private payors,
including insurers and individuals.
In Southwestern Pennsylvania, this systematic underreimbursement is cited as the
cause for shrinking hospital operating margins. As shown in Exhibit 19, although
hospital profitability showed a peak under Medicare's payment reforms of the early
1980's, more recent Medicare payment adjustments have eliminated it. Reportedly,
nearly half (21 of 45) of Southwestern Pennsylvania hospitals have negative patient
revenue margins. Medicare payment for most long-term care is nonexistent, and
Medicaid payment for intermediate nursing home care is inadequate. This is important,
since at least 70% of this kind of nursing care in the region is paid for by the Medicaid
program (see Exhibit 20).
15
The result of all this is a two- or three-tiered delivery system, in which patients
are classified based on their payor and providers are classified based on their payor mix
of patients. Those patients whose sponsors (like Medicare and Medical Assistance)
reimburse below the cost of care are less "desirable" to a provider than privately insured
patients. Those providers who treat large proportions of these patients are often
financially strapped and lacking in prestige. Furthermore, below-cost reimbursement
makes indigent care less available. It is believed that private physicians are now seeing
fewer uninsured and fewer Medical Assistance patients.
Lack of Leadership and Planning
Health care cost problems need long-term solutions, but decision makers
(including employers, government officials, and others) tend to think only in the short
term. The economic self-interest of every health care constituency stands in the way of
reform, and special interest groups control political decision-making. Insurers are seen as
trying to avoid paying benefits with bureaucratic complexity. For now, generous
employment-based benefits packages remain the norm in this region, and many people are
not willing to accept limits. Payors are unable to control the design of health benefits
"Hospital Council of Western Pennsylvania, Flash Survey Highlights < Analysis, July 1, 1992 to December 31,
&
1992. Warrendale, PA: 1993.
A29
�Exhibit 19
Mean Operating Margins and Mean Total Revenue Margins
in S.W. PA Hospitals, FY 1983 to FY 1991*
Percentage
>
u>
o
Total Net Rev Margin
Net Operating Margin
*For fiscal years 1988 through 1991, percentages are based on unaudited figures.
Source: Hospital Council of Western Pennsylvania
�Exhibit 20
Medical Assistance Intermediate Care Patient Days
as a Percentage of Total Intermediate Care
Patient Days in S.W. PA Nursing Homes, 1989
% Intermediate days
Medical Assistance
County
Allegheny
68%
Metro:
Beaver
Butler
Washington
Westmoreland
90%
62%
71 %
67%
Subtotal
71%
Armstrong
Fayette
Greene
Indiana
Lawrence
Subtotal
76%
85%
91%
69%
77%
78%
Rural
Region
71%
Source: PA State Health Data Center
A31
�packages unilaterally, because of the demands of large group employers and negotiated
labor contracts.
Without outside planning controls, either voluntary or regulatory, providers
engage in technological rivalries. Hospitals respond to surgeons' demands for expensive
technology and highly skilled support teams because hospitals' revenue bases depend on
surgeons so heavily. Health planning, which had a history of several decades in this
region, was dismantled just when it was beginning to mature and to become effective.
Pennsylvania's Certificate of Need Law provides for regional level planning boards. The
new CON law also expands planning and review jurisdiction to a broad range of
providers. This corrects a major defect in the previous law, which by focusing only on
hospital capital expenditures permitted unfettered proliferation of independently-owned
health care assets. New Medicare regulations may also curtail the level of physician
investment in referral facilities. However, whether the new regional boards and these
regulatory changes can achieve rational allocation of capital resources in the regional
health care system remains to be seen. It is reasonable to expect that capital spending
will continue and that, so long as reimbursement for services is available and profitable,
providers will continue to win regulatory approval.
The overuse of high-tech services is encouraged by consumers' buying into the
myth that even the most serious health problem can be cured. People perceive that health
care is free when bought through employment benefits programs; and employers are
insulated from these costs, and therefore less sensitive to them, because of the tax
exemption these benefits enjoy. The result of this "wishful thinking" (in Reinhardt's
view) and cost-insulation is systematic over-use and overspending.
16
The local mindset demands first-dollar coverage. Many union representatives are
well aware of how expensive and inflation-inducing this is, but their rank-and-file still
insist on keeping it - even when this means limiting wage increases or risking their jobs.
The same mindset insists on preserving choice among providers and financing
arrangements. These are expensive luxuries that may have to be moderated. Finally,
this mindset extends to proximity of services. Each community, no matter how small,
"Reinhardt, U.E., "Reorganizing the Financial Flows in American Health Care," Health Affairs Supplement:
172-193 (1993).
A32
�believes that it should have a full-service hospital or that residents should not have to
drive as much as thirty minutes for a particular service.
QUALITY IN JEOPARDY
Health care is fragmented, due to lack of cooperation among organizations, with
attention to organizational survival rather than to the best interests of the community.
This results in people "falling through the cracks." There is fragmentation and mistrust
among health care professionals: each specialty tends to see itself as preeminent and the
others as inferior; specialists look down on generalists; physicians fail to include other
health care professionals in creating treatment plans; nursing and ancillary personnel are
educated and licensed without regard for each other's roles and skills.
Institutions are driven by competition and turf issues. Hospitals compete with
doctors over high-technology services and are disadvantaged by being more heavily
regulated. Hospitals and their trustees have institutional egos that equate bed-counts and
high-tech equipment with excellence. Hospitals compete with each other, resulting in
duplication of expensive services and large advertising budgets. Antitrust laws present a
legal barrier to cooperation among providers and insurers, even when they are motivated
by sound health policy.
Competition among insurance providers prevents them from studying the best
applications of new technology cooperatively. The federal funding for studies of outcome
measures and utilization protocols is not sufficient; private payors need to become more
involved in this developmental work as well.
There are wide gaps between health and other social services. Medicine is overspecialized and neglects personal care management. Patients are discharged from acute
care needing some form of continued care, but community-based programs intended to
provide this suffer from inadequate funding. This is particularly true of the transition
from psychiatric inpatient care to community-based care. The inevitable result is a
"revolving door" into community hospital emergency rooms, where seriously mentally ill
persons return over and over again.
A33
�Conversely, there is a tendency to view problems with social antecedents (like
hypertension and infant mortality) as if they were strictly medical problems.
Professionals in health and social services think and function in separate spheres.
People need better information about using the health care system and taking care
of themselves, which they do not currently get from their doctors and hospitals. They do
not buy health care based on price or quality but on the provider's reputation. Efforts
like those of the Pennsylvania Health Care Cost Containment Council to gather and
disseminate quality and price information about providers should and will continue. But
such information alone is insufficient. The elderly in particular defer to the physician
rather than taking primary responsibility for their own health. Health care providers tend
to reinforce patients' disabilities, making them more dependent on services. "Lack of
compliance" by patients can be attributed to a passive, rather than active, approach to
one's own health, to lack of knowledge, and to sociocultural barriers between patient and
provider.
Even though medical ethics problems are being confronted and ethics committees
are becoming more common in health care institutions, ethics and provider economic
interests may conflict. Sometimes, observers perceive that financial considerations
precede and outweigh compassion for the poor and disenfranchised.
The health care system can be discriminatory, based on racial and socioeconomic
perceptions and stereotypes. Education for health care professionals tends to assume a
uniformly upper-middle class, insured patient population; it does not adequately address
cultural and economic variations. Even when physicians are sensitive to the needs of
patients unable to pay, they may be insensitive to the needs of patients insured with plans
carrying limitations and exclusions. Such limitations can profoundly affect a treatment
plan.
Continuous quality improvement (CQI) as a management approach has been
introduced to virtually all health care institutions in this region, but its effects are not
known. To some people working in hospitals, CQI is just another passing fad of
management. In some cases such as mental health, the quality improvement standards of
the Joint Commission on Accreditation of Healthcare Organizations are creating pressure
to "do more with less" because of funding constraints.
A34
�Appendix B
ETHICAL PRINCIPLES TO GUIDE
HEALTH CARE REFORMS
by
Beaufort B. Longest, Jr., Ph.D.
Professor and Director
Health Policy Institute
�Because decisions about health care in Southwestern Pennsylvania have been - and
will continue to be - made by people, the decisions are influenced by altruism and egoism,
or by a mixture of both. Human control of the decisions also means that the outcomes and
consequences of the decisions are affected by the ethics of the decision makers. One of the
keys to the realization of a new vision for health care in Southwestern Pennsylvania will be
the strict adherence to ethical behavior throughout the decision-making process through
which changes will occur. This view does not challenge the ethical behavior of individual
care-givers in their relationships with their patients, nor does it challenge the traditional
ethical underpinnings of the decisions made by the managers and trustees of individual
organizations about their strategies and operations. Instead, it reflects the conviction that
realization of the vision outlined in this report for the region's health care system will call
for far more collaboration among the participants in the health care system than has been the
practice heretofore and that this new way of operating will require attention to specific
ethical principles: respect for the autonomy of other people, justice, beneficence, and
nonmaleficence. The reasons these ethical considerations are so important include the fact
that reform will directly impact on the ways in which people provide and receive health care
services and on the economic exchanges that occur within the health care system. Changes
as fundamental as these require the exercise of extreme care in making decisions affecting the
changes, including adherence to ethical principles. These philosophical principles are briefly
outlined below.
The concept of autonomy is based on the notion that individuals have the right to their
own beliefs and values and to the decisions and choices which further these beliefs and
values. The ethical principle of respect for autonomy undergirds many of the pleasures of
citizenship which the founders of our nation envisioned. Specifically, autonomy pertains to
the rights of individuals to independent self-determination regarding how they live their lives
and to their rights regarding the integrity of their bodies and minds. Respect for autonomy
in health care decision making will influence issues such as liberty rights, privacy, and
individual choice, including behavioral or life-style choices.
Decision making that reflects a respect for the principle of autonomy can sometimes
be better understood in contrast to its opposite - paternalism. Paternalism implies that
someone else knows what is best for other people. Decisions guided by a preference for
autonomy limit paternalism. One of the most vivid examples of the kind of decisions that
result from adherence to the principle of autonomy in health care decision making is the
B3
�federal 1991 Patient Self-Determination Act (PL 101-508). This law is designed to give
individuals the right to make decisions concerning their medical care, including the right to
accept or refuse treatment, and the right to formulate advance directives regarding their care.
These directives are a means by which competent individuals give instructions about their
health care that are to be implemented at some later date should they then lack the capacity
to make medical decisions. In concept, this law gave people the right to exercise their
autonomy in advance of a time when they might no longer be able actively to exercise the
right.
The principle of respect for autonomy includes several other elements that are
important in guiding ethical behavior in decision making, especially as health care reform
more closely integrates many parts of the health care system. One of these is truth telling.
Respect for people as autonomous beings implies honesty in relationships with them. Closely
related to honesty in such relationships is the element of confidentiality. A third element of
the autonomy principle is fidelity. This means doing one's duty and keeping one's word.
Fidelity is often equated with promise keeping. When participants in the decision-making
processes that will lead to the changes in our health care system envisioned in this report tell
the truth, honor confidences, and keep promises the processes will be more ethically sound
than if these things are not done.
A second ethical principle of significant importance to any consideration of reforming
the health care system in Southwestern Pennsylvania is justice. The concept of justice,
which is derived from political philosophy, impacts directly on the decision-making process
and on the decisions themselves. In Rawls' words, "One may think of a public conception of
1
justice as constituting the fundamental charter of a well-ordered human association." Much
of its impact on health reform decisions and on the process of decision making hinges upon
defining justice as fairness. The principle of justice also includes the concept of desert:
2
justice is done when a person receives that which he or she deserves. The practical
implications for health care decision making of the principle of justice are felt mostly in
terms of distributive justice; that is, in terms of fairness in the distribution of health care
benefits and burdens in society.
'Rawls, John. A Theory of Justice. Cambridge, MA: The Belknap Press of Harvard University Press, 1971.
2
Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics. 3rd edition. New York: Oxford
University Press, 1989.
B4
�The key question for those whose decisions influence health care in Southwestern
Pennsylvania deriving from attention to the ethical principle of justice is, of course, "What is
fair?" Insight into the range of possible views on the question of what is fair can be gained
from considering the three most prominent general theories of justice.
Egalitarian theories hold that all should have equal access to the benefits and burdens
of health care and that fairness requires a recognition of different levels of need. The
influence of the egalitarian view of justice can be seen in a number of health care decisions
that have already been made here and elsewhere. Decisions intended to remove
discrimination in the provision of health care services reflect the preference for equality.
Decisions intended to provide more resources to those thought to need them most (e.g.,
Medicare for the elderly or Medicaid for the poor) are also based on an egalitarian view of
fairness. Libertarian theories hold that fairness requires a maximum of social and economic
liberty for individuals. Policies that favor unfettered markets as the means of distributing the
benefits and burdens of health care reflect the libertarian theory of justice. Utilitarian
theories hold that justice is best served when public utility is maximized. This is sometimes
expressed as the greatest good for the greatest number. Many public health policies,
including those pertaining to restricting pollution, ensuring safe work places, and controlling
the spread of communicable diseases, have been heavily influenced by a utilitarian view of
what is just in the distribution of the benefits and burdens of health care.
Two other ethical principles have relevance to decision making and to the decisions
that will help change the health care system in Southwestern Pennsylvania. These are
beneficence and nonmaleficence. Beneficence in decision making means acting with charity
and kindness. This principle incorporates and values acts through which benefits are
provided; thus, beneficence characterizes most health care. But beneficence also includes the
more complex concept of balancing benefits and harms. This forms the philosophical basis
for using relative costs and benefits of alternative decisions to choose from among the
alternatives. The growing emphasis on cost-effectiveness in medical care and the
development of policies to support this will increasingly call into play the ethical principle of
beneficence in developing ethically sound policies. Decision makers who are guided by the
principle of beneficence make decisions that maximize the net benefits to society as a whole.
Nonmaleficience, a principle with deep roots in medical ethics, is exemplified in the
dictim primum non nocere -- first, do no harm. Decision makers who are guided by the
principle of nonmaleficence make decisions that minimize harm to society as a whole. The
B5
�principles of beneficence and nonmaleficence are clearly reflected in health care decisions
that seek to ensure the quality of health care services.
In view of the consequences, for people and for institutions, of the decisions that will
be made at every level of the health care system in the name of health care reform, decision
makers should carefully take these ethical principles into account in each of their decisions.
B6
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Health Policy Institute] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-012-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/707ca4617a40eb7866dc3572c2407d00.pdf
397b0d1212bf55e66d9ffa3ed4645526
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1971
FolderlD:
Folder Title:
[Health Policy] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
10
2
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�SOCIAL SCIENCE
&
MEDICINE
it"
an international iournal
�SOCIAL SCIENCE
&
MEDICINE
an international journal
Editor-in-Chief
Peter J . M. M c E w a n
Health Economics, Health Policy
Medical Anthropology, Medical Ethics, Medical Geography
Medical Psychology, Medical Sociology
PERGAMON P R E S S
OXFORD • NEW YORK • SEOUL • TOKYO
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Health Policy] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-011-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/d6ca225f2ff3c61e06280053d6436ff2.pdf
ba3b74a2cf89ef16c439d45745496104
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1977
OA/ID Number:
FolderlD:
Folder Title:
[Health Care Working Group] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
1
2
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
001. memo
SUBJECT/TITLE
DATE
Maggie Williams to Ira Magaziner [partial] (1 page)
2/17/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1977
FOLDER TITLE:
[Health Care Working Group] [loose]
2006-0885-F
wr831
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - |5 U.S.C. 5S2(b)|
PI National Security Classified Information |(a)(l) of the PRA|
P2 Relating to the appointment to Federal office |(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information |(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. memo
SUBJECT/TITLE
DATE
Maggie Williams to Ira Magaziner [partial] (1 page)
2/17/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1977
FOLDER TITLE:
[Health Care Working Group] [loose]
2006-0885-F
wr831
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)l
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute 1(a)(3) of the PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA|
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the F01A|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�r.
February 17, 1993
MEMORANDUM FROM MAGGIE WILLIAMS
TO
: IRA MAGAZINER
SUBJECT : HEALTH CARE WORKING GROUP
HILLARY WOULD LIKE THESE TWO INDIVIDUALS TO PARTICIPATE IN ONE OF
THE HEALTH CARE WORKING GROUPS:
PERCY MALONE !!|f«I
j
i ! - S a a f t fw
' W ' i ^ i e ' .d
1/
ROB MCGARRAH'S NUMBER I S DIRECTOR OF PUBLIC POLICY OF AFSCME,
1625 L STREET, N W , WASHINGTON DC 20008. HIS TELEPHONE I S 429..
1155.
FYI: DR. VAGELOS, CHAIRMAN OF MERCK, WOULD LIKE TO MEET WITH
HILLARY TO DISCUSS A "NON-ADVERSARIAL" RELATIONSHIP. (FAX
ATTACHED) MESSAGE PASSED ON TO MELANNE ALSO. SHOULD YOU HANDLE?
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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[Health Care Working Group] [loose]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
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Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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https://clinton.presidentiallibraries.us/files/original/6d10aabcdb9487b991c132e8f9fc8767.pdf
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Clinton Presidential Records
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Health Care Task Force
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Tarmey
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1988
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FolderlD:
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S
56
2
5
1
�GAO
United State*
General Accounting Office
Waahington, D.C. 20548
Hainan Resources Dtviaion
B-246421
March 3,
1992
Mr. Frank Clemente
Senior Policy Advisor
Committee on Government Operations
House o f Representatives
Dear Mr. Clemente:
As agreed during your January 29 meeting w i t h members o f
my s t a f f , t h i s l e t t e r summarizes GAO's f i n d i n g s ,
recommendations, and other information from four recent
reviews on Medicaid t h i r d - p a r t y l i a b i l i t y . As you know,
the f i r s t three reviews r e s u l t e d i n two reports t o
Mr. Conyers and a r e p o r t t o Mr. Waxman. A f o u r t h
review, on the O f f i c e o f Child Support Enforcement's
(OCSE) medical support r e s p o n s i b i l i t i e s , i s i n progress.
We expect t o issue a r e p o r t on t h i s work t h i s spring.
The information we discuss from t h i s review i s
preliminary.
1
BACKGROUND
The Congress intended t h a t Medicaid, as a p u b l i c
assistance program, pay f o r health care only a f t e r a
r e c i p i e n t ' s other health care resources have been
exhausted. Bureau o f the Census 1990 Current Population
Survey data showed t h a t 13.2 percent o f Medicaid
r e c i p i e n t s had p r i v a t e or employer-provided h e a l t h
insurance. I n a d d i t i o n , r e c i p i e n t s ' h e a l t h care
expenses may be paid through other t h i r d p a r t i e s , such
as l i a b i l i t y insurers and workers' compensation plans.
Medicaid: M i l l i o n s of Dollars Not Recovered From
Michigan Blue Cross/Blue Shield (GAO/HRD-91-12, Nov. 30,
1990) ; Medicaid; HCFA Needs A u t h o r i t y t o Enforce T h i r d Party Requirements on States (GAO/HRD-91-60, Apr. 11,
1991) ; and Medicaid: L e g i s l a t i o n Needed t o Improve
C o l l e c t i o n s From Private Insurers (GAO/HRD-91-25, Nov.
30, 1990).
GAO/HRD-92-21R, Medicaid Third-Party
Liability
�B-246421
Federal regulations require state Medicaid agencies to
take certain measures to identify and recover payments
from l i a b l e third parties. In addition, regulations
generally require state child support enforcement
agencies to assure that noncustodial parents of Medicaid
children provide health insurance (medical support) when
i t i s available through employment. They do t h i s by
petitioning the court or administrative authority for
such coverage in court orders and taking steps to
enforce the orders.
The Department of Health and Human Services' Health Care
Financing Administration (HCFA) oversees state Medicaid
agency recovery efforts, while i t s Office of Child
Support Enforcement oversees state medical support
efforts.
SUMMARY
Medicaid could save millions of dollars i f states
ensured that l i a b l e third parties paid Medicaid
recipients' medical b i l l s . To r e a l i z e these savings,
states need to
—
improve compliance with federal requirements to
identify and recover from l i a b l e health insurers, for
example, by collecting health insurance information
at the time of Medicaid e l i g i b i l i t y determination and
seeking payment recovery within 60 days and
—
improve child support enforcement techniques to
assure that noncustodial parents of Medicaid children
provide health insurance when i t i s available through
employment.
To give states incentives to improve t h e i r third-party
i d e n t i f i c a t i o n and recovery efforts, we have recommended
that the Congress amend federal law to allow HCFA to
withhold Medicaid matching payments when states f a i l to
comply with federal third-party requirements. Moreover,
federal guidance i s needed to provide clearer standards
for state medical support enforcement a c t i v i t i e s .
GAO/HRD-92-21R, Medicaid Third-Party L i a b i l i t y
�B-246421
States, however, cannot optimize collections on t h e i r
own.
They have limited authority over out-of-state
insurers and self-insured plans governed by the Employee
Retirement Income Security Act of 1974 (ERISA).
Consequently, states cannot e f f e c t i v e l y prohibit problem
practices (such as not recognizing a Medicaid
recipient's assignment of rights to health care payments
to the state Medicaid agency) that these insurers and
health plans use to avoid making payments. States'
limited authority over ERISA plans may also jeopardize
future medical support e f f o r t s . Some of these plans are
excluding coverage for dependents that, for example,
l i v e outside the home of the policyholder. To minimize
future losses, we have recommended that the Congress
amend federal l e g i s l a t i o n to c l a r i f y Medicaid's role as
payer of l a s t resort and enhance the s t a t e s ' a b i l i t i e s
to ensure that out-of-state insurers and ERISA plans
cannot avoid paying Medicaid. The problems that we
identified, and our recommendations to resolve them, are
discussed in the enclosure.
APWA'S RESPONSE
The American Public Welfare Association (APWA),
representing state Medicaid directors, has responded to
our recommendations. APWA supports l e g i s l a t i o n to
c l a r i f y Medicaid's last-payer role and increase states'
a b i l i t y to assure that ERISA plans pay before Medicaid
and cover Medicaid children. APWA has indicated,
however, that states do not believe HCFA should be
allowed to withhold federal matching to enforce
compliance. APWA maintains that states are taking
corrective actions to resolve problems on t h e i r own and
that states prefer a system that rewards them for doing
a superior job rather than penalizing them for doing
poorly.
As you requested, our Office of the General Counsel's
s t a f f i s preparing a comprehensive l e g i s l a t i v e proposal
integrating the various l e g i s l a t i v e recommendations from
our Medicaid third-party l i a b i l i t y reports. W w i l l
e
forward t h i s to you upon i t s completion.
GAO/HRD-92-21R, Medicaid Third-Party
Liability
�B-246421
Should you have any questions concerning these reports,
please contact me on (202) 512-7119.
Sincerely yours,
Janet L. Shikles
Director, Health Financing
and Policy Issues
Enclosure
GAO/HRD-92-21R, Medicaid Third-Party L i a b i l i t y
�ENCLOSURE I
ENCLOSURE I
PROBLEMS IDENTIFIED AND RECOMMENDATIONS MADE
The problems we have identified i n our past and ongoing work
concerning third-party l i a b i l i t y , and our recommendations to
resolve them, are as follows.
Medicaid: Millions of Dollars Not Recovered From Michigan Blue
Cross/Blue Shield (GAO/HRD-91-12, Nov. 30, 1990)
This report identified problems with the Michigan Medicaid
agency's third-party recovery program. Over 18 years, the
Michigan agency encountered serious problems i n recovering
payments made for Medicaid recipients insured by Blue Cross/Blue
Shield. Michigan did not f u l l y use i t s authority or take a l l
actions that i t could to enforce Blue Cross/Blue Shield
compliance with Medicaid's third-party recovery provisions.
Also, federal and state monitoring and oversight of the Michigan
Medicaid third-party recovery program were ineffective. Because
Michigan and Blue Cross/Blue Shield did not implement a system
for Blue Cross/Blue Shield to pay claims, Blue Cross/Blue Shield
avoided or forestalled payments to the state's Medicaid program
and, i n effect, shifted considerable costs to the federal and
state governments.
We concluded that ineffective state management, coupled with lack
of HCFA leadership, allowed millions in Medicaid payments to go
unrecovered from Blue Cross/Blue Shield. We made no
recommendations i n t h i s f i r s t report, as a concurrent review was
addressing problems HCFA had found at the national l e v e l . (See
GAO/HRD-91-60 below.)
Medicaid: Legislation Needed to Improve Collections From Private
Insurers (GAO/HRD-91-25, Nov. 30, 1990)
This report identified two major obstacles that states face i n
making third-party recoveries from certain types of insurers.
F i r s t , because states lack j u r i s d i c t i o n over certain insurers,
they cannot prohibit some out-of-state insurers from practices
they use to avoid reimbursing state Medicaid agencies. For
example, some out-of-state insurers write clauses i n contracts
that exclude, or have the effect of excluding, payment for outof-state Medicaid recipients. Second, states' limited authority
over certain employee welfare benefit plans does not allow them
to prohibit practices these plans use to avoid paying for
recipients' covered costs, such as not recognizing the
recipient's assignment of rights to health care payments to the
state Medicaid agency. Further, many states have not exercised
t h e i r authority to l e g i s l a t e that no such plan include any
�ENCLOSURE I
ENCLOSURE I
contract provision having the effect of limiting or excluding
payments for Medicaid recipients' health care costs.
We recommended that the Congress c l a r i f y Medicaid policy and
authorize states to recover d i r e c t l y from a l l appropriate third
parties. S p e c i f i c a l l y , we recommended that l e g i s l a t i o n :
—
State e x p l i c i t l y that Medicaid i s payer of l a s t resort.
—
C l a r i f y that appropriate third parties have a duty to pay or
reimburse Medicaid regardless of any contract provision.
—
Provide an e f f i c i e n t , comprehensive enforcement scheme that
would include amending ERISA to broaden s t a t e s ' existing
authority to allow them to f u l f i l l their third-party
obligations under Medicaid law. Additionally, the enforcement
scheme would provide for double damages, as i s in place in
Medicare law for similar circumstances, against any l i a b l e
third party that f a i l s to f u l f i l l i t s payment obligations
under the provisions.
Medicaid: HCFA Needs Authority to Enforce Third-Party
Requirements on States (GAO/HRD-91-60, Apr. 11, 1991)
This report examined HCFA's oversight efforts of state t h i r d party programs and i t s authority to enforce compliance. In 1988
and 1989 program reviews, HCFA identified significant state
noncompliance with federal third-party requirements. Our work in
Michigan and C a l i f o r n i a pointed to continuing problems in 1990
with federal requirements not being met.
HCFA lacks effective
enforcement authority, we concluded, because the current
authorized mechanism for imposing financial penalties on states
that did not comply with federal third-party requirements i s
ineffective. States could do poorly in third-party recoveries
and face l i t t l e or no financial penalty. Without the a b i l i t y to
withhold federal matching funds, the federal government cannot
adequately protect i t s financial interests when states f a i l to
comply with third-party requirements.
We recommended that the Congress amend the law to authorize HCFA
to withhold federal matching funds when states do not comply with
federal third-party requirements.
Review of the Office of Child Support Enforcement's Medical
Support Responsibilities (In progress)
This review i s addressing state child support enforcement efforts
to pursue health insurance from noncustodial parents for their
Medicaid children, and federal oversight of those e f f o r t s .
Preliminary findings indicate that states are not ensuring that
�ENCLOSURE I
ENCLOSURE I
noncustodial parents provide health insurance for t h e i r children,
even when such insurance i s available through t h e i r employers.
Our tentative conclusions are that two main problems l i m i t the
effectiveness of state enforcement efforts. F i r s t , federal
regulations permit wide v a r i a b i l i t y among states i n adopting
practices to enforce medical support. Consequently, the
effectiveness of states' programs varies widely. Second, certain
employee welfare benefit plans are thwarting state efforts by
excluding noncustodial parents' children from coverage, for
example, by requiring that dependents l i v e with the policyholder
in order to be covered. As noted i n our previous report,
(GAO/HRD-91-25 above), states have l i t t l e a b i l i t y to force these
plans to comply with state requirements.
�GAO
United States
General Accounting Office
Washington, D.C. 20548
Human Resources Division
B-245950
March 12, 1992
The Honorable John D. Dingell
Chairman, Committee on Energy and Commerce
House of Representatives
The Honorable Ron Wyden
House of Representatives
In response to your request, GAO i s currently assessing
state-level small group health insurance market reforms.
In light of current congressional consideration of
potential federal small group market reform, you asked us
to briefly summarize our preliminary findings on this
ongoing work and any earlier work we completed related to
this issue.
Small Group Reforms Will Raise Costs for
Some and Reduce Costs for Others
GAO i n i t i a l l y identified the developing c r i s i s of
affordability and availability of health insurance for
small firms in a 1990 report to the Committee on Energy and
Commerce—Health Insurance-; Cost Increases Lead to Coverage
Limitations and Cost Shifting (GAO/HRD 90-68). In recent
testimony before the Subcommittee on Health, House
Committee on Ways and Means, we discussed serious problems
caused by underwriting and rating practices in the small
group health insurance market.
1
In our earlier work, we pointed out that while reforms
addressing availability and equity in the small group
market were needed to deal with these problems, these
proposed reforms would not address several key issues. The
rating reforms w i l l narrow the range of health insurance
premium costs among firms; they do not reduce premiums
overall. By requiring the inclusion of high-cost
individuals into group plans, the recommended reforms w i l l
cause those currently paying the lowest premiums to pay
Private Health Insurance; Problems Caused bv a Segmented
Market, GAO/T-HRD-91-21, May 2, 1991.
1
GAO/HRD-92-27R, Small Group Market Reforms
�more i n order to cover the high-cost i n d i v i d u a l s .
Excluding expensive individuals from insured groups lowers
costs for others purchasing insurance. With costs
increased for some insured and decreased for others, what
remains unclear i s how much more (or l e s s ) health insurance
w i l l be purchased for the employees of small businesses.
Reforms Do Not Address
Underlying High Cost Growth
The reform proposals neither stop nor reduce the r i s i n g
cost of health care, the major reason small businesses give
for not providing health benefits. Health care cost
i n f l a t i o n has components outside the realm of insurance
reform. For example, a portion of costs originating within
the insurance i n d u s t r y — t h e high cost of overhead for small
businesses' health i n s u r a n c e — i s not addressed.
2
Most States Have Already Enacted
Small Group Market Reforms
Our ongoing work on state reform i n i t i a t i v e s reinforces
these conclusions. We found that many states have recently
implemented small group market reforms—including r a t i n g
and underwriting reforms, elimination of mandated benefits,
and subsidies.
Forty-three states have l e g i s l a t e d at l e a s t one of the
following regulatory reforms: (1) l i m i t i n g r a t i n g
practices and r e s t r i c t i n g premium p r i c e s , (2) mandating
guaranteed issue that requires insurance companies to cover
a l l persons i n an insured group, (3) requiring continuation
of coverage for those already insured/ and (4) requiring
disclosure of insurance p r a c t i c e s . These reforms improve
the a v a i l a b i l i t y of health insurance regardless of an
individual's health status by limiting coverage exclusions
and waiting periods, prevent employer "churning" of
3
2
W. David Helms, "Problems With Employment-Based Insurance:
Implications of the Robert Wood Johnson Foundation Health
Care for the Uninsured Program," National Health Policy
Forum, December 16, 1991.
^Churning occurs where low-cost groups migrate from one
insurer to another i n order to obtain lower premiums. This
migration occurs because f i r s t year premiums are lower than
subsequent years due to the wear-off of preexisting
condition exclusions and the development of new conditions
by the covered group.
2
GAO/HRD-92-27R, Small Group Market Reforms
�insurance companies, and narrow the differences between
rates for insured groups and individuals.
While these reforms address the problems related to
a v a i l a b i l i t y of health insurance, they have an ambiguous
e f f e c t on problems related to cost. Blue Cross recently
performed an analysis of 6 of i t s plans which showed that
rating proposals that allowed rating adjustments only for
demographic variables would r e s u l t i n rate increases for
about half of i t s s u b s c r i b e r s — t h e other half would
experience decreases.
To address problems related to a f f o r d a b i l i t y , nearly half
the states have given insurers greater f l e x i b i l i t y i n
designing lower-cost insurance plans, generally by waiving
mandated benefits. While these mandate-free plans were
offered with lower premiums, i n many cases these plans with
waived mandates also involved higher co-payments and
deductibles. Therefore, i t i s not c l e a r how much of the
price reduction was due to eliminating mandates as opposed
to increasing consumers' out-of-pocket payments. Mandates
were often estimated to account for l e s s than 10 percent of
t o t a l claims cost.
Approximately one-quarter of the states have gone further
and also provide d i r e c t subsidies or tax c r e d i t s to reduce
premiums for small firms. State-subsidized plans, which
reduce premiums up to 50 percent have had few takers. A
recent study showed that only about 3 percent of uninsured
small firms added insurance i n response to a 50 percent
premium subsidy. Even when f u l l y implemented, the
authors estimate that t h i s subsidy would only expand
coverage to 16.5 percent of currently uninsured small
firms.
4
Response to Small Group Market Reforms Marginal.
But Conclusive Judgments Cannot be Made
I t may be too early to judge f u l l y the success of these
reforms—many were l e g i s l a t e d by states during or a f t e r
1990. But, the early response has shown that these reforms
have induced few small businesses to provide health
benefits to t h e i r employees. States also continue to be
concerned that the reforms lowering prices for high-risk
*Thorpe Jtenneth; Jtendricks* Ann; Garrnick, Deborah;
Donelan, Karen; Newhouse, Joseph; "Reducing the Number of
Uninsured by Subsidizing Employment-Based Health
Insurance," Journal of the American Medical Association,
Vol. 267, No. 7, February 19, 1992.
v
3
GAO/HRD-92-27R, Small Group Market Reforms
�individuals w i l l generate increases i n premiums for the
larger part of the small group market. Unfortunately,
there i s no data on the net e f f e c t of these reforms on
average premiums and l e v e l s of coverage, and i t i s not easy
to develop these estimates given the complexity of the
state e f f o r t s .
State Insurance Departments May Not Have
S u f f i c i e n t Resources to Enforce New Regulations
F i n a l l y , you asked us to comment on whether our p r i o r work
on state insurance departments suggests that they have
adequate resources to assure regulatory compliance with a
comprehensive small business reform proposal. None of
GAO's e a r l i e r work on the capacity of state insurance
departments focused on t h e i r role related s p e c i f i c a l l y to
health insurance. However, e a r l i e r GAO work indicated that
some states may not a l l o c a t e s u f f i c i e n t resources to
e f f e c t i v e l y deal with t h e i r primary objective of assuring
insurance company solvency.
Many states also have not
adopted key standards established by the National
Association of Insurance Commissioners for long term care
insurance. GAO expects that these questions regarding the
adequacy of resources would be magnified i f states were
given added'responsibilities to monitor the functioning of
the health insurance market.
9
Unless you publicly announce i t s contents e a r l i e r , we plan
no further d i s t r i b u t i o n of t h i s report u n t i l 30 days a f t e r
i t s issue date. At that time, i t w i l l be made a v a i l a b l e on
request.
I f you have any questions regarding t h i s l e t t e r , please
c a l l me at (202) 275-5470.
Lawrence H. Thompson
Assistant Comptroller
General
(108788)
'insurance Regulation; Problems in the State Monitoring
Property/Casualty Insurer Solvency. GAO/GGD-89-129,
September 1989.
4
of
GAO/HRD-92-27R, Small Group Market Reforms
�GAO
United States
General Accounting Office
Washington, D.C. 20548
Human Resources Division
B-248045
A p r i l 1, 1992
The Honorable Edward Roybal
Chairman, Subcommittee on Health
and Long-Term Care
Select Committee on Aging
House of Representatives
The Honorable Ron Wyden
House of Representatives
During GAO's testimony at the Subcommittee hearing on the
use of medications in board and care homes for the elderly,
on March 13, 1992, you requested additional information\
You asked us to determine how many individuals within t h ^
Department of Health and Human Services (HHS) are involvec
in issues related to board and care homes for the elderly.
To provide this information, we interviewed HHS o f f i c i a l s
and reviewed selected data developed i n preparation for GAO's
recent testimony. We did t h i s work during a 2-week period
in March, 1992.
l
Background
The Office of the Assistant Secretary for Planning and
Evaluation (ASPE) leads HHS involvement i n issues related
to board and care homes for the elderly. However, a t l e a s t
eight other units within HHS have direct or indirect
involvement with these issues. Enclosure I l i s t s those units
and t h e i r r e s p o n s i b i l i t i e s .
Task forces within HHS also address topics that i n d i r e c t l y
affect board and care home issues. An example of
^oard and Care Homes: Medication Mishandling Places E l d e r l y
at Risk (GAO/T-HRD-92-16, March 13, 1992.)
GAO/HRD-92-29R, HHS Staff for Board and Care Issues
/
/
�such a task force i s the Secretary's Task Force on Elder
Abuse. That task force included representatives from seven
units. I t s report addressed abuse and neglect of the elderly
in many settings, including board and care homes.
2
Few Staff Address Issues
HHS devotes few staff to board and care issues. An o f f i c i a l
in ASPE confirmed that no positions in HHS are dedicated
full-time to board and care issues. We identified four s t a f f
members in HHS who worked d i r e c t l y on board and care issues
within the l a s t year. One i s overseeing a study on the
effects of regulation on the quality of care provided in
homes while another oversaw a study on the use of census data
to identify unlicensed homes. The third i s drafting
implementing regulations for the community care provisions of
the 1990 Omnibus Budget Reconciliation Act and the fourth
administers State compliance with the Keys Amendment. Our
findings are consistent with those reported by the HHS Office
of the Inspector General in i t s March 1990 report on board
and care.
That report characterized HHS' role in these
issues as limited.
3
4
The amount of time these staff spend on board and care issues
may be small. For example, the staff person who administers
the Keys Amendment told us that her board and care-related
r e s p o n s i b i l i t i e s are ongoing but may consume less than 15
percent of her time.
Staff in other units have some indirect involvement with
issues related to board and care homes for the elderly. For
example, the Administration on Aging, the National I n s t i t u t e
of Mental Health, and the Administration on Developmental
D i s a b i l i t i e s each provide grants to states to operate an
Ombudsman or a protection and advocacy program for their
respective c l i e n t groups, some of whom may reside in board
department of Health and Human Services, Report from The
Secretary's Task Force on Elder Abuse (internal report, Feb.
1992.)
3
I n 1976, the Congress enacted the Keys Amendment to the
Social Security Act, which required states to c e r t i f y , to
HHS, that a l l f a c i l i t i e s in which a s i g n i f i c a n t number of
Supplemental Security Income (SSI) recipients resided or were
l i k e l y to reside met appropriate standards.
A
Richard P. Kusserow, Board and Care (U.S. Department of
Health and Human Services, Office of Inspector General. OEI02-89-01860, March 1990.)
2
GAO/HRD-92-29R, HHS
Staff for Board and Care Issues
�and care homes. We cannot estimate the s t a f f time spent on
these i n d i r e c t a c t i v i t i e s , based on our l i m i t e d work.
R e s p o n s i b i l i t y I s Fragmented
and Units Operate Independently
Although a t l e a s t nine u n i t s have d i r e c t or i n d i r e c t
involvement w i t h board and care issues, there has been l i t t l e
c o o r d i n a t i o n between the u n i t s . To address t h i s problem, HHS
i s e s t a b l i s h i n g a task force t o include representatives from
ASPE, the Social Security A d m i n i s t r a t i o n , the Health Care
Financing A d m i n i s t r a t i o n , the National I n s t i t u t e of Mental
Health, the A d m i n i s t r a t i o n on Developmental D i s a b i l i t i e s , t h e
National I n s t i t u t e on Aging, and the O f f i c e of the A s s i s t a n t
Secretary f o r Health. However, an o f f i c i a l w i t h ASPE—the
u n i t t h a t chairs the task f o r c e - - t o l d us t h a t representatives
from these u n i t s have not yet been named and ASPE could not
provide a timetable f o r implementing the task force.
The HHS O f f i c e of Inspector General recommended the formation
of such a task force i n i t s March 1990 r e p o r t a f t e r f i n d i n g
t h a t there was l i m i t e d contact between u n i t s regarding board
and care issues. I t reported t h a t each u n i t functions
independently and has l i t t l e awareness o f r e l e v a n t a c t i v i t i e s
o c c u r r i n g elsewhere i n the Department.
I f you have any questions concerning
c a l l me a t (202) 512-7215.
h i s i n f o r m a t i o n , please
Sincerely yours.
oseph F. D e l f i c o U
D i r e c t o r , Income Security Issues
Enclosure
GAO/HRD-92-29R, HHS S t a f f f o r Board and Care Issues
�ENCLOSURE I
ENCLOSURE I
HHS Units Involved i n Issues Related to
Board and Care Homes for the Elderly
Unit
Area of Responsibility
Office of the
Assistant Secretary
for Planning and
Evaluations (ASPE)
- Oversees ongoing study on the effects
of regulation on quality of care.
- Oversaw study on the use of census
data to identify unlicensed homes.
- Scheduled to chair board and care task
force.
Administration for
Children and Families
(ACF)
- Administers the Keys Amendment.
- Provides information on a model act
for regulating board and care homes.
Health Care Financing
Administration (HCFA)
- Writing regulations to implement the
1990 Omnibus Budget Reconciliation
Act.
- Issues Medicaid program waivers i f
states c e r t i f y compliance with Keys
Amendment.
- Scheduled to be member of board and
care task force.
Social Security
Administration (SSA)
- Receives states' reports on Keys
violations.
- Provides states with information on
unlicensed homes, when requested.
- Administers the representative payee
system for SSI r e c i p i e n t s .
- Scheduled to be member of board and
care task force.
Administration on
Aging (AoA)
- Oversees grants for Ombudsman Program.
National I n s t i t u t e of
Mental Health (NIMH)
Oversees advocacy and protection
programs.
Scheduled to be member of board and
care task force.
Administration on
Developmental
D i s a b i l i t i e s (ADD)
Oversees advocacy and protection
programs.
Scheduled to be member of board and
care task force.
GAO/HRD-92-29R, HHS Staff for Board and Care Issues
�ENCLOSURE I
ENCLOSURE I
Office of the
Assistant Secretary
for Health (OASH)
Cosponsored study on the use of census
data to identify unlicensed homes.
Scheduled to be member of board and
care task force.
National I n s t i t u t e on
Aging (NIA)
Scheduled to be member of board and
care task force.
(105812)
5
GAO/HRD-92-29R, HHS Staff for Board and Care Issues
�GAO
United States
General Accounting Office
Washington, D.C. 20548
Human Resources Division
B-249868
September 25, 1992
The Honorable John D. Dingell
Chairman, Committee on Energy
and Commerce
House of Representatives
Dear Mr. Chairman:
This l e t t e r responds to your request for a review of f i s c a l
and other implications of the long-term care (LTC) insurance
projects sponsored by the Robert Wood Johnson (RWJ)
Foundation. The Foundation sponsors projects that link
private LTC insurance with the Medicaid program i n four
states.
We agreed to provide information on (1) the basis for the
Department of Health and Human Services' (HHS) approval of
amendments to several Medicaid state plans that allow those
states to implement these LTC insurance projects, (2) the
financial implications for the federal government of using
section 1902(r)(2) of the Social Security Act as the basis
for approving these projects, and (3) the federal role i n
protecting consumers who purchase LTC insurance p o l i c i e s
through the RWJ projects.
1
You expressed concern about the extent of federal oversight
for these projects because they were approved as Medicaid
state plan amendments rather than as demonstration projects.
With demonstration projects, HHS has authority to impose
r e s t r i c t i o n s and to exert substantial oversight. With state
plan amendments, however, HHS has limited authority to
impose r e s t r i c t i o n s or exert oversight, as long as the state
Medicaid i s an entitlement program that provides medical
assistance to certain low-income people. To qualify for
Medicaid, people usually must meet income and asset c r i t e r i a
that are linked to e l i g i b i l i t y c r i t e r i a for the cash
assistance programs, Aid to Families With Dependent Children
and Supplemental Security Income. Section 1902(r)(2) allows
states to compute income and resources i n a manner that i s
less r e s t r i c t i v e than these cash assistance programs
require.
GAO/HRD-92-44R, LTC Insurance
Partnerships
�plan complies with t i t l e XIX of the Social Security Act.
You were p a r t i c u l a r l y interested in whether issues such as
cost and consumer protection, raised previously by GAO and
in congressional deliberations, had been addressed by HHS
as part of i t s approval of these projects.
2
In September 1990, we issued a report on several proposed
RWJ LTC insurance projects, suggesting that the projects
needed close federal scrutiny. We raised several concerns
with these projects, including the potential for increased
Medicaid costs and the need for adequate consumer
protection. As a r e s u l t , we suggested that the Congress
ensure that the projects are designed to (1) minimize the
r i s k of cost increases for the Medicaid program, (2) require
states to meet the minimum LTC insurance standards of the
National Association of Insurance Commissioners (NAIC), (3)
require states to demonstrate that they w i l l provide
adequate consumer education, and (4) require states and
insurance companies to c o l l e c t information and to share data
with HHS so the projects can be adequately monitored.
OVERVIEW
Our current work shows that HHS approved Connecticut's state
plan amendment for the RWJ project because i t had no grounds
to disapprove the amendment. We believe that HHS's decision
i s a reasonable interpretation of the law ( t i t l e XIX of the
Social Security Act). HHS must approve amendments when they
conform to t i t l e XIX and i t s implementing regulations.
Regarding financial implications, the federal government has
no assurance that the RWJ projects w i l l not increase current
or future Medicaid costs. Concerning the federal role i n
protecting consumers, there are no federal consumer
protection standards for LTC insurance.
BACKGROUND
RWJ Foundation Projects
Four states (California, Connecticut, Indiana, and New York)
currently participate in the RWJ Foundation's Program to
Promote Long-Term Care Insurance for the Elderly. The
2
H.R. Conf. No. 964, 101st Cong., 2d Sess. 881-893, reprinted
in 1990 U.S. Code Cong. & Admin. News 2374,
2588-2598.
3
Lonq-Term Care Insurance: Proposals to Link Private
Insurance and Medicaid Need Close Scrutiny (GAO/HRD-90-154,
Sept. 10, 1990).
2
GAO/HRD-92-44R, LTC Insurance
Partnerships
�program links private LTC insurance with the states'
Medicaid programs. One purpose of these LTC insurance
projects i s to promote private long-term care insurance as a
way for older people to avoid impoverishment and to reduce
the need for middle-income older people to r e l y on Medicaid.
Other purposes include improving consumer education about
LTC insurance and improving the quality of LTC insurance
policies.
Typically, these projects allow people who purchase a
c e r t i f i e d LTC insurance policy to become e l i g i b l e for
Medicaid after the policy pays for a period of long-term
care costs. Purchasers would not have to deplete as much
of t h e i r assets, as i s required to meet current Medicaid
e l i g i b i l i t y thresholds. In effect, purchasers are offered
impoverishment protection by using Medicaid as "backup"
insurance i f their long-term care costs exceed the amount
that their policy w i l l cover.
4
To implement the LTC insurance projects, states must obtain
approval from the Health Care Financing Administration
(HCFA) to change their Medicaid e l i g i b i l i t y c r i t e r i a .
One
method of obtaining such approval i s to apply to HCFA for a
waiver or demonstration authority. Another method i s to
apply to amend their state Medicaid plan.
HCFA Demonstration Projects
HCFA, which administers the Medicaid program, generally
approves waivers for demonstration projects of limited
duration. Under these LTC insurance projects, 10 years or
more could elapse between consumers' purchase of an
insurance policy, their eventual use of benefits, and t h e i r
subsequent application for Medicaid. Because of this time
frame, state o f f i c i a l s believed that the LTC insurance
projects would not be appropriate as demonstration projects
under existing l e g i s l a t i v e authority. Consequently, states
5
4
A c e r t i f i e d LTC insurance policy has been reviewed and
approved by the state as meeting certain consumer protection
and other standards.
5
Section 1915(c) of the Social Security Act enables states to
engage in demonstrations by permitting HHS to waive Medicaid
requirements for a state for an i n i t i a l period of 3 years,
with a subsequent extension of 5 years. Demonstration
waivers are also granted for research purposes under section
1115(a). Most projects authorized under t h i s section run
for a limited period, no more than 3 or 4 years, and are
usually not renewable.
GAO/HRD-92-44R, LTC Insurance Partnerships
�sought federal l e g i s l a t i o n to e x p l i c i t l y permit HHS to
approve these projects for a longer period. Although
l e g i s l a t i o n was introduced i n 1989 and 1990, i t never became
law.
State Plan Amendments
As an alternative to l e g i s l a t i o n , states have requested
federal approval for such projects as an amendment to their
Medicaid state plans under the authority of section
1902(r)(2) of the Social Security Act. Under Medicaid law,
each state operates i t s Medicaid program according to a
detailed state plan that must comply with federal
requirements and be approved by HCFA. States can amend
t h e i r Medicaid plans as long as they remain i n compliance
with federal requirements, but such amendments must be
submitted to HCFA for approval. State plan amendments are
not generally required to contain time l i m i t s .
SCOPE AND METHODOLOGY
To obtain information on the basis for approving the LTC
insurance projects, we focused on the approval of
Connecticut's state plan amendment because this process s e t
the precedent for the later approval of amendments from
other states. W interviewed o f f i c i a l s i n HCFA's Medicaid
e
Bureau, HCFA's regional office i n Boston, and HHS's Office
of General Counsel. We also interviewed o f f i c i a l s from the
state of Connecticut and the RWJ Foundation's national
program office to obtain information on oversight a c t i v i t i e s
by the state and the Foundation. To obtain d e t a i l s about
the projects and the approval process, we reviewed several
studies, evaluations, progress reports, HHS memorandums,
legal opinions and relevant regulations. For information on
the financial impact of the projects on Medicaid, we
reviewed several analyses of Connecticut's LTC insurance
project. However, we did not independently assess these
analyses.
BASIS FOR HHS APPROVAL OF RWJ
LTC INSURANCE PROJECTS
To implement i t s project, Connecticut decided to amend i t s
Medicaid plan. The amendment allows Medicaid recipients who
use c e r t i f i e d LTC insurance policies to retain assets above
the Medicaid e l i g i b i l i t y thresholds. That i s , the amount of
assets that can be retained above these thresholds i s equal
to the amount of insurance benefits paid for long-term care.
The insurance benefits that are paid would be equivalent to
depleting assets to establish Medicaid e l i g i b i l i t y .
GAO/HRD-92-44R, LTC Insurance Partnerships
�In early 1990, Connecticut contacted HCFA to request
informal guidance on an amendment. HCFA i n turn sought
guidance from HHS's Office of General Counsel. HCFA was
concerned about various issues, including extending Medicaid
e l i g i b i l i t y to people with significant assets and pending
federal l e g i s l a t i o n to authorize this project as a
demonstration project. As noted e a r l i e r , the proposed
l e g i s l a t i o n was not enacted, and i n November 1990, HHS's
Office of General Counsel concluded that HCFA had no grounds
for disapproving the amendment. In May 1991, Connecticut
submitted an amendment to HCFA that was approved i n August
1991.
HHS's conclusion i s a reasonable interpretation of the law
( t i t l e XIX of the Social Security Act). Amendments to state
plans must be approved as long as they conform to t i t l e XIX
and i t s implementing regulations. Section 1902(r)(2) of the
act grants states considerable latitude i n how individuals *
assets can be treated. There i s s p e c i f i c language i n t i t l e
XIX that e f f e c t i v e l y limits the extent to which states can
disregard income for the purpose of determining Medicaid
e l i g i b i l i t y , even under section 1902(r)(2). However, there
are no similar l i m i t s on the amount of assets that states
can disregard.
FEDERAL FINANCIAL IMPLICATIONS OF
RWJ INSURANCE PROJECTS
There i s no assurance that the RWJ projects w i l l not
increase the federal government's Medicaid costs. The
federal government i s f i n a n c i a l l y responsible for i t s share
of Medicaid costs for services to people covered under an
approved state plan, including costs that r e s u l t from the
RWJ insurance projects.
There are no l i m i t s that are
relevant to the RWJ projects on federal payments for
Medicaid services provided under a state plan.
6
In our 1990 report, we said that many factors can affect the
likelihood that these projects w i l l increase Medicaid
expenditures. The most significant factor i s how much
income and assets the projects allow people to retain and
s t i l l qualify for Medicaid.
6
Medicaid i s paid for by state and federal governments. The
federal proportion varies from 50 percent to about 80
percent, depending on a state's per capita income, r e l a t i v e
to the national per capita income.
GAO/HRD-92-44R, LTC Insurance
Partnerships
�The Connecticut RWJ project would reduce the r i s k of
increased Medicaid expenditures by limiting the amount of
assets that people can protect and by requiring people to
spend their incomes to Medicaid e l i g i b i l i t y thresholds.
As
we stated in 1990, Connecticut's Medicaid program i s
protected from additional expenditures to the extent that a
LTC insurance policy pays the same amount as an individual
would have paid in out-of-pocket payments before qualifying
for Medicaid. Because the RWJ projects in Indiana and
California are similar to the Connecticut project, the r i s k
for increased Medicaid costs in these states should also be
reduced. However, this view may not necessarily be true for
the New York project because i t i s structured d i f f e r e n t l y
from the projects in the other three s t a t e s .
7
Several analyses of the Connecticut project, sponsored by
various organizations (including the state of Connecticut
and the RWJ Foundation), have examined the long-term f i s c a l
impact of these projects. Most analyses that we reviewed
show that these projects w i l l not change Medicaid costs or
w i l l produce modest savings to the Medicaid program. One
analysis, done for the American Association of Retired
Persons, shows modest increases in future costs to Medicaid.
However, estimates of the cost implications of these
projects depend largely on assumptions and predictions about
people's future behavior.
Information we obtained during our work indicates that other
states may be interested in amending their Medicaid plans to
establish LTC insurance projects. The projects in these
states would not be part of the RWJ program. Given the
considerable latitude that states have under section
1902(r)(2), and HHS's limited authority over projects
approved as state plan amendments, the federal government
has no assurance that a new Medicaid LTC insurance project
would be structured to minimize the p o s s i b i l i t y of
increasing Medicaid costs. I f such projects were
established as demonstrations, rather than state plan
amendments under section 1902(r)(2), the federal government
could exercise greater oversight and could l i m i t i t s
financial l i a b i l i t y for Medicaid costs resulting from the
projects.
7
The New York project w i l l allow people who exhaust the
benefits of a policy, covering a minimum of 3 years of
nursing home care or 6 years of community care, to become
e l i g i b l e for Medicaid without regard to their assets beyond
the amount paid out by insurance.
GAO/HRD-92-44R, LTC Insurance
Partnerships
�FEDERAL ROLE
IN PROTECTING CONSUMERS
There are no federal consumer protection standards for LTC
insurance. Consequently, HHS has no basis to impose
consumer protection standards on the RWJ projects. With
the exception of Medicare supplemental ("Medigap")
insurance, the federal government plays a limited role in
the regulation of insurance. Such regulation i s the
responsibility of states and state insurance commissioners.
Previous GAO reports have shown problems with insurance
p o l i c i e s , consumer protection, and other issues. Because
many states had not adopted a l l of NAIC's standards for LTC
insurance, we suggested establishing minimum federal
standards for such insurance.
8
One goal of the RWJ Foundation's program i s to improve the
quality of LTC insurance p o l i c i e s by requiring state
projects to meet NAIC's minimum standards i n c e r t i f i e d
insurance p o l i c i e s . To date, the four states that
participate in the RWJ LTC insurance project have agreed to
meet the standards. However, since there are no federal
consumer protection standards for LTC insurance, there i s no
guarantee that such programs established by other states
w i l l provide adequate consumer protection.
I trust that this response addresses your concerns. I f you
have any questions, please contact me on (202) 512-7119.
Sincerely yours,
Mark V. Nadel
Associate Director, National and
Public Health Issues
(108951)
8
See Long-Term Care Insurance: Better Controls Needed in
Sales to People With Limited Financial Resources (GAO/HRD92-66, Mar. 27, 1992); Long-Term Care Insurance: Risks to
Consumers Should Be Reduced (GAO/HRD-92-14, Dec. 26, 1991);
and Long-Term Care Insurance: State Regulatory Requirements
Provide Inconsistent Consumer Protection (GAO/HRD-89-67,
Apr. 24, 1989).
GAO/HRD-92-44R, LTC Insurance Partnerships
�GAO
United States
General Acconntnig Office
Washington, D.C. 20548
Ha man Resources Division
B-251469
December 1 , 1992
The Honorable Donald M. Payne
A c t i n g Chairman, Human Resources and
I n t e r g o v e r n m e n t a l R e l a t i o n s Subcommittee
Committee on Government Operations
House o f R e p r e s e n t a t i v e s
Dear Mr. Chairman:
Over t h e past 18 months, concerns have been r a i s e d over t h e
s a f e t y o f s i l i c o n e g e l b r e a s t i m p l a n t s , which a r e u s u a l l y
i n s e r t e d as p a r t o f r e c o n s t r u c t i v e s u r g e r y f o l l o w i n g a
mastectomy o r f o r cosmetic purposes. S p e c i a l a d v i s o r y
p a n e l s , convened by t h e Food and Drug A d m i n i s t r a t i o n (FDA),
concluded t h a t (1) no d e f i n i t i v e s a f e t y data e x i s t on these
i m p l a n t s , (2) a l l women should be advised o f t h e a s s o c i a t e d
r i s k s , and (3) r u p t u r e d i m p l a n t s should be removed.
E a r l i e r t h i s year, FDA placed a moratorium on t h e use o f
s i l i c o n e g e l b r e a s t i m p l a n t s , l i m i t i n g t h e i r use t o women
in c a r e f u l l y controlled studies.
The Subcommittee expressed concerns t h a t some women who a r e
e x p e r i e n c i n g medical problems w i t h s i l i c o n e g e l b r e a s t
i m p l a n t s have been unable t o have them removed due t o t h e
l a c k o f f i n a n c i a l resources.
As agreed w i t h t h e
Subcommittee s t a f f , we determined t h e payment p r a c t i c e s o f
government and p r i v a t e i n s u r e r s r e l a t i n g t o t h e removal o f
b r e a s t i m p l a n t s . What we found o u t about t h e v a r i o u s
i n s u r e r s ' payment p r a c t i c e s i s discussed i n t h i s l e t t e r .
Also i n t h i s l e t t e r , we a r e p r o v i d i n g i n f o r m a t i o n we
o b t a i n e d from Medicare and s t a t e Medicaid o f f i c e s on ( 1 )
t h e number o f s u r g i c a l procedures t h a t i n v o l v e d t h e removal
of b r e a s t i m p l a n t s , b r e a s t i m p l a n t m a t e r i a l , and o t h e r
GAO/HRD-93-5R, Removal o f Breast
Implants
�B-251469
c o m p l i c a t i o n s o f b r e a s t i m p l a n t s and (2) p h y s i c i a n charges
and Medicare and Medicaid payments f o r such procedures.
1
The Subcommittee s t a f f a l s o asked us t o p r o v i d e i n f o r m a t i o n
on procedures t h a t i n v o l v e f l a p surgery--a procedure i n
which f a t and t i s s u e a r e removed from one p a r t o f t h e body,
such as the stomach, b u t t o c k s , o r back, and t r a n s p l a n t e d t o
the c h e s t . The data we o b t a i n e d on such procedures a r e
presented i n t h e e n c l o s u r e .
To i d e n t i f y the i n s u r e r s ' payment p r a c t i c e s , we c o n t a c t e d
Medicare and Medicaid headquarters o f f i c i a l s , Department o f
Defense (DOD) o f f i c i a l s , and r e p r e s e n t a t i v e s from t h e Blue
Cross and Blue S h i e l d A s s o c i a t i o n (BCBS), t h e H e a l t h
Insurance A s s o c i a t i o n o f America (HIAA), and t h e American
P u b l i c Welfare A s s o c i a t i o n . I n a d d i t i o n , we c o n t a c t e d
Medicaid o f f i c e s i n e i g h t s t a t e s t o c o n f i r m t h e i r payment
p o l i c i e s . The Subcommittee s t a f f s e l e c t e d f o u r o f these
s t a t e s — F l o r i d a , L o u i s i a n a , Nevada, and Texas--and we
s e l e c t e d the o t h e r f o u r - - C a l i f o r n i a , New York, V i r g i n i a ,
and West V i r g i n i a - - b a s e d on the a v a i l a b i l i t y o f d a t a .
2
RESULTS IN BRIEF
Most government and p r i v a t e i n s u r e r s w i l l pay
removal o f s i l i c o n e g e l b r e a s t i m p l a n t s . A l l
r e q u i r e t h a t t h e p a t i e n t ' s p h y s i c i a n determine
procedure i s m e d i c a l l y necessary. G e n e r a l l y ,
t h a t t h e p a t i e n t i s s u f f e r i n g h e a l t h problems
for the
insurers
that the
t h i s means
due t o t h e
'W used the 1992 Physician's C u r r e n t P r o c e d u r a l Terminology
"e
(CPT) handbook t o i d e n t i f y these s u r g i c a l procedures.
The
handbook i s a u n i f o r m l i s t i n g o f m e d i c a l , s u r g i c a l , and
d i a g n o s t i c procedures performed by p h y s i c i a n s . The
procedures s e l e c t e d i n v o l v e d the removal o f b r e a s t i m p l a n t s
(code 19328) and b r e a s t implant m a t e r i a l (code 19330), and
o t h e r c o m p l i c a t i o n s of b r e a s t implants (codes 19370 and
19371) .
2
The DOD h e a l t h care system p r o v i d e s medical care t o
e l i g i b l e a c t i v e duty m i l i t a r y p e r s o n n e l , m i l i t a r y r e t i r e e s ,
and e l i g i b l e dependents of both groups. A c t i v e d u t y
dependents, r e t i r e e s and t h e i r dependents, and s u r v i v o r s o f
deceased members r e c e i v e care through t h e C i v i l i a n H e a l t h
and Medical Program of the Uniformed Services (CHAMPUS)
when care i s not a v a i l a b l e through m i l i t a r y h o s p i t a l s .
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b r e a s t i m p l a n t s o r t h a t t h e i m p l a n t s have r u p t u r e d o r
leaked.
I n c o n t r a s t , i f b r e a s t i m p l a n t s a r e b e i n g removed
s o l e l y because o f e m o t i o n a l o r p s y c h o l o g i c a l s t r e s s , some
government and p r i v a t e i n s u r e r s may deny coverage.
Medicare, Medicaid, DOD, and most p r i v a t e i n s u r e r s w i l l pay
f o r t h e removal o f b r e a s t i m p l a n t s even when t h e o r i g i n a l
i m p l a n t i s done f o r cosmetic purposes. However, CHAMPUS
w i l l n o t pay f o r any c o m p l i c a t i o n s t h a t r e s u l t from b r e a s t
i m p l a n t s done f o r cosmetic purposes, i n c l u d i n g t h e removal
of r u p t u r e d o r l e a k i n g b r e a s t i m p l a n t s .
Government o f f i c i a l s t o l d us t h a t t h e y have n o t heard o f
any b e n e f i c i a r i e s b e i n g denied coverage f o r t h e m e d i c a l l y
necessary removal o f b r e a s t i m p l a n t s . Moreover, o n l y a
r e l a t i v e l y s m a l l number o f requests f o r payment o f i m p l a n t
removal procedures have been s u b m i t t e d t o government
i n s u r e r s . However, t h e number p a i d by Medicare has
i n c r e a s e d over t h e past few years.
PUBLIC AND PRIVATE. PAYMENT PRACTICES
None o f t h e government o r p r i v a t e i n s u r e r s w i l l pay f o r
b r e a s t i m p l a n t s done f o r cosmetic purposes, such as
augmentation.
However, a l l t h e i n s u r e r s , except some
commercial i n s u r e r s and CHAMPUS, cover removal based on
medical n e c e s s i t y r e g a r d l e s s o f t h e reason f o r t h e o r i g i n a l
implant.
Medicare
Medicare covers s e r v i c e s t h a t a r e reasonable and necessary
f o r t h e d i a g n o s i s o r t r e a t m e n t o f an i l l n e s s o r i n j u r y o r
to improve body f u n c t i o n s . Medicare pays f o r t h e removal
of s i l i c o n e g e l i m p l a n t s t h a t pose a h e a l t h t h r e a t and
those t h a t a r e r u p t u r e d o r l e a k i n g . A Medicare o f f i c i a l
s t a t e d t h a t t h e program covers items o r s e r v i c e s t h a t a
p h y s i c i a n decides a r e m e d i c a l l y necessary. As a r e s u l t .
Medicare has n o t developed s p e c i f i c guidance r e l a t i n g t o
t h e removal o f b r e a s t i m p l a n t s .
Medicaid
Under Medicaid, s t a t e s must p r o v i d e f o r h o s p i t a l and
p h y s i c i a n s e r v i c e s , b u t t h e i r programs can v a r y . W i t h i n
broad f e d e r a l g u i d e l i n e s , each s t a t e designs and
a d m i n i s t e r s i t s own Medicaid program and s e t s e l i g i b i l i t y
standards and coverage p o l i c i e s . A l l e i g h t s t a t e Medicaid
3
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agencies t h a t we c o n t a c t e d pay f o r t h e removal o f b r e a s t
i m p l a n t s , b u t t h e r e are some v a r i a n c e s i n a p p r o v i n g such a
procedure.
For example, t h r e e s t a t e s r e q u i r e p r i o r
a u t h o r i z a t i o n o r peer review b e f o r e a p p r o v i n g a b r e a s t
procedure.
Two o t h e r s t a t e s r e q u i r e a p s y c h i a t r i c
e v a l u a t i o n b e f o r e paying f o r t h e removal o f i m p l a n t s based
on e m o t i o n a l o r p s y c h o l o g i c a l s t r e s s .
L o u i s i a n a ' s Medicaid program, f o r example, covers b r e a s t
i m p l a n t s performed as p a r t o f r e c o n s t r u c t i v e s u r g e r y
f o l l o w i n g a mastectomy and w i l l pay f o r t h e removal o f
i m p l a n t s when m e d i c a l l y necessary. However, a L o u i s i a n a
Medicaid o f f i c i a l s t a t e d t h a t , over t h e p a s t s e v e r a l y e a r s ,
p h y s i c i a n s have n o t s u b m i t t e d any c l a i m s f o r t h e removal o f
b r e a s t i m p l a n t s . Because o f t h i s i n a c t i v i t y , t h e s t a t e
Medicaid c l a i m s p r o c e s s i n g system w i l l a u t o m a t i c a l l y deny
any c l a i m f o r t h e removal o f b r e a s t i m p l a n t s and i m p l a n t
m a t e r i a l , o r o t h e r c o m p l i c a t i o n s o f i m p l a n t s . The Medicaid
o f f i c i a l s t a t e d t h a t i f a p h y s i c i a n o r p a t i e n t requests
Medicaid t o r e c o n s i d e r t h e denied c l a i m , i t w i l l be p a i d i f
a p h y s i c i a n determines t h e procedure i s m e d i c a l l y
necessary.
L o u i s i a n a i s c o n s i d e r i n g changing i t s p o l i c y o f
a u t o m a t i c a l l y denying c l a i m s i n v o l v i n g b r e a s t i m p l a n t
problems. L o u i s i a n a Medicaid may soon b e g i n p a y i n g f o r t h e
removal o f b r e a s t i m p l a n t s when t h e r e i s evidence o f
leakage.
Claims f o r t h i s procedure would be reviewed by
medical c o n s u l t a n t s b e f o r e payment i s made. The Medicaid
o f f i c i a l expected t h a t t h i s change would be implemented.
The Texas Medicaid p o l i c y , by c o n t r a s t , does n o t p r o v i d e
coverage f o r b r e a s t i m p l a n t s f o r augmentation purposes o r
f o l l o w i n g a mastectomy. A l l b r e a s t augmentation procedures
are viewed as cosmetic s u r g e r y .
I n e x c e p t i o n a l cases,
coverage o f b r e a s t augmentation procedures, e i t h e r
i n d e p e n d e n t l y o r i n c o n j u n c t i o n w i t h a mastectomy, may be
c o n s i d e r e d as a "waived e x c e p t i o n . " I n these cases, a
p a t i e n t must demonstrate t h e i n a b i l i t y t o p e r f o r m d a i l y
l i v i n g s k i l l s and o b t a i n p r i o r a u t h o r i z a t i o n b e f o r e payment
i s made. However, Texas Medicaid does pay f o r t h e removal
of b r e a s t i m p l a n t s o r i m p l a n t m a t e r i a l and o t h e r i m p l a n t
problems a f f e c t i n g a p a t i e n t ' s h e a l t h . The Texas p o l i c y
a l l o w s coverage f o r c o m p l i c a t i o n s a r i s i n g from a
nonapproved procedure when t h e c o m p l i c a t i o n s may o r do
adversely a f f e c t a p a t i e n t ' s health.
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DOD
DOD's p o l i c y i s t o remove any b r e a s t i m p l a n t a f f e c t i n g the
p a t i e n t ' s h e a l t h , r e g a r d l e s s o f t h e reason f o r t h e o r i g i n a l
i m p l a n t . On the o t h e r hand, CHAMPUS b e n e f i t s , which are
p r o v i d e d t o m i l i t a r y dependents and r e t i r e e s , do not cover
a l l b r e a s t i m p l a n t removals.
CHAMPUS i s d e v e l o p i n g a p o l i c y f o r t h e removal o f s i l i c o n e
g e l b r e a s t i m p l a n t s . The proposed p o l i c y , o u t l i n e d i n a
September 1992 l e t t e r t o us, s t i p u l a t e s t h a t b e n e f i t s f o r
b r e a s t i m p l a n t removal are not a l l o w e d i f t h e i n i t i a l
s u r g e r y i s not a covered CHAMPUS s e r v i c e . Thus, autoimmune
d i s o r d e r s and damage, leakage, and hardening o f b r e a s t
i m p l a n t s done f o r cosmetic purposes are c o n s i d e r e d
u n f o r t u n a t e consequences o f a noncovered s u r g e r y .
However,
b e n e f i t s may be allowed f o r a systemic i n f e c t i o n . A
CHAMPUS o f f i c i a l s t a t e d t h a t a b l o o d i n f e c t i o n would be
c o n s i d e r e d a systemic i n f e c t i o n and, i f r e l a t e d t o a b r e a s t
i m p l a n t , might be a basis f o r paying f o r removal even i f
the i m p l a n t was f o r cosmetic purposes.
CHAMPUS o f f i c i a l s s a i d t h a t no women seeking reimbursement
f o r the removal o f b r e a s t i m p l a n t s have been denied and
t h e r e has been o n l y one i n q u i r y c o n c e r n i n g CHAMPUS's
reimbursement p r a c t i c e s f o r t h e removal o f i m p l a n t s .
However, CHAMPUS's proposed p o l i c y i s i n d i r e c t c o n f l i c t
w i t h DOD's and most o t h e r i n s u r e r s ' p o l i c i e s .
Private Insurers
Many p r i v a t e i n s u r e r s cover the removal o f b r e a s t i m p l a n t s .
I n May 1992, HIAA q u e r i e d 160 medical d i r e c t o r s o f i t s
member o r g a n i z a t i o n s about the (1) use o f s i l i c o n e g e l
b r e a s t i m p l a n t s a f t e r a mastectomy and (2) removal o f these
i m p l a n t s . The 44 medical d i r e c t o r s , r e p r e s e n t i n g about 70
percent o f the major u n d e r w r i t e r s o f commercial i n s u r a n c e ,
who responded a l l s a i d t h a t t h e i r companies pay f o r b r e a s t
i m p l a n t s as p a r t o f r e c o n s t r u c t i v e b r e a s t s u r g e r y . They
added t h a t t h e i r companies a l s o pay f o r t h e removal o f such
i m p l a n t s i f deemed m e d i c a l l y necessary. A l t h o u g h some
companies request i n s u r e r s t o exclude c o m p l i c a t i o n s a r i s i n g
from cosmetic s u r g e r y , most HIAA members cover t h e removal
of s i l i c o n e g e l i m p l a n t s i n s e r t e d f o r cosmetic purposes.
BCBS has not surveyed i t s member plans t o determine t h e i r
p o l i c i e s f o r coverage o f the removal o f s i l i c o n e g e l b r e a s t
i m p l a n t s . Each Blue Cross and Blue S h i e l d Plan i s an
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independent company t h a t e s t a b l i s h e s i t s own coverage and
reimbursement p o l i c i e s . However, a BCBS spokesperson
s t a t e d t h a t where b e n e f i t s are p r o v i d e d f o r i m p l a n t a t i o n o f
s i l i c o n e g e l b r e a s t i m p l a n t s , t h e i r m e d i c a l l y necessary
removal i s u s u a l l y considered a covered s e r v i c e .
Emotional
or Psychological
Stress
Most government and some p r i v a t e i n s u r e r s cover t h e removal
of b r e a s t i m p l a n t s based on e m o t i o n a l o r p s y c h o l o g i c a l
s t r e s s . Some i n s u r e r s s a i d t h a t coverage d e c i s i o n s would
be made on a case-by-case b a s i s . Some Medicaid
r e p r e s e n t a t i v e s s a i d t h a t emotional o r p s y c h o l o g i c a l s t r e s s
might not j u s t i f y coverage, w h i l e o t h e r s s a i d t h a t s t r e s s
c o u l d l e a d t o a d e t e r m i n a t i o n o f medical n e c e s s i t y and,
t h e r e f o r e , would be grounds f o r removing b r e a s t i m p l a n t s .
Symptoms o f e m o t i o n a l o r p s y c h o l o g i c a l s t r e s s c o u l d r e q u i r e
e x t e n s i v e documentation.
Two s t a t e Medicaid o f f i c i a l s s a i d
t h a t a p s y c h i a t r i c e v a l u a t i o n would have t o be completed
b e f o r e t h e i m p l a n t removal procedure would be covered.
The HIAA survey showed t h a t 11 o f t h e 44 i n s u r e r s would
cover t h e removal o f s i l i c o n e g e l i m p l a n t s i f t h e p a t i e n t
i s s u f f e r i n g from p s y c h o l o g i c a l s t r e s s w i t h o u t any o t h e r
medical i n d i c a t i o n s o r c o m p l i c a t i o n s . A BCBS spokesperson
s t a t e d t h a t t h e removal o f b r e a s t i m p l a n t s based on
e m o t i o n a l o r p s y c h o l o g i c a l s t r e s s has not a r i s e n as an
issue.
RELATIVELY FEW REQUESTS MADE TO
GOVERNMENT INSURERS FOR IMPLANT REMOVAL
PROCEDURES, AND NONE REPORTED DENIED
Government o f f i c i a l s s a i d they are unaware o f program
b e n e f i c i a r i e s being denied coverage f o r procedures t o
remove s i l i c o n e g e l b r e a s t i m p l a n t s t h a t were deemed t o be
m e d i c a l l y necessary. Medicare and Medicaid o f f i c i a l s added
t h a t , i n view o f t h e r e c e n t p u b l i c i t y s u r r o u n d i n g i m p l a n t s ,
they b e l i e v e t h a t program b e n e f i c i a r i e s would v o i c e t h e i r
concerns i f coverage was denied f o r removal o f r u p t u r e d o r
leaking breast implants.
A r e l a t i v e l y few claims f o r b r e a s t i m p l a n t removals have
been s u b m i t t e d t o Medicare, but t h e number i s i n c r e a s i n g .
From 1989 t o 1991, t h e number o f b r e a s t i m p l a n t removal
claims p a i d by Medicare increased by 91 p e r c e n t , from 270
t o 517.
I n a d d i t i o n , claims i n v o l v i n g t h e removal o f
b r e a s t i m p l a n t m a t e r i a l i n c r e a s e d by 63 p e r c e n t , from 180
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t o 293. I n 1991, Medicare p a i d p h y s i c i a n s about $255,000
f o r these c l a i m s , o r an average o f $309 and $326,
r e s p e c t i v e l y . The Medicare payments r e p r e s e n t e d about 49
percent o f t h e amounts b i l l e d .
Medicare a l s o covers two o t h e r s u r g i c a l procedures t h a t
i n v o l v e medical c o m p l i c a t i o n s o f b r e a s t i m p l a n t s . I n 1991,
Medicare p a i d claims f o r 1,270 of these b r e a s t capsule
procedures, an i n c r e a s e o f 135 percent from 1989. I n
1991, Medicare reimbursed p h y s i c i a n s $494,000, an average
of $389 per c l a i m , o r 45 percent o f t h e amount p h y s i c i a n s
billed.
3
S t a t e Medicaid o f f i c i a l s s a i d few requests have been made
f o r t h e removal o f b r e a s t i m p l a n t s . For example:
-- From J u l y 1, 1991, t o June 30, 1992, t h e C a l i f o r n i a
Medicaid program p a i d 12 claims i n v o l v i n g t h e removal
of b r e a s t i m p l a n t s o r i m p l a n t m a t e r i a l . On average,
the program reimbursed p h y s i c i a n s $258 (24 p e r c e n t o f
the amount b i l l e d ) f o r 8 b r e a s t i m p l a n t removals and
$195 (26 percent o f t h e amount b i l l e d ) f o r 4 c l a i m s
i n v o l v i n g t h e removal o f b r e a s t i m p l a n t m a t e r i a l . The
program a l s o p a i d p h y s i c i a n s $303 (21 p e r c e n t o f t h e
amount b i l l e d ) f o r another 15 c l a i m s i n v o l v i n g
problems w i t h b r e a s t capsules.
-- A F l o r i d a Medicaid o f f i c i a l s a i d t h a t t h e number o f
claims i n v o l v i n g complications of breast implants i s
i n c r e a s i n g , a l t h o u g h o n l y a few i m p l a n t removal
procedures have been done. From J u l y 1, 1990, t o June
30, 1991, F l o r i d a p a i d one c l a i m i n v o l v i n g t h e removal
of b r e a s t i m p l a n t m a t e r i a l . The next y e a r , t h e r e were
18 c l a i m s - - ! i n v o l v i n g the removal o f a b r e a s t
i m p l a n t , 8 i n v o l v i n g implant m a t e r i a l and t h e o t h e r 9
i n v o l v i n g b r e a s t capsules.
Between J u l y 1 and
September 30, 1992, t h e r e were 9 p a i d c l a i m s , 3
i n v o l v i n g t h e removal of b r e a s t i m p l a n t s , 1 i n v o l v i n g
i m p l a n t m a t e r i a l , and 5 i n v o l v i n g b r e a s t capsules.
P h y s i c i a n s were reimbursed an average o f $308 f o r t h e
3
A capsule i s a w a l l t h a t the body forms around a b r e a s t
i m p l a n t . The capsule can c o n t r a c t , causing hardening o f
the i m p l a n t . S u r g i c a l procedures a r e performed t o e i t h e r
expand t h e b r e a s t pocket and r e l i e v e t h e hardness o r remove
t h e capsule.
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b r e a s t i m p l a n t removals and $211 f o r t h e removal o f
breast implant m a t e r i a l .
-- From October 1, 1990, t o September 30, 1991, New York
Medicaid p a i d 6 claims i n v o l v i n g t h e removal o f b r e a s t
i m p l a n t s , 10 claims i n v o l v i n g t h e removal o f b r e a s t
i m p l a n t m a t e r i a l , and 4 c l a i m s i n v o l v i n g b r e a s t
capsules.
-- During t h e p e r i o d J u l y 1991 t h r o u g h June 1992, Texas
Medicaid p a i d 2 claims i n v o l v i n g t h e removal o f b r e a s t
i m p l a n t s , 1 c l a i m i n v o l v i n g t h e removal o f b r e a s t
i m p l a n t m a t e r i a l , and 3 c l a i m s i n v o l v i n g b r e a s t
capsules.
Although data p r o v i d e d by s t a t e Medicaid programs cover
d i f f e r e n t time p e r i o d s , summarizing data from some o f t h e
l a r g e r Medicaid s t a t e s can p r o v i d e an i n d i c a t i o n o f how
many b r e a s t i m p l a n t removal procedures a r e b e i n g p a i d f o r
by Medicaid i n t h e U n i t e d S t a t e s . I n summary, d u r i n g t h e
p e r i o d s discussed above, C a l i f o r n i a , F l o r i d a , New York, and
Texas, which account f o r about 34 p e r c e n t o f t h e Medicaid
p o p u l a t i o n , p a i d p h y s i c i a n s f o r 20 b r e a s t i m p l a n t removals,
25 procedures f o r t h e removal o f b r e a s t i m p l a n t m a t e r i a l ,
and 36 b r e a s t capsule procedures.
We w i l l make copies o f t h i s l e t t e r a v a i l a b l e t o o t h e r
i n t e r e s t e d p a r t i e s upon r e q u e s t . Please c a l l me at. (202)
512-7119 i f you have any q u e s t i o n s about t h e i n f o r m a t i o n
discussed.
S i n c e r e l y yours.
Janet L. S h i k l e s
D i r e c t o r , Health Financing
and P o l i c y Issues
Enclosure
GAO/HRD-93-5R, Removal o f Breast
Implants
�ENCLOSURE I
ENCLOSURE I
FLAP BREAST RECONSTRUCTION
Table 1.1: Procedures Paid f o r by Medicare (1989-91)
Type o f f l a p procedure/CPT code
Muscle
19360
Year
1989
Back
19361
TRAM
19362
Free
19364
326
0
0
11
a
Number o f
procedures
b
b
c
Average Medicare
payment
Average p h y s i c i a n
bill
1990
$1,513
$2,545
_
_
$1,807
374
0
0
19
Number o f
procedures
$1,174
Average Medicare
payment
Average p h y s i c i a n
bill
_
_
$2,716
329
1
0
30
$1,502
$972
Average p h y s i c i a n
bill
a
$2,669
Average Medicare
payment
1991
$1,586
$2,834
$6,000
Number o f
procedures
$1,503
$1,525
-
$4,521
T h i s procedure i s n o t l i s t e d i n t h e 1992 CPT handbook.
b
These procedures were f i r s t l i s t e d i n t h e 1992 CPT handbook. CPT 19362 i n v o l v e s
t h e use o f t h e t r a n s v e r s e r e c t u s abdominis (TRAM). Medicare c o v e r s t h i s
procedure.
c
F r e e f l a p s u r g e r y i n v o l v e s removing f a t and t i s s u e from e i t h e r t h e stomach,
b u t t o c k s , o r back and t r a n s p l a n t i n g i t t o t h e chest t h r o u g h m i c r o s u r g e r y .
�Table 1.2:
Procedures Paid f o r by Selected Medicaid S t a t e s Over a 1-Year P e r i o d
Type o f f l a p procedure/CPT code
Muscle
19360
Back
19361
TRAM
19362
Free
19364
5
d
d
0
$849
_
_
_
$4,594
—
—
_
3
State
0
0
0
_
_
_
0
2
d
a
California
Number o f
procedures
b
b
c
( J u l y 1991-June 1992)
Average Medicare
payment
Average p h y s i c i a n
bill
Florida
Number o f
procedures
( J u l y 1991-June 1992)
Average Medicare
payment
$1,045
Average p h y s i c i a n
bill
Louisiana
Number o f
procedures
d
( J u l y 1991-June 1992)
Average Medicare
payment
$1,549
Average p h y s i c i a n
bill
New York
(Oct.
_
Number o f
procedures
0
$4,860
0
_
0
5
1990-Sept. 1991)
Average Medicare
payment
$365
Average p h y s i c i a n
bill
Texas
Number o f
procedures
_
1
e
_
d
d
0
-
-
-
( J u l y 1991-June 1992)
Average Medicare
payment
d
Average p h y s i c i a n
bill
T h i s procedure i s n o t l i s t e d i n t h e 1992 CPT handbook.
b
These procedures were f i r s t l i s t e d i n t h e 1992 CPT handbook.
t h e use o f t h e t r a n s v e r s e r e c t u s abdominis (TRAM).
c
CPT 19362 i n v o l v e s
F r e e f l a p s u r g e r y i n v o l v e s removing f a t and t i s s u e from e i t h e r t h e stomach,
b u t t o c k s , o r back and t r a n s p l a n t i n g i t t o t h e chest t h r o u g h m i c r o s u r g e r y .
d
Not payable.
e
T o t a l Medicaid payments f o r these procedures.
;i01259)
10
�
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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Title
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[GAO [General Accounting Office] Letters] [loose]
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
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2006-0885-F Segment 3
Is Part Of
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Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
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Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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Adobe Acrobat Document
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3/16/2015
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42-t-12092971-20060885F-Seg3-035-009-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/67c083f3ebcf163ed4fc94cb08861c95.pdf
d771bc252d754522e23fc45da00b83f1
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1983
FolderlD:
Folder Title:
[Framework for Public Policy Activities of the Coalition on Smoking or Health] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
2
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�0
American
Heart
Association
AMERICAN ±
LUNG ASSOCIATION'
The Christmas Seal People »
AAAERICAN
CANCER
SOCIETY®
Coalition on Smoking OR Health
Steering Commillce
Alan C. Davis. Chairman
American Cancer Society
Scott D. Ballin,
American Hean Association
Fran Du Melle
American Lung Assnciaiion
A d m i n i s t r a t o r • Federal Issues
The Coalition on Smoking OR Health is pleased to present its
Joy Silver Epstein
Administrator - Stale Issues
FRAMEWORK FOR PUBLIC POLICY ACTIVITIES
Peler Fisher
FOR 1993
Mailhew L. Myers
Asbill. Junkin &Myers
Legislative Advisory Council
American Academy of Family Physicians
to Federal and State legislators and policymakers, health advocates, and the
public. The Framework will guide the public policy activities of the Coalition
as we work towards the Surgeon General's goal of a Tobacco Free Society by
the Year 2000.
American Academy of Pedialrks
American Association for
Respiratory Care
American College of Cardiology
American Public Health Association
American Sociciy of Inlcmal Medicine
Association of Stale and Teirilurial
Heallh Officials
March of Dimes Binh Defects Foundaiion
This document has been developed by the American Cancer Society, the
American Heart Association, and the American Lung Association, united as
the Coalition on Smoking OR Health, in collaboration with the Legislative
Advisory Council of the Coalition.*
The members of the Legislative
Advisory Council are:
American Academy of Pediatrics
American Academy of Family Physicians
American College of Cardiology
American Association for Respiratory Care
American Public Health Association
American Society of Internal Medicine
Association of State and Territorial Health Officials
March of Dimes Birth Defects Foundation.
The implementation of the recommendations in the Framework would be a
giant step in the improvement of the health of all Americans.
* In addition, approximately 150 additional health, consumer, and religious
groups support Coalition initiatives on an ad hoc basis.
1150 Connecticut Avenue, NW, Suite 820, Washington, DC 20036
Telephone: (202) 452-1184 FAX: (202) 452-1417
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Framework for Public Policy Activities of the Coalition on Smoking or Health]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-008-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/caaf18e89e5c2e81e0584acaf3162bff.pdf
ba66717605f5347493f3d77b71822937
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1975
OA/ID Number:
FolderlD:
Folder Title:
[Extending Managed Competition to Small Metropolitan and Rural Areas] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
11
3
�Extending Managed Competition to
Small Metropolitan and Rural Areas
March 1993
Submitted to:
The New England Journal of MedicineSounding Board
Douglas G. Cave, Ph.D., M.P.H.
Managed Care Division
Hewitt Associates
Newport Beach, California
�A recent article published by Kronick et al concluded that "....reform of the
United States health care system through expansion of managed competition is
feasible in medium-sized or large metropolitan areas. Smaller metropolitan
areas and rural areas would require alternative forms of organization and
1
regulation of health care providers to improve quality and economy."
The authors defined medium-sized areas as those with populations greater
than 360,000 persons (covering 63% of the United States population) and large
areas as those with populations greater than 1.2 million persons (representing
only 42% of the United States population). Small areas have populations
greater than 180,000 persons (including 71% of the United States population).
As defined by Kronick et al, up to 37% of the population—those not in
1
medium or large areas—may not benefit from managed competition.
In estimating the minimal population required to support managed
competition, the authors used four assumptions: (1) the extent to which
competing health care organizations need to be independent; (2) the minimal
number of health care organizations needed to support healthy competition;
(3) the ratios of physicians to enrollees and of hospital beds to enrollees in
efficiently managed health plans; and (4) the geographic boundaries of health
1
services markets.
Of these assumptions, the authors' definition of the location and size of the
health care market is important to consider. Kronick et al assumed that
2
"...metropolitan areas, as defined by the Office of Management and Budget,
Cave 3/93
�are the relevant market areas for health services in nonrural parts of the
United States. Metropolitan areas are defined as a place with a population of at
least 50,000 or an urbanized area, as defined by the United States Bureau of
the Census, with a population of at least 50,000 and a metropolitan area with a
total population of at least 100,000. This definition of metropolitan area results
in high-density geographic units with economic and travel ties that are
3,4
consistent with a regional economic market."
We agree that a central tenet of the managed-competition theory is that
providers are divided into competing economic units as defined by some
geographic boundary. However, we suggest that geographic boundaries need
not be defined by the Office of Management and Budget or the United States
Bureau of the Census. Instead, the location and size of the health care market
might be defined more broadly to include many surrounding small areas and
rural counties.
Using this broader definition, demographic factors will not limit the full
implementation of managed competition as the vehicle for reforming the
United States health care economy. Instead, the limiting factor now is whether
competing health plans will extend their current network coverage areas from
existing medium-sized and large metropolitan areas to small areas and rural
counties. The answer is yes, if the proper financial incentives are employed
under the managed-competition theory.
PROVIDING GRANTS AND SURCHARGES
The Federal government could offer financial assistance to encourage new
and existing health plans to extend their network coverage areas to the new
Cave 3/93
�geographic boundaries established under managed competition. Authorized
grants of up to $100,000 could be offered to conduct feasibility studies, grants
of up to $200,000 for more detailed planning, and grants of up to $2 million for
initial network development costs. Congress also could stipulate that 20% or
more of the managed-competition grants must go to health plans that will
enroll a given percentage of their members—say one-third—from small areas
and rural counties.
These grants are similar to those Congress authorized for prepaid health
plan development under The Health Maintenance Organization Act of 1973
56
(P.L. 93-222). '
Another approach could be to implement a surcharge on all health plans
that fail to expand their networks to all areas within the geographic boundary
of their respective health care markets. A reasonable surcharge might be
10% on all hospital bills or 5% of all medical care bills. And health plans can
reduce the surcharge by 25%, 50%, and 75% as they expand their coverage
areas and enroll an equivalent percentage of the targeted small areas and rural
counties.
This type of financial arrangement is presently being used by the
State of New York to provide HMOs with incentive to enroll Medicaid
7 8
patients. -
ADDRESSING THE DISTRIBUTION OF PROVIDERS
Alternatively, the Federal government could provide financial incentives
that more directly address the distribution of health care providers. For
instance, a health plan could exclude from taxable income, say, $20,000 for
Cave 3/93
�physicians devoting 50% or more of their medical practice to patients in small
areas and rural counties. The provincial government of Ontario, Canada uses
this type of incentive (although the government directly pays physicians
9
annual compensation for practicing in rural areas).
Another way to target health care providers is to require all new
physicians to devote 100% of their medical practice to small areas and rural
counties for four years (or 50% for eight years). If these physicians insist on
practicing in medium-sized and large metropolitan areas, they would be
reimbursed for only 70% of their bills or a predetermined fee
schedule—or 70% of the health plan's average salary or capitation level. The
provincial governments of Ontario and Quebec, Canada have proposed
reforms along these lines.
9,10
EXPANDING NETWORK COVERAGE
A qualified health plan must provide primary care services, specialist
1
services, acute-care hospital services, and tertiary hospital services. Following,
we define one way that health plans could expand their networks to small
areas.
Primary Care Services
To provide full coverage under an established geographic boundary, health
plans must target a minimum number of enrollees in each small area within
that geographic boundary. Kronick et al showed that 2,000 persons are
required to support one full-time-equivalent primary care (family medicine)
Cave 3/93
�1
physician. This is not a large number; consequently, health plans should be
able to establish extensive independent primary care networks.
Primary care physicians presently living in small areas will need to fully
commit their practice to one health plan's network. If some small area
physicians will not participate, a health plan could hire one or more new
10
primary care physicians to service the small area. Competition for patients
could become fierce, and physicians not fully committed to one organization
may be forced out of the market.
Specialist Services
For most populations, 10% of the individuals spend about 70% of health
care dollars (and 1% of individuals spend about 30% of health care dollars).
Alternatively, 90% of the individuals in a geographic area spend about 30% of
11
the health care dollars. Generally speaking, these findings imply that 90% of
the individuals in small areas can be cared for through a health plan's primary
care network. The remaining 10% will require more resource-intensive
specialist and hospital care.
However, a health plan enrolling only 2,000 persons in a small area could
not commit any one type of specialist physician full time to that area. Instead,
the health plan will need to develop specialist travel programs to service these
areas. As an example, the provincial governments of Ontario and Quebec
arrange for urban-based specialists to travel to rural areas once a week and
9,10
provide services.
When small area enrollment reaches 10,000 persons, a health plan can
commit one full-time-equivalent obstetrician/gynecologist. And once small
Cave 3/93
�area enrollment reaches 20,000 persons, a health plan can support one general
surgeon, one orthopedist, one emergency medicine physician, one
anesthesiologist, one radiologist, and one psychiatrist. However, a specialist
travel program would still need to be developed for cardiology, urology, and
12
many other specialty services.
Specialist travel programs actually will enhance access to specialty care for
many patients in small areas. In those small areas that cannot support full-time
specialists, patients presently have to travel long distances, sometimes
hundreds of miles, to receive specialist care. Under the specialist travel
program, the specialist comes to the patient.
Acute-Care Hospital Services
Health services research shows that 35% to 40% of all hospital admissions
13,14
are planned and are single nonrepeat events.
For small areas, these
hospital services can be delivered in one of several ways. Ideally, a health plan
would enroll 60,000 members per small area and then build and support a 125
1,12
bed hospital. Under certain circumstances, this enrollment level can be
achieved. However, this is more the exception than the rule.
A more realistic goal would be small area enrollment of 20,000 persons. For
this population size, a health plan could deliver acute-care hospital services by
1,12
building mini-hospitals (about 45 beds).
Essentially, the mini-hospitals
would be expanded surgicenters and would provide mainly maternity, some
general surgery, emergency medicine, and some radiology services. Other
Cave 3/93
�specialist services could also be provided, but each health plan would need to
determine the cost efficiency of delivering these services at
mini-hospitals.
For small areas with enrollment between 2,000 and 20,000 persons, health
plans could arrange for patient travel programs to their acute-care hospitals in
medium-sized or large metropolitan areas. Generally, well organized patient
travel programs should be viewed favorably by many small area residents.
Once enrollment reaches the 20,000 person threshold, a mini-hospital could be
supported.
Of course, there will be clinical situations where a patient travel program
will not be sufficient. For example, if a woman goes into premature labor, a
planned hospital admission instantly becomes an emergency admission. For
this reason, a contingency plan must be developed that replaces the patient
travel program.
One arrangement might be to negotiate emergency-type admission rates
with an existing small area hospital. Or if this hospital is now owned by
another health plan, the negotiations would have to be with that health plan.
The Federal government may need to legislate that health plans owning a
hospital in small areas open-their-doors to all other health plans for emergency
admissions. A definition would need to be established for emergency
conditions, and limits would need to be placed on charged per diem or per
case rates.
Cave 3/93
�Tertiary Hospital Services
Two distinct types of patients will require tertiary hospital care. The first
type of patient is characterized by either a single cost-intensive or single
prolonged hospitalization. About 10% to 15% of all hospital admissions fall
13,15
under this category.
Conditions include spinal cord injuries, head trauma,
strokes, neurological diseases, organ transplants, and premature infants.
Many existing small area hospitals are not equipped to deal with these
tertiary-care patients. Consequently, once vital signs are stabilized, the patients
are airlifted to an urban tertiary care hospital for treatment.
Health plans servicing small areas could treat these patients in a similar
fashion. Mini-hospitals or acute-care hospitals providing emergency services
would be responsible for patient stabilization. Then, the health plan would
employ a state-of-the-art air transport program to fly the patient to the health
plan's tertiary care hospital. Resource-intensive care would be provided at this
facility.
The other type of patient requiring tertiary hospital services is
characterized by repeated hospitalizations for the same disease. These patients
1316
account for about 50% of all admissions.
Conditions include acquired
immunodeficiency syndrome, cancer, congestive heart failure, diabetes mellitus
(in patients with a low hematocrit and an elevated creatinine), and renal
failure/nephritis.
One way to properly manage this group of patients is for health plans to
develop coordinated care gatekeeper programs in small areas. Primary care
network physicians would serve as the foundation of this program. Each
Cave 3/93
�patient would be assigned to one primary care physician. Working with the
health plan, this physician would closely monitor the patient's natural disease
process. As greater complications and systemic involvement occur, the primary
care physician would be required to develop a treatment plan, and to
coordinate all care delivered.
Patient travel, specialist travel, and air transport programs would all play a
role in treating these types of patients. The primary care physician would
continually reevaluate the patient's medical condition and have the power to
recommend any treatment plan modifications.
We applaud the efforts of Kronick et al in undertaking this evaluation.
However, we do not feel they reached the proper conclusion. Kronick et al
stated that demographic factors will limit the full implementation of managed
competition as the vehicle for reforming the U.S. health care economy. Instead,
we conclude that the geographic boundaries defining a health care market
should not be too narrowly defined; the boundaries must be large enough to
include some small metropolitan areas and rural counties.
We showed how health plans could extend their current networks and
provide services to small area enrollees. But "could" and "will" are often two
different things. Thus, we defined financial incentives that the
Federal Government could use to encourage qualified health plans to extend
their present service areas. In this manner, a large number of health plans—at
least five or six—could feasibly compete to enroll small area populations.
Geographically isolated areas where providers have a natural monopoly would
effectively be eliminated. And managed competition would work.
Cave 3/93
�REFERENCES
1. Kronick R, Goodman D C, Wennberg J. The marketplace in health care
reform: the demographic limitations of managed competition. The New
England Journal of Medicine 1993; 328(2): 148-152.
2. Codes, titles, and components of metropolitan areas (MSAs, CMSAs, and
PMSAs). Washington, D.C: Bureau of the Census, 1990. (Department of
Commerce report 2-52).
3. 1990 Census of population and housing: summary population and
housing characteristics—New Hampshire. Washington, D.C: Government
Printing Office, 1991. (Bureau of Census report CPH-1-31: A-8).
4. Half the nation's population lives in large metropolitan areas. Press
release of the Department of Commerce, Washington, D C ,
February 21, 1991.
5. Dorsey J D. The Health Maintenance Organization Act of 1973
(P.L. 93-222) and Prepaid Group Practice Plans. Medical Care 1975; 13(1):
1-9.
6. Marks H M. The Health Maintenance Organization Act of 1973
(P.L. 93-222). Unpublished paper for the executive program in Health
Policy and Management, Harvard School of Public Health, 1978.
7. HMOs facing higher charges until signing Medicaid pacts. Press release of
the Capital District Business Review, Albany, N.Y., July 20, 1992.
8. Cause for worry: HMOs, Medicaid. Press release of Grain's New York
Business, Grain Communications, Inc., September 6,1992.
9. Drastic steps pending to cut number of MDs in Metro area. Press release
of The Toronto Star, Toronto, Canada, October 24, 1992.
10. No quick fix: Americans are looking to Canada for ideas about reforming
health care—but Canadians are facing problems too. Press release of
Washington Post Foreign Service, Montreal, Canada, July 23, 1991.
11. Henderson M A, Bergman A, Collard A, Souder B, Wallack S. Privatesector medical case management for high-cost illness. Advances in Health
Economics and Health Services Research 1988; 9(4): 41-52.
12. Mulhansen R, McGee J. Physician need: an alternative projection from a
study of large, prepaid group practices. Journal of the American Medical
Association 1989; 261: 1930-1934.
Cave 3/93
10
�13. Zook C J, Moore F D. High-cost users of medical care. The New England
Journal of Medicine 1980; 302(18): 996-1002.
14. Cave D G, Tucker L J. Preventing hospital readmissions— a new direction
for case management programs. Compensation and Benefits Management
1991; 7(2): 21-27.
15. Schroeder S A, Showstack J A, Roberts H E. Frequency and clinical
description of high-cost patients in 17 acute-care hospitals. The New
England Journal of Medicine 1979; 300(23): 1306-1309.
16. Zook C J, Savickis S F, Moore F D. Repeated hospitalization for the same
disease: a multiplier of national costs. Milbank Memorial Fund Quarterly
1980; 58: 454-471.
Cave 3/93
11
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Extending Managed Competition to Small Metropolitan and Rural Areas]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-007-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/9e625d5ed875fa46cfb29281e27b52e7.pdf
dc8ed67c6719ce39e681d3b76e9314f9
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1971
OA/ID Number:
FolderlD:
Folder Title:
[Earthletter] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
10
2
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
�EARTHLETTER
"Man did nol weave lhe web of life. He is merely a strand in it..." Chief Seattle, circa 1880
Vnlumft 1 N n m h p r A
HOW E N Z Y M E S WORK
Are Thdyr Safe or Necessary?
AIDS; Children of Chernobyl;
Another Plant Bites the Dust;
Leaky Nukes, Waste Dump
Dear Friends,
Welcome to the tourth issue of
Earthletter.
For new readers,
this newsletter is an extension of my
book, R a d i a t i o n
Protection
M a n u a l , 3 r d E d i t i o n . All of
these articles are f r o m my own
research and clinical experience. No
one has paid me to say anything in
this newsletter. I describe certain
products that I use in my practice.
I know that there may be other similar
products but I can only speak from
my o w n experience.
I welcome
research and information and use rt
wherever possible.
I give thanks to my expert editor
and assistant, Joyce Jordan, who
helps make sense out of my garbled
writings!
Sincerely,
EARTHLETTER
Dec. 1991 Vol.1, No. 4
"Enzymes are substances that
make life possible. They are needed
for every chemical reaction that takes
place in the human body. No mineral,
vitamin, or hormone can do any work
without enzymes. Our bodies, all of our
organs, tissues, and cells, are run by
metabolic enzymes.
They are the
manual workers that build our body
from proteins, carbohydrates, and fats,
just as construction workers build our
home.
You may have all the raw
materials with which to build, but
without the workers (enzymes) you
cannot even begin." (Dr. Edward
Howell, Enzyme N u t r i t i o n , the
Food Enzyme Concept, 1985).
Enzymes
are
very
special
proteins.
They have been called
biological catalysts, for no biochemical
reaction occurs without them. But this
term does not emphasize
their
biological force, vitality or enzyme
activity, a quality that is measurable
and dependent on temperature, pH
(acid-base balance) and the presence
of moisture (water). In other words
each enzyme does its work only at its
own specific pH and temperature
range. Outside of its pH range, the
enzyme is deactivated. Outside of its
temperature range, the enzyme may be
destroyed. In fact, enzymes are much
more heat-sensitive
(labile)
than
vitamins and are the first to be
destroyed during cooking, pasteurization, canning, microwaving,
or
heating above 118 degrees Fahrenheit.
You can swallow pounds of vitamins
and minerals but without enzymes,
nothing works and you are wasting your
money.
Enzymes can be divided into
classes according to function.There
are about
5,000
metabolic
enzymes,
which run the body
chemistry and are involved in all body
processes including breathing, talking,
movement, behavior, and maintaining
the immune system.
I learned most of the following
from Dr. Howard Loomis of 21st
Century Nutrition who, along with the
late Dr. Edward Howell are the two
foremost pioneers in food enzyme
nutrition and therapy. I am speaking
not just from book knowledge but from
several years of clinical therapy with
food enzymes.
The results of food
enzyme
therapy
are
profound.
(Earthletter,
Vol. 1, No. 1 , March.
1991.)
The food enzymes to which I refer
are made by the National Enzyme
Company and marketed by the NESS
(Nutritional Enzyme Support Systems)
company. NESS enzymes are the result
of Dr. Howard Loomis' ten years of
research. There are about 28 NESS
formulations with more on the horizon.
Although the National Enzyme Company
provides food enzymes for several other
companies, do not expect any over-thecounter food enzyme system to do the
work described in this article. Health
food stores carry many brands of food
enzymes. These are excellent as a
digestive aid but they are not potent
enough to correct a deviated blood pH or
to alleviate a crisis condition.
NESS food enzymes are strong
enough to do this additional work.
Because of their potency, they can be
obtained only from licensed health
practitioners who use specific tests to
determine exactly what kind of food
enzymes are needed to correct deviated
body chemistry and bring the blood back
to homeostasis.
Introduction
I was surprised to read the
following statement in an article on
�ORDER FORM
Please make check or money order payable to LKa Lee, 2061 Hampton Ave., Redwood City, CA 94061.
Call our office for wholesale ordering information: (415)369-2554. Ask for Joyce.
f
\
Introductory Issue (Including postage)
Per year (4 Issues) (Including postage)
Radiation Protection Manual (Including postage)
(Californiaresidentsadd 50 cents tax on book)
Total enclosed
Name (please print clearly).
Address
City
State
Zip.
EARTHLETTER
Ltta Lee, Ph.D.
2061 Hampton Ave.
Redwood City, CA 94061
$5.00
$20.00
$10.00
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Earthletter] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
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2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
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42-t-12092971-20060885F-Seg3-035-006-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/d83339ae4f667805e694677c2350e93f.pdf
63747e1ec511b0d6838d5d1ae7d4e398
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1338
OA/ID Number:
FolderlD:
Folder Title:
[Cassidy Letter] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
6
2
�CASSIDY INSURANCE AGENCY
230 MOUNT HEIiMON ROAD • SUITE 208 • SCOTTS VALLEY, CA 9506fi
August 10,
1993
Honorable W i l l i a m J. C l i n t o n
President of the United States
The White House
1600 Pennsylvania Ave., NW
Washington, D.C. 20500
Dear President C l i n t o n :
As professional insurance agents, we agree that the current health
care financing system needs reform. However, to dismantle i t before
discovering the workings of the replacement system would be unwise.
I t i s conceivable that under a system of "exclusive" a l l i a n c e s
a l l of the services c u r r e n t l y provided by health insurance agents would
be terminated. We are concerned t h a t , such exclusive a l l i a n c e s w i l l
have an adverse impact on the a b i l i t y of small employers, t h e i r employees
and self-employed i n d i v i d u a l s to gain access to the needed i n f o r m a t i o n a l ,
assistance and advocacy services t h e i r agents c u r r e n t l y provide. Already,
a f t e r only one month of operation, the need f o r agent assistance has
been demonstrated i n the HIPC Plan here i n C a l i f o r n i a .
Therefore, we do support health-care reform, but also advocate
voluntary health a l l i a n c e s operating alongside p r i v a t e system plans
which would operate under the same rules as the l o c a l health a l l i a n c e s .
I f health a l l i a n c e s are t r u l y more a d m i n i s t r a t i v e l y e f f i c i e n t and b e t t e r
at pooling r i s k s , then the c a r r i e r s operating through the a l l i a n c e w i l l
have lower premiums and w i l l n a t u r a l l y gain market share. I f , on the
other hand, employers and i n d i v i d u a l s prefer to deal d i r e c t l y w i t h an
insurance agent rather than a l a r g e , impersonal bureaucracy, they should
have that choice.
We a l l desire the most humane and c o s t - e f f e c t i v e medical plan available.
We f e e l t h a t , as independent health insurance agents, we have a great
deal to c o n t r i b u t e to t h i s goal and should not be cut out of any proposed
health care reform system.
Sincerely,
rence D. Cassidy
T. Michael U l w e l l i n g
cc: I r a Magaziner
(408) 438-5490
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Cassidy Letter] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-005-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/45b5d1b875d8fc182daf95f78ababe04.pdf
bb7004e2822a3ee9070488eb30b90d63
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1981
OA/ID Number:
FolderlD:
Folder Title:
[Carol Pollack Dworkowitz] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
2
3
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
DATE
SUBJECT/TITLE
RESTRICTION
001. letter
Carol P. Dworkowitz to Hillary Clinton [partial] (1 page)
2/1/1993
P6/b(6)
002. statement
Description of paper from Carol P. Dworkowitz [partial] (1 page)
n.d.
P6/b(6)
003. essay
"Health Care - America's Shame" by Carol P. Dworkowitz [partial]
(1 page)
7/1991
P6/b(6)
004. form
Carol P. Dworkowitz' Insurance Information (1 page)
9/30/1988
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA|
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PKA|
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
Carol P. Dworkowitz to Hillary Clinton [partial] (1 page)
2/1/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the F01A|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute [(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of Ihe FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOI.A|
b(8) Release would disclose information concerning the regulation of
financial institutions |(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA)
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA)
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�February
1, 1 993
Carol P o l l a c k Dworkowitz
O
O
Mrs. H i l l a r y C l i n t o n
C/O The White House
1600 Pennsylvania Ave.
Washington, D.C.
Dear Mrs.
Clinton,
I hope t h a t you w i l l take the time t o peruse the contents
this mailing.
There i s much t h a t I would l i k e t o t e l l you about the h e a l t h
care system as I see i t , but my student o b l i g a t i o n s preclude
me from doing so. However, t h e r e i s some v a l u a b l e i n f o r m a t i o n
i n my essay although since my daughter's i l l n e s s I have learned
much more.
Unquestionably, reform must begin by c o n t r o l l i n g p r i c e s .
I n a d d i t i o n , the a t t i t u d e of those i n d i v i d u a l s whose business
i t i s t o d e l i v e r Health Care t o the p u b l i c must change. L i k e
a c h i l d who has never known r u l e s or l i m i t s , i t w i l l not be
easy t o now c o n t r o l an e n t i r e i n d u s t r y t h a t has run w i l d f o r
over a decade -- e s p e c i a l l y one t h a t sees i t s e l f as omnipotent
and has mastered the economic concept o f i n e l a s t i c demand.
I n my o p i n i o n , many o l d e r members o f Congress, those whose
war-chests have been l i n e d by l o b b y i s t s r e p r e s e n t i n g the Health
Care I n d u s t r y , w i l l be r e s i s t a n t t o change as w e l l — even our
esteemed democrats. B e l i e v e or n o t , I see George M i t c h e l l as
your worst enemy. P e r s o n a l l y , I hate the man.
of
Feel f r e e t o c o n t a c t me i t 1 ma'y h6ip i n any
Regards,
way.
�9
Victim of the health care quagmire in America
By CAROL POLLACK
M
ANY SOUTH Floridians holding
individual health insurance policies are
hoping that The Herald, or someone, will
help them. Someone needs to question the
legitimacy of recent rate-hike
approvals sanctioned by
Insurance Commissioner Tom
Gallagher's ofFice.
Last year my premium
| jumped to $790 a month from
$520 — a 52 percent increase.
To get the earlier premium
down to $520,1 had already
raised my deductible and
co-payment limit. Now this
year my new premium is going
up to $948 — a total increase
of 82 percent. Although high,
health care costs have not
Carol Pollack
risen 82 percent.
My initial reaction is therefore to ask: If the
insurance commissioner's office was doing its job,
how could such exorbitant back-to-back rate
increases have been approved?
The insurance commissioner's staff informed
me that insurance companies must submit
x
proposed rate increases for individual policies to
his office for approval. Yet Mutual of Omaha, my
insurance carrier, tells me that, even though they
must submit proposed rate hikes, the state does not
have to approve them. Who is telling the truth?
Health insurance rates in Dade County rank
among the four highest in the United States.
Because Florida permits health insurers to
Balkanize people with pre-existing conditions into
smaller risk groups with higher premiums, many
are forced to drain their savings to pay these
unconscionable premiums. Many have already
exhausted their savings and now live in fear.
While insurance rates have climbed in other
parts of the state, rates for the same policy in Dade
and Broward are often twice as high as in other
Florida counties. Someone living in South Florida
with a pre-existing condition thus bears a double
financial burden.
Recently The Herald has printed several
editorials advocating a major overhaul of the
nation's health care system. However, until
Washington grants all Americans equal access to
quality health care, residents of Dade and Broward
counties who have pre-existing conditions and
don't get health benefits through their employer
must turn to the state for help. Becausee these
individuals are only solitary whispers, they need a
strong voice to speak for them.
It has become apparent that our state
government listens only to the insurance lobby and my last two years at the University of Central
is no longer responsive to constituents. Individuals Florida.
On May 5, 1991,1 graduated from Miami-Dade
or families dealing with an illness are already
with honors and a straight-A average. On May 12,
victims. Must Florida enforce a system that seeks
1991,1 sold my house. But the following week my
to punish them twice?
I am a widow. When my husband died, I decided daughter was diagnosed with a platelet disorder.
that I would try my best to make life normal for my She did not respond to the usual medication, and
young daughter and avoid day care at all costs. Our other treatments would have to be tried. Since we
had no family or friends in Satellite Beach, I
support systems were very limited. I worked part
couldn't muster the courage to go it alone. Luckily,
time for several years until she began junior high
I was able to get out of the sale of my house.
school. Searching for a full-time position, I found
, In five weeks I will be a senior at Florida
that many things had changed since I had last
International University. With my health
sought permanent employment in New Jersey 16
insurance premiums so high, I am not sure that my
years ago.
financial situation will allow me to finish. Now, at
I already had a pre-existing medical condition.
the age of 46,1 am angry that I too may become a
Small firms would hire me, but not offer me
medical benefits. Large companies offered me only victim of the health care quagmire in America — a
system that rations health care by wealth.
clerical positions at a low salary and low growth
potential. I was refused many interviews because I
Last year I went to see if Medicaid would help
was not a college graduate.
me absorb my deductible. I was declined because I
Although quite unsure of myself, I decided to try had health insurance, but I was shocked when the
college. After my first year at Miami-Dade
gentleman who interviewed me said: " I wouldn't
Community College, I realized that the cost of
pay those premiums. I f l were you, I would drop my
health insurance might be the one obstacle in my
health insurance and let the state help you." I
way. I searched for a town in Central Florida where replied, " I am not a gambler."
health insurance rates were half what I am now
After doing extensive research during the last
paying — a town that had both a superior high
five years and writing several papers on the issue of
school and a four year college. My daughter and I
health care, plus dealing with it first hand, I am
decided that the year she finished junior high we
firmly convinced that if this issue is not resolved
would move to Satellite Beach, where I could finish soon, it will strangle America.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002. statement
SUBJECT/TITLE
DATE
Description of paper from Carol P. Dworkowitz [partial] (1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act - (44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA]
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA]
P3 Release would violate a Federal statute 1(a)(3) of the PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�I mailed a copy o f t h i s essay, along w i t h a b r i e f cover
l e t t e r , t o many prominent democrats i n congress, and o u t o f
approximately 10 m a i l i n g s , t h e o n l y i n d i v i d u a l t o answer w i t h o u t
a form l e t t e r was Dante F a s c e l l . The r e s t responded w i t h t h e
usual a p o l o g e t i c r h e t o r i c . Sen. Graham's o f f i c e t o l d me t h a t
any major h e a l t h care reform was a t l e a s t t e n years
away.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003. essay
SUBJECT/TITLE
DATE
"Health Care - America's Shame" by Carol P. Dworkowitz [partial]
(1 page)
7/1991
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOI A]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy ((b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA)
National Security Classified Information |(a)(l) of the PRA)
Relating to the appointment to Federal office 1(a)(2) of the PRA)
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�^7
r o A c ^ t ^
Health Care —
/
n hi
America's Shame
Equal access t o medical care should be every c i t i z e n ' s
u n a l i e n a b l e r i g h t , r e g a r d l e s s o f t h e i r age o r income, f o r w i t h o u t
adequate h e a l t h c a r e , l i f e , l i b e r t y , and t h e p u r s u i t o f happiness
are t h r e a t e n e d and o f t e n an i m p o s s i b i l i t y . However, w h i l e every
developed country except South A f r i c a agrees w i t h t h i s concept,
the U.S. government e l e c t s tc^ u n f a i r l y burden t h e middle c l a s s
and t h e small business person w i t h s k y r o c k e t i n g medical costs
r a t h e r than adopt a program t h a t would serve i n t h e best i n t e r e s t
of " a l l " Americans.
The middle c l a s s , some o f whom are unemployed and cannot
a f f o r d p r i v a t e insurance, o r are u n i n s u r a b l e due t o a p r e e x i s t i n g c o n d i t i o n , l i v e i n f e a r o f l o s i n g t h e i r homes and l i f e
savings. S t i l l o t h e r s i n t h i s category who were f o r t u n a t e enough
to have had p r i v a t e insurance before they became i l l , can only
watch as t h e i r premiums soar and t h e i r savings dwindle.
C e r t a i n l y , t h e impact o f d e a l i n g w i t h an i l l n e s s i s i n i t s e l f
d e v a s t a t i n g ; t h e r e f o r e , i t should n o t be c o r r e l a t e d w i t h
f i n a n c i a l concerns.
Conservatives i n t h i s country s t i l l subscribe t o t h e t h e o r y
t h a t o n l y t h e "have-nots" are w i t h o u t medical insurance; however,
a segment o f t h e middle c l a s s has now j o i n e d t h e ranks o f t h e
uninsured. As p r o o f , medical costs are now t h e l e a d i n g cause
of " p e r s o n a l " bankruptcy i n t h i s c o u n t r y . Americans should
not be f o r c e d t o choose between h e a l t h care costs and t h e basic
n e c e s s i t i e s o f l i f e , nor should government expect those f a m i l i e s
who have achieved t h e dream o f owning a home t o f o r f e i t i t i n
order t o pay f o r medical t r e a t m e n t .
While l a r g e f i r m s are able t o s e l f - i n s u r e , small businesses
are dependent upon insurance companies f o r h e a l t h b e n e f i t s .
The small businessman i s o f t e n a v i c t i m o f "Medical Red-Lining"
and f r a u d . At present t h e r e a r e no s t a t e o r f e d e r a l r e g u l a t i o n s
t h a t p r o t e c t them from these unscrupulous p r a c t i c e s . A d d i t i o n a l l y , many small businesses are v i c t i m i z e d by insurance companies
t h a t do n o t meet r e s e r v e requirements; consequently, as claims
come i n , these companies c l o s e t h e i r doors l e a v i n g p o l i c y holders
stranded.
In t h e l a s t decade h o r r o r s t o r i e s have increased i n number,
and y e t government has n o t responded t o t h e needs o f the people.
In t h i s c o u n t r y s i c k people a r e punished t w i c e , once by
u n f o r t u n a t e l u c k , and second by a governing body t h a t responds
to i t s "own needs" r a t h e r than those o f i t s e l e c t o r a t e .
Many U.S. c i t i z e n s f e e l shame t h a t a l l t o o f t e n fund r a i s e r s
are h e l d t o pay medical c o s t s f o r a f a m i l y member, f r i e n d , o r
co-worker. Why does our government approve monetary a i d f o r
the needy people o f o t h e r n a t i o n s , b u t looks t h e o t h e r way when
Americans c r y o u t f o r help?
As a l i f e t i m e r e g i s t e r e d democrat, I f a i l t o understand
why my chosen p a r t y has been s i l e n t on an issue t h a t n e g a t i v e l y
a f f e c t s t h e e m o t i o n a l , f i s c a l , and p h y s i c a l w e l l being o f people
across t h i s l a n d . Of course, t h e wealthy a r e n ' t a f f e c t e d because
they can a f f o r d insurance p o l i c i e s t h a t o f f e r t h e best protection .
r(_ 2.
00
�-2Since I have done e x t e n s i v e r e s e a r c h on t h e h e a l t h insurance
i s s u e s f a c i n g Americans, please read my comments and suggestions
r e g a r d i n g t h e proposed i n s u r a n c e p l a n by Senator R o c k e f e l l e r .
Although i t i s n o t a permanent s o l u t i o n , i t would o f f e r many
Americans a temporary compromise. My comments a r e based on
an enclosed a r t i c l e .
COVERAGE: I t i s n o t f a i r t o p u t t h e burden on employers.
F i r s t o f a l l , s m a l l businesses a l l over t h e c o u n t r y are c l o s i n g ,
and o t h e r s have stopped o f f e r i n g employee h e a l t h b e n e f i t s because
o f t h e c o s t . A d d i t i o n a l l y , even w i t h Managed H e a l t h Care Plans
(HMO's and PPO's), l a r g e c o r p o r a t i o n s have n o t been a b l e t o
stem t h e t i d e o f r i s i n g c o s t s .
I n c r e a s i n g l y , more and more
companies and l a b o r unions a r e c a l l i n g f o r some type o f n a t i o n a l
health plan.
"The amount o f c o r p o r a t e p r o f i t s consumed by h e a l t h c o s t s
are now a s t a g g e r i n g 49%," and " h e a l t h care c o s t s c o n t i n u e t o
r i s e a t almost t w i c e t h e r a t e o f i n f l a t i o n " ( C r o n k i t e ) . I f U.S.
f i r m s a r e t o be f o r m i d a b l e c o m p e t i t o r s i n t h e new g l o b a l market,
h e a l t h care c o s t s must be c o n t r o l l e d . To compensate f o r h e a l t h
e x p e n d i t u r e s , companies have r a i s e d r e t a i l p r i c e s , y e t employees
are n o t p r o f i t i n g s i n c e r e a l wages have n o t kept up w i t h
i n f l a t i o n . As more and more i n d i v i d u a l s see t h e i r d i s p o s a b l e
income s h r i n k i n g , l e s s money i s a v a i l a b l e t o spend o r save.
In a d d i t i o n , "3/4 o f a l l l a b o r s t r i k e s i n 1990 were over h e a l t h
b e n e f i t s " ( C r o n k i t e ) . While Republicans endorse c u t t i n g t h e
c a p i t a l g a i n s t a x , c i t i n g t h e supply s i d e t h e o r y as a way t o
s t i m u l a t e t h e economy, why haven't t h e democrats e x p l o i t e d t h e
adverse economic e f f e c t s h e a l t h care c o s t s have produced?
O f f e r i n g h e a l t h b e n e f i t s t h r o u g h employers promotes
d i s c r i m i n a t i o n . As h e a l t h c o s t s have soared, employers have
begun q u e s t i o n i n g j o b a p p l i c a n t s about p r e - e x i s t i n g c o n d i t i o n s ,
as w e l l as t h e h e a l t h o f any dependent who might be e n r o l l e d
i n t h e program. While some a p p l i c a n t s have d i s c r e e t l y been
t u r n e d down, o t h e r s have been o f f e r e d j o b s , b u t have had h e a l t h
benefits withheld.
I have enclosed p r o o f o f t h e l a t t e r , and
i t s h o u l d be noted t h a t t h i s was permanent.
Since p a r t - t i m e j o b s c a r r y no b e n e f i t s , many b u s i n e s s e s ,
e s p e c i a l l y r e t a i l , have t u r n e d f u l l - t i m e p o s i t i o n s i n t o p a r t time as a means o f l o w e r i n g c o s t s .
Some people work two o r
t h r e e j o b s and a r e s t i l l n o t a f f o r d e d b e n e f i t s .
BENEFITS: U n t i l a u n i f o r m b e n e f i t package e x i s t s , b e n e f i t s
f o r a l l c i t i z e n s o f t h i s c o u n t r y w i l l s t i l l n o t be e q u a l . I s
government prepared t o p o l i c e businesses t o ensure t h a t w h i t e
and b l u e c o l l a r workers o f t h e same c o r p o r a t i o n a r e o f f e r e d
the same coverage?
W a i t i n g p e r i o d s o f 30 days as proposed a r e f i n e p r o v i d e d
i n d i v i d u a l s would be covered under t h e proposed Americare d u r i n g
t h a t t i m e . E l i m i n a t i n g t h e w a i t i n g p e r i o d on p r e - e x i s t i n g
c o n d i t i o n s i s d e f i n i t e l y an i m p o r t a n t p a r t o f t h i s proposed
p l a n , and s h o u l d be passed as law i m m e d i a t e l y . F i r s t , i t would
�-3g i v e a sense o f s e c u r i t y t o those people w i t h p r e - e x i s t i n g
c o n d i t i o n s who u n t i l now have been a f r a i d o f changing j o b s .
Second, i t would a l s o p r o t e c t those i n d i v i d u a l s w i t h i l l n e s s e s
who are p r i v a t e l y i n s u r e d from p a y i n g "double" premiums d u r i n g
the usual one year w a i t i n g p e r i o d when b e g i n n i n g a new j o b .
However, i n an e f f o r t t o a v o i d f u r t h e r d i s c r i m i n a t i o n a g a i n s t
those i n d i v i d u a l s w i t h p r e - e x i s t i n g c o n d i t i o n s , c o n s i d e r a t i o n
should be g i v e n t o passing a law t h a t would make i t i l l e g a l
t o ask t h e h e a l t h o f a p r o s p e c t i v e worker and/or dependents.
AMERICARE: 80% o f d o c t o r s w i l l not accept i t . Drawbacks
t o Medicaid are the myriad o f b u r e a u c r a t i c paperwork and fee
schedule t h a t accompany i t . A l s o , w o r k i n g women w i t h young
c h i l d r e n who do not have b e n e f i t s , complain o f l o s i n g t o o much
time from work w a i t i n g t o be seen i n overburdened c l i n i c s .
How would t h i s p l a n c o r r e c t these shortcomings?
Would t h i s
p l a n cover f u l l t i m e c o l l e g e s t u d e n t s and s i n g l e p a r e n t s who
are not employed?
SMALL BUSINESSES: Along w i t h i n d i v i d u a l p o l i c y h o l d e r s ,
they are a t the mercy o f i n s u r a n c e companies. I n c r e a s i n g l y ,
s m a l l businesses, once t h e backbone o f t h e American economy,
have c l o s e d due t o t h e c o s t o f h e a l t h c a r e ; moreover, o t h e r s
have been f o r c e d t o withdraw b e n e f i t s i n o r d e r t o s u r v i v e / a d d i n g
more t o the number o f u n i n s u r e d . A l s o , businesses l o c a t e d i n
m e t r o p o l i t a n areas are a t a d i s t i n c t disadvantage s i n c e they
pay c o n s i d e r a b l y h i g h e r r a t e s (sometimes between 50-60% h i g h e r )
than do those s i t u a t e d i n l e s s densely p o p u l a t e d l o c a t i o n s .
As mentioned e a r l i e r , would government r e g u l a t e t h e i n s u r a n c e
i n d u s t r y more c a r e f u l l y so s m a l l businesses would n o t become
v i c t i m s o f " r e d - l i n i n g " and f r a u d ?
Although t h i s proposed N a t i o n a l i n s u r a n c e p l a n i s c e r t a i n l y
b e t t e r than what p r e s e n t l y e x i s t s , i t has t h r e e main f l a w s :
^
1.
H e a l t h care c o s t s w i l l never be s t a b i l i z e d or c o n t a i n e d
as l o n g as i n d i v i d u a l s and c o r p o r a t i o n s must r e l y on i n s u r a n c e
companies. Insurance companies do not operate on a s o c i a l l y
o p t i m a l p r o f i t margin, they o p e r a t e s o l e l y w i t h two t h i n g s i n
mind — p r o f i t and s t o c k h o l d e r s . As a p o i n t o f i n t e r e s t , many
have accused t h e i n s u r a n c e i n d u s t r y o f j a c k i n g up insurance
r a t e s t o compensate f o r a l l t h e l o s s e s i n c u r r e d as a r e s u l t
of t h e drop i n r e a l e s t a t e v a l u e s and t h e j u n k bond market d u r i n g
the l a t t e r p a r t o f t h e 80's.
There i s no mention o f p r o t e c t i n g i n d i v i d u a l p o l i c y
holders
from t h e p r a c t i c e o f r i s k p o o l s . I n t h e s t a t e o f F l o r i d a , and
I b e l i e v e i n o t h e r s t a t e s as w e l l , i n s u r a n c e companies f i l e
f o r r a t e i n c r e a s e s based on t h e i r c l a i m l o s s e x p e r i e n c e .
Every
few years i n s u r a n c e companies i n t r o d u c e brand-new p o l i c i e s .
Agents w i l l then t r a n s f e r i n d i v i d u a l s who are a b l e t o meet t h e
medical u n d e r - w r i t i n g c r i t e r i a i n t o the new p o l i c y . Those
i n d i v i d u a l s who have subsequently developed a " p r e - e x i s t i n g
�-4c o n d i t i o n " s t a y w i t h t h e o r i g i n a l p o l i c y ; t h e r e f o r e , the l o s s
experience i s g r e a t e r s i n c e e i t h e r one or more p a r t i c i p a n t s
of the p o l i c y now have a medical problem. i n essence, the o l d e r .
p o l i c y h o l d e r s are t e c h n i c a l l y i n an "assigned r i s k p o o l " o n l y
no one l a b e l s i t as such. Once a g a i n , s i c k people are punished
t w i c e . Since i t i s obvious t h a t t h e people who need coverage
t h e most may be p r i c e d out of t h e market, awarding the insurance
companies r a t e i n c r e a s e s u s i n g these g u i d e l i n e s i s not o n l y
u n f a i r -- i t i s c r i m i n a l . Indeed, i t g i v e s credence t o the
t h e o r y t h a t i n s u r a n c e companies no longer wish t o take any r i s k
w i t h o u t undue compensation. I t i s i m p o r t a n t t o note t h a t f o r
r e s i d e n t s o f m e t r o p o l i t a n areas, where r a t e s are c o n s i d e r a b l y
h i g h e r , t h e burden i s even g r e a t e r .
2. The p l a n does a b s o l u t e l y n o t h i n g t o e l i m i n a t e t h e
enormous amounts o f b u r e a u c r a t i c paper work. F u l l y 25<P o f every
d o l l a r spent on h e a l t h care pays f o r an i n d i v i d u a l t o process
t h e myriad o f paperwork i n v o l v e d i n c l a i m p r o c e s s i n g and b i l l i n g .
"A t y p i c a l Canadian h o s p i t a l may employ fewer than a dozen
b i l l i n g c l e r k s , w h i l e a comparable U.S. h o s p i t a l may employ
over 3 0 0 " ( C r o n k i t e ) .
3. The p l a n would c r e a t e g u i d e l i n e s r e g a r d i n g procedures
and p r i c e s f o r b o t h d o c t o r s and h o s p i t a l s ; however, when speaking
about d o c t o r s ' f e e s , i t i s v e r y hard t o c o r r a l a runaway b u l l .
I f any p o s i t i v e changes are t o be made i n the c o s t o f h e a l t h
care i n t h i s c o u n t r y , i t must begin w i t h p h y s i c i a n s . As a
n a t i o n , we need t o q u e s t i o n why "American d o c t o r s earn 50% more
than t h e i r Canadian p e e r s " ( C r o n k i t e ) .
My e x t e n s i v e r e s e a r c h enables me t o make these a d d i t i o n a l
c o n s t r u c t i v e comments about h e a l t h care i n t h i s c o u n t r y :
1. Most h o s p i t a l s pad t h e i r b i l l s .
As an a l e r t consumer,
I have had them c o r r e c t e d , b u t how many people, e s p e c i a l l y t h e
e l d e r l y , examine t h e i r b i l l s .
2. Everyone t a l k s about t h e c o s t of m a l p r a c t i c e i n s u r a n c e ;
however, no one suggests a means by which incompetent d o c t o r s
may be r e p o r t e d . Kenneth S. Abramowitz, a h e a l t h care a n a l y s t
a t Sanford C. B e r n s t e i n & Co., s t a t e s , "The p r o b l e m . . . i s t h a t
no one knows who t h e good d o c t o r s and bad d o c t o r s a r e . Only
d o c t o r s know and they are not t e l l i n g " ( D e G e o r g e 118).
C o n f i d e n t i a l r e v i e w boards must be e s t a b l i s h e d i n an e f f o r t
to c o r r e c t t h i s s i t u a t i o n .
I n a d d i t i o n , m a l p r a c t i c e s u i t s should not be heard i n f r o n t
of uninformed j u r i e s who, as a way o f g e t t i n g back a t i n s u r a n c e
companies f o r t h e i r h i g h r a t e s , o f f e r huge s e t t l e m e n t s even
i f the evidence does not support t h e award.
was
3. The Cobra Law i s b e n e f i c i a l o n l y i f t h e i n d i v i d u a l
employed i n a group o f 20 or more, remains h e a l t h y , can
�-5a f f o r d t h e premiums w h i l e unemployed, o r f i n d s another j o b w i t h
b e n e f i t s i n t h e time a l l o t t e d . To use an o l d c l i c h e , i t has
more h o l e s than swiss cheese.
4. The excesses o f t h e e i g h t i e s a l l o w e d p h a r m a c e u t i c a l
and medical supply companies t o f u r t h e r expand t h e i r p r o f i t
margins.
I n a d d i t i o n , b o t h charge t h e i r customers i n t h e medical
p r o f e s s i o n more than they charge t h e r e s t o f t h e p r i v a t e s e c t o r ,
a p r a c t i c e t h a t i s known as t h e "Pentagon E f f e c t . " What w i l l
be done t o curb t h e "greed" t h a t e x i s t s i n t h i s s e c t o r o f t h e
economy?
5. We must s t o p spending m i l l i o n s o f d o l l a r s i n an e f f o r t
t o p r o l o n g t h e l i v e s o f t e r m i n a l l y i l l p a t i e n t s f o r whom t h e r e
i s no hope and no q u a l i t y o f l i f e .
6. With an e s t i m a t e d 37 m i l l i o n people u n i n s u r e d , h o s p i t a l s
are r e c o u p i n g some o f t h e c o s t s they i n c u r t r e a t i n g t h e
u n i n s u r e d , by i n f l a t i n g everyone e l s e ' s b i l l — hence " c o s t
s h i f t i n g . " H e w i t t A s s o c i a t e s , i n Chicago, a b e n e f i t s c o n s u l t i n g
f i r m , " e s t i m a t e s t h a t 'cost s h i f t i n g ' i s r e s p o n s i b l e f o r one
t h i r d o f t h e y e a r l y i n c r e a s e i n some companies' medical b i l l s "
(Bradburn 4 8 ) .
7. The burden o f d e a l i n g w i t h t h e u n i n s u r e d and Medicaid
i s u n f a i r l y g e n e r a t i n g f i n a n c i a l h a r d s h i p s t o many c i t i e s and
s t a t e s — e s p e c i a l l y those communities d e a l i n g w i t h u n r e s t r i c t e d
immigration.
8. E f f o r t s s h o u l d be made t o f i n a n c i a l l y h e l p s t u d e n t s
who i n c u r s u b s t a n t i a l debt d u r i n g t h e i r years i n medical s c h o o l .
S t a r t i n g a p r a c t i c e w i t h a s i g n i f i c a n t debt might tempt even
the most honorable person t o perform unnecessary t e s t s i n an
e f f o r t t o earn more, thus p a y i n g o f f t h e debt more q u i c k l y .
9. I n d i v i d u a l s a r e w o r r i e d about s u r v i v i n g b o t h p h y s i c a l l y
and f i n a n c i a l l y w i t h America's d y s f u n c t i o n a l system o f h e a l t h
c a r e . "When p o l l s t e r s asked U.S. c i t i z e n s i f t h e y ' d p r e f e r
Canadian h e a l t h care over t h e i r own, 72% s a i d ' y e s ' " ( S c h m i t z ) .
10.
Many s t a t e Blue Cross and Blue S h i e l d p l a n s a r e i n
financial trouble.
11.
S i n g l e p a r e n t f a m i l i e s , those where a spouse i s e i t h e r
deceased o r n o t i n t h e p i c t u r e , a r e a t a d i s t i n c t disadvantage
s i n c e t h e r e i s o n l y one a d u l t t o shoulder t h e burden o f p r o v i d i n g
h e a l t h b e n e f i t s and f u l l - t i m e care should a c h i l d develop a
s e r i o u s m e d i c a l problem.
S t a t i s t i c a l l y , t h e m a j o r i t y o f these
f a m i l i e s a r e headed by women l a c k i n g t h e s k i l l s o r e d u c a t i o n
necessary t o secure a good j o b t h a t o f f e r s b e n e f i t s .
Kate Cagney, a w r i t e r and h e a l t h care advocate
from Chicago,
�-6summarizes t h e i s s u e s u c c i n c t l y when she says "No c o u n t r y i n
the i n d u s t r i a l w o r l d devotes a l a r g e r p o r t i o n o f i t s resources
t o medical c a r e ; y e t no i n d u s t r i a l i z e d c o u n t r y has denied a
l a r g e r p o r t i o n o f i t s p o p u l a t i o n access t o such c a r e " ( 3 0 1 ) .
The t i m e has come f o r America t o meet t h e needs o f i t s
c o n s t i t u e n c y and a b o l i s h i t s system o f r a t i o n i n g h e a l t h care
by " w e a l t h . " When i t comes t o p r e - n a t a l care and i m m u n i z a t i o n s ,
the U.S. i s g u i l t y o f spending zero up f r o n t and m i l l i o n s l a t e r .
U n q u e s t i o n a b l y , g r e a t e r access t o h e a l t h care i n t h e U.S. c o u l d
save b o t h l i v e s and money w i t h e a r l y d i a g n o s i s and prompt
t r e a t m e n t o f many i l l n e s s e s .
For y e a r s , e l e c t e d o f f i c i a l s and i n s u r a n c e i n d u s t r y spokespeople have p e r p e t r a t e d t h e "myth" t h a t s o c i a l i z e d medicine
doesn't work i n o t h e r c o u n t r i e s and w i l l n o t work h e r e . I n
a d d i t i o n , t h e y c l a i m Americans w i l l never accept i t . M a n i f e s t l y ,
Congress i s n ' t l i s t e n i n g t o what Americans a r e s a y i n g .
F a c t u a l l y , Canada expands 9% o f i t s G.N.P. on h e a l t h care
and i n s u r e s a l l o f i t s c i t i z e n s ; c o n v e r s e l y , t h e U.S. spends
almost 12% o f i t s G.N.P. on h e a l t h care b u t s t i l l has 37 m i l l i o n
people u n i n s u r e d and m i l l i o n s more u n d e r - i n s u r e d .
Unquestiona b l y , i f t h e American system o f d e l i v e r i n g h e a l t h care were
an i n v e s t m e n t , i t would y i e l d zero r e t u r n .
Americans are no longer willing to accept the propaganda
surrounding the issue of socialized medicine. As more individuals file for unemployment, more families will find themselves
facing the health insurance quagmire. Congress must act quickly
to find an equitable solution that protects "all" Americans
-- if not, the people may decide to hold their elected officials, /
accountable the next time they enter the voting booth, -j- •f/^cti^f [
�Works C i t e d
Bradburn, E l i z a b e t h , e t a l .
"Can You A f f o r d t o Get S i c k . "
Newsweek 30 Jan. 1989: 45-51.
Cagney, Kate.
"Health K i c k . "
Cronkite, Walter.
The N a t i o n 25 Sept. 1989: 301.
" B o r d e r l i n e Medicine."
PBS S p e c i a l 20 Mar,
1 991
DeGeorge, G a i l , e t a l .
"Ouch!"
Business Week 20 Nov. 1989:
110-118.
Schmitz, Anthony.
39-47.
"Health Assurance." I n H e a l t h Jan. 1991:
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
004. form
SUBJECT/TITLE
DATE
Carol P. Dworkowitz' Insurance Information (1 page)
9/30/1988
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
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an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute |(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
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PS Release would disclose confidential advice between the President
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P6 Release would constitute a clearly unwarranted invasion of
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C. Closed in accordance with restrictions contained in donor's deed
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PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�\
/
N T N L NW
AI A E S
O
PS
THURSDAY. JUNE 6,1991 1 C «
THE MIAMI HERALD l O A ?
insurance plan unveiled
HIGHLIGHTS O DEMOCRATS' H A T P A
F
E LH L N
• Covaragt: A
O
Americans vmukf b*
covered, either
through their jobs or a
new program that
wouldreplaceMedicaid
Emptoyers that choose not to
offer coverage would face a new
6 to 8 percent payroll tax.
• Benefits: All
health plans would
have to meet or
exceed a standard
periods could not exceed _
SOURCE: HwMtWMMq]
days; Btnlts on coverage of
pre-existing conditions would be
^minated
• AmeriCare:
Medfeaid would be
replaced by a new
federal-st^e
program called
AmeriCare, with an initial cost
of $6 billion. The program
would cover the poor and those
not insured through work. It
would pay doctors, hospitals
more than Medicaid now does.
Medicaid would continue paying
for nursing home care.
-O^i
:
_
• Costa: Savings
of $78 bSHon projected
over five years, mainly
by eliminating unneeded procedures.
New federal agency would set
spending targets, negotiate rates
between providers, consumers.
m Small
businesses:
Would have up to
five years to
provide coverage. To
encourage them to buy insurance,
businesses with fewer than 60
employes would get tax credits. —
�You m i g h t f i n d these two a r t i c l e s i n f o r m a t i v e .
Although
you have p r o b a b l y read t h e one on f r a u d , t h e o t h e r one i s from
a r e l a t i v e l y obscure magazine.
�IN CANADA, A LITTLE PLASTIC CARD GETS YOU FREE CARE ANYWHERE. WHAT'S THE CATCH?'
I
HE LAST SNOW HAD MELTED JUST DAYS BEFORE, though
the mountains .towering
over Vancouver were still blanketed. In the city flowers bloomed—crocuses,
daffodils. A fresh breeze swept in from the Pacific, through the open windows of the
heart ward at Vancouver General.
Six days after open heart surgery, Tom Berrie lay naked on his bed. A nurse bent
over him, tugging at the glinting metal staples that held the sixty-three-year-old
retiree together.
"I'll be done here in a minute," he said in a Scotsman's brogue that was surprisingly hale, considering the circumstances.
Berrie had every reason to be pleased. He'd gotten the operation he needed. He'd
lived to tell about it. And thanks to Canada's health care system, he hadn't paid a cent. Still,
there was one substantial hitch. Berrie had waited to get his surgery for the better part of a
year. During those long months he wondered if this were a bargain that would kill him.
When the nursefinished,he rose and wrapped himself in a hospital gown. With his full
head of hair and trim dark mustache, Berrie lookedfit—solong as he stood still. When he
moved it was with the caution of a man who feared he might fly apart.
A Scot by birth, Berrie left Glasgow for Canada with his wife and two children in the
19.50s. "1 came here because it was far away from Britain," he said. "Too far to turn back.
Once I got here I had to make a go of it." In Burnaby, a Vancouver suburb, Berrie returned
to law enforcement, the occupation he'd left behind in Scotland. He'd been retired for just
ten months in January of 1989 when he suffered a heart attack while reading the morning
, ::.(#•- ' • • , .
Illustrations
by
RAFAL 0 L B I N S K I ~ T 0 M E K
OLBINSKI
JANUARY/FEBKUARY 19!* 1 I N H L A L T H
39
�paper. His daughter rushed him to a local hospital.
ON OUR SIDE OF THE BORDER, as Tom Berrie obAnywhere in the United States, an intake clerk
served, we cover neither everything nor everybody.
would have grilled Berrie about how he planned to
The number of U.S. citizens with no health insurpay his bills. In British Columbia, Berrie simply
ance at all—37 million—exceeds Canada's total
handed over his bright plastic "Care Card," which
population. Ask Americans whether they believe
guarantees him free treatment anywhere in Canaour health care system needs wholesale reform (as
da. A $55 monthly premium, paid through Berrie's
several polls have), and nine out of ten say yes.
pension plan, covers him and his wife. "The emerMost say they'd rather have care like Canada's.
gency ward was packed," Berrie recalled, "but 1
This is not an opinion shared by the American
was on a table, snap, with a cardiologist looking
health industry. Every few months, organizations
after me."
such as the American Medical Association or the
Health Insurance Association of America deliver a
This, however, was the last aspect of his care that
gloomy report on Canada's health scheme, pormoved with any speed. After two weeks, Berrie was
traying it as a rotten edifice on its way to ruin, a
released with a May referral to a specialist for an
system only fools would emulate.
angiogram, a procedure to reveal blockages in the
vessels that supply the heart musTo make this argument requires
cles with blood. The specialist rethat one skip lightly over a few nigferred him to Vancouver heart " I W O U L D N O T LIKE T O LIVE UNDER YOUR SYSTEM. gling points._Qinadians, for insurgeon Lawrence Burr, and from
stancejj^enOT^n medicine for
Burr, Berrie learned that he needed
every liOjwe spend. They live longIF I TRIED T O GET INSURANCE D O W N THERE
a six-vessel bypass. On June 2,
er than we do. Fewer of their babies
1989, the surgeon entered Berrie on
N O W , T H E Y D COVER EVERYTHING BUT M E
die. Everyone has full health coverVancouver General's waiting list.
age. No one is denied insurance beHe joined no fewer than 720 other
cause of an expensive illness. No
HEART. IF 1 NEEDED CARE FOR M Y HEART AGAIN
^patignts waiting in a nerve-racking
one pays a deductible for a doctor's
aueujpfor beds in British Columcare. People pick their own doctors.
I ' D FINISH M Y DAYS O N T H E STREET."
bia's three heart surgery wards.
Their family doctors see them
quickly, either in the office or, when
Berrie waited through summer,
necessary, at home.
fall, then most of winter. He lived in
Canada has accomplished all this with a system
slow motion, fearful of another heart attack. Simof sweeping controls. Private insurance that comple jobs like washing the car took three times as
petes with the provinces' medical plans is illegal.
long. He relied on his sons-in-law for help around
Health ministry officials keep a lid on doctors' fees.
the house. During his many idle hours he fumed at
Almost all hospitals are publicly owned. The govthe government. "They're more interested in giving
ernment caretully limits the number of hospital
away things people can see," he reckoned. "A new
beds and the purchase of expensive new equipbridge, a new ferry. A guy waiting for a heart
ment. In the process, it drastically trims costly
operation, he's all but invisible."
.paper-shuffling in doctors' offices and wipes out
Finally in late February of 1990 he got a call from
insurance company overhead and profit.
Burr. Another surgeon was leaving on a week's
vacation, so Burr had appropriated his two surgery
uur health industry charges that Canada runs a
slots. He could operate on March 5. Berrie was
bargain-basement operation that Americans would
simultaneously grateful and bitter.
never tolerate. The AMA claims that Canada jeopar"I'd get angry, but then I couldn't afford to get
dizes the public health by scrimping on items such
angry," he said. " I wasn't supposed to have any
as magnetic resonance imaging, radiation therapy,
stress. I was supposed to take everything nice and
and open heart surgery. The Health Insurance Ascalm." At this Berrie assumed a tone of mock transociation argues that Canadian bureaucrats' fear of
quility. "'Oh,' I said, 'I'll get my operation evenspending stifles creative programs such as those
tually. They may do it with me in a wooden box,
that send surgery patients home that day. Doctors
but I'll get it.'
complain that Canadian fees are so low that brilliant surgeons and innovators flee to the United
"Ah, but it was a worry. I worried when I went to
States, where their talents are rewarded.
bed at night, 'Am I going to be here in the morning?'
Then I got here and, poof, the weight came off my
But the objection most consistently raised
shoulders."
against Canadian health care is that patients wait in
line for major operations. The AMA, for instance,
As Berrie's eyesflutteredshut, 1 asked him one
recently paid for ads depicting a winsome girl belast question. "Do you think you'd have gotten
neath the headline, "In Some Countries She Could
better care in the States?"
Wait Months for Her Surgery."
He sighed. " I would not like to live under your
system. If I tried to get insurance down there now,
It's the queues for heart operations that attract
they'd tell me I had a heart problem. They'd cover
the greatest attention—and most sharply illuminate
everything but me heart. If I needed care for my
the distinctions between care in Canada and the
heart again I'dfinishmy days on the street.
United States. The Canadian newsweekly Mac"Canada," he said slowly, "covers everything."
Lean's defined the issues with the case of a particu40
IN HEALTH
JANUARY/FEBRUARY
1991
�larly hapless Toronto patient named Charles Coleman. The 63-year-old diamond setter's operation
was postponed 11 times to make room for more,
seriously ill heart patients. Eight days after Coleman finally got his bypass, he died. Before his case
could fade into obscurity, the issue flared again in
British Columbia. Provincial health officials, beset
by criticism of the long queue in which Tom Berrie
and 720 others languished, announced a plan to
send patients to the United States for their heart
surgery.
Surely, if waiting for treatment routinely harms
Canadian heart patients, the proof could be found
in Vancouver. Or so I thought.
f
TAKING COVER I N OHIO, NEW YORK, AND OREGON
: .vy^v
WHEN LOUIS SULLIVAN, the top health official in the United States, unveiled
his strategy for the 1990s recently, he suggested smoking less, eating right,
and using seat belts. But as for extending health insurance to the 37 million
Americans who have. none, he had nothing to say.
The message from Washington to the states was clear: If you want all
your citizens to receive decent health care, do it yourselves. And many have
been trying. Hawaii, for instance, has beefed up its state-run health plan
while maintaining the requirement that employers offer health plans, so
all its citizens are covered. But several states are attempting the more
.,. ^ y •<
aggressive reforms they believe their citizens want and need. .'
V : ^frV--.:.!;,;';-^
companies and from Medicare and
OHiOi IYIINO CANADA Sometimes
Medicaid. Doctors benefit from a simthe burden of reform falls on unlikely
pler, cheaper payment system, while . •
AFTER i LEFT T O M BERRIE 1 called on his surgeon,
) shoulders. "I'mV locomotive engi- 'v.
the state gains an advantage: As New
Lawrence Burr, to find out why Berrie had waited
neer," says Ohio legislator Bobby
York medicine's sole paying customer,
so long. We met in Burr's office, a modest room on a
. Hagan. "What the hell do l.know .,
it can demand lower rates and more
side street. Bamboo stood outside the window.
about health?" Yet shortly after he
efficient service. With the state's budget
Geese pecked at the courtyard grass. Perched on the
took office in 1987, Hagan{'dove into
corner of Burr's desk was a plastic model of a
currently squeezed tight, however, the ^
^
the debate on health insurahce. He
human heart.
represents the Ypungstownlarea,
proposal is on hold.
C
where steel mill shutdowns have left . ^ ^OMOONsWriONINOCAU H o p i n g - t j ? ; , ^ ^ ^
An American surgeon, considering Burr's lot,
might call this a hardship post. When Burr does a
thousands with neither paycheck nor . get all.its residents covered, Oreigoni^
routine four-vessel bypass, the British Columbia
mcuranro
• - ••>. .• • x \ i - r recently passed legislation that will|^;.fj
insurance.
government pays him $1,700. He'd earn $6,575 for
...soon qualify 116,000 uninsured.proplje-f
"1 felt compelled to do something
the same piece of work at a teaching hospital in
for Medicaid, benefits they can t get#,'.C;v.t,:;
to help protect those people,"'sayS'.
Minneapolis. There, he'd get as much operating
Hagan. He introduced a bill proposing now because they aren t poor enpughi; • JSPVT
time as he wanted, because the heart unit runs at
that everyone in Ohio be covered un- . The state will then rank all m e d i c a j ^ ^ , ,
about half capacity. In Vancouver, he's allowed to
procedures, weighing their cosB*^**^'.
der a Canadian-style health scheme
operate 12 times a month, eight times fewer than
against their known health benefits?^'/
_
financed by taxes. Hagan's bill bars'
he'd prefer. Because Burr has far more patients than
Expensive, ineffective treatmentsj^^k ^
private insurers from competing with
surgery slots, most wait months.
will be lopped off the list. By t h i s - ' ^
the state's basic coverage plan. The
kind of rationing the state intends^ \ ^ ^
"1 promised Tom Berrie he wouldn't wait more
measure was quickly condemned by
to save enough money to coverall ' . ^ j f ^ j - ^
than a year," Burr said quickly, with the supremely
the state's medical association and by
confident manner of a person who holds a beating
insurance industry representatives, but • - the neyv;people e n r o l l e d ; ; % . S § ^ &
But a moral fog bank has now.rolled;^*^!
heart in his hands several times a week. " I had other
embraced by labor, church, and senior
in. Thefirst attempt to create sucha U s t f e ^
patients who were worse, who had more chest
groups representing 3 million of ; !
ended in disaster, with care for thumbr
pain. But they'd only been waiting two months. 1
Ohio's 11 million residents. Hagan's
' sucking-related jaw problems ranked l ) {
decided come hell or high water I was going to keep
bill—considered a long shot by local
. higher than some AIDS treatments..'
this promise."
observers—is slowly making its way
Oregon's number-crunchers are back
through the legislature. ''Y.4? .'«..• • >:.
•
Berrie was one of 75 patients on a waiting list
at their computers, aiming at a new
NIW YORKi MYINO THI •ILLS ITMLF
that Burr keeps in a small black book. The surgeon
deadline in early 1991. Even if they conAs a state where 2.5 million people
, decided that Berrie was an urgent case, one of many
lack health insurance, New York has ': '• coct an acceptable list, Oregon will
in the broad range between emergency and elective
seen its share of proposals! A provoca-' ' have to ask Congress to let it rob Peter
surgery. Burr can take an emergency case into the
to pay Paul—trim the roster of treatfive new one calls for all employers to
operating room almost immediateiy by trading anments now available to Medicaid pacover their workers or pay afine.The
other surgeon for operating time. Urgent cases wait
tients so it can offer the same reduced
state itself will insure the unemployed
until Burr fits them into one of his three weekly
care to a larger group. The state.should
and low-income part-time workers,
operating slots.
with a sliding fee scale for.the 1
"Every week I have to decide," Burr said. "Is the
• instead be raising t^xes, critics say, and-ysl;
more affluent.
"
guy who's been waiting ten months worse than the
looking for ways to'cut waste so.eyery- V^, '
guy who's been waiting five months? But even if he
one can be given decent care. V But this plan has an especially bold
isn't, the guy waiting ten months has got to have
"It's harder to do something than to
provision. Right now, doctors and hossome pride of place. After all, he's been waiting
build up an ideal that no one could
pitals send bill after bill to patients, to
twice as long."
their insurance companies, and to the .. ever actually pay for," says John GoThe long lists don't have to exist, Burr explained.
federal government—a bureaucratic ..: j.lenski, a bioethicist who helpeddesign.
If British Columbia's 15 heart surgeons took on a
Oregon's plan? Among the states this is 5 ^
nightmare that wastes millions. New
full, combined work load of 60 to 75 operations a
York proposes instead that dortors and • an increasingly common refrain: If we
^
week, the waiting list could be whittled down in less
hospitals send all their bills straight to
can't afford everything medicine has
than a year. As it is, in a good week they operate 50
the state. The state sends out checks,
to offer, then how and where do we
t
times. They're limited by the number of hospitals
then collects in bulk from insurance
draw the line?
.—
ASK^J
:
:
•f
1
%
�"HE SAYS FIFTEEN DIED on the waiting list?" said
quipped for open heart surgery—three for a popuRobin Hutchinson with an odd touch of glee.
ition of 3 million, or about a third the number
As senior medical consultant to the health minisou'd find in the United States—and by the amount
try's heart program, Hutchinson helps decide how
> operating room time these hospitals parcel out.
f
many people ought to get heart surgery each year in
The Ministry of Health limits the number of
British Columbia. His office is in the capital city of
ieart surgery wards, claiming operations are done
Victoria, separated from Vancouver by about 30
heaper and better at hospitals that handle at least
miles of water. Not that the distance brings
iOO heart patients a year. It then gives these hospiHutchinson much peace. He dashed into our meetals enough money to perform about 2,100 heart
ing late, just off a helicopter from a meeting on the
>perations annually, a number set by ministry offimainland. His desk was piled high with papers, his
ials working with a panel of cardiologists and
phone rang incessantly, his hair was a mess.
ieart surgeons. The Canadian rate of heart surgery
"That's right," I said. "Fifteen."
s less than half ours.
"Well,'now," said Hutchinson. "We know the
"In the States," Burr said, "too many cases are
mortality rate on the operating table is between
lone. People have a bit of angina, they come i n t o " ^ ^
two and three percent. So if they
he hospital, get an angiogram
operated on the whole waiting list
done, and bang, they're referred to
last year we'd expect them to kill off
surgery without a good trial of
" W H A T ' s t B E L O N ^ S T YOU
'AIT I N L I N E
twenty-two! You don't hear about
medications. The bed is empty, the
the guys who never get off the table.
riospital wants to make money. 1
YAr&QYfD?
AT A BANK BEFORE GETTING
They only talk about the guys who
don't think that's an indication for
die on the waiting list and some of
surgery, but that's not a view that's
FIVE MINUTES?
them would die no matter what.
always shared by my colleagues in
the States. You're overeager to use
"Look, it's hard for me to sit here
WHAT IF YOU NEEDED A HEART ( ' E R A T I Q ^ ^
the technology that's available. In
and say there is a huge amount of
Canada, on the other hand, we've
medical necessity to take care of
HOW LONG WOULD YOU WAIT THEN^"
been excessively conservative."
every case on our waiting list.
That's a little harsh because many
By carefully pinching the supply
people feel they need surgery. But
of heart surgery slots, British Cosome medical necessity is iatrogenic—which is to
lumbia has created a sensible but high-strung syssay the docs themselves create it. So many surgeons
tem. Disruptions at any of the surgery units—the
portray coronary bypass as a lifesaving operation.
recent nurses' strike, for instance, or the chronic
But then you look at the outcome studies and they
shortage of operating room technicians, or the brief
show it isn't."
walkout of workers who sterilize instruments—all
lead to maddening backups.
Research to date generally reveals that except for
patients with certain types of heart trouble, such as
Meanwhile the demand for heart surgery keeps
obstructions of the left main coronary artery or
growing. "Our population has increased," said
three-vessel disease, those with bypasses don't live
Burr, "but even so the growth in demand is out of
longer than people who take heart medicine and
proportion to population growth alone. We've got
watch their diet. In fact, the patients most likely to
better diagnosis, better treatment. We can operate
benefit from a bypass are also those most likely to
on people now that we wouldn't have touched ten
die from one.
years ago. We've got a better product."
"So what do the surgeons say ro this?" HutchinI asked Burr whether waiting for an operation
son asked. "They say, 'Yeah, well, but a bypass
harmed patients such as Berrie.
relieves chest pain when medicine won't.' To which
He tapped on the armrest of his chair. His fingers
I say, 'Of course. But you bastards, you haven't
were surprisingly pale, the nails well-trimmed.
been going to the press saying Mr. So-and-So has
"People decline while they wait," Burr said.
anginal pain and we think he'd feel better if he had
"They're less active. They gain fat, they lose muscle.
an operation. You're saying this guy has a time
They can have a heart attack that makes surgery
bomb in his chest that only you can defuse, and the
more risky. Some people have become depressed.
government is preventing you from laying your
They withdraw to their family.
God-guided hands inside this guy's chest and mak"The only positive thing about waiting is that
ing him better.'"
people have time to think about what's happening
Nonetheless, 720 people waited for surgery they
in their life. They can ask, 'Who am I? Where am I
thought would help them. Taking up the American
going?' All the questions we never have time to ask.
Medical Association's line, I proposed to HutchinOften they say, 'Okay, I've smoked too much or
son that his government was rationing medicine,
eaten too much. I can change these things.' They
promising everyone health care, then withholding
can start changing their life around."
it to save money.
But there's one other possibility. "They can die,"
"We ration according to the severity of the disBurr said. By his count, 15 British Columbia pagase," Hutchinson replied. "For us, those who need
tients did just that last year while waiting for their
care most get it first, regardless of economic status.
heart surgery.
3
JANUARY/FEBRUARY 1 9 9 1
I N HEALTH
43
�That's a fundamental philosophical difference be"As of now," Hutchinson said, "we've had nine
tween Canada and the States. Both sides ration.
people sign up. The opposition party, the press,
You've got thirty-seven million people who don't
everybody's making a big stink about our waiting
have diddley-squat for an insurance plan. They're
lists. And we've got nine people signed up! The
rationed, too.
surgeons ask their patients and they say, 'I'd rather
wait.' We thought we could get maybe two hun"Second, it's not a conscious decision by the bean
dred and fifty done down in Seattle and get our own
counters here that there should be this many heart
list down to four hundred and some. Which sounds
operations done and the rest can just line up and the
a little grisly but isn't really so bad. Ideally we'd
ones that survive get it and theothers, good, wedon't
have a four- to six-week waiting list to make the
have to pay for it. It's not a case of someone deciding
system flow smoothly. But if nobody wants to go to
we're not going to do these things because it costs
Seattle, we're stuck."
too much. But we have a hard time grappling with
this waiting list. We don't know who's waitingor for
Did the people offered the Seattle operations
how long. We don't know how severe their case is.
actually need bypass surgery?
We do know that all the real emergencies are get"If I can be convinced that this is a medical
ting done, but we're left struggling
necessity I'll go to bat," Hutchinson
with this nebulous class of elective
said. "But there are a thousand
operations."
other things all clamoring for attenWHEN POLLSTERS ASKED U.S. CITIZENS
tion and resources. I have to be very
The rewards of promptly operatconfident in believing these heart
ing on everyone are anything but
IF THEY'D PREFER CANADIAN HEALTH CARE OVER
operations are a real need. Right
certain. Research shows that far
now we just don't know what hapfewer than half the people who get
THEIR OWN, 72 PERCENT SAID YES.
pens to these people. Besides just
bypasses later pronounce themliving or dying, what are they doing
selves free of chest pain. Follow-up
AS FOR THE NUMBER OF CANADIANS WHO'D
five years later? Are they back at
studies of bypass patients show
work? What's their quality of life?
they're only 25 to 40 percent more
CHOOSE T H E U . S . SYSTEM! 3 PERCENT.
We're trying to get some kind of
likely to be relieved of pain than
handle on what the public is buying
people who stay on heart medicine.
with its money."
But the provincial ministry decidIn the States, the social cost of a dubious operaed it couldn't afford to stand on statistics. As the
tion, paid for by an insurance company, is at best
waiting list grew, the British Columbia Medical
obscure. In British Columbia the tradeoff is obAssociation hammered the government with radio
vious. Medicine is a staggering line item in the
ads that asked, "What's the longest you'd wait in
provincial budget—a third of all expenditures, for a
line at a bank before getting really annoyed? Five
total of $3.65 billion last year. Money spent on
minutes? Ten minutes? What if you needed a heart
medicine can't be spent on roads, schools, or job
operation to save your life? How long would you
programs. That the money might be wasted on
wait then?" The association aimed to pressure the
operations that profit only surgeons is more than a
provincial government into spending more tax
nagging thought.
money on hospitals, medical hardware, and not
coincidentally doctors' fees. Local newspaper editors, of course, heard news knocking every time a
TOM BERRIE'S ANGUISHED WAIT for his surgery
waiting patient fell dead.
lingered in my mind as I drove from place to place
"Because of the public outcry over these poor
in Vancouver. Yet as I talked to Canadians about
souls walking around with their hearts about to
their health care, the stories 1 heard were typically
pinch off and drop like flies all over the province,"
mundane. A reporter, a professor, a salesman, a
said Hutchinson wearily, "we did a deal with the
clerk in a store—all had the same prosaic experiUniversity of Washington in Seattle." The deal, he
ence. If they or their children got sick they picked
explained, called for the hospital there to take 50
up the phone and called the doctor of their choice.
bypass cases at $18,000 per head, a bargain comUsually they got in within a day. They didn't have
pared to the $40,000 to $75,000 a bypass typically
any complaints. Deductibles, copayments, preexcosts in the States. Still, for the government iarepreisting conditions—the routine curses of American
sented a loss on several fronts. The same operation
health care—seemed to horrify them more than
costs $15,300 in Vancouver. In addition, all the
their own waiting lists. "If our worst-case scenario
money was going out of the province. In theory the
happened to someone in the States," one labor
Seattle operations promised to take the heat off the
leader told me, "they'd still think they got lucky."
Ministry of Health until a fourth heart surgery unit
When pollsters asked Canadians if they'd prefer the
opened in the Vancouver suburb of New WestminAmerican system over their own, only 3 percent
ster. If the first batch of Seattle bypasses went
answered yes.
smoothly, Hutchinson said, then the government
"Here," said Morris Barer, an expert in health
planned to buy three or four more 50-head blocks.
policy at the University of British Columbia, "yOu
But four weeks after announcing the plan, health
don't have to think about how much a doctor's visit
administrators had to admit they were stumped.
is going to cost or whether you can afford to go at
44
IN HEALTH
JANUARY/FEBRUARY
1991
�i' Jjr-'T-w/
WOULD A CANADIAN UMBRELLA LEAK I N THE UNITED STATES?
In fact, however, most people in the
United States don't really have full coverage. Overall, American insurance now
covers just 74 percent of the costs of doctors' services, 39 percent of dentists' services, and 25 percent of prescription drug
charges. We pay the rest out of pocket.
"SOCIAUZED HEALTH AND MEDICAL SERVICES," said the politician, "are incompatible with
the rights and responsibilities inherent in a free and democratic society." The year was
1959, and the speaker was J. Donovan Ross, Alberta's Minister of Health. Remarkably,
Canada's citizens disagreed. By 1966 the government had declared itself the nation's only
health insurer, and by 1971 every Canadian had full, free coverage.
Now Americans are jealous. Anyone bold enough to endorse Canada as a suitable
model, however, can expect an argument. Here are eight objections and the rejoinders.
WOULDN'T FREE CARE ENCOURAGE PEOPLE T O ^ j ^ C
RUN TO THE DOCTOR FOR EVERY ACHE AND P A I N T ^ -' <,
WOULDN'T NATIONAL HIALTH INSURANCI
AMOUNT TO "SOCIALIXID MIDICINI," FULL Ot
•URIAUCRATS TILLING OUR DOCTORS HOW
TO TRIAT UST
THE THOUGHT of handing Washington
power over everyone's health is indeed a
little spooky. Who can forget the government's attempt to "simplify" our income
tax forms by adding a mass of befuddling
new instrurtions?
But look at U.S. health care now. Our
doctors already obey legions of intrusive
bureaucrats: Insurance officials regularly demand that your doctor call for permission to go ahead with treatment. Medicare
officials dictate precisely how long patients
can stay in the hospital. The number of U.S.
health care administrators has climbed 3.5
times faster than the number of doctors. In
Canada, there are no meddling insurers,
while the government's main power is in
raising money and paying bills, with minimal monitoring for outlandish practices.
"No one second-guesses me," says the
president of British Columbia's medical
association. "I've got clinical freedom."
DON'T WE ALREADY HAVE THE WORLD'S
BEST HEALTH CARET
IT'S CERTAINLY the most expensive. In
1987, we spent $2,050 per citizen on health
care. Canada spent an average of $1,480,
most European nations even less.
Unfortunately, spending the most hasn't
made us the healthiest. Canada, culturally
most like the United States, has an infant
mortality rate 25 percent lower. Their rate
of heart disease death is 20 percent lower.
Their average life span—77.1 years—is
almost two years longer.
paper-shuffling. (Even the picky Consumers Union recently came to that same conclusion and endorsed a Canadian-style
plan.) In Canada, according to the latest
study, citizens each spent $J£. a year for
"administrative costs," while each of us
spent $95—for a total of $20 billion more
than we would have with Canadian-style .
insurance. That's not allTOur doctors, hos-¥^
pitals, and nursing homes spend much
more—$62.1 billion by a 1983 estimatefilling out insurance forms, billing patients,
and collecting.
PEOPLE WHO GET free treatment do go to ^ V / ^
the doctor and hospital about a third mor6V t a /
often than those who have to pay a share^of^V^
their medical bills.
^"C^'*^<*
Still, Canadians—who pay nothing atithe'^e ^
doctor's—have a lower per-person healtli^- ^ . " ^
bill than we do. That's because, among ^L*** S
other things, they've given their govern- JgjJSo
ment power to bargain with doctors and ^
hospitals over fees. An office visit that's
$52 in Seattle is $18 in Vancouver.
THERE'S NO WAY THE GOVERNMENT CAN PAY
FOR EVERY AMERICAN'S CARE WITHOUT RAISING
TAXIS THROUGH THE ROOF.
MORE NEEDLESS TREATMENTS AND TESTST
THE FEDERAL GOVERNMENT ivould have to
come up with billions of dollars more than
the $115 billion it now spends on its health
programs for the poor and aged. Some
could come from income taxes, some from
luxury taxes on cigarettes or cosmetic surgery. In Canada, several provinces charge
a small monthly premium.
But before you reflexively holler "No
new taxes," consider what you're already
paying. That grand total of $2,050 we
spend per citizen doesn't come out of thin
air. It comes in dribs and drabs out of your
own earnings—in existing state and federal
taxes, insurance premiums, payroll deductions, deferred wages, deductibles, copayments, and ordinary cash transactions with
doctors and hospitals. Canadians pay theirs
once in taxes but get more care—for $600
less out of each citizen's earnings. Last year
our country spent $640 billion on health
care. With a Canadian-style system, at
Canadian rates, we could cover everyone
for $365 billion.
SYSTEM SO IT REACHES ALL THE PEOPLE WHO
WOULDN'T NATIONAL HEALTH INSURANCE
AREN'T NOW COVEREDT
MEAN THAT AMERICANS WHO ARE NOW FULLY
MANY PROPOSALS for full U.S. health coverage would require all businesses (except
the smallest) to insure the health of their
workers, with the government looking out
for everyone else.
Suchfine-tuningcan improve our system
but won't reallyfixits biggest problem: the
billions of dollars we waste every year on
IN CANADA, provincial insurance covers all
health costs except dental care, eyeglasses,
prescription drugs, ambulance service,
and private hospital rooms—so many
Canadians do end up buying some private
insurance. A policy to cover all of these
things runs about $30 to $40 a month.
IN HEALTH
JANUARY/FEBRUARY
1991
DOISNT LETTING DOCTORS SEND PATIENTS'
BILLS STRAIGHT TO THE GOVERNMENT LEAD TO
WHY NOT JUST FINE-TUNE OUR EXISTING
46
1
INSURED MIGHT HAVE TO SETTLE FOR LBSST
!'
WHEN PATIENTS get free care and doctors .
can charge no more than a set amount per >
treatment, the tide does tend to run toward
more and more treatments. Studies in Canada have shown jumps in the number of
doctors' billings—and in their incomesafter the government froze their fees.
But the same thing's now going on in this
country—except here federal regulators
and private insurers have been trying, witlv
even less success, to keep a lid on physi- ,
cians' incomes. Last decade American
doaors increased their cut of the national
^ _ income by 40 percent while "Canadian
doctors captured only another 10 percent.}
ISN'T THE PRIVATE HIALTH INSURANCI INDUS* .
TRY JUST TOO BIG AND POWERFUL TO KILLT
DISMANTLING the health segment of our
insurance industry would be "politically
thorny," in the quiet words of one advocate
for a national plan. Some 1,200 firms now
sell more than $192 billion in health insurance. They'd put up a hard fight. Not only
has the industry grown eightfold since
Canada shut down its own health insurers,
but our government leaves politicians
more open to lobbyists than does Can- '
ada's parliamentary system.
Still, there's no legal barrier to making
health insurance an American public
service. The states have broad powers to
legislate business affairs and to promote citizens' health. Likewise, the federal government can use its control of tax revenues—
as it does'with highway funds—to set standards for the states. .
��tion study showed 44 percent of all U.S. bypasses
all." Barer, for example, with a wife and two chilwere performed for dubious or inappropriate readren, pays a $51 monthly premium. Around 20
percent of his income tax is set aside for health care.
sons. (For instance, some patients with one clogged
Above that, the only bills he'll ever see are for
heart vessel got bypass surgery though no evidence
prescription drugs, ambulance service, or a private
indicated it would do any good.) At one hospital
hospital room. He's never had trouble finding a
the rate of unwarranted surgery was more than six
likable family doctor with an office nearby. In Canin ten. If a waiting list withholds operations from
ada, as in the United States, there are about 490
patients who'd be better off without, then some
people per physician. In both countries, in fact, the
American hospitals could use one.
number of practicing doctors keeps going up.
"You've got to remember that you've got a waitBarer's one experience with the trumpeted shorting list as well," Anderson said when I asked for his
coming of Canadian care began when he realized
view. "Your waiting list is based onfinances,just
his daughter had a problem with her feet. He took
like ours, but it's not as obvious. If you're poor and
her to the doctor and was told there'd be a six"you don't have insurance, you don't go to a surmonth wait to see an orthopedic surgeon. Instead
geon. In the States you ration by ability to pay."
of waiting, said the doctor, she
could see an occupational therapist
A SHORT WHILE" LATER I headed
next week. The therapist recomYOU'VE GOT TO REMEMBER, YOU'VE GOT
back to the United States, a trip that
mended shoe inserts; but when
for Canadians evokes a sense of
Barer's daughter finally did get in to A WAITING LIST AS WELL, BUT I T S N O T AS OBVIOUS
dread. What if they get sick or have
see a surgeon, he declared there was
an accident? Their health plan pays
nothing wrong with her. And that
U.S. doctors the going rate in CanaIF YOU'RE POOR AND YOU DON'T HAVE
was it: Case closed.
da—$277 for an emergency appendectomy, for instance, less than half
Had she needed surgery, Barer's
INSURANCE, YOU DON'T GO TO A SURGEON.
the typical surgeon's bill across the
daughter would have gone on a
border. Prudent Canadians buy
waiting list, just as Tom Berrie had.
I N THE STATES YOU RATION BY ABILITY TO PAY."
special traveler's insurance before
In some Vancouver area hospitals,
they leave.
queues for elective surgery are
13,000 patients long. Similar situaStill, they fear the worst that
tions abound across Canada. People in Saskatoon
American medicine can do. They believe that
can expect to wait almost five months for a hip
Americans routinely die from lack of insurance
replacement. In Winnipeg, patients who need
right in the hospital foyer. They're appalled by the
emergency surgery routinely wait an extra day.
unfairness of American care as well as by its bloated
That's the landscape in Canada, though it's
costs—$2,000 a year for each citizen, compared to
changing continuously and not necessarily for the
Canada's $1,400. People with no particular reason
worse. The lists regularly shrink or even vanish
to know, such as a retired cigarette salesman I enwhen new medical centers open, or when citizens
countered, can cite with reasonable accuracy the
and doctors pressure the government into spending
cost of both paper slippers and major heart surgery
more on health care. And no citizen who needs
in a U.S. hospital.
surgery—or any other form of treatment—ever
At the Vancouver airport, a customs agent took
goes without it, except by choice. Emergencies, of
it upon himself to give me one last lecture. He asked
course, get top priority. It's rationing by medical
the usual questions: occupation, nature of visit. His
need, as Hutchinson said, but Barer and most other
ears pricked up when I said I was reporting on
Canadians accept it the way we'd accept waiting
Canada's health care system.
for someone in a wheelchair to board an airplane.
"And what's your conclusion?" he asked me
Even Tom Berrie preferred his own long delay to a
suspiciously.
roll of the dice with American health care.
"Some people wait for surgery." I shrugged. It
I couldn't help but wonder, though: Was Berrie's
didn't seem like the place for a symposium.
surgeon wrong when he claimed that heart patients
" I just want to make sure you understand," he
decline while waiting for surgery? Wouldn't pasaid in that commanding tone of a man with a
tients in the United States fare better?
badge. "When my kids need to see a doctor, I call in
"Right now, no one knows whether being on the
the morning, they get in that afternoon. When I
waiting list is any more harmful to you than being
hurt my shoulder I got sent to the top joint man in
operated on earlier," Barer said. "Studies that would
the province." He was getting worked up, waving
show that haven't been done. Meanwhile, no one in
my passport to make his point. "It doesn't matter
the States has demonstrated that your heart surgery
how much money you have. This is a great system."
rate is optimal or anything close to it."
A line backed up behind me. I nodded earnestly.
Just the opposite seems to be true. A study re"Okay," he said. Then, noticing that he still held
cently completed by Geoffrey Anderson, a univermy passport, he stamped it with a flourish and sent
sity colleague of Barer's, revealed that American
me on my way.
•
Medicare patients get bypass operations at double
the rate of Canadians. Yet a 1988 Rand CorporaAnthony Schmitz is a contributing editor.
JANUARY/FEBRUARY 1 9 9 1
I N HEALTH
47
�mm
C VR SO Y
OE T R
HEALTH CARE
Up to $80 billion is stolen each yearfrom
taxpayers and insurers. Bolder scams arise
all the time, and little is done to stop them
W
hite-collar "wilding," one regulator calls it — an orgy of economic crime. As America's
health-cure bill spirals to an estimated
$817 billion this year, it is attracting an
ever more impudent and wily army of
scam professionals. Experts now estimate that fraud and abuse in the healthcare field cost somewhere between $50
billion ancl $80 billion each year-a figure that dwarfs the estimated $5 billion
lost through criminal fraud in the entire
savings and loan debacle. And of course,
consumers and businesses arc paying for
these heallh-carc rip-offs in higher taxes
and skyrocketing insurance premiums.
The thing that spooks insurers and
federal regulators these days is that the
scums are growing dramatically bigger,
bolder and more sophisticated. "Previously, the usual situation was single-subject fraud, involving one doctor or supplier," said Assistant Attorney General
Stuart Gerson. "Now we are encountering more cartel-type frauds." Florida,
with its huge elderly population, is a hotbed ol health fraud, especially around
Miami. The Philadelphia region has also
been host to a variety of unsavory
schemes, as have New York, Texas, Arizona. California and Michigan.
Investigators stress that the overwhelming majority of physicians and other health-care providers arc dedicated
and honest. But it doesn't take many to
steal a lot, argues Richard Kusserow, inspector general for the Departmenl of
Health ancl Human Services. " A welfare
citieen would have to work mighty hard to
steal $100,000. Somebody in the [medical] practitioner or provider community
can burp ancl steal $100,000."
Authorities worry, too, that shifts in
health care are opening the door wider
for fraud. A burgeoning movement to
electronic claims filing is eliminating the
paper trail that provided investigators
with many of their best leads. And as
more health care moves away from the
hospital ancl into outpatient settings ancl
homes, keeping an eye on it gets tougher.
Finally, each new advance in medical
technology presents a new forum for
fraud. The result is an endless game of
cat and mouse. "For every loophole in
the system we close," says IZclward Kuriansky, New York's special Medicaidfraucl prosecutor, "the voracious provider seems to find another." What follows
is a look at some of the more ingenious
and far-reaching new kinds of fraud.
ROLLING LABS
One of the hottest schemes involves socalled rolling labs that conduct unnecessary ancl sometimes fake tests on unsuspecting patients, while billing insurance
companies or the government for the
cost. Federal authorities allege that the
biggest such operation took place in
Southern California, masterminded by
two Russian immigrant brothers, M i chael and David Snuishkevich. Investigators claim the Smushkeviches and 10 cohorts filed $1 billion in false claims, of
which some $50 million was paid by government and private insurers. At its peak
between 1986 and 1988, the operation
involved 1,000 separate companies and
400 bank accounts worldwide, according
to insurance-firm estimates.
Indictments allege that patients were
solicited through "boiler room" telemarketing operations. Phone sales represenU.S.NiavSA WOKI.I) KKmKT. I-'KIIKUAKY
m>
�talives olTerccI comprehensive physical
In order lo work, the alleged scheme
exams, including siate-ol'-lhe-arl diag- had to circumvent imporlant health-innostic testing, at little or no lee to the surance basics: Most policies provide litpatient. The tests were conducted at tle or no coverage for preventive tests.
health clubs, retirement homes, mobile- They cover only testing that is medically
home parks or shopping malls serviced necessary for a specific, current illness.
by the rolling labs, and later at free- And most require patients to pay a porstanding clinics. To Constance Otero of tion of the fee —usually 20 percent.
Irvine, Calif., and many like her, it all
Investigators say patients were resounded legitimate. The woman on the tiuircd to fill out medical-history forms
phone was "such a personable lady that that were used lo later justify the "medshe sounded like my best friend," Otero ical necessity" of the tests —though
recalls. Although Otero, then 65, wasn't many said they were not complaining
feeling ill, after many phone calls, "given about any symptoms. A battery of diagmy age, 1 thought, 'what the heck.' " The nostic tests would be performed, sometwo-hour exam at a Tuslin, Calif., clinic times before the patient had been exin 1988 resulted in $7,500 in billings.
amined. The defendants then doctored
U.S.NEWS a WoKi.n RKIORT. I-'KHKUAKY 2.1. mu
the medical records with false facts designed to result in payment by the insurance company or (he government,
according to the charges.
A major break in the case came in mid1987 when Dr. William Marr, who
worked for Pacific Mutual Insurance, got
a phone solicitation. Marr was promised
a complete physical and was told there
would be no charge to him. When he
reported for the exam, Marr told investigators, he filled out a routine healthhistory form, but was asked nothing specific about his current health. After some
tests, his insurance firm, Pacific Mutual,
was billed for more than $7,500. The diagnoses on the claims included high
III USIRATlON'j UY S C O n SWA! ES FOR USNAWR
35
�• C VR S O Y
OE T R
blood pressure, diabetes,
heart disease and cancer, but
Marr claimed he suffered
from none of these conditions. Eight months later, authorities, prompted by private
insurers with other claims
against the Smushkeviches,
raided their boiler rooms,
clinics and offices.
Some of their alleged victims were haunted by the
wild diagnoses. One was
Craig Keoshian, a Woodland
Hills, Calif., chiropractor.
An active athlete, Keoshian
was astounded when he
learned months after his
tests that a life-insurance application had been rejected.
"All of a sudden, this glaring
thing comes up on my record
stating that 1 have all these
diseases, including heart defects and obstructive pulmonary emphysema," says KeoFraud artists sell services like unneedshian. "According to their
ed lab tests or unnecessary medical
diagnoses, I was ready to
die." It took him two years
supplies through high-pressure phone sales operations run out of "boiler
to clear his medical record.
Most of the defendants
rooms." The pitch is aimed at getting unsuspecting patients, especially the
will be tried in May in U.S.
District Court in Los Angeelderly, to agree to undergo tests or buy high-profit medical equipment. Often,
les. They are charged with
175 counts of mail fraud,
the pitch deliberately confuses people into believing the caller represents the
money laundering, rackegovernment. Insurers or the government picks up the tab.
teering and other offenses.
Michael Smushkevich, the
alleged ringleader, has
pleaded not guilty. His lawyer, James selling overpriced and unneeded wares tion employing teenage girls operating
out of boiler rooms in Philadelphia-area
Barber, says the issues really should be to the elderly.
An ongoing case against a Philadel- shopping centers. The girls called local
handled in civil court, and focus on who
determines what tests were "medically phia supplier illustrates how authorities Medicare beneficiaries who had renecessary." David Smushkevich is in claim the operations work. In their civil sponded to newspaper advertisements
Amsterdam, fighting extradition. His at- suit, federal officials allege that Mark offering a "free Medicare covered packtorney, Howard Schecter, says David is Mickman, the former owner of a televi- age." The telemarketers would obtain
sion rental business, and his companies, the seniors' Medicare numbers and ask
"absolutely" not guilty.
Federal Home Care and Home them if they had any physical comHealth Care Products, filed plaints. If so, the caller said, their firm
EQUIPMENT SALES
al least 2,200 fraudulent could get equipment that would help.
i ^ ^ r T ^ ' , - ^ c l a i m s and bilked Medi- Though Medicare requires beneficiaries
Some of the slickest operators in the health-care field
i&ZsS-Jtii".. .Vv-^&V
care out of several mil- to pay 20 percent of the cost of any suphave set up what HHS Secion dollars in l%K and plies, the seniors were told that Mediretary Louis Sullivan
1989. The case will care would pay "100 percent for everycalls a "high-tech, moclnot go to trial thing," according to the complaint.
em medicine show"
until the spring, "Teenagers who had no medical trainthat is treating Medibut the govern- ing were making medical diagnoses
care like an open checkmenl did get an upon which sophisticated, expensive
book. Experts estimate that
injunction in Decem- equipment was being purchased for pacrooked marketers of items
be r 1989, at which time a tients that neither needed nor wanted
like seat lift chairs, oxygen
federal judge's opinion the equipment," said Judge Donald
concentrators, braces and
called Mickman's operation VanArtsdalen in a bench opinion.
home dialysis systems may be
an "out-and-out scam."
Authorities say the companies easily
ripping the government off for as
Mickman's plan relied short-circuited another "safeguard" in
much as $200 million yearly by
on a telemarketing opera- the system by filling out elaborate forms
T L M R EI G
EE A K T
N
pkooucT ntoios IJY mrmy M.TCMIUAN - USHAWH
US.NFAVS * WORLD Ri-mHT. KEHRUAKY M. VW
�m
C P Y E T W VR
OAMN AE
I
Unsuspecting patients often
agree to undergo tests or buy
medical equipment on the promise that they will not have to pay anything for
With doctors' signatures in
place, Mickman was entitled
to fill the orders and bill
Medicare, he says.
In many frauds, the equipment is not only nonessential
but also often outrageously
overpriced because suppliers
have cleverly manipulated
a variety of loosely drawn
Medicare rules. For instance,
a bed-size hunk of tlimsy pink
foam that cost a supplier $28
was charged to Medicare as a
"dry flotation mattress" to
prevent bedsores. Medicare
was billed $900. One highprol'il item is called a transcutaneous electronic nerve
stimulator, or TENS unit,
which generates electrical impulses that can help control
pain. It has legitimate therapeutic benefit for some, but
has been marketed as a virtual
magic elixir by high-pressure
pitchmen. The components
could be purchased at Radio
Shack for about $50, but
Medicare is often billed $500
for each one.
the service. Under most insurance or government regulations, the patient
Savvy equipment companies also take advantage of
regional variations in paythe provider offers to waive that copayment. The consumer sees the service as
ment rates. Medicare contracts with 35 private firms to
free and loses any incentive to keep an eye on what's being done.
oversee payments for equipment. Each of these "carriers" until recently had the unthat only required a doctor's signature was 72 and suffering from the early stages restricted right to establish its own
before the claim was filed. Medicare of Parkinson's disease, but he was still pricing schemes for the suppliers in its
will not pay lor such equipment unless bowling and jogging regularly. "My wife region. For instance, Medicare pays
lhe patient's doctor certifies it is neces- answered the call. They gave their name $41.93 for a wheelchair seat cushion in
sary. Surprisingly, many doctors do sign as Federal something. It was our impres- Tennessee, but pays $248.96 in Pennsylprccomplcted forms. Why? Sometimes sion the government was calling," recalls vania for the very same item. Not surbecause they are buried under exasper- McCarthy. Authorities charge that the prisingly, lots of suppliers have set up
ating paperwork and don't really exam- certificate of medical necessity prepared "branch offices" that are little more than
mail drops in high-priced states.
ine the form; sometimes because they by Federal said McCarthy was conMost shocking of all is that
figure the patient wouldn't have or- fined to his room on a floor withMedicare doesn't even
dered il if it weren't needed, and some- out bathroom facilities, neither
know who the supplitimes because patients apply pressure, of which was true. A few
ers are, or if they
threatening to find another doctor if weeks later, two large boxare legitimate.
es were delivered, conthey don't sign.
Suppliers must
taining among other
When the forms were completed,
be assigned
a
items a wheelchair, a
l ederal Home Care or Home Health
"provider numCare would bill Medicare and ship the commode chair and an
ber" by Medicare to
equipment, says the government com- electric heating pad. Medicare
gel paid, but getting
plaint. Seniors attempting to return the was billed $1,800 for the equip•i number requires virment. "1 didn't need anything
equipment —there were at least 50 such
tually no documentation.
calls to the companies a day-would be that was in the box," says
"It's like the government issuMcCarthy. Mickman's attorput on hold, cut off or told the responsiing a lifetime gold card with
ney, Neil Jokelson, said the
ble person was not available.
an unlimited balance and no
deeision to order the
John McCarthy was among those enannual service fee to these supsnared in the alleged scheme. When the equipment was based on
pliers without first running a
doclor-approvcd orders.
company called in June 19SJ, McCarthy
would have to pay a portion of the cost, usually 20 percent. But in this fraud,
l
U.S.NKWSX WOHI.I) Khll )KT, l-'KHKUAKY 2.1, HW
:i7
�al Care Inc. of Plainview, N.Y. Professional Care and its top two officers paid a
credit cheek," argues Sen. William Co- total of $5.2 million in restitution, fines
and interest for Medicaid overcharges.
hen of Maine.
In addition, PCI pleaded guilty to grand
larceny and falsifying business records,
INFLATED HOME-CARE BILLS
while the two officers pleaded guilty to
Like all tliieves, heallh-carc crooks fol- conspiracy. Working with an inside inforlow the money, and these days, the mant, Kuriansky charged that the commoney is increasingly in private homes. pany systematically overbilled the state
Patient preferences, new technologies over a four-year period for home health
and a Medicare-mandated trend toward services rendered by untrained and unshorter hospital slays have created a qualified workers, or in some cases, by no
booming $15 billion market in home- one at all. The state charged that home
health-care services. More than 12,500 health aides billed for many more hours
firms now provide some kind of home- of care than they actually provided.
care services, and the business is "atRight now, regulators are especially
Iracting the sharks," says Kuriansky, the worried about lhe growing number of
New York special prosecutor-in part companies providing intravenous drugs
because the market is relatively unregu- or nutrients at home. These so-called
lated. "From an investigative stand- home infusion services have proved espoint," says Kuriansky, "it's far harder pecially popular for AIDS treatment.
to get at, because you're talking about But a report by the New York City Definding out what's going on behind partment of Consumer Affairs charged
closed doors in hundreds of thousands that the home infusion market for
of individual homes, where there may AIDS patients was plagued by widebe no other witness than an incompe- spread price gouging. For instance, a
lent, vulnerable elderly person."
milritional supplement called TPN that
In August 1990 Kuriansky's office set- is often used by AIDS patients wholetled one of lhe largest medical-fraud sales for about $1,300 a month-but
cases in recent times, against Profession- home infusion billings for TPN ran as
• C VR S O Y
OE T R
D CO SG - F
O T R I NO F
Under federal guidelines, Medicare will pay
for equipment only after a physician signs forms certifying that it's
needed. Rip-off artists sometimes fake these signatures or pay off
corrupt doctors to sign the forms indiscriminately. Honest but
busy doctors occasionally sign without thoroughly examining the
forms, or sign under pressure from patients.
high as $10,000
monthly.
MENTAL
HEALTH
Similar storm clouds
are appearing over
the once growing field of
mental-health services.
Coverage for mental-health
and substance-abuse maladies
sprouted in the 1970s,
and the tendency among
insurance firms was to
reimburse for inpatient
stays rather than outpatient treatment. One result was massive growth
throughout the 1980s in forprofit psychiatric hospitals
hoping to take advantage of
these new streams of revenue. But problems began when the industry was overbuilt and insurance firms, alarmed by
exploding costs, began scrutinizing payments more carefully - a process that ultimately trimmed the average patient's
length of stay.
The result is that "private hospitals
that once made a great deal of money are
now desperate for patients," says Dr.
Alan Stone, former president of the
American Psychiatric Association. And
that desperation has opened the door for
fraud. Among the alleged abuses: Patienls abducted by "bounty hunters";
others hospitalized against theirwill until
their insurance runs out; diagnoses and
treatments tailored to maximize insurance reimbursement; kickbacks for recruiting patients; unnecessary treatments; gross overbilling.
The most infamous charges have
been leveled in Texas. Last April, two
security agents showed up at the Harrell family home in Live Oak to pick up
Jeremy Harrell, 14, and admit.him on
suspicion of drug abuse to Colonial
Hills Hospital, a private psychiatric facility in San Antonio that was owned by
the Psychiatric Institutes of America.
Family members believed the agents to
be law-enforcement officers. If Jeremy
didn't cooperate, the agents said, they
could obtain a warrant and have him
detained for 28 days. "They acted just
like the Gestapo," the boy's grandmother—and legal guardian —later told
a Texas State Senate committee.
According to that testimony, Jeremy
was denied any contact with his family
for six days and released only after a
state senator intervened. State officials
discovered that the boy had been ordered detained by a staff doctor after
his disturbed younger brother lied
U.S.NKWS & WORLD REIWT, KEBKUARY 24,1'JSH
�EKSESS
general is suing PIA
for an allegedly illeabout Jeremy's drug use. The guards gal patient-referwho brought him in worked for a pri- ral system. Texas
vate firm paid by Colonial Mills for each officials also suspatient delivered. And the doctor who pect some psychisigned the admission order had falsified atric hospitals are
recruiting crime vichis own credentials.
Jo Ann De Hoyos, an attorney repre- tims for unnecessary treatsenting the Harrell family, claims the boy ment ancl billing the state's
was snatched because his family was fully Crime Victims Compcnsa- v
covered for extensive mental-health tion Fund up to $25,000 per
benefits under CHAMPUS, a military patient; as a precaution, the
insurance plan. Soon after the ordeal, the state recently froze all reimHarrells got a bill for Jeremy's six-clay bursements to such facilities.
stay: a stunning $11,000. CHAMPUS And last summer, a PIA-alTilipaid the tab but has asked the Depart- ated hospital in New Jersey paid
the state a $400,000 settlementment of Defense to investigate.
It was the Harrell case that led to though it admitted no criminal
those Texas Senate hearings, which in wrongdoing—after officials there alturn brought to light other allegations legeel fraudulent billings.
of fraud and abuse. They involved some
Other patients who voluntarily sought
of PIA's 12 other Texas facilities and help claim they were imprisoned.
at least three other national hospital Among them is Susan Aklcrson, who
chains. Similar charges have been made told the Senate committee how her docagainst hospitals in New Jersey, Florida, tor referred her lo Brookhavcn PsychiatAlabama ancl Louisiana; three federal ric Pavilion near Dallas, another PIA
agencies have opened investigations, hospital, after she had a psychotic reacand more lhan a dozen slates now have tion to pain medication. "1 thoughl I'd be
probes underway. Some have already there a day or two and released," she
taken legal action: The Texas attorney said, "bul lhal dav or (wo lasted three
• C VR S O Y
OE T R
KC B C S
I KA K
Health care provides many opportuni-
ties for kickbacks for steering business
to suppliers, pharmacies or laboratories. A medical-equipment
supplier might pay off a hospital to get a monopoly on its business,
or slip cash to a doctor in return for patient referrals; a pharmacy
may pay "incentives" for a nursing home to steer patients its way;
labs may reward doctors for a stream of patient referrals.
U.S.Nl-:U'S & WOKI.I ) Klil-OKT, l-'liMKUAKY M. IMK
-.••••r^.'-'.'r"'-.v-
months." After Icarn'ng the terms of her
insurance policy with
Aetna Life and Casually, she testified, the
hospital tried twice to
change her status from
"psychiatric" lo "medical,"
therebv increasing her coverage from'$50.()00 10"$! million.
She says she was heavily sedated, isolated from visitors and
warned by her doctor that
she'd "be in a mental hospital the rest of her life" if
she made waves. When her
ccwcragc was exhausted, and
a family member threatened to call
the police, Alderson was told to pack her
bags ancl leave, she claims. Once home,
she learned her insurance company had
paid a $48,864 bill.
In recent months, a number of doctors have gone public with stories portraying Ihcir former employers as
greedy, mielhical and corrupt. Quentin
Dinardo, director of clinical services at
Laurelwood Hospital in suburban
Houston before he ciuil in disgust, says
"every decision was based on dollars
ancl cents. If you're selling shoes that
might nol be so bad, but wc are talking
about human beings." A clinical psychologist with 20 years' experience, Dinardo claims the entire hospital staff
spent half its time promoting the P1Arun facility to prospective clients. He
also alleges lhal Laurelwood charged
unconscionable fees for deplorable care.
David Olson, a spokesman for National Medical Einterpriscs Inc., which
absorbed PIA last December, calls Dinarclo's charges "absurd." Hospital employees are never required to spend
half their time marketing, he says, although the company docs expect staff
to educate the public about services offered. "Wc don't regard that as unreasonable," he adds. Olson says Laurelwood offers "quality" care.
Dr. Duard Bok, who ran a chemicaldependency unit at the Psychiatric Institute of Fort Worth, makes similar
charges about abuse in a recent lawsuit
against that facility. The suit alleges
that the PIA hospital routinely gave financial support lo doctors, social workers and even local high-school guidance
counselors for referring patients, ancl
pressured doctors to change discharge
orders "so patients could be maintained
in the hospital for a longer period for
no therapeutic reason whatsoever."
Bok was fired last August, he says, after
criticizing the facility's practices. PIA
contends Bok was disabled by a personality disorder ancl that they suspended
41
�• -
,
.»rg-re™»w*aOTWMy^^
TriTir" T
J
• C VR S O Y
OE T R
his contract only alter he failed to show
up for work for two months. The company has filed a countersuit.
Privacy rules prohibit hospital staff
from discussing patients' cases-like
Susan Alclcrson's — without their permission. Bul Olson disputes the general
charges leveled against PIA facilities,
calling allegations of abduction •'absolutely, utterly false." There is no evidence to support charges that professionals are paid kickbacks to refer
patients lo PIA hospitals, or to detain
them once they've been admitted, he
says. Olson maintains the staff would
never revise a diagnosis to maximize insurance coverage, though he adds that
"it's not unustial for a patient's diagnosis to change" during a stay. "We're not
perfect," Olson says, "but to draw the
conclusion that isolated patient complaints mean widespread problems is
extremely dangerous to people who
need care."
ENFORCEMENT PROBLEMS
Despite the sums at slake, there has been
no great call lo arms againsl health-care
fraud among governmenl regulators,
law-enforcement agencies and private
insurers. There has been a recent awakening in some ijuarters, but the effort
still too often falls victim to funding
crunches and conflicting priorities.
Since 1985, 27 insurance companies
have joined a special investigative consortium against fraud, and the number
of special anlifraud units at Blue Cross
and Blue Shield plans has grown from 28
to 41 in the past three years. Several
firms have developed sophisticated artificial-intelligence programs lo massage
computerized claims data and
spot suspicious anomalies.
Still, many believe lhal private
insurers have been sluggish in
confronting fraud. A survey two
years ago by the Health Insur
ance Association of America
found that only half the
companies queried had
organized anlifraud programs. "Health-insurance companies, with
some exceptions, are content to pass the cost associated with fraud along lo their customers in the form of higher
premiums," charges Louis
I'ai isi, director ol the New
Jersey insurance department's fraud division.
The governmenl record is
spotty as well. Much of the
HM C R Ri OFFrrrr
O E AE P
tect. It involves charging insurers for more services than patients
got, billing for more hours of care than were provided, falsifying
records and charging higher nurses' rates for care given by aides.
flak is directed at lhe Health Care Financing Administration, which runs the
$115 billion Medicare program and
oversees the 58 private firms that process and pay Medicare claims. Congress
and the HHS inspector general's office
complain bitterly that HCFA is lousy at
closing loopholes that invite fraud and
at correcting administrative laxity. Reports with recommendations on how to
fix the flaws "seem lo disappear into a
black hole," says Harvey Yampolsky,
former chief counsel lo the HHS inspector general. One such report,
written in March 1988,
spotlighted abuses of provider numbers by equipment suppliers, but
HCFA didn't announce
changes in the system until
last fall. Critics arc also exasperated by HCFA's delays
in implementing new laws to
fix (he system. A 1987 law
authorized HCFA to develop rules for physician
investments in medical facilities, bul those prescriptions
didn't come out until last July.
as "payment safeguards" —has fallen
from $358 million in 1989 to $333 million in 1992, despite the fact that each
dollar spent this way saves Medicare as
much as $11.
The congressional General Accounting Office also roasted one of the contractors' primary tools for sniffing out
fraud: toll-free hot lines for Medicare
beneficiaries. The GAO study said that
over half the calls from beneficiaries
complaining of possible fraud were not
properly referred for investigation. Part
of the problem, says the GAO, is inadequate oversight from HCFA. Many beneficiaries complain of poor treatment
when they do call. "Why do they give you
this runaround?" argued OttoTwitchell,
who tried to report an excessive bill. "1
was beginning to feel like I was the guilty
party." HCFA Administrator GaifWilensky counters that her agency is caught
in a philosophical and financial squeeze.
It is often difficult, she says, to balance
the conflicting priorities of getting the
money out quickly, reducing the hassles
for legitimate physicians and suppliers
and keeping an eye out for fraud. In
addition, she says, new laws require exWorst of all, HCFA is pro- tensive time for public comments before
viding the private contractors rulescan be implemented. And workload
with less money lo watch out increases have outpaced manpower.
for fraud. Funding for these Medicare claims rose from 217 million in
watchdog activities— known 1981 to 600 million in 1991, but HCFA's
U.S.NKWS & WOKU) Kl-lWr. Hl'HKUARY 2-1. W>
�aBj>»3^r'i-Ti--™---'
, r
1
l
~~' ' ''*
i m
SI
PY H SA
SC CM
Some for-profit mental-health facilities reportedly pay "bounty
hunters" to bring in patients, hospitalize patients against their
will, tailor treatments to maximize insurance payments, take
kickbacks for recruiting patients and overbill for services.
stall' has fallen to 4,027 from 4,972 a
(.leeatle ago. Meanwhile, HCFA has also
been overwhelmed by other duties, like
instituting a massive change in physician
payment rates. Wilcnsky notes that
HCFA did announce a major package of
reforms last November to clean up the
medical-ec]uipmcnt industry. HCFA
would love to hike spending to sniff out
fraud, Wilensky says, but is doing the best
it can vmder budget constraints.
The same goes for the HHS inspector
general's office, which shares responsibility with the Justice Department for
investigation of hcalth-care-fraud cases.
The IG's office has boosted prosecutions for 1 years, bul has only 270 in1
vestigators nationwide'-.who are also re-
SIMPLE PRECAUTIONS
sponsible for HHS's 300-odd other
programs. "A lot of cases can't be
opened because we just don't have the
resources," says James Cottos, the IG's
head sleuth in Atlanta. Cottos has just
13 investigators for the whole state of
Florida, which is home to 2.3 million
Medicare beneficiaries. Their overtime
pay was cut off last fall.
Until recently, there wasn't much
good news at the Justice Department
cither. The focus at the FBI and among
U.S. attorneys during the 1980s was on
violent crime, the drug crisis and the
savings and loan scandal. Health-care
cases were boring and difficult to prove.
Those problems still exist. But a sense
of alarm is slowly starting to yield more
resources for battling health-care fraud.
The FBI has tripled its commitment
over the past three years, to 95 agents,
and early this month Attorney General
William Barr announced that 50 more
agents would be transferred from counterintelligence duties to health-fraud
probes. The number of states with special Medicaid fraud control units has
grown from 31 in 1984 to 42 today.
Still, no one believes the good guys
are catching more than a small fraction
of the health-related crime. Many feel
the system is too big and too geared toward processing the claims. Cracking
down may ultimately depend on smarter, more vigilant consumers who are fed
up. After all, it's their money.
•
BY GORDON WITKIN WITH DORIAN
KKIKDMAN AND MONIKA GU'ITMAN
licensed by the state, certified
by Medicare (about 5,800 of ..
the nation's 12,500 agencies'/;
are) and accredited by either '
the Joint Commission for the'
• Watch your bills. You could Accreditation'of Healthcare
be paying for part of the scam Organizations (1,800 agencies
accredited) or the Comfnuni- ;
when you pay your'share of
your bill. Be sure to check out' ty Health Accreditation Program Inc. (375 agencies \ . '
billing discrepancies very
accredited).
thoroughly.
• Home-care safeguards. Get • Fraud fighters. They can be
found at all major insurance" " .
the advice of a doctor you
companies, Medicare and \
trust on the level of home
Medicaid, arid most states' at- •''
care.you need. Be wary if
someone tries to sell you ser- torney general's offices. Medicare beneficiaries can file susvices or equipment no one
else has suggested. It's best to picions with the government'
by calling a toll-free fraud hot
choose a home-care agency
that has been operating in the line (1-800-368-5779): \ , ";
community for five years or
longer and one that has been
B STEVEN KINDLAY
Y
How to thwart health-care fraud
I ere are some'ways to '
1 spot arid prevent fraud:
• Be wary. Phone solicita-'.
tions, especially those promising free checkups, testing or
equipment, should trigger
suspicion. Don't give out your
Social Security, insurance policy or Medicare numbers!
• Rolling labs and health fairs.;
Rip-offs usually involve a
battery of tests rather than,
say, a single test like one for a
cholesterol check or a mammogram. Don't provide a de-.
tailed medical history or sigri'
multiple insurance forms that
US.Ni'WS
assign reimbursements to a
provider.
• White lies;. Be skeptical if
someone tries to talk you into
a "free" treatment scheme/
brie scenario: The provider
says your insurance will probably cover only $500 of a treatment for which he usually
charges $1,000. He says he's '
going to submit fees of
$2,000 — expecting to get reiriibursed around $1,000 —and
waive your part of the bill. .
These lies could prevent you "
from getting life or health insurance down the road.
& WORLD RKI-OKT. I'TUKUARY 21 MM
:
1
1
:
A3
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
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Paper
Dublin Core
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Title
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[Carol Pollack Dworkowitz] [loose]
Creator
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
Is Part Of
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Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
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William J. Clinton Presidential Library & Museum
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3/16/2015
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42-t-12092971-20060885F-Seg3-035-004-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/fe18d1f9a6a2debf88ff491ccf45f069.pdf
e38ad1a7a85a6a07a60c6c8e0c17fd69
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task. Force
Series/Staff Member:
Tarmey
Subseries:
1978
OA/ID Number:
FolderlD:
Folder Title:
[California Policy Seminar Biennial Report] [loose]
Stack:
Row:
Section:
Shelf:
Position:
s
56
2
1
3
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a publication.
Publications have not been scanned in their entirety for the purpose
of digitization. To see the full publication please search online or
visit the Clinton Presidential Library's Research Room.
��
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Title
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Health Care Task Force Records
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White House Health Care Task Force
Is Part Of
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[California Policy Seminar Biennial Report] [loose]
Creator
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
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Reproduction-Reference
Date Created
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3/16/2015
Source
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42-t-12092971-20060885F-Seg3-035-003-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/046163539700c6a8f096e32610753782.pdf
0d5b95dcbf750e336db902fec151994b
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
OA/ID Number:
1983
FolderlD:
Folder Title:
[Building Assisted Living for the Elderly into Public Long Term Care Policy: A Technical Guide for
States] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
2
�BUILDING ASSISTED LIVING
FOR THE ELDERLY
INTO PUBLIC LONG TERM CARE POLICY
A TECHNICAL GUIDE FOR STATES
A PUBLICATION OF THE
THE CENTER FOR VULNERABLE POPULATIONS
A .loint Project Sponsored By:
The National Academy for State Health Policy
and
The Institute for Health Policy
Brandeis University
September, 1992
�Assisted Living Guide
CENTER ON VULNERABLE POPULATIONS
The Center on Vulnerable Populations provides it unique opportunity to link research and practice to assist
states to serve vulnerahle populations, including persons with developmental and physical disalnlities, those with
severe mental illness aud the trail and chronically ill elderly. Working directly with states and guided by an Advisory
Committee, the Center will conduct research and policy analysis, examine state best practices tor these populations
and make practical and useful infonnation readily available to state officials. A series of intensive best practice
evaluations and leaders seminars will be convened to more fully explore policy and program innovations. Finallv the
Center will help inform the media and general public about the needs and abilities of vulnerable populations and their
families and the challenges confronting state governments in addressing them.
The Center is co-directed by the National Acadi'iny f o r State Health Policy and the Institute l o r Health
Polity at Brandeis University. An advisory committee representing key state officials. Congress, consumers and the
media will identity critical concerns, assisted the Center to develop an annual work plan and help maintain active
relationships wit a wide variety ot states and national organizations working on issues affecting vulnerable
populations. In the Center's tirst year, tour cross-cutting policy issues will be considered, pending review of the
Advisory Committee:
•
•
•
•
The
The
The
The
development of flexible community-based systems of care;
process for targeting clients anil the benefits they receive;
financing of a broad array of cost effective services;
role of institutional services in the delivery of care.
The Center shall produce:
•
•
Policy analysis papers and policy studies;
Research studies;
•
•
•
•
"Spotlight," a best practice newsletter;
Short issue papers;
Seminars and workshops;
Practical guide books for state policy makers.
The Center will examine issues across populations and seek policy and program innovations from one
population which may, i f adapted properly, serve other populations in need. The Center's efficacy will Lie determined
by the states in their decisions about whether or not the Center's products are useful and responsive to them as they
confront the challenges of serving vulenrable populations.
National Academy f o r
State Health Policy
50 Monument Square, Suite 302
Portland, Maine 04101
207-874-6524
Institute f o r Health Policy
Brandeis University
415 South Street
Waltham, Massachusetts 02254
617-736-3800
CVP
�BUILDING ASSISTED LIVING
FOR THE ELDERLY
INTO PUBLIC LONG TERM CARE POLICY:
A GUIDE FOR STATES
Prepared By:
Robert L. Mollica
Professional Staff
National Academy for State Health Policy
Richard C. Ladd
Commissioner
Health and Human Resources Commission, Texas
Susan Dietsche
Assistant Administrator
Senior and Disabled Services Division, Oregon
Keren Brown Wilson
President
Concepts in Community Living, Oregon
Barbara S. Ryther
Housing Consultant
Massachusetts
Funded by grants from the Robert Wood Johnson Foundation
and
The Henry J. Kaiser Family Foundation
September, 1992
�Assisted Living Guide
CONTENTS
Executive Summary
II.
Introduction
1
Population and Functional Impairment Trends
Measures of Need
Supply trends
Assisted Living - A New Resource
Common Ground for a Definition of Assisted Living
I.
i
2
3
5
6
9
10
12
13
14
15
16
Quality Assurance
17
Adherence to Model Principles
Program Capacity
Outcomes
IV.
10
Values Orientation
Setting
Services
Staffing
Tenant Profiles
Costs
III.
Description
18
19
20
State Models
21
Oregon
Washington
New York
Florida
Massachusetts
State Summary
21
27
31
37
40
48
CVP
�Assisted Living Guide
V.
56
56
60
62
65
Federal Programs Administered by State
Low Income Housing Tax Credits
Tax Exempt Bonds
Community Development Block Grants
HOME
66
66
69
70
71
State and Local Programs
72
Rent Subsidies and SSI Issues
75
Services in Assisted Living
79
General Revenue Programs
Medicaid
Home and Community Based Services Waivers (2176)
Home and Community Based Services Waivers for the Elderly (1915d) . . . .
Frail Elderly Community Care Act
Older Americans Act
Robert Wood Housing Demonstration Project
VII.
55
Federal Programs
Section 202
Section 232 Mortgage Insurance
Congregate Housing Services Program
Farmers' Home Administration
VI.
Sources of Housing Financing
79
80
80
83
85
93
93
Policy Implications
Recommendations
97
107
Endnotes
Appendix
• HI
114
CVP
�Assisted Living Guide
ACKNOWLEDGEMENTS
The authors wish to thank the many people who provided information for the Guide:
Florida: Larry Polivka, Vickie Flynn and Vicki Campos, Aging and Adult Services;
Massachusetts: Jan Levinson and Jean Moltenbrey, Executive Office of Elder Affairs;
Diane Flanders, Medicaid Division; Paul Dreyer, Department of Public Health; Cynthia
LaCasse and Maureen McAllister, Massachusetts Housing Finance Agency, and Judy
Sklare, Massachusetts Industrial Finance Agency; New York: Barry Berberick and Frank
Rose, Department of Social Services; Washington: Harry Sedies, Aging and Adult
Services; Sharron Dreyer, Fairfax County Department of Housing; Kathleen Bloom and
Mary Clarkson, U.S. Health Care Financing Administration; Jerold Nachison, U.S.
Department of Housing and Urban Development.
And thanks also to those who reviewed drafts of the Guide: the CVP Advisory
Committee and Jim Hooley and Arthur Webb, co-project directors of the Center;
Barbara Matula, Director, Medicaid Division, North Carolina; Donna McDowell,
Director, Wisconsin Bureau on Aging; Sally Richardson, Director of the West Virginia
Employees Insurance Agency; Charles Reed, Assistant Secretary, Aging and Adult
Services, Washington; Don Redfoot, Legislative Representative, American Association
of Retired Persons; Lee Bronfman, American Association of Homes for the Aging; and
special thanks to Jan Fisk and Julia Hanauer for their technical support and editing and
to Trish Riley, Executive Director of the Academy for her guidance and insight into this
work.
Copyright
0
1992 by
The Center for Health Policy Development/National Academy for State Health Policy,
50 Monument Square, Suite 302, Portland, Maine 04101
CVP
�Assisted Living Guide
FOREWORD
Using the Guide. The Guide was prepared for multiple audiences policy leaders in housing agencies and service agencies and staff whose
knowledge of the issues and resources related to assisted living may
vary. To some, the Guide may present too many details and for others,
not enough. Sections of the Guide will be more familiar to one group
than another. The Guide presents a thorough but not exhaustive look at
assisted living, the resources available to make it work and the
problems that must be resolved to do so.
The Introduction presents an overview of long term care spending, our
reliance on nursing homes to meet long term care needs and the
emergence of a new resource for serving elders. Some of the confusion
surrounding definitions of assisted living are presented. Since no one
definition exists, policy makers are left to decide how the concept will
be implemented in their state. The Description and Quality Assurance
chapters present conceptual frameworks for developing definitions,
standards and examples based on work in several states. Moving from
concept to operational detail requires cross-cutting and collaborative
work among a range of agencies and interests. Existing state policies
and programs that represent varying approaches to assisted living are
described in chapter IV. Chapters V and VI present descriptions of the
existing programs available to finance housing and services. The
advantages and obstacles of each resource also are described. The final
chapter highlights the policy conflict and changes that would make it
easier for states to develop and expand residential models for meeting
long term care needs.
Actually using the Guide to develop policies and programs requires
active discussions among leaders in the respective state service
(Medicaid, Aging, Social Services, Health) and housing agencies. With
hard work and thorough involvement of all parties, the limitations of
existing programs can be overcome to produce successful assisted living
CVP
�Assisted Living Guide
models and to expand the "repertoire" of long term care services, as
Rosalie Kane, D.S.W., professor at the University of Minnesota, has
noted.
The Plan. This Guide represents the initial focus of the Center's effort
on assisted living. Policy makers developing assisted living as a
resource for elders can learn from the experience of similar programs
in mental health and mental retardation fields which have developed
smaller, more home-like settings than institutions, but which retained
their institutional character. The Center will issue a similar Guide on
Assisted Living Programs for people with disabilities that will examine
these models.
The Quotes. The comments and quotes highlighted in boxes throughout
the document were made at the Public Policy Seminar on Assisted
Living sponsored by the National Academy for State Health Policy on
April 15, 1992 in Washington, D.C. The agenda for the seminar is
included in the appendix and edited video tapes are available. Please
contact:
Robert L. Mollica
National Academy for State Health Policy
50 Monument Square, Suite 302
Portland, Maine 04101
207-874-6524
CVP
�Assisted Living Guide
EXECUTIVE SUMMARY
What is it?
A recent addition to the array of long term care services, assisted living
combines the medical aspects of long term care with a model of
supported housing and social services. Definitions of assisted living
vary and sometimes the services provided overlap with other models:
board and care, personal care homes, residential care facilities, rest
homes and others. Generally, assisted living emphasizes consumer
direction over regulation. Comparing assisted living to nursing homes,
Michael Rodgers, Vice President of the American Association of
Homes for the Aging, says, "Our role is to assist with, rather than to
do for, residents in assisted living."
Key variables are the philosophy of operation, the services provided,
the residents who can be served and the design of the units and the
building itself. Thus far, state programs are not consistent in their
approach to these variables. State definitions should be determined by
the primary goal of their program - to replace a portion of the supply
of nursing home beds, reduce the future rate of growth in supply, or
expand home care services to support aging in place.
Assisted living is an important policy issue because of the cost of long
term care; our reliance on expensive institutional models; the
demographic trends, especially the growth of people over 85 years of
age; and the demands of consumers themselves for services in homelike environments. The Guide examines assisted living policy in five
states: Florida, Massachusetts, New York, Oregon and Washington.
Philosophy
The philosophy of this model - as much as the description of the
building, the characteristics of people served or the services provided CVP
�Assisted Living Guide
separates assisted living from other models that combine housing and
varying levels of oversight and care. Assisted living emphasizes "homelike" living units, privacy, resident choice, independence, shared risk,
and shared responsibility in which residents actively participate in the
accomplishment of regular tasks and activities. Oregon and Washington
implement the assisted living philosophy in buildings with single
occupancy units (unless shared by resident choice) with baths and
cooking capacity. Florida's program creates a new operating philosophy
and broader services within its residential care program. New York
requires higher service levels, more training for staff and other
important improvements.
States that increase the services provided in board and care facilities
will make a real difference in the operation of and services available in
these facilities. However, implementing assisted living within the
existing stock of board and care facilities may hamper its image and
emergence as a distinct option. As states continue to license assisted
living, the requirements that apply can differ. Oregon and Washington
distinguish assisted living from board and care by including skilled
nursing among the services provided, requiring units that are larger
than units in their board and care facilities and requiring a bathroom
and cooking capacity within each unit.
State programs reflect their own unique environments and
circumstances. With a strong legislative mandate to develop assisted
living, Florida's regulations contain an extensive list of services that
can and cannot be provided in assisted living. Guidelines in New York
and Washington contain similar though not as extensive lists which
limit who can be served more so than in Oregon's program. The
Massachusetts draft policy suggests an open-ended policy regarding the
target population.
Who is it for and what services are available?
All states, except Massachusetts, have based their policy on serving
nursing home eligible Medicaid recipients in assisted living programs.
Though Massachusetts' providers will be encouraged to serve nursing
home eligible elders, the programs were developed to serve elders who
are no longer eligible for placement in a nursing facility due to changes
CVP
ii
�Assisted Living Guide
in the state's level of care criteria.
While the target populations are similar - elders with impairments in
activities of daily living, cognitive impairments and some skilled
nursing needs - state models vary. The current status of publicly
subsidized assisted living ranges from mature models (Oregon) .which
rely on newly constructed or rehabilitated units to incremental models
(Florida, New York) which build on the existing supply of housing
resources.
Personal care and administration of medications are two core services.
The availability and scope of skilled nursing determines the extent to
which assisted living serves as nursing home replacement model for
many nursing home residents. Housekeeping, shopping, meals,
laundry, transportation and social or recreational activities are basic
assisted living services.
Facilities in Oregon can provide any service available in a nursing
home, however people who require continuous medical or nursing care
are not served. Other states have listed services which can and cannot
be provided in assisted living. (See page 50 for a comparison of state
programs.)
How much does it cost?
Private rates for assisted living range from $900 to $3,000 a month and
higher for room, board and services. Variables include the building
design, development costs, service packages and amenities. Public costs
in Oregon, which serve very impaired residents, average 80% of the
cost of comparable care in a nursing facility. The Medicaid cost in
other state programs are generally 50% of comparable nursing, facility
care.
How are they financed?
States have used existing housing and service financing programs to
develop remarkably different programs (See page 73 for a summary of
housing resources). Though most were not designed to focus explicitly
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on assisted living, policy leaders, providers and developers can
combine housing and service resources to support such projects but it
requires extensive collaboration between state agencies. While only
Oregon has intentionally encouraged new construction, state housing
finance agencies and service agencies have the tools to collaborate and
set priorities for the use of state tax exempt and taxable bonds and tax
credits to attract developers to start new facilities.
Medicaid waiver programs and state community based care programs
financed through general revenues are most amenable to assisted living.
Modifications to the Medicaid income eligibility guidelines and SSI
payment standards offer options for states to increase eligibility and
gain access to private, mixed income projects. Most states rely on
Medicaid to pay for services. Florida, Oregon and Washington will
utilize their home and community based care waivers to pay for
services. New York, which does not have a waiver for its elderly
recipients, will provide a flat capitation payment for state plan services
provided in assisted living facilities. The supponive services, which are
required by regulation (housekeeping, limited personal care, laundry,
activities), are covered by a higher SSI payment rate. States can
develop programs with state general revenues to divert elders with
incomes near but above Medicaid levels and avoid the costs for those
who would spend down if admitted to a nursing facility.
The U.S. Housing and Urban Development's 202 elderly housing and
232 mortgage insurance programs can be used to develop supportive
housing and assisted living resources. Low Income Housing Tax
Credits and Industrial Development Bonds can also be used. Because
these resources were not developed expressly for assisted living, there
are many complications, obstacles and conflicts that, if resolved, would
facilitate the construction of new assisted living facilities.
Future policy changes
While assisted living concepts will change the operation of existing
licensed board and care programs and the operation and design of
nursing facilities, the real potential for this model is in new
construction or rehabilitation to realize the full scope of the concept
(home-like buildings, single occupancy units with baths and cooking
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capacity, privacy, shared responsibility and risk sharing, and skilled
nursing and support services available to nursing facility eligible
residents). To develop effective assisted living policies and programs,
officials from the housing finance and service programs need to work
together to develop common goals, definitions, priorities, guidelines
and packages.
To facilitate the expansion of assisted living, state and federal policy
makers might:
• Develop stable long term funding commitments for services in bond
financed projects.
• Expand funding for services for non-Medicaid low income elders.
• Address the ability of Medicaid recipients to pay for the shelter
(room and board) costs outside an institution.
• Develop subsidies for the shelter costs for elders who are not eligible
for Medicaid and cannot afford market rate "rents."
• Differentiate licensed housing and service models from institutions
which could be eligible for HUD 202 funding.
• Reconcile cost sharing differences between HUD and Medicaid
programs.
• Allow the cost of mandatory service packages outside the rent caps
in the Low Income Housing Tax Credit program.
• Modify the HUD 232 guidelines to support single occupancy units
with baths and cooking capacity.
• Develop quality assurance measures that focus on consumer
satisfaction and outcomes.
• Coordinate funding and RFP cycles for housing and service
programs that must be combined to implement successful projects.
• Build policies and programs that reflect consumer preferences.
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Don Redfoot, Legislative Representative for the American Association
of Retired Persons, offers this advice to policy makers: "Always keep
your ears tuned to what consumers are saying and how markets reflect
demand from older consumers themselves; not what you think they
ought to want, not what you think is tasteful but what consumers
themselves are saying."
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1. INTRODUCTION
Since the inception of Medicaid in the late 1960s, long term care services have been
provided traditionally in medically regulated nursing facilities. At the same time, housing for
the elderly has developed without significant attention, until recently, to the relationship
between shelter and services. Combining services with housing options to support
independent living has become a priority for state policy leaders.
Interest among state policy makers has been fueled by the rising cost of Medicaid
expenditures for long term care. Adjusted for inflation, Medicaid spending for all services
grew 34% between 1981 and 1988, 23% between 1988 and 1990 and 22% in 1990 alone.
The Congressional Budget Office predicts that Medicaid spending will rise almost 120%
between 1990 and 1996. The study attributed growth in long term care spending to the
increase in the average payment per elderly recipient and increases in both the number of
disabled recipients and the average payment per recipient. In 1990 Medicaid payments were
made for 1.5 million, primarily elderly recipients (excluding ICF-MR) at a cost of $17.7
billion. Aged recipients comprise 5% of the Medicaid recipients yet they account for 23% of
expenditures.
1
2
Spending rates vary significantly by states (See Table 1). A Congressional Research
Service (CRS) report projects that total Medicaid spending in actual dollars will increase
Table 1. Rate of Medicaid Increase over Previous Year
1988
1989
1990
1991
Florida
26.2%
26.4%
26.8%
30.0%
Massachusetts
12.8%
12.5%
30.1%
44.0%
10.1%
12.6%
22.1%
22.7%
20.0%
24.8%
9.0%
20.7%
24.5%
12.2%
18.6%
26.9%
New York
6.6%
Oregon
26.2%
Washington
16.9%
National Ave.
8.6%
Source: Congressional Research Service.
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from $92 billion in 1991 to $197 billion in 1996. Medicaid expenditures for long term care
services grew 60% between 1987 and 1991, from $22 billion to $35.7 billion. By category,
nursing home expenditures for the elderly and disabled grew 53.5%. Home health spending
grew 136% and spending for home and community based waiver services grew 256%/
While spending for nursing homes grew more slowly than other Medicaid services,
expenditures grew faster in 1991 than the previous year by
4
Table 2. Medicaid Spending Growlh
1987
1991
Nursing Homes
$13.6 billion
$20.8 billion
Home Health
$440 million
$ 1.0 billion
HCBS Waiver Services
$451 million
$ 1.6 billion
Increases in nursing home spending rates have been attributed to the effects of the
nursing home reform provisions of the Omnibus Budget and Reconciliation Act of 1987
(which requires functional and cognitive assessments of residents, raises the staffing ratios
for licensed nurses and requires added training for nurses aides), and the effects of court
suits under the Boren Amendment which requires reimbursement methodologies which are
"reasonable and adequate." States with stable bed supply and numbers of Medicaid recipients
are experiencing increases due to the rising cost of care.
Population and Functional Impairment Trends
Population trends and the functional characteristics of an aging population confront policy
makes with further challenges. As the cost of care rises, demand and increased supply
complicate the situation even further.
Who needs long term care and what are the demands and risks for long term care?
Today over 1.5 million people live in nursing homes. Five percent of the people over 65 and
22% of the population over age 85 live in nursing homes. Though most nursing home stays
are short, 21% stay between one to five years and six percent stay more than five years (See
Table 3).
7
In 1990, 2.2 million people turned 65. A study by Peter Kemper and Chris Murtaugh at
the Agency for Health Care Policy Research projected that 43%, or 946,000, of the people
who turned 65 in 1990 will enter a nursing home in their lifetime. Twenty-six percent of
8
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Table 3. Average
Length of Stay in
Nursing Facilities
3 months
51%
3-12 months
22%
1-5 years
21%
> 5 years
6%
the people turning 65 in 1990 will spend less than three months in a nursing home (See Table
4). Nineteen percent will stay between three and 12 months. Thirty-four percent, 322,000,
will stay one to five years at a cost between $30,000 and $180,000, and 200,000 will spend
$150,000 to $180,000 during their stays of five years or longer. The costs are based on
current nursing home rates and are not adjusted for inflation. The expansion of assisted living
and community care programs may alter the projected nursing home utilization rates by
offering more choices to those who need long term care.
Table 4. Projected
Lifetime Nursing Home
Use Rates
< 3 months
26%
3-12 months
19%
1-5 years
34%
> 5 years
21%
Measures of Need
Between 5 and 8% of the population over 65 - about 6 million people - living in the
community have limitations in activities of daily living (ADL), depending upon the survey
and the definitions used in the survey. Age is an important variable in predicting
impairment. Impairment rates for people over 85 are often three to six times higher than for
the 65-74 age group (see tables 5 and 6).
9
10
The number of people needing long term care will rise from just under 7 million in 1988
to 9 million by 2000 and 18 million by 2040." As the rate of impairment increases with
age, the population trends among the aging highlight the importance of these rates. In 1990,
1.3%, or 3.2 million, of all Americans were 85 or older. By 2000, the number will rise to
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4.6 million and by 2010, 6.1 million will be over 85. Assuming other trends remain
constant, the number of people over 85 with bathing impairments will increase from 694,000
in 1990 to 1.3 million in 2010. A 1988 study of long term care financing options by the
Brookings Institute projected that the number of elders in nursing homes during the course of
a year would increase from 2.3 million between the 1986-1990 based period to 4 million in
2016-2020 and 51 % of all people over 85 would spend part of a year in a nursing home
during the projection period. While this represents a nine percent increase over the base
period, the actual number of people over 65 spending pan of the year in a nursing home will
more than double (1.0 million to 2.2 million).
13
Table S. Percentage of
Community Residents 65+ by
Impairment
Bathing
6.5%
Toileting
4.7%
Dressing
4.1%
Mobility
3.6%
Transferring
3.6%
Eating
2.1%
Table 6. Percentage of Elders with ADL
Impairments by Age
Age
65-74
75-84
85 +
Bathing
3.5%
10.6%
21.7%
Dressing
2.9%
5.1%
13.2%
Mobility
1.9%
4.6%
13.3%
Toileting
1.2%
2.9%
8.3%
Transferring
1.8%
3.7%
8.9%
Eating
0.6%
1.5%
2.7%
ADL
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While policy makers feel pressure from today's utilization and expenditure rates, a look
to the future using these figures highlights the urgency of planning now to shape the system
for the next generation of elders. Some policy makers believe that assisted living can serve
35% to as many as 80% of the people who live in nursing homes.
Supply Trends
Projections of future expenditures are predicated on demand, price and supply
assumptions. The supply variable receives little attention in most estimates. Projections
assume that the mix of resources available to meet demand reflects past supply patterns.
Between 1971 and 1988, the supply of nursing home beds grew at an annual rate of 2.3% to
a total of 1.6 million beds. However, the population 85 years of age and older, which
comprises 40% of the nursing home residents, grew 4.2% annually for a net loss of 1.9 beds
per thousand during the period. This trend suggests that new dynamics are affecting the ways
in which demand is met. On recent study attributed the slow growth to certificate of need
programs, nursing home reimbursement policies and the cost of construction. The study
showed that despite the increase in the number of elders, occupancy rates have held fairly
stable at around 91 %. The expansion of community and residential care options may also
have contributed to the relative "loss" of bed supply. While the imbalance between nursing
facilities and community care continues, projected demand and cost trends support the need
14
15
Table 7. Supply of Nursing Home Beds and
Percent of Costs Paid by Medicaid, 1989 Data
State
Beds/1000'"
Number of beds'"
Percent
Medicaid^
1978
1989
1992'"
1978
1989
1989
Florida
34,939
61,127
68,199
22.3
26.8
61.3%
Massachusetts
43,295
49,182
53,288
61.2
60.5
78.1%
New York
90,178
102,595
119,760
42.5
43.8
68.9%
Oregon
14,653
12,381
14,963
50.9
39.2
48.7%
Washington
28,225
28,636
31,912
69.2
50.5
67.5%
1. 1978, 1989 supply data: Institute for Health and Aging, University of California, San Francisco.
2. "The Guide to the Nursing Home Industry." Health Care Investment Analysts, Inc. and Arthur
Anderson, 1991.
3. 1992 figures obtained from each state's licensing agency.
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for expansion of community and residential programs such as congregate housing and
assisted living.
Assisted Living - A New Resource
Perhaps the primary force behind assisted living has been elders themselves. The cultural
and social preference to reside in one's own home is strong among older Americans and has
resulted in the growth of in-home services and a variety of supportive housing arrangements
such as retirement centers and congregate living centers. In-home service programs as well
as other community based care programs are generally regulated as social services. The
concept of "aging-in-place" has replaced the notion of "the continuum of care" which expects
a person to move from place to place as frailty or deterioration occurs. Aging-in-place allows
a resident to remain "at home" with the array of services provided in that home changing as
needs change.
Assisted living is a recent addition to the repertoire of long term care services. Assisted
living combines the medical aspects of long term care with a model of supported housing and
social services. Definitions of assisted living vary and sometimes the services provided
overlap with other models: board and care, personal care homes, residential care facilities,
rest homes and others. However, more than the description of the building, the
characteristics of people served or the services provided, it is the philosophy of this new
model that separates assisted living from others that combine housing and varying levels of
oversight and care. The current status of publicly subsidized assisted living ranges from
mature models (Oregon) which replace nursing homes to incremental models (Florida, New
York) which build on the existing supply of housing resources. Incremental programs will
expand as state funding for services and construction of housing for the elderly permit.
16
A recent publication by Regnier, Hamilton and Yatabe suggests that assisted living
differs from board and care (small scale, family operated models) and personal care (based
on a more medical model of care). Assisted living "represents a model of residential long
term care. It is a housing alternative based on the concept of outfitting a residential
environment with professionally delivered personal care services, in a way that avoids
institutionalization and keeps older frail individuals independent for as long as possible. Care
consists of supervision with minor medical problems, assistance with bladder or bowel
control and/or management of behavioral problems as a result of early stages of dementia. In
an assisted living environment, all of these problems are managed within a residential
context."
17
The Regnier description emphasizes important dimensions that differentiate assisted living
from other models. However, there is no commonly accepted definition. Others see similar
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care provided in a range of licensed,
regulated models. The Assisted Living
"We've been struggling on Capitol Hill
Facilities Association of America definition
for 20 years to define board and care. We
has a much broader scope: "[A] special
haven'tfiguredout where assisted living
combination of housing and personalized
fits between board and care and in-home
health care designed to respond to the
care," Bill Benson, Senate Labor and
individual needs of those who need help
Human Resources Committee.
with activities of daily living. Care is
provided in a way that promotes maximum
independence and dignity for each resident
and involves the resident's family, neighbors and friends." This definition encompasses
facilities that are licensed as board and care, residential care, adult homes and other names.
In addition to definitional variations, facilities which describe themselves as assisted
living provide varied service packages to residents with a wide range of needs. Residents
served range from people with impairments in instrumental activities of daily living
(housekeeping, shopping, laundry, meal preparation) and limited impairment in activities of
daily living (ADLs) (bathing, dressing, eating, toileting, continence) who would not qualify
for admission to a nursing facility to residents with extensive ADL impairments and skilled
nursing needs who would readily qualify for nursing facility admission.
In some states assisted living is seen as something very close to retirement homes, with
perhaps some minimal services for residents with light care needs. In other states, assisted
living is seen as a replacement for the nursing home level of care. Indeed, while assisted
living is not usually equipped to handle chronic complex medical problems, it is serving
many people who would otherwise be in both custodial and skilled nursing facilities.
Several states limit the population eligible for board and care facilities to those who do
not require the services provided in a nursing facility. In Massachusetts, rest homes are
defined as "a supervised supportive and protective living environment and supportive services
incident to old age for residents having difficulty in caring for themselves and who do not
require level II or III nursing care (formerly SNF and ICF) or other medically related
services on a routine basis." As defined, rest homes could not serve as an assisted living
facility and care for someone who required services provided in a nursing facility.
Similarities in services and populations served by assisted living, board and care,
residential care facilities, rest homes and nursing homes create confusion for policy makers.
The Massachusetts policy is being revised, but it highlights the policy conflicts states are
facing as they consider the purpose and place of assisted living in the context of their existing
licensing and regulatory framework. The definitions are critical in relation to state licensing
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requirements which often attempt to create mutually exclusive categories of entities which
serve impaired populations. State definitions will determine the type of licensing
requirements that apply, who can be served in a facility, and what services may be provided
which may artificially constrain the scope of assisted living.
Many older persons need services that can be provided in multiple settings: home,
assisted living, board and care or a nursing facility. People living in their own homes or
apartments can receive any service a licensed professional can deliver. Home and
Community Based Medicaid Waivers allow nursing home eligible elders to receive extensive
nursing and support services at home. The definition of "home" is critical in determining
what and how services can be delivered. Once people move from their private residences,
different rules apply. Both the housing and the services are subject to regulation. As the
regulatory framework takes over, care becomes more health or medically oriented,
institutionalized, less responsive to individual capabilities and more responsive to
dependencies. To a considerable degree the source of financing dictates the degree of
regulation of the setting in which services are provided. Government income and service
programs, including Supplementary Security Income (SSI) and Medicaid, define and
regulate both the services provided and the setting in which services are provided. Housing
financing programs almost always separate the housing and service aspects. Modifying the
definition of "home" will have a significant effect on where people with functional
impairments and skilled nursing needs can be served.
18
Despite the continuing identity confusion, this increasingly popular model is becoming
known to investors, developers, and social and health service providers. Government has also
developed an interest in replicating and regulating these facilities. The promising potential of
assisted living facility development may be hampered by the lack of a standard definition, an
uncertain regulatory environment, disagreement about the appropriate resident population, a
lack of financing for construction, start up and operating costs and limited public subsidies
for the low income population.
Assisted living attempts to resolve the
issues surrounding housing and services and
the accompanying regulation. In order to
promote the concept of independence and
ability with assisted living, government
policy will have to clarify the extent to
which these environments will be
considered a person's home. While the
services provided and the setting in which
services are provided are essential
"It shouldn 7 matter which door you live
behind, whether it's the door of a single
family home on Main Street or at the
Sunnyvale nursing home, it's the services
that count," Trish Riley, Executive
Director, National Academy for State
Health Policy.
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components, ultimately, the definition of assisted living will be shaped by the philosophy and
values orientation reflected in a state's policy.
In a sense assisted living may represent a movement, a new vision in the delivery of long
term care toward a less regulated, or more appropriately regulated/licensed, housing and
service model. In all but a few states, assisted living serves primarily private pay markets. A
key test for government policy makers will be to maintain the essential elements of the
assisted living environment at a cost that middle income populations can afford and that
government will be willing to absorb for the low income population.
Is There Common Ground for A Definition of Assisted Living?
Conceptually at least, assisted living can be described from four perspectives: the
philosophy of the model, the environment or setting, the services available and the residents
who live there. Programs by many other names may represent elements of one or more
components or perhaps portions of each. State definitions range from assisted living as a
unique combination of the four variables to adding services in existing programs regulated as
board and care and its multiple terms. Proponents of the full concept (single units with baths
and cooking capacity, privacy, shared responsibility, managed risk, skilled services and other
components) support definitions and policies that clearly differentiate assisted living from
nursing homes and board and care. Definitions which differentiate assisted living from board
care attempt to set higher standards for providing residential long term care and to eliminate
consumer confusion caused by programs that offer a range of physical settings, service
options and costs.
Others recommend a broad definition that encompasses the full range of residential
options. This view contends that a narrow definition will restrict innovation and the
continued development of models based on competition and consumer choice. Strict
definitions may hinder the development of new programs to finance the housing and service
components and limit state flexibility to develop policies based on local needs. What is
common among states is their effort to provide additional services frail elders to encourage
and support aging in place.
If a uniform national definition of assisted living existed, states would ask for flexibility
to develop policies and models that meet state needs. On the other hand, the absence of a
clear definition and considerable overlap among models frustrates people looking for clarity
and a path to pursue. States might take advantage of the flexibility to determine the definition
and policy that is best suited to their own state. Setting policy, states might first determine
the goal and purpose of assisted living in their long term care system. The goals may be: to
develop a nursing home replacement model which reduces the need for beds over time and
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offers residents a choice to move into
assisted living; to contain the growth in the
supply of beds over time and diven new
admissions; or to expand the home care
system to facilitate aging in place. While
these goals may overlap, the major
emphasis differs among the options.
"The definition of assisted living should
include the nursing home level of
service," Rosalie A. Kane, D.S. W,
University of Minnesota.
II. DESCRIPTION
This section is based on the core components of assisted living as it has emerged thus far
in the public and private sectors. Traditionally, community programs, such as adult day care,
are described in terms of the services offered and the clients served. For assisted living that
description must be broadened to include the setting where service is given in order to
establish such settings as home-like environments. Alternatively, institutional programs
contain very clear descriptions of the environment which emphasize minimizing risks and
create an environment that is regimented and contrary to "home-like." In describing assisted
living, perhaps the most subtle but important parameter is its value orientation. Programs
may differ in their scope of service, the impairment level of the people served and the
characteristics of the physical environment. The principles which guide the development and
operation of assisted living uniquely shape the core elements or components inherent in the
environment and the services as well as the clients who are served. Assisted living is
characterized by its value orientation, setting and services, which are described below.
Programs by many other names may share elements of these characteristics.
Values Orientation
Difficult to describe, harder to operationalize and measure, values are always reflected in
public policy. Assisted living emphasizes clear values. These values respect client decision
making in ways which foster dignity, independence, privacy, individuality and choice.
Underlying this respect is an affirmation that vulnerable adults can participate meaningfully
in directing their care, even when physically, intellectually or psychologically impaired. This
participation occurs in a way which delineates mutually accepted limits, responsibility and
risks by the stakeholders.
Thus, assisted living puts new emphasis on the approach or philosophy used to deliver
services. Unlike traditional models of long term care (e.g. nursing facilities) which are
focused on responding to illness and disability, assisted living is directed toward functioning
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and competency based on personal
preferences. Ultimately, this values
orientation acts to influence the
conceptualization, regulation, development
and operation of assisted living.
More than the description of the building,
it is the philosophy of this new model that
separates assisted Ihing from others that
combine housing and varying levels of
oversight and care.
In the past ten years numerous attempts
have been made to describe this values
orientation." At least three states (Oregon,
Washington and Florida) have incorporated explicit values in their standards for assisted
living. The common theme in these efforts is the focus on human values especially strong in
American culture. It is also important to understand that the personalization of these values
will vary individually and culturally. Thus, the ultimate goal in policy formation and
implementation for assisted living has to be flexibility to accommodate variability in the
expression of commonly accepted values.
This is illustrated by observing how the value of independence is reflected in daily
activity. The ability to make decisions, and describe them, regarding one's own life is central
to "independence." Yet, individuals willingly defer to others in many circumstances; in some
cultures, group consensus is far more important than individual expression of self. The
central criteria for assisted living is the extent to which opportunities and suppon for
individual decision making are readily available.
Ability and willingness to personalize values should characterize assisted living. This can
only be accomplished when the balance between control over decision making and
responsibility for the results of decisions are shared. This is in contrast to traditional
approaches to long term care where historically both control and responsibility lie primarily
with the provider. Efforts to "give" more control to residents are hampered by both an
unwillingness to create expectations for residents and a reluctance to permit them to exercise
the right to assume risk. This is a crucial issue, for only when resident-defined priorities are
viewed in conjunction with professional judgements of "best interest" can the meaning of
values such as choice be readily realized. Promoting consumer choice means allowing
residents to take some risks. Risk can be managed through the care planning process in
which preferences are discussed and risks are identified. The outcome may reflect
compromise between the resident and the facility staff but the process respects the person's
preferences rather than "facility rules."
In sum, assisted living owes much of its potential as a viable option for long term care to
a shift in thinking about how resident empowerment can be achieved for vulnerable adults.
While there is little disagreement over expressed values such as dignity, individuality,
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privacy, independence or choice, consensus still
is being sought on the operationalization of
these principles for vulnerable adults.
Setting
"Our role is to assist wiih. not to do
for elders in assisted living," Michael
Rodgers, Senior Vice President,
American Association of Homes for
the Aging.
The term "setting" or "environment" is
more descriptive of assisted living than
"facility." The term "facility" has become
linked emotionally (for consumers) and operationally (for providers) with undesirable,
institutional qualities. Indeed, payors refer to "facility rates," an orientation at odds with
assisted living's focus on individualized plans of care. These qualities include over-reliance
on bureaucratic decisions which act uniformly to limit personal freedom and designs which
ignore features most frequently associated with "home." Assisted living addresses both of
these issues. As a consumer-driven option which meshes housing and services, the setting
feels more "homelike." One reason assisted living feels more "homelike" is the design of the
physical plant. Common design elements include:
20
•
Individual sleeping space, typically studio/efficiency or one bedroom units.
•
Full baths accessible without exit to common corridor.
•
Kitchen space with food preparation and storage capacity.
•
Lockable doors, individual temperature controls, personal furnishings.
•
Community space for resident use (e.g. dining rooms, laundry, living rooms,
libraries, television lounges).
•
Residential approach to construction and commercial furnishings (e.g. dormer
windows, carpet, upholstered furniture).
This normalization of the environment includes enhanced ability of the individual to
control access to personal space and continue, to the extent possible, lifestyle patterns which
help define the functional, social and emotional elements of home.
In addition, the apartment type complexes which range in size from small (20-35 units) to
large (more than 100 units) have incorporated many features to facilitate "aging in place."
These often include:
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•
Accessible design features in private and public space (e.g. wider doorways,
lever handles, special showers, wider hallways).
•
Enhanced life safety features to accommodate non- and semi-ambulatory
residents (e.g. sprinkler systems, additional fire walls, single story
construction).
•
Additional support services capacity (e.g. intercom systems, central kitchen and
laundry, medication storage and distribution, optional grab bar installation).
While the amenities vary in assisted living, general consensus exists regarding the need
for:
•
Private space, shared only by personal choice.
•
Increased client control over access to private space and lifestyle practices
which do not put others at undue risk or inconvenience.
•
Non-institutional furnishings and interior design.
•
Support space capacity to ensure delivery of a full complement of services.
The size of facilities in the private sector range from 40 to 120 units. Each building
includes common areas, service areas and living units. Common areas, which may include
dining rooms, lounges, libraries, living rooms, beauty salon, gift shop, activity rooms and
laundry areas, account for 30-40% of the building's square footage. Between 10-15% of
the area is developed as service areas (kitchen, laundry, administrative offices, housekeeping
and maintenance) while individual units range from 300 to 600 square feet.
21
22
The standards for assisted living in
some states are less prescriptive and more
flexible than governmental approaches to
either nursing facilities or board and care
programs. Yet the standards are developed
to promote higher levels of "livability."
Principles of Assisted living in Sunrise
Retirement Homes: personal services;
maximizing independence; encourage
independence; protect privacy; enable
freedom of choice; preserve dignity;
nurture the spirit. Paul J. Klaassen,
President, Assisted Living Facilities
Association of America.
Services
Great diversity currently exists in the
range of services available and the
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mechanisms used to provide the services in assisted living. In what might be called
developing models of assisted living, services can be characterized as low intensity. Services
typically include housekeeping, structured activities, one or more meals, laundry and
transportation. Some states refer to these arrangements as congregate housing. In the middle
range, services focus on the provision of personal care, such as bathing, dressing and
assistance with medication in addition to the "hotel" type services. At the high end in the
most mature model, services generally include nursing care (e.g. injections, skin care,
dressing changes, health assessment and monitoring of clinical symptoms) and specialized
programs for incontinence, significant memory impairment and less stable medical conditions
which require frequent ongoing monitoring (e.g. insulin dependent diabetics, oxygen
dependent COPD, history of TIA). Core service capacity in assisted living, at a minimum,
includes:
•
Twenty four hour response capability to meet unscheduled, unpredictable needs.
•
Service coordination capability to arrange access to services not provided
directly.
•
Service planning capability to create individualized service plans.
Skills capability to address the most common dementia related problems (e.g.
memory loss, depression, sleep disorders).
In some models a full range of services is available directly from project based staff.
Other models use third party providers for all or most personal care and nursing related
services. Such decisions are often related to existing regulatory or reimbursement policy. For
example, generally, the more restrictive existing licensure requirements are, the higher the
incentive to use third party providers contracting independently with clients. Such an
arrangement may also facilitate more frequent utilization of Medicare dollars, shifting the
cost from the client and/or the state. Generally, facilities with project based staff have greater
core service capacity.
Staffing and training
A unique feature of assisted living is the flexible configuration of services to meet needs
incrementally. Variable levels of service delivered to the client facilitate aging in place. This
variability serves to improve the availability, acceptability and affordability of assisted living.
In part the ability to individualize service packages is tied to the merger of staff functions.
Staff typically are cross-trained and respond to varying needs with significantly less focus on
departmental segmentation or task restricted job descriptions unlike nursing homes where
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regulations determine how many of what type of staff are needed to care for a specified
number of residents. Even when staffing ratios are imposed, much more flexibility exists to
organize staff more effectively to meet fluctuations in needs.
Tenant Profiles
Characteristics of the tenant population in assisted living is a function of admission and
retention policies of state regulatory agencies and provider practice. Consumers of services in
developing models tend to be younger (low 80s), more mobile (less likely to be wheelchair
or transfer dependent), have few critical ADL dependencies (less likely to need toileting or
eating assistance), and have more cognitive abilities (less likely to need protective oversight
or dementia related care) than those in mature models. Tenants of mature models are likely
to be older (high 80s), more ADL impaired, more at risk due to impaired intellectual
functioning and more compromised medically.
Generally, assisted living serves a population at some risk of institutionalization. In more
mature models (whether the service is provided directly or by contract), tenants are likely to
have needs very similar to nursing facility residents who do not receive continuous skilled
care.
Typically, residency restrictions are focused upon issues related to ambulation,
incontinence, ability to self transfer, need for regular nursing intervention, and degree of
deviation from commonly required social skills. State policies differ on each of these
variables. Even when guidelines exist, it is common for providers to stretch their own and
state policies to meet care needs of tenants on a case by case basis. State guidelines in these
areas will determine the extent to which assisted living can substitute for nursing facilities.
In developing models, the frailty of tenants may be more directly related to aging in
place. To accommodate the needs of existing tenants, services are added incrementally.
Special-purpose-built assisted living appears to attract tenants forced to relocate after a
serious health episode resulting in
hospitalization, "needs" based eviction from
"When 1 go into an assisted living
another form of multi-person housing,
facility, I always have the feeling that 1
significantly altered access to a caregiver or
insufficient "in-home" services, cost or
could live there. 1 could not live in a
coordination difficulties. This is often a
nursing home." Richard Ladd,
function of the lack of accessible design in
Commissioner, Health and Human
their previous living unit.
Resources Commission, Texas.
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While assisted living programs vary widely, a survey by the Assisted Living Facilities
Association of America indicates that the average resident is 85 years old, female who
resides in assisted living for 2.5 years. On entrance, residents have 2.5 ADL impairments.
Between 30-40% are incontinent and a similar range have cognitive impairments.
Cost
Charges to residents vary as greatly as the definitions of assisted living. They are a
function of the service package, amenities in the setting and payment source. As discussed
earlier, rates for shelter, food and services range from $900 to $3,000 per month and higher.
The shelter and food portion can range from $150 per month in low income projects utilizing
tax credits or other public subsidies to $1,000 per month in upscale projects in higher income
communities. In most cases the board and care rate established by states for public pay
clients (SSI) covers the property related costs of shelter and food. This ranges from the
federal payment of $422 a month to $857 a month in states with supplemental payments.
Total service payments for both public and private pay clients ranges from 50% to 80% of
comparable rate for care in a nursing facility.
Development costs for market rate units range from $40,000-50,000 per unit in Oregon
to as high as $100,000-125,000 per unit in Massachusetts. A typical cost breakdown among
development components is land (15%), construction (60%), soft costs (15%) and
financing/interest (10%)."
At least some of the cost difference between nursing facilities and assisted living is due to
regulation. Almost every aspect of nursing facility construction standards and operations are
regulated by state and federal agencies which prescribe in detail how to staff and manage the
facility. These regulations exist because of poor living conditions and inadequate care
provided by some operators. Agencies have tried to ensure quality by adopting a punitive
model of regulation, which has met with only partial success.
In many areas of the country, the lack of long term care options has created a monopoly
for nursing homes. Services provided through a regulated monopoly and its financing
structures often do not support the value base described earlier. The lack of competition has
limited the impact consumers can have
when there are real choices and it has left
"/ regulate nursing homes in Washington.
government regulators with full
I wish I could tell you that regulation
responsibility for ensuring quality.
assures quality. It does not," Charles
Introducing competitive forces may increase
Reed.
quality by offering other options to people
in a way that government regulations alone
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are unable to accomplish. By and large, regulatory approaches have improved safety for
residents and produced double digit inflation without changing the "institutional" environment
or significantly improving less tangible quality of life indicators.
Other housing models, such as congregate care, generally have been able keep cost
increases consistent with the general inflation rate for other goods and services. This is
assumed to be related, at least in part, to greater managerial flexibility to control costs and
increased competition for consumers. Assisted living may offer a model in which these
factors can be taken into account. A different regulatory process, in conjunction with a
consumer oriented approach to service, may result in higher quality long term care and lower
costs.
/ / / . QUALITY ASSURANCE
Assisted living offers an opportunity to alter the approach used to assure quality care in
long term care settings. Historically, nursing facilities have been regulated and surveyed to
ensure appropriate utilization, adequate capacity based upon fixed standards and outcomes as
measured by predetermined results. This posture has generated a defensive operational mode
in which the prevailing response is to follow the letter of the regulations. Regulations
intended to represent minimum standards often become a ceiling for achievement.
Preventing deficiencies often becomes
the primary focus of staff when they count
"Problems are not always the fault of
the number of caregivers on duty, record
regulators; there is very little competition,
information in the resident's chart, or make
market forces and choice at work here,"
decisions related to the provision of care.
Paul J. Klaassen, President, Assisted
The survey process assumes that fear and
Living Facilities Association of America.
negative reinforcement will motivate
operators to a consistently better
performance. Unfortunately, while this approach usually has a temporary positive effect on
providers, it has also led to impersonal, sterile environments, in which fear of negative
outcomes acts to restrict resident autonomy and to increase cost.
State efforts to measure quality in assisted living have been focused on capacity and
outcomes. In addition, significant attention has been paid to adherence to the values that
underpin a client centered approach to service delivery. Virtually no attention has been paid
to utilization (services needed and the setting in which needs are best addressed), except in
states with very strict admission and retention standards. Ironically, when such utilization
criteria are enforced in assisted living, it is typically to move tenants who utilize higher
amounts of service into nursing facilities.
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Adherence to Model Principles
The Setting
Perhaps the most easily evaluated principle of assisted living is the setting. This is the
most conventional of the quality assurance measures. Typically, evaluation is focused upon
structural features, which include the following:
•
Assurance that personal space meets established criteria (e.g. unit size, lifestyle
preferences honored, occupancy, privacy, accessibility).
•
Assurance that unit features support normalization of environment (e.g. cooking
capacity, locking doors, personal furnishings).
•
Assurance that community space is appropriate (e.g. accessible, residential
furnishings, adequately designated support services space).
•
Assurance that tenants are not exposed to undue risk (evidence of working life
safety system, adequate sanitation to prevent illness, general precautions to
prevent injury).
Absence or presence of these criteria generally are easily confirmed visually. Risk factors
such as those above often are evaluated by other regulatory agencies such as local fire
departments, building inspectors, sanitation inspectors and workers' compensation safety
analysts. Accepting these reports avoids duplication of regulatory efforts.
Criteria related to the principles of consumer empowerment and a client-based approach
to service delivery are significantly less developed. These are the most commonly used:
•
Assurance that plans reflect individualization of services to reflect
needs/preferences/priorities of tenant.
•
Assurance that tenant decision making is supported in day to day practice.
•
Assurance that values (e.g. dignity, independence, choice, privacy) are
understood by staff and upheld in day to day interactions with tenant.
•
Resident and/or family satisfaction surveys.
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The consumer empowerment criteria are measured through confirmation of policy
practices, record review, observation of tenant-staff interaction and tenant (or proxy)
perceptions.
Program Capacity
Part of the interest in assisted living stems from its program capacity. While measures of
capacity in nursing facilities have focused upon numbers and types of staff, assisted living
has targeted other criteria, including:
•
Assurance that the defined range/intensity/scope of services is available and that
practice illustrates staff ability to implement it when needed.
•
Assurance that service linking and monitoring mechanisms (e.g. case
management, managed care, service coordination,) are present and working as
evidenced by:
D
an assessment of the tenant which identifies service needs, preferences,
priorities;
D
a service contract with the tenant which articulates his/her needs, a plan for
meeting the needs and the shared responsibility for meeting those needs;
n
a method for amending the service contract in response to the tenant's
changing needs, preferences and priorities;
D
a process to formally manage risk (and uphold tenant autonomy) when
tenant decision making may result in poor outcomes for him/her or other
tenants.
Assurance that policy and procedures are adequately developed to provide
guidance to staff in the day to
day operations of the program.
"Safety is the most important value for
Assurance that staff respond
regulators. It's the quality of life that
appropriately to a variety of
should count most, not safety. In pursuing
situations (personal interaction
quality of life, I'm willing to take a lot of
with tenants, emergencies,
risk," Richard Ladd
technical knowledge base).
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The licensing process may include submission of a written plan to demonstrate program
capacity and adherence to model principles. On-site reviews to assess capacity are typically
conducted before a license is issued. Periodic "monitoring" via informal program visits plays
a more prominent role in assessing program capacity. Generally, licensure is bi-annual and
participation in ombudsman programs is common. A consultative model which emphasizes
technical assistance, backed by traditional sanctions, may be used to maintain or enhance
program capacity.
Outcomes
In the past quality assurance programs for nursing facilities were too process oriented.
Outcome measures generally focused on the prevention of risk (e.g. falls), the absence of
selected conditions (e.g. bedsores), and the success of clinical interventions (e.g.
ambulation). Ideally, regulations should address the mutual responsibilities of the provider
and the tenant. Recent legislation (the Omnibus Budget and Reconciliation Act of 87, OBRA)
addresses the provider side of the equation by focusing on resident plans of care, goals for
intervention and the extent to which residents are moving toward goals stated in their plan of
care. In assisted living the focus on outcomes is also broadly focused and consumer oriented,
including tenant preferences and the tenant's role and responsibilities for achieving agreed
upon outcomes. For examples, measures typically would include:
•
Assurance of tenant and/or family satisfaction with services delivered and
results achieved.
•
Assurance of working systems which result in mutually agreed upon plans of
service, process of implementation and outcomes.
•
Assurance of appropriate ancillary service use as evidenced by:
D
amount/cost/timing of medical/non-medical service use (e.g. emergency
room use, supplemental provider charges, specialized care agreements);
°
move-out experience due to limited provider capacity to address tenant
service needs or inadequate knowledge of the appropriate responses to
meeting tenant needs;
•
process of initiating, accessing ancillary health services.
Throughout the range of quality measures, the intent is to examine assisted living's
ability to make tenants or their families feel, whatever the outcome, that the process used
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was appropriate and the result is the best that could be achieved under the circumstances.
While consumer satisfaction may not fully substitute for professional standards, clearly it is
given considerable prominence in assisted living as an important indicator of quality.
IV STATE MODELS
OREGON
Background
Oregon initiated its assisted living program in 1986 with a demonstration project in a
licensed residential care facility. After successful implementation of the pilot, the state
decided to develop a nursing facility replacement model that would not only promote
consumer driven long term care, but would also address the increasing fiscal crisis that was
developing in long term care. The assisted living program is expressly designed to serve
elderly persons who meet the criteria for placement in a nursing facility. Several assisted
living projects are designing programs to target younger persons with a disability.
The Oregon Senior and Disabled Services Division (SDSD) has stimulated the
construction of nearly 1000 assisted living units in 21 licensed facilities ranging in size from
15 to 105 units. All projects have been funded privately or through the Oregon Housing
Finance Agency. Four projects have been submitted for HUD funding and six more are in
advanced developmental stages. Projects have opened at the rate of one per month. One
nursing facility has converted to assisted living. The owner remodeled the building and
reduced capacity from 130 nursing facility beds to 76 assisted living units. The state's
residential care facilities operate about 4,000 beds of which 1,000 are subsidized by state
programs.
Although assisted living is still an affordable option for the middle class, it is also a
service offered to Medicaid eligible persons by both the state's 1915(c) and 1915(d) home
and community based care waivers. The 1915(c), or 2176, waiver, allows the state to
provide support services and services that are not part of the state plan to nursing home
eligible Medicaid recipients. The number of people served is capped in relation to the
number of available or vacant nursing home beds, or the capacity of the nursing home
system to serve people in the absence of the waiver. The 1915(d) waiver is limited to persons
65 and older and caps the amount of funds spent on long term care for institutional and
community services. In exchange for a fixed level of federal reimbursement, the state has the
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flexibility to cover services similar to the 1915(c) waiver. The primary difference is the basis
for determining spending and federal reimbursement. Oregon is the only state that has
applied for and received a 1915(d) waiver. Other states have thus far been reluctant to accept
a cap on federal reimbursements, adjusted annually for population growth and inflation,
despite the increased flexibility that accompanies such a waiver.
Principles
The assisted living model is built on six key principles: individuality, independence,
privacy, dignity, choice and a home-like environment. Facilities maintain written policies,
approved by the state agency, that incorporate these principles. The policies recognize
resident rights, responsibilities and preferences, describe the form of addressing the resident,
and assure that residents may select or refuse service. In practice, service delivery is similar
to client-directed or client-employed arrangements.
Access
All clients applying for Medicaid long term care services are assessed by the local Area
Agencies on Aging (AAA) who contract with the state to administer Medicaid's long term
care programs. Applicants are assessed by a case manager or a pre-admission screening team
using a uniform assessment document that records information on demographics, functional
impairments, a medical assessment, income and resources. Clients are provided information
about available resources, including nursing facilities, community care and assisted living.
Clients interested in assisted living are assessed by the facility to determine their
appropriateness for placement.
Residents supported by Medicaid must qualify for placement in a nursing facility;
however, assisted living facilities cannot serve residents who require 24 hour skilled nursing
care or monitoring. Residents who are permanently bed bound and unable to ask for
assistance, or who are medically unstable, require IV treatments, heart monitors and feeding
tubes, for example, are not served in this setting. Medically stable means that a resident's
clinical and behavioral status is known, does not change rapidly and does not require
continuous licensed nursing observation and evaluation.
When a resident moves in, the service coordinator, AAA case manager, resident and
family develop a service plan that describes the services to be provided and the manner in
which they will be provided. Oregon requires that assisted living staff manage the services
for the residents. The facility must develop a service plan with each resident that clarifies the
shared responsibility for meeting the service needs. The plan must reflect the choices and
preferences of the resident and maximize each resident's capability and independence.
_
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The facility must provide agreed upon services, monitor outcomes and change service
plans as needed. The AAA case manager continues to authorize Medicaid payment and to
monitor the plan. Each service plan contains written outcome measures that address
functional abilities, psycho-social well-being, stability of medical conditions and client/family
satisfaction, which are monitored by the AAA case manager.
The assisted living environment allows individuals to live in their own apartments and
receive the services they would otherwise receive in a nursing facility. Services are provided
in a social model that complements each resident's capabilities and strengths in day-to-day
activities. The model is developed to support independence, respect for dignity and privacy
and freedom from restraints. Staff are available 24 hours a day to provide services based on
the resident's needs. The average resident is female, age 87 with dependencies in 3.4 ADLs.
Forty percent are incontinent and over half have cognitive impairments.
24
Assessment. Costs and Service Rates
Charges for private pay residents are based on market rates. Charges to Medicaid
residents include a monthly shelter (room and board) rate and a service rate. The total rate is
based on the impairment of the resident and ranges from $517 to $1,483 per month. The
shelter portion of the rate is constant across the range and the variable portion is the service
component. Rates increased 4% between 1991 and 1992. The five levels for service
payments are based on impairments in less critical ADLs (dressing/grooming,
bathing/personal hygiene, mobility) and critical ADLs (bowel and bladder control,
eating/nutrition, and behavior/cognition). During the assessment process, distinctions are
made between total dependency in an ADL and the need for partial assistance to complete an
ADL. Separate weighting is given for the presence of impairment in the behavior (cognition)
ADL. The shelter portion of the rate is a constant across all five categories. (See Table 8.)
Most assisted living residents are reimbursed at level 3 or 4 rates. Only rarely are
residents admitted at level 5 rates. Residents with this level of impairment usually are those
who have declined since admission.
The Supplemental Security Income (SSI) standard is $423.70 a month. However, Oregon
has elected the Medicaid Special Income Level eligibility option (see page 82) and residents
with income below 300% ($1,266) of the federal SSI payment standard ($422 a month) are
eligible for Medicaid. The maintenance level, the amount of income a recipient under this
option can retain to pay for room and board, is $423.70 a month. Any income above
$423.70 and below $1,266 a month is applied to the cost of services.
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Table 8. Oregon Impairment Threshold and Medicaid Rate Matrix
Primary Eligibility
Level 5
Level 4
Level 3
Level 2
Level 1
Dependent in 3-6 ADLs
Dependent in 1-2 ADLs
Assistance in 4-6 ADLs
Assistance in 3 critical ADLs
Assistance in 2 critical ADLs or
assistance with 3 ADLs
Alternate Eligibility
Rate
Dependent in 1-2 ADLs & Dependent in
behavior ADL
$1483
Assistance in 4-6 ADLs & Dependent in
behavior ADL
$1200
Assistance in 3 critical ADLs and
assistance in behavior ADL
$ 915
Assistance in 2 critical ADLs and
assistance in behavior ADL
$ 688
Assistance in 1 critical ADL & 1 less
critical ADL
$ 517
Note: Dependent means a person cannot do an activity without substantial hands-on help.
Assume that both Client A and B are assessed as Level 3, which warrants a service rate
of $915 a month. Client A has no income other than SSI. S/he may retain $63 a month for
personal needs. The remaining $360.70 is paid to the facility to cover room and board costs.
The Medicaid program pays the full service rate of $915, but pays no room and board.
Client B has income of $1,123 a month which is below 300% of the federal SSI payment
and client B is therefore eligible for Medicaid. However, since the maintenance level has
been set at the state's SSI payment standard of $423.70 a month, all "excess income" must
be applied to the costs of services. Thus, client B retains $63 a month for personal needs,
pays $360.70 to the facility for room and board costs and applies the remaining $699.30
toward the service cost. The state pays the balance of $215.70 (See Table 9.)
In Oregon, the average development costs are $40,000 to $55,000 per unit. Staffing
accounts for about half of the facility's costs; food and supplies, 10-15%; and debt service
and related physical plant costs, 35-40%.
Occupancy and Service Package
Assisted living programs in Oregon operate at 100% occupancy with waiting lists. This
compares to an 85% occupancy rate for nursing facilities. The average level of impairment
for both private and public residents is only slightly lower than the average impairment of
nursing facility residents.
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Table 9. Oregon Income and Cost Examples
Client A
Client B
Facility Charge - Level 3
$ 1,275.70
$ 1,275.70
Client Income
$
423.70
$ 1,123.00
Less R&B Allowance
$
360.70
$
360.70
Less Personal Needs
$
63.00
$
63.00
Income applied to $915 service rate
$
0.00
$
699.30
Net Cost to Medicaid
$
915.00
$
215.70
The typical service package includes: meals in a common dining room, opportunities for
individual and group social interaction, housekeeping, laundry, transportation, support for a
broad range of activities of daily living including bathing, dressing, eating, bowel and
bladder management, personal hygiene and special approaches for behavior management.
Other services include medication management, nursing services such as injections, catheter
care, wound care, health status monitoring and assessment, and planning and reviewing the
direct and ancillary services for supporting resident independence. Assisted living programs
must have the capacity to respond 24 hours a day to unscheduled and unpredictable needs.
Standards
Licensing for nursing, residential care and assisted living facilities is the responsibility of
SDSD. Standards include requirements for services and service delivery, standards for the
physical plant including both the living units and the common space, and a demonstration of
an understanding of the program's philosophy. The manager of an assisted living facility, to
qualify, must participate in a training program approved by the state licensing agency.
Unlike most state residential care or board and care standards, Oregon's assisted living
model requires that each resident have a locking private apartment that includes a
handicapped accessible bath and at least a galley kitchen and a voice-to-voice emergency
communication system. Units generally have a kitchen area, dining area, living and sleeping
area. Newly constructed units must have a minimum of 220 square feet of barrier-free living
space (not including the bathroom). Rehabilitated units must provide a minimum of 160
square feet. All buildings must meet zoning, building and fire safety codes. Facilities must
have a rental/service agreement with residents that covers the terms of occupancy, charges,
fees, services to be provided and the conditions under which fees may be increased.
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Staffing
Defined staffing ratios are not required by the standards. Instead, facilities are required to
maintain staffing patterns and ratios that are sufficient based on the resident mix, special
needs and the services identified in the resident service plans. Staff in assisted living facilities
are expected to provide comprehensive services to residents to enhance quality of life. Staff
may provide personal care, administration of medications, assistance with housekeeping,
laundry, assistance in the dining room, as well as structured socialization and behavioral
interventions. This "cross-training" of staff differs from the role of the nursing assistant in a
nursing facility, who usually performs only one set of tasks.
In addition to cross-training, Oregon's Nurse Delegation Act permits registered nurses to
delegate certain tasks formerly restricted to licensed personnel. The Act requires nurses to
assess the client, teach the non-licensed person how to perform the task and monitor the
outcome. The delegation must be made for each task, each client and each non-licensed
person.
Implementing the model required collaboration between providers of long term care,
representatives of the assisted living industry and consumers, who were interested in
promoting the new model. The state agencies played a leadership role by promoting the
concept, defining the parameters for regulation and providing incentives for developers to
participate in the process. The program was launched with the understanding and expectation
that assisted living contributed to the goal of establishing an affordable, accessible and livable
option for both the public and private pay persons in need of long term care.
Housing Finance Agency Role
The SDSD, which provided the leadership, had several advantages as it embarked on the
project. The Division regulates all of the long term care residential programs: nursing
facilities, adult foster care homes and residential care facilities. The Division also administers
the state's Medicaid nursing home program, the Medicaid waiver programs, the Older
Americans Act program, and the state general revenue program - Oregon Project
Independence. The Division also has a strong working relationship with the state housing
finance agency which issues elderly housing bonds and influences other financing for elderly
housing.
At the outset, SDSD, the Office of Health Policy and the Housing Finance Agency
(HFA) met to review the policy to ensure that each agency understood and agreed with the
goals and substance of the program. The HFA made assisted living a priority for its tax
exempt and taxable bond issues. The agency also agreed to use the physical plant and
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program standards set by the Office of Health Policy and SDSD as review criteria. This
inter-agency coordination explains some of the major differences between Oregon and other
state programs.
WASHINGTON
Background
Assisted living is the latest component in Washington's plan to reduce reliance on nursing
home beds by expanding community programs. In 1989, the state expanded its personal care
program in boarding homes and individual homes. The Medicaid waiver program was
expanded. Assisted living and other options are expected to reduce the supply of nursing
facility beds to 45 beds per 1,000 people 65 and older. The ratio in August, 1992 is 52
beds/1,000, down from 53/1,000 in January, 1992.
Washington's assisted living program will fund 180 units by the end of 1992 in existing
licensed boarding homes which meet program standards to provide assisted living services.
The project is designed to "promote the availability of services for elderly and disabled
persons in a homelike environment enhancing the dignity, independence, individuality,
privacy, choice and decision making ability of the resident." The program stresses an
environment that provides individual apartments where people can receive services that
support and maximize independence.
The program was based on the results of a 45 unit pilot project in Seattle that began in
October 1990. An evaluation compared the pilot project to nursing homes and housing
facilities that marketed themselves as assisted living and found that residents had an average
of 4.5 ADL impairments. Thirty-eight percent of the residents were relocated from nursing
facilities and the remaining residents had lived independently but needed medication
management or some other regular nursing intervention, did not have a caregiver,
experienced frequent, unscheduled care needs or required protective oversight. More than
35% were periodically incontinent. The highest impairment rates were for bathing (94.4%),
dressing (67.9%) and personal hygiene (69.6%).
25
Residents received an average of 2.3 health services a day. The most common
interventions were assistance with insulin injections, assistance with other medications and
assessment of health conditions.
While all publicly supported residents were eligible for nursing facility placement,
assisted living residents tended to be younger and less likely to have been admitted from a
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hospital than from a nursing facility. More nursing facility residents tended to be totally
dependent in critical ADLs (transferring, eating and continence) than assisted living
residents. On average, nursing facility residents had one more ADL impairment than assisted
living residents. Much of the difference was attributed to a higher incidence of residents who
were bed bound and had cognitive impairments.
The evaluation gave the project high marks for respecting dignity, providing privacy and
choice. Staff knew the residents well. Since the facility was originally built for different
purposes, some of the design and furnishing elements of assisted living were lacking
(window treatments, auxiliary lighting) although the units were home-like and appropriate.
Resident satisfaction was high.
Seventy-one percent of the residents were publicly subsidized. The rate for publicly
subsidized residents for the study period was $40 a day compared to $54.51 paid by private
residents. Resident payments averaged $13.72 a day and the state costs were $26.28 a day.
The pilot project was compared to 21 assisted living facilities in Washington with a total
of 1,478 units. Most facilities offered studio units and about 35% had kitchenettes and
another 40% offered limited cooking capacity. Most residents were relatively independent on
entry. More than 1,000 units were licensed as boarding homes and 16% of the units were
occupied by clients of the state's community care program. Rates for the programs varied
and many offered a la carte service options. Those with flat fees ranged from $806 to $2,035
per month for IADL assistance and $1,500 to $3,270 for minimal ADL assistance (1991
figures).
Newer facilities tended to offer less services as part of their program, due in pan to
boarding home regulations. Outside service providers frequently provide additional services
to residents. Older facilities offer more services but provide double and triple occupancy
rooms with few amenities. The pilot site offered private apartments with baths and
kitchenettes.
Based on the findings from the evaluation, the state decided to fund an additional 135
units. Contracts for 102 new assisted living units began in July 1992. The balance, 32 units,
will be available by September, 1992. The number of units occupied by Medicaid recipients
in any given facility is limited to 12 to ensure a public private resident mix and to spread
limited resources to as many parts of the state as possible.
The origin of the program in Washington differs from other states. While the legislature
approved funding for a specified number of units, the program policies and guidelines are
contained in a contract modification for board and care homes.
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Units
On a moratorium: "There will be no new
The primary changes from the state's
nursing home beds in Washington until
board and care standards are the
2005. That's important. You've got to do
requirements that facilities provide complete
thai first to get a handle on institutional
apartments that include a minimum of 220
costs," Charles Reed, Assistant Secretary,
square feet of living, and kitchen space (not
Aging and Adult Services, Washington.
including bathroom). Units are private
except when couples or persons choose to
share a unit. Regular board and care homes must provide 80 square feet of useable space in a
single room unit and 70 square feet per person in a double room. Kitchens must be furnished
with a refrigerator, two burner stove top or 1.5 cubic foot microwave oven and a sink. If
kitchens are not provided, the facility must provide space for residents to prepare food. Each
room must be equipped with an emergency response system. Common areas must be smoke
free and handicapped accessible. Most boarding homes do not meet these standards. The state
agency views the current contracting standards as a test to gain experience for a broader
program. Existing boarding homes have indicated an interest in upgrading the facilities to
meet assisted living standards when broader implementation occurs.
Program Guidelines
The program policies balance safety, independence, choice and risk through a service
plan that defines responsibility and distinguishes between "managed risk" in which a resident
is capable of weighingrisksand choosing services, "shared responsibility" in which the staff
present the consequences of a resident's choices but the resident is responsible for making the
choices and "bounded choice" in which the resident choices are structured. Facilities must
have written procedures to document staff efforts to involve residents in their care.
The general service package includes meal (three per day) service, laundry, and
housekeeping, as well as personal care (except positioning), behavior management,
incontinence care and the following nursing services: assessment, monitoring, medication
administration, stage one skin care, and temporary bed care.
Facilities may provide an enhanced level of care as needed by the resident and described
in the "negotiated service agreement" (see appendix). These allowable health related services
include range of motion exercises, wound care, ostomy care, occupational therapy,
psychiatric consultation, podiatrist services, nutritional supplies and medical equipment and
supplies. The enhanced services are not included in the daily rate and must be billed to other
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payers, e.g. Medicare. Nursing services must be provided by a licensed nurse employed,
rather than contracted, by the facility.
Facilities must also have agreements with dieticians and pharmacists for consulting
services. The contract modifications also require that facilities establish a resident council "to
provide input on all aspects of the facility or care provided to residents."
The continuing discussion of this model among agencies and providers highlights the
tensions and conflicts between assisted living, nursing facilities and a consumer focused
model. The initial guidelines allowed assisted living facilities to be responsible for ensuring
the provision of additional skilled nursing services (catheter care, stage 2-3 skin care and
changing sterile dressings.
Health department staff concluded that such care was beyond the scope of a boarding
home license. However, residents may still receive such services in assisted living and
facility staff may help residents arrange such services with certified home health agencies.
The facility is not now responsible for such care. The distinction reflects concerns among
regulators and providers over the model. As the pilot program progresses, separate licensure
requirements may be developed for assisted living to resolve this issue.
The program was developed to divert or relocate up to 180 current nursing home
residents. Residents must be sufficiently impaired to need the level of services available in
the assisted living program and they must be eligible to receive services under the state's
community options programs.
Rate
The rate (1992) for Medicaid recipients is $45.90 per day, which includes the room and
board portion paid by the resident from their income (SSI, Social Security). The state SSI
payment standard is $450 a month. The resident retains $38.84 as a personal needs allowance
and pays the remaining $411.16 to the facility to cover room and board. The facility receives
a service payment from Medicaid of $965.70 a month. On average, residents are paying
$15.61 a day, compared to $13.72 during 1990. The state's costs average $30.30 a day.
Washington also uses the Medicaid Special Income Level (300% of the federal SSI
standard) for its waiver program (COPES). This allows people who qualify for placement in
a nursing facility whose income exceeds the normal Medicaid levels to participate in the
program. Income above the personal needs allowance is applied to room and board and
service costs.
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Staffing
Similar to Oregon, staffing standards are flexible and require the capacity to meet the
needs of residents as contained in the service plans. Registered nurses must be available onsite eight hours a day and accessible 24 hours a day.
Housing Finance Commission Role
The Washington Housing Financing Commission offers bond financing for profit and
non-profit borrowers to develop nursing homes, Continuing Care Retirement Communities,
Assisted Living and independent housing. The Commission completed several bond offerings
over the last 2 1/2 years. While no free standing assisted living projects have emerged,
several projects have included assisted living as part of a larger proposal. All projects funded
thus far have been done by non-profit organizations. The Commission's tax exempt bonds
require a low income set aside of 20% of the units for people below 50% of the area median
income or 40% of the units for those below 60% of the median income.
NEW YORK
Background
Based on legislation passed in 1991, the New York Departments of Social Service and
Health are implementing an assisted living model that combines adult care facilities and home
care services for individuals who are medically eligible for placement in a nursing facility.
One goal of the program is "to develop a less restrictive and lower cost residential setting
that can serve people who do not need the highly structured, highly medical environment of a
nursing facility." Revisions to the state's long term care need methodology showed a need
for 4,200 assisted living units across the state.
Adult care facilities (ACFs) provide residential care and services to adults who do not
require continual medical or nursing care but are unable, or substantially unable, to live
independently. ACF options include adult homes, enriched housing, family type homes (four
or fewer residents), shelters and residences for adults. The assisted living program is open to
ACFs who operate as adult homes and enriched housing programs. These programs provide
long term residential care, room, board, housekeeping, personal care and supervision to five
or more unrelated adults.
The program builds upon the existing adult care facilities and enriched housing programs
to meet changing resident needs. The state has licensed 455 Adult Homes with a capacity of
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30,995 units. There are 119 non-profit facilities with 6,986 units, 329 proprietary facilities
with 23,604 units and seven facilities operated by local governments with 407 units.
In May 1992, the supply of nursing home beds totalled 119,760, including 14,291 beds
approved but not yet built, for a ratio of 50.7 beds per thousand. The goal to approve 4,200
assisted living units was based on a direct substitution of assisted living units for nursing
home beds in the bed need formula. The formula projection is based on estimates of the
projected number of people in ICFs who could be served in assisted living. The planning
figure assumes that people seeking admissions to a nursing facility will be diverted to assisted
living rather. Existing nursing facility residents will not be required to relocate. While a
certificate of need is not required for an assisted living facility, approval and contracts with
the state agencies are required and no more than 4,200 units will be approved on a
competitive basis.
Adult Homes
Adult Homes must provide room and board, housekeeping, personal care, supervision,
case management and activities. Personal care functions include "direction and some
assistance with" grooming, dressing, toileting, walking, eating, taking and recording weights
monthly and assistance with self-administration of medications.
Adult homes constructed after 1978 limit bedrooms to two people. Single bedrooms must
provide at least 100 square feet of space and double rooms, 165 square feet (excluding foyer,
toilet room and closet). Units are not required to include a bathroom. At a minimum
buildings must contain one toilet and wash room for every six residents and tub or shower
facilities for every 10 residents. The regulations contain minimum standards and most
facilities exceed these minimums. Facilities which have expressed an interest in applying for
an assisted living approval have either single or double units with an attached bath.
Residents may not be served who are chronically chairfast or bedfast, need continual
medical or nursing care provided by a nursing facility, chronically need physical assistance
with walking or stairs, have unmanaged incontinence and other chronic personal care needs
that cannot be met by facility staff or community agencies.
Residents must have a complete examination from a physician and an interview with the
facility staff to determine that the resident's physical, personal care and dietary (including
religious and cultural preferences) needs can be met.
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Staffing varies with the number of units.
Personal services staffing is based on a
"We are working with what we have:
minimum of 3.75 hours per resident per
30,000 adult home beds and a very
week, one hour for housekeeping and two
extensive community care system," Barry
hours for food service. Supervisory staffing
Berberick, Director of Long Term Care,
is based on one staff for the first 40 units,
Department of Social Services, New York.
two up to 80 units and three up to 150
units. Facilities are required to meet the
needs of residents and to operate with staffing that is adequate to do so. If the aggregate
service needs of residents exceed the capacity of minimum staffing levels, the facility must
increase its staffing capacity.
Enriched Housing
Enriched housing programs operate in existing conventional elderly housing buildings.
They were developed to address aging-in-place in elderly housing projects. No more than
25 % of the total units in a building with individual or shared units can be designated as
enriched housing. Buildings in which all space, other than bedrooms, is shared are limited to
seven residents at any single site. Units in larger buildings must contain living, dining and
sleeping areas and full baths, including a toilet, lavatory and a shower or tub. The minimum
size for single bedrooms is at least 85 square feet excluding foyer, bath and closets.
Enriched housing residents must also have a health examination from a physician, an
interview by the program sponsor's coordinator and a functional assessment by a case
manager, nurse or program coordinator. A physician must sign a statement that the resident's
needs can be met in an enriched housing environment. Enriched housing programs exclude
the same residents with conditions describe for adult homes.
Enriched housing programs provide (or arrange for) supervision, personal care, case
management, activities, housekeeping and food service. Personal care includes "some
assistance with personal hygiene, including dressing, bathing and grooming; and assisting
with the self-administration of medications." If authorized by a physician, the provider can
assist by prompting the resident, identifying the medication to be taken, bringing the
medication and necessary supplies, opening the container, positioning the resident, disposing
of used supplies and storing the medication.
Enriched housing programs must offer a minimum of one meal a day in a congregate
setting and provide sufficient food for all meals prepared in the resident's unit. Operators
must employ a full time coordinator per 32 residents. The coordinator may also provide case
management services. Minimum staffing standards require six hours of housekeeping,
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personal care and food service per resident per week. However, these minimum levels must
be increased as the service needs of the residents increase.
The regulations allow the state to make development grants to new facilities in order to
reduce their initial operating deficit caused by low occupancy rates during the initial rent up
phase.
Assisted Living
The assisted living program organizes a more extensive in-home service package to
support residents who are aging-in-place by adding additional health services. Assisted living
providers must be licensed as ACF adult home providers or enriched housing programs.
They must also hold a license as a home care services agency, a certified home health agency
or a long term home health care program. Licensed home care services agencies provide
persona] care but not skilled nursing. Adult care facilities and enriched housing programs can
expand their programs by obtaining a license to provide personal care as a home care
services agency and contracting with a certified home health agency to provide nursing
services and therapies.
now
key
and
The
The program will be jointly administered by two Departments. The Department of Health
licenses home care agencies. Two divisions of the Department of Social Service have
roles. The Division of Medical Assistance reviews and monitors personal care contracts
the Division of Adult Services regulates the adult home and enriched housing programs.
Depanment of Social Service issues the license.
Eligibility
Assisted living residents must have stable medical conditions. The program will not serve
people who need continual nursing or medical care; anyone who is chronically bedfast or
chairfast and requires lifting equipment or assistance from two persons to transfer; or anyone
who is cognitively, physically or mentally impaired to a point where safety is compromised.
Residents may be served if they can transfer independently or with assistance from one
person.
The assessment and eligibility process begins with physicians who must make a finding
that the person requires nursing facility services. Recipients are free to explore assisted living
options. An assessment is done for Medicaid recipients by the assisted living facility's staff
to determine program eligibility and the appropriate Resource Utilization Group (RUG)
category which determines the nursing facility's reimbursement rate. Assessments are
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reviewed by the local Department of Social Services office. Once eligible, the assisted living
provider develops a plan of care based on the physician's orders and the assessment.
Rates
SSI payments will cover room and board costs as well as the services that are required in
Adult Care Facilities. The monthly SSI payment levels for this living arrangement are $857 a
month in New York City, Nassau, Suffolk and Westchester Counties and $827 a month in
the rest of the state. The state agencies do not set the amount that providers can charge
residents for room and board. Rates are negotiated between the provider and the resident,
however, and the resident is permitted to retain at least $94 a month as a personal needs
allowance.
Services will be covered through a daily prospective payment per resident (capitation
payment) for nursing, personal care, home health aide, therapies, medical supplies and
equipment (which do not require prior approval), personal emergency response and adult day
health care. The service package bundles Medicaid community services covered by the state
plan. The primary distinction between personal care services that must be covered by the
resident's SSI payment and the Medicaid capitation payment is the intensity and duration of
care. State plan activities cover total assistance with an activity for someone with a chronic
impairment. Personal care under the ACF licensure provides partial assistance with an
activity for a resident whose impairment is not expected to continue indefinitely. The
capitation rate will be 50% the amount that would have been spent in a nursing facility based
on the resident's classification under the RUG prospective payment methodology. There are
16 RUG categories and the payment rate for each category may vary across the state's 16
regions. Program information indicates that the expected rate will range from $30 to $47 a
day depending upon the geographic area of the state.
Status
Prior to the final design and implementation of the program, the Depanment of Social
Services issued a notice to potential sponsors/applicants which outlined the program and
invited "letters of interest" in order to accelerate implementation. More than 200 letters were
received from existing licensed adult care facilities, hospitals, nursing homes and other
organizations who were interested in developing programs. The regulations to implement the
program have been published for public comment. The regulations will be finalized in the
fall. Application forms have been issued and the deadline for proposals is October, 1992.
Because one goal is to expand the supply of services, a criteria in selecting sponsors will be
whether the proposal adds capacity to the system. The program will save a projected $61.8
million annually based on a supply of 4,200 assisted living units.
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Housing Finance Agency Resources
While the program will likely be implemented initially in existing Adult Care Facilities,
the New York Housing Finance Agency (HFA) will become a resource for developers and
agencies seeking funds to build new facilities. The HFA is using a tax exempt bond to
finance a project that will rehabilitate a school building into an enriched housing facility and
construct congregate housing apartments in a new, separate building. Both buildings are
designed for elders who are still independent but who may need varying levels of assistance.
The philosophy of the sponsor is to maximize the independence of residents by providing the
supportive assistance necessary to enable the resident to accomplish daily activities.
Based on a market analysis, sponsors concluded the largest unmet need was among
moderate income elders. Twenty percent of the units are reserved for elders with incomes
below the area median income.
The 50 apartment congregate building will include full apartments (620 to 920 square
feet) with kitchens and baths, one meal a day in a common dining room, emergency call
system, security, transportation, activities and a washer and dryer on each floor. Monthly
charges will range from $1,375 to $1,600 per month per unit and include all utilities and
basic cable. Units with a second person will be charged an added fee of $350. Extra services
such as meals are available on a fee-for-service basis. Congregate housing does not require
licensing by the state.
The "enriched housing" units, which must be licensed, will provide 260 square feet for a
sleeping and sitting area with bathroom, including a step-in shower. Units will also include a
refrigerator and a cook top stove or microwave oven. The units are designed so that two
units may be connected to accommodate couples. Monthly charges of $1,485 include rent and
services similar to the congregate facility, as well as all meals and unlimited access to
services of a "resident aide" who provides personal care. A case manager is available to
conduct assessments and monitor care. Residents from both buildings have access to a
convenience store, a beauty parlor and other common spaces but each building has its own
lobby, lounges and dining room.
Financing was obtained from several sources. The construction loan, at prime plus .5%,
was obtained from a local bank. An 8% percent, 30 year mortgage was obtained from a tax
exempt bond issued by the (HFA) and is insured by the State of New York Mortgage Agency
(SONYMA). The project also received a $408,000 grant from the HFA's Infrastructure
Development Demonstration Program for infrastructure costs and $1.3 million from the New
York State Housing Trust Fund for soft costs associated with development, including a
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reserve fund required by SONYMA to cover potential operating losses prior to achieving full
occupancy.
The project will be ready for occupancy in the fall of 1992 and marketing for the
congregate units has been completed. Sponsors expect that over time residents of the
congregate building will move into the enriched housing units as they become more frail.
Three additional congregate buildings are planned for the site.
While this project was not developed as an assisted living facility, or with the state's new
initiative in mind, it provides an excellent example of how a developer could utilize existing
housing and service financing sources to build and operate a new, mixed income assisted
living facility. Although assisted living residents may be slightly frailer and require more
services than projected in the financial plans, the rates planned by the sponsor are
comparable to the combined shelter and service rate available for state subsidized assisted
living. This is one of several examples of facilities being financed or planned by the HFA.
The HFA's interest in financing supportive housing models complements the policies being
developed by the Department of Social Service.
FLORIDA
Background
Regulations issued by the Florida Department of Health and Rehabilitative Services to
implement the Adult Congregate Living Facilities Act were effective in August, 1992. The
Act builds on the Adult Congregate Living Program and creates a new licensure category,
extended congregate care. The law codifies the principles of assisted living and describes the
intent of the Act:
"... to promote the availability of appropriate services for elderly and disabled
persons in the least restrictive and most home-like environment, to encourage the
development of facilities which promote the dignity, individuality, privacy and
decision-making ability
The law further states that facilities "shall be operated and regulated as residential
environments with supportive services and not as medical or nursing facilities."
The Act guides the activities of state agencies responsible for implementing the program. It
says, "Regulations shall be flexible to allow facilities to adopt policies which enable residents
to age in place when resources are available to meet their needs and accommodate their
preferences."
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During the license application process,
facilities specify how their policies will
"The major issues in negotiating regulaallow aging in place and maximize
tions with nursing home representatives
independence, dignity, choice and decision
were nursing services and people with
making. The policy also describes the
cognitive impairments," Larry Polivka,
staffing pattern (but does not specify
Assistant Secretary for Aging and Adult
staffing ratios) required to achieve these
Services, Florida.
goals and the personal, supportive and
nursing services that will be provided to
residents, as well as the extent of service, the manner in which services are provided and the
type of staff who will provide them. Applications must also describe how the facility will
meet unscheduled service needs.
Facilities are allowed to provide care to people who do not need 24 hour nursing care.
Facilities can serve people who are terminally ill with additional care provided by a hospice
program if the person's physician agrees that the person's physical needs can be met.
Administrators and supervisors in the Extended Congregate Care programs (ECC) must
receive six hours of training in assisted living. Facilities must have a registered nurse,
licensed practical nurse or nurse practitioner on staff or contract and a staffing pattern that is
adequate to provide the services outlined in resident plans of care.
Florida has 68,199 licensed nursing home beds and 7,545 beds in the pipeline. The law
focuses on the existing supply of licensed Adult Congregate Living Facilities (ACLFs).
Florida has about 1,450 licensed ACLFs with a capacity to serve 62,000 residents. Sixtythree percent of the facilities serve fewer than 17 residents. About 11% of the residents are
subsidized by the state. Residents must be age 60 and over or disabled adults. ACLFs were
initially licensed to serve people who do not need 24 hour skilled nursing care or
supervision, except for terminally ill residents. ACLFs must provide an apartment, private
room or shared room, one or more meals and assistance with one or more ADLs such as
bathing, dressing, ambulation or supervision of medication. Monthly fees range from $500 to
$3,000 a month. Eighty of the facilities are part of larger Continuing Care Retirement
Communities.
Licensure Standards
The ECC or assisted living program allows ACLFs to apply for a special license to
provide supportive and nursing services in an environment which promotes dignity and
independence, limited nursing services and limited mental health services. All or a portion of
the facility's units may be licensed as Extended Congregate Care. ECC facilities must offer
—
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residents a private room or apartment, or a semi-private room (2 person) shared with a
person of their choice. All entry doors shall have a lock unless it jeopardizes the resident's
safety and this is noted in the service plan.
The minimum room size for a single unit is 80 square feet. Bathrooms may be shared by
a maximum of three other residents. However, the size of units varies widely among, licensed
facilities. Facilities which serve private markets are more likely to have bathrooms and
kitchens facilities included in the unit. Those that serve higher percentages of public residents
are more likely to have smaller units, shared by two to four residents, and shared baths.
In an effort to improve access of low income elders to better facilities, the legislature
considered increasing the SSI payment standard from $575 a month to $750 a month. Due to
the state's budget crisis, the increase was not adopted. Facilities, especially those which do
not yet serve low income residents, are likely to delay applying for an ECC license until
payment rates are increased. The Department of Health and Rehabilitative Services plans to
develop a service rate for ECC that will be based on 50% of the rate that would have
otherwise been paid to a nursing facility. The rate would be paid through the state's home
and community based waiver (Section 2176). The new payment methodology has to be
approved by the legislature in the next session before it can be implemented. Until a new
methodology is approved, services will be reimbursed on a fee-for-service basis.
Waiver eligible recipients can now be served in ACLFs, although, the waiver does not
allow facilities to be reimbursed as providers of waiver services. ACLFs have to contract
with a community agency to deliver services. The state plans to amend its waiver to allow
ECCs to be reimbursed as providers of the additional services.
Opposition and Compromise
While the law sets a solid foundation for developing the program, opposition grew from
a section of the nursing home industry which complained, according to an article in the Wall
Street Journal, that the program did not differentiate between services that could be provided
in a nursing home and those provided in assisted living. While other states (Washington,
Oregon) specify that residents could receive services similar to those provided in an
Intermediate Care Facility, opponents in Florida sought clear distinctions between the two
types of care.
After a lengthy series of negotiations, the final regulations identify the characteristics of
people who may and may not be served in ECC facilities. People may not be served who:
•
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Are dependent in four or more ADLs (bathing, dressing, eating, grooming,
toileting).
Require 24 hour nursing supervision.
Have medically unstable conditions.
•
Have complex medical needs (stage 3 or 4 pressure sore or multiple stage 2
pressure sores).
•
Have cognitive decline severe enough to prevent simple decisions such as
choosing a dessert.
•
Are a danger to themselves or others.
The regulations also list a series of services that ECC facilities may not provide: oral
suctioning, assistance with gastrostomy or tube feeding, monitoring of blood gases,
intermittent positive pressure breathing therapy, intensive rehabilitation due to stroke or
fractures, and treatment of a surgical incision unless the causal condition has stabilized.
Quadraplegics, paraplegics and residents with muscular dystrophy may be served if they can
communicate their needs and do not require assistance with complex medical needs.
Prior to the new regulations, residents who met the criteria for ICF placement but who
needed some skilled nursing services generally could not be served in an ACLF. Early
versions of the regulations allowed all residents who qualified for an ICF to be served in an
ACLF that obtained an extended congregate care license. The final regulations reached a
compromise between the two positions.
MASSACHUSETTS
Background
While other states developed their publicly subsidized assisted living models for those
who meet the criteria for placement in a nursing facility, Massachusetts has taken a different
route. The state tightened its level of care criteria in 1991. Nursing home residents must
have a combination of at least three care needs including one nursing need (at least three
times a week) and two ADL needs. In July 1992, a further tightening of the eligibility
criteria would have required a combination of four care needs including at least one nursing
need, e.g., two ADLs, two nursing; three ADLs, one nursing need. However, the policy was
_
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reversed by legislation despite a gubernatorial veto. To meet the needs of people who are no
longer eligible for admission to a nursing facility, the state has supplemented the existing
community care programs with assisted living; however, there are no maximum criteria and
people who are eligible for nursing facility admission may also be served.
In 1991, two programs were created to complement changes in the criteria for admission
to a nursing facility. As the criteria became tighter, efforts to address the service needs of
people who were no longer eligible for placement were developed. The Medicaid Division
developed a "Group Adult Foster Care Program," or assisted living model. In addition, the
legislature appropriated $8.3 million for the Executive Office of Elder Affairs to implement a
managed care program for frail elders. The agency decided to develop a program as a
companion to the Medicaid Group Foster Care program.
Group Adult Foster Care
The Medicaid program was implemented, initially, in existing conventional housing
developments in which elders were aging in place. New facilities may emerge as state and
federal sources of housing financing are used. Medicaid contracts with approved community
agencies (Home Care Corporations/Area Agencies on Aging, Certified Home Health
Agencies) or housing management companies were signed to operate the program. Eligible
residents are likely to require 24 hour supervision and require routine assistance with
activities of daily living. Client eligibility must be approved by the pre-admission screening
process and a physician must certify that the resident's health needs can be met in the group
care setting. The contracting agency conducts resident assessments and a nurse (agency staff
or contract) develops and monitors a care plan. Services can be delivered by the agency staff
or through subcontracts.
Medicaid makes two payments to the contracting agency. An administrative rate based on
actual approved costs, averaging $18 per person per day, covers overhead and staffing costs
(except personal care services) and "other services necessary for the maintenance of a helpful
environment, (including housekeeping, shopping, arranging for transportation)." A separate
rate of $13.60 per person per day is paid to cover personal care services. (See Table 9.)
Managed Care In Housing
The Executive Office of Elder Affairs' program is targeted to elders with incomes under
$15,540 for single persons who are not financially eligible for Medicaid, and its Group Adult
Foster Care program, and who need supervision and assistance with personal care. The
program operates through contracts with 27 Home Care Corporations (HCCs) which
administer the agency's home care program. The state appropriation of $8.3 million will fund
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850 slots statewide. HCCs receive $814 per client per month to cover administration, case
management and direct service costs. Eligible residents are assessed by a multi-disciplinary
case management process. Unlike the regular home care program which covers a specified
list of services, the HCCs have the flexibility to use managed care funds to provide the most
appropriate and cost effective services. Contractors must provide access to 24 hour service
and operate an emergency response system. A "responsible person" must be available
between 10 P.M. and 6 A.M. and personal care services must be available between 6 - 8
A.M. and 6 - 10 P.M.
Since the programs were developed in separate agencies, housing sites and program
contractors have to deal with separate reimbursement schemes, targeting criteria and
regulations. However, despite the differences, these programs form a bridge between the
existing community care system and assisted living. The state has extensive experience
operating community care programs and more than half the clients in the state general
revenue funded home care program live in publicly subsidized housing. The managed care
program has formalized a series of efforts to address aging-in-place to take advantage of
economies of scale which included clustering care managers and service providers and
restructuring the delivery of personal care and homemaker services. No longer are individual
clients approved for specific hours of care; rather, based on individual assessments, discrete
tasks are identified for all participating clients and a total "block" of hours is authorized
which allows flexibility and individual variations depending on client needs.
As developers submit proposals for new assisted living projects, the two programs will
help support the service costs associated with serving a more frail population.
New Regulatory Approach
Since these two programs were developed, state agencies have begun working together to
create a new regulatory approach to assisted living. Historically, the state has licensed rest
homes that "provide or arrange to provide, in addition to basic care, a supervised, supportive
and protective living environment and support services incident to old age for residents
having difficulty in caring for themselves and who do not require Level II or III (nursing
facility) care or other medically related services on a routine basis." The new approach will
maintain a register of facilities which seek to operate as assisted living programs. The
register will be maintained by the state housing agency, the Executive Office of Communities
and Development. Staff will conduct a paper review to ensure that facilities comply with the
filing requirements. Facilities will have to meet program standards set by funding agencies
(Medicaid and Elder Affairs) to participate in their programs. Certificate of Need and
Department of Public Health licensure are not required.
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Table 10. COMPARISON O F MASSACHUSETTS' HOUSING AND SERVICES INITIATTVES
ISSUE
MEDICAID
E L D E R AFFAIRS
Rate
$31.60/day ($13.60 personal care, $18
administration & other services).
$814/client/month to cover services
and administration.
Funding
No limits.
Capped at $8.3 million. Allocation for
each HCC.
Target Group
Aged (65 + ) and disabled.
Aged (60 + ) who are not Medicaid
recipients.
Eligibility
Likely to require 24 hour supervision,
routine assistance with ADLs.
Elder in need of a managed home
environment due to the supervision
and assistance with personal care tasks
required to maintain them safely in a
community setting.
Certification
Approved by screening process. Physician
signs plan of care and certifies that the
resident's health needs are met in group care
setting.
Approved by multi-disciplinary case
management process. Plan of care
done by Client Management Team.
Agency Role
Evaluation, health and care plan monitoring
done by staff RN.
Assessment and care plan done by
Client Management Team which
includes HCC case managers, RN
(preference for CHHA contract) and
housing manager/staff.
Service Delivery
Delivered by agency staff or contract.
Delivered through provider contract.
Requires a "clustering" of Case
Managers, providers and service tasks
by HCCs.
Covered Services
Personal care (assistance with medication
management and ADLs); and "other
services necessary for the maintenance of a
helpful environment which includes
housekeeping shopoine. arrancine
transportation."
"Maximum flexibility to provide the
most appropriate and cost effective
services."
Service
Requirements
24 hour supervision. Emergency response
system, daily personal care.
24 hour access to emergency response
system. Responsible person available
10 PM - 6 AM; on-site not required;
beeper ok; Personal care must be
available 6-8 AM and 6-10 PM.
Agency Staffing
Program director, RN, clerical. 1 caregiver
per 10 residents.
NA - See Agency role.
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The philosophy outlined in the draft guidelines states that assisted living entities should
adopt policies which enable residents to age-in-place. Needed services should be added,
increased or adjusted to compensate for the physical or mental status of the individual while
maximizing the person's dignity and independence.
The guidelines describe a baseline model that all assisted living entities must meet. A
responsible person must be on the premises 24 hours a day. Residents must have access to an
emergency response system. Facilities shall provide direct assistance with or reminders to
perform any activities of daily living that the entity indicates it will cover. The guidelines
allow an organization to set admission criteria by limiting the ADLs it will address; however,
at a minimum, entities must provide assistance with bathing, dressing and ambulation and
they are "strongly encouraged" to assist with feeding, transferring and toileting. Entities must
provide 24 hour response availability to an unscheduled or emergency need.
Services must be provided that ensure adequate daily nutrition and are appropriate to the
resident's needs. Household services provided include "laundry, floor cleaning, dusting, bedmaking, dish washing, vacuuming, cleaning kitchens and bathrooms and shopping."
Resident Agreements
Assisted living entities serve elderly (no age specified) and disabled adults. Written
agreements of at least one year duration must be executed with residents that address the
following issues:
•
Responsibilities of the resident.
•
Responsibilities of the entity.
•
Services included in the assisted living package.
•
Supportive services that are provided, as well as services that are not provided.
•
Frequency of services.
•
The cost of standard and optional services.
The guidelines do not specify the characteristics of residents of who may be served but
the resident leases or agreements must describe these characteristics and the responsibilities
of the parties for finding alternative living arrangements if it becomes necessary.
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Service Planning
Service plans must be developed for each resident. The resident or family member must
agree in writing with the service plan. The plan "must address the unique physical and
psychosocial needs, abilities and personal preferences of each resident" and describe the
services to be provided, the modality of delivery, a service schedule and the purpose and
benefits of the service. An assessment of personal care needs must be done by a licensed
nurse.
Dealing with Medication
The guidelines require the provision of assistance with medication administration.
"Unlicensed personnel may supervise the administration of medication. This supervision
includes: reminding residents to take medication, opening bottle caps for residents,
opening pre-packaged medication for residents, reading the medication labels, observing
residents while they take medication, checking the self-administered dosage against the
label, reassuring residents that they have obtained and are taking the dosage as
prescribed, and immediately reporting noticeable changes in the condition of a resident to
the resident's physician."
Actual administration of medications may be done by any duly licensed personnel.
Facilities must provide locked storage cabinets in multi-bedroom units. Single units must
have lockable bedroom doors.
The Ombudsman Program administered by the Executive Office of Elder Affairs will be
used to provide advocacy and consumer protection. Its role will be conflict resolution and
mediation. Consumer protection issues that cannot be resolved will be referred to appropriate
oversight agencies (local building inspectors, fire and safety authorities or to the state
consumer affairs agency).
The only physical plant guidelines require that "locations where service is delivered must
meet local fire, safety and building codes and applicable state and Americans with
Disabilities Act requirements."
This policy has significant implications for the existing supply of rest homes and free
standing facilities which were formally licensed as ICFs. Both of these groups will have the
option of dropping their current license and operating as assisted living programs. Those
facilities which do not convert must continue to meet the standards for rest homes or nursing
facilities.
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The draft policy was developed to deal with pressing realities. The supply of rest homes
has declined over the past several years and costs of upgrading free standing ICFs to meet
nursing facility criteria suggested other alternatives were needed. Tightening of the nursing
home level of care criteria created a need for an increase in the supply of living and service
models to serve those who are no longer eligible for placement. A less intrusive, nonregulatory approach to assisted living has emerged to address each of these areas.
Massachusetts has a supply of 53,288 nursing facility beds and 4,794 rest home beds. Of
these, 8,745 nursing home beds are in 180 free standing ICFs and nearly all rest home beds,
4,295, are free standing. The supply in 1980 was 48,808 nursing home beds and 6,461 rest
home beds. The number of free standing ICFs was 14,730, almost double the current supply
and the number of free standing rest home beds was 4,907. The supply of nursing home beds
per thousand people over 65 is 65.0 compared to 67.2 in 1980.
26
Housing Financing
Massachusetts has two agencies that provide financing for elderly housing and assisted
living. The Massachusetts Industrial Finance Agency (MIFA) is an independent public
agency created to issue bonds, insure loans and make direct loans to attract private
investment in the state. MIFA is able to finance nursing homes, continuing care retirement
communities and assisted living projects. MIFA issues tax exempt and taxable bonds for nonprofit and for-profit long term care providers in Massachusetts. Since 1980, the agency has
financed $335 million for 58 long term care facilities. As the leading issuer of debt for
Massachusetts elder care facilities, MIFA is committed to providing funding opportunities for
assisted living facilities.
In reviewing assisted living proposals, MIFA assesses the strength and experience of the
manager and developer, the strength of the sponsoring organization, the projected project
reserves and the feasibility study. Given the various costs associated with a bond issue, the
project size should at least $2 million.
Because MIFA is a dominant issuer of debt for the private, non-profit and public sectors,
it offers a well-recognized name in the capital markets. Strong relationships with
underwriters, feasibility consultants and lawyers in the field of bond finance and health care
enable MIFA to provide new financing options for long term care transactions. MIFA has
structured a variety of elder care projects including multi-purpose continuing care retirement
communities that involve assisted living programs and hospital sponsored start-up nursing
homes.
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The Massachusetts Housing Finance Agency (MHFA) has been developing plans to
finance housing and service packages, including assisted living, for several years. The
program originally planned to use operating and rent subsidies but financing for this
component was terminated during the state's budget crisis. MHFA is now developing
guidelines using tax exempt and taxable bonds. MHFA will require that a minimum of 20%
of the units be set aside for low income residents. The agency's statutory guidelines also
require apartments with baths and kitchens. The definition of a kitchen is being refined to
give developers more flexibility to offer models that allow varying balances between use of a
meals program and meals prepared in the resident's unit.
MHFA may become a resource for ICFs and rest homes seeking funds to renovate
buildings to convert to assisted living programs. Without rent subsidies, facilities with high
public occupancy rates may need a substantial shift to private pay residents to generate
sufficient cash flow to repay the MHFA mortgage. Depending upon the size of the mortgage
needed to complete the renovations, the current SSI payment standard may not support the
public/private occupancy mix in most free standing ICFs and Rest Homes. However,, the
home care program administered by the Executive Office of Elder Affairs, which serves frail
elders with incomes up to S 15.540 for a single person, creates an opportunity for elders with
incomes above Medicaid to afford a higher room and board rate. The service package for
these residents could be covered by the Managed Care in Housing Program, however, the
program is capped each year by the appropriation and it may not be accessible to developers
when construction is completed.
In addition to these efforts by agencies responsible for housing financing, the state
Division of Capital Planning and Operations has contracted for a study of the feasibility and
options for converting surplus state property to assisted living. The study is reviewing elderly
population trends, and current housing, health and financing options for elders. The study
will also review the regulatory, financing and programmatic changes needed to facilitate such
a conversion and the costs to the state of such policy changes. The details of the program are
being developed in the context of state policy on assisted living and the available financing
sources. The value of the land might be used as an incentive to make a portion of the units
available to low income residents.
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Summary of State Programs
Assisted Living Does Vary from Board and Care
Much of the present confusion stems from the absence of a universal, commonly
accepted or mandated definition of assisted living. In addition, regulatory definitions and the
nomenclature of board and care programs also vary widely. As a result, states can determine
what assisted living will be, how it will operate, who it will serve and who can be served.
While it may be difficult to define assisted living as distinct from board and care, the
continued use of the terms interchangeably masks some important differences. Key variables
are the philosophy of operation, the range and intensity of services provided, the residents
who can be served and the design of the units and the building itself. As noted earlier, state
policy leaders can choose from incremental steps that add services to existing housing models
to definitions that encompass all components of assisted living. At a minimum, broad
definitions will include models that add services to existing conventional housing buildings,
congregate housing and licensed board and care programs. As a state's definition covers
more components, the more it varies from traditional board and care. Further steps can be
taken to change the philosophy and the focus of regulation.
States can follow combined approaches. Policies and programs that add services to
existing housing programs can and will be used as developers seek financing for new
programs following housing financing guidelines which require full units (living area,
bedroom, bath and kitchen capacity). This path will leave states with a wide range of
programs that could be called assisted living. However, projects that offer full units may
want to differentiate themselves from providers offering added services to double occupancy
(and higher) units without kitchenettes and baths.
States adopting a "parallel policy track" would define assisted living as distinct from
board and care and include all the components. At the same time, states would also add
services to existing board and care and other supportive housing programs without calling
them assisted living.
State officials are very practical. They develop pragmatic approaches to solve pressing
problems. States often cannot delay policy initiatives or decisions until the results of lengthy
research and demonstration programs are known. A series of incremental steps are more
likely to emerge than large-scale policy revisions. Imperfect programs that can be improved
and modified as experience dictates are preferred over extensive delays until "the perfect
solution" can be developed. In this context assisted living has emerged in several states as a
practical step to address the increasing frailty of board and care residents who are "aging-inplace." Still, policy makers have to be mindful of the medium and long range implications of
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and opportunities created by their efforts to address today's financial and service pressures
with the tools available to them now. Programs developed for the existing housing supply
will be explored by developers and other providers who see new directions emerging in
government policy.
States that develop assisted living in facilities that are unchanged in appearance from their
operation as board and care type facilities contribute to the confusion. This is not a criticism
of state efforts. Indeed, assisted living emerges in varying environments that are not
replicated across state lines. Florida's program creates a new operating philosophy and
broader services within its residential care program. New York requires higher service
levels, more training for staff and other important improvements. States that increase the
services provided in board and care facilities will make a real difference in the operation and
services of these facilities. However, implementing assisted living within the existing stock of
board and care facilities may hamper its image and emergence as a distinct model. As states
continue to license assisted living, the requirements that apply can differ. Oregon and
Washington distinguish assisted living from board and care by requiring units that are larger
than required in their board and care guidelines and requiring baths and cooking capacity
within each unit and higher levels of service. These decisions have been facilitated through
coordination with their housing finance agencies to generate new construction.
Four states developed policies to serve nursing home eligible Medicaid recipients in
assisted living programs. Though providers will be encouraged to serve nursing home
eligible elders in Massachusetts' assisted living programs, the programs were developed to
serve elders who are no longer eligible for placement in a nursing facility.
States have designed their policies to enhance the current supply of board and care, adult
care facilities or equivalent facility. As a result, two states set standards for unit size and
configuration which mirror those of existing programs. These are minimum standards and the
actual "look" of a facility may depend less on the state standards and more on the adequacy
of financing to support the design and furnishing of units that are "home-like." Facilities
built and marketed to private pay residents are licensed but exceed the minimum standards in
order to attract residents. As the occupancy rate of publicly supported residents increases, the
design and amenities of the building will reflect the cash flow generated by public programs.
To succeed, state policies must combine and balance building standards, private/public
occupancy mix and state/federal subsidies for services, income support and mortgage
enhancements.
States have used existing housing and service financing programs to develop remarkably
different programs. While only Oregon has intentionally encouraged new construction, state
housing finance agencies and service agencies have the tools to collaborate and set priorities
for the use of state tax exempt and taxable bonds and tax credits to attract developers to start
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Table 11. Comparison of State Assisted Living Programs and Policies for Public Residents
Oregon
Washington
New York
Florida
Massachusetts
Status
Operating
Operating
Fall start up
August start up
Operating "
Operating
requirement
Licensure
Licensure
Licensure
Licensure
Medicaid and EOEA
certification.
(Registration:
pending)
Source of
service
financing
Medicaid
waiver
Medicaid waiver
Medicaid state
plan
Medicaid
waiver
Medicaid state plan
and Home Care
Program' '
Income
eligibility
Medicaid
Special Income
Level ''
Medicaid
Special Income
Level'-
Community
standard
Medicaid
Special Income
Level'"
Medicaid: community
standard; HC:
program, $15,540
Resident
functional
standard
Nursing facility
eligible
Nursing facility
eligible
Nursing
facility eligible
Nursing facility
eligible
24 hour supervision,
ADL assistance, need
for managed home
environment
SSI monthly
payment
5423.70
$450.00
$857.0O•'
$633.00
$551.00'
PNA""
S 63.00
$ 38.84
$ 94.00
$ 35.00
$ 65.00
Service rate
$156 - $1123 a
month based
on functional
evaluation"
$965.70 a month
50% of RUG
category; est.
$900-$ 1410 a
month' '
50% of nursing
home rate "
Medicaid:
$31.60/day;
Home Care,
$814/month
Program
authority
Agency
regulations &
financing
Legislative
appropriation,
agency provider
contracts
Legislation and
regulations
Legislation and
regulations
Agency financing and
program guidelines"
Services
allowed
Any service
provided in a
nursing facility
Specific nursing
services from
regulations
Nursing, home
health,
personal care,
et. al.
Specific skilled
services listed
in regulation
No specific
exclusions
Services
excluded
24 hour skilled
nursing
24 hour skilled
nursing
24 hours
skilled nursing
Specific skilled
services listed
in regulations
24 hour skilled
nursing. Home
health, adult day
health are limited
under Medicaid
CoN
No
No
Modified
No
No
1
2
1
1
0
,
1
7
1
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�Assisted Living Guide
(1) Financing programs initiated in 1991; assisted living policy statement and registration requirements pending.
(2) Funded from state general revenues.
(3) 300% of the federal SSI payment, in addition to categorical eligibility groups.
(4) Rate for New York City. Nassau, Suffolk & Westchester Counties, $827 in all other counties.
(5) Creation of a new living arrangement and higher payment standard is pending.
(6) Personal Needs Allowance.
(7) There are 16 separate RUG categories and the rates vary among 16 regions throughout the state.
(8) Projected payment rate will range from $30-$47 a day.
(9) Legislation may be filed for the next session.
(10) Total rate of $517 - $1483 includes resident's share for room and board that is covered by the SSI
payment.
(11) Total rate, including SSI share, is calculated at $45.90 a day. The example assumes a 30 day month.
new facilities. In the absence of collaboration, developers, housing management agencies and
service agencies may develop proposals for new projects, independent of state direction,
utilizing a combination of funding sources.
Policies Reflect State Differences
State programs reflect their own unique environments and circumstances. With a strong
legislative mandate to develop assisted living. Florida's regulations contain an extensive list
of services that can and cannot be provided in assisted living. The compromise regulations
reflect a change in the political climate, opposition from segments of the nursing home
industry that emerged subsequent to the passage of the legislation and the public process
through which regulations travel. Policy in New York and Washington contain similar,
though not as extensive, lists which limit who can be served more so than in Oregon's
program. The Massachusetts draft policy suggests an open-ended policy regarding the target
population.
Administration of medications for impaired populations is a major concern. The borders
between nursing facilities and board and care facilities are often drawn by how and by whom
medications are administered. Distinctions among administration, assistance and supervision
of medications often blur in practice. The spirit of the provisions is often easier to follow
than the letter. State policies generally allow extensive assistance with self-administration of
medications and appropriately licensed personnel are allowed to administer medications in
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accordance with their license. Oregon has benefitted from legislation that allows nurses to
delegate procedures to other staff.
Most states rely on Medicaid to pay for services. Florida, Oregon and Washington will
utilize their home and community based care waivers to pay for services. New York, which
does not have a waiver for its elderly recipients, will provide a flat capitation payment for
state plan services provided in assisted living facilities. The supportive services, which are
required by regulation (housekeeping, limited personal care, laundry, activities), are covered
by a higher SSI payment rate. States could develop programs with state general revenues to
divert elders with incomes near but above Medicaid levels and avoid the nursing home costs
for those who spend down.
Poiicv Options
Aggregate Cost
The primary issue facing policy makers is how to meet growing human needs with
limited funds. Policy makers face conflicts between cost effectiveness and fulfilling the intent
of a particular program. Maximizing revenue, usually from federal sources, is a popular
route for budget stressed state officials. Medicaid is frequently used as a vehicle to access
federal reimbursements while it is criticized for its increased spending.
Policy makers examine the cost of individual programs and the aggregate cost of
programs that cross agency lines in considering their options. Costs are a function of several
factors: services covered, supply, reimbursement rates and methodology, eligibility
thresholds (income, assets, functional and health) and participation rates. States may be
concerned that a new supply of long term care services will increase the total number of
people served at state expense. States establish policies to limit these factors to control
spending. Spending levels are often acceptable if they can be predicted and managed. Policies
which expand assisted living may be combined with steps to curtail the supply of nursing
facilities. States have attempted varying strategies to control spending. Oregon has decided to
control nursing home spending by creating an adequate supply of the most desirable
alternatives. Oregon's policy is premised to some extent on competition and an expectation
that occupancy rates in nursing facilities will decline as consumers have other options. The
number of Medicaid recipients in nursing homes in Oregon has declined from 8,400 in 1981
to 7,640 in 1992. The supply of beds per thousand in Oregon and Washington has also
declined. Given an adequate supply of assisted living projects, recipients will usually select
assisted living over a nursing facility. The desired level of supply may take several years and
the proper financial incentives and targeting to generate.
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Massachusetts took a different approach. Tighter nursing home level of care criteria
produced more immediate savings by limiting who is eligible to enter a nursing facility. The
state has accompanied this policy change with new assisted living programs that are intended
to create additional housing and supportive service options in the community. Over time the
supply of assisted living will expand and nursing home occupancy rates, which have dropped
2%, may continue to decline.
States often premise their policy decisions on the basis of cost to a specific program.
Medicaid officials, who must create budget and service options in the context of their own
budget, are often unable to control resources that serve people who are not eligible for
Medicaid. However, serving people who are just above Medicaid eligibility thresholds
prevents frail elders from becoming recipients once they enter a nursing home and "spend
down." States agencies that are able to work together can develop complementary policies
and programs that increase spending in one agency or program in order to save a greater
amount in another agency. An increase in general revenue programs for elders just above
Medicaid eligibility levels may prevent placement in nursing homes at a higher net state cost
to Medicaid. Policy makers would be well advised to consider net state cost as they decide
whether or not to expand a program and expand state revenues since new expenditures may
create savings elsewhere. Net state cost is a principle that extends beyond individual
programs.
The Massachusetts Office of Elder Affairs' assisted living program uses state general
revenues to serve non-Medicaid elders with incomes up to $15,540 for a single person. If it
was targeted to elders who are eligible for admission in a nursing facility, it would produce
more direct savings to Medicaid. However, until the supply of affordable assisted living
expands, units in the existing private, market rate facilities would have to be accessed to
achieve direct savings. As supply does expand through MHFA and MIFA financing, the
program may offer more impaired elders a lower cost option to nursing home placement
through this program.
Assisted living presents numerous conflicts and obstacles. Neither institutional nor strictly
housing, it must adapt to the rules and constraints of existing financing programs. Since
Medicaid is primarily a health program, financing the shelter component is acceptable in a
health related institution even though perhaps the majority of nursing home residents receive
functional support which is primarily non-medical care. If assisted living provides a "homelike" environment that clients prefer and is cost effective, as state experience suggests,
Medicaid policy leaders have a self-interest in developing assisted living programs that
substitute for nursing home use. Yet they must rely on other sources of funding (SSI and the
range of housing programs) to develop the supply. Budgetary purists will claim that states
will save money in the aggregate only if the expenditures for both assisted living and the
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remaining nursing home residents fall below the amount that would otherwise have been
spent in nursing homes alone. This approach focuses on real, current supply, not demand or
future increases in supply based on rising demand/need. Similar arguments have been applied
to the Medicaid Home and Community Based Waiver programs since their inception. The
argument assumes that long term care policy is stagnant and the supply of services expands
in a linear fashion in the absence of new options, or that state action to expand supply, and
its costs, can be predicted based on past experience. Instead, policy should be based on the
premise that government will continue to spend resources to address demand fueled by
demographic trends and that program and spending decisions should be based on the most
cost effective and appropriate resource mix for consumers.
With today's rules, states can expand Medicaid eligibility for community services such as
assisted living by selecting the Special Income Level option (see page 82). This allows states
to provide supponive services through 2176 waivers to assisted living residents. States with
higher average room and board costs can set higher maintenance amounts that allow a
recipient to pay the rate while the service costs are paid by any remaining resident income
and Medicaid funds. Since acute care will be covered by Medicare, and eligibility is targeted
to nursing home eligible recipients, spending can be controlled. True savings will accrue if
actual nursing home occupancy rates decline, supply declines in part through conversion of
nursing facilities to assisted living programs or future growth rates in the supply are reduced.
Other steps can be taken to control expenditures. Appropriation limits, regulatory
standards and contracting provisions, rather than certificate of need or other measures, can
be used to control the supply of assisted living facilities in order to manage total costs.
Shelter costs
Though providers will debate its adequacy, many current SSI state supplementary
payment standards provide a reasonable source of funding for shelter costs. States generally
use their payment standard for aged recipients living alone. New York uses the higher rate
for Congregate Care II living arrangements. However, the rate reflects both the shelter and
service costs required by the Adult Care Facility regulations. Massachusetts is considering
setting a higher payment standard for assisted living. States might undertake a review of
shelter and service costs in assisted living projects to assess the adequacy of SSI payment
standards to cover actual room and board costs. On average, room and board costs account
for half the total rate. State housing finance agencies or other organizations that provide
financing for board and care or assisted living projects may be a source of data for this
analysis.
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States have several options to use SSI while retaining a favorable "net state cost" at least
in states with a 50% Medicaid reimbursement rate. The federal SSI payment is $422 a month
for an individual. States may supplement the federal payment at 100% state cost. States with
a 50% Medicaid matching rate can set their state supplementary payment standard up to $844
a month and remain cost neutral compared to Medicaid. In other words, Medicaid payments
can cover room and board in an institution but not in assisted living or the person's own
home. If the room and board portion of the cost in assisted living totalled $844 a month, the
state's net cost would be the same for both a nursing facility and an assisted living program.
A state with a 60% federal matching rate remains neutral at a state SSI benefit of $704 a
month. However, these figures must be adjusted for the personal needs allowance.
SSI based programs can leave a substantial gap between very poor elders receiving SSI
and elders with incomes that are sufficient to cover the market rate for assisted living.
Without housing subsidies, there are few options for this group.
Conclusion
In short, some states are upgrading building design standards, increasing service
financing and developing programs to replace nursing homes for 30-40% of the nursing
home population. Some policy leaders believe the replacement potential may be as high as
75-80%. Other states are improving the services provided to board and care residents who
are aging-in-place. Still others are developing assisted living to offer new options to elders in
the community. While these valuable efforts are implemented, states can also collaborate
with housing finance agencies to expand the supply of projects that reflect the design
standards of assisted living. Modifying Medicaid eligibility rules under home and community
based waivers and adjusting state SSI payment standards are two avenues to increase access
to "market rate" facilities. These steps may also increase the financial feasibility of projects
financed by housing finance agencies and HUD programs by increasing the amount of
income available to cover shelter costs while qualifying residents for Medicaid service
packages.
IV. SOURCES OF HOUSING FINANCING
Government financing for rental housing developments, including assisted living, takes a
variety of forms. Financing is available for development and operating costs. Development
costs include the purchase of land, "soft" costs (designing and legal fees), site development
and construction. Financing is available to cover debt service (construction loans) and to
supplement tenant payments. Federal and state resources, described in this chapter, offer a
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�Assisted Living Guide
variety of mechanisms to cover some or all of the cost areas, cash grants, donations of land
and/or buildings and loans.
Federal Programs
Section 202 Supportive Housing for the Elderly
Formerly known as Housing for the Elderly and Handicapped, this HUD program has
been in operation since the 1960s. The National Affordable Housing Act of 1990, however,
made significant changes (effective October 1, 1991), including replacing the combination of
mortgage loans and Section 8 rental subsidies with capital advances and "project rental
assistance," and creating a separate program for housing for persons with disabilities (Section
811). In addition, provisions that address supportive service needs make it more feasible for
202 funds to be used for certain assisted living facilities. The program is open to private,
nonprofit housing developers or consumer cooperatives proposing projects of up to 125 units,
with a 40 unit minimum for projects in urban areas.
The capital advances are essentially grants which need not be paid back if the
development meets very-low-income occupancy targets fcr 40 years. Advances are available
to cover the costs of construction, rehabilitation and certain acquisitions.
The amount of the capital advance is determined by per-unit development cost limits
established by HUD. As an example, a one bedroom unit in a building with an elevator
would currently qualify for $33,816 in funds. An efficiency unit qualifies for $29,500. These
cost limits will be revised periodically by HUD to reflect changes in construction and
rehabilitation costs. In addition. Field Offices have the authority to adjust these limits where
necessary by the "high cost factors" used in other HUD programs. The maximum adjustment
is 240%.
Example: Worcester, Massachusetts has a high cost factor of 200%. The
development cost limit for a one-bedroom unit in an elevator building is,
therefore, $67,632. A project of 50 one-bedroom units would be able to
apply for a maximum of $3,381,600 in capital advances.
In determining per-unit amounts, certain design elements and amenities (e.g. balconies,
decks, dish washers, trash compactors, washers and dryers in the units and common space
that exceeds 10% of the gross square footage) are ineligible for HUD funding. The
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maximum unit size is 415 square feet for
efficiencies and 540 square feet for one"Assisted living models can be adapted
bedroom units. These design restrictions
and used in HUD housing," Jerold S.
may, however, be waived if the owner can
Nachison, HUD.
pay for the additional elements from other
"non-federal" sources. If funds for these
extra elements are borrowed, the sponsor must obtain HUD Field Office approval to ensure
that the loan does not provide the lender with control of the property, or increase the need
for HUD funds (e.g., the project rental assistance amount must not be used to repay the
loan.)
Project rental assistance is based on operating cost standards, determined regionally,
which are adjusted periodically by HUD to reflect changes in housing costs (using
"appropriate indices such as the Consumer Price Index"). For example, the current standard
for the Boston region for fiscal year 1992 is $4,080 per person per unit. No adjustments are
made for the size of the unit. Since no projects currently operate under the revised 202
program, it is not clear whether the periodic adjustments will in fact keep pace with increases
in operating costs.
Eligible residents for 202 buildings are households with at least one person age 62 or
over and with a household income at or below 50% of the area median income, as
established by HUD. Residents pay no more than 30% of their income for rent and may
contribute up to 20% of their income for services.
Example: In the Worcester, Massachusetts area, 50% of the HUD established
median annual income for a one-person household is $15,100. A resident at the
maximum eligible income would pay no more than $377 per month for rent and up
to an additional $252 for services. Another resident, whose income is $10,000,
would pay no more than $250 for rent and $167 for services. An SSI recipient in
Massachusetts would pay $165.30 a month.
The HUD project rental assistance provides $340 a month. Rental income for such a
unit will range from $505-$717 a month from HUD and SSI.
Services and eligibility
The program requires that services be provided, including but not limited to: meals
(which must not be mandatory), housekeeping, personal assistance, transportation and health.
No medical personnel are allowed on staff, however, and any health-related services must be
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based in the community rather than the project. The policy allows preventive health
screening, wellness clinics, and care for episodic health problems. Residents may access
services offered by the certified home health agency, for example, but the project itself
cannot offer continuous medical services. Fifteen percent of the service costs, up to a
maximum of $15 per unit, per month, is available through the Project Rental Assistance
Contract for the service costs of qualifying "frail" elderly tenants.
Frail elders are currently defined in the Program Handbook as persons with limitations in
at least three Activities of Daily Living (ADLs) as established by HUD, which include
eating, bathing, grooming, dressing and home management. Toileting, which is frequently
included as an ADL in other state and federal programs, was specifically omitted. HUD's
position is that incontinence is a health problem and not within the scope of HUD's housing
programs.
The position of service coordinator may be covered through the operating budget if at
least 25% of the residents in the development are frail or "at risk" (have limitations with at
least one ADL and are in danger of premature institutionalization). Coordinators may serve
the entire resident population regardless of their frailty.
Application process and criteria
Each HUD Field Office receives an annual allocation of units. Prospective developers
must apply to the appropnate Field Office according to the national timeline and proposals
compete with other proposals in the same geographic area (metropolitan with metropolitan
and non-metro with non-metro). Each Field Office is responsible for a preliminary review of
applications for completeness and for threshold requirements involving the sponsor, the site,
the market area, and the proposed project. Applications which pass this technical review are
scored by standard rating criteria covering:
1.
The Sponsor's ability to develop and operate the proposed housing on a long-term
basis (20 points maximum);
2.
The Sponsor's financial capacity (25 points maximum);
3.
Need for supponive housing for the elderly in the area to be served and the
desirability of the proposed site (20 points maximum);
4.
Project design (15 points maximum); and
5.
Provision of supportive services (20 points maximum).
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These scores are submitted to the appropriate Regional Office, which ranks projects within
each Field Office allocation area (with separate lists for metro and non-metro). A minimum
of 50 points is required for selection and funds are allocated to projects as far down the list
as there are funds available. During FY 1991, funds for 9,389 units were available nationally
and in 1992, 10,500 units.
Assisted living implications
The 202 revisions take a significant step in dealing with aging-in-place. Funding is
limited and the tradition of funding conventional housing poses obstacles to a building in
which all of the units were assisted living. HUD funding for community space is limited to
10% of the total square footage, yet the norm for assisted living is 30-40% of total square
footage. These projects cannot be seen as institutions and the presence of residents with
nursing needs creates a gray area in HUD policy. While owners and managers cannot
employ a nurse to provide the care, nursing services can be provided by outside agencies to
202 residents. In addition the HUD guidelines do not include transferring or continence in its
list of ADLs and presume that residents who need care with continence are not appropriate
for these facilities.
Despite these limitations, 202 buildings could include a wing or a section of the building
designed as assisted living. Designating portions of a building may enable a project to meet
the 10% limitation for common space. 202 projects have a tremendous advantage over other
financing sources - rent subsidies for low income tenants. The rent cap, 30% of income,
leaves residents with additional discretionary income that can be applied to service costs, a
particular advantage for residents who are not eligible for SSI. Very frail elders, who meet
the criteria for placement in a nursing facility, and who have incomes under $1,266 a month
($15,192 annually) could be served if the state's Medicaid program elects the Special Income
Level eligibility option. Cost sharing for services covered by Medicaid will have to be
reconciled with Medicaid cost sharing policies.
Highlights
/
Conducive to organizing assisted living services through provider contracts.
/
Good targeting to low income residents.
/
Rent subsidy leaves residents with income to apply to service costs.
/
May need other financing for extra common space.
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/
Some service eligibility gaps for non-Medicaid residents.
/
Potential conflicts with Medicaid cost sharing requirements.
Section 232 Mortgage Insurance
This HUD/FHA program was originally designed for nursing homes and intermediate
care facilities. In 1985 the program was expanded to include board and care homes, defined
as "a type of residential facility that provides room, board and continuous protective
oversight" for "individuals who cannot live independently, but who do not require the more
extensive care offered by intermediate care facilities or nursing homes." Many assisted
living facilities would qualify under this definition. The mortgage to be insured can cover
new construction or substantial rehabilitation by a for-profit or a private non-profit
mortgagor. Public entities (such as local housing authorities) are not eligible. The official
HUD handbook for the 232 program has not yet been revised to include board and care
homes, but special requirements and instructions are available in a HUD Notice. It should be
noted that some of these requirements are based on past problems HUD experienced with
insuring housing with services under the Retirement Service Center (ReSC) portion of the
221(d) insurance program for rental housing, which has been discontinued.
As a mortgage insurance program, Section 232 can assist developers in securing long
term mortgage loans which include the construction period, but it does not provide for rental
assistance or ongoing operating subsidies. Under the program, a developer/owner locates
mortgage financing through a bank, mortgage company, state housing financing agency, or
other lender approved by FHA (which makes lists available through Field Offices) and the
developer and the lender then pursue the insurance through the appropriate HUD Field
Office.
There are three processing stages: site appraisal and market analysis, which requires site
control; conditional commitment, after a loan has been approved by a lender; and firm
commitment, by which time final architectural designs are required. A relatively new
"delegated processing" option allows certain approved lenders to undertake much of the
processing themselves and may shorten the total application time. Fees apply at various
stages of processing, from both FHA and the lender. The mortgage insurance premium rate
is .5%. Mortgages insured under 232 have a maximum 40 year term and a 90% loan-tovalue ratio.
Example: One private mortgage company currently financing board and care
facilities insured with 232 is offering a 40 year mortgage rate of about 9%. These
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facilities have resident payments between $80-90 a day and development costs which
vary considerably depending on the physical design of the building.
To be eligible as a board and care, the facility may have shared bedrooms and baths (for
up to four people) or individual efficiency or one-bedroom apartments. Even if individual
apartments are provided, however, the building must have central dining, kitchen, lounge and
recreation areas. A 232 board and care facility must offer "continuous protective oversight"
and three meals per day, which are mandatory for residents in units without kitchens.
Residents in efficiency or one-bedroom units are required to take at least one meal per day.
Meals may be brought in from another location or may be prepared on site, but the facility
must have either a full service kitchen or sufficient building space (or adjacent land) to allow
for the eventual installation of one if it becomes necessary. Additional services can include,
but are not limited to: housekeeping, laundry, supervision of nutrition or medication and
assistance with daily living (such as bathing, dressing, shopping or eating).
There are no income limits for residents set by the program, or limits on rents and
charges. When reviewing applications, HUD looks at comparable facilities in the area to
determine if the charges being suggested are marketable.
Assisted living implications
This financing source is expressly directed toward nursing facilities and board and care
programs. It can be adapted to some assisted living programs and it allows, but does not
require, a developer to focus the subsidies derived from a lower mortgage rate on low and
moderate income residents. Program guidelines limit its application to assisted living
programs that provide single occupancy units with kitchens and baths. Per unit cost
calculations force developers to design double occupancy rooms without kitchens unless other
financing is available for the extra costs. The 10% equity requirement makes it difficult for
non-profit organizations to comply.
Highlights
/
Compatible with some assisted living models.
/
Does not provide funding for services.
/
Program has a track record with board and care programs.
/
No income eligibility requirements.
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Congregate Housing Services Program
The HUD Congregate Housing Services Program (CHSP) provides housing and
supportive services to low income frail elders. Administered by HUD (and a portion of the
funds will be made available through the Farmers' Home Administration), it bridges the
housing and service systems by including funding for services. The Act recognizes that 2030% of residents in federally assisted housing have some form of frailty and that "the
effective provision of congregate services may require the redesign of units and buildings to
meet the special physical needs of the frail elderly." The 1990 amendments revised the
program and may encourage developers/owners of existing projects to apply for the program.
The Act lists eight general purposes of the amendments:
•
Retrofit existing buildings to meet the special physical needs of residents.
•
Create and rehab congregate space to accommodate supportive services.
•
Improve the management capacity to assess service needs and coordinate
supportive services.
•
Provide services that prevent premature and inappropriate institutionalization.
•
Provide readily available and efficient supportive services through an on-site
coordinator.
•
Improve the quality of life for residents.
•
Preserve the viability of existing affordable housing for low income residents
who are aging-in-place.
•
Develop partnerships between the federal and state governments in providing
services to frail elders.
•
Utilize federal and state funds in a more cost-effective and humane way.
Eligible applicants and projects
States, local government agencies and local non-profit agencies are eligible to apply for
five year grants for service coordination and supportive services. The funds may used in
Section 202, 236. 221(d), Section 8 and public housing projects. Approved sponsors may
contract with other agencies to implement the service program.
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Use of funds
Funds may be used to retrofit an existing building by widening doorways, relocating light
switches, outlets, thermostats, and other environmental controls, installing grab bars in
bathrooms or reinforcing walls to allow later installation of grab bars, redesign of useable
kitchens and bathrooms to permit use by people in wheelchairs and other adaptive designs
that meet the needs of frail older people. Retrofit activities also include creating space to
accommodate the delivery of supportive services.
Service coordinators
These positions are responsible for chairing a professional assessment committee,
working with service providers to meet resident needs, mobilizing public and private
resources, and monitoring and evaluating the impact of services.
The professional assessment committee consists of at least three people appointed by
housing management and include medical and other health and social service professional
competent to appraise the functional abilities of frail elders. The committee determines
resident eligibility for services (three or more ADL impairments).
Services and delivery
Grant funds can be used for transportation, personal care, dressing, bathing, toileting,
housekeeping, chore, non-medical counseling, group and socialization activities, assistance
with medication (in accordance with state law), case management, personal emergency
response and other services. Meal service must be offered to residents and coordination with
the nutrition program under Title III of the Older Americans Act is encouraged. Title III
nutrition providers receive preference for providing meal services in a congregate housing
facility.
Services are intended for residents with three or more ADL impairments. However, the
law allows other residents to receive services if the housing manager, service coordinator and
professional assessment committee determine that their participation will not adversely affect
the provision of services to residents with three ADLs.
Resident fees will cover 10% of the service costs. Fees for meals may be set between
10% and 20% of the person's adjusted gross income if they receive one meal a day.
Residents receiving less than one meal a day pay 10% of their adjusted income.
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Funding
The HUD funds for new projects will cover 50% of the cost of the program. The
remaining 50% must come from resident fees (10%), in-kind contributions or state or other
sources (40%). Fees may be waived for residents who cannot afford them. These conditions
do not apply to existing programs. Housing owners, or states on behalf of owners, may apply
for funds.
Status
Regulations and a program handbook to implement the revised program were expected to
be issued in the fall. A Notice of Available Funding was expected by early October to fund
about 100 projects nationally, the first new round of funding in over a decade.
Assisted living implications
CHSP facilitates aging-in-place though it has many of the characteristics of assisted living
- individual units with baths and kitchens, and primarily as a housing program, it does not
require licensing. Many residents with three ADL impairments are also likely to have health
conditions that require skilled monitoring. HUD's concerns about delivering medical care are
likely to limit the nursing services that can be delivered with project funds. The program
mirrors many of the components of assisted living though the percentage of residents who
meet the criteria for placement in a nursing facility will be higher in assisted living than in
CHSP projects.
Highlights
/
Designed to assist frail elders to age in place.
/
Provides funds to retrofit existing buildings to accommodate frail residents.
/
Provides 40% of the funding for services.
/
Requires collaboration between housing providers and service programs to obtain
full funding for services.
/
Funding available for program expansion.
/
Program could be strengthened by adding the ability to provide some skilled nursing
services.
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,
Farmers Home Administration
The Farmers' Home Administration (FmHA) provides development loans and rental
assistance for congregate housing and group homes for people 62 and older and people with
disabilities. Loans may be made to a variety of organizations, state or local public agencies,
consumer cooperatives, individuals, trusts and associations. Loans are generally made in
towns with populations of less than 10,000. Loans may be made in areas with populations
between 10,000 and 20,000 if the area is not part of a standard metropolitan statistical area
or adjacent to one. Funds are allocated by state and awarded by local FmHA offices. Loans
under $1.5 million for less than 25 units can be approved at local offices. Loans above these
limits must be approved by the central office. Loans may be made for up to 50 year terms.
Public agencies and non-profit organizations may receive a loan for the entire cost of a
project. Other borrowers must provide three percent equity. Applicants must provide initial
operating capital equal to two percent of the total project cost which may be included in the
loan for non-profit and government organizations. Project cost per unit is considered in
relation to area costs. For example, the average cost per unit for New England projects is
$55,000 to $60,000.
Projects include private apartments (about 550 square feet) with central dining rooms.
Projects must be located as close to service providers and shopping as possible. Units must
include bathrooms and a kitchen that includes a cooktop, stove, sink, refrigerator and food
preparation surface. Units must be equipped with an emergency call system. The program
encourages borrowers to work with architects experienced in adaptive design and congregate
housing concepts. Loans may be used to build, purchase or renovate housing.
Tenants must not be totally dependent on others and must be able to vacate a unit in an
emergency, and have the legal capacity to enter into a lease. Projects must provide at least
one meal a day, seven days a week, transportation, routine housekeeping, personal care,
recreation and social activities. Personal services are defined as nonmedical services which
can include personal hygiene, nutrition counseling and general health screening. It does not
include "recurring medical assistance such as dispensing medication or constant medical
supervision." Projects are encouraged to collaborate with state and area agencies on aging.
Borrowers may also contract with home health agencies, hospitals, nursing homes and other
organizations to provide services or they may hire staff directly. The service package must
be affordable to low and moderate income tenants. Projects may not serve anyone who need
continuous medical or institutional care.
All tenants must meet the income eligibility criteria which are related to area median
income. Tenants pay 30% of their income for rent in projects participating in the rental
assistance program.
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Assisted living implications
/
Requires source of financing for services.
/
Tenant income may be able to support limited service needs.
/
Designed for tenants with limited service needs.
/
Emphasis on specialized design and management requirements.
/
Requires policy changes to address needs of moderately to severely impaired tenants.
/
Guidelines allow space for service providers.
Federal Funds Administered bv States
Low Income Housing Tax Credits
The Tax Reform Act of 1986 created a new tax incentive program for investment in lowincome housing. The Lew Income Housing Tax Credit (LIHTC) allows owners/developers of
mixed-income rental housing to receive credit against tax liability. This program,
administered by the U.S. Treasury Department, is intended to improve on past forms of tax
"shelters" (such as accelerated depreciation) by creating a more direct connection between
the amount of tax benefit taken and the amount of low-income housing created and by
increasing the targeting of the housing. The sale of credits to individual or institutional
investors raises upfront cash for a project (equity which can be used to reduce the amount of
debt financing required). It provides investors with credit against their own tax liabilities
over a 10 year period. State credit allocating agencies (most frequently the state housing
finance agency) establish additional restrictions, targeting goals and requirements for
developments using tax credits, schedule competitive funding rounds and monitor compliance
with both state and federal regulations. Some states have established targeting goals that
include a variety of special needs housing.
Example: The Washington State Housing Finance Commission included 10
points in its initial scoring system for projects in which at least 10% of the
units were reserved for special needs groups (including elderly) and which
included a referral and marketing agreement with a service provider and a
monitoring agreement. That year, 47% of projects allocated credits fulfilled
this criteria. [The points have since been increased for this item.]
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An allocating agency may also set-aside a portion of the total allocation for certain types
of housing projects. Ranking systems and set-asides may change from year to year to reflect
shifting state priorities, practical experience (e.g., if no applications are received for set-aside
allocations, they may be eliminated in ensuing years), or federal requirements.
The maximum amount of credit is calculated as a percentage of the funds spent on the
"qualifying basis" - the low-income portion of the housing development, including
construction, rehabilitation and/or acquisition costs. The percentage varies according to
several factors, including type of development (new construction and substantial rehab
receive a 9% credit while acquisition or projects that make use of other federal funds only
receive 4%). The applicable percentage applied to the qualifying basis establishes the
maximum amount of credit which may be allocated to a proposed development and that
amount is then reduced by the allocating agency to the minimum amount required for
financial feasibility. In 1991, the average allocation was $4,000 per unit, with investors
paying roughly 45 cents to the dollar of credit.
The total volume of tax credits is controlled by Treasury in two ways. There are credits
available under an annual state volume cap, administered by state allocating agencies and also
credits available for projects financed through tax-exempt bonds, which are themselves
subject to state volume caps. Since its creation, the LIHTC program has required frequent
reauthorizations by Congress. The latest reauthorization was for a six month period and was
due to expire in June of 1992. As ot July, the pending House bill would provide the program
permanent status and the Senate bill authorizes an 18 month extension.
Minimum occupancy requirements reserve 20% of the units for residents at or below
50% of the area median income, or 40% of the units for residents at or below 60% of the
area median income. Rents on these units are capped at 30% of the qualifying income level
rather than the resident's income.
Example: A 50-unit building in Worcester, Massachusetts includes 20 units
(40%) targeted for elders at or below 60% of median income
(approximately $18,120 for one person, $20,760 for two). Rents on units
occupied by an income-qualified single person could not exceed $453 and
for two people $519, regardless of the actual income level of the resident.
These restrictions are "locked in" for a minimum of 15 years, with the program
incentives encouraging even longer periods.
Service charges may come under the rent cap in certain situations. According to an IRS
ruling, services which are mandatory are considered a condition of occupancy and therefore
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the cost could not be used to increase the resident's rent beyond the established level. The
cost of a mandatory meals program, for example, would need to be covered in the rent (30%
of the qualifying income level of 50% or 60% of median) or would have to be covered by
state programs or other sources.
Assisted living implications
LIHTCs are more difficult to apply in assisted living than 202 or 232 programs. This
program may be more suited to a project for less impaired residents or a mix of independent
and less impaired residents. In this way services may be offered on a voluntary basis and the
costs would not be covered by the rent. Yet rents, though capped, are higher for low income
residents than in 202 buildings. Low income residents are still likely to be able to afford a
reasonably priced service package. On the other hand, an owner may have difficulty
projecting staffing and food costs for a voluntary package.
An IRS "interpretation" complicates combining credits with bonds. According to the
interpretation, if units include kitchens, the bonds cannot be used to finance common kitchens
needed to prepare congregate meals. This requires a higher equity ratio which is difficult for
non-profit organizations to meet. In addition, some states do not allow common space in
projects financed by credits which makes housing with services or congregate housing models
easier to finance than assisted living projects.
Tax credit financing addresses the needs of elders who qualify for SSI and Medicaid and
those with incomes above the thresholds to be charged market rates. Elders between these
levels could not afford to pay for the service package though owners may find them more
attractive than a SSI recipient in a straight rental arrangement since the income base on
which the rent is calculated is higher.
Elders with incomes under $1,266 a month ($15,192 annually) who meet the criteria for
placement in a nursing facility could be served if the state's Medicaid program elects the
Special Income Level eligibility option.
Highlights
/
States can establish assisted living as a priority for the use of tax credits.
/
Low income targeting.
/
Other programs can be combined with credits to finance services to deal with rent
caps.
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/
Complex process and financing mechanism.
/
IRS interpretations and state policies can hinder or preclude assisted living projects.
/
Limited application for 100% assisted living project because mandatory service costs
must be included in the rent caps.
Tax-Exempt Bonds
Industrial Development Bonds, or IDBs, secure private investment and serve a public
purpose. Under the authorization of the U.S. Treasury Department, states and certain other
entities such as state housing finance agencies may issue bonds which fund construction and
long term mortgage loans. Since the interest earned by individuals and corporations buying
the bonds is exempt from federal taxes, the interest rate is generally lower than that of
similar investment instruments. The actual bond rate depends on many factors, including the
strength and reputation of the issuing entity, the long term viability of the underlying project
and overall bond market conditions. This lower bond rate results in a mortgage rate below
prevailing commercial rates.
Example: A bond issued by a state housing finance agency with a good rating
and credit enhancements (mortgage or bond insurance) would carry an interest
rate of about 7%. The insurer adds a .5% financing charge which results in a 30
year mortgage rate of 7.5%. A taxable bond with the same credit enhancement
would carry a 9.5% rate.
The lower rate allows the borrower to access a higher mortgage based on the cash
flow generated by project income. A project that generates $500,000 a year to cover
debt service could receive a $4.5 million loan without tax exempt bonds or other
credit enhancements and $5.6 million using tax exempt bonds.
Under Treasury Regulations, housing developments financed with the proceeds of these
bonds must reserve at least 20% of the units for residents at or below 50% of median
income, or 40% at 60% of median income, for a minimum of 15 years. The housing must be
permanent, rental housing (transition housing or resident ownership is not allowed) and
apartments must include their own kitchens and baths. Certain requirements are waived if the
bond proceeds are to be used by 501(c)(3) non-profit organizations. For example these bonds
would not fall under the state's volume cap and proceeds could be used not only for new
construction or substantial rehabilitation, but also for acquisition of properties which do not
require substantial rehabilitation. Like tax credits, issuers frequently impose additional
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restrictions on bond-financed developments, including greater low-income targeting, or
incentives for targeting certain geographic areas or certain special needs groups.
A bond may be issued specifically for one larger project, or several projects may be
funded from a single bond. Generally, some level of mortgage loan processing has been
completed before a bond will be issued and issuers may provide "bridge loans" to projects
which are ready for construction before bond proceeds are available.
Highlights
/
Targeting for low income residents.
/
Strong financing source for housing component.
/
Can be combined with service programs.
Community Development Block Grant (CDBG) Program
HUD's CDBG Program has been used successfully for a number of years by states and
cities. While its primary purpose is neighborhood revitalization and economic development,
housing activities which benefit low and moderate income people or prevent or eliminate
slum conditions are allowed. Approximately 70% of the national funds are allocated directly
by HUD to metropolitan cities and urban counties and 30% of the funds are allocated to
states for a small cities program. Program priorities are established (with public input) at the
state and local levels, within federal guidelines, including targeting 70% of the funds for
activities which benefit low and moderate income residents. Units of government receiving
funds have the flexibility to provide grants or loans for a variety of purposes including
property acquisition and rehabilitation of residential property. In the past, CDBG funds have
been used in conjunction with several housing programs to provide the gap financing that
projects need to assure affordability.
Highlights
/
Responsive to local projects.
/
Flexible source of funding but it competes with multiple community needs.
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/
States and localities can set priorities that include assisted living or housing and
services programs.
HOME
Title I I of the National Affordable Housing Act of 1990 makes funds available to state or
local governments which can be used to ensure the availability of affordable housing. The
intent is to encourage community-based partnerships, using federal matching funds to
leverage funds from other public and private sources. Funds are allocated annually by HUD
on a formula basis and are placed in a "HOME Investment Trust Fund" which works as a
line of credit, for participating jurisdictions. Monies drawn from the Trust Fund must be
matched at rates equal to 25% for funds spent on rental assistance and housing rehabilitation,
33% for substantial rehabilitation and 50% for new construction.
Fifteen percent of the national program funds are set aside for Community Housing
Development Organizations - private, nonprofit organizations addressing low-income housing
needs. HOME also provides a "model program" option through which HUD encourages state
and local development of certain types of programs, including a rental housing production
program. Under this option, jurisdictions use Trust Funds to advance up to 50% of the cost
of certain housing options, including "projects which provide congregate facilities and
supportive services" for frail elders. Advances are repayable and carry an interest rate of no
more than 3%. Repayments go back into that jurisdiction's Trust Fund for continued use.
Program regulations contain multiple tests for low income affordability. In general:
Ninety percent of funds spent on rental housing must go toward units occupied by
residents at or below 60% of median income.
A minimum of 20% of the units in projects constructed or rehabilitated must be
occupied by residents at or below 50% of the median income and rents cannot
exceed 30% of income.
Rents on the remaining units must be the lower of the HUD fair market rent or 30%
of 65% of median income.
Housing must remain affordable for 20 years for newly constructed buildings and 5
to 15 years for rehabilitated structures, depending upon the amount of rehabilitation.
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HUD will establish per unit limits for use of program funds, varying by market area and
by the different eligible activities, which include: new construction, moderate or substantial
rehabilitation, acquisition, site improvements, financing costs, or tenant-based rental
assistance. The formula for new construction, for example, is 67% of the high cost limits
under the HUD 221(d)(3) mongage insurance program for multi-family rental housing, which
in a high cost New England area would be about $50,000.
When HOME funds are used for rental assistance, the maximum assistance is set at the
difference between 30% of income and the local Fair Market Rent, and rents must be
between 80% and 100% of the Fair Market Rent. Eligible tenants are those at or below 60%
of median income.
Highlights
/
Very well targeted to low income residents.
/
Revolving trust fund.
/
Priority for assisted living type projects.
/
Requires coordination with service programs.
/
Suited to local projects.
State/Local Programs
Given limits on federal funds and the matching requirements of several federal programs,
state, local and private sources of funds are becoming more and more crucial.
State Programs
Programs established to create affordable housing vary from state to state and like federal
programs, many have limited funding. State financing sources may take the form of:
appropriations for rental subsidies (either project based or tenant based); donations of surplus
buildings or land; zoning incentives; tax or fee deferments; or organizational development or
seed loans, particularly for nonprofit organizations. Several states now have housing trust
funds or similar arrangements, which use state appropriations or dedicated revenue sources
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�Table 13. Comparison of Housing Prngram Criteria
Component
Unit Size
Industry Average
H U D 202
H U D 232
LIHTC
IDBs
HOME
0- BR 415 sf
1- BR 510 si
NA "
Local decision
NA
NA
20% < 50% o f
income; or 40% <
60% of median income
20% < 50% o f
median income
20% < 50% of
income
125 unit iiuiximum
Units
reserved for
low iiu-oine
"bed" qualifies as a
unit; 0-BR; l-BR
100% < 50% of median
income
0 - 2 Bedroom
5 bed or unit niimmiim
NA'
Local decision
5 unit minimum
$29,500 O-BR "
$33,816 l-BR
NA
NA
Tied to 221(d)(3) limits
NA
1
Development
Size
Varies
Developmenl
C«»sl Per Unit
$85,000 - $9S,000
Individual
Kitchens
Varies
Required
Not Required
Not Required
Not addressed
Required
Meals
3 |>er day offered
Must not he mandatory
3 per day offered hut
not mandatory
NA
Not addressed
NA
Services
Allowed
Meals, housekeeping, personal
assistance, transportation and
heallh
May provide housekeeping, supervision,
personal care, 1 meal a
day (minimum)
Rent Limits
30% of 50% o f median income
Market
30% o f 50 or 60% o f
median income
(1) 30% for low
income units; (2) lower
of FMR or 30% o f
65% o f median income
NA""
20% o f 50% of median income
($ 15/iinit/montli subsidized)
Market
Must come under rent
cap if mandatory
Not addressed
NA
{ $1,300 per
{ month per
{ unit"'
Service
Charges
1.
2.
3.
4.
5.
6.
|,,
1
:i
LSI
Not applicable or not regulated by this program.
May be restricted by allocating agency due to limited funds.
Coopers and Lybrand figure.
Adjustments are available for high cost areas.
See page 69. Applies to the use of program funds.
Not restricted by bond regulations, but frequently required by the issuing agency.
Not addressed
�Assisted Living Guide
targeted to affordable housing initiatives.
Local Programs
Cities, towns or counties interested in creating affordable housing may provide funds or
land, or make zoning or other regulatory concessions to developers. This can significantly
lower the cost of a development and increase its affordability. For example, town owned land
which is donated or sold at nominal cost can significantly reduce the amount of debt
financing required by a project and consequently reduce operating expenses (through
decreased loan payments). Similarly, measures which remove or reduce the need for the
expensive and time consuming pursuit of variances which keep pre-construction costs lower
and zoning for increased density can reduce per unit costs. Cities or towns may also conduct
site improvements or construct access roads.
One example of a locally sponsored project is a 52 unit Home for Adults in Fairfax
County, Virginia. It is part of a larger complex called the Lincolnia Senior Center and
Residences which includes a senior center, adult day health program and 26 units of
congregate housing. The Home for Adults serves elders who need some assistance, but who
do not need nursing home care. The Home provides all meals, 24 hour on-site staffing,
assistance with bathing, medication monitoring and a nurse on-site 40 hours a week who
conducts health maintenance and prevention activities. Residents may be in wheel chairs, but
must be able to transfer independently. Incontinence must be self-managed.
Residents have a semi-private room (approximately 425 square feet) with bathroom but
no cooking facilities. To be eligible, incomes must be below $17,850 (the very low income
limit for public housing) with priority given to elders below poverty. About half of the
current residents are eligible for the "Auxiliary Grant Program" (incomes below $752 a
month), which is a state and county assistance program targeted specifically to Homes for
Adults. The state establishes monthly cost standards for each facility that cover shelter, food
and non-health services. The auxiliary grant pays the difference between a resident's income,
less a personal needs allowance, and the standard. Other residents pay 60% of their income.
A range of county agencies provide operating funds: the Recreation Department (Senior
Center); Health Department (Adult Day Health Program); Human Development (on-site
social service staff); and the Community Services Board (on-site mental health therapist).
The Department of Housing is responsible for the building's operating budget and provides a
Director of Senior Housing and Services who coordinates the participation of all agencies and
oversees the management contract with Sunrise Retirement Homes which manages the
residences.
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The County also contributed a surplus school building and land. Funds for the
rehabilitation of the school into the senior center and construction of an adjacent three story
building, $8 million, were obtained from a capital grants program financed by county
revenues. The new building houses the kitchen and the Adult Day Health Program on the
ground floor, the Home for Adults on the second floor and the congregate units on the third
floor.
Rent Subsidies and SSI Issues - A Kev Resource
In every state, the potential to implement the full concept of assisted living lies in newly
constructed facilities. A "home-like" environment will be difficult to create in facilities that
were not designed on assisted living principles. One barrier to new construction is the source
of the subsidy for the "rent." States have looked to Medicaid as the primary source of
support for assisted living because of the cost effectiveness of the Federal Financial
Participation (FFP) for the full range of assisted living services (except room and board)
under their waivers. Except for HUD's 202 program, there is little likelihood that rent
subsidies will be available in the near future and SSI will be the primary payment source for
room and board for low income people. In some states, SSI covers the room and board costs
although providers contend the SSI payments are cross-subsidized by market rate or private
pay residents. Adjusting the payment standards and definitions or categories of living
arrangements under SSI can substitute for rent subsidies.
States can change the number and definition of living arrangements, and the payment
standard for each, under their SSI state supplementary programs. The existing structure of
living arrangements in a state need not prevent modifying and targeting payments to support
assisted living programs. Federal regulations have been changed to allow states to define up
to six living arrangements (including personal needs allowances to recipients in facilities in
which Medicaid pays more than 50% of the cost as one arrangement). The regulations list
four examples of acceptable arrangements: living alone, living with an ineligible spouse,
personal care facilities and domiciliary care or congregate care facilities. There are no
definitions in federal regulations or manuals that explain these arrangements and federal
Social Security Administration staff indicate that it is up to the states to define the categories.
Many states list more than six arrangements (New York has seven, Michigan eight).
The process for changing the living
arrangements is fairly simple and few states
have submitted changes at least during the
past five years. States can define the class
of recipients that will be included in any
"We need to capitalize on SSI to make
assisted living affordable for low income
people," Rosalie A. Kane.
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new living arrangement, i.e. aged. A state does not have to apply the living arrangement to
all categories of SSI recipients but it must apply the criteria to all members of the defined
class. Aged recipients could be covered and blind or disabled recipients could be excluded.
The living arrangement can be defined by the needs or functional status of the resident
and/or the characteristics of the setting. States can also include conditions that require that
eligible residents are determined by a screening or approval process.
In some state board and care programs, a higher SSI payment is made to cover the costs
of care. As services are added to existing facilities through Medicaid, the combination of SSI
and Medicaid will cover the costs of providing care. Facilities often focus on the Medicaid
program for rate increases as costs rise. Yet SSI also plays an important role. Increasing the
state SSI payment standard for assisted living may enable a state to target people who are
eligible to enter a nursing home and are likely to "spend down" to Medicaid levels anyway.
In the absence of other programs, this approach enables the state to serve a person in the
community through assisted living rather than in the nursing facility. As an alternative to
higher SSI supplements, states may use the Special Income Level approach to broaden
Medicaid coverage (see discussion on Medicaid waiver programs, page 78). Each approach
offers different ways to limit expanded coverage to residents in assisted living programs
only.
Adjusting SSI to support assisted living - a state example
In Massachusetts, pending changes in defining and regulating rest homes will affect SSI
payments. Currently, rest homes are reimbursed as domiciliary care at $715 a month.
Additional supplemental payments are made at state cost based on allowable cost guidelines.
The average rest home payment is $32 a day ($960 a month). If current rest home facilities
choose to covert to an assisted living facility, it will change their standing as a living
arrangement under SSI since they will not be licensed. The current description of living
arrangements will reduce the payment that residents will receive in rest homes to $551 a
month.
27
While the SSI payment will decline, converting facilities will receive two payments room and board from the resident's SSI check and a service payment from Medicaid. Private
sector assisted living rates range from
$1,200 to $3,000 and more a month. The
"We have to be concerned that low
existing Group Adult Foster Care rate
income people participate in assisted
($948) plus SSI for an elder living alone
living programs," Robert Clark,
($551) is $1499 a month. Depending upon
DHHS/ASPE.
how much the resident retains, this payment
may be adequate in the aggregate.
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However, the distribution of an assisted living facility's expenses between operating and
service costs may not match the sources of income.
Cost Effectiveness
Assisted living is cost effective from several perspectives. Net state cost is typically
measured in Medicaid and state general revenue programs. Massachusetts also operates a rent
subsidy program with state general revenues. (A rider to the state budget for FY 93 changed
the program from an operating subsidy to a fixed voucher plan). The various financing
approaches raise cost effectiveness questions. The net state cost can be compared across three
payment sources (Medicaid, SSI and rental assistance) and five settings (ICFs, Rest Homes,
Adult Foster Care, Group Adult Foster Care in buildings with rent subsidies and ICFs/Rest
Homes which may later convert to assisted living facilities). At an average rate of $80 a day
for a free standing ICF (minus $5.60 a day patient paid amount and 50% FFP), the state
share is about $37.20 a day. The service rates for assisted living could be increased
substantially and still remain cost effective as long as the recipients live in existing subsidized
housing. However, the cost effectiveness test extends beyond Medicaid and should include all
sources of state funding - SSI state supplements and state rent subsidies (see Table 14).
Including rent subsidy costs, the true state cost of the Group Adult Foster Care program
is $908 a month which is still 21 % below the Medicaid cost of an ICF. The absence of a rent
subsidy could limit construction of new facilities in Massachusetts and the capacity to
implement a true assisted living program. Combining SSI and Medicaid will have varied
effects depending on the setting: ICFs converting to assisted living; rest homes converting to
assisted living; and existing private, market rate assisted living projects. Assuming the state
adopts the payment standard for SSI recipients living alone, an ICF facility will see a
reduction in its income from $2,400 to $1,499 a month (less the amount retained by the
recipient). However, the reduction will be offset by reduced staffing and operating costs
resulting from the higher levels of licensure requirements for nursing facilities. Free standing
ICFs were required to increase their staffing levels under OBRA while the resident mix may
not have matched the higher staffing requirements.
Rest Homes will experience an increase in their payment from $960 a month, on
average, to $1,499. Private projects may now be able to serve Medicaid recipients. A key
factor in each area will be the ability of the facility to provide room and board for $551 a
month (minus the amount retained by the resident). Medicaid service funds may not be used
to subsidize room and board. If additional subsidies for room and board were justified and
the state policy goal was to quickly expand the supply of assisted living units, supplementary
SSI payments could be made by creating a new SSI living arrangement or broadening the
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existing definition of domiciliary care. In this situation, the resulting net state costs will still
be lower than the cost of care in an ICF.
Table 14. Net State Cost of Massachusetts Programs
Costs in Two Assisted Living
Settings
Rest
Home
ICF
Adult Foster
Care
Rent
Subsidies,
Adult Foster
Care
ICF/Rest
Homes
Converting to
Assisted Living
1804
1499
Toral Cost
2400"'
960
SSI Share
60
960
551' >
557°
55/'"
State SSI
30
538
129
129
129
Rent Subsidy
0
0
0
305
0
948
:
Medicaid
22 i C '
36a''
948
948
948
State
Medicaid
1115
180
474
474
474
Net state
Cost
1145
TIS '
16
603
908
603
J
Total Costs = SSI Share (line 2) + state rent subsidy (707) + Medicaid (line 5) [Italics]
Net state costs = State SSI + 707 + State Medicaid.
1.
2.
3.
4.
5.
6.
Average patient amount is $170 a month.
Tenants pays a portion of the costs from their SSI payment: $300 a month in Adult Foster Care,
$210 on average in 707 buildings.
Using current SSI living arrangements. Creation of a new living arrangement and a higher payment
level is pending.
Average rate minus patient paid amount.
Based on the use of adult day care three days a week. Not every resident uses this service.
Net state cost for residents who do not use adult day care is $538 a month.
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V SERVICES IN ASSISTED LIVING
The capacity to provide home and community based services to frail elders has increased
steadily through the '80s and '90s. As state systems emerged, they focused on the needs of
elders who preferred to live independently and the systems necessary to effectively reach the
appropriate market, to evaluate their functional ability and dependencies and to deliver
services. Many states have developed extensive networks of case management agencies as the
cornerstone of their community systems. During the '70s and '80s, states focused on the
organization and delivery of services. In the '90s housing, which did not receive as much
attention, has emerged as the central building block of long term care systems. As a result,
traditional concepts of "home" and the regulatory approach to service delivery and quality
care have been challenged.
The typical service package in assisted living includes meals, housekeeping, laundry,
activities, 24 hour supervision, personal care with activities of daily living and varying levels
of health services. Sources of financing for these services include state general revenue
programs, Medicaid, the Older Americans Act, the Social Services Block Grant, and to a
lesser extent the Community Development Block Grant and the Small Cities programs.
General Revenues
States have used general revenues to establish home and community care programs. The
size and scope vary. Some states such as Illinois and Massachusetts, created large programs
to provide services that were not covered under Medicaid and to serve frail elders, and often
disabled adults, who may or may not have been eligible for Medicaid. Eligibility for state
services vary by income level and functional status. Several states limit eligibility to elders
who meet the criteria for placement in a nursing facility while others serve those who are
defined as "at risk" or who have impairments that make independent living difficult, yet who
do not require placement in a more service intense environment.
While states systems are well known and effective at serving frail elders in their homes,
the complexity and limitations of programs for consumers and the housing system are also
well known. Separate eligibility guidelines for housing and service programs create confusion
and gaps in coverage. Service packages may be available for some elders in subsidized
housing and not others. More recently as the supply of various housing and service options
has failed to keep pace with the growing need, states have looked more creatively at
modernizing their service programs to address the needs of elders as they age and become
more frail. For example, states have traditionally limited services to elders in board and care
or residential facilities. Residents received meals, housekeeping and limited other services in
such licensed facilities. As residents have developed impairments in activities of daily living
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(bathing, dressing, eating, mobility, toileting), states have explored ways of providing
personal care through community agencies to residents in these facilities. In addition, states
are continuing to review their programs to provide the flexibility to adapt to changing models
for meeting the housing and service needs of elders as they age.
Medicaid State Plan
The largest source of service funding for the poor is Medicaid. There are three sources
of funds for community care: state plan services, home and community based waiver services
and the relatively new optional community care program.
States are able to provide a range of services to all eligible recipients living in the
community. The primary services include skilled nursing, home health aide and personal care
with the latter being vital in an assisted living setting. Medicaid cannot reimburse for room
and board services except in an institutional setting (hospitals and nursing facilities). Home
health aide services can include tasks such as housekeeping, meal preparation and shopping,
can be covered as a component of personal care as long as they remain a subordinate part of
the service plan. Personal care services include direct care such as assisting with
administration of medications, assisting or supervising with basic personal hygiene, eating,
grooming, and toileting. Personal care also includes tasks that maintain a safe and clean
environment such as light house cleaning, changing linens and tasks that maintain nutritional
needs such as meal preparation or shopping. Personal care services must be approved by a
physician and supervised by a registered nurse.
States have recently developed approaches to providing personal care in board and care
and adult residential care facilities that are licensed by the state but are not themselves able
to provide such service under the state's licensing requirements. Arrangements with home
health agencies and home care providers are made to deliver care to frail residents. The
practice meets a growing need among residents in these facilities who do not require care in
a nursing facility but whose care needs exceed the care allowed by older licensing standards.
Concerns about standards of care, monitoring and licensing have been raised. Yet states have
been pushed by a combination of consumer demand for nursing home options, a shortage of
nursing facility beds, constraints on the growth of beds and budget driven efforts to develop
more cost effective long term care resources for frail elders.
Home and Community Waiver Services Program
In 1981, Section 2176 of the Omnibus Budget and Reconciliation Act allowed states to
receive waivers of plan requirements to provide home and community based services to
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recipients who met the criteria for admission to a hospital or nursing facility. The waiver
offers states several advantages. It allows states to pay for services that are not covered
under the state plan (e.g., homemaker, personal care, home delivered meals) and to limit the
populations eligible for services. It allows states to define services, such as personal care,
differently from the state plan. As a waiver service, states must have physicians sign the plan
of care and registered nurses must supervise the service delivery. Under a waiver, physician
involvement can be changed or eliminated and registered nurses do not have to be as
involved in the supervision of the care plan as they do under the state plan.
Finally, states can provide other services such as case management, homemaker, respite
care, home delivered meals, chore service, adult day care, transportation, and other services
approved by the secretary. In 1986, case management was added as an optional state plan
service.
States have used their waivers to serve specified numbers of frail elders, disabled adults
and children and other groups. The waiver authority allows a state to limit its fiscal liability
by specifying the number of slots that will be funded. The waiver programs must also meet a
cost effectiveness test.
In addition to providing a flexible service package, the waiver also allows states to set
higher income eligibility levels for people receiving waiver services who would not otherwise
be eligible for Medicaid while living in the community. States may receive federal
reimbursement for waiver and other Medicaid services to people with incomes up to 300% of
the federal SSI payment standard, or SI,266 a month in 1992. States may also determine how
much of a person's income may be kept to maintain a person in the community. Any income
above the maintenance level is applied to the cost of waiver services. This would allow
nursing home eligible elders to apply more of their income toward the monthly rent or room
and board costs in an assisted living facility that does not have rent subsidies.
Assisted living facilities have not been accessible to low income elders because of the
high monthly rates required in projects without rent subsidies and the inability of Medicaid to
cover room and board costs outside an institution. However, it is possible to establish
eligibility under a 2176 waiver to cover nursing home eligible elders who live in an assisted
living program that does not have rent subsidies. This approach gives most recipients enough
income to cover the monthly fee for room and board charges. It addresses a major gap
caused by the absence of rent subsidies and financing for the room and board costs for a
segment of the elderly population. This may offer a way to expand the supply of mixed
income assisted living developments without rent subsidies.
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Eligibility Steps
Eligibility for Medicaid may be expanded through the following steps. A state may cover
people under several "optionally categorically needy" options. One option, the Special
Income Level (SIL), covers people whose income is below 300% of the federal SSI standard
[S1902(a)(10)(A)(ii)(5)]. States may select an SIL between their community standard and
300% ($1,266) of the federal SSI payment standard ($422 in 1992). People with incomes
above $1,266 a month are not eligible under this category.
The SIL option must be applied in both institutional and community settings, however,
states with a Medically Needy program may use both standards in their state plan. States do
not have to choose one or the other. The SIL option generally does not expand eligibility for
institutional care in states with a medically needy program. However, it may expand
eligibility for home and community based services waiver programs. Medicaid may cover
people in the community who would be eligible if they were institutionalized and if they
would require institutional care in the absence of home and community based services (CFR
435.217). Since people with incomes below the special income level are eligible in an
institution, they become eligible in the community.
The SIL option triggers very different procedures for treating income. First the state sets
the SIL at any amount between the state's community standard and 300% of the federal SSI
payment standard. Second, it must apply the post eligibility treatment of income rules
(435.726 & 435.735) rather than the medically needy spend down rules. In so doing, the
state must exempt an amount of income that the state determines is necessary to meet the
individual's maintenance needs in the community. Until 1986, the maximum maintenance
amount was based on the state's SSI standard or its medically needy standard. After 1986,
states are free to set an amount for maintenance needs at any level.
Income that exceeds the maintenance level must be applied to the cost of waiver services.
There is no other spend down. Excess income is not applied to covered medical services.
Here are two examples:
Clienr A
Clienr B
Recipient Income
$1,266
$1,266
Maintenance Level
$1,266
$ 800
0
Excess
$ 466
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Assuming a state sets the maintenance level for exempt income at the maximum, client A
could keep all their income which allows them to pay a reasonable monthly fee for the room
and board component in an assisted living facility. If the maintenance level were set at $800
a month, a recipient with monthly income of $1,266 would have to apply $466 toward the
cost of waiver services. They may be able to pay the monthly fees but they will have very
little income available once it is paid and excess income is applied to waiver services.
Assisted Living Implications
This option would allow states to expand eligibility under a 2176 waiver to support
assisted living. The maintenance level should be determined based on the expected costs of
room and board, the cost of waiver services that would be paid by the recipient, and the
amount of discretionary income a recipient will need in a such a setting. A higher
maintenance level will increase participation. Depending on the room and board costs and the
state's maintenance income level, recipients with incomes near the $1,266 maximum may be
more likely to participate in an assisted living program than someone with income of $700 a
month. The closer the room and board component of the facility's fee is to the recipient's
income, the less discretionary income that is available. If a facility's negotiated room and
board rate were between $500 and $800 a month, someone with $1,200 a month would have
$400 and $700 a month for other expenses. A maintenance threshold of $1,000 would leave
the resident with $200 a month after the remaining $200 was applied to the service costs.
Residents with incomes above $1,266 would not be eligible as Medicaid recipients.
The waiver approach allows the state to control participation through enrollment caps.
This will preclude every existing private facility from trying to enroll their eligible residents
in the program though some added steps may still be necessary to focus available slots on
real nursing home diversions.
While waivers can be used to serve residents in assisted living facilities, they may not
convince a lender as to the long term viability of a new project. Initial waivers are approved
for a three year period and renewed for a five year period and cannot guarantee continuation
during the full term of the financing.
Home and Community Based Services Waivers for the Elderly (1915d
waivers)
The Omnibus Budget and Reconciliation Act of 1987 created a new waiver program for
home and community based services to elders. The program was developed as an alternative
to the 2167 waiver primarily for states that could not demonstrate unused capacity or "cold
beds." The waivers apply only to Aged Medicaid recipients (except in Texas) who are likely
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to enter a nursing facility in the absence of community services. States may receive waivers
of income and resource limits, comparability and statewideness. In exchange, states must
limit expenditures for long term care (nursing homes, home health, personal care, private
duty nursing and community care services).
Rather than compare the amount of spending that would have occurred with and without
a 2176 waiver, the 1915(d) waivers simply cap Medicaid spending for all long term care
services. The limits are set based on projected increases in spending for institutional,
community and in-home services and population growth (65 + ). FFP for state expenditures is
tied to an Aggregate Projected Expenditure Limit (APEL). The APEL uses federal fiscal year
1989 as the base. Expenditures required by federal mandates, such as the OBRA nursing
home reform amendments, are added to the base year. Base year expenditures are trended
forward using the greater of 7% per year or the sum of adjusted expenditures for nursing
facility and home and community based care. The formula steps include:
Base year nursing faciliry expenditures
• plus the market basket increase for such services;
• plus 2% per year;
• plus the percentage increase in the number of people 65 and older.
Base year home and community: based care expenditures
• plus the market basket annual increase;
• plus 2%;
• plus the percentage increase in the number of people 65 and older.
The market basket increase for nursing home expenditures is based on the Medicare SNF
Input Price Index and the inflator for community care is based on the Medicare Home Health
Agency Input Price. The population 65+ in a state is based on a count of Medicare
beneficiaries.
This waiver approach includes the same services as the 2176 waivers: case management,
homemaker, personal care, adult day health care, and "other medical and social services that
contribute to the well being of individuals and their ability to remain in the community." The
program's interim final regulations, published June 30, 1992, contain some suggested
definitions though states are free to propose alternative definitions. The regulation do allow
personal care to be provided by a family member, other than a spouse. The waiver must
describe the conditions under which this is allowed and states must have a mechanism to
ensure that care is provided and it would not be furnished in the absence of payment, e.g. a
relative leaves a job or moves to care for a family member.
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These waivers also allow states to use the institutional deeming rules (e.g., income of the
husband or wife is not counted toward the spouse's eligibility) and the special income level
eligibility category.
i
Only one state, Oregon, has applied for and received a 1915(d) waiver. In order to
successfully use this waiver, states need:
•
To control the supply of nursing facility beds;
•
A case management system that screens recipients for entry into the long term care
system;
•
An expanding supply of appropriate community and residential services; and
•
An effective nursing home reimbursement methodology.
8
Frail Elderly Community Care as an Optional Service (Section 4711V
While the 2176 waiver program brought considerable flexibility, it also brings added
requirements and responsibilities. States must document the financial impact of the waiver on
their projected and actual Medicaid expenditures. Initial waivers are approved for three years
and renewed every five years. Waivers must be evaluated. More importantly, state policy
makers contend that home and community based services that allow frail elders to function in
the community should be the rule rather than the exception. Some would argue that states
should be required to provide home and community based services and seek waivers in the
absence of adequate community care to cover care in a nursing home.
States have been seeking opportunities to provide home and community based care
without the lengthy processes and procedures that have become part of the Medicaid 2176
waiver program. Over a period of several years. Congress developed proposals that created a
permanent program free of the limitations of the waivers. As steps to deal with the federal
budget deficit evolved, it became more difficult to pass new legislation carrying the large
costs of community care expansions. To respond to the constraints of the budget agreements,
sponsors of a new home and community care bill agreed to compromises which, while
necessary to secure passage, have made it difficult for states to implement the new authority.
Section 4711 of the 1990 Omnibus Budget and Reconciliation Act (sometimes called the
Rockefeller Bill) offers states an optional state plan approach to providing home and
community based services.
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Eligibility
Eligibility is limited to elders who need substantial assistance with two of three ADLs
(toileting, transferring and eating); or to elders with Alzheimer's Disease who cannot
perform two of five ADLs (bathing, dressing, toileting, transferring or eating), or who are so
cognitively impaired that they require substantial supervision. These tight criteria may be
more restrictive than a state's criteria under the waiver program. States may further limit
eligibility using reasonable classifications based on age, degree of functional disability and
need for services. This provision allows states to test approaches to serving high risk,
vulnerable elders. For example, states could develop a separate program for elders over 85
who live alone, do not have a caregiver and who require full assistance with two or more
ADLs.
Funding
Funds are capped at $40 million nationally for FY 91, $70 million for FY 92; $130
million in FY 93; $160 million in FY 94 and $180 million in FY 95. The law caps a state's
maximum reimbursement based on its relative share of "elderly individuals 65 and over."
The law also says that "elderly individuals, to the extent practicable, shall be low income
elderly individuals." Since there is no standard measure of low income elders across states,
HCFA has concluded that this formula element is not practical.
Language allows the Secretary of HHS some flexibility in setting state caps based on the
number of people 65+ in relation to the rest of the country. HCFA will use the flexibility to
base each state's maximum reimbursement on its relative share of elders 65+ among states
participating in the program. For example, HCFA would determine the number of elders
65+ in each of the participating states and cap each state's share proportionally. A state with
35% of the 65+ population would receive a maximum of $14 million in FY 92. If the
relative share were 5%, the maximum reimbursement would be $3.5 million.
In order to facilitate budget planning, state participation would begin at the October 1st
start of a federal fiscal year. Otherwise a state may begin the year with 10% of the available
funds and see its cap reduced if additional states enter the program during the year. Each
year on September 30th, once the number of participating states is known, state caps based
on the authorization will be allocated among the states with approved amendments. While
this reduces mid year reductions in the cap, it leaves some measure of uncertainty at the
beginning of the state's fiscal year since states will not know until October 1st what their cap
will be for the remainder of their fiscal year.
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As more states participate each year, the relative shares drop. The annual increases in the
appropriation may be enough to prevent a state from receiving less in a subsequent year if
additional states choose to submit amendments. Yet, there are no guarantees that caps will
not decline for early participants.
Capped Entitlement
Once a state elects to participate, it must serve aU eligible elders regardless of cost. FFP
will be limited and states are required to provide care at 100% state cost if additional eligible
applicants apply. States must guarantee services to all eligible recipients for the duration of
the state's "election period." In developing its plan, a state must determine the length of time
it will operate the program. The "election period" may be four or more calendar quarters
selected by the state. Once selected, states cannot withdraw the amendment. The regulations
will clarify whether state action will be necessary to extend the program after the expiration
of the initial election period.
Maintenance of Effort
The statute includes a maintenance of effort provision that is cumbersome and probably
cannot be implemented as drafted. Section 4711 requires that states report their expenditures
for community care beginning in fiscal year 1990. If expenditures fall below FY 89 levels,
federal reimbursements are reduced by an equal amount yet there is no requirement that
states submit a report for FY 89 expenditures.
Though the Secretary probably has the authority to require a report for FY 89, other
provisions create more extensive problems. While the Congress intended to establish a
maintenance of effort provision, the language cannot be easily applied to state general
revenue programs. In addition, the maintenance of effort is to be applied to functionally
disabled elders, as defined by the Act, who are assessed by an instrument approved by the
secretary. No state presently uses such a definition of eligibility and therefore there is no way
to determine how many eligible elders received home and community based services under
state programs or Medicaid. In addition, the Secretary has not approved any assessment tool.
As a practical matter the maintenance of effort requirement will most likely be applied only
to Medicaid home and community based care expenditures for elderly recipients.
Assessment and Case Management
The Act requires that eligible clients be assessed by an interdisciplinary case management
process. Applicants cannot be charged a fee for the assessment. Based on the assessment,
care managers must develop an Individual Community Care Plan which identifies the
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services needed, the services to be provided and the amount, duration and scope of any
limitations accompanying the care plan. The care plan must also indicate the individual's
service and provider preferences.
Case management can be performed under contract by a public agency or a non-profit
agency that does not provide direct services. The language allows states to contract with Area
Agencies on Aging or other non-profit organizations which do not provide home and
community care or nursing facility services and which have no financial interest in any
agency that provides such services.
The assessment and care planning process is consistent with the case management systems
in many states. HCFA has developed a standard assessment form, however, states may use
their own form as long it contains the minimum data that must be collected. At a minimum,
quarterly visits will be required.
Standards for Community Care Settings
The law sets new standards for providers of home care services and facilities in which
services are received. Facilities can be day care centers, rest homes, board and care homes,
even CCRCs. These complex provisions grew from concern about unregulated board and
care programs in many states. Elders who reside in rest homes, board and care facilities and
conceivably some CCRCs seem to be eligible to receive community services. The law applies
survey and certification standards to any setting or facility in which elders receive services.
For example, an elder who receives personal care in a day care center (or social day care
center) under the program, or someone living in a rest home receiving services forces the
setting in which services are received to comply with new requirements. The standards will
apply life safety code requirements that are appropriate to the setting.
States must establish an annual survey and certification process for all facilities
(residential settings, community care settings) and providers of in-home services. HCFA will
conduct on-site surveys of a sample of settings to validate state survey procedures. HCFA's
regulations will be based on comparable procedures for nursing facilities, modified as
appropriate for community care settings.
The law also requires that HCFA establish guidelines for minimum compensation to
individuals providing care. HCFA will allow states to use current rates for similar services or
their existing rate setting process to comply with this provision.
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Status
Section 4711 was covered by the President's moratorium on issuing new regulations. The
law required that final regulations must be issued by October 1, 1992. Because of the
moratorium, there is no date planned for issuing the regulations. However, the absence of
regulations does not preclude implementation of the program, nor does it reduce a state's
responsibility for complying with all requirements.
So far, few states have actively considered this approach. Only Texas and Rhode Island
have sought and received approval to implement the program to replace an expiring
demonstration program. Language in the law exempts Texas from the functional eligibility
criteria in order to grandfather all participants in their demonstration program.
Pennsylvania explored the program and has decided to submit a 2176 waiver application.
Florida's interest in submitting a plan amendment has been delayed by budget constraints that
affect the state match.
State Impact
There are several variables to consider in determining the impact of the new authority on
states with existing 2176 waivers. First, what are the similarities and differences in the
populations that can be served? Second, will states be able to predict participation rates?
Third, what are the revenue implications? And fourth, what are the incremental financial
and management costs of meeting the survey and certification requirements of the new
program?
Population. States with existing waivers that are considering the program should analyze
how the new eligibility criteria will apply to their current 2176 waiver participants. The
major differences in the 2176 and 4711 eligibility criteria are the ADLs considered and
skilled care needs of elders. Most states include from five to seven ADLs in assessing
functional impairment: bathing, dressing, eating, toileting, transferring, continence and
mobility. Bathing and dressing, the two most frequent ADL impairment, are not included in
the definition of "functionally disabled" in the new program unless the person is also
cognitively impaired. Elders could have three ADL impairments (dressing, bathing, eating)
and problems with continence and not be eligible under the state plan option.
States whose current waiver participants exceed the new criteria must operate two similar
programs or eliminate services to elders who will no longer qualify under the tighter criteria.
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However, states may devise programmatic reasons for testing and developing new models
to serve an impaired population in a controlled manner without undertaking the process of
developing a new and separate waiver request. The law allows states to waive statewideness
under the state plan approach.
States may consider the optional program if they are near their maximum number of
people who can be served through their waiver. States that have reached their maximum
number of approved waiver slots may consider a section 4711 plan amendment and transfer
eligible clients to the new program to free up slots for new eligible waiver participants. In
this circumstance, states may also consider submitting an amendment to their waiver to
increase the number of approved slots.
Florida's interest in the law can be attributed to several factors. Enrollment in their
waiver is approaching its maximum of 11,000 slots and the dynamics of the cost
effectiveness formula make it difficult to increase the number of slots. High nursing home
occupancy rates, new and tighter CoN bed need guidelines and the relatively low nursing
home rates make it difficult to serve increased numbers of high cost elders and still meet the
waiver's cost effectiveness test. The section 4711 approach was explored to provide more
intensive, higher cost service plans to severely impaired elders and avoid potential conflicts
with the waiver formula.
Staring March of 1992, Rhode Island covers elders with a primary or secondary
diagnosis of Alzheimer's Disease who need personal care and would be a danger to
themselves if left unattended. Officials felt many in this group would not meet the criteria for
admission to a nursing home. The program extends an existing state funded program to a
new group and covers personal care, homemaker, personal emergency response and adult
day health care. The program was developed to provide support for caregivers. In three
months, the program has built a caseload of 300 people including some who were transferred
from the state's Social Services Block Grant program.
The new law recognizes the importance of care in residential settings and supports the
expansion of assisted living models. While the eligibility criteria may fit the profiles of
functionally impaired elders in subsidized housing, the 2176 waiver allows greater flexibility
for those in unsubsidized facilities. Spend down requirements apply to the 4711 program,
while states have greater leeway under 2176 to set higher levels for the maintenance needs of
individuals in the community who are eligible under the "special income category." Higher
disregards are necessary to allow a nursing home eligible elder enough income to pay for
room and board in a facility without rent subsidies.
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Participation. Services provided under an amendment will have to be made available to
eligible recipients in their homes and in community care settings that meet the requirements.
State participation and expenditure projections based on the current provider supply may
under-estimate actual costs if provider supply expands in reaction to new financing sources.
The most likely source of new supply is from providers of care in residential settings since
financing sources for in-home care are reasonably well established through Medicaid and
state general revenue programs. However, more restrictive eligibility criteria can be used to
limit the eligible population and service definitions can be developed that lend themselves
toward environments in either in-home, community or residential care settings and thereby
indirectly limit potential supply and participation rates.
Revenues. With limited participation among states in the early years of implementation,
states may be eligible for fairly sizeable reimbursements. The revenue implications should be
examined carefully. From a financial standpoint, operating dual programs may not increase
revenues, especially for states that are below their waiver enrollment caps or that are able to
increase the number of slots, since elders served under the state plan option may also be
served under the waiver. Revenues earned by the 4711 participants are, in effect, transferred
from the 2176 program.
States that are not able to enroll additional waiver clients may gain from this optional
plan approach.
Administrative Costs. The optional program will increase administrative costs to the state.
If the 4711 authority does not replace the waiver, states would have to manage, administer
and track two programs instead of one. In addition new survey and certification requirements
will apply to case management agencies, in-home care providers, community care and
residential settings that may be serving elders through both programs.
In summary, the law provides support for states interested in developing assisted living
programs and expanding supportive housing and services models, yet section 4711 does not
have the flexibility found in section 2176 to set higher income eligibility levels that would be
necessary to serve frail elders in unsubsidized projects. Section 4711 carries additional
constraints and limitations. The programmatic and financial advantages of this new authority
seem limited for most states with existing 2176 waivers that can be used to achieve similar
goals and, in fact, the law may create financial risk if enrollment levels exceed federal
reimbursement caps. The management and financial consequences of developing new sets of
standards, survey and certification requirements cannot be fully measured until regulations
are issued.
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The legislative history of the program over several years suggests that extensive
compromises were necessary to control eligibility and to hold spending within ever tightening
budgetary guidelines. Though many observers concluded that the program has been so
hampered by compromises that, although necessary to win passage, severely limited its utility
to states. However, efforts to develop its potential may launch legislative initiatives to modify
the law or spawn state experiments with new combinations of care in residential and
community settings.
Table 15. Comparison of Medicaid Programs
Official
name
Home and community
based services waiver
program
Home and community
based services waivers
for the elderly
Community care
for the elderly as a
state plan option
State Plan
Common
name
Section 2176; 1915 (c)
Section 1915 (d)
Section 4711;
Rockefeller bill
Same
Functional
eligibility
requirements
Nursing facility criteria
Nursing facility criteria
Impaired in 2 of 3
ADLs (eating,
toileting,
transferring) or 2 of
5 with Cognitive
impairments
Medical necessity
H-P limits
Based on approved
number of people to be
served
Long term care
expenditure cap
Maximum based on
relative share of the
funds appropriated
Federal matching
rate for all
expenditures
Formula
Cost effectiveness test
based on nursing home
capacity, and costs
with/out the waiver
Aggregate projected
expenditure limit
(FY89 adjusted)"
Based on relative
share of recipients
in each narticinatinc
state
Relative per capita
income
State liability
100% of costs for
people served above
approved limit
100% of expenditures
above APEL
100% of
expenditures above
maximum allocation
NA
Special rules
Deeming waiver;
special income level;
post eligibility
treatment of income
Deeming waiver,
special income level;
post eligibility
treatment of income
Regular rules apply
Regular rules
apply
1
1. Adjusted each year based on the inflation rate for nursing facility and home health spending (Medicare
indices), plus 2% per year, plus the percentage increase in the number of Medicare beneficiaries in the state.
Oregon's base year is 19S7.
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Older Americans Act
The Older Amencans Act (OAA) provides relatively small grants to assist State Units on
Aging and Area Agencies on Aging (AAAs) to develop and implement comprehensive and
coordinated systems to serve elders. However, its flexibility readily supplements funds
available from other sources, to states to support services that promote independence. The
Act's broad mandate and limited funding hinders its ability to serve as a funding source for
extensive programs. Services are targeted to those in greatest social and economic need with
particular attention to low income minority elders. Funding for three broad areas receive
priority: access, in-home and legal services. State Units on Aging administer the program
through regional AAAs. Local AAAs have discretion to fund services that respond to local
needs based on a needs assessment and an area plan. The most common services include
health, transportation, housing assistance, community long term care (meals, homemaker,
personal care, day care and others), legal assistance, health promotion and information and
referral. Separate funding is allocated to states for congregate and home delivered meals.
OAA funds are used to supplement services in states with large general revenue programs. In
many states, the OAA and Medicaid waiver services, are the primary sources of funds for
home and community based care.
Robert Wood Johnson Foundation Supportive Services in Senior Housing
Demonstration Program
This demonstration project was designed to add consumer driven service packages to state
HFA-fmanced housing developments for the elderly and make creative use of the unique
funding sources available to those developments and to Housing Finance Agencies (HFAs). It
is unique in that grants were administered through the housing provider network rather than
the service network.
HFA's in Colorado, Illinois, Maine, Massachusetts, New Hampshire, New Jersey,
Pennsylvania, Rhode Island and Vermont and Virginia received $4 million in grants from the
Foundation in 1988. These grants have been combined with $1 million in housing finance
agency funds, development funds ($2.5 million), tenant contributions ($300,000) and other
resources. The states spent three years designing and implementing mechanisms to provide
services to elders who were aging-in-place. By the third year, 240 sites were participating in
the demonstration program.
The profiles of residents were similar in some respects to assisted living residents. First
year surveys conducted by the sites showed that resident profiles varied slightly by state.
Between 23-26% of residents were over 80 years old, 70-88% were female and 78-94% lived
alone. Data collected on participants between May 1990 and April 1991 by Brandeis
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University, the National Program Office for the project, found that 37.9% of the residents
used meals, 19.6% received housekeeping, 14.1%, transportation and 10.1% received
personal care.
Service coordination was a key factor in the program. Service coordinators were
developed to "broker" services for residents and to access existing local service programs.
Coordinators arranged for traditional services to be provided in non-traditional ways (such as
contracting for a block of service time which was then allocated among residents according
to their preferences). Coordinators also worked with local businesses to arrange discounts,
deliveries and other special treatment. One goal of coordination was to reduce the cost of
services to the consumers.
Another key principle was the consumer focus of the project. Sites did extensive resident
surveys to determine which services were most important to residents. Service use was based
on resident choice rather than screening, assessment and authorization based on frailty or
income. This aspect of the demonstration parallels the trend in assisted living toward a
social, residential service model that maximizes independence.
In part because of the consumer orientation, resident contributions to service costs
totalled $300,000 in the first three years. Although most service users (80.6%) had incomes
below $10,000, 57% of service units included resident fees for all or part of their cost.
Table 16. Fees Paid
Percent of
Costs paid
by residents
Service
Chore
96.87c
Shopping
83.77c
Health Services
78.4%
Transportation
62.7%
Meals
57.8%
Personal care
50.0%
Light housekeeping
40.0%
4.4%
Coordination
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Services most likely to include a fee were meals (90%) and chore services (80%). The least
likely was service coordination (10%). Service usage and fee payments varied by state. After
two years, one state reported that in 23 panicipating developments, a high percentage of
residents paid fees for all or part of services (see table 16).
Health services included screening, wellness clinics, education events such as nutrition
classes and exercise programs. The remaining service costs were covered by contributions
from the developer - $2.5 million by September, 1991 - including capital improvements
(adding or enlarging kitchens in common space, improving accessibility for frail elders), staff
(particularly the service coordinator) and equipment (van and others).
While the residents were not as impaired as the population served in assisted living, the
demonstration program effectively involved HFAs in meeting the needs of residents who are
aging-in-place and sets the stage for HFA involvement in assisted living. Participating states
are continuing the program and expanding the number of sites.
Lessons for assisted living and government policy
Most of the participating projects were subsidized under the HUD Section 8 New
Construction/Substantial Rehabilitation program, which means that the developments'
operating and reserve funds are controlled by HUD and the state H F A . Decisions by housing
management staff to develop service capacity and renovate space may need to be reviewed by
the state HFA and HUD. The use of the funds for service related activities highlights the
need for more flexible regulations governing the use of funds as projects respond to the
changing needs of their residents. The experience also highlights the need to modify the
design standards for new buildings to reduce costly retrofitting as the building and its tenants
age.
The presence of Section 8 rental subsidies limited tenants' rents to 30% of their income.
Because of the rent subsidies, low income tenants had funds available to share in the cost of
the services. Residents with an income of $5,000 in a section 8 unit might pay $125 a month
for rent which left $291 a month in disposable income. Another resident with an income of
$10,000 might pay $559 a month, the average rent for a one bedroom unit in a high cost
area, leaving $274 a month for other expenses.
Lessons from the demonstration support the experience of private assisted living models.
Others reinforce the potential to successfully manage assisted living using multiple funding
sources for low income residents who could not afford the private rates. The project results
stressed the benefits of a consumer oriented program, cost efficiencies available through
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packaging of services, the ability to administer a program of "unbundled" services with a
variety of funding sources, and the ability to separate but coordinate "housing" functions and
"service" functions.
Putting It All Together
Despite the seemingly lengthy list of problems and conflicts, existing programs can be
tapped to develop successful assisted living programs.
/
At a minimum states can use the flexibility in Medicaid to develop service packages
for elders in conventional housing that simulate the service component of assisted
living programs and allow elders to age in place in conventional housing.
/
Service programs can be fashioned to support delivery of personal care, skilled
nursing and support services to residents in existing board and care and similar
facilities for residents who are aging in place.
/
While HUD policy generally limits frailty of residents (incontinence), and prohibits
the direct provision of "medical care" (space for on-site nursing staff, use of HUD
funds to hire a nurse, residents may receive skilled nursing care and personal care
provided by community agencies.
/
States can use the flexibility in SSI to increase resident income to cover room and
board costs in the low to moderate end of market rate assisted living projects.
/
States can use Medicaid waivers to serve nursing home eligible elders.
/
States can use the Medicaid Special Income Level option to increase income eligibility
and to cover room and board costs.
/
States can coordinate priorities, guidelines and funding between Medicaid agencies
and Housing Finance Agencies to expand the supply of affordable assisted living
units.
/
Housing financing sources can be successfully used to create a new supply of assisted
living.
/
Each housing program has its advantages and limitations but each can be used to
finance assisted living.
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VII POLICY IMPLICATIONS
GOVERNMENT
FOR FEDERAL AND STATE
Existing programs do allow states to move forward. The previous chapters have described
some of the opponunities and problems associated with attempts to re-shape older programs
to new uses. The conflicts and obstacles are many though not insurmountable. The final
chapter describes the issues that state and federal policy makers could address to make it
easier to develop assisted living programs.
General Climate for Setting Long Term Care Policy
State experience with assisted living has implications for both state and federal policy
makers in three areas: consumer protection through regulation, offering consumer driven
social long term care models over traditional medical models and containing the fiscal crisis
fueled by population growth and the increasing cost of nursing home care.
Issues related to regulation are extensive. Currently the level of laws and regulations
governing assisted living are limited compared to nursing facilities, which may be one of the
most regulated industries in the country after passage of the Nursing Home Reform Act of
1987. Our national approach to nursing facilities emerged from the Medicaid and
Medicare regulation of acute care hospitals. Policy developed in the 1970s and 1980s for
long term care attempted to solve care problems by making nursing facilities look more like
hospitals even though residents in nursing facilities primarily require assistance with activities
of daily living rather than treatment of acute conditions. Lengths of stay are much longer in
nursing homes than in hospitals. Instances of abuse and accidents generated regulations
governing staffing, health and safety, inspection and enforcement to increase resident safety
and protection. This approach forces the industry to operate like hospitals while diminishing
resident privacy, dignity and control over one's life. Regulations that focus on safety,
treatment and documentation run counter to much of the philosophy of assisted living which
emphasizes shared responsibility for care and the ensuing risks, individual client differences,
and a "home-like" environment that emphasizes liveability rather than safety.
If assisted living develops as a nursing facility replacement model, regulators must alter
their approach. The challenge to policy makers will be to develop regulations which allow
and encourage maximum resident choice. Decision making by vulnerable adults brings risks.
Balancing resident protection against adverse risk while maximizing choice carries policy
makers into uncharted waters.
State and federal policy makers are interested in making assisted living responsive to the
desires and needs of elders. The notion of shifting long term care from the medical model to
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a more social model has both enchanted
policy makers who are interested in the
client empowerment movement and
threatened those who are highly invested in
the current system.
"For now, we need, within the current
limits of law, to give states the ability to
blendfimdingstreams for services,"
William Benson.
One of the most potent forces driving
policy is the projected increase in spending for nursing homes in the next 10 to 20 years.
State and federal Medicaid dollars currently pay for about forty two percent of the total
nursing home bill. The state share varies from 50% in the most affluent states to less than
25% in states with lower per capita income levels. The higher the cost of care in relation to
average elderly income, the higher the percentage of residents on Medicaid. In New York,
for example, close to 90% of nursing facility residents are Medicaid recipients.
State spending on nursing home care will double by the year 2000. At 1 % inflation,
0
states spending 4 percent of their revenue on nursing facility care today, assuming present
policies do not change, will spend over 8 percent of revenues on nursing home care in seven
years. States are aware of this phenomenon and have been looking for ways to limit this
liability. Over the last 15 years most states have moved heavily into providing home care for
the elderly. Providing this alternative care, along with moratoriums on nursing facility
construction in many states, has limited nursing facility bed growth in the last 10 years to
modest amounts. Continued expansion has been slowed by declining state revenues and
reductions needed to balance budgets. Several states, under growing pressure, have lifted
their moratoria on construction and are currently building new nursing facilities.
The Nursing Home Reform Act of 1987 set the stage for double digit inflation for
nursing facilities during the next 10 years. Since inflation rates for nursing facilities exceed
the annual increases in the income of elders, the percentage of nursing facility residents
funded by Medicaid is likely to increase substantially. The elderly population most likely to
use long term care (85 + ) will increase 44% by 2000. High inflation, higher percentages of
nursing facility residents on Medicaid and higher at risk populations translates into increased
pressure on state and federal resources.
Equity - Conflicts between Medicaid and Housing Poiicv
Tenant Discretionary Income
Straddling the line between a housing model and more traditional long term care model,
assisted living raises questions of equity between Medicaid recipients in state licensed
facilities and those financed from other sources. Residents in state licensed facilities retain a
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personal needs allowance while tenants in subsidized housing pay 30% of their income for
rent and retain the remaining portion of their income (Social Security, SSI). As developers
submit assisted living type models for 202 funding, residents of assisted living are treated
differentially depending upon the sources of financing for the housing component.
An SSI recipient whose benefit is $551 a month pays $165.30 for rent in a 202 facility,
leaving $385.70 available. HUD 202 guidelines also allow projects to charge residents up to
20% of their income, in addition to the rent, for services, which leaves more income for the
tenant. The same person in a licensed facility retains only the personal needs allowance of
$30-$94 a month, depending on the state and all other income is applied to the service costs.
This additional source of service funding may conflict with state Medicaid policies
concerning cost sharing for state plan services. Waiver programs use the post eligibility
treatment of income rules which generally require more than 20% cost sharing. Waiver
programs also serve nursing home eligible recipients. Many states do not require cost sharing
for state plan services. States that do require copayments are unlikely to require payments as
high as could be set in a HUD setting with assisted living units. In addition, cost sharing
rules apply to all recipients rather than those in a particular setting. A capitated service rate
might be developed and the Medicaid share would be based on the costs remaining after
applying funding from HUD and the resident. Fee for service payment methodologies may be
more difficult to devise unless the 20% cost sharing is not applied or is waived for Medicaid
recipients. Waiving the fee creates further inequities with other tenants. In order to maximize
opportunities to develop assisted living options for low income elders, Medicaid cost sharing
rules and HUD tenant service caps will have to be reconciled.
Service Policy Issues
Outside of Medicaid, the greatest single need on the service side is simply a source of
financing for low income elders who do not meet the Medicaid income guidelines. However,
service programs can be readily tailored to assisted living models though they were not
originally designed to support such a setting. A building with nursing home eligible Medicaid
recipients who qualify for a waiver, frail but not nursing home eligible Medicaid recipients
and nursing home eligible non-Medicaid recipients are treated differently. In states with a
home care program financed from general revenues, a housing management company may
have to follow three separate billing and documentation guidelines for the same package of
services.
Medicaid programs could be revised to be more "user friendly." In addition to new
survey and certification requirements, the Section 4711 or Frail Elderly Community Care Act
leaves states at risk if participation exceeds the amount of federal reimbursement under the
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appropriations cap. States should be able to
limit enrollment in accordance with their
allocation of federal funds.
Housing Poiicv Issues
"We need to look at new ways of
combining sources offunding - a revised
congregate housing services program,
Medicaid waiver and resident fees. There
is no other way to go in times of limited
funding but to deal with partnerships,"
Jerold S. Nachison.
In order for assisted living to become a
more widely available option for elders,
financing mechanisms need to: specifically
address assisted living requirements;
establish monthly resident charges (for both shelter and services) that are affordable by low
and moderate income elders, either by themselves or in combination with other funding
sources; and offer sufficient funding streams to create an incentive to leverage non-federal
sources.
Affordable Assisted Living
Financing sources are increasingly focusing on the need for services in housing for the
elderly. None of the public sources described, however, are specifically or solely targeted
toward affordable assisted living options. Despite their limitations, they do provide tools that
states and developers need to produce assisted living.
The 232 Mortgage Insurance Program is compatible with the assisted living design and
service packages through its board and care regulations, but it does not by itself assure
affordability for low and moderate income elders. Guidelines that increase allowable per unit
costs would encourage developers to add kitchens and baths which would broaden the
program's application to assisted living. Insuring 100% mortgages would enable non-profit
organizations to participate in the program.
Section 202 housing is exclusively for low income elders yet the requirement that 85% of
service costs come from non-202 sources forces the housing and service sides to work
together to complete the funding package. A 202 service cap of $15 per month, per unit is
insufficient to sustain an assisted living package. HUD does not provide direct funding for
health services in 202 housing. Legislative changes must be developed that make it easier to
dedicate service funding for assisted living programs that reflect the unique characteristics of
the program.
The new HOME program, which includes housing with supportive services in its model
programs and targets elders at a lower income level, is not a major funding source and the
CDBG program must cover a broad range of programs in addition to housing. In both
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HOME and CDBG programs, targeting of funds for assisted living options depends on state
and local priorities. They can, however, be a valuable resource for specific projects in some
areas.
Low income housing tax credits and tax-exempt bonds are partially targeted to low
income residents, but a focus on elders or supportive services must come from the state or
local level and the funds themselves are not sufficient to ensure long term affordability of
either rents or service packages. Tax credits were initially not allowed for housing that
provided significant services. That has since been changed, but now mandatory services are
considered a "condition of occupancy" and their cost to the tenant must fall within the 30%
of income rent cap. This is a disadvantage to models which include a "basic" service package
purchased by all residents and it is not compatible with design models that do not include
individual kitchens, which therefore make meal programs mandatory. It is not even consistent
with the provisions of the HUD 202 program that tenants can be expected to pay up to an
additional 20% of their income, beyond the 30% for rent, for a service package.
Assisted living developers need to make maximum use of existing targeting and set-asides
within current programs to develop viable programs. Over the long term, continued efforts
are needed at the federal and state levels to increase policy sensitivity to assisted living
models.
Compatibility of Housing Financing Programs
Many current federal programs cannot be combined to finance an assisted living facility.
For example, 202 building design costs excluded under the capital advance can be met only
by non-federal funds. HOME matching funds (as much as 50% of the cost of new
construction) must also come from non-federal sources.
When combined, the value of federal programs is sometimes reduced. For example, the
value of the low income housing tax credit is reduced from 9% to 4 if other federal funds
%
are used on the project. Also, if tax credits are combined with the 232 program, the project's
normal market-based system of rents and incomes changes to the tax credit income limits
(50% or 60% of area median) and rent caps apply (30% of qualifying income) for all units
designated as low income. This increases access for low income tenants. However, other
provisions compromise a project's viability. Tenant contributions for meals (which are
mandatory in a 232 board and care) and services must fall within that 30% rent cap. The tax
credits by themselves may not provide sufficient funds to the project to cover those long term
costs. Despite the limitations for "middle income" populations, these conditions will work
well if state funds are available for the service components.
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Income limits themselves are not consistent among the federal programs. While this may
not be a problem as long as most programs cannot be combined, it does have implications
for other sources of funds to be used with federal programs. Non-federal programs would
benefit from compatible income and rent eligibility thresholds. Varying income and eligibility
standards for Medicaid and state funded community based service programs mean that frail
residents who qualify for assisted living and low income housing may not be eligible for
service programs needed to complete the package.
One of the most serious areas of incompatibility is between the underwriting requirements
for long term mortgage financing and short term contracts for services or rental assistance.
Investors in tax-exempt bonds or Low Income Housing Tax Credits and lenders about to
issue 20-40 year mortgage notes are very concerned about the long term viability of the
development and its ongoing compliance with governmental regulations. Bonds also achieve
the lowest mortgage rates when purchasers of the bond are assured of the long term financial
stability of the underlying project. Long term financial stability, in turn, relies on
mechanisms that allow a sufficient cash flow through tenant payments and/or long term
subsidies.
In contrast, sources of service subsidies, rental subsidies, or other operating funds are
subject to annual legislative authorization or appropriation. This includes contracts which are
dependent on annual adjustments determined by HUD, such as the 202 Project Rental
Assistance Contract. An additional problem is the increasing trend toward tenant-based,
rather than project-based, rental subsidies. Subsidies that leave when a tenant leaves and may
or may not accompany an incoming tenant, such as Section 8 vouchers or the rental subsidies
allowed with HOME monies, do not provide long term cash flow assurances. Market rate
projects are able to project their cash flow based on the income and resources of tenants.
Some facilities may ask residents to leave when their resources are exhausted. Programs that
are dependent upon public programs for low income residents are reluctant to or cannot
"evict" tenants when government funding declines or terminates.
Program Funding Limits
Most programs limit their funding levels through annual program caps (such as 202, taxexempt bonds. Low Income Housing Tax credits, CDBG and HOME), or development or
per-unit limits (202, tax credits, HOME). These limits may create practical problems in
program implementation. For example, the authorization or appropriation levels for the 202
program may affect the maximum unit size. It is usually set at 125 units, but in fact many
HUD Field Offices do not receive sufficient allocations of funds, resulting in lower limits for
most non-metropolitan areas and some metropolitan areas. In the first round of funding for
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202, in fact, the appropriation for rental assistance funds only covered approximately 5 to
6,000 units, while the capital advances would have covered 9,400. The decreased size of the
funding pool forced HUD to move the competition from the Field Office level to the
Regional Office level.
Heavy competition for small pools of federal funds means that state or local agencies
need to provide timely and helpful assistance to individual applicants, including providing
necessary certifications (such as the certification by the appropriate state agency that the
service plan for a 202 building is well designed), or allocating state and local funds on
convenient timetables. Having a financing "pipeline", for example, where projects are
submitted for processing as they are ready, rather than annual funding competitions that
occur long before or after annual federal 202 competitions, or state competitions for tax
credits, would be most helpful to projects that combine multiple funding sources.
The clear intent of many federal programs is to leverage state, local and private funds
with limited federal funds. This means that in states that do not have sufficient funds to
create their own programs, or where housing with services for the elderly is a relatively low
priority, creating affordable assisted living options is very difficult.
States and localities that do have existing programs and funding sources need to be
careful to match them with federal programs, in terms of income limits, rent restrictions and
timetables for applications.
Uncertainty of Programs
Financing sources that are new, in transition or need reauthorization complicate long term
planning. For example, the effectiveness of operating cost standards in the new 202 program
is untested. It is unclear how well they will reflect actual market conditions and whether
HUD will find suitable comparable projects in order to determine these levels. The 232
program handbook has not been revised to include complete board and care provisions,
although that portion of the program was created in 1985. The Low Income Housing Tax
Credit program has required re-authorizations every two years or less since its creation in
1986. Unless it is made permanent by pending House legislation, the program will
periodically halt when re-authorization is delayed.
In order to succeed, future funding
mechanisms must acknowledge the major
differences between assisted living and both
housing and health care.
"We need to promote market diversity,
choices, price and quality competition,
Don Redfoot, AARP.
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Differences from Conventional Housing
Assisted living can be very staff intensive with unusual staffing patterns (e.g., heavier in
evenings when personal care needs are highest) that affect operating costs. Assisted living
also works best with architectural designs that foster greatest self sufficiency for residents,
such as short distances from units to dining room, a small "footprint" or foundation area,
elevators in two story buildings, etc. These design factors may not fit design and/or cost
standards or limits, but they may in fact help reduce the cost of service delivery and
therefore operating costs.
Differences from Health Facilities
Successful marketing of this option depends greatly on a residential appearance and in
fact on looking as little like a nursing home as possible. Regulatory or licensing standards
based on health facility standards will not work with assisted living. The provision of skilled
nursing service does not make a home into an institution and housing policies which equate
the two are probably more concerned with perception than the ability of a resident to age in
place. The prevailing philosophy of maximum resident involvement and a minimal amount of
hands on service to promote independence makes it hard to "bundle" service packages and
plan long term. This may also affect operating costs.
Operating Conflicts
HUD guidelines allow 202 projects to provide services, including personal care, yet 202
funds cannot be used to hire nurses. Most state rules require a role for nurses in assessing,
supervising and monitoring the need for and provision of personal care. If implemented
literally, HUD projects could receive contracts from Medicaid to provide services to
Medicaid recipients, yet they would have to contract with a community agency for the
nursing component. While HUD appropriately wants to avoid funding institutions, the
provision of personal care and nursing services do not make an apartment or assisted living
unit into an institution.
Further conflicts may exist in states that require the licensing of assisted living. HUD's
202 program does not fund sites that require a license since licensure is equated with
institutional care. While HUD guidelines are consistent with the configuration and service
packages in assisted living, licensure requirements may force owners to adopt terms that do
not fit the licensure requirements or, more likely, to develop service packages and resident
guidelines that are not considered assisted living. There are two approaches. First, state
licensure guidelines could focus on the services delivered in assisted living rather than the
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facility in which services are provided. This approach could be applied to all facilities or an
exception could be developed for those that are funded by the HUD 202 program. Second,
HUD could consider modifying its policy against funding all facilities that require a license.
As a housing and service option, assisted living could be considered a residential program
which, despite licensure, does not classify assisted living units as institutions.
Sgrnmary
Despite the multiple limitations and conflicts between programs, states do have options
for developing assisted living programs in existing and new buildings. The task is more
challenging because policy has not caught up with state of the art practice and knowledge
about this new model. Creative use of SSI and Medicaid eligibility options can provide
enough support to interest private sector facilities in serving publicly supported residents.
Service agency staff and HFA staff should talk about their mutual interests in developing
supportive housing and service arrangements before assisted living policies are finalized.
Collaboration between Medicaid, Aging and Housing Finance Agencies can create incentives
for developers and owners to build facilities that set aside units for low income residents.
Standards for assisted living units can be upgraded more easily when sources of financing for
construction and rehabilitation can be accessed through HFAs and HUD.
Each of the resources described in Chapters V and VI includes opportunities and
limitations. Some are more amenable to assisted living than others. HUD's mortgage
insurance (232) and construction programs (202) are easier to use than the LIHTC approach.
The state programs describe in Chapter IV demonstrate that workable models can be
designed to fit a range of priorities.
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Table 17. Summary of Housing Programs
Program
Benefits
Problems
Serves low income.
HUD & Medicaid income levels
differ.
Addresses aging in place.
Impairment guidelines target less frail
residents than Medicaid waivers.
Provides funding for services and
coordinator staff.
HUD 202
Requires matching funds for 65-85%
of service costs and outside contract
for nursing services.
Can use other non-federal sources of
funding to enhance project design and
amenities.
HUD 232
Provides financing enhancements.
Directed toward assisted living and
board and care.
Needs rent and service subsidy for
low income residents.
LIHTC
Amount of credit tied to number of
low income units.
Income levels vary with Medicaid.
Includes services: cost of optional
services allowed above rent caps,
(mandatory services within rent caps).
Limited ability to include mandatory
service package.
Reduced credit when combined with
other federal housing programs.
Tax Exempt bonds
Favorable financing rates, mixed
income (may discourage some
developers).
Underwriting standards require stable
financing for service funding.
HOME
Multiple uses, low income focus.
Requires non-federal matching
sources; availability vanes by state
and local priorities.
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Recommendations
Housing Poiicv
For a national program to be responsive, it needs to be flexible in design, cost, service
packaging and "frailty" guidelines. Different states need to be able to develop programs that
work in that state and can't be hamstrung by one national model. Conversely, for a state
program to be responsive, it needs to access the growing pool of expertise of
developers/sponsors, other states and localities. The existing, workable models around the
country should be allowed to create umbrella programs, rather than trying tofitfuture
developments into a narrowly defined national program. Accomplishing this will require that
each state seek out input from the appropriate agencies, including the state unit on aging, the
housingfinanceagency and the Medicaid agency.
Successful state programs can pave the way for legislative and regulatory changes which
will facilitate the expansion of publicly subsidized assisted living. The steps that will support
such an expansion are:
/
Allow HUD 202 projects to support assisted living projects or units within a project
even if they require state licensing as long as they remain residential and "home-like."
Licensure alone does not equal institution.
/
Establish broad criteria that allowflexibilityin the physical design, resident profile
and service package. There are a range of opinions (and practices) regarding the most
appropriate resident population and the best way to serve this population. Industry
experience is developing basic parameters and standards which will evolve over time.
Today's practices should not be "frozen" or standardized with rigid program
guidelines that may limit later improvements and innovations.
/
Cost and/or design standards should accommodate a variety of models (e.g., with and
without individual kitchens) and not rely on other types of housing for comparables.
Regulatory oversight should be
limited to basic safety concerns
(e.g.,firecodes) and avoid attempts
to create quality through over
regulation.
"We need to bring housingfinancepeople
to the table when talking about the figure
of long term care," Don Redfoot, AARP.
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/
The 232 mongage insurance per unit cost guidelines should be increased to cover
single occupancy units with kitchenettes and baths.
•
Equity requirements for 232 mongage insurance should be waived for non-profit
organizations with track records for developing and managing elderly housing.
/
Service subsidies and shelter subsidies should have the same contract terms and
eligibility guidelines.
/
Originating agencies need housing and services expertise. This is crucial in the initial
design of a financing program (i.e., service delivery patterns have implications for
architectural design) and for operating the program (developer should not have to go
to several places to get funding for different pieces.) Traditional housing philosophies
and medical care approaches must be modified to implement successful projects.
/
Reconcile income eligibility differences between housing and Medicaid programs or
develop service programs for non-Medicaid residents.
/
Upgrade standards for living units in board and care and assisted living.
Service Poiicv
/
Expand funding for services in assisted living sites.
/
Expand financing for services for residents who are not eligible for Medicaid but are
eligible for subsidized housing.
/
Reconcile cost sharing requirements and restrictions between housing and Medicaid
programs.
/
Review state nurse practice acts to determine the potential for delegation of more
functions to assisted living staff.
•
Implement payments for personal care, skilled nursing and other services in board and
care programs.
General Recommendations
/
Policy makers in both state and federal housing and service agencies should
coordinate their policies to complement mutual goals to suppon aging in place.
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/
Time frames for funding, issuing RFPs and awarding contracts for housing and
service agencies should be consistent to facilitate maximum use of resources
developers, service agencies and providers.
The descriptions in this Guide and the resources available cannot always be applied easily
in a state. Successful policy and program development requires careful deliberation and
collaboration between service agencies, housing agencies, service providers and housing
providers. Many of the obstacles cited in the descriptions of housing and service resources
can and have been overcome. The results may be a program that is different from what
would have developed in another environment. The limitations were drawn from the
experiences of those who have "done" assisted living. Despite the problems, assisted living
and housing and supportive models operate today. The limitations teach us what must be
done to make government resources more "user friendly."
In many respects it is difficult to present exactly how specific projects worked around the
limitations since program guidelines and agency policies are often shrouded in shades of
gray. There is no substitute for local brain-storming, creative programming and
communication with agency field and regional offices to resolve questions and chart a course.
Assisted living represents an entirely new approach to meeting the long term care needs
of elders. The Fair Housing Act and the Americans with Disabilities Act adds even further
impetus to the trend toward offering consumers choices based on their preferences. The seeds
of a consumer driven model were planted years ago in independent living models for adults
with disabilities and more recently in elderly housing models through the Robert Wood
Johnson Supportive Services Housing Demonstration project.
Closing Comment
Participants at the Academy's assisted living seminar in April heard several key criteria
that explain how assisted living differs from past models and how policy makers, program
administrators, developers and providers should view assisted living. Michael Rodgers,
Senior Vice President of the American Association of Homes for the Aging said, 'Our role
is to assist with, not to do for elders in assisted living."
And co-author Dick Ladd raised a more personal variable. 'Wlien 1 go into an assisted
living facility, I always have the feeling that I could live there. 1 could not live in a nursing
home." Policy makers might heed that thought as they design long term care policies and
models for the future.
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Finally, Don Redfoot, Legislative Representative for the American Association of Retired
Persons, concluded the April seminar with this advice: "Always keep your ears to what
consumer are saying and what markets reflect as far as demand from older consumers
themselves; not what you think they ought to want, not what
think is tasteful but what
consumers themselves are saying."
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Endnotes
1. Linda Bilheimer, Ph.D., et. al. "Factors Contributing to the Growth of the Medicaid
Program." Staff Memorandum. Congressional Budget Office. May, 1992.
2. Kaiser Commission on the Future of Medicaid. Medicaid Poiicv Overview: Medicaid's
Role and Problems. Staff paper. 1992.
3. Ibid.
4. Kathleen King, Richard Rimkunas and Dawn Neuschler. "Medicaid: Recent Trends in
Beneficiaries and Spending." CRS Report to Congress. Congressional Research Service.
March 27, 1992.
5. Ibid.
6. Ibid.
7. Peter Kemper, Ph.D. and Christopher Murtaugh, Ph.D. "Lifetime Use of Nursing Home
Care." The New England Journal of Medicine. Volume 324, Number 9. February 28, 1991.
8. Ibid.
9. Robyn I. Stone, DrPH and Christopher Murtaugh, Ph.D. "The Elderly Population with
Chronic Functional Disability: Implications for Home Care Eligibility." The Gerontologist.
Volume 30, Number 4. November, 1990.
10. Depanment of Health and Human Services, National Center for Health Statistics. 1984
National Health Survey, Supplement on Aging.
11. "Aging in America: Trends and Projections." U.S. Senate Special Commission on
Aging, American Association of Retired Persons, Administration on Aging, National Council
Washington. 1991.
12. Ibid.
13. Alice M. Rivlin, Joshua M. Wiener, et. al. Caring for the Disabled Elderly.
Who Will Pav? The Brookings Institution. Washington, D.C. 1988.
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14. Office of National Cost Estimates. "National Health Expenditures, 1988." Hgglth Care
Financing Review. Health Care Financing Administration. Washington, D.C. Summer, 1990.
Volume 11, Number 4.
15. Charlene Harrington, Steve Preston, Leslie Grant and James H. Swan. "Revised Trends
in States' Nursing Home Capacity." Health Affairs. Volume 11, Number 2, Summer, 1992.
16. Victor Regnier, Jennifer Hamilton, and Suzie Yatabe. Best Practices in Assisted Living:
Innovations in Design. Management and Financing. Los Angeles, California: National Elder
Care Center on Housing and Supportive Services, Andrus Gerontology Center, University of
Southern California. May, 1991.
17. Ibid.
18. Throughout the Guide, SSI refers to both the federal payment and the state
supplementary payment.
19. Keren Brown Wilson, Ph.D. "Beyond Loving Care." Paper presented for the Oregon
Gerontological Society. Portland, Oregon; Wilson, Keren. "Assisted Living: The Merger of
Housing and Long Term Care Services." Long Term Care Advances. Duke University
Center for the Study of Aging and Human Development. Durham, N.C. 1992; Regnier,
Ibid.; Association of Assisted Living Facilities Association. Newsletter, June 8, 1992.
Fairfax, Virginia.
20. Unfortunately, a more appropriate term has not yet emerged. Despite its limitations, the
Guide uses the term "facility" top describe assisted living environments in the absence of a
better term.
21. "Development of Residential And Health Care Services for the Elderly on Surplus State
Property: Report to the Massachusetts Division of Capital Planning." A/D/S/ Consulting
Group. Inc. Cambridge, Massachusetts. July, 1992.
22. Ibid.
23. Ibid.
24. Keren Brown Wilson, Ph.D. "Assisted Living: A Model of Supportive Housing." Journal
of the American Geriatrics Society. Fall, 1992."
25. Keren Brown Wilson, Ph.D. and Michael R. DeShane, Ph.D. Implementation df
Assisted Living in the State of Washington. Concepts in Community Living. Portland,
Oregon. 1992.
.
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26. Free standing ICFs are generally wood framed, 2 story dwellings without elevators. To
meet nursing facility standards, these facilities must have an isolation room(s) with private
bath close to the nursing stations, emergency generators, elevators if non-ambulatory
residents live above the first floor and accessible toilets and bathing facilities. Susan
McDonough, Lanzikos, McDonough and Associates. Boston, Massachusetts.
27. The Massachusetts Department of Public Welfare is considering creating a higher
payment standard for programs which meet the draft guidelines for assisted living.
28. Since this program is relatively new, it is presented in more detail than the other
programs.
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�APPENDIX
�Developed by Concepts for Community Living
NEGOTIATED SERVICE AGREEMENT
Resident:
Unit Number:
Date of Anival:
/
/
Date Agreement Initiated:
/
/
The following Negotiated Service Agreement is a joint effort between the resident, family
members (when appropriate), Aging and Adult Services Case Manager and facility staff.
Its purpose is to define the services that will be provided to the resident, with consideration for preferences of the resident as to how services are to be delivered.
For each service item, develop a statement which includes service delivered, who provides
the service, when the service is provided, how the service is provided, and the frequency
of the service provided.
NURSING SERVICE NEEDS AND PREFERENCES
Health Monitoring
Nursing Intervention
Special requests
Supplies/Services Coordination
Medication
PERSONAL SERVICE NEEDS AND PREFERENCES
Toileting
Bathing
PM Preparation
Dressing
Hygiene
Ambulation
�AGENDA
BUILDING ASSISTED LIVING INTO PUBLIC LONG TERM CARE
PROGRAMS: A SEMINAR ON PUBLIC POLICY
Wednesday, April 15, 1992
8:30 - 9:00 a.m.
Wtlcomt and Introduction: This segment will review purpose of the meeting, format
and agenda, defining assisted living and outline what states can do now to implement
assisted living.
Charles Reed, Chair NASHP Long Term Care Steering Committee and Assistant
Secretary, Aging and Adult Services, State of Washington.
Robert L. Mollica. Professional Staff, National Academy for State Heallh Policy.
9:00 - 10:00 a.m.
The Assisted Living Approach: Privait Sector Approaches
Paul J. Klaassen, President of the Assisted Living Facilities Association of America
will describe the design, service package, frailty and health status of residents and
costs of the private sector models. He will also address how assisted living avoids the
institutional syndrome, builds a residential environment and balances social and health
services to avoid the medical model.
10:00 • 12:00 a.m.
Adapting Private Models for Public Programs - State Models of Innovative
Programming and Financing
State models are targeting nursing home eligible populations. This session will
present how states have developed assisted living despite multiple obstacles in current
law and program regulations. The state experiences will highlight both the
innovations and the lessons for policy considerations.
Richard Ladd, Administrator, Senior And Disabled Services Division, State of
Oregon.
Charles Reed, Assistant Secretary, Aging and Adult Services, State of Washington.
Barry Berberkh, Director of Long Term Care, Department of Social Services, State
of New York.
Larry Polivka, Assistant Secretary for Aging and Adult Services, Depanment of
Health and Rehabilitative Services, State of Florida.
Luncheon
12:00 - 1:55 p.m.
Assisted Living and Long Term Care: What Is lis Place Along the Continuum?
Rosalie A. Kane, D.S.W., Professor, School of Public Health University of
Minnesota, will discuss the potential of this approach to maintain independence as a
necessary part of an effective long term care system. She will also explore the
services, and the need to restore the essential components of residential living to
support and promote independence.
�2:00 - 3:10 p.m.Tht Sexl Generation: Charting a Public Policy Course
1
Focus. This interactive working session will explore the policy conflicts between assisted
living and existing programs, the need to implement a sound public assisted living model and
the public policy changes that are necessary to advance this approach. Respondents and
seminar participants will react to short statements on key issues.
Moderator: Robert L. Mollica, Professional Staff, National Academy for State Health policy.
Respondents: Richard Ladd, Administrator, Senior and Disabled Services Division, State of
Oregon.
Charles E. Reed, Assistant Secretary, Aging and Adult Services, State of Washington
Michael Rodgers, Senior Vice President, American Association of Homes for the Aging.
Jerold S. Nachison, Chief, Services Bureau, U.S. Depanment of Housing and Urban
Development.
Robert Clark, Policy Analyst, ASPE, U.S. Department of Health and Human Services.
William Benson. Staff Director, Senate Labor and Human Resources Committee,
Subcommittee on Aging.
Issues
Models: Where does assisted living fit with other models (Board and Care, Adult Homes,
Congregate Housing, Conventional Housing with Services Arrangement, Nursing Facilities)?
Is assisted living new packaging of old models or a new approach?
Resident profile: Who is it for. how do you target them, how much health care can be
delivered in assisted living, how does assisted living fit in relation to long term care priorities?
Impact on state expenditures: What are the goals: cost savings or new services options. Is
assisted living a cost effective alternative that will limit aggregate expenditures or new supply
that will boost marginal long term care program costs?
Financing: What are the sources of financing for the services and housing (construction and
operating costs). Can you balance design, size, amenities and costs.
Eligibility: What are the eligibility conflicts and limitations among programs: housing
subsidies, Medicaid eligibility, National Affordable Housing Act and state general revenue
programs.
Safeguarding Quality: Do we need licensing and/or standards? Can you safeguard quality
without the high cost of extensive regulation? How do we avoid excessive bureaucracy and its
added costs? How do you reconcile the roles of multiple state agencies? Which agency should
administer the program?
4:30 - 5:00 p.m.
TTie Next Steps • Creating an Agenda For Policy Reform
Don Redfoot, Legislative Representative, American Association of Retired Persons. The
wrap up session will synthesize the issues explored during the seminar, highlighting areas of
consensus and recognizing issues that require further development to develop a working
agenda to pursue steps that will advance assisted living as an affordable state supponed option
for frail elders and disabled adults.
�STATEMENTS TO THE RESPONDENT PANEL
1.
What is it?
Assisted living emphasizes a home environment and the provision of health and support
services in a residential atmosphere. In a sense it represents a new approach that
emphasizes the housing environment and home care services. Assisted living represents
a new enthusiasm for serving elderly and disabled individuals. Some contend that assisted
living facilities operate as unlicensed nursing homes. Others compare it to other housing
and service models. Do today's models differfromnursing homes, board and care,
personal care homes, adult homes? And is there a difference between congregate
housing, retirement housing and assisted living or is assisted living a generic term that
covers multiple models?
2.
Profile
Assisted living interests public policy makers and program managers as an alternative to
nursing homes. Private models may sometimes require independence in most ADLs upon
entrance. Others do not. The resident mix of most facilities includes a sizeable
percentage who are eligible for placement in a nursing facility.
Public models have thus far been developed for people who would otherwise be placed
in a nursing home. Who is best served in assisted living? How much medical care can
be delivered? Should skilled care be provided? Can everyone in a nursing home be cared
for in this model? Is there still a place for nursing homes?
3.
Aggregate Long Term Care Costs
Governments at all levels are desperate for effective steps to control long term care
expenditures. Community care promised savings that never materialized. Maybe the
expectations were faulty and community care is now valued in its own right.
Still states search for alternatives. Is cost savings the driving or even primary force in
assisted living? Will new assisted living models mean an increased supply of long term
care? What are we looking for in this model?
4.
Financing
There are several ways tofinancehousing and services. The first approach selects a
single program for both services, housing construction and operating costs. On the
service side, a Medicaid approach creates a struggle to avoid the heavy regulatory
tendencies that brought us institutions. Using HUD or a Government Sponsored
Enterprise would ask housing agencies to care for, and manage services to, a frail
population. In addition it would encroach upon the jurisdictions of multiple congressional
committees.
�The second approach builds on the expertise of both the housing and service systems. But
this requires that existing policies be reviewed and revised from a totally new
perspective. On the housing side, HUD or a government sponsored entity such as Fannie
Mae could be used. Funds from service programs would have to meet underwriting
requirements to ensure the viability of the housingfinancing.Which is the preferred
approach? What is the best vehicle to finance services? Can it be done?
Funding streams affect the product. Should we separate funding streams for housing and
services or keep them together like Medicaid nursing home reimbursements?
5.
Eligibility
Public programs labor under conflicting eligibility guidelines governing income, assets,
functional and health criteria. Guidelines have two basic purposes: to control costs by
limiting participation and expressing the goal of the program by identifying the target
population. The resulting criteria leave gaps.
How do you bridge the housing and service systems criteria? If HUD provides the
housing financing, can only Medicaid recipients receive services? Must HUD cover
services for non-Medicaid recipients? Should we preserve the traditional lines between
housing development and management and the service systems? Does the new housing
bill blur those lines and is the most effective approach.
6.
Quality
In a private home or apartment, nearly any long term care service can be provided.
When the locus of care moves out of the home, it becomes highly regulated, more
institutional and it encourages dependence. A medically and functionally frail adult can
often receive very extensive care in their own home and no one worries about the stairs,
the corridor a locked medicine cabinet or the distance from the resident to the caregiver.
Once the care setting moves outside the home, regulatory steps to protect the resident's
safety take over and gradually the home like environment turns institutional.
As this industry comes under public scrutiny, do we accept too much of the regulatory
approach? How can the goals of safety be converted into practice without making
facilities and staffing requirements toorigid?Can we develop regulation on outcomes and
avoidrigidstandards for buildings and staffing?
�Page Two
FOOD SERVICE NEEDS AND PREFERENCES
Dietary
Eating
ENVIRONMENTAL SERVICE NEEDS AND PREFERENCES
Safety
Housekeeping/Laundry
SOCIAL/EMOTIONAL SERVICE NEEDS AND PREFERENCES
Family Intervention
Information/
Assistance
Counseling
Orientations
Behavior
Management
Socialization
ADMINISTRATION NEEDS AND PREFERENCES
Business Management
Transportation
�Page Four
RESIDENT DIRECTED GOALS
NAME:
APARTMENT #:
PREFERS TO BE CALLED:
PHONE#
PHYSICIAN:
PHONE #
FAMILY/CONTACT PERSON:
PHONE#
AAFS CASEMANAGER:
^s^^=
====;
FORMER OCCUPATION/CURRENT INTERESTS
PHONE#
BRIEF HEALTH HISTORY
The following statements are written in an effort to assure that the services provided are carried
out in a maimer consistent with the principles of Assisted Living, supporting choice.
Independence, individuality, dignity, privacy, and a sense of home. To the extent possible,
they should reflect the resident's own values and goals.
Date new entries.
GOALS AND APPROPRIATE STAFF PROCEDURES
�Page Three
SPECIAL NEEDS/REQUESTS AND PREFERENCES
COMMENTS
L E V E L O F ASSISTANCE NEEDED:
For this Service Agreement to be effective, signatures of participating are requested. Signing
below indicates that the services that are provided to the resident shall be provided as outlined
in this Service Agreement. Amendments shall be added as necessary, when services and/or
needs and preferences change.
RESIDENT SIGNATURE:
DATE:
FAMILY MEMBER:
DATE:
FACILITY STAFF:
DATE:
AAFS SOCIAL WORKER
OR COMMUNITY NURSE:
j
�A E A P E O A S S E LIVING U I S
N XML F S I T D
NT
U N I T
A
14 ft. x 22 ft. moduli
I
I
I
I
1
I
I
I
�State Contacts
Florida
Vicki Flynn
Vicky Campos
Aging and Community Services
Aging and Adult Services
1317 Winewood Boulevard
Tallahassee, Florida 32399
904-488-2881
Massachusetts
Diane Flanders
Medical Assistance Division
600 Washington Street
Boston, Mass. 02111
617-348-5570
Jan Levinson
Jean Moltenbrey
Executive Office of Elder Affairs
1 Ashbunon Place
Boston, Mass. 02108
617-727-7750
New York
Barry Berberick
Director of Long Term Care
Department of Social Services
40 N. Pearl Street
Albany, New York 12243
518-473-5611
Frank Rose
Division of Adult Services
40 North Pearl Street
Albany, N.Y. 12243
518-432-2404
Oregon
Susan Dietsche
Assistant Administrator
Senior and Disabled Services Division
313 Public Service Building
Salem, Oregon 97310
503-378-3751
Washington
Charles Reed
Harry Sedies
Aging and Adult Services
MS OB-44A
Olympia, Washington 98504
206-586-3768
�C E N T E R FOR H E A L T H POLICY DEVELOPMENT
National Academy for State Health Policy
Thi.- Cenler tor Heallh Polioy Developmenl, a nol-lbr-profil eduealiorul organization, brings the best available analytical and
operational expertise to bear on critical issues in heallh eare financing and delivery. Organized in 1987 in Washington. DC,
the Cenler moved its headquarters lo Maine in 19S9 and affiliated with the University of Southern Maine. The Cenler
conducts policy research, evaluation and analyses, and convenes symposia of experts from the public and private sectors and
lhe research communily.
To address state concerns, lhe Center provides staff support for the National Academy for Slate Heallh Policy. The
Academy provides a forum lor leading stale heallh policy officials lo exchange insighls, infonnation and experience and to
develop practical solutions io problems they confront. An executive committee of leading state officials governs the
Academy which represents slate policy planning offices, budget offices, state insurance commissions, heallh departments,
Medicaid agencies, legislative leadership, heallh cost data commissions, aging offices and state university policy institutes.
The Academy recognizes lhal responsibility for health care does not reside in a single stale agency or department and
provides a unique forum for productive inlerchangc across both department and agency and executive and legislative lines of
authority. Steering commillees of volunteers from various executive branch agencies and legislatures play a key role in
identifying the Academy's agenda and in developing innovative and effective strategies to improve the delivery and
financiiig of health careTo disseminate information and analyses of promising policy innovations, both the Cenler and its Academy develop and
distribute a variety of publications including issue briefs, policy analyses, case studies and leehnical resource documents.
The Cenler and Academy also convene lorums and workshops, provide leehnical assistance to slates and sponsor an annual
stale heallh policy conlercnce.
Examples of proiecls include:
Center f o r Vul/icrublc Pnpulatinns. A three year program, co-directed by the National Academy for Stale Health
Policy and The Bigcl Inslilutc for Health Policy, Brandeis University and supported through a grant from The
Henry J. Kaiser Family Foundation. The Cenler will conduct research and policy analyses, examine best stale
practices for vulnerable populations, and aggressively disseminate lhe results to stale health policymakers.
Medicaid Mana^id Care Resource Center Supported through a grant from The Pew Charitable Trusts, the
Resource Center will place special emphasis on the dynamics of adequately meeting the needs of key groups of
Medicaid enrollees: women and children served under AFDC and EPSDT. the elderly, and lhe cognitively
impaired. The Cenler will create a eenlralized source from which technical assistance may be provided to states in
meeting the challenges presented by these growing programs.
State Health Policy Reform Commissions: A Guide f o r States, supported through a grant from the Robert Wood
Johnson Foundation. January, 1992
Access and the Uninsured: A Guide to States, supported by The Pew Charitable Trusts and the Health Resources
and Services Admimslralion, DHHS, 1991.
State Heahh Policy: A Sourcebook, supported in part through grants from the Pew Charitable Trusts and the
Robert Wood Johnson Foundation, 1991.
Medicaid Managed Care: A Guide to States, supported by the John A. Hartford Foundation. 1990.
Collaborative Strategies to Improve State & Local Public Health Systems, funded by lhe Health Resources and
Services Administration. DHHS, 1990.
Institute on State Health Policy. March 14-16, 1991, Washington, DC.
Public Policy Seminar on Assisted Living. April 15, 1992, Washington, DC, supported by the Robert Wood
Johnson Foundation and lhe Center for Vulnerable Populations/Henry J. Kaiser Family Foundation.
Annual State Health Policy Conferences (1988-1992)
1993 Stale Heallh Policy Conference. August 8-10
For additional copies of this or other publications,
or for multiple copy discounts, please contact Jan Fisk al the
50 M.mumenl Square. Suae M2't'onlaiid, ME'04101 1'h: 2()7-li74-6i24/Fajt: 2<)7->l74-6527
Academy.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
[Building Assisted Living for the Elderly into Public Long Term Care Policy: A Technical Guide for States] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-035-002-2015
12092971
-
https://clinton.presidentiallibraries.us/files/original/eddb8160f0c9864ccd336fa94c8a75a1.pdf
480e56360a3494c8ec83484142e725df
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1338
OA/ID Number:
FolderlD:
Folder Title:
[Blair Letter] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
1
6
2
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
Arlene Blair to President Clinton [partial] (1 page)
8/30/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1338
FOLDER TITLE:
[Blair Letter] [loose]
2006-0885-F
wr830
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information [(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute [(a)(3) of the PRA)
P4 Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency [(b)(2) of the FOIA)
b(3) Release would violate a Federal statute [(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information [(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
Arlene Blair to President Clinton [partial] (1 page)
8/30/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1338
FOLDER TITLE:
[Blair Letter] [loose]
2006-0885-F
wr830
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)]
PI
P2
P3
P4
b(l) National security classified information [(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA|
b(3) Release would violate a Federal statute [(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells [(b)(9) of the FOIA]
National Security Classified Information |(a)(l) of the PRA|
Relating to the appointment to Federal office [(a)(2) of the PRA]
Release would violate a Federal statute [(a)(3) of the PRA]
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRIM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�1
a.
00
August 30,1993
President of the United States
The White House
Washington,D.C.20500
Mr. President:
To begin with, let me quote Moliere: "Unreasonable haste is the direct road to error." We
do not need another government agency—"The National Health Board"—you are only
shifting the cost from one area to another. You are supposed to be downsizing
government. The cost of trying to enact a Health Reform Program is astronomical and
you have no idea how to finance it making this a devastating situation. The American
public is against price controls, against mandates, against government control of any
sort we want fcee enterprise, the American Way of Life. To quote the Heritage
Foundation: "With a fixed national health care budget, a federal bureaucracy will decide
on the standards of care for the nation to meet the spending limit they set." This scares
me!
Of course some reforms are needed, but first let each State perfect its own plan as some
already have done. One program cannot deal with the diversity of 50 states. Let the
pharmaceutical companies, the insurance companies, the hospitals, and all other medical
facets develop their own resources to cut costs. Take care of the 37 million uninsured
but leave the 80% alone who are satisfied.
Health Care is not the sole cause of our burgeoning deficit. There are many other
government agencies who contribute to this problem. Cut the spending! Where is the
25% spending cut you promised? How about a Congressional pay cut before you start
cutting people's social security checks by adding taxes to them? Adding a new
government bureaucracy for health care does not correspond with your promised 25%
spending cut.
Arlene E. Blair
�Beware this 'reform'
Don't destroy
OPPOSING VIEW the many
good •sports ol the prosant
hoatth-cart systam.
Americans are living longer and
healthier than ever before. Infant mortality hitsrecordlows every year, while
average length of life
hi is record highs.
This is true despite
AIDS and despite the
scourge of homicides.
But instead of provoking celebration,
these facts go unnoticed. One would
think that in time of By Harry
national debate about Schwartz, a
Scarsdale, N.Y.,
health reform, the writer who spegreat achievements of cializes in mediour health system cal topics.
would be known to
everyone; but the mediafindgood news
boring and the White House wants to focus attention on what's wrong with U.S.
healthcare.
.
If the American peoplerealizedwhat
t
a superb job their doctors, nurses, hospitals, pharmaceutical companies, et al.
are doing, they might ask why we need a
completereorganizationof our healthcare system — with all the confusion,
mistakes and, yes, lives needlessly lost
this will certainly bring.
Essentially, the Clinton plan wants to
forcibly corral us all into health maintenance organizations where we will become numbers to our caregivers. Doctors will be trained to look at their sick
patients as cost criminals who should get
as little care as possible to spare the
budget We will lose our choices about
who treats us and how.
If the Chnton plan — or anything like
it — becomes law, we will all be losers,
except therichand people in politically
powerful positions who will be able to
command first-class care for themselves.
Of course there are problems in today's system, like people without insurance, but they arerelativelyfew. And
their problem can be solved without destroying the world's best health-care system for the great majority of Americans.
Why fix it if it ain't broke?
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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Health Care Task Force
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Rump Group
Stack:
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s
52
7
9
2
�THE W H I T E H O U S E
W A S H I N G T O N
MEMORANDUM
To:
Distribution List
From: Chris Jennings
Date: August 19, 1994
Re:
"Rump" Group Recommendations
Attached is a copy of the just released summary of the Mainstream "Rump" Group's proposal.
As of this writing, Senator Mitchell is being briefed on this document and the Mainstream
Group will hold a press conference soon after this meeting concludes.
It is absolutely imperative to note that the numbers on this document are not final and are
incomplete. For example, if one were to look at just the total financing line on the final page
of this document, one might conclude that this proposal has $454 billion of deficit reduction.
It does not. This table does not include the cost of the subsidies that this agreement proposes.
It is likely that the subsidy proposed would eat up all or most of this number. Other notable
changes include: 1) this plan has no medicare drug benefit and 2) the long-term care
proposal has been reduced from $48 to $10 billion and was made into a means tested
program. Lastly, the Mitchell mandate trigger has been replaced by a soft trigger designed
similarly to that of the finance committee mark.
Distribution
Leon Panetta
Pat Griffin
Harold Ickes
Ira Magaziner
Steve Ricchetti
Alice Rivlin
Linda Blumberg
Gary Claxton
Judy Feder
Debbie Fine
Karen Hancox
John Hart
Monica Healy
Christine Heenan
Jerry Klepner
Jennifer Klein
Greg Lawler
Jack Lew
Larry Levitt
Mike Lux
Lynn Margherio
Lome McHugh
Meredith Miller
Nancy Ann Min
Len Nichols
Kim O'Neil
Karen Pollitz
Laura Quinn
Pam Short
Gene Sperling
Bridgett Taylor
Ken Thorpe
Eric Toder
Melanne Verveer
Bruce Vladeck
Marina Weiss
Marilyn Yeager
�Major Components of Mainstream Agreement
The Mainstream agreement dramatically reduces insecurity and price
unpredictability for the 220 million Americans who are currently insured or
underinsured. Additionally, the Mainstream Coalition is committed to expanding
coverage to the majority of Americans who currently have no insurance. The
agreement ensures that Congress will vote on recommendations to achieve
universal coverage if we're not there by 2002.
The agreement reduces health care costs through market-based system
reform, rather than a regulatory approach. The agreement also locks in deficit
reduction. It changes the rules for buying and selling health insurance plans.
Consumers will become better purchasers by being able to compare quality and price
information. It combines national insurance reform, voluntary cooperatives for
small businesses and individuals, adjusted community rating, and expanded tax
deductibility to expand access to coverage without mandates.
Ail individuals, including Medicaid and Medicare beneficiaries, will be able
to purchase private health plans.
The agreement includes a provision which removes the uncertainty from
CBO estimates about the cost of health reform by putting in place a fail-sa/e
mechanism to ensure that deficit reduction and cost containment goals will be met.
In addition, the phase in of subsidies will be based on actual market experience
rather that CBO projections.
INSURANCE REFORMS
GUARANTEED ACCESS:
All qualified health plans must:
*
Guarantee issue to all applicants;
*
Guarantee availability through the entire community-rating coverage area;
*
Guarantee portability and renewal to all;
*
Not deny, limit or condition coverage based on health status;
*
No pre-existing conditions in open enrollment period;
*
Age-adjusted community rating for all small firms (under 100) individuals
and self-employed buyers (states define community rating coverage areas).
�BENEFIT PACKAGES:
Consumers need the ability to compare health plans on the basis of cost and
quality. The bill offers nvo benefit options, a standard and a basic (alternative
standard) plan. The standard plan will include the 12 benefit categories with an
actuarial value equivalent to FEHBP's Blue Cross/Blue Shield standard option plan.
The basic package will have a lower actuarial value, with fewer benefits and/or high
deductibles.
Congress defines and sets forth the standards for determination of medical
necessity or appropriateness. The plans must provide all medically necessary or
appropriate care within the benefit categories.
The National Health Benefits Boafd, like the Office of Personnel
Management at FEHBP, will design the packages based on criteria set in law. The
Board does not have regulatory authority .
ADMINISTRATIVE SIMPLIFICATION:
Implements a national health information network to reduce the burden of
administrative complexity, paper work, and cost on the health care system; to
provide the information on cost and quality necessary for competition in health
care; and to provide infonnation tools that allow improved fraud detection,
outcomes research, and quality of care.
QUALITY:
All health plans must comply with insurance reforms and quality standards
to ensure:
*
*
*
*
quality improvement and assurance
fair utilization management
consumer protection and consumer information
equal access for all enrollees
HHS will be advised by a Quality Council. Regional quality improvement
will be supported through a demonstration project.
�NATIONAL
RULES:
All anti-competitive state laws, including laws that limit managed care,
restrict corporate practice of medicine or impose benefit mandates are preempted,
except as modified by this Act. Essential community providers are limited to two
categories: Rural Health Clinics and Federally Qualified Health Centers.
EMPLOYERS' RESPONSIBILITY
All employers must distribute comparative information and offer their
employees a choice of 3 qualified health plans, including a point-of-service (POS)
option or fee-for-service if available. Employers must provide for payroll deduction
at the employee's request, but are not required to pay a portion of the employees
health insurance premiums. Employers with fewer than 100 employees may join a
purchasing cooperative in lieu of offering three plans. All firms employing more
than 100 employees may negotiate rates or may self-insure.
Association Health Plans:
Grandfathers certain association health plans. Qualified association plans
(QAP) must have covered at least 500 covered lives as of date of enactment.
QAPs may enroll association members only.
•Multiple Employer Welfare Arrangements (MEWA):
A MEWA must meet the standards for either a qualified association plan or a
purchasing cooperative.
Rural Cooperatives:
Rural Electric Cooperatives and Rural Telephone Cooperative Associations
are treated as large employers.
SUBSIDIES
LOW-INCOME:
The government would provide subsidies for premiums for individuals and
families with incomes of up to 200% of poverty. A full premium subsidy would be
extended to persons with incomes below the poverty line; that premium subsidy
would become available once the bill became effective. A partial premium subsidy
(the amount of the subsidy would decline as income rose) for persons with incomes
�between 100% and 200% of poverty; that subsidy would be phased in between 1997
and 2004. Subsidies would be available for pregnant women and children up to 18
years with incomes up to 240% of the federal poverty level.
MIDDLE - INCOME::
The proposal makes health insurance more affordable for individuals
without employer-provided health insurance and the self-employed by phasing in a
100% deduction for their health insurance premiums.
FEDERAL HEALTH PROGRAMS
MEDICAID:
;
Allows states to enroll Medicaid patients into managed care plans without
applying for a federal Medicaid waiver. The proposal sets standards by which states
may enter into contracts with managed care plans.
MEDICAID:
The Medicare fee-for-service is not changed. In addition. Medicare
beneficiaries have expanded choices. Seniors and the disabled may choose the same
qualified basic benefit package, offered through their employer or purchasing
cooperative. The Medicare managed care program is improved to encourage more
plan participation, including revision of federal payment to health plans to reflect
market costs. Provides easy access to compare infonnation and allows all Medicare
beneficiaries access to all Medicare choices during an open enrollment period,
regardless of health status.
UNDERSERVED AREAS:
Competitive grants are authorized to develop community health groups,
certified community health plans, community health networks, and provide capital
assistance. The grants will help address geographic, financial and other barriers to
health care services in underserved urban and rural areas. This section also
authorizes rural health plan demonstrations to improve access to plans in rural
areas, and a telemedicine program to assist rural providers with specialty
consultation, continuing education, referrals, provider collaboration. The
telemedicine program emphasizes projects that maximize the use of existing
community resources.
�LONG TERM CARE
Home and Community-based Long Term Care Program:
Establishes a new capped federal program for home- and community-based
long term care services. This program will be administered by the states and will be
limited to those with incomes below 150% of the federal poverty level.
Tax Treatment of Long Term Care Insurance:
The agreement makes it easier for individuals to deduct expenses for long
term care and premiums for long term care insurance policies. In addition,
employer-provided long term care is excluded from an employee's taxable income.
Amounts paid out under a long term care insurance policy up to $150 per day would
not be subject to federal income tax.
UNIVERSAL COVERAGE
Provide»-that at least 95% of all Americans will have health care coverage by
2001. Every 2 years a Commission will issue a report that outlines who is uncovered
and why, as well as how cost containment is working. If 95% coverage is not
reached, the Commission must submit recommendations to Congress on how to
achieve the goal. Congress must vote on the recommendations, or propose
alternatives, in an expedited legislative process that guarantees a Congressional
vote.
FINANCING
The agreement raises additional revenues to finance health care reform by
increasing tobacco taxes by $.45 a pack; pxtendiny tht* Modi care Hospital Insurance
tax to all state and local employees; raising Medicare part B premiums for
individuals with incomes over $73,000 and couples with incomes over $100,000;
imposing a tax on high cost health plans; and other Medicare and Medicaid
spending reductions.
�COST CONTAINMENT
MARKET REFORMS:
Cost containment would be achieved through market reforms: changing the
unfair insurance market; establishing adjusted community rating; establishing
comparable benefit packages so consumers can compare price and quality; preempting anti-competitive state laws; reforming medical liability laws; and revising
the tax code to promote cost-conscious buying of health care.
HIGH COST HEALTH PLAN ASSESSMENT:
^ \ ^ )
^
e agreement ihcludes a ifew tax orUtigh cosj^hsuf^^e plans, the/eby
dd^nonal inc&n^ves for insurers toVin^down the co??*«44i^health
h more effidemJgfealth care deliveK/^High cost plans geflef&i^are
e amorjg th^ft^t^xpensive p ^ s S « i ^ i n a markeL/HoweverJ^e
those/w!
n ^Xvay whiclMeeien^ie impacTlSf Um u / i n areas which
tax wtirfx calc
e low health capro^osts relative to/naffonal benchmarks.
alreaGy efficient and
MALPRACTICE:
Limits non-economic damages in medical malpractice cases to $250,000.
Within one year, an advisory committee will develop and recommend to Congress
a sliding scale of limits for non-economic damages. In addition, requires nonbinding ADR, with incentives to abide by ADR. Imposes limits on attorneys fees.
75% of punitive damages are deposited in a state fund for quality and discipline.
Establishes several liability for non-economic and punitive damages. Does not
preempt state laws to the extent such laws impose greater restrictions on attorneys
fees or liability, or permit additional defenses to malpractice actions.
REMEDIES FOR CLAIMS DISPUTES:
All claims disputes are adjudicated by a neutral third-party, not affiliated with
the health plan. Remedies are limited to the amount of the claim, and attorneys
fees. In addition, health plans conducting preauthorization or utilization review
are required to use reasonable care in making medical judgments.
A health plan that fails to use reasonable care may be liable for compensatory
damages with a $250,000 cap on non-economic damages. A health plan is not liable
if the claimant fails to use the third-party claims dispute process, or if the plan
decision was upheld by a neutral third-party.
�ANTI-FRAUD AND ABUSE CONTROL PROGRAM:
Requires the HHS Secretary and Attorney General to jointly establish and
coordinate a national health care fraud program to combat fraud and abuse in
government and private health plans. Monies from penalties, fines and damages
assessed for health care fraud are dedicated to financing anti-fraud efforts. It also
expands criminal and civil penalties for health care fraud to provide a stronger
deterrent to the billing of fraudulent claims and to eliminate waste in our health
care system resulting from such practices, and provides better guidance to health
care providers (new safe harbors, interpretive rulings and special fraud alerts) to
help them comply with fraud and abuse laws.
fk^^ * ^\ A
i
t>
FAIL-SAFE;
The agreement protects against inaccurate cost estimates by adopting a "payas-you-go" mechanism. Automatic cuts in health care spending would be made if
the expenditures otherwise authorized by the proposal exceeded projections. The
automatic cuts-would be targeted at new spending authorized by the bill-such as
expanded subsidies and tax deductions-rather than existing health care programs.
When savings from competition occur, they would be applied to the deficit.
It also requires the President to notify the country of the percentage of Federal
taxes that are being spent - each year - on total Federal health care. For each year
when total Federal health.spending rises. Congress is required to report, to the
American people on the additional amount of Federal taxes that are attributable to
Federal health care spending.
�Mitchell
Mainstream
SPENDNG
New Subsidies
Medicaid Subsidies
New Graduate Medical Education
Vulnerable Hospital Payments
Comm. Based Long Term Care
Medicare prescription drugs
$466
$634
$82
X
X
X
X
X
X
$0
$10
$10
$0
$48
• $95
$20
$1,343
$263
$120
• $10
$0
$0
$294
$155
X
X
$634
$13
X
X
$393
$1,096
Total Spending
FINANCING
Medicare Cuts
Medicaid Cuts
Conrad Auto Insurance Otfset
Medicaid Transfer
Other Spending Reductions
Total Spending Cuts
Revenues:
Tobacco tax
High cost plain assessment
Premium excise tax
Elim cafe plans/FSAs
Inc Medicare Part B premiums
Expanded Tax Deduction
Other tax changes
Total Revenues
$57
-
$0
$10
$29
($29)
$9
$81
Total Financing
NET DEFlCfT INCREASE (DECREASE)
(without Failsafe)
X
t
\
$18
X
X
A
X
$57
$73
$74
$47
$36
($14)
($12)
X
X
X
X
X
X
X
$261
$1,357
($14)
From CBO estimate of original Mitchell proposal.
A =. From separate JCT revenue estimate.
Unless otherwise Indicated, the amounts provided have been estimated by staff using the
available information and is subject to change.
�The Mainstreamer Plan
HE PLAN produced by what is caUed the
mainstream health reform group m the Senate
has a couple of strong points, though much of it
is a disappointment. If the strengths can be developed
and the weaknessesfinessedin the negotiations that
he ahead, the result could yet be a decent bill But it's
an uphill fight.
Senous health carereformrequires two tough steps
that for the most part this proposal fails to take. First,
to reduce the number of uninsured. Congress needs to
raise the money to helpfinancethe insurance which
these people generally can't afford. The new proposal
does only a modest amount of this. Most of the
uninsured would likely stay uninsured. That constitutes a problem for haves as well as have-nots.
Hospitals and other institutions would continue to be
under enormous pressure to provide uncompensated
care, the cost of which they would have to keep trying
desperately to shift though higher charges to the
pnvateiy insured. Better to regularize the process and
do it nght.
The related goal of reform is cost containment.
Congress can raise all the money it wants; there still
won't be enough to stand up to current trends in health
care costs. The country can't afford the health care
system that it has, much less an expanded one. There
has to be some gradual constraint. The problem is that
no one quite knows how to achieve this, and hardly
anyone has full confidence in any of the means that have
been proposed. Their weaknesses are better established than their strengths. There aren't the votes m
the Senate to impose direct controls on the system (for
example, by limiting annual premium increases as the
president proposed). The mainstreamers would rely
instead (as would majority leader George Mitchell in his
plan) mainly on competition plus a shift in tax policy to
deter instead of subsichzmg and encouraging people to
buy high-pnced plans. The idea is that, ii peopie are
made to feel the cost of health care more directly, they
will be led to get it as cheaply as they can. which would
add tc the pressure on providers to cut their pr.ces. and
thus be a lot dmerent trom now. But the mainstreamers
didn't do enough to structure the competition on which
their plan depends, and their proposed tax change is too
weak (though given labor and liberal Democratic opposition, it isn't dear that even it could pass the Senate).
Much of the "cost containment" in the mainstream
plan would also be confined to containing federal costs
rather than health care costs in general: it is budgetcutting. To reduce projected deficits, the plan would
impose a kmd of entitlement cap by another name on
federal health care spending. The group is right that if
Congress doesn't sit on future health care spending,
the deficit will again begin torise.But it tried to snatch
too much money for the purpose too soon, one of the
reasons it had so little left over for reducing the
number of uninsured.
A possible compromise would be to keep the theme
of deficit reduction in the bill, but change the mix (or
find some extra funds) to do more for the uninsured
than the mainstreamers have proposed: then sharpen
the compeunve structure in their bill. The mainstreamers are nght as well in arguing that the Mitchell plan
seeks to regulate some aspects of the health care
system best left alone for now. The government
needn't be in the business of allocating medical
education slots among specialists and generahsts. for
example. The leader can give these up. The question
is whether, in picking and choosing among the better
elements of their proposal, he can then pick up the
votes among the mainstreamers for a stronger bill.
That's where thefightis now.
Intimidating Pblitical Protest
E PUBLISH today on the opposite page an
arbcle by Roberta Achtenberg, assistant secretary of housing and urban development,
concerning enforcement of the fair housing laws.
Recent media accounts, including a Washington Post
editorial, have raised questions about HUD actions
directed against individuals and citizen organizations
that protest government decisions relating to the
location of housing for the disabled, specifically for
alcoholics and drug addicts. Such activity is, of course,
clearly proteaed by the First Amendment.
While Miss Achtenberg disclaims any intention to
infringe on rights, she maintains that the department
is under the obligation at least to investigate any
charge of discrimination. This sounds reasonable on its
face. But in operanon, these investigations alone can
be so intimidating as to quash speech. HUD field
personnel, acting only on vague and broad accusations,
for example, routinely demand infonnation from these
abzen groups, including membership hsts, fund-raising
informanon and copes of all correspondence, notes
and publicationsregardingthe dispute, including communications with elected representatives. In addition,
even before anyfindingof discrimination, the accused
are offered conciliation agreements which, in effect,
conceoe that the political activity in question is wrong
and will be discontinued. Those who don't accept these
Washington-drafted conciliation agreements are
threatened with prosecuuon.
An example of such a proposed agreement is the
one presented to a neighborhood group in Seattle.
Tnis group was protesting the proposed use of five
buildings in a single block for housing for addicts and
the mentally ill. This was in a neighborhood that
alreadv had a number of other similar facilities. The
citizens' group, the Capitol Hill Association for Parity,
is asked to acknowledge the right of Pioneer Human
Services (the organization supporting the contested
housing) to locate in the specific buildings at issue.
CHAP is also required to notify and meet with PHS
officials "before the drculation of petitions, the scheduling of community meetings or meetings with city
offibals" about PHS operauons. The citizens must also
pledge "not to oppose PHS's plans for purchase,
refinance and remodeling of the referenced buildings."
It must provide its fund-raising mailing list and wnte to
everyone on that list supporting the PHS program.
And. for good measure. CHAP is required to give a
block party "to which all residents, mcluding residents
of PHS housing, will be invited. CHAP shall solicit
support for the block party from local businesses, and
will ensure that free entertainment and inexpensive
food are provided." Nothing isrequiredof PHS.
This sort of demand is not for conciliation but
capitulation, with the added kick in the teeth requinng
sponsorship of the celebration. This is not mere
investigation but intimidation backed by a threat to
refer the complaint for prosecution if the agreement is
not accepted. HUD must do more than say it is
mindful of First Amendmentrights.It must establish a
reasonable threshold before investigations are undertaken, especially when the conduct complained of is
political action directed by citizens to their government. Written guidelines should be prepared tor the
field so that investigators know what conduct is
constitutionally protected and what is not. Ana regulations governing the enforcement of this section of the
law should be prepared and publisheci so that aniens,
couns and advocacy groups have dear iniormauon on
the law's reach.
•7
Ka
�Bipartisan Plan Moves to Fore
As Best Bet for Health Reform
Effect on Deficit
For wnrKine-cias?
the chief
Tilt' reneweu einunaais on aeiicu ream • exception is a program families, providing
M a " Reverters lit T H F W A L L S T R E E T J O I RNAL
aimea at
WASHING TON - Health-care reiorm non poses problems. 100. for the House insurance for children and pregnant
hanps by a thread in Congress, as Presi- Democratic leadership after the emphasis women in families eamine up to 240^ '
bloody cnme-bill dedent Clinton is now reduced to trying to on spendine in the estimates by the Con- of the poverty level. Moderates may yet
salvage a bill that at best lays the founda- Pate. Preliminary Office indicate that revi- decide to raise taxes more to fund this
tion for some day achieving his goal of gressional Budget in the House leader- subsidy, which is both an important politisions must oe made
medical coverage for all Americans.
ambitious
bill just to cal symbol and an easy means to boost
These efforts now turn on a plan put ship's within the health-careAnd without coverage, because children are cheaper to
stay
budget.
forward by a bipartisan bloc of Senate tougher controls to contain rising medical insure than adults.
costs - controls that are opposed by many Roles of Dole, Kennedy
HeaKh Care for the Poor
of the same moderates who want deficit
The politics in the Senate may be best
An unuiuaJ Detroit healtb-cmre managereduction - Democrats would have to scut- understood through two old warhorses.
meat company take* health care directly
tle ancillary benefits they had promised I Minority Leader Robert Dole and Sen.
to patienu. many of whom a n poor or
supporters.
: Edward Kennedy, both of whom were in
destitute. Enterpriie, page B2.
the chamber
Nixon tried to
By their own admission, the Senate enact health when Richard than two decmoderates, who propose a progressive set moderates' S100 billion. 10-year deficit-rereform more
of insurance-market reforms with a much- duction target is a seat-of-the-pants figure ades ago.
scaled-back subsidy program for poor and advanced in the final days by Democratic
Many of the GOP moderates are longworking-class families. Proponents say Sens. David Boren of Oklahoma and Rob- standing Dole allies, and Sen. Nancy Kasthe so-called "mainstream coalition" plan ert Kerrey of Nebraska. Achieving that sebaum. his fellow Kansan, joined the
is the last, best chance for health-care
group in the final days last week. Friends
have little
reform this year. But by putting more reduction may Among the to do with health argue that the situation gives him an
reform itself.
moderates, there
emphasis on deficit reduction than univer- was concern it would have an adverse opportunity to show his power to get things
sal coverage, the plan would leave more impact on subsidies for higher-income done and be a dealmaker on historic
than 2 million people without insurance at states such as California, represented in legislation, as he has in the past on civil
0
the turn of the century.
the group by Democratic Sen. Dianne rights and the deficit. But this hope is :
"We've tried to do the doable and leave Feinstein.
undercut by the tensions between Mr. j
the rest for next year," said Sen. David
Dole's staff and that of the mainstream
In
the new
in the planDurenberger (R.. Minn.), a member of the about fact, billion to taxesbillion over 1 group and a sense that the Republican
S2
10
S3
10
0
coalition. Even this progress is fragile. Mr. years -will be all but exhausted just meet- leader has retreated into an argument that
Durenberger warned, if the Senate re- ing the deficit goal rather than paying i it is already too late to act this year.
cesses for the summer without agreeing on
In a floor speech Friday evening, he
of the
what to do. "You go home and health-care subsidies. Partbillion revenues would pay I disparaged the new plan as "entry No. 8."
for nearly S30
in expanded deducreform is dead," he said.
tions for the self-employed and individuals I And this 71-year-old would-be presidential
Ideological Dual
buying health insurance. But any subsi- i candidate has taken to using health reform
The health care-reform debate has al- dies to expand coverage for poor and as a chance to cast himself as a champion
ways come down to an ideological dual working-class families must depend on of the younger Generation X. whose insurover v/hether market forces can cure the savings from federal programs like Medi- ance costs would go up under the sharethe-risk reforms in the moderate plan.
ills of high medical costs and inadequate care and Medicaid.
coverage, or whether extensive governPayments under Medicaid to hospitals "You had better tune in on health care."
ment involvement is necessary to finance that serve a disproportionate share of Mr. Dole said, "because you are going to
and deliver care equitably. Virtually every uninsured poor families would be cut, get stuck big time."
Younger firebrands on the left, reother industrialized country has given up yielding a savings of between $110 billion
on the free market for medical care. But to S 2 billion. And the plan assumes sponding to complaints by labor and the
10
despite a Democratic president and con- • increased savings from Medicare of S 6 elderly, are ready to bolt from the leader20
gressional leadership pushing for a billion - or about S60 billion more than the ship as well. But Sen. Kennedy, at age 62
greater government role, business-backed net reductions proposed in a health-care and facing a reflection challenge at home
market advocates are prevailing.
plan approved by the Senate Finance Com- in Massachusetts, seems determined to
Sen. John Chafee (R., R.I.), a leader of mittee or a version put forward by Sen. use his liberal credentials to keep the
Lprocess alive. At an emotional Democratic
the moderate bloc and persistent optimist, Mitchell.
luncheon last week, he vented his frustrais slated to meet today with Majority 'There's Not Much Give'
tion with therightwardmovement of the
Leader George Mitchell of Maine and other
If market reforms turned out to yield debate. But in public, he has been a
Senate Democrats. But in trying to reach a more savings, the moderates would find it
compromise, he and Mr. Mitchell nsk easier to meet their schedule of expanded shield of sorts for Majority Leader Mitchbeing undercut by competing camps on the subsidies. But the tight budget leaves little ell, allowing the leadership to move closer
to the moderates and try to isolate Mr.
left and right.
room for such programs as a new prescrip- Dole and the Republicans as the obstacle to
The elderly are protesting the proposed tion-drug benefit for the elderly or aid for action.
savings from Medicare in the moderates' academic-research centers.
plan. Labor unions and conservative anti"I don't know where the give is." Sen.
tax Republicans are working against a Boren said. "There's not much give.
provision that would limit corporate deduc- That's the answer."
tions for higher-cost health plans.
The plan most resembles the bill apThe White House wants to give Mr. proved by the Senate Finance panel last
Mitchell wide leeway but still hopes for a month. That proposal, as calculated by the
deal that preserves a backup provision to Congressional Budget Office, would offer
10
require employers to help pay for their S 3 billion in deficit reduction over the
workers' insurance if voluntary measures next 10 years but would raise taxes much
higher and reap savings by bringing Meddon t sufficiently expand coverage.
icaid more fully into its subsidy scheme.
Precise numbers aren't available, but
by their own calculations the moderates
may have S 0 billion less for subsidies
10
than the Finance Committee bill, which
would achieve only 9 7 coverage by the
2c
turn of the century. The same mainstream
group in June had proposed to fully implement the subsidies by the year 2001. phasing tnem out for families earning 2 0 - of
4S
the poverty level. The revised plan would
phase tnem out at double the poverty level
and wouldn't be fully in place until 2004.
Bv DAVID ROGERS
\n<l HILARY ST^r-
;
{
THE WALL STREET JOURNAL MONDAY. AUGUST 22. 1994
�Familiarity Breeding Contempt?
- r . r - a z r :•* each state's adui: ooow-ai-or ;^at said ma; tne;'
ro.'e'nc was doing anexceiieni or a good job.
Cnns'iine Todd wniiman s
positive joD rating
M a n o M. Cuomo'S
positive job rating
HOV. i t M Cuomo re-etected
with record 65 percent of vote
Nov. I t M Whitman is
elected governor of New
Jersey with 49 percent
of the vote
JULY 1M4 Cuomo gives
keynote address to Democratic
Convention in San Francisco.
NOV. i m
Cuomo elected governor
of N e w York with 51 percent of the vote
flecession
1M1 After
waiting yntii the last
hours before the filing
deadline m New
Hampshire. Cuomo —
decides not to run
for President.
d e g m s in i
New York State
985
10S6
1
1«7
JAM. 1M2 Moody's rating
for New York State bonas
falls below A for first time m
three decades reflecting
the bad economy and
budgetary problems.
i Firs: net job gam
' after recession
n
.tan.: 4 * 4
The N e * Vo'k pons were conducte(H>y me Marist CoHege institute lor Public Opinion and
involved teiepnone interviews witn registered voters around trie state. Tne most recent survey
was conducted Fee 28 through March 1 »nth'706 people and has a marg'n ot sampling error
of plus o- f-mus lour percentage points.
Tne N e * Je'sey pons were conducted oy Tne Newark Star-Ledger/Eagleton Institute, and involved teiepnone interviews with
ao v.s a'Cj-fl r^e s;ate Tne most receni suwey was conducted June 14 through 22 with 800 people anc nas a margm o'
sa~3 g e - 0 ' o D'US C minus lour percentage points
i
1
Th» Nfw Yorli Times
Keep Health Care Moving
The health care proposal by the "Mainstream
Coalitioa," a bipartisan group of Senate moderates,
would fMve millions of Americans without insurance. But it would increase coverage above current
rates and reform insurance laws so that ill people
could not be discriminated against and workers
could carry insurance from job to job. The plan is
too flawed to be inspiring, but a bill based on this
proposal is probably the only one the Senate can
pass anytime soon.
The choice, then, is between passing something
like the mainstream proposal and passing no bill at
all. Because the proposal would do some good and
no major harm, it is worth grabbing. It is a valuable
first step in an incremental process of reform, and
as such it should not be allowed to slip away.
The other option is to junk reform for this year.
That would play into the hands of the Senate minority leader. Bob Dole, and the House minority whip,
Newt Gingrich, who seem to share no grander
vision than to give President Clinton a drubbing
before the November elections. If the Republicans
pick up seats, then any chance for genuine reform
will have been squandered.
The proposal includes many wise provisions. It
would prohibit insurers from discriminating
against the chronically ill. It would pre-empt state
laws that, at the behest of politically powerful
physician groups, would sump out health maintenance organizations. And it would begin to standardize the package of benefits every American
must buy — a key to stopping insurers from picking
off low-risk customers by artfully tailoring benefits.
The coalition also took the brave step of proposing a tax cap — a limit on the tax deductibility of
high-cost policies and another powerful incentive
for consumers to seek cost-effective insurance.
The faults are also numerous. The plan needlessly permits uneconomic choices, for example, it
allows employers who help pay their workers' premiums to contribute higher subsidies to workers
who choose expensive policies. It does nothing to
establish purchasing cooperatives for small employers and individual buyers where private parties
do not create them on their own.
But the proposal s worst flaw is that it drops an
employer mandate — a requirement that employers help pay premiums — and provides only puny
subsidies to help low-income families buy coverage.
Premiums for the poor would be paid by government; but low-income families whose employers
opt out would be hit with $5,000 premiums with little
or no help from Washington. The proposal would
probably raise coverage to only about 92 percent —
well shy of its goal of 95 percent.
The attempt to use subsidies, rather than a
mandate, to cover the uninsured might well backfire. Some employers might drop coverage and
thereby qualify their workers for Federal subsidies
If that happens, costs will soar and Congress will
probably be forced to adopt an employer mandate.
President Clinton deserves credit for moving
health care to the top of Congress's agenda. But he
also bears responsibility for cornering Congress
into passing second-rate reform. The first blunder
was to create a task force of 500 experts to write a
policy in secret. When the 1,300-page bill was delivered to Congress, no one identified with the architecture except the architects. Take the idea of
purchasing cooperatives. They started out as shopping malls where anyone could travel up and down
the aisles to pick the plan they liked best. But the
task force, insulated from public reaction, turned
them into regulatory monsters. Harry and Louise,
the characters in the insurance industry's TV commercials, ridiculed them nearly out of existence.
The bipartisan proposal, though sadly imperfect, is probably the best framework for reform that
can pass. If it works to bring down costs, it will
make subsequent steps toward universal coverage
much less scary. More broadly, the plan establishes
the principle that Congress must overhaul the
system. It is not the end of reform but a constructive beginning to- what now must become a long,
grinding march toward the inevitable goal of health
care that covers every citizen for life.
I
I
in
in
.*<:
9
�C O M P A R E AND C O N T R A S T
Government Garners
Low Marks in Pol!
How Two Senate Proposals Stack Up
THE SENATE B I P A R T I S A N BILL
THE M I T C H E L L P L A N
Seeks lo cover al least 95 percenl ol all Americans by 2000
through voluntary purchasing cooperadves. insurance market
changes and subsidies II coverage is nol achieved by Jan 1,
2000, a commission would make recommendations to
Congress; il Congress does nol act by Dec 3 1 . 2000. a standby system would go into eltecl that would include some
employer payments
A standard package would include preventive services,
prescription drugs, mental health services, family planning
and services lor pregnanl women Also has several initiatives to
provide long-term care lo the elderly and disabled
All employers must provirin eomparalive inlormalion and ofler
employees a choice of Ihrei; plans, including a traditional leelor-service plan Employers are nol required to pay a portion of
the premium Employers with lower lhan 100 employees may
join together lo purchase insurance lor (heir workers
Companies with more lhan 100 employees may sell-insure
All employers would be required lo offer but not lo pay lor al
least three plans, including a traditional lee for-service plan and
a managed care plan Businesses with fewer than 500
employees would be allowed to buy coverage through health
insurance purchasing cooperatives
Increase lhe cigarette tax (rom the current 24 cents a pack to
69 cents Raise Medicare I'ail B premiums lor higher income
people Limit companies' ability to lake lax deductions lor highcos( health plans Reduce ihc growth in Medicare and
Medicaid spending
The measure would gradually increase the Federal tobacco lax
lo 69 cents a pack, from 24 cents; increase the Federal lax on
certain handgun ammunition; slow the rale ot growlh in
Medicare and eliminate much ol the Medicaid program There
would be a 1 75 percenl lax on heallh insurance premiums
Governmenl subsidies lor those with incomes of up lo 200
percenl of poverty, and lor pregnant women and children in
families with incomes up lo 240 percenl ot lhe poverly level
Individuals wiih incomes below the poverly level would receive
lull subsidies; partial subsidies lor people with incomes up lo
200 percent ol the poverty level would be phased in by 2004
Starting in 1997. the Government would pay the lull cost ol
heallh premiums lor people below the poverly level In addition,
the Government would pay the premiums lor pregnanl women
and children under 19 with incomes up to 185 percenl ol the
poverly level I here would be subsidies lor employers
providing insurance to employees not previously covered
Achieved through market changes, placing limits on employer
deductibility ol health insurance premiums, limits on damages
lor pain and sutlering in malpractice cases, nnd a national
program to combat fraud and abuse. Automatic culs would be
made il health spending exceeded proieciions
INSMANCt
Seeks lo cover at least 95 pcrctMii ot all Ami means by 2 0 0 1 .
(hough sponsors say il may kill short by 2 or ;t percent If the
goal is nol reached, a national commission wouldmake
recommendations on how lo achieve it
Comprehonsive benefits wiih a variety o( coverage options
Establishes a program lor home- and community-based longterm services to be administered by the states and limited to
those wiih incomes below 150 percent of the poverty level
covotAOI
A 25 percent lax will be imposed on heallh insurance plans
whose costs grow laster lhan a prescribed pace
Heallh plans could nol deny coverage or renewal lo any eligible
applicants People could retain insurance il Ihey changed jobs
The Governmenl would limit variation in piemiums
Insurance companies could not reject applicants lor pie
cxisling coniliiinns I'eople could relam insurance il they
changed |<>bs Policy renewal guaranteed
MONICA ROnKOWSKI
WASHINC.TON. Aug 20 (AP) - In
a bleak asscssmcni of Ihcir Govt-i n
mem. 91 percent of lhe people sur
veyed in a poll said Ihey had hide or
no confidence in Washington to solve
problems. Republicans got more
blame for gridlock than did Presidcnl
Clinion.
The Time magazine-CNN poll, re
leased today, found thai 64 percenl
considered gridlock between Con
gress and the President a majur
problem. Asked who was lo blame. 48
percenl said Congressional Republi
cans and 32 percent said Mr. Clinton
Twelve percenl said Clinton and ihc
Republicans were equally al fault
The poll did nol give respondents lhe
choice of blaming Congressional
Democrats.
The survey of 1,000 adults, lakrn
Aug. 17-18. has a margin of error of
plus or minus three percentage
points.
As in other recent polls, the results
showed a gap between Americans'
desire lor change and their faith ihai
Washington can deliver it. Ninety
percent said ihey wanted a Govern
meni lhal promotes change, while
jusl 6 percenl said the Government
should keep things as they arc.
But only 7 percent said they had a
great deal of confidence lhal Mr. Clin
lon and Congress could deal wiih ihe
country's problems. Nearly three
fourths, 73 percent, said they had only
a liule confidence, and 18 percenl
said Ihey had none.
Thai mood would suggest lough
Hcmin f<» incumbenis this fall, re
Hitidless of political parly
Ke
iiilmciiig ihai view, 27 percenl said
ihey would vole for an indc|>cndenl
lamlid.ile for Congress Ihis Nuvem
IK-I il ihey had lhe chance. I wenty
nine percenl said ihey would suppon
a Democrat and 2.1 percenl a Kepulihtan the others were underided or
t iled a spe< ihc third parly affiliulion
W
O
s
to
ft:
w
z.
X
�THE COMPROMISE
Diverse Elements Criticize
'Mainstream Senate Plan
9
By ROBERT PEAR
Special to Thf N f * York Times
WASHINGTON, Aug. 20 - Business groups and labor unions said
lodav thai a bipartisan health care
proposal offered on Friday by a
group of nearly 20 senators would
create perverse, unintended incentives for employers now providing
heakh insurance to drop it.
In addition, the proposal has created an odd alliance between the A.F.L.".I.O.. a longtime crusader for nation;ii heallh insurance, and Senator Phil
Gramm, a conservative Texas Republican to whom such proposals are
anathema. Both detest the bipartisan
group's proposal for a new tax on
heallh insurance benefits richer than
a standard package io be defined by
the Federal Government. Many
unions have given up wages to win
such extra coverage
The
bipartisan
proposal, announced by Senators John H Chafee.
Republican of Rhode Island, and John
B. Breaux. Democrat of Louisiana,
illustrates both the advantages and
the pitfalls of attempts 10 find a middle ground.
The proposal avoids the most politically contentious elements of the
plans offered by Presideni Clinton
and by the Democrauc leaders of the
House and the Senate. It would not
require employers to pay anything
for employee health benefits. There is
no "employer mandate" and no
threat of one.
Senator George J. Mitchell of
Maine, the majority leader, said on
Friday that he would study the Chafee group's suggestions and decide in
a few days wheiher to accept any of
them But the reactions of those to the
left and the right of the Mainstream
Coalition, as the group is known, suggest that efforts to gain some votes
may cost others
Instead of employer mandates, the
bipartisan
proposal
encourages
states to form insurance purchasing
cooperatives. It would provide billions of dollars in Federal subsidies to
help low-income people buy private
insurance. Self-employed people and
workers who received no coverage
from their employers could take tax
deductions for the full cost of insurance premiums covering the standard package of heallh benefits.
/"
/
^
\
/
A Reverse Incentive
Richard I Smith, director of health
policy at the Association of Private
Pension and Welfare Plans, a trade
group composed mainly of Fortune
500 companies, said today, "The big
consequence of this proposal is
there's a real possibility that a lot ot
employers will drop insurance they
now provide to employees.
"Employers now offering coverage
would give employees cash instead,''
Mr. Smith said. "The employees
could buy coverage at group rates
with tax-free dollars. A lot of younger,
healthier employees will bail out of
the market, take the cash, not the
insurance."
Senator Paul Wellstone. Democrat
of Minnesota, expressed similar concerns about the new proposal. "Subsidies and tax deductions for individuals, with no employer contribution
required, would result in employers'
reducing coverage while enjoying a
Government-subsidized bailout." Mr.
Wellstone said.
People who lost insurance in this
way would become eligible for Federal subsidies to help them buy private insurance. That would increase
the demand for subsidies, and the
pool of money available for such assistance "would be drained without
the predicted increase in overall coverage," Mr. Wellstone said.
Mr Wellstone said that employers
were unlikely to drop coverage under
Mr Mitchelfs bill In general, he said,
that bill does noi make individual
purchase of insurance coverage tax
deductible," as the Chafee-Breaux
bill would do.
Also, the Mitchell bill would require
employers to help buy health insurance for workers if more than 5 percent of the population lacked coverage in 2000. Thus employers that
dropped coverage before then could
bring a Federal mandate upon themselves.
Aides io Mr. Chafee and supporters
of his proposal said they were surprised at the Idea that it might
prompt employers to drop coverage.
That was not the intent, they said.
Disputed Tax Provisions
In proposing a limit on tax deductions for health insurance, the Mainstream Coalition embraced an idea
long favored by many health policy
experts as a way to discourage exct cive health spending. Under current
law, employers can take tax deductions for the full cost of heallh insurance benefits that they provide to
employees. The benefits do not count
as taxable income to employees.
A summary of the Chafee-Breaux
bill says limiting the lax deductibility
of health benefits would "create additional incentives for employers and
employees to bring down the cost of
their health plans."
But Gerald W. McEntee, president
of the American Federation of State,
lounty and Municipal Employees,
which has 1.3 million members, said .
"This is a new tax on middle-income
working Americans. The bedrock of
America is taxed to pay for employers who in the past carried no health
insurance at all."
Senator Gramm said: "The mainstream group may be mainstream in
Washington, but they are not mainstream in America Americans do not
want the Clinton Administration or
anybody else telling them what kind
of insurance policy they've got to
have. The American people do nol
want to be taxed on health insurance
benefits that they've worked hard to
gel for themselves and their families."
In an interview, Mr. McEniee said:
"Phil Gramm will be on the Senate
floor defending working middle-income America as well as the A.F.L.C.I.O I've heard of strange political
bedfeliows, but this is ridiculous. If
Phil Gramm is defending us, something must be radically wrong wiih
this plan."
Mr McEntee said employers would
cut back heallh insurance if ihey lost
tax deductions for coverage more
generous than the standard package.
"It will mean worse plans for people
who now have decent ones, he said
" I f ihis is national health care reform, I need an aspirin."
Under the Chafee-Breaux proposal,
the limit on an employer's tax deduction for insurance would be sei at 10
percent above the average cost of
health plans in the local market
Costs beyond that would not be deductible.
In addition, there would be new
limits on tax breaks for supplemental
health insurance covering co-payments and deductibles.
Business groups listed other elements of the Chafee-Breaux proposal
that they said would increase employ
ers' costs and create incentives for
companies to drop coverage.
For example, a company thai provided coverage to one full-time employee would have to provide insurance to all full-time employees. The
employer would have to contribute
the same amount for each employee
who worked more than 24 hours a
week. That requirement is intended
to prevent employers from discriminating against low-wage workers.
But Mr Smith of the Association of
Private Pension and Welfare Plans
said: "This requirement significantly
increases costs for employers."
THE NEW YORK TJMES, SUNDAY. AUGUST 21, 1994
1
0
�ILatest Health Care Plan Aims
rib Break Logjam in Congress
By Helen Dewar and Dana Pnest
WMtmpca Pog Sua Wmert
HEALTH CARE HIGHLIGHTS
: A bipartisan group of senators yesterday unveiled a plan to break Con• k SENATE MAINSTKAM group last night unveiled its minimalist
gress's deadlock over health care that
[.health reform plan to noncommittal response from Republican and
Walls far short of President Clinton's
Democratic leaders.
•jgoal of universal coverage and instead
• SEN. PHIL GRAMM (R-Tex.) vowed to defeat it and, if not, to offer
Stresses a target of $100 billion in
a long explanation" of its deficits.
federal budget deficit reduction over
! next decade.
• PRESIDENT CLINTON said senators "should keep working at i t . . .
Acknowledging that the plan would
if we don't move now, there's a chance that [health reform) won't
millions of Americans without
happen at all."
health insurance into the next centu• TOP OFFICIALS of Mobil Oil, Eastman Kodak. IBM and a number
fry, the group presented it to Senate
of other large U.S. companies have urged their employees to contact
Majority Leader George J. Mitchell
members of Congress to oppose the two main Democratic bills in the
JD-Maine) and Senate Minority LeadSenate and House.
er Robert J. Dole (R-Kan.) as what
one senator called the "best chance
3or getting a bill this year."
J "You don't see here an answer to package, no doubt about it." Softening ism. "I'm optimistic there's some
Jiniversal coverage however it's de- his harsher criticism of the plan earli- movement; I'm pessimistic that it's
f n t d " said Sen. Dave Durenberger er in the day, Dole said it was "a little movement in the wrong direction,"
late in the process" to introduce a said Sen. Howard M. Metienbaum
JR-Minn.).
t "We're taking one step at a time new plan. He suggested that the Sen- (Ohio), who has urged Mitchell to
father than trying to do everything at ate take its already delayed recess strengthen, rather than weaken, his
fmce," said Sen. John Breaux (D-La.). and come back in Septeihber to con- proposal.
j Mitchell was more posiuve in his sider the proposal
But the group got a boost from
Mitchell was considerably more Sen. Robert C. Byrd (W.Va.). an influresponse than Dole. But both senators agreed to study the plan over the positive, describing the proposal as "a ential Democrat who had not particiVeekend before the Senate begins its step toward gettingfinalaction on a pated in their talks. Byrd endorsed
third week of what has so far been b i l l . . . a constructive suggestion we the idea of a stripped-down bill, say•virtually fruitless work on the issue. all ought to consider.'' But he declined ing the "last, best hope of real deficit
'» ID its scope and financing, the to comment on the details until he reduction" lies in cutting bealth care
tyan—developed by nearly 20 sena-studied them and consulted with coltors of both parties under the leader- leagues over the weekend.
The Chafee plan's main cost-conship of Sen. John H. Chafee (R-R.I.)—
Dole's views are critical because at trol mechanism would be the pro4s closer to a aunimalist health ore least some members of the bipartisan posed new tax on some health beneyfal sponsored by Dole than it is to group believe that the plan wiD not fits. By including this provision, it
Mitchell's scaled-back version of Clui- succeed unless it is embraced by both picks up the key element of the "manRepublican and Democratic leaders. aged competition" approach devel.ton's plan.
The Chafee plan, which relies "Without both of them, you aren't go- oped by the "Jacksoo Hole Group" of fee group's plan for Americans who
«largely on insurance market reforms ing to get a bill," said Sen. William S. health analysts and insurance industry cannot now afford the cost of health
and incentives to cut costs and ex- Cohen (R-Maine), a member of the executives that held sway over Clin- care. It also lacks teeth to stop companies from dropping or limiting cov-pand coverage, would cut by two- group.
ton's thinking for a while.
erage as they are now doing by the
Several participants also sought to
' thirds the amount of new money that
Although it contains no require*was available in Mitchell's bill for sub- squelch the notion that Mitchell could ment that everyone have insurance— tens of thousands each year.
sidies to low-income people. It raises bargain with the group to incorporate and thus means that many Americans The Mitchell bill, for example, can
• only $10 billion a year for subsidies, some of their proposals to broaden would still wind up in emergency claim to cover 27 million additional
raising serious questions about support for his plan. There might be rooms without any way to pay the people because it would raise and
. whether it could reduce the number amendments to our bill, but we aren't bill—it would require employers who spend an average of $30 billion a year
of uninsured by any measurable num- amending their (the leaders'] bills." voluntarily pay for insurance to offer more in subsidies than currently in
said Sen. David L. Boren (D-Okla.).
ber.
employees a choice of three types of each of thefirstfiveyears.
At a news conference before the health plans. One of them would have The Chafee plan would raise about
It also contains a new tax on health
care benefits, which are currently plan was formally unveiled, President to be a plan in which the choice of $100 billion over 10 years for subsidies from the following sources: S57
tax-free. Such a new tax was consid- Clinton said he was encouraged by pfaysicun is iffircstnctod*
billion by increasing the current 24ered and discarded by both Clinton the group's efforts to believe "there is
Each health plan would have to cent-a-pack cigarette tax by 45 cents,
and Mitchell because it is politically still a chance that people will work toprovide a standard benefits package up to $10 bilbon from taxing health
unpopular with middle-class constitu- gether and resolve this."
ents, labor unions, the elderly and
Clinton declined to comment on which would indude a comprehensive benefits, another $10 billion by taxing
supplemental health benefits, $29 bilothers.
any of its specific proposals, saying, "I range of medical services.
Insurance companies could not de- i Ikn by raising Medicare Pan B preChafee's plan requires no one— think we need to let this thing unfold
employers or employees—to buy in- a little more. I wouldn't prejudge it ny coverage to people with pre-exist- miums for individuals with incomes
surance. To fund the subsidies and yet." But he also cautiooed agamst ing conditions, except under restrict- lover $75,000 and couples over
: achieve its deficit-reduction goal, the whittling back his proposals too far, ed circumstances, nor could insurers : $100,000. and another $9 billion from
plan proposes raising the cigarette saying "the so-called 'something less* limit or deny coverage to people other unspffifipri sources, according
tax by 45 cents, increasing the premi- approach often does more harm that based on health status or because to the group's preliminary fmanong
they changed jobs.
um for high-income Medicare recipi- good."
i document.
Individuals and employers with
•ents. and cutting Medicare by S230
Mainly he urged Congress not to
The bottom line of the Chafee plan
billion and Medicaid by $120 billion give up. "Keep working, keep working •fewer than 100 employees would be is $500 billion over five years—$400
..over 10 years.
at it, because if you delay you may allowed to purchase insurance • billion for health reform and $100 bil:
It was a measure of the legisla- well lose it all together." he said.
! through voluntary purchasing cooper- lion for deficit reduction.
tions precarious state that the biparWhile the group appeared united at atives whose goal is to give small pur- The proposal would contain no new
tisan moderates' plan—even though a news conference after its meetings chasers the same bargaining clout as money for prescription drug coverit departed so far from the sweeping with Mitchell and Dole, it had already big businesses. Also, insurers would
goal of health care for all Americans lost one participant as the day start- have to price their policies based on age—a sweetener to the elderty in
the cost of insuring a typical member both Mitchell's and Clinton's bill. It althat Clinton laid out nearly a year ed.
so sharply reduces money for longago—drew words of encouragement
Sea Bill Bradley (D-NJ.) said the of the entire community.
from Clinton, Mitchell and other group had strayed too far to the right
Clinton vowed to veto any bill that term care.
Democrats.
in abandoning universal coverage and does not guarantee universal cover- To protect agamst deficit spending,
It was also a measure of the plan s "shared responsibility" through em- age by a certain date, but then em- the plan includes a fail-safe mechaviability that some conservative Re- ployer contributions to workers' braced Mitchell's plan to cover 95 nism under which spending for subsi• publicans immediately hinted at de- health care costs. "When people want percent of the population by 2000. dies would be automaticaUy cut back
laying tactics. "We're going to beat it to come back to the middle, I'll be Chafee said yesterday his plan might if government health spending apon a straight upor-down vote, but, if back there waiting for them," he said cover upwards of 93 percent of the peared to be headed beyond annual
we don't, they better be here to listen as he left the meeting after no more population sometime around the turn limits.
erf the century.
to a long explanation of what they're than two minutes' attendance.
It includes a limit of $250,000 for
doing." said Sen. Phil Gramm (Tex.).
Even if Chntonfindsa way to ac- non-economic damages from medical
Others remained in the group deWhile clearly skeptical of the plan. spite misgivings about its direction.
cept the bill, there is little in the Cha- malpractice cases.
Dole joined Mitchell in praising the efDemocratic liberals were torn befort. But the best thing that Dole tween a yearning for something to
1
tould say about the plan was that "it's jump-start the process and a distaste
a sharp departure from the Mitchell for the group's drift toward minimalr
1
TJ
�sota Republican, conceded to reporter, "You don't see here an answer to
universal coverage, however it is dethe Rhode Island Republican who is fined."
one of the coalition's leaders, told
The group says it wants to subsireporters, "We would be distressed to dize fully insurance for people under
see major changes " Others in his the Federal poverty level, which i;
group were even more insistent on $14,764 for a family of four, and io
their proposal being taken as a whole, phase in partial subsides people with
income up to twice the poverty level
once they finish it
by the year 2004. There would be
And Senator Bill Cohen, a Maine somewhat greater subsidies (or chilRepublican who is a member of the dren and pregnant women
group, said the plan "will have to
But the group said its ability to do
have the support of both senator that would depend on more budget
Mitchell and Senator Dole" or else estimates and possibly on calling for
opponents from one side of the Senate more taxes. The senators appeared to
of the other would sink it.
make the $100 billion in deficit reducSenator Chafee said, "This is a bill tions the least negotiable of all those
that can pass this year."
interrelated elements.
But in Its effort to appeal to modern
Senator Cohen said that after Robates and some Senate conservative,! ert Retschauer. director of the Conthe Mainstream Coalition has include gressional Budget Office, warned the
ed elements certain to be unaccept- group Wednesday that subsidies were
able to groups favoring more sweep- expensive, "There was a rather siging changes in Ute health care nificant shift from the concept of
system, especially advocates of the mandated universal coverage to one
of cost containment."
elderly and organized labor.
Its approach to universal coverage
The bill does not provide prescription drug coverage for the elderly, as is to call for a commission to recomMr. Mitchell's bill and a companion mend to Congress what should be
measure in the House do. And it pro- done if 95 percent of the public is not
vides much less money for long-term insured by the year 2001, a provision
care, S10 billion instead of the $48 almost identical to the version adopted in the Senate Finance Committee
billion in the Mitchell bill.
Those two elements have been Congress would be required to conprime demands of such organizations sider the proposal and vote on it, but
as the American Association of Re- there would be no backup mechanism
tired Persons, and serve to compen- like Mr. Mitchell's employer paysate, in part, for cuts in the rate or ment requirement if it did not act
growth of spending for Medicare that
The subsidies in this bill are quite
almost all bills provide. The Mitchell similar to those in the Finance Combill foresaw $294 billion in such cuts mittee measure, which the C.B.O.
over 10 years; preliminary esUmates. said would lead to 92 percent of
for the Mainstream proposal were for I Americans being insured, so its 95
$263 billion in cuts.
percent goal Is very unlikely to be
The National Council of Senior Citi- reached.
zens issued a statement tonight call- L The propOMl focuses -heavily on
ing for "total defeat" of any legislachanges In insurance regulation, such
tion based on the coalition propoaaL as eliminating exclusions for pre-exThe group's director, Lawrence T.
isting medical conclusions, and it
Smedley, said the group's proposals
would require employers to offer —
"rob Medicare to create a Rube Gold- but not to pay for — health insurance
berg health system monster."
for their workers.
The coalition propoaal's lack of re-i
They would be required to offer
qutrements for employer payments
them three different plans, including
displeased organized labor, which
one allowing them to choose any docwas already unhappy with the Mitchtor. Employers of 100 or more workell bill for not requiring employer ' ers could bargain directly with msurcontributions immediately. Unions' i ance companies. Smaller companies
also fsar the Mitchell's S percent | would insure their workers through
O
payment requirement, would encour-< voluntary health insurance purchasage companies that now provide In- ing cooperatives.
surance to reduce their contributions.
"What you see here is the doable,"
The House Democratic leadership's
said Mr. Durenberger, who is retiring
bill would require employers to pay
this fall, "and what you're not going
80 percent of their workers' insurto see here is what the rest of these
ance premiums starting in 1997.
fellows are going to have to do next
Lane Kirkland, president of the
year." Among the issues left unreA.F.L.-C.I.O., sent a letter to Senate
solved, he acknowledged, were emDemocrats tonight -attacking the:
ployer payments for workers' insurMainstream Coalition proposal. He
ance; long-term care; and public
said, "Any legislation that fails to
health programs and medical educaprovide universal coverage and an
tion, for which the Mitchell proposal
employer mandate — and is based on allocated $82 billion over ten years.
the foolish belief that health costs can
The proposal's tentaUve set of taxbe contained by taxing employee
es includes raising the cigarette tax
benefits — is not genuine reform and from the current 24 cents per pack to
will not solve the critical and funda- 69 cents. But several senators identimental problems of our health care
fied that as one tax they would readsystem." A member of the coalition, , ily consider raising if they needed
Senator David Durenberger, a Minnemore monev.
BATA GOP
I RI N RU
P S
I SNT OFR
N EAE FES
N HAT PA
E ELH LN
W
Continued From Page 1
LEADERSHIP IS CAUTIOUS
Sponsors Assert T e C n Cut
hy a
the Deficit W ie Expanding
hl
C v r g u to 93%
o ea e p
By ADAM CLYMER
A {
Stacui te-ft* Hm Yerts TMMt
WASHINGTON, Aug. 19 — A bipartisan group of nearly 20 senaton today proposed health care legislation
aimed at reducing the Federal deficit
by S100 billion over 10 years and
increasing insurance coverage from
85 percent of Americans today to 92
or 93 percent by 2004.
The proposal by the self-styled
"Mainstream Coalition" has been described by its members as the best
hope for leading the Senate to action
on health care legislation thts year.
Some other senators shared that
hope. The immediate reaction to the
plan in the Senate provided no clear
indication of whether the group would
succeed.
Senator George J. Mitchell of
Maine, the majority leader who has
broader naUonal health legislation
pending before the Senate, welcomed
the proposals In the measure. He said
in a sutement that he would study
them and respond "early next week."
"I believe there are a number of
areas on which we will agree and
others that may need to be resolved
by the full Senate." Mr. Mitchell said.
But Senator Bob Dole of Kansas,
the Republican leader, responded Jubiously. "Maybe it's a good place to
sun," he told the Senate, but he
added, "It's pretty late in the game."
He ticked off a sertM of elemenu tn
the proposal he dtaUtad, Including the
requirements of a standard benefits
package and limits on how much
more the elderly could be charged
than young people.
At a news conference President
Clinton said he had been encouraged
by reactions from Senator Mitchell
and from Senator Edward M. Kennedy, Democrat of Massachusetts.
"Their comments made me believe
that there is still a chance that people
will work together and resolve this,"
he said. "So 1 would say to them, keep
working, keep working at it, because
if you delay, you may lose it altogether."
But while Mr. Clinton was friendly
today, he has also said he could not
accept a bill that provided less In the
way of universal coverage than Mr.
Mitchell's. That bill aims to reach 95
percent coverage quickly and provides for a possible requirement that
employers pay half of workers' Insurance premiums if that goal is not
reached by 2000.
_ The mainstream proposal has a
lesser aim and no requirements for
employer payments.
Mr Mitchell expects to spend the
weekend studying the proposal, while
the coalition waits for findings from
the Congressional Budget Office on
what kind of subsidies and taxes
would be necessary to achieve tu
goals.
Where matters lead thereafter is
unpredictable. Mr. Mitchell and Mr.
Kennedy expect to negotiate, as do
several of the Democrats in the
group. But Senator John H. Chafee,
Continued on Page S, Column 1
1
1
HIGHLIGHTS
The Bipartisan Proposal
Here are some major features of the health insurance legislation
being devised by a coalition of moderates. Some elements,
including subsidies and taxes, remain subject to revision.
•
Coverage of 92 to 93 percent of Americans by 2004 While
Senator George J. Mitchell s bill would cover 95 percent of
Americans by the year 2000. other bills before Congress
mandate universal coverage sooner
•
Cnanges in insurance taws, like reauinng companies to offer
coverage to people despite pre-existing medical conditions
B Raising the Federal tobacco tax on a pack of cigarettes from 24
cents to 69 cents. Mr. Mitchell's bill also calls for the tax to rise to
69 cents a pack
•
Eliminating employers' ability to take tax deductions on certain
high-cost insurance coverage for their workers.
• . Eliminating provisions common to other proposed legislation,
like coverage of prescription drugs under Medicare ana new aid
tc academic medical centers
m
Z
tu
>
•
O
&
in
C
a
c
CA
H
K>
O
�
Dublin Core
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Title
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Health Care Task Force Records
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White House Health Care Task Force
Is Part Of
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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White House Health Care Task Force
Health Care Task Force
Jason Solomon
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2006-0885-F Segment 3
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Box 34
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093764" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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42-t-12093764-20060885F-Seg3-034-014-2015
12093764
-
https://clinton.presidentiallibraries.us/files/original/db614c65e3e681207f5325973d2aa02f.pdf
b92c543a690911d650557b9af7eaa043
PDF Text
Text
FOIA Number:
2006-0885-1
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MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton ('residential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Solomon, Jason
Subseries:
3327
OA/ID Number:
FolderlD:
Folder Title:
Work Memos [2]
Stack:
Row:
Section:
Shelf:
S
52
7
9
Position:
�Prom: Ed R6th«ohlld Te: Jaton Solomon
Dato: 6/6/04 Tim*: 1$:07:46
Citizen Action
FAX COVER PAGE
To: Jason Solomon
From : Ed Rothschild
Fax Number : 456-G485
Company : Citizen Action
Date : 5/5/94
Time : 16:07:28
Subject:
Created using WinFax PRO 3.0 Delrina Technology Inc.
For Information Call: 202 775-1580
Fax Number: 202 296-4054
P«0« 1 ol 8
�May 6, 1994
MEMOKANDUM FOR DAVID D R E Y E R
FROM:
MEEGHAN PRUNTY
JASON SOLOMON
SUBJECT:
Relevant
1, Individual
•
Statistics
- Part II
Mandate
Numbers
•
W a r n i n g : For the most part, all of these -- except for the Citizen Action
cite -- are analyses of the Chafee proposal before Congress today. I t is
probably not in our interest to target Chafee by name so we should find a
way to say "For example, under one current proposal" or something like
that.
•
As a basis of comparison with these statistics, our approach has an income
cap of 3.9% for families with incomes below 40,000. We expect, however,
that people will pay on average only 1-2 percent of their income on health
insurance premiums. [Validation can be found for this, if needed].
•
For families with no employer contribution, the net cost of health
insurance under the Chafee proposal is zero for families with incomes
below the poverty line, rising to 16 percent Of income at 225-250
percent of poverty. [KPMG Peat Marwick, 4/21/94]
•
Under an individual mandate, the cost to individuals would amount to
$1.5 trillion over 5 years. Under this mandate, where individuals and
families pay the entire annual health insurance premium, the
additional annual costs would be $1,680 for a single person, $3,360 for
a couple, $3,276 for single-payer family, and $4,452 for a two-parent
f a m i l y . [Citizen Action]
NOTE:
•
This assumes no subsidies at all, which is not realistic. A l l
individual mandates before Congress now have subsidies for
low income families.
Under the Thomas/Chafee bill, a family earning $18,000 could be left
with bills as high as $1,400 (7.8 percent of income). A family earning
about $29,000 could pay as much as $3,900 (13.1 percent of income).
[Kaiser Commission on the Future of Medicaid]
�"A worker earning a poverty-level wage who increases her earnings by
50 percent could lose over 23 percent of her wage increase to higher
premiums under the Thomas/Chafee plan." [Kaiser Commission on the
Future of Medicaid]
Under Senator Chafee's subsidy approach, families earning between
$22,200 and $37,000 would pay between 9.0 and 15.0 percent of their
incomes - up to almost eight weeks in pre-tax wages. [Families USA]
NOTE: Older number - they can do another if we need them to.
Polls
More Americans prefer an employer-based system (40%) over either
single-payer (19%) or an individual requirement (17%). [Robert Wood
Johnson Foundation, 2/94]
73% favor a federal law requiring all employers to provide health
insurance to full time employees and 69 percent support a law requiring
employers to pay some of the health insurance costs for part-time
employees. [ABC/Washington Post, 2/24 - 27/94]
In the most recent CBS News poll (February 15-17), a 2-to-l majority (53
to 27 percent) favor an employer mandate over an individual mandate as
the better way for the government to make sure all Americans are
covered.
Our DNC research shows that:
- The public favors and employer mandate by more than 2-to-l (64 to 28
percent) with a plurality strongly in favor. Support is still 2-to-l after
an attack claiming that an employer mandate will crush small
business.
-
By nearly 2-to-ln, a majority favor an employer mandate plan over an
individual mandate plan (56 to 30 percent) to achieve universal
coverage.
4. Cass Ballenger's Legislation
•
Amendment to William's Mark in House Education and Labor [i.e., not a freestanding bill] May come up next week, at the earliest.
�•
Based on the assumption that the employer mandate will pass and all
businesses will pay for coverage and all workers will be covered through the
workplace.
•
Make health benefits permissive rather than mandatory for collective
bargaining -- meaning workers couldn't strike over it, owners couldn't lock
out over it. They would not necessarily have to negotiate over it at all,
although they could if they chose to.
•
Rep. Ballenger is a Republican from North Carolina
•
Steve is getting me something from their office.
c:\meeghan\facts\dd-work.2; 05/06/94 02:24 PM
�(A At?
financial incentive to support, his employer or the government, as the case may "be, in their efforts
to manage the system, e.g., adding or reducing benefits and cost sharing and controlling costs.
^
The final weakness of the employer mandate as structured in the Adrainistration's plan is
that the incentive for employers to play a major role in containing health care costs is also
substantially weakened. This occurs because of the cap on employer contributions. As premiums
grow faster than wages, more and more firms will exceed the cap. They will simply pay 7.9
percent of ipayroll and befreeof any additional obligation. The result is that neither individuals
nor employers will have afinancialstake in the government's success in containing costs.
An Individual Mandate
Because of these problems with an employer mandate, many have come to believe that an
individual mandate may be superior. First, thefinancialresponsibility for obtaining insurance
rests upon the individual. This gives the individual a much stronger personal stake in monitoring
- the health care system. The individual would no longer believe that health care benefits are
something provided to him or her by the employer or by the govemment Rather, individuals
themselves, are both beneficiaries and payers.
It Li also possible with an individual mandate to target subsidies more direcdy on lowincome individuals, resulting in a more progressive system of financing. And the inefficiencies
of employer subsidies are eliminated.
Finally, an individual mandate has no adversefinancialimpacts on business (though this
depends on how the subsidies arefinanced).Assuming there are no other financial
responsibilities placed on business, employers will not attempt to shift the costs onto workers in
the form of lower wages or to increase prices. There are no possible adverse effects on
employment even in the short term.
g:\jh\misc\eongiesuxt 3/13/94 ll:25aiii
6
�It
The disadvantages of an individual mandate are that there are potentially high costs to
low-income individuals because health insurance premiums are expensive relative to income. To
reduce the cosCs to individuals, substantial new subsidies would be required to limit the financial
contributions of individuals and famUies. The govemment cost of an individual mandate depends
on the subsidy schedule and how many employees drop coverage. An individual mandate that
provides generous subsidies to individuals and families below 250 percent of poverty could
3
require more new govemment revenues than the Clinton plan.
One reason government costs would be higher is that many employers who now provide
health inj;urance would cease doing so. For example, if employers stopped providing health
insurance and gave workers higher wages instead, wo±ers could buy their own health insurance
and low-income individuals would gain govemment subsidies. If employers continued to provide
health ins urance, workers would not be eligible for subsidies.
In addition, under an individual mandate, there are higher marginal tax rates on earnings
than under an employer mandate, providing serious disincentives to greater work effort. This
occurs because individuals lose part of the subsidy as their income increases. For example, the
Thomas/Chafee bill would structure the individual mandate so that individuals with income below
100 percent of poverty would pay nothing, while individuals at 240 percent of poverty would pay
the full premium. The result is that increased earnings mean rather sharp losses of subsidies. In
addition, these individuals would pay payroll taxes, begin to pay federal income taxes and lose
earned income tax credits, and pay higher state income taxes. It is estimated that the marginal
'This ir, based on preliminary simulations conducted at The Urban Institute of subsidy schedules that would
provide full subsidies for those below poverty, with subsidies declining with income up to 250 percent of poverty. It
assumes th;u most employers of low wage workers would drop coverage. It is clearly possible to design a subsidy
schedule that would keep the govemment costs lower.
g:VjhVmisc\con||tes«.txt 3/13/94 11:25am
7
�tax rate would exceed 60 percent in this income range if subsidies were to be phased out at 240
percent of poverty.
"
The onfy way to avoid this effect is to reduce the overall value of the subsidy for those
below poverty or to phase it out more slowly, giving some assistance to those with incomes
above 240 percent of poverty. In the former, the costs to the poor increase while in the latter the
cost to the govemment is higher.
Thefinalproblem with an individual mandate is the difficulty in enforcement The
govemment would have to assure compliance by 225 million nonelderly Americans on a case-bycase basis. While in principle, employers could be required to provide evidence of their
employees' compliance, this would be more difficult than under an employer mandate
(particularly if alliances are small or voluntary or non-existent) because individuals would be
choosing many different plans with varying premiums and would berequiredto pay different
amounts depending on their eligibility for subsidies. The alternative would be to place the
responsibility solely on the govemment to identify and penalize those who fail to enroll, either
through the income tax system or when these individuals try to use health care services.
Combining Employer and Individual Mandates
A compromise lies in using both an employer and individual mandate as with the Clinton
plan, but with some important changes. First the required employer contribution should be
reduced to 50 percent of the weighted average premium of plans offered in an area, using the
composite premium structure of the Clinton Administration proposal. Employers could continue
to contribute more if they chose to do so. Furthermore, there would be no percentage of payroll
cap on the employer contribution.
g:\jh\misc\coijgtesLBrt 3/13/94 11:25am
�NUMBER AND PERCENT UNINSURED BY CONGRESSIONAL DISTRICT
ESTIMATED FROM 1990 CENSUS AND MARCH 1993 CPS
MAY 25. 1994
MAY NOT ADD TO STATE TOTALS BECAUSE OF ROUNDING AND METHODOLOGY
STATE
DISTRICT
EMPLOYED
EMPLOYED
TOTAL
TOTAL
PERCENT
PERSONS
UNINSURED
POPULATION
UNINSURED
UNINSURED
ALABAMA
all
1.804.133
329.254
4,185,200
677.225
ALABAMA
1
44,608
598,039
96.608
16.15%
ALABAMA
2
244,428
260.139
47,475
597,861
95.631
16.00%
ALABAMA
ALABAMA
3
253,310
96.247
16.10%
254.352
46,229
46,419
597,771
4
597,711
97 105
16.25%
16.18%
ALABAMA
5
280,196
51,136
597,894
97.477
16.30%
ALABAMA
291,947
53,280
597,827
98.344
16.45%
ALABAMA
6
7
219.763
40,107
598,096
95 813
16.02%
ALASKA
1
1.087,435
243,912
2,437,600
461.405
18.93%
ARIZONA
ALL
1.510,229
296,765
3,679,700
532.990
14.48%
ARIZONA
1
327.264
60,315
93.306
15.22%
ARIZONA
2
228,011
42.022
613,229
612,676
85.847
14.01%
ARIZONA
ARiZONA
3
4
243,099
322.128
44,803
612,834
86.941
14.19%
ARIZONA
5
265,172
59,368
49.055
613,119
613,541
92 919
87.812
15.16%
14.31%
ARIZONA
6
223,555
41.201
614,301
86 165
14.03%
ALL
1
223,413
528,200
132,254
16.54%
52.147
45,822
10,695
87 341
ARKANSAS
21.582
16.32%
ARKANSAS
2
60,733
12,456
131,990
21.930
16.62%
ARKANSAS
ARKANSAS
3
4
58.580
12,015
132,464
22.156
51.953
10,655
131,493
21 572
16.73%
16.48%
ARKANSAS
.
�•••UMBER AND PEncSNi
ESTIMAIED
.'/AV 2o.
r
U'.TJSUHEO
FROM l :50CE:JSU3
B'' CONGriESSlOr.'/-!.
AND MARCH innj
DlS'llili;]
CP'i
1991
.'/AY NOT A[)[) TO STATE TOTALS BECAUSE Of- RUUNOlNG ANL) WET TfODCLO'V''
RICT
_IFORNIA
ALL
EMPLOYED
EMPLOYED
PERSONS
UNINSURED
TOTAL
POPULATION
TOTAL
UNINSURED
urjiNSu^ED
14.794.357
3.223,690
^'FORNIA
261.168
56.909
31,255.000
605.534
5 994.204
1 14 835
l6.96'-
ORNIA
232.660
50,701
605.910
1 14.679
i5. g;--
.irORNIA
15.15-'
j
272 961
59.478
604.134
115.380
-
277.390
60.443
503.586
1 16.335
19 10'-15.27---
274 103
59.728
606.35S
1 16.357
19.15--
5
7
312,960
68 195
603,938
117.757
_'FORNIA
19.5C'-19.94--,
70,757
499.619
500.173
99.637
c
290.76-:
324,720
63,362
_ ^RNIA
282.705
61.602
606.379
:
-!. ORNIA
_:FORNIA
.IRORNIA
_ -ORNIA
102,969
1 15.597
20 5 5 ' -
1 18.035
19.52'--
114.535
IS.SS-
504.263
119.076
1 i 7 -'- •
68 720
604.967
1 17.701
15 4 6 - .
73.835
603 619
1 18.676
19.55-.
15.72'--
j=ORNIA
10
318.252
59.349
..-ORNIA
1 T
254.153
55.387
604,592
604.245
_ FORNIA
12
327.361
71 336
_.FORNIA
l j
315,372
338.846
. FORNIA
_.FORNIA
•.5.05'--
341.8S7
74,497
604.995
119.285
.iFORNIA
IS
294.44=
64,160
604 044
_:FORNIA
116.501
19 2 5 ' -
17
268.71 l
58.552
603 639
111.686
ie.50--..
IS
19
237.43'.
51,747
603.936
113.275
•.6.76--
57.092
605.753
115.543
19.07'--
20
262.006
199.774
43.531
606.255
1 1 1.834
i 6.45'-
2"
248.937
54.243
603.709
113.945
1 £ £7'--
22
23
285.465
299.054
62,207
605.625
116.792
1S.29 -
35,164
604 152
2-
337.551
73.559
604.916
1 15.S35
l 19.425
19
•.5.74 = .
25
300.172
55.408
505.671
1 17.066
'.5 53 = -
23
27
293 735
•34.006
55,464
604.125
I 16.565
15 3C = -
605.279
i 18.253
• r- - - =
25
65,575
604.614
117.357
:5 4C
2i
300.935
339.422
603 935
120.73 =
1 16.47-,
15.99 =
15 24-
-J=ORNIA
.'FORNIA
. -ORNIA
_ -ORNIA
_ -ORNIA
_ - ORNIA
. =ORNIA
. - ORNIA
r
_ ORNlA
_ -ORNIA
=
_ ORNlA
r
_ OnNIA
305.1 l-i
:
:
30
276.6-, 2
73.960
50.274
3-,
257 750
56,166
605 415
32
284.0: :
51.886
605 250
1 15 455
117.224
1 05 = 15.37 =
33
234.361
51.072
603 4 - -
113.852
15 37 = :
3-
269.503
58,725
506.154
i ' 5 550
= 5 -.3 =
35
245 4 3 -
53.480
604.294
114.336
35
37
345.733
226 473
75.335
606 374
1 19 751
1= 92 =
15 75 = -
49,348
604.E16
1 13.145
1=7-=-
35
291.644
53.549
605 329
1 15 541
15 i : =
59
319.705
•39.664
1 16 355
;5 ;• =
-0
233 462
50.876
60S 555
606.564
292.176
53.565
••2
255 4 2 ;
55.657
-:-
267 153
234.654
53,213
.. -'ORNIA
•'•5
. =0=NIA
.:5
341.525
291.435
-7
329 702
71 842
604.197
1 :7.573
282 1 15
61.473
605.855
1 10 935
300 252
237.4=2
65.425
606.133
i 10.452
51 747
605.925
110 8 ; ;
51
308.657
67 256
52
270.40:
58.920
505 513
506.047
116.252
1 14.864
_ -ORNIA
:
. OSNIA
. =ORNIA
. =ORNIA
_ = ORNIA
_ -ORNIA
_ -ORNIA
:
. ORN!A
:
_ ORN!A
:
. ORNIA
:
. ORNIA
. - ORNIA
r
_ ORNIA
r
_ OR;-.'iA
r
. ORNIA
_ -ORfvIA
. -ORNIA
•19
_ =ORNIA
50
:
_ ORNIA
:
. ORNIA
605 253
6 0 5 . ! 74
604 156
l l 1,22-115.357
;
.5 2 j
' 14.120
i 14..343
51.181
503 353
604.4-5
74.440
612 004
120 450
53.506
503.515
1 15 7£7
114545
• = =5 = -
=; =-:•=
=: :•=
•.£5: =
= 9 65
:
:
•5 :
15 4= =
:
15 2 £ 15.25 =
IS 2L-
:£55 =
�NUMBER AND PEHCENr UNINSURED BV CONGRESSIONAL [lis I RICT
EST1MA! =D FROM 1990 CENSUS AMU MARCH 1993 CPS
MAY 25. :99'l
MAY NOT ADU 10 STAIE TOTALS BECAUSE OF ROUNDING AND MET HC;C'-OGY
STATE
COLORADO
DISTRICT
ALL
COLORADO
TOT A _
EMPLOYED
EMPLOYED
TOTAL
PERSONS
UNINSURED
POPULATION
UNINSUREC
PERCENT
1.G4G.273
248.587
3.320.600
396.154
272.221
41,105
553,421
65.755
1 1 89°.o
UNINSURED
1 1.93%
COLORADO
2
300.776
45.417
553,320
68,255
12.34%
COLORADO
3
1 1.75%
251.886
38.035
553.488
65.024
COLORADO
264.154
39,887
553 585
65.954
11.91%
COLORADO
251 946
38 044
553.633
62.754
1 1.34%
5
305.290
46 099
553.153
68.372
12.36%
ALL
1,563.871
147 086
3.230.800
268,45'
8.31%
274.290
24.247
538,591
6.36%
COLORADO
CONNECTICUT
•CONNECTICUT
CONNECTICUT
2
271.359
23,988
538.629
45.0C43 6 4 -
CONNECTICUT
3
276.493
24.442
538,517
45,12-
B.38%
CONNECTICUT
i
276.007
24.399
538 180
45,05-
8.38%
CONNECTICUT
5
279.253
24.666
538,520
CONNECTICUT
6
286.469
25.324
538.363
44,655
44.655
8.30%
6.34%
DELAWARE
l
363.840
51.447
723,200
74.975
10.37%
'.WASHINGTON D.C.
1
266,176
65.426
531.400
114,395
21.53%
1,447,104
18.84%
='..ORIDA
8.1 0 %
ALL
5,186,849
13.776 000
2.595,954
LORlDA
1
248,393
58 099
599.017
108,155
18.06%
='_OR!DA
-.ORiDA
2
267.737
62.524
598,841
113.254
18.92%
242.709
56.770
599.553
599.568
1 1 1.67;
1 13.254
: 5.92%
:
18.66%
:
_ORIDA
289.515
67.713
;
_ORlDA
5
222.120
51.S54
= _0R1DA
5
7
243.400
55.931
599,401
597,834
108, IC^
109.75L
'•5.04%
293.557
55.665
600.057
1 15 9 5 -
19 3 2 %
S
g
317 093
74.168
598.664
1 16,3C£
15.43%
272 0 1 ' .
63.323
599,271
113 235
15 9 0 %
267 516
52 596
598,725
112 1 5 "
13.73%
LORIDA
10
i i
300.455
70.284
598.716
116.092
19.39%
= LOR!DA
12
59.323
598.610
1 12 5 2 "
18.79%
13
253 525
241.541
55 497
15.32%
= _ORlDA
:
'.ORIDA
-LORIDA
-LORIDA
1
:
.ORlDA
16.35%
596.938
'.09.725
_ORlDA
14
253.459
59 2 9 '
598,925
.ORlDA
15
267.621
52.543
598,982
i l 1.255
'. 1 2 . 7 4 ;
1
LORIDA
261.759
51.228
596.251
1 12.3:4
19.62%
18 7 7 %
:
.ORIDA
13
17
1c
246.636
5.7.759
599.772
112.95;
15 5 5 %
287.136
57 152
598.824
114.5:;
IS 12%
_ORlDA
19
2'67 129
•32.48'.
559.446
1 12.40"
IS. 75%
•• .ORiDA
30
299 465
70.05.-1
599.121
115
:9 3 2 %
".ORIDA
2:
595.832
1 17.-3; i
13 3 5 %
22
iri
307 316
27= 335
7 : 952
".ORIDA
".ORIDA
55 563
597.295
•:•• 704
300 155
1 1 1.25;
1 14 - 5 :
15 3 5 ° ,
263 505
;,
:
"LORIDA
:
1 8 55%
• 9 07%
�N U M U E R A N D ' ' E R C E l . ' ' . - E N S U R E D MY
E S I IMA TED FROM.
MAY 2U.
GEORGIA
ALL
C C ' .'CRESS D'.'Ai.
MA-C -
1993
DISTRICT
C-3
1994
MAY NOT ADD
DID I RIG r
1590 V E N S U S A N D
IO SI ATI "OTALS
B E C A U S E JF
R O L ' . D ' NG AND
EMPLOYED
EMPLOYED
PERSONS
UNINSURED
=OPULA"
3.097.233
•5E5 9 6 6
•3.492
METHODOLOGY
TOTAL
PERCENT
UNINSURED
UNINSURED
TC"AL
ON
530
1
192.170
18.35%
GEORGIA
1
245.756
54
509
590
55 i
GEORGIA
2
220.565
46.926
595
344
102.155
17.22%
GEORGIA
3
289.424
54.',94
595
115
" 0 . 2 0 9
18.58%
GEORGIA
4
341.554
75
753
590
520
: 14.442
19
GEORGIA
5
278
060
51
678
5E7
340
107
556
18.30%
GEORGIA
6
342
154
75
892
5E7
552
1 14.595
15.49%
GEORGIA
7
285.647
53.401
585
24i
109.256
16.54%
GEORGIA
8
268.023
59.448
552
-55
107.383
18.13%
GEORGIA
9
287,635
53.509
5E7
530
108.798
16.52%
GEORGIA
10
278.7 IE
51.320
553
Vic
107,875
IS.19%
GEORGIA
1 1
259
57.527
565
655
107.082
16.25%
-.AWAII
17.40%
36%
557.975
37.364
1.155
3 30
69.544
5
-AVJAii
1
291.040
15.500
564
463
35.1 IE
5.01%
-AV/AII
2
266.935
17.855
564
337
34.426
5.89%
468
88.534
•OAnO
ALL
353
102.818
ALL
7'.5
95%
1.063
500
156,447
O A H O
1
235.020
44
442
531
303
83.093
15.63%
OA.-.O
2
233.565
44.192
53!
557
83,353
1 5.57%
525.552
- » f O ) S
ALL
5 597.;>;:•
15
55%
! 2 02C
;•". -j
-JNOlS
235.35;
34
335
SO-
557
76.696
12
._.,'.OlS
245
33:
35.277
50-
552
76,523
12.72%
355
7S
1.549
095
12.59%
75%
__I;-.OIS
3
296
254
4 3 . 1 10
500
296
13.04%
._:.\OlS
-i
239.567
34.301
300 5 " 3
75.686
12.50%
-•_i.\OlS
5
330
s : ;
45.107
500
455
79.651
13.25%
-JN'OlS
•3
332
-.E;
4£
333
•SO".
77;
78.945
13.12%
ET;
—i.NQlS
7
233
34.029
50-.
=.45
76.325
'2.59%
-J.S'OlS
E
336.7;;
49
434
500
95:
78.379
13.04%
-L^.'OIS
o
321
46
772
50:
:55
79
521
12.23%
-J\'OlS
10
305.225
44.412
•sec
75
609
12.5E%
4;7
.LINOIS
1 1
2 7 5 . 1 '.5
40
50G 4 5 ;
77.323
12.E=%
-LlNOlS
12
247.505
35.055
300
76.097
12.55%
-•-I.N'OIS
13
322.453
45
9;£"
30C 5 74
77
959
12.95%
— INOIS
14
306.043
44
529
so: :•:•
77,535
12.90%
77
12.57%
4=5
5:5
_.i\OIS
15
285
4
463
60C
74 =
- I N O I S
IB
301.555
45
535
500
5:5
--i\OiS
17
267
35.557
so-- ::• =
77.451
i
j :
5 ; ;
321
77.662
:2
53%
.-•NOiS
15
261.75-:-
4-.
000
50:
"44
77.500
12
50%
._.\'OiS
13
250.;L4
35
445
5 0 C .= : ;
77.165
12
55%
._ r-.ois
20
270
5-E
55
-27
•JOC-
77.313
:2 5 7%
•.r-iANA
ALL
2 672
0;-
555
277
'.GlANA
'
246
337
;- •-- 0 7 ;
553
5;:'
57.200
10
15%
7-f
55
533
535
454
57.913
10
25%
10
47%
5
55;
555.455
:0.3S%
'. D'AN'A
2
259
•-.r'ANA
3
272.L;;
37
530
53:
57-
56
'OIANA
4
280.0.:
35
557
533
- 1 -
59.677
1C ; S %
'•.DIANA
5
256
35.703
5-33
; £ :
57.652
10.27%
'.DIANA
6
296.02;
40
3-.0
55; :•:•:•
30.600
10
265.555
35
757
555
545
58.344
10.35%
'.DIANA
54-
991
75%
'•.DIANA
s
2 5 8 . 5 ' ;•
35
725
565
455
57.769
10
25%
'.DiANA
9
250.55;
35
006
535 55 2
59.14.1
10
32%
'.DIANA
10
273
37.55!
563 5 4-
58.969
10.43%
5:5
�NUM1.1EP AND P E H C E N l UNINSURED L'Y CONGRESSIONAL DISTHIC!
ESTIMATED FROM 1390 CENSUS AND MARCH 199.1 CPS
MAY 2n
'994
MAY NOT ADD TO S T A I E TOTALS BECAUSE OF ROUNDING AND METHODOLOGY
STATE
DISTRICT
EMPLOYED
EMPLOYED
TOTAL
TOTAL
PERCENT
PERSONS
UNINSURED
POPULATION
UNINSURED
UNINSURED
OWA
ALL
1.399 873
165,325
2,900,300
276.852
9.55%
IOWA
1
291.812
34,463
579.933
55.973
9.65%
IOWA
2
269 397
31.816
580.209
54.869
9 46%
IOWA
274.803
32,454
580.006
54.893
9.46%
IOWA
3
4
297.361
579,982
56.335
9.71%
IOWA
5
266.500
35,1 18
31,474
580.171
54.782
9 44%
KAMSAS
ALL
1 192.392
158,587
2.520.200
255.491
10.14%
KANSAS
1
295 959
39,363
630,027
64.131
10.18%
KANSAS
2
273.550
36,383
630,041
61,240
9.72%
KANSAS
3
322.528
42,896
630.102
65.833
10.45%
KANSAS
4
300.33b
39.945
630.029
64 286
10 2 0 %
ALL
1 560.312
252.771
3 676,700
523.173
14.23%
KENTUCKY
1
246 687
39.996
13.96%
2
263 221
42,642
612.775
613 749
85.680
KENTUCKY
86.267
14 0 6 %
KENTUCKY
3
289,224
46,854
611,836
88.587
14.48%
KENTUCKY
4
274.41 1
KENTUCKY
;
44,455
612 977
88.364
14 4 2 %
KENTUCKY
5
189.905
30.765
612.547
85.290
13 9 2 %
KENTUCKY
5
296.664
48.060
612,812
88.985
14.52%
LOUISIANA
ALL
1 543.375
22 1 4 %
408.050
4.224.500
935 237
LOUISIANA
i
269 667
67.008
22.51%.
2
224 3 9 '
3
232 237
55.716
57,664
603.495
603.42!
135.832
LOUISIANA
LOUISIANA
133.300
133 678
22.09%
22.'4%
LOUISIANA
4
196.023
49.169
603.719
133 342
22.09%
-OUISIANA
5
60.328
503.660
LOUISIANA
3
242 555
244.577
50.728
502 775
134.081
131.046
22.20%
21.74%
231.314
57.435
503.326
134.007
22.2'%
590.177
78 841
LOUISIANA
MAINE
ALL
603 905
1.267.300
135.538
10.70%
MAINE
1
321.332
41.837
656,937
71111
10.63%
MAINE
2
25S.345
35.004
510.363
64.428
10.56%
ALL
2 535 327
335.596
l 1.16%
i
310.695
4 1,105
4.858.000
61 1,141
546.683
MARYLAND
68.161
11.15%
MARYLAND
2
316.672
MARYLAND
41.922
610,761
68.503
11.22%
MARYLAND
3
311.013
•33.300
1 1.13%
4
34 1 955
41.147
45.24 1
•31 1,025
MARYLAND
n
3
335 550
44 393
511.110
610.687
58.258
MARYLAND
38.074
! 1 1 4%
303 594
40.325
510.976
66 357
11.19%
255.3 = 5
35.233
51 1.016
•37.748
11.09%
MARYLAND
MARYLAND
MARYLAND
S
17%
•15 676
•31 1.078
69.252
l l .33%
2 933 i ; 5
316 .243
10 3 3 %
275 505
30.355
5.628.000
562.676
603 684
'.•.ASSACHUSETTS
50.31 1
10 35%.
MASSACHUSETTS
282 055
30.G03
532 652
•30.355
'.0.33%
31.331
10 3 7 %
MASSACHUSETTS
ALL
345.24'
MASSACHUSETTS
3
286 7 5 :
562 003
50.472
MASSACHUSETTS
4
266 562
31.344
582 557
•30.404
10.37%
MASSACHUSETTS
5
289.152
31.374
552.688
60 01 1
'0 30%
MASSACHUSETTS
5
7
301.215
32.682
592.963
50 523
10.35%
312 543
33 954
582 039
60.527
10 3 9 %
305.152
33 105
583.530
MASSACHUSETTS
5
9
582.420
60 598
60 41 i
10.37%
10
296.350
2H8.747
32 158
MASSACHUSETTS
31.329
582.672
60.271
10 3 4 %
MASSACHUSETTS
MASSACHUSETTS
10.39%
�NUMBER A-.D " E n C E N I ' UNINSUHEU BY CONGRESSIONAL OISTRICI
r
ESTIMATEC ' R O M lC ;U C E N S U S ANIJ MARCH 1953 CPS
MAY 26. ' 554
MAY NOT 4 0 0 TO STATE TOTALS FIECAUSE OF ROUNDING AND M E T H O D O L O G •
•isrnicT
T
S ATE
EMPLOYED
EMPLOYED
TOTAL
TOTAL
PERCENT
-ERSONS
UNINSURED
POPULATION
UNINSURED
UN.NSURED
MICHIGAN
ALL
4.156 757
516.518
9.278.700
887,388
9.56%
MICHIGAN
i
29.286
579.969
53.981
9.31%
MICHIGAN
2
235 799
255.547
32.236
579.980
55,523
9.5770
MICHIGAN
3
250 752
56.641
9.77%
4
242.915
34.869
30.1 71
579.837
MICHIGAN
579.653
54.592
9.42%
MICHIGAN
5
233.555
29.057
579.944
53 967
9.31%
MICHIGAN
6
7
270 3 4 :
33,576
579.936
56,056
9.67%
MICHIGAN
259 554
32.238
579.968
55.462
9.56%
MICHIGAN
8
263 300
35.807
580,034
56,972
9.82%
579.871
55.560
9.58%
MICHIGAN
9
250.662
32.377
MICHIGAN
10
279 107
34,665
579,937
56.416
9 73%
MICHIGAN
11
303 135
37,649
579.897
57,745
9.96%
MICHIGAN
12
292.245
36 297
579.950
57,160
9.86%
MICHIGAN
13
293.S25
37 114
579.845
MICHIGAN
14
215.265
26,863
579.940
57,502
53.224
9.16%
9 92%
MICHIGAN
16
171.455
21.295
579.896
50,808
6.76%
MICHIGAN
IB
255.64 1
33.018
579.847
55.779
9 62%
MINNESOTA
ALL
2.174 227
234,164
4,338 800
322.343
7.43%
MINNESOTA
1
255.122
28,877
542.371
40,057
7.39%
MINNESOTA
2
257.555
27,772
542.337
39.352
7.26%
MINNESOTA
3
307.023
33,066
542 438
42,519
7.84%
MINNESOTA
4
542 275
41,054
7.57%
5
31.309
542,339
4 1.693
7.69%
MINNESOTA
5
2b3 0 - ' "
250.705
295 0 7 :
30,480
MINNESOTA
32 210
542.516
41,935
7.73%
MINNESOTA
7
240 444
7 05%
G
2 2 - 557
542,483
542,041
38,259
MINNESOTA
25.896
24.554
37,473
5.91%
ALL
2 040.5=2
445. IS7
334 451
5,104.000
688,470
',3.49%
72,956
1.021.896
140,171
13.72%
57,643
1,020.454
135,890
13 3 2 %
7 1,091
1.021 954
138,969
MISSISSIPPI
MISSISSIPPI
1
1
MISSISSIPPI
2
2
MISSISSIPPI
3
3
3 5 : 654
453 74 =
MISSISSIPPI
4
4
405.523
56,973
1.018.959
137 966
1 3.60%
13.54%
MISSISSIPPI
5
5
40: 55:
55.788
1.020.736
135.475
13.27%
19.27%
MISSOURI
ALL
'• 245 51 2
294.477
2,599.200
519,953
MISSOURI
1
13: 054
30.925
299.752
57.250
19.10%
MISSOURI
2
•59 525
37.585
259 740
59.524
••9.86%
MISSOURI
3
•.45 - 7 5
55 422
19.50%
4
'•25 7 - '
34.389
50.377
255.558
MISSOURI
300.186
56.131
••3.70%
4 ; 555
34.434
300.182
58.532
19.50%
MISSOURI
MISSOURI
3
7
•4-. 5 = 5
33.472
299.937
58.162
: 3.7,5%
MISSOURI
"33 524
299.512
57 693
: 9 26%
MISSOURI
3
'• '• 5 374
32.279
27 854
299.700
5G 1 96
16.75%
MISSOURI
q
-.40 575
53. 162
299.628
58.043
19.37%
�H U M s E R AND PERCENT UNINSURED BV CONGRESSIONAL DISTRICT
ESTIMATED - R O M I O B O C E N S U S A N D MARCH ; 5 5 3 CPS
V.AV
2-3
-,594
'.'AY NOT ADD TO STATE TOTALS BECAUSE O ' " O u N D I N G AIJD METHODOLOGV
DISTRICT
STATE
•.'ONTANA
NEBRASKA
ALL
NE3RASKA
NEBRASKA
2
NEBRASKA
EMPLOYED
EMPLOYED
'OTAI.
TOTAL
PERCENT
PERSONS
UNINSURED
POPULATION
UNINSURED
UNINSURED
3 5 1 L'75
48.143
524.700
71.256
8.54%
795.231
85.656
148 866
9.13'-,
273.980
29.396
543.635
50.173
9.23%
259
28
543.926
49.1 1 7
9.02%
515
930
1 530
400
254.SSS
27.328
542.839
49.577
9.13%
1.306,100
NEVADA
ALL
550 133
148,267
293.631
22.48%
NEVADA
i
328 154
73.706
553
186
146.952
22
50%
NEVADA
2
331 9 7 3
74.561
552.914
146.679
22
47%
ALL
597 143
79.659
•..153.500
145,368
12 6 0 %
255
39,988
576.414
72,457
12 5 7 ' %
72.931
12 5 4 %
NEW
HAMPSHIRE
NE'.'J
HAMPSHIRE
N'E'.V H A M P S H I R E
753
2
297.333
39,671
577.086
NEW
JERSEY
ALL
3.873,259
562.784
7.736.500
NEW
JERSEY
i
263.938
41,256
595.195
76.43B
12.84%
NEW
JERSEY
2
230.353
40,735
595.424
76.634
12 5 7 %
\EVJ
JERSEY
2
262.589
41,060
595.366
75.736
12.72%
NEW
JERSEY
277.401
40,306
555.374
76.344
12.82%
NEW
JERSEY
f;
309.558
44,979
555,282
77.486
13.02=i
NEW
JERSEY
•5
313 ;3S
45
595
351
77.622
13.04%
NEW
JERSEY
7
321 4 7 i
46.710
354.744
77,963
13.1 1 %
NEW
JERSEY
3
500
904
43
595
77.524
13.02=o
NEW
JERSEY
c
313
053
45,486
595.49',
78.'.88
13
NEW
JERSEY
ID
270
034
39.236
554.575
76.353
12 £ 4 %
NEW
JERSEY
NEW
JERSEY
12
NEW
JERSEY
:
NEW
MEXICO
NEW
MEXICO
NEW
MEXICO
MEXICO
NEW
.'•JEW Y O R K
'-
721
613
12 9 5 %
13%
330.754
46.060
555
227
78.040
1 3 11= =
312
271
45,373
555
275
77.240
12.95%
277.775
40,361
555.575
76.844
12 90=-.
289.351
IE 52=-
234
151.565
2 4 3 . 1 14
57.106
516
2
154.555
45
728
3:7.57:
94.593
16 2 £ =
;
207.45'
48
730
51-782
96.054
18 5 5 =
ALL
AL^
'.•£'.'.' Y O R K
NEW
499
1 002.441
545
£.24 1
157
1 553,500
147
99
705
19.05%
!
0
1 267
490
383.615
13 4 £ %
277.£54
42
734
571.098
77 059
13 50=o
17 7 12 0 0 0
2
YORK
2
253 144
45.086
571.321
77.655
13 5S = o
'.E'.'.'YORK
5
297
957
45.827
371.4B4
7S.15S
13 5 6 %
'.'EW
YORK
253
£22
44
421
571 5 0 7
77.779
13 5 : = :
NEW
YORK
-
29: 454
44.330
3 72.079
75 1 5 6
13 3 3 = :
253 123
40.4 70
572.B07
75.901
15 4 2 - - ;
272.745
4 1 949
571.137
77.500
13 5 2 = :
257
65:
45
810
572
76.716
13 7 3 %
252.373
40
353
570.901
77.421
13 5 5 = -.
2:7
553
33
429
572
314
75.26:
13
245.931
33
286
372.319
73.155
13 2 5 = :
34
470
558.015
75.105
13
570.551
75.885
13 4 £ = c
'.'EW
YORK
NEW
YORK
'.•j-IW Y O R K
NEW
v
'.EW
YORK
NEW
YORK
ORK
•
:
z
•.:
\::W
YORK
'.2
224
NEW
YORK
T 2
252.552
-.23
40.447
346
53
:5%
;o-=
NEW
YORK
304
53 9,683
50.44.3
14. •.2-%
NEW
YORK
•,5
205.050
31.995
57:.37 1
75.357
13
NEW
YORK
1-3
172 551
25.535
572.060
73.403
12 £ 5 = ,
YORK
•• 7
247
39
032
539.47 1
76
212
13.45%
IS
2 5 2 4-31
44.S31
572.028
78.343
13 7 0 = ;
13 4 5 %
' .EW
NEW' Y O R K
•-
577
453
254
•
19=:
NEW
YORK
1 =
259.44-3
44.517
57 1,403
75.917
NEW
YORK
20
284
324
43
729
571.047
77.161
13
NEW
YORK
2-
231.404
43
280
57 1.338
77.545
T3.57
NEW
YORK
22
271.775
4 1 300
571.537
76
632
13.44%
NEW
YORK
248
33
280
571.276
75.880
13.28%
NEW
YORK
2-
231.535
35
584
57 1.393
74 1 7 3
1 2 . 5 5 = .-
NEW
YORK
2:
275.278
42.338
571 2 5 2
77,022
13
NEW
YORK
23
267.065
41 0 7 5
571,554
7 7 1 16
l3.4S=o
NEW
YORK
27
277.272
42
644
571.335
77.105
13 5 0 %
NEW
YORK
25
279.050
42
919
571 3 6 4
77
227
13.52%
NEW
YORK
25
265.453
40
982
570.856
76,884
13 4 7 %
NEW
YORK
30
254.214
39.098
571,828
76.692
13 4 1 %
NEW
YORK
3'.
245.513
33
571,417
76.163
13 3 3 %
892
237
5;':
:
0
45%
�NUMBER A N D PERCENT UNINSURED BV CONGRESSIONAL DISTRICT
ESTIMATED m o u 1SP0 CENSUS AND MARCH 1993 C P S
MAY 26 1634
MAY NOT ADD TO STATE TOTALS BECAUSE OF ROUNDING AND M E T H O D O I . O "
UIS"'R'CT
STATE
EMPLOYED
EMPLOYED
TOTAL
TOTAL
PERSONS
UNINSURED
POPULATION
UNINSURED
UN
-.SURED
NORTH
CAROLINA
ALL
3.266.467
522,565
5.686.100
889.577
NORTH
CAROLINA
l
229.682
36,772
558.224
72.919
NORTH
CAROLINA
2
276.231
44,225
557.319
75.141
NORTH
CAROLINA
3
249.083
35.878
556,703
71.502
NORTH
CAROLINA
4
313.002
5 0 . 1 12
557,230
77.235
:5.55 o
NORTH
CAROLINA
5
280
44,94 1
557,125
75,473
: 5.55%
NORTH
CAROLINA
5
307.059
49.152
557.454
76,969
13 5 :
NORTH
CAROLINA
7
211.994
33.940
555.623
63,727
:
=5%
NORTH
CAROLINA
6
262.149
41.970
556,825
73,680
: 5
25%
NORTH
CAROLINA
c.
735
45
425
557.279
7 7 , 1 11
• 5 54-%
NORTH
CAROLINA
10
297.1 l 1
47
568
557,091
76.438
: = 72%
NORTH
CAROLINA
1 i
255.046
40.993
557,287
74,107
; 2 J'-^o
NORTH
CAROLINA
12
274.575
43
976
556.742
75.274
:3
NORTH
DAKOTA
i
275.259
30
513
513.700
ALL
5,069.510
626
59i
OHIO
308
708
' i
:5
30%
-, 3 4 5 - ,
:
%
52%
46.746
•• - 4 - C
151.000
1,216.547
-os-%
OHIO
1
265.653
32.659
587.050
64.036
;3.5-%
OnIO
2
283.306
35
596.770
64,347
•0
OHIO
3
27 l
905
33.508
586
907
63.755
. 0 55-%
OHIO
4
260.595
32.210
5 8 6 91 1
63.899
•9.3 = %
OHIO
5
270.84 =
33.477
536.941
64,041
Cr-.IO
5
226.21 1
25.207
585.795
63.250
O.-.IO
7
265.194
32
585
934
63.605
C-.IO
5
275
G-.iO
r.
O.-.IO
10
317
017
775
34.153
596,829
64.185
254.590
32.7:5
585.905
64,001
273.33;
55
235
57=,
=.%
:•.•o -s%
•0.54=;
•0
54%
• 0 5" = i
=55
585.514
64
415
29.997
587.300
63,459
250 7 34
33.555
537
347
64,51 1
13
277.555
34.245
585.830
64,192
• n
O H I O
14
259.97:
23.335
585.983
64,255
• 3 5r=,
O-.IO
1 5
307
4:2
37
555
555.729
65,080
•;
3-:io
l .3
264
07:
32.355
555.593
63,971
••:; 5; = :
OHIO
1 7
243
204
30.050
553.559
63,645
••:
Or.lO
16
235.344
25. : 25
555.775
63,400
OnIO
ig
264
503
35.140
566.626
64,604
ALL
1.413
505
352.553
O-IO
OHIO
12
OHIO
OKLAHOMA
306
3.259.000
676.525
;
234
450
57.54 =
343,033
11S.334
OKLAHOMA
2
2:5
4:2
55.670
343.295
n
OKLAHOMA
2
212.550
34
543.190
110.623
OKLAHOMA
OKLAHOMA
555
1.635
225.0;;
55.5=1
345.315
109.430
OKLAHOMA
3
255.550
57.;:-5
542.512
1 15.955
"KLAHOMA
5
230. 3 ; 9
5=
543
1 12.545
O-EGON
ALL
OREGON
O-EGON
0=EGON
2
O-EGON
OREGON
r
332
554
1 401 43=
23:
752
017.700
384.957
3 i 1 i : :
5;
4; =
303.579
78.943
2
253
2:4
42.375
303.51 1
75.420
295
044
45
500
503.340
77.955
252
004
•'-5 3 5 5
503.467
75.891
277
032
=03.803
76.757
=2;
= 0 55 = ,
•o ;•=,
• 3 55 = ,
44:.
39 =,
54=,
=
•:•%
5 3 37 = -
z - ; -=-
•:;=,
• :
7==.
' £. 4" _ " -.
• 2 il'-.
• 2.330
• .. 7 - •,
�N U M B E f t u n PERCEMT UNINI-TUHEO RV C O N G R E S S
ESTIMATED ••ROW 1950 CENSUS AND M A R C - 1995 ".
MAY 25
155-:
MAY NOT ADD 1 O STATE TOTALS L-ECAUSE O - R O L ' I ' . G AND M E T H O D O L O G
STATE
-ENNSYLVANIA
D:S"RIC-
ALL
-ENNSYLVANIA
v
EMPLOYED
EMPLOYED
TOTAL
PERCENT
=ERSONS
UNINSURED
POPULA"
UNINSURED
UNINSURED
5 590 627
557.813
20.524
12.222
214.OSS
TC" A _
1.042.016
5.53%
582 5=4
48.301
S 29%
S.51%
PENNSYLVANIA
2
249,466
24.001
58- 4 7 ,
49,460
PENNSYLVANIA
5
257 577
24 779
582 - 3 5
49.598
5.52%
PENNSYLVANIA
-5
249.143
23.9-39
562
49,412
6 49%
247.230
23 784
581
49.384
8 49%
5
7
275 135
296 814
26 468
49.832
S 56%
28 554
582 • " =
582 : - : 7
50,178
S.52%
5
9
306.429
29.478
582 -.7 2
49,905
5 57%
PENNSYLVANIA
254 755
24 503
582 • • •
49.369
S 46%
PENNSYLVANIA
10
257.655
24 783
582
49.478
6.50%
582 •
49,655
8 53%
12
254 795
225.107
24.511
PENNSYLVANIA
21.555
582 : • :
49.119
6 44%
PENNSYLVANIA
13
305.695
255.077
29.403
58;
:
50.257
5.54%
24.538
582 : 5 :
49.756
5.55%
PENNSYLVANIA
PENNSYLVANIA
PENNSYLVANIA
PENNSYLVANIA
PENNSYLVANIA
PENNSYLVANIA
•
-.;E
PENNSYLVANIA
:3
284.652
27.384
582 - . " :
49.924
= .53%
PENNSYLVANIA
13
296.31 l
26.505
582 - 4 2
49,811
5.56%
PENNSYLVANIA
•,7
299.231
26 785
58=
49,934
5 58%
PENNSYLVANIA
1c
265.763
25 566
582 :-;-2
49,869
8.57%
PENNSYLVANIA
15
28.993
582
50,007
5.59%
PENNSYLVANIA
20
301.360
240.947
23,179
562
49.401
5.49%
PENNSYLVANIA
21
253.03;
24.342
582
::;
49,366
6.48%
E n O D E ISLAND
ALL
47 1.107
235.477
53 471
965
464 4 - ;
87,367
5.02%
23.540
43.545
5 99%
S
234 630
25.531
484 4=5
43.821
5.05%
AL.
:.574 51 :
370.424
3 64; :;.;
607,077
15 5 7 %
274 927
30.615
507
97.721
;5.09%
SOUTH CAROLINA
2
2S9 42A
54.021
60S 4 ; - l
100,591
SOUTH CAROLINA
5
234.5-, A
33.023
60S
103.491
; 5 59%
;7 03%
SOUTH CAROLINA
A
301.55:
55 770
•307 • ==
104.967
; 7
SGUTn CAROLINA
5
275 5 5 ;
5
247.465
51 045
34.745
60S
507 ;•;
100,931
SOUTH CAROLINA
99.375
;6 53%
-:5.37%
330.214
53.353
71A
104,006
;4 57%
2.315 055
553 575
25i.535
40.235
557
255.25 =
42 352
557 4 - ;
252 573
242 52 7
40 352
557 - - •
55 733
557 ; 4 _
74,481
-.2 3-3%
4 5 S£ 7
557;"=
76,403
-,5 7 0 %
557
=.iODE ISLAND
P - O D E ISLAND
EOUTn CAROLINA
50UT.-, CAROLINA
EOUTn DAKOTA
"EN.NESSEE
A _
"ENNESSEE
"ENNESSEE
"ENNESSEE
"ENNESSEE
/:
3
'.A;
5 015 5 : :
; E :
2P%
673,310
- =2%
75.080
; 5 455;
75.549
••5 5 5 %
75,006
'•5 4 5 %
"ENNESSEE
-3
"ENNESSEE-
5
275.522
4 4 001
75.779
"• 5 5 9 %
"ENNESSEE
;
230.625
4-..555
557
A;;
73,569
"ENNESSEE
5
240 457
35 407
557 5 ; :
73,276
-•3 ; s %
••5 •.=%
"ENNESSEE
'-
239 4 5 -
35.228
557 4 ; . ;
74,166
-3 5 ; %
�N1JM13EFT AND PEHCENT UNINSURED BV CONGRESSIONAL DISIRIC'I
ESI'IMATED FROM 1900 CENSUS AND MARCH 1993 CPS
MAY 20
1994
MAV NOV ADD TO STATE TOTALS BECAUSE OF ROUNDING AND METHODOLOGY
STATE
TEXAS
DISTRICT
A^L
TEXAS
EMPLOYED
EMPLOYED
TOTAL
TOTAL
PERCENT
PERSONS
UNINSURED
POPULATION
UNINSURED
UNINSURED
7.777,419
1.906.245
17.305.000
234.228
57.409
576.199
12L.32'
3.810
113
22.02%
22 0 1 %
TEXAS
2
217
883
53.403
576.517
126 2 3 3
21.91%
TEXAS
3
321.792
78.871
576
185
130 2 4 7
22 6 1 %
TEXAS
A
263.353
54.548
577,866
126.299
22
20%
TEXAS
3
257
755
53.176
576.527
127
22
16%
TEIXAS
5
322.907
79.144
576
130 01 i
873
772
22.54%
TEXAS
7
321
78.744
577,061
130.317
TEXAS
3
282,776
69
308
577,195
128,826
22.32%
TEXAS
9
259.607
63.630
576.769
127,706
22.14%
TEXAS
10
273
303.375
74.358
576,976
216.575
53.063
55
22
58%
128,859
22.33%
576.898
118.333
20.51%
177
576.500
127.437
22. l 1 %
240.019
58.825
577,307
125.843
21.80%
246.179
50.336
576.620
127,255
22.07%
15
193.351
47
390
577.432
124.950
21.64%
TEXAS
15
2 1 1.962
51
552
576,855
122.595
21 3 1 %
TEXAS
1 7
233
368
57.199
576.872
125.68-3
21.79%
TEXAS
It
257.172
63.033
575.296
127.545
22.17%
TEXAS
; 2
268
720
65.863
576,536
127.759
22.16%
TEXAS
20
231.171
55.660
575.456
122.233
21.24%
TEXAS
21
273.535
5 7 . 1 16
576.719
126.923
2 2 01 %
TEXAS
22
297.755
72.990
578.499
129,645
22.4 1 %
TEXAS
22
216.745
53.124
577
125.215
21.69%
"EXAS
24
270.475
55.293
576.387
127.649
22
18%
"EXAS
2;
288
70.71 1
575
799
126.721
22
36%
340.153
£3.38:
577
346
131
TEXAS
TEXAS
: 2
2S5.916
TEXAS
••2
TEXAS
14
TEXAS
"EXAS
467
362
150
22.72%
"EXAS
57
217.215
53.240
576.604
125.456
21
TEXAS
23
214
52.520
577,068
124 7 0 4
21.61%
-EYAS
25
223.537
57 2 4 0
.-7 ^ i ^
577.557
126
21.95%
577.508
128,492
22
1 1.30%
"EXAS
275.457
_ 7 AH.
-TA.-.
-TA-
2
.TA-.
-
.'E.RMONT
7=G'NlA
25'
A__
.' R G I N I A
.'RGlNIA
2
.' R G I N I A
5
/'.RGINIA
4
.'•PGiNIA
512
73%
25%
747.530
102
832
1.745.700
197,711
242.169
33
637
583.154
55.294
11.20%
270.295
37.556
563.364
66.957
11 4 8 %
234.555
32.537
583.182
55.430
l
303.557
35
604.200
56.051
9.2E%
2.542.315
030
1.22%
439.£2',
5.194.300
724.455
13.35%
222.525
35.546
472.745
54.974
13.74%
194.057
45.574
472.463
56.543
12.05%
156.545
54.355
470.658
54.057
13.61%
215.547
37.290
472.813
65.232
13.£1%
223.45:
35. l £4
472.02S
57.335
14.26%
.' R G I N I A
3
225.565
5"
597
472.158
67.525
14.32%
.' R G l N i A
7
255.435
44
334
472
412
66.51 7
14 5 0 %
.' R G I N I A
3
275.5.'.:
472
478
68.272
14.45%
.'..RGINIA
A
195.432
33.E10
472.227
66,034
13.55%
.' R G I N I A
• r\
257.75'
44.555
472.0TS
67, EO;
14.25%
270.565
45.523
472
07,515
14.32%
.' R G I N I A
301
�N U M B S " i M J PESCEN I UNINSURED BV CONGRESSIONAL DISTRlC*
ESTIMATED TROM : 9 p n CENSUS AND MARCH isg.'i CPS
MAV 26 •
MAV N O " •••DD TO S I , M E TOTALS BECAUSE OF ROUNDING AND METHODOLOGY
STATE
WASHINGTON
DISTRICT
EMPLOYED
EMPLOYED
TOTAL
TOTAL
PERCENT
"ERSONS
UNINSURED
POPULATION
UNINSURED
UNINSURED
ALL
1
2.385 597
275.775
5.061.100
497.465
9.83%
'WASHINGTON
293.265
34 479
561.699
56.588
10.07%
WASHINGTON
2
257.666
29,786
562.467
54,919
9.76%
'WASHINGTON
3
2-19 315
28.821
562 255
55.140
9.81%
WASHINGTON
<l
240 473
27.799
562,300
55.055
9.79%
WASHINGTON
5
240.355
27.785
562,471
54.505
9.69%
WASHINGTON
231.726
26.788
562,441
53,497
9 51%
WASHINGTON
6
7
305.473
35 659
562.821
56.692
10.07%
WASHINGTON
8
292 555
33.654
562.336
56.861
WASHINGTON
9
266.470
30.804
562,1 1 1
54.208
10 1 1 %
9.64%
ALL
1
565 107
122.313
1,777 500
266,082
14.97%
WEST VIRGINIA
235.553
43 318
592.728
89.476
15.10%
'.VEST VIRGINIA
2
237.745
43.721
592.594
89.669
15.13%
WEST VIRGINIA
3
151 509
35.274
592.177
86.937
14.68%
ALL
1
2 482.707
256.464
5.089.100
444.483
8.73%
WISCONSIN
273.553
28.258
565.300
49 302
8.72%
WISCONSIN
2
306.182
31 629
565.555
50.360
8.91%
WISCONSIN
3
271.S76
565.369
WISCONSIN
a
287 777
28 085
29.727
49.253
49.724
6.79%
WISCONSIN
5
250.970
25.925
565.536
46 564
S.59%
WISCONSIN
S
7
270.515
27.955
555.457
49.21 1
6.70%
256 162
565.496
6
c
270.2'.5
25.568
27.514
565.452
48,816
49,227
3 53%
£.71%
253.545
30.302
565.531
50.026
5 85%
2'.6 510
25 '.gS
473.100
54.357
i ;.4S%
WEST VIRGINIA
WISCONSIN
WISCONSIN
WISCONSIN
WISCONSIN
WYOMING
565.406
8.71%
�MEMORANDUM
To: Ken Thorpe
Fr: Jason Solomon
Re: Congressional Database For Health Care
Date: May 18, 1994
As I told Veronica, we're working on gathering information for a Congressional database
on health care. This information could be used in a variety of ways, including showing
members how their constituents will benefit under reform, (much like your state-by-state
study for state governments and employers)
At the end of the budget fight last year, for example, the Economic War Room released to
the Hill CD breakdowns of EITC "winners" and income tax hike "losers."
Our goal is to eventually have spreadsheets with the following by CD:
#
#
#
#
of people
of people
of people
of people
working and uninsured
with pre-existing conditions
with lifetime limits on their coverage
who will lose health coverage in the next two years without reform
I realize some of this may be very rough, and I know your shop is overstretched already.
But if you can help us get some of it done or tell us how to get it done, I know it will be
much appreciated over here. And if you have other ideas as to how we can show members
this will be good for their district, that would be great.
Veronica has put me on your schedule for tomorrow at 10:00; I'll bring over Thomas
Burke, a data analyst who works with us in the War Room. Thanks a lot for your help.
�We're looking for a spread sheet with the following:
By CD, county or, less preferable, by state:
For:
1981-1984
1985-1988
1989-1992
1992-latesl
average
average
average
average
annual job growth
annual unemployment
real disposable income growth
real wage growth
fz^S
raW in
IM-ML
-char
Current data also by CD:
J
EITC beneficiaries
income-tax losers
Family and Medical Leave beneficiaries
people who got help with financing a college education
people who refinanced their homes
manufacturing job losses
export job increases
retraining beneficiaries
school-to-work beneficiaries
people who are working and uninsured people who have pre-existing conditions
people with lifetime limits on their coverage
people who will lose their health coverage in the next two years without reform
(This is obviously a wish list which can and should be prioritized)
�HEALTH BENEFITS GUARANTEED AT WORK
FACT SHEET
THE PRESIDENT'S APPROACH BUILDS ON CURRENT SYSTEM:
• Nine out of ten Americans with private health insurance receive their coverage
through the workplace
1
•
On average, employers who provide coverage today pay 80% of the cost of their
employees' premiums.
2
•
Yet, right now, eight out of ten people who do not have health insurance are in
working families -- workers or dependents of workers.
3
SMALL BUSINESSES WILL BENEFIT MOST FROM REFORM:
• The Wall Street Journal wrote: "For many small businesses, saddled with
escalating health-care costs, President Clinton's health-care package comes
as an unexpected windfall."
4
PLAN PROVIDES DISCOUNTS TO HELP SMALLEST BUSINESSES:
• With the President's approach, many small low-wage businesses will receive
substantial discounts on the insurance they provide for their employees. In fact,
the smallest businesses will receive discounts of between 25 and 85 percent bringing affordable insurance into reach for America's smallest companies.
5
REFORM SAVES MONEY FOR FIRMS THAT NOW PROVIDE:
• In 1991, companies that covered their employees spent more than $26 billion to
cover members of the families of their workers, simply because other firms di d
not provide insurance.
6
•
Under the President's plan, American businesses will save $90 billion in the
next ten years, even when spending from businesses that currently don't provide
health care is included, according to the Congressional Budget Office.
7
JOBS: EXPERTS SAY IMPACT OF PRESIDENT'S PLAN NEGLIGIBLE:
• The CBO analysis states clearly that the President's approach will have a
negligible net effect on employment. "The Clinton plan, [CBO] concluded, mould
not significantly slow the economy or result in the loss of jobs, as many critics
have charged."
8
Employee Benefit Research Institute with 1993 Current Population Survey data, January 1994
1991 data; Urban Institute, Analysis of March 1992 Current Population Survey and HIAA data
Employee Benefits Research Institute, 1994
(emphasis added) "Small Business Sees Burdens Getting Lighter, "Wall Street Journal. 9/13/93
HHS analysis
Nation al Association of Manufacturers, "Employer Cost-Shifting Expenditures," prepared by
Lewin-ICF, December 1991.
CBO Analysis.. 2/9/94
Pearlsteui and Broder, Washington Post. 2/9/94.
2
3
4
5
6
7
8
�•>
382
OCTOBER TERM, 1949.
Syllabus.
339 U. S.
AMERICAN COMMUNICATIONS ASSN., C. I . 0.,
ET AL. v. DOUDS, REGIONAL DIRECTOR OF
THE NATIONAL LABOR RELATIONS BOARD.
i
NO. 10. APPEAL FROM T H E UNITED STATES DISTRICT COURT
FOR T H E SOUTHERN DISTRICT OF N E W YORK.*
Argued October 10-11, 1949.—Decided May 8, 1950.
Section 9 (h) of the National Labor Relations Act, as amended by
the Labor Management Relations Act, 1947, which imposes certain restrictions on, and denies the benefits of certain provisions
of the National Labor Relations Act to, any labor organization
the officers of which have not filed with the National Labor Relations Board the so-called ''non-Communist" affidavits prescribed
by § 9 (h), is valid under the Federal Constitution. Pp. 385-415.
1. One of the purposes of the Labor Management Relations Act
was to remove the obstructions to the free flow of commerce
resulting from "political strikes" instigated by Communists who
had infiltrated the management of labor organizations and were
subordinating legitimate trade-union objectives to obstructive
strikes when dictated by Communist Party leaders, often in support of the policies of a foreign government. Pp. 387-389.
2. Section 9 (h) does not merely withhold from noncomplying
unions benefits granted by the Government; it also imposes on
them a number of restrictions which would not exist if the National
Labor Relations Act had not been enacted. However, it does not
prohibit persons who do not sign the prescribed affidavit from
holding union office. Pp. 389-390.
3. The remedy provided by § 9 ( h ) bears reasonable relation
to the evil which it was designed to reach, since Congress might
reasonably find that Communists, unlike members of other political
parties, and persons who believe in the overthrow of the Government by force, unlike persons of other beliefs, represent a continuing danger of disruptive political strikes when they hold positions of union leadership. Pp. 390-393.
•Together with No. 13, United Steelworkers of America et al. v.
National Labor Relations Board, on certiorari to the Court of Appeals
for the Seventh Circuit, argued October 11, 1949.
1
�COMMUNICATIONS ASSN. v. DOUDS.
383
Syllabus.
382
4. Section 9 (h) is designed to protect the public, not against
what Communists and others identified therein advocate or believe,
but against what; Congress has concluded they have done and are
likely to do again; and the probable effects of the statute upon
the free exercise of the right of speech and assembly must be
weighed against the congressional determination that political
strikes are evils of conduct which cause substantial harm to interstate commerce and that Communists and others identified by
§ 9 { h ) pose continuing threats to that public interest when in
positions of union leadership. Pp. 393-400.
5. In view of the complexity of the problem of political strikes
and how to deal with their leaders, the public interest in the good
faith exercise of the great powers entrusted by Congress to labor
bargaining representatives under the National Labor Relations Act,
the fact that § 9 (h) touches only a relatively few persons who
combine certain political affiliations or beliefs with the occupancy
of positions of great power over the economy of the country, and
the fact that injury to interstate commerce would be an accomplished fact before any sanctions could be applied, the legislative
judgment that interstate commerce must be protected from a continuing threat oi political strikes is a permissible one in this case.
Pp. 400-406.
6. The belief identified in § 9 (h) is a belief in the objective
of overthrow by force or by any illegal or unconstitutional methods
of the Government of the United States as it now exists under
the Constitution and laws thereof. The sole effect of the statute
upon one who holds such beliefs is that he may be forced to relinquish his position as a union leader. So construed, in the light
of the circumstances surrounding the problem, § 9 ( h ) does not
unduly infringe :reedoms protected by the First Amendment. Pp.
406-412.
7. Section 9 (h) is not unconstitutionally vague; it 4
violate the prohibition of Article I , § 9 of the Constitution against
bills of attainder or ex post facto laws; and it does not require a
"test oath" contrary to the provision of Article V I that "no religious
Test shall ever be required as a Qualification to any Office or
public Trust under the United States." Pp. 412-415.
79 F. Supp. 563,170 F. 2d 247, affirmed.
o e s
n o t
No. 10. Although the officers of appellant union had
not filed with the National Labor Relations Board the
affidavit prescribed by § 9 (h) of the National Labor
874433 O—SO
211
�384
OCTOBER TERM, 1949.
Counsel for Parties.
339 U. S.
Relations Act, as amended by the Labor Management
Relations Act, 1947, 61 Stat. 136, 146, 29 U. S. C. (Supp.
I l l ) §§ 141, 159 (h), appellant, claiming that the section
was unconstitutional, sued to restrain the Board from
holding a representation election in a bargaining unit in
which appellant was the employee representative, until
a hearing was granted to appellant. The three-judge
district court dismissed the complaint. 79 F. Supp. 563.
On appeal to this Court, affirmed, p. 415.
No. 13. On an unfair labor practice complaint filed with
the National Labor Relations Board by petitioner unions,
the Board found that the employer had violated the
National Labor Relations Act in refusing to bargain
on the subject of pensions; but the Board postponed
the effective date of its order compelling the employer
to bargain, pending the unions' compliance with § 9 (h).
77 N . L. R. B. 1. The Court of Appeals sustained the
Board's action on both counts. 170 F. 2d 247. This
Court denied certiorari on the pension issue, 336 U. S.
960, but granted certiorari on an issue regarding the
constitutionality of § 9 (h). 335 U. S. 910. Affirmed,
p. 415.
Victor Rabinowitz argued the cause for appellants in
No. 10. With him on the brief was Leonard B. Boudin.
Samuel A. Neuburger was also of counsel.
Thomas E. Harris argued the cause for petitioners in
No. 13. With him on the brief were Arthur J. Goldberg
and Frank Donner.
Solicitor General Perlman argued the cause for appellee
in No. 10 and respondent in No. 13. With him on the
briefs were Robert L. Stern, Stanley M. Silverberg, Robert N. Denham, David P. Findling, A. Norman Somers,
Mozart G. Ratner and Norton J. Come.
I
�COMM UNICATIONS ASSN. v. DOUDS.
385
Oi)inion of the Court.
382
Briefs of amid curiae supporting appellants in No. 10
were filed by Arthur J. Goldberg, Frank Donner and
Thomas E. Harris for the Congress of Industrial Organizations; and Osmond K. Fraenkel and Jerome Walsh for
the American Civil Liberties Union.
Briefs of amid curiae supporting appellants in No. 10
and petitioners in No. 13 were filed by Robert W. Kenny,
Robert J. Silbe stein, Richard F. Watt and Edmund Hatfield for the National Lawyers' Guild; and Allan R. Rosenberg for the United Electrical, Radio & Machine
Workers (C. I . 0.).
r
M R . C H I E F JUSTICE VINSON
delivered the opinion of
the Court.
These cases present for decision the constitutionality
of § 9 (h) of the National Labor Relations Act, as
amended by the Labor Management Relations Act, 1947.
This section, commonly referred to as the non-Communist affidavit provision, reads as follows: "No investigation shall be made by the [National Labor Relations]
Board of any question affecting commerce concerning
the representation of employees, raised by a labor organization under subsection (c) of this section, no petition under section 9 (e) (1) shall be entertained, and
no complaint shall be issued pursuant to a charge made
by a labor organization under subsection (b) of section 10, unless there is on file with the Board an affidavit executed contemporaneously or within the preceding twelve-month period by each officer of such labor
organization and the officers of any national or international labor organization of which it is an affiliate or
1
1
61 Stat. 136, 146, 29 U. S. C. (Supp. Ill) § 141, § 150 (h), amending the National Labor Relations Act of 1935, 49 Stat. 449, 29 U. S. C.
§ 151 et seq.
�386
OCTOBER TERM, 1949.
Opinion of the Court.
ii
i
1
in--
in
•; f
• I,
i
! !
•.)
339 U. S.
constituent unit that he is not a member of the Communist Party or affiliated with such party, and that he
does not believe in, and is not a member of or supports
any organization that believes in or teaches, the overthrow of the United States Government by force or by
any illegal or unconstitutional methods. The provisions
of section 35 A of the Criminal Code shall be applicable
in respect to such affidavits."
In No. 10, the constitutional issue was raised by a suit
to restrain the Board from holding a representation election in a bargaining unit in which appellant union was
the employee representative, without permitting its name
to appear on the ballot, and, should the election be held,
to restrain the Board from announcing the results or certifying the victor, until a hearing was granted to appellant. A hearing had been denied because of the noncompliance with § 9 ( h ) . The complaint alleged that
this requirement was unconstitutional. Appellee's motion to dismiss the complaint was granted by the statutory
three-judge court, 79 F. Supp. 563 (1948), with one judge
dissenting. Since the constitutional issues were properly
raised and substantial, we noted probable jurisdiction.
No. 13 is the outcome of an unfair labor practice complaint filed with the Board by petitioner unions. The
Board found that Inland Steel Company had violated the
Labor Relations Act in refusing to bargain on the subject
of pensions. 77 N . L. R. B. 1 (1948). But the Board
postponed the effective date of its order compelling the
company to bargain, pending the unions' compliance with
§ 9 (h). Both sides appealed: the company urged that
the Act had been misinterpreted; the unions contended
that § 9 (h) was unconstitutional and therefore an invalid condition of a Board order. When the court below
upheld the Board on both counts, 170 F. 2d 247 (1948),
with one judge dissenting as to § 9 (h), both sides filed
petitions for certiorari. We denied the petition pertain-
�COMMUNICATIONS ASSN. v. DOUDS.
382
387
Opinion of the Court.
ing to the pension issue, 336 U. S. 960 (1949), but granted
the petition directed at the affidavit requirement, 335
U. S. 910 (1949), because of the manifest importance of
the constitutional issues involved.
I.
The constitutional justification for the National Labor
Relations Act was the power of Congress to protect interstate commerce by removing obstructions to the free flow
of commerce. National Labor Relations Board v. Jones
cfe Laughlin Steel Corp., 301 U. S. 1 (1937). That Act
was designed to remove obstructions caused by strikes
and other forms of industrial unrest, which Congress
found were attributable to the inequality of bargaining
power between unorganized employees and their employers. I t did so by strengthening employee groups,
by restraining certain employer practices, and by encouraging the processes of collective bargaining.
When the; Labor Management Relations Act was
passed twelve years later, i t was the view of Congress
that additional impediments to the free flow of commerce
made amendment of the original Act desirable. I t was
stated in the findings and declaration of policy that:
"Experience has further demonstrated that certain
practices by some labor organizations, their officers,
and members have the intent or the necessary effect
of burdening or obstructing commerce by preventing
the free flow of goods in such commerce through
strikes and other forms of industrial unrest or through
concerted activities which impair the interest of the
public in the free flow of such commerce. The elimination of such practices is a necessary condition to
the assurance of the rights herein guaranteed."
2
2
29U.S.C. (Supp. I l l ) § 151.
�388
OCTOBER TERM, 1949.
Opinion of the Court.
w-i-
:i
339 U. S.
One such obstruction, which it was the purpose of
§ 9 (h) of the Act to remove, was the so-called "political
strike." Substantial amounts of evidence were presented to various committees of Congress, including the
committees immediately concerned with labor legislation,
that Communist leaders of labor unions had in the past
and would continue in the future to subordinate legitimate trade union objectives to obstructive strikes when
dictated by Party leaders, often in support of the policies
of a foreign government. And other evidence supports
the view that some union leaders who hold to a belief in
violent overthrow of the Government for reasons other
than loyalty to the Communist Party likewise regard
strikes and other forms of direct action designed to serve
ultimate revolutionary goals as the primary objectives
of labor unions which they control. At the committee
hearings, the incident most fully developed was a strike
at the Milwaukee plant of the Allis-Chalmers Manufacturing Company in 1941, when that plant was producing
vital materials for the national defense program. A full
hearing was given not only to company officials, but also
to leaders of the international and local unions involved.
Congress heard testimony that the strike had been called
solely in obedience to Party orders for the purpose of
starting the "snowballing of strikes" in defense plants.
3
*
i'
: I ""
ii Ii i
4
No useful purpose would be served by setting out at
length the evidence before Congress relating to the prob3
i
A detailed description of the aims and tactics of the Socialist
Workers Party, for example, may be found in the transcript of
record in Dunne v. Uriited States, 320 U. S. 790 (1943), certiorari
denied. We cite the record as evidence only and express no opinion
whatever on the merits of the case. See record, pp. 267-271, 273274, 330-332, 439, 475, 491-492, 495-496, 535, 606, 683-688, 693,
737, S04-S05.
* See Hearings before House Committee on Education and Labor
on Bills to Amend and Repeal the National Labor Relations Act,
80th Cong., 1st Sess. 3611-3615.
�COMMUNICATIONS ASSN. v. DOUDS.
382
389
Opinion of the Court.
Jem of political strikes, nor can we attempt to assess the
validity of each item of evidence. I t is sufficient to say
that Congress had a great mass of material before it which
tended to show that Communists and others proscribed
by the statute had infiltrated union organizations not to
support and further trade union objectives, including the
advocacy of change by democratic methods, but to make
them a device by which commerce and industry might be
disrupted when the dictates of political policy required
such action.
II.
The unions contend that the necessary effect of § 9 (h)
is to make it impossible for persons who cannot sign the
oath to be officers; of labor unions. They urge that such
a statute violates fundamental rights guaranteed by the
First Amendment: the right of union officers to hold what
political views they choose and to associate with what
political groups they will, and the right of unions to choose
their officers without interference from government.
The Board has argued, on the other hand, that § 9 (h)
presents no First Amendment problem because its sole
sanction is the withdrawal from noncomplying unions of
tho; "privilege" oii using its facilities.
Neither contention states the problem with complete
accuracy. I t cannot be denied that the practical effect
of denial of access to the Board and the denial of a place
on the ballot in representation proceedings is not merely
to withhold benefits granted by the Government but to
impose upon norcomplying unions a number of restrictions which would not exist if the Board had not been
5
5
The First Ainentlinent provides: "Congress .shall make no law . . .
abridging the freedom of speech, or of the press; or the right of
the people peaceably to assemble, and to petition the Government
for a redress of grievances."
�1U7
f-iiiXND STKKI' CO. v. NATIONAL T<AROR RELATIONS ROAltD
J B n j K v g a s i ! -•• - " ' *
Cite tut HO F . M 247
NATIONAL LA^ H f ^CO.'
A . -V. MA
§§ 1 ct seq., 1(b), 29 U.S.C.A. §§ 141 et
scq, 141(b).
iTIONS BOARD.
R S E R S
OF AMER,
^ S t r V . NATIONAL LABOR
Jp'CX'f IONS BOARD.
• •-••I
UM.tiftlfes Court of Ajj]
i^ilw^flevchth Circuit.
'•: !h.
I'-,
"• t '
I ^ ^ i o r w i Granted Jan. 17, 104!).
M ^ ' l e e 60 S.Ct. 480.
u-.-|,
. \hr
.!;:ni.
h a
• ^ S g & B & t e ' r e q u i r i n g an employer to
^&&lK
r h V e l v with rcorescntative
of
iSfKIn
eoilcctivcly
representative of
kfi'emDIOyees m respect to rates of pay,
oj; employment,, or other con''emijloymcnt, includes retirement 6. Constitutional law ©=90, 275(1)
^ '
National Labor RelaMaster and servant <S=I5(I0)
9(a), as amended
Searches and seizures <S=>7(I)
Relations Act of
The section of the Labor Management
| g p S . a A . § § 158(a) (5), 159(a).
Relations Act requiring affidavits by officers of labor organizations in respect of
. JommerMj^7:IJ
•
^jjlt^ong.'ressional authority to protect membership in Communist Party, etc., is
BleriUtif'corimerce from burdens and ob- not unconstitutional on ground that the
rtft<ii6n$'.. w not limited to transactions phrases "any organization that believes in,
whlchfcan bis deemed an essential part of or teaches the overthrow of the United
\\:u:
|ir„
I Ilti.
• vi;.
• i),
' \irrlac: i
I'VI'SI:
•.VDII! I
:.; ni
m iL:
i (.»:
5. Constitutional law €=70(3)
Master and servant C=I5(I0)
Whether the benefits of the National
Labor Relations Act should be. extended to
Communists and their followers is for Congress to decide, and section of Labor Management Relations Act requiring officers
of any national or international labor organization to file affidavits that they are
not members of the Communist Party or
affiliated with it, etc., has a substantial basis
in fact and is constitutional. National La^ Relations Act, § 9(h), as amended by
I-abor Management Relations Act of 1947,
29 U.S.C.A. § 159(h); U.S.C.A.Const. art.
1, § 9, cl. 3; Amends. 1, 5, 9, 10.
:
^.floV^lii'tcrstate
or foreign
commerce, States viuv
Government
any i l W^now^ot interstate or
toreign commerce,
i.m.i.m by iforce
i or
, by *„,
.!iii'J)r«ti--x.-.i—
ti
.
.
•_
letrnl
or
unconstitutional
methods",
iBSivthf'ixSiVer' to regulate commerce is Sal o unconstitutional methods", ""affiIhe^wer tc enact all appropriate legisia".
"supports" are
vague and
and indefinite
indehmte and
and therefore
therefore obtioh'toy".Such
power <
is« nl^narv
plenary and
tioiiViiiy-S-urh nnwpr
^nrl may vague
be.^oTerted'to protect interstate commerce noxious to the First, Fourth, and Fifth
m^AatVer what the source of the dangers amendments. National Labor Relations
whichjlireaten it.
> § 9(h), as amended by Labor Managemcnt Relations Act of 1947, 29 U.S.
1 .institutional law ©=84, 215, 275(1)
C.A. § 159(h); U.S.C.A.Const. Amends.
^ A J l a w applied to deny a person a right j
*
&
hold any job because of ' '
Wstilityto his particular race, religion, be- 7. Constitutional law e=82
|i«ft. 'or'because of any other reason havMaster and servant e=l5(IO)
in^fio' rational relation to regulated acSection of the Labor Management Retjvities , cannot be supported under the con'
Act requiring affidavits of officers
•tifii'tion, biit Congress has the power to
unions concerning membership in
withhold, benefits which it confers for the Communist Party, etc., is not unconstituMcdmplishrient of legitimate purposes ti°»al
ground that it constitutes a bill
'.thin its CDnstitutional powers from those
attainder. National Labor Relations
^O-it ha;,, cause to believe may utilize Act, § 9(h), as amended by Labor Manthose, bene fits for directly opposite pur- agement Relations Act of 1947, 29 U.S.
PMiS-tf 6tit i - •
C.A. § 159(h); U.S.C.A.Const. art. 1, § 9,
cl.
3.
* Master and servant ©=15(9)
C
IIUTIIS
lc
l i a t e d
: now
.i:ii!f(l
•.iizi.il.
:
F.2d
the
0C':u-
nd all
1 rcnan.!
it i-'
tanci'
takf
..Ml
t c
u
U J
w i t h
a
n
d
t h e
w
o
r
d
A c t
4
l i v i n
:tions
i collision
Wc
. Its
atory
U
r
5
o r
v
1
l a t
o f
o n s
, a b o r
o
w
n
o f
^-Thc L::bor Management Relations Act 8. Constitutional law G=82
* 'ycsigncd to lessen industrial disputes.
A "bill of attainder" is a legislative
.9/, Management Relations Act of 1947, act which inflicts punishment without a juas
A
4
�f
24S
170 FEDERAL REPORTER, 2d SERIES
. The Union, in case No. 9634,
condition attached to the orde
quires as a prerequisite to its
that the Union comply with J
the Act. Obviously, if the Con
, tion is sustained, the Union's f
not be considered. On the
if the Ccmpany's contention is
will be confronted with the que
by the Union.
dicial trial. U.S.C.A.Const. art. 1, § 9, inafter called the Company), to review
and set aside an order issued by the Nacl. 3.
tional Labor Relations Board on April 12,
Sco Words ond Phrases, Permanent
1948, against the Company, pursuant to
Edition, for oil other definitions of
"Bill of Attainder".
Sec. 10(c) of the National Labor Relations
Act, following the usual proceedings under
9. Constitutional law C=8I
Sec. 10 of the Act, and upon petition (in
Nothing in the Constitution prevents
No. 9634) of the United Steel Workers of
Congress from acting in time to prevent
America, C.I.O. (hereinafter called the
potential injury to the national economy
Union), to review and set aside a condifrom becoming a reality.
tion attached to the Board's order.
MAJOR, Circuit Judge, dissenting in
In the beginning, it seems appropriate to
part.
set forth that portion of the Board's order
which gives rise to the questions here in
controversy.
The order requires the ComOn Petitions to Review and Set Aside an
Order of the National Labor Relations pany to
Board.
"Cease and desist f r o m :
1
MAJO'R, Circuit Judge (dissenting in
part).
These cases are here upon pctit'ion (in
No. 9612) of Inland Steel Company (hrre-
"(a) Refusing to bargain collectively
with Local Unions Nos. 1010 and 6-1,
United Steelworkers of America (CIO),
with respect to its pension and retirement
policies if and when said labor organization shall have complied within thirty (30)
days from the date of this Order, with
Section 9 ( f ) , (g), and (h) of the Act,
as amended, as the exclusive bargaining
representative of all production, maintenance, and transportation workers in the
[petitioner's] Indiana Harbor, Indiana, and
Chicago Heights, Illinois, plants, excluding
foremen, assistant foremen, supervisory,
office and salaried employees, bricklayers,
timekeepers, technical engineers, technicians, draftsmen, chemists, watchmen, and
nurses;
"(b) Making any unilateral changes, affecting any employees in the unit represented by the Union, with respect to i '
pension and retirement policies witlumi
prior consultation with the Union, wlicn
and if the Union shall have complied witl>
the filing requirements of the Act, as
amended, in the manner set forth aboveThe Company, in case No. 9612, attacks
that portion of the order which require
it to bargain with respect to its rctirerm "
and pension policies. The Union has bc^
permitted to intervene and joins the Boar
in the defense of this part of the order-
iTho Nutional Labor Relations Act, 40
Stnt. 440, 20 U.S.C.A. | 101 et acq.
(bemimftcr referred to ns the Act), was
omcndeU by the Labor Management Itulatiima Act, 1017, effective August 22,
1017, 01 Stut. .130, 2D U.S.C.A. 8 1 U ot
gcq. (herciimftcr referred to as the
amended Act). Tho unfair labor pi^"
tices found by the Roard herein '
curred, in part, prior to the effective A-.i^
of tlio amendment and, in part, t ' " " "
after.
Petitions by Inland Steel Company and
by United Steel Workers of America, C. I .
0., and others to review and set aside an
order of the National Labor Relations
Board.
Petitions denied and order enforced.
Ernest S. Ballard and Merrill Shepard,
both of Chicago, 111. (Pope & Ballard, of
Chicago, I I I , of counsel), for Inland Steel
Co., for petitioner.
Arthur J. Goldberg, of Chicago, 111., and
Frank Donner and Martin Kurasch, both
of Washington, D . C , for United Steel
Workers o::' America.
David P Findling, Ruth Weyand, Marcel Mallet-Prevost, and A. Norman Somers, Asst. Gen. Counsels, and Mozart G.
Ratner, Atty., National Labor Relations
Board, all of Washington, D. C, for respondent.
Edmund Hatfield, of Chicago, 111., filed a
brief as amicus curiae for National Lawyers' Guild.
Before MAJOR, KERNER, and M I N TON, Circuit Judges.
5
INLAND STEEL C<
k We shall, therefore, first o
question presented on the Com]
tion for review. ]n doing so,
.overlook the Board's contentic
are without authority to con
question on the ground that
pany is not aggrieved until ther
compliance by the Union with
tion attached to the order. We
..contention is without merit and
be discussed.
i
^ e r e is no question as to j i
nnd no dispute of any consequenc
facts in either case. The Comj
fusal to bargain concerning a r
and pension plan is based solely o
tention that it is not required
Jinder the terms of the Act. T
has refused to comply with the
attached to the order insofar as
» concerned,
the ground that
Sraph.is unconstitutional. Thus, a
of law u presented in each case.
o
c o
n
e c t i v e
In!?* "
bargaining requir
™ we original Act was embraced
•^8(5)
.
^
™sed as to any change in the
^ Parties because of the amen
" "ems, therefore, that the orig
. o importance only as an aid in
a
n
d
m e n d c d
Olf'/ l
9 ( a )
2
N
A c t w h c r e i
o
» Cong
the identical language, so
j y e n t to the instant ^ n o n , ^
,.^ongi ,
r ) a
C
' ?
P
"^d^
) y
u s c d
, p a n y
a t C c J
r c , a t c s
n a t l l r e
i n
o f
lcn
Sth
^5 rc
-1
^ibl?'
!^^
r
T
Sh0W,
n
'S
t h a t
is
6c cti
v f e ^ i
ons were recVnc't,
' ^ ^ W
>
"'" '"'
%ftev,"
material cbanRo s,
- • Present
^»o.rd f
concern,,
•S^W
d that retirement and „,
170 *\2e]—icfc
r
oC
h
^ _ ^ y rate highly impract
< 5 >
a n , 1
0 ( u
, t h o u t
r
S e n t
f o , l n
i s s u c
i s
o f
�IT
INLAND STEEL CO.
v. NATIONAL LABOR RELATIONS BOARD
249
Cite as 170 F.2d
247
• The Union, in case No. 9634, attacks the it to bargain relative thereto with the
condition attached to the order, which re- multiplicity of bargaining units which the
quires as a prerequisite to its enforcement Board has established in its plant. I t
that the Union comply with Sec. 9(h) of states in its brief:
the Act. Obviously, if the Company's posi..
. tion is sustained, the Union's pet.tion need
.
not be considered. On the other hand,
,
i.
.f the Ccmpanys contention ,s denied, we
will be confronted with the question raised
.
. by the Union.
gaining within units of the character e»
R c t i r e n l e n t
t h e
p e t i t i o n e r
t h
h
l e c t i v e
L
;
We shall, therefore, first consider the
question presented on the Company's petition for review. In doing so, we do not
. overlook the Board's contention that we
are without authority to consider such
question on the ground that the Company is not aggrieved until there has been
compliance by the Union with the condition attached to the order. We think this
contention is without merit and need not
be discussed.
There is no question as to jurisdiction
and no dispute of any consequence as to the
facts in either case. The Company's refusal to bargain concerning a retirement
' and pension plan is based solely on its content.on that it is not required to do so
• under the terms of the Act. The Union
has refused to comply with the condition
attached to the order insofar as Sec. 9(h)
is concerned, on the ground that the paragraph is unconstitutional. Thus, a question
of law ,s presented in each case.
ay, The collective bargaining requirement in
in the original Act was embraced mainly in
• Sees. 8(5) and 9(a).
No question is
• raised as to any change in the status of
• the parties because of the amended Act.
: It seems, therefore, that the original Act
• is of importance only as an aid in constru' &
amended Act wherein Congress emPloyed the identical language, so far as
'-•pertinent to the instant question, which it
jjhad originally used.
The Company relates in lengthy detail
'^h'e complicated nature of its retirement
^and pension plan, for the purpose, as we
^Understand, of showing that it is impos. . ' ^ e , or at any rate highly impractical, for
8cc
m
e
n
t
f
r
o
m
s
s c s
b a r g a i n i n g
r
p e n s i o n
c a n n o t
t h e
A c t >
p l a n s
b e
o f
b
s u c h
d c a l t
c o m p u
r e q u i r e d
R e l a t i o n s
y
w h i c h
w i t h
s o r y
t h c
t h e
c o n i p u I s o r y
p e n s i o n
p l a n s
s
i s
t h e
w i t h
e
a
t h e
a l s 0
a
m
e
l a s t
r
c
o {
h
e
] a w /
T
,
l
c o
N a t i o n a l
e n t a i l
a
w
i s
e
s e n t t ; n c e
t h e
v i e w
a
|
a
w
a g r e e >
o f
t h a t
f o r
o f
t h i s
t h e
a
n
e
n
a s
t
a
n
d
o f
p c n s i o n
t h c
A
p l a n s
c
t
o r
i n c
u d c
K
w
i
•HP
M
m
'•x
1
q u o t a t
i
o n
a
r e t i r e
n o n c
s
U
matters were suhjects of compulsory
colleetive barfainiMf; under the Act and
Hint they remained so under the amended
Act.
•in
•m
.
b a r g a i n i n g
t
n
•If
d
s o m
n
•t!
c o u r s e |
,i
.
. Otherwise,
he Board points out, "some employers
would have to bargain about pensions and
e would not, depending entirely upon
the unit structure in the plant and the
nature of the pension plan the employer
has established or desires to establish."
Such a holding as to the Act's rcquircwould supply thc incentive for an
employer to devise a plan or system which
o l d be sufficiently comprehensive and
difficult to remove it from the ambit of
the statute, and success of such an effort
would depend upon the ingenuity of the
formulator of the plan. Wc arc satisfied
no such construction of thc Act can rcasonably be made.
r c q u i r e m e n t s
m
i
a I ]
m
b a r
bar
W
>>
a s
t h a t
i t
W
1 1 1 6
' J f L « - 8(a) (5) ond 0(a) of ilie aii«i'iid:-d
.iMk-Act, without material change si> far ns
•.-•Jrithe present issuc is conccnicd. Tho
^Board found that retirement and peuuion
170 F.2d—IGVi
o
d
Thc
Company concedes that "Congress
could have established a requirement of
compulsory collective bargaining upon any
subject which a representative of thc employees chose to present for that purpose,"
and we understand from some parts of its
argument that it tacitly concedes that some
retirement and pension plans may be within
the scope of the bargaining requirement.
However, we find in the Company's reply
brief, in response to the Board's argument,
what appears to be the inconsistent state"Congress intended to exclude
g a i n i n g requircmcnt of the Act all industrial retirement and
2
• r??rfj(v
^ T Z* .These
:
:
sections were reenncted in
b
n
tablished by Section 9(a) and (b) of that
Act."
:
, n
a
a
%
�250
170 FEDERAL, REPORTER, 2d SERIES
It is, therefore, our view that the Company's retirement and pension plan, complicated as it is asserted to be, must be
treated and considered the same as any
other such plan. It follows that the issue
for decision is, as thc Board asserts,
whether pension and retirement plans are
part of the subject matter of compulsory
collective bargaining within the meaning
of the Act. The contention which we
have just discussed has been treated first,
and perhaps somewhat out of order, so
as to obviate the necessity for a lengthy
and detailed statement of the Company's
plan. .
Briefly, ;:he plan as originally initiated
on January 1, 1936, provided for the establishment of a contributory plan for the
payment of retirement annuities pursuant
to a contract between the Company and the
Equitable Life Assurance Society. Only
employees with earnings of $250.00 or more
per month were eligible to participate.
Effective December 31, 1943, the plan was
extended to cover all employees regardless of the amount of their earnings, provided the;,- had attained the age of 30 and
had five years of service. Thc plan from
the beginning was optional with the employees, who cotdd drop out at any time,
with rights upon retirement fixed as of that
date. On December 28, 1945, the Company entered into an agreement with the
First National Bank of Chicago, wherein
the Company established a pension trust,
the purpose of which was to augment the
Company's pension program by making
annuities available to employees whose
period 'Df service had occurred largely
during years prior to the time when participation in the retirement plan was available to them. These were employees whose
retirement date would occur so soon after
the establishment of the plan that it would
not afford them adequate retirement annuity benefits. The employees eligible to
participate in thc pension trust were not
required to contribute thereto, but such
fund was created by the Company's contributions.
An integral and it is asserted an essential part of thc plan from thc beginning
was that cinployccjj be cumpulsorily retired at the age of 65. (There are some
INLAND STE:
exceptions to this requirement which are
not material here.)
The Company's plan had been in effect
for five and one-half years when, because
of the increased demands for production
and with a shortage of manpower occasioned by thc war, it was compelled to
suspend the retirement of its employees
as provided by its established program.
In consequence there were no retirements
for age at either of the plants involved
in the instant proceeding from August 26,
1941 to April 1, 1946. This temporary suspension of thc compulsory retirement rule
was abrogated, and it was determined by
the Company that no retirements should
be deferred beyond June 30, 1946. By
April 1, 1946, all of the Company's employees, some 224 in number, who had
reached thc age of 65, had been retired.
Thereupon, the Union filed with the Company a grievance protesting its action in
the automatic retirement of employees at
the age of 65. Thc Company refused to
discuss this grievance with the Union,
taking the position that it was not required
under the Act to do so or to bargain concerning its retirement and pension plan,
and particularly concerning the compulsory
retirement feature thereof. Whereupon,
the instant proceeding was instituted before the Board, with the result already
noted.
This brings us to the particular language
in controversy. Sec. 8(5) of the Act requires an employer "to bargain collectively with the representative of his employees, subject to the provisions of Sec.
9(a)," and the latter section provides that
the duly selected representative of the
employees in an appropriate unit shall be
their exclusive representative "for the purposes of collective bargaining m r a p e d to
rates of pay, wages, hours of employment,
or other conditions of employment * * *•
(Italics supplied.) The instant controversy has to do with the construction to
be given or the meaning to be attached to
thc italicized words; in fact, the controversy is narrowed to thc meaning to bf
• ittnched to the term "wages" or "other
conditions of employment."
Thc Board found and concluded that t '
benefits accruing to an employee by rea|K
*r son of a retirement or
encompassed in both cate:
. former it stated in its dcci
• i . . "With due regard for 1
...poses of the Act and th
. sought to correct, we ar
. find that the term 'wages'
. tion 9(a) must be const
•emoluments of value, like
surancc benefits, which m;
ployccs out of their cmpl,
. ship. * * * Realistically ,
of wage enhancement or i
. than any other, becomes ;
of the entire wage stru
character of the employee
interest in it, and the tcrr
. is no different than in any c
a change in the wage struct
[1] The Board also f,
eluded that in any event a
pension plan is included in
employment" and is a matte
bargaining. After a carefi
' well written briefs with w
been favored, we find ours,
ment with the Board's conch
we are convinced that the
ployed by Congress, conside
tion with the purpose of thc
ly includes a retirement ant
as to leave little, i f any, root
tion. While, as the Compat
strated, a reasonable argume
that the benefits flowing fro
are not "wages," we thinkmore logical argument is on
and certainly there is, in o
sound basis for an argumer
Plan is not clearly included
other conditions of cmplo
• 'anguage employed, when v
' nection with the stated purpc
- leads irresistibly to such a coi
find nothing in thc nunn
J'es called to our attention o
Native history so strongly relic
demonstrates a contrary intcn
on the part of Congress.
' ' T h opening sentence in t
'••JJffHincnt is as follows:
t
!
?
c
n,1
<l 9(a) of thc Act do
."Wiistrial retirement and p
^
as h,
t
t
o
f
t h c
l K t i t i (
�INLAND STEEL CO.
v. NATIONAL LA BOH
Cite
son of a rctinmcnt or pension plan arc
ciicoinpassccl in both categories. As to the
former it stated in its decision:
"With due regard for the aims and purposes of thc Act and the evils which it
sought to correct, we are convinced and
find that the term 'wages' as uscd in Section 9(a) must be construed to include
emoluments of value, like pension and insurancc benefits, which may accrue to employccs out of their employment relationship. * * * Realistically viewed, this type
of wage enhancement or increase, no less
than any other, becomes an integral part
of the entire wage structure, and the
character of the employee representative's
interest in it, and the terms of its grant,
is no different than in any other case where
a change in the wage structure is effected."
r>" [1] The Board also found and coneluded that in any event a retirement and
pension plan is included in "conditions of
employment" and is a matter for collective
bargaining. After a careful study of the
•well written briefs with which we have
' been favored, we find ourselves in agreement with the Board's conclusion. In fact,
"we are convinced that the language employed by Congress, considered in connection with the purpose of the Act, so clearly includes a retirement and pension plan
as to leave little, i f any, room for construe
tion. While, as the Company has demon'strated, a reasonable argument can be made
that the benefits flowing from such a plan
are not "wages," we think the better and
more logical a:-gument is on the other side,
and certainly there is, in our opinion, no
sound basis for an argument that such a
.plan is not clearly included in the phrase,
.."other conditions of employment." The
language employed, when viewed in connection with the stated purpose of the Act,
. leads irresistibly to such a conclusion. And
we find nothing in the nunicrous authorities, called to our attention or in thc legis.latiye history so strongly relied upon which
demonstrates a contrary intent and purpose
Pn thc part of Congress.
t The opening sentence in the Company's
afgitment is as follows: "Sections 8
(5) and 9(a) of the Act do not refer to
mdustrial retirement and pension plans,
such as that of thc petitioner, in haec
j;
RELATIONS BOARD
251
170 F.2d 247
vsrba." Of course not, ancl this is equally
true as to the myriad matters arising from
the employer-employee relationship which
are recognized as included in thc bargain' S requirements of the Act but which are
not specifically referred to. Illustrative
are thc numerous matters concerning which
the Company and the Union have bargained and agreed, as embodied in their
contract of April 30, 1945. A few of such
matters are: a provision agreeing to bargain concerning nondiscriminatory discharges; a provision concerning seniority
rights, with its far reaching effect upon
promotions and demotions; a provision for
the benefit of employees inducted into the
military service; a provision determining
vacation periods with pay; a provision concerning the safety and health of employees,
including clinic facilities; a provision for
^ "
^' " * P
°
^
the Company and the Union to bargain, in
conformity with a D.rect.ve Order of the
o
i J dis" ,
° severance pay for employees
"
[
f? f
^
• "duct.on >« the working force
following the termination of the war.
, ?
^
°
"
. " C l o n e d are referred
'
^
^
"cognized generally, and
y
specifically recognized by
P a n y >" the instant case as proper
bargaining and, as a result,
. '"eluded in a contract with the
i o
l
Properly be designated as
"wages," and they arc all "conditions of
employment." We think no common sense
o
P"™
distinction to be
to the bencfits inuring to the emPayees by reason of a retirement and pen'
P' The Company in its brief states the
reasons for thc establishment of a uniform fixed compulsory retirement age for
all of its employees in conirCction with its
retirement annuity program, among which
arc (1) "The fixed retirement age gives the
employee advance notice as to the length
of his possible service with the Companj
and enables him to plan accordingly," (2)
"Thc fixed retirement age prevents gricvm
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�252
170 FEDERAL REPORTER, 2d SERIES
ances that otherwise would multiply as
the question of each employee's employability arose," (3) " A fixed retirement age
gives an incentive to younger men," and
(4) " I t is unfair and destructive of employee morale to discriminate between
types of jobs or types of employees in
retiring such employees from service."
These reasons thus stated for a compulsory retirement age demonstrate, so we
think, contrary to the Company's contention, that thc plan is included in "conditions of employment."
The Supreme Court, in National Licorice
Co. v. N . L . R. B., 309 U.S. 350, 360, 60
S.Ct. 569, 84 L.Ed. 799, held that collective bargaining extends to matters involving discharge actions and, as already
noted, the Company in its contract with
the Union has so recognized. We arc unable to differentiate between the conceded
right of a Union to bargain concerning
a discharge, and particularly a nondiscriminatory discharge, of an employee and its
right to bargain concerning the age at
which he is compelled to retire. In either
case, thc employee loses his job at the command of the employer; in cither case, the
effect upon the "conditions" of the person's employment is that the employment
is terminated, and we think, in cither case,
the affected employee is entitled under thc
Act to bargain collectively through his
duly selected representatives concerning
such termination. In one instance, thc
cessation of employment comes perhaps
suddenly and without advance notice or
warning, while in the other, his employment ceases as a result of a plan announced
in advance by the Company. And it must
be remembered that the retirement age in
thc instant situation is determined by thc
Company and forced upon the employees
without consultation and without any voice
as to whether the retirement age is to be
65 or some other age. The Company's
position that thc age of retirement is not
a matter for bargaining leads to the
incongruous result that a proper bargaining
matter is presented if an employee is suddenly discharged on the clay before he
reaches thc age of 65, but that thc next day,
when he is subject to compulsory retire-
ment, his Union is without right to bargain concerning such retirement.
The Company, however, attempts to
escape thc force of this reasoning by arguing that the retirement provision affects
tenure of employment as distinguished
from a condition of employment. The
argument, as wc understand, rests on the
premise that the Act makes a distinction
between "tenure of employment" and "conditions of employment," and attention is
called to the use of those terms in Sees.
8(3) and 2(9) of the Act. Having thus
asserted this distinction, the argument
proceeds that tenure of employment is not
embraced within the term "conditions of
employment." Assuming that the Act recognizes such distinction for some purposes,
it does not follow that such a distinction
may properly be made for the purpose of
collective bargaining, as defined in Sec.
9(a). "Tenure" as presently used undoubtedly means duration or length of employment. The tenure of employment is terminated just as effectively by a discharge
for cause as by a dismissal occasioned by
a retirement provision. And in both instances alike, the time of the termination
of such tenure is determined by the Company. As already shown, a terminattoii
by discharge is conccdcdly a matter for
collective bargaining. To say that termination by retirement is not amenable to
the same process could not, in our judgment, be supported by logic, reason or common sense. In our view, the contention
is without merit.
The Company also concedes that seniority is a proper matter for collective bargaining and, as already noted, has so recognized by its contract with the Union. I '
states in its brief that seniority is "flivery heart of conditions of employment.
Among thc purposes which seniority sen' "'
is the protection of employees against arlntrary management conduct in connccti""
with hire, promotion, demotion, trans' '
and discharge, and the creation of j '
security for older workers. A unilatcr:'
retirement and pension plan has as
main objective not job security for old^
workers but their retirement at an
predetermined by the Company, and '
1
1 1
0 1
1
u
�INLAND STEIIL CO. v. NATIONAL LAROIt RELATIONS BOARD
Cite as 170 F.Sd 247
think the latter is as much included in
"conditions of employment" as the former,
What would be the purpose of protecting
senior employees against lay-off when an
employer could arbitrarily and unilaterally
place thc compulsory retirement age at
any level which might suit its purpose?
If the Company may fix an age at 65, there
is nothing to prevent it from deciding that
50 or 45 is the age at which employees are
no longer employable, and in this manner
wholly frustrate the seniority protections
for v/hich the Union has bargained. Again
we note that discharges and seniority
rights, like a retirement and pension plan,
are not specifically mentioned in the bargaining requirements of the Act.
The Company in its brief as to seniority
rights states that it "affects thc employee's
status every day." In contrast, thc plain
implication to be drawn from its argument
is that an employee is a stranger to a retirement and pension plan during all the
days of his employment and that it affects
him in no manner until he arrives at the
retirement age. We think such reasoning
is without logic. Suppose that a person
seeking employment was offered a job
by each of two companies equal in all reSf)ec:ts except that one had a retirement
a'nd pension plan and that the other did
not. We think it reasonable to assume an
acceptance of the job with the company
which had such plan. Of course, that
might be described merely as the inducemerit which caused the job to be accepted,
but on acceptance it would become, so we
think, one of the "conditions of employment." Every day that such an employee
worked his financial status would be cnhsinced to the extent that his pension benefits increased, and his labor would be performed under a pledge from the company
that' certain specified monetary bencfits
Would be his upon reaching the designated
§>'': i t surely cannot be seriously disputed
that such a pledge on thc part of the
company forms a part of the consideration
' . ^ w o r k performed, and wc sec no rcaJ ^ w h y an employee entitled to the beneJtjf.ihe plan could not upon thc refusal of
We company to pay, sue and recover such
wnefitsi- In this view, thc pension thus
S . ' ' ' w o u l d appear to be as much a
a
i f e
d
part of his "wages" as the money paid him
at the time of the rendition of his services.
But again we say that in any event such
a plan is one of the "conditions of employment."
The Company makes the far fetched
argument that the contributions made to a
pension plan "differ in no respect from a
voluntary payment that might be made to
each employee on his marriage, or on the
birth of a child, or on attaining thc age
of 50, or on enlisting in the armed forces
in time of war or on participating as a
member of a successful company baseball
team," but wc think there is a vast difference which arises from the fact that
such hypothetical payments are not made
promise contained in a
P
program. They represent nothing
£ - Assume, however, that
such supposed payments were made to employees as a result of a company obligation contained in a plan or program. Such
an obligation would represent a part of the
consideration for services performed, and
payments made in the discharge of such
obligation would, in our view, be "wages"
or included in "conditions of employment."
a s
t h e
l a n
m
0
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r e S l l l t
o f
a
o r
t h a n
a
i f t
The Board cites a number of authorities
wherein the term "wages" in other fields
of law has been broadly construed in support of its conclusion in the instant case
that the term includes retirement and pension bencfits for the purpose of collective
bargaining. While we do not attach too
much importance to the broad interpretation given the term in unrelated fields, we
think they do show that a broad interpretation here is not unreasonable. For instance, the Board has been sustained in a
number of cases where it has treated for
the purpose of remedying thc effects of
discriminatory discharges, in violation of
Sec. 8(3) of the Act, pension and other
"beneficial insurance rights of employees
as part of thc employees' real wages and,
in accordance with its authority under Sec.
10(c), to order reinstatement of employees
with * * * back pay," and has required
the employer to restore such bencfits to employccs discriminated against. Sec Butler
Bros., ct al. v. N . L . R. B., 7 Cir., 134 F.2d
981,985; General Motors Corp. v. N . L. R.
B., 3 Cir., 150 F.2d 201, and N . L. R. B.
•Hi
�254
170 F E D K R A I , REPORTER, 2d SERIES
v. Stackpole Carbon Co., 3 Cir., 128 F.2d
188. In thc latter case, thc court stated
(128 F.2d at page 191) that the Board's
conclusion "seems to us to be in line with
the purposes of thc Act for thc insurance
rights in substance were part of thc employee's wages."
In the Social Security Act, 49 Stat. 642,
Sec. 907, 42 U.S.C.A. § 1107, the same Congress which enacted the National Labor
Relations Act defined taxable "wages" as
embracing "all remuneration * * * [
services performed by an employee for his
employer], including the cash value of
all remuneration paid in any medium other
than cash * * *." This definition has
been construed, as thc Supreme Court
noted, in Social Security Board v. Nierotko, 327 U.S. 358, 365, 66 S.Ct. 637, 90 L.
Ed. 718, 162 A.L.R. 1445 (note 17), as
including "vacation allowances," "sick
pay," and "dismissal pay."
f o r
In the field of taxation, pension and
retirement allowances have been deemed
to be income of the recipients within the
Internal Revenue Act definition of wages
as "compensation for personal services."
26 U.S.C.A.Int.Rev.Code § 22(a). Thus, in
Hooker v. Hoey, D.C, 27 F.Supp. 489, 490,
affirmed, 2 Cir., 107 F.2d 1016, the court
said: " I t cannot be doubted that pensions
or retiring allowances paid because of past
services are one form of compensation for
personal service and constitute taxable income * * *."
The Company in its effort to obtain a
construction of Sec. 9(a) favorable to its
contention devotes much of its brief to
the legislative history of the Act which it
is claimed demonstrates that Congress did
not intend to subject retirement and pension plans to the bargaining process. In
view of what we have said, this argument
may be disposed of without extended discussion. It is sufficient to note that we
have studied this legislative history and,
while there are some portions of it which
appear to support thc company's position,
yet taken as a whole it is not convincing.
It would, in our judgment, require a far
stronger showing of congressional intent
than exists here before we would be justified in. placing a construction upon the
provision in question which would do vio-
lence to thc plain words of thc statutory
requirement and which would result in
an impairment of the purpose of the Act.
It may be true, as argued by the Company,
that retirement and pension plans were
employed only to a limited extent in 1935,
when the original Act was passed. Such
provisions, however, were being generally
uscd at the time of thc passage of the
amended Act in 1947. And wc doubt the
validity of the argument that the language
of the latter Act cannot be given a broader scope even though Congress uscd the
same phraseology. We do not believe that
it was contemplated that the language of
Sec. 9(a) was to remain static. Congress
in the original as well as in thc amended
Act uscd general language, evidently designed to meet the increasing problems
arising from the employer-employee relationship. As was said in Weems v. United
States, 217 U.S. 349, 373, 30 S.Ct. 544,
551, 54 L.Ed. 793, 19 Ann.Cas. 705:
"Legislation, both statutory and constitutional, is enacted, it is true, from an
experience of evils, but its general language
should not, therefore, be necessarily confined to the form that evil had theretofore
taken. Time works changes, brings into
existence new conditions and purposes.
Therefore a principle to be vital must be
capable of wider application than the mischief which gave it birth."
The Company places great stress upon
the bargaining language used in the Railway Labor Act of 1926, 45 U.S.C.A. § 151
et seq., on the theory that the instant Act
is tn pari materia. It points out that
numerous retirement and pension plans
were put into effect by thc railroads ami
that they were never subjected to tinprocess of collective bargaining. This
showing is made for the purpose of demonstrating that Congress in the enactment or
thc legislation now before us did not
intend to include such matters. In tins
connection, we think it is pertinent to noU'
that in the Railway Labor Act the bargaining language was quite different from that
of the instant legislation. There, it read,
"rates of pay, rules, or working cowVtions." Here, it reads, "rates of pay.
wages, hours of employment, or otlu-r
conditions of employment." A comparis '::
�INLANE' STEEL CO. v. NATIONAL LABOR RELATIONS BOARD
255
Cite as 170 F.?<1 247
of the language of the two Acts shows that
Congress in the instant legislation must
have intended a bargaining provision of
broader scope than that contemplated in
the Railway Labor Act. Certainly the
term, "wages" was. intended to include
something more than "rates of pay."
Otherwise, its use would have served no
purpose. Congress in the instant legislation uscd the phrase, "other conditions of
employment," instead of the phrase, "working' conditions," which it had previously
used in the Railway Act. We think it is
obvious that the phrase which it later used
is more inclusive than that which it had
formerly uscd. Even though the disputed
language of thc instant Act was open to
construction, we think a comparison of the
language of these two Acts is of no benefit
to the Company.
issuance of the same, the Union satisfied
the condition attached thereto insofar as
it pertained to Sec. 9 ( f ) and (g) of the
Act,
but failed and refused to comply
with Sec. 9(h).
On May 14, 1948, the Union filed with
the Board a document entitled "Return by
United Steel Workers of America to Conditional Order of National Labor Relations
Board," in which the Union requested the
Board to amend its order by making it
unconditional. In this document, the Union alleged "that it had not complied with
.
t h e
r e q i l i l
c n l e n t
a m e n d c d >
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e
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9
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"Upon due consideration of the matter,
the Board believes that the Union's request
for an amendment rendering the Board's
order unconditional must be, and it hereby
is, denied. In thc absence of authoritative
judicial determination to the contrary, the
Board assumes the constitutional validity
of the provisions of the amended Act."
s s u e d
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The Company places much reliance upon
a statement from the opinion in J. I . Case
Co.. v! N . L. R. B., 321 U.S. 332, 339, 64 S.
'CCS76, 88 L.Ed. 762. While the court was
not considering a question such as that
with which we are now concerned, we
think it must be conceded that the language
furnishes some support for the Company's
Thus, we have presented the important
position, and if this, case stood alone as the and perplexing problem as to the constitusole expression of the Supreme Court rela- tionality of Sec. 9(h), the relevant portion
tive to the question before us it would at of which provides:
least cause us to hesitate; however, in a
"No investigation shall be made by the
later case, United States v. United Mine
_
Board * * *, no petition * * * shall be
Workers of America, 330 U.S. 258, 286, entertained, and no complaint shall be
W> #t-.S-Ct. 677, 91 L.Ed. 884, the court i
pursuant to a charge made by a
made a statement which indicates a view i
. organization * * * unless there
^f?jy .
P y ' present position. i
fii i h ^ Board an affidavit exe?f«»n.'/however, the question here present- t e d contemporaneously or within the
edwas not before the court and wc do not preceding twelve-month period by each
regard "either of these cases as an expres- oflicer of such labor organization and the
sion- of the view of thc Supreme Court officers of any national or international
upon the instant question.
Thc support labor organization of which it is an affiliate
which the Company professes to find in the or constituent unit that he is not a member
Csise case is at least offset by the court's of the Communist Party or affiliated with
statement in the United Mine
Workers such party, and that he does not believe
casK7 ••*'•
in, and is not a member of or supports any
' Jt.i? our.view, therefore, and wc so hold organization that believes in or teaches, thc
tj/at the order of thc Board, insofar as it overthrow of thc United States Govern[Quires the Company to bargain with ment by force or by any illegal or unconf' P, £t'tp retirement and pension matters, stitutional methods. The provisions of secf ^ a j i d , and the petition to review, filed by tion 35 A of thc Criminal Code shall be
applicable in respect to such aflidavits."
^ i C o t p p a n y in No. 9612, is denied.
.UTfm brings us to thc Union's petition
Thc Union attacks thc constitutionality
.forjeyievv of thc order in No. 9634. Upon of Sec. 9(h) on thc ground that it i *
li:
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a
1
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4,
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�256
170 FEDERAL BEPOHTER, 2d SERIES
violative of the Constitution in numerous
respects. I t asserts (1) that the provision
invades the political freedom of Philip
Murray (petitioner), as well as that of
other officials of the Union of which he is
the head, and of the members of such
Union, in violation of the First, Ninth and
Tenth Amendments; (2) that it constitutes a bill of attainder within the meaning
of Article I , Sec. 9, Clause 3; (3) that
it deprives the Union, its officials and members of liberty and property without due
process of law and arbitrarily discriminates
against them in violation of the F i f t h
Amendment, and (4) that it is unconstitutional because of its vagueness, indefiniteness and unccrtainncss. The constitutionality of the provision has also been attacked by the National Lawyers Guild in a
brief which we have permitted to be filed
as amicus curiae.
The Board defends the constitutional
power of Congress to require as a condition to the compulsory right of a labor
organization to bargain collectively that
each of its officers make the required
affidavit. I t is argued (1) that the withholding of such benefits does not impinge
on the constitutional right to self-organization; (2) that the condition imposed and
the congressional policy which it effectuates docs not invade rights of freedom of
speech or freedom of the press, or deny
freedom of political belief, activity or
affiliation; (3) that Congress could reasonably believe that the policies of the
Act, and the security interests of the nation, would not be fostered by the extension of thc bencfits of the Act to labor
organizations whose officers are Communists or supporters of organizations dominated by Communists; (4) that the means
adopted by Congress to accomplish such
purpose are appropriate; (5) that the language of the provision is sufficiently definite and certain to escape constitutional
impairment, and (6) that it does not constitute a bill of attainder.
Warehouse Workers' Union, etc. v. Douds,
79 F.Supp. 563. Each of these cases was
decided by a three-Judge statutory court in
proceedings wherein it was sought to enjoin the Labor Board from giving effect
to thc provision in controversy. In the
Herzog case the court rendered a lengthy
opinion in support of its position, which
was approved in the Douds case. In each
of the cases there was a dissenting opinion
in which the dissenting Judge viewed the
provision as unconstitutional. In the Herzog case the court also sustained the
constitutionality of Sec. 9 ( f ) and (g). On
appeal, the Supreme Court in a Per Curiam order entered June 21, 194S, 334 U.
S. 854, S.Ct. 1529, affirmed the statutory
court as to these two paragraphs but found
it unnecessary to consider the validity of
Sec. 9(h).
I find myself in disagreement with my
associates. Judge Kerner has written an
opinion, concurred in by Judge Minton,
upholding the constitutionality of the section. I think to the contrary. Among
many Supreme Court cases cited and discussed by the respective parties, there are
none which present an analogous situation;
in fact, the section is unique in the annals
of the entire legislative and judicial field.
The cases do teach, however, in unmistakable fashion, especially in recent times, the
broad interpretation given the First Amendment and the zealous protection which the
Supreme Court has afforded it from impairment or encroachment.
As illustrative, a few cases may be
noted. "That priority gives these liberties
a sanctity and a sanction not permitting
dubious intrusions. And it is thc character
of the right, not of the limitation, which
determines what standard governs the
choice." Thomas v. Collins, 323 U.S. 516,
530, 65 S.Ct. 315, 322, 89 L.Ed. 430. "For
the First Amendment does not speak
equivocally. I t prohibits any law 'abridging the freedom of speech, or of the press.'
It must be taken as a command of the
The constitutionality of Sec. 9(h) has broadest scope that explicit language, read
been sustained in National Maritime Union in the context of a liberty-loving society,
v. Hcrzog, D.C, 78 F.Supp. 146, and by will allow." Bridges v. California, 314 U.
the District Court for thc Southern Dis- S. 252, 263, 62 S.Ct. 190, 194, 86 L.Ed. 192,
trict of New York, in Wholesale and 159 A.L.R. 1346. " I f there is any fixed
�I N L A N r STEEL CO. v. NATIONAL LABOR RELATIONS BOARD
Cite aa 170 F.Sd 247
star in our constitutional constellation, it
is that no official, high or petty, can prescribe what shall be orthodox in politics,
nationalism, religion, or other matters of
opinion or force citizens to confess by
word or act their faith therein. I f there
arc any circumstances which permit an
exception, they do not now occur to us."
West Virginia State Board of Education
v. Barnette, 319 U.S. 624, 642, 63 S.Ct.
1178, 1187, 87 L.Ed. 1628, 147 A.L.R. 674.
"The freedom of speech and of the press
guaranteed by the Constitution embraces
at thc least the liberty to discuss publicly
and truthfully all matters of public concern
without previous rcistraint or fear of subsequent punishment " Thornhill v. Alabama, 310 U.S. 88, 101, 60 S.Ct. 736, 744,
84 L.Ed. 1093.
Referring to the opinion in the Herzog
case, thc Board states:
"The Court concluded that thc consequences upon self-organizational activity
of wilful non-compliance by a union with
conditions which Congress was entitled to
impose could not be attributed to Congress
or to the Board, but solely to the union
itself, and that denial of the benefits of the
Act to labor organizations which refused to
comply could therefore not be said to deprive those labor organizations of their
constitutional right to freedom of association."
Thus, the fallacious premise is laid for
the Board's argument that Congress, having endowed labor organizations with certain benefits, was justified in imposing a
condition that such benefits should not be
enjoyed by Communist-dominated organizations. A hypothetical situation is created
which bears no resemblance either to the
requirements of the section or to the bencfits bestowed by the Act. Sec. 9(h) imposes no obligation upon a Union, Communist-dominated or otherwise; in fact, a
Union is without power to comply with the
condition which Congress has imposed.
This is in marked contrast with Sec. 9 ( f )
and (g), which require the Unions to file
certain factual reports as a prerequisite to
their right to act as a bargaining agent.
The instant section is directed at the individual officers of this far-flung labor organization, each of whom has been empowered to stymie the entire bargaining
process and thus deprive the Union of its
right to act as bargaining agent. And a
single official can do this very thing by
refusing to make the affidavit for any
reason or no reason. He may refuse solely
because of an arbitrary or capricious attitude, because the terms of thc statute are
so vague as to make it uncertain whether
the affidavit can be truthfully made, or
because he belongs to the proscribed class.
Thus, the section gathers within its devastating reach a Union all of whose officials save one are willing and able to make
thc affidavit.
The Board in substance concedes that the
section cannot be justified by what the
Supreme Court has characterized the
"clear and present danger" rule. Bridges
v. California, supra, 314 U.S. at page 263,
62 S.Ct. at page 194; Thornhill v. Alabama, supra, 310 U.S. 88; at page 104, 60
S.Ct. 736. Rather, the Board attempts to
uphold its validity on the reasoning of the
Herzog case that Congress, having bestowed upon labor organizations certain
benefits and privileges, had a right to
attach as a condition to their enjoyment
the requirement contained in Sec. 9(h).
The Board in its brief states and restates
that the purpose of Congress was to eliminate from the bargaining process Communist-dominated Unions. Its position is
stated thus:
i'^ •
;;"We turn then to the precise questions
which may here properly be presented,
whether denial of thc benefits of the Act
to labor organizatiens whose officers are
Communist or members of Communist
dominated organizations, or who believe
Hi;:.or support organizations which advocate violent overthrow of thc government,
'sr. reasonably related to the objectives
which Congress legitimately sought to promote by enactment of the statute, and
whether the methods utilized to promote
The impact which this section has upon
these objectives are appropriate means for
employees represented by the Union is even
"fer effectuation."
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170 FEDERAL REPORTER, 2d SERIES
more pronounced. As illustrative, the Union in the instant situation has been duly
selected by some 12,000 employees of an
appropriate bargaining unit as_their agent.
The Board minimizes, in fact almost ignores, their predicament. Their interest
is disposed of on the erroneous theory that
their rights stem from Congress, and what
Congress has given it can take away.
It is well to keep in mind, however, what
the Board appears to overlook, that is,
that employees have certain constitutional
rights irrespective of any benefit bestowed
by the Wagner Act or its successor.' I t has
been held that the right "to organize for
the purpose of securing redress of grievances and to promote agreements with the
employers relating to rates of pay and
conditions of work" is a constitutional
right, and that the right of employees to
self-organization and to select representatives of their own choosing for collective
bargaining or other material protection is
fundamental.
Further, that employees
have as clear a right to organize and select
their representatives for a lawful purpose
as an employer has to organize its business
and select its own officers and agents.
National Labor Relations Board v. Jones
& Laughlin Steel Corp., 301 U.S. 1, 33, 57
S.Ct. 615, 627, 81 L.Ed. 893, 108 A.L.R.
1352. And it has been held that thc right
of workmen or of Unions "to assemble and
discuss their own affairs is as fully protected by the Constitution as the right of
business men, farmers, educators, political
party members or others to assemble and
discuss their affairs and to enlist the support of others." Thomas v. Collins, 323 IJ.
S. 516, 539, 65 S.Ct. 315, 327, 89 L.Ed. 430.
And as employees have a constitutional
right to organize, to select a bargaining
agent of their own choosing and, if members
of a Union, to elect thc officials of such
Union, so I would think that thc bargaining agent when so selected had a right of
equal standing to represent for all legitimate purposes those by whom it had been
selected. The employees in the instant
situation have availed themselves of constitutional rights in selecting the Union as
their bargaining agent and in the election
of its officials.
At this point it is pertinent to observe
that the Wagner Act was enacted primarily
for the benefit of employees and not for
Unions. The latter derive their authority
from the employees when selected as their
bargaining agent, rather than from the law.
The very heart of the Act is contained in
Sec. 7, which provides: "Employees shall
have the right to self-organization, to form,
join, or assist labor organizations, to bargain collectively through representatives of
their own choosing * * *." This was
not a Congress-created right but the recognition of a constitutional right, which Congress provided the means to protect. This
is clearly shown by the declared policy of
the Act that commerce be aided "by encouraging the practice and procedure of
collective bargaining and by protecting thc
exercise of workers of full freedom of association, self-organization, and designation
of representatives of their own choosing,
for the purpose of negotiating thc terms and
conditions of their employment or other
mutual aid or protection."
In my view, the condition attached to the
Board's order in thc instant case is a
direct and serious impairment upon these
constitutional rights of both thc employees
and thc Union. The rights of the former
to organize, select a bargaining agent of
their own choosing and elect officers of
the Union have been reduced to a state of
meaningless gesture. Sec Texas & N . O.
R. Co. v. Brotherhood of Ry. & S. S.
Clerks, 2S1 U.S. 54S, 570, 50 S.Ct. 427, 74
L.Ed. 1034, and National Labor Relations
Board v. Jones & Laughlin Steel Corp.,
supra, 301 U.S. 1, at page 34, 57 S.Ct. 615.
In order to comply with the condition of
thc Board's order, they must select a bargaining agent not of their own choosing
but one which conforms to the pattern
which Congress has prescribed. The fuadamcntal right to elect officers of their
Union, untrammcled and unfettered, has
been made subservient to the congressional
edict as to the character of officials which
will be tolerated. Not only docs thc section
represent an intrusion by Congress in the
internal affairs of a Union and its members, but it is legislative coercion express!;,
designed to compel Union members to
�INLAND STEEL CO. v. NATIONAL LAIiOU RELATIONS ROARD
2-)0
Cite as 170 F.^d 247
forego their fundamental rights. "Freedom of speech, freedom of thc press, and
freedom of religion all have a double
aspect—freedom of thought and freedom
of action. Freedom to think is absolute of
its own nature; the most tyrannical government is powerless to control the inward
workings of thc mind." Murphy, J., disscnting in Jones v. City of Opelika, 316
U.S. 584, 618, 62 S.Ct. 1231, 1249, 86 L.Ed.
1691, 141 A.L.R. .514, subsequently a majority opinion of thc court in 319 U.S. 103,
63'S,Ct. 890, 87 L.Ed. 1290.
(3). I do not think that thc constitutional
rights of thc employees or the Union can
be suspended in mid-air for a time of such
dubious and uncertain length.
The upshot of the whole situation is
that employees when members of a Union
are under a continuing compulsion to elect
officers who will meet the congressional
prescription in order that their Union may
remain in the good graces of the Board,
and they must do this even though it be
contrary to their belief, conscience and
better judgment. Experience, ability, honContrast this philosophy with that which esty and integrity of candidates for official
the Board attributes to the Act, as evi- positions in the Union must be cast aside.
denced by the following statement: "The
For similar reasons, the section also
assumption is that i f the facts are known affects, and I think seriously impairs, the
through this filing procedure, union mem- fundamental rights of Union officials. The
bers * * * will soon remove Commu- affidavit prescribed is directed at the belief
nists from leadership rather than allow entertained by the affiant in contrast to
themselves to be precluded from enjoying conduct, behavior or action. Assuming
the bencfits of the Act. Northern Virginia arguendo, however, that it has no effect
upon the constitutional right of an officer
Broadcasters, Inc., 75 N . L. R. B. No. 2."
who refuses to make it, what about the
But it is argued that employees have in
effect upon those who comply? The right
their own hands the means of obtaining
of the officers of a Union to manage and
compliance by the selection of a bargaining
control its affairs is a basic right and I
representative whose officers are able and
would suppose to be exercised in accordwilling to make the affidavit. Assuming
ance with thc principle of majority rule.
that employees ar<; always members of a
The section, however, limits the rights of
Union which acts as their bargaining agent,
the officers of a Union by making them
which is not the case, it is a shallow and
dependent upon the affirmative action of
unrealistic argument. How can employees
each officer. The officers who make the
when they select a Union as their bargainaffidavit, even though in the majority, are
ing agent know that each of its officers
no better off than i f they had refused.
will be able and willing to make thc affiMore than that, the affidavit, particularly
davit? And how can they compel such
in view of its vague and uncertain terms,
officers to do so subsequent to their elecis calculated to create in the mind of the
tion? , How could the members rid their
maker a continuous apprehension lest the
IJnion of an officer who refused to make
affiant make some expression, perform
the affidavit, for good reason or no reason?
some act, have some association or indulge
The record before us does not disclose who
in conduct which might later be used as
or how many officers refused to make the
evidence to show that the affidavit was
affidavit. Assuming, however, that it was
false. As was said in the dissenting opinPhilip Murray, president, of a national
ion in Mincrsvillc School District v. Golabor organization of which the instant
bitis, 310 U.S. 586, 606, 60 S.Ct. 1010, 1018,
Union is an affiliate, how long, I wonder,
84 L.Ed. 1375, 127 A.L.R. 1493:
would it take the 12,000 employees of thc
bargaining unit here involved to replace
"Thc Constitution expresses more than
him with an officer who would comply ? The the conviction of thc people that democratic
Act provides that no election shall be di- processes must be preserved at all costs.
reeled in any bargaining unit wherein a It is also an expression of faith and a
valid election has been held within thc pre- command that freedom of mind and spirit
ceding twelve-month period. Sec' 159(c) must be preserved, which government must
.SK'
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170 FEDEltAI, REPORTER, 2d SERIES
obey, i f it is to adhere to that justice and 2103, "Since an alien obviously brings
moderation without which no free govern- with him no constitutional rights, Congress
may exclude him in the first instance for
ment can exist."
In my view, Congress has attempted to whatever reason it sees fit." In other
do indirectly what it could not do directly words, an alien, at least in the first inunder the Constitution. " I n approaching stance, is not entitled to thc benefits of the
cases, such as this one, in which federal Bill of Rights. In the Hawker case, supra,
constitutional rights are asserted, it is in- it was held that a State could constitucumbent on us to inquire not merely tionally prevent persons who had previwhether those rights have been denied in ously been convicted of a felony from pracexpress terms, but also whether they have ticing medicine. The decision goes no
been denied in substance and effect." further than holding that the State under
Oyama v. California, 332 U.S. 633, 636, 68 its police power had the authority to fix the
standards to be met by one who sought thc
S.Ct. 269, 270.
privilege of administering to the health
Many cases are cited and relied upon in and well being of its citizens. In Hamilton
support of thc argument that Congress was v. Board of Regents, supra, it was held
reasonably justified in attaching the condi- that the State might properly bar from its
tion contained in Par. (h) as a prerequisite colleges persons who refused to attend
to the right of employees to compulsory classes in military training. Again, thc
bargaining. Without attempting to men- condition attached to the privilege could
tion all of such cases, a few may be noted be met at the discretion of the person who
as typical. Turner v. Williams, 194 U.S. sought to become the recipient of the
279, 24 S.Ct. 719, 48 L.Ed. 979; Hawker v. State's favor.
New York, 170 U.S. 189, 18 S.Ct. 573, 42
A more relevant pronouncement is that
L.Ed. 1002; Hamilton v. Board of Regents,
contained in Frost Trucking Co. v. Rail293 U.S. 245, 55 S.Ct. 197, 79 L.Ed. 343;
road Commission, 271 U.S. 583, 46 S.Ct.
United Public Workers v. Mitchell, 330
605, 70 L.Ed. 1101, 47 A.L.R. 457. There,
U.S. 75, 67 S.Ct. 556, 91 L.Ed. 754. The
the court held that Congress was without
strongest of these cases, in my judgment,
constitutional power to do indirectly what
is the Mitchell case. There, the question
it was prohibited from doing directly in a
involved was the constitutionality of the
matter wherein it had attached a condition
Hatch Act, now 18 U.S.C.A. § 594 et seq.,
to be performed as a prerequisite to the
which forbade government employees to
receipt of a benefit. The court 271 U.S. on
engage in political activity, admittedly a
page 593, 46 S.Ct. on page 607 stated:
right protected by the First Amendment.
"May it stand in the conditional form in
There, the favor bestowed by Congress was
governmental employment, and an em- which it is here made? I f so, constituployee had the choice between accepting tional guaranties, so carefully safeguarded
the favor and foregoing his right to engage against direct assault, are open to destrucin political activity, or in declining the gov- tion by thc indirect, but no less effective,
ernmental favor and exercising such right. process of requiring a surrender, which,
This is quite a contrast to the instant situ- though, in form voluntary, in fact lacks
ation where the grant is bestowed upon the none of the elements of compulsion. Havemployees with the power lodged in a ing regard to form alone, the act here is
third person to prevent them from obtain- an offer to the private carrier of a privilege, which the state may grant or deny,
ing the benefit.
upon a condition which thc carrier is free
Turner v. Williams, supra, is of no bene- to accept or reject. In reality, the carrier
fit to the Board's position. There, it was is given no choice, except a choice between
held that Congress could properly make the the rock and the whirlpool—an option to
privilege of immigration turn upon the forego a privilege which may be vital to
political beliefs of the immigrant. As his livelihood or submit to a requirement
later pointed out in Bridges v. Wixon, 326 which may constitute an intolerable burU.S. 135, 161, 65 S.Ct. 1443, 1455. 89 L.Ed. den."
�INLAND STEEL CO. V. NATIONAL LABOR RELATIONS BOARD
201
Cite as 170 F.2d 247
The Board reviews at length the congressional history and other data for the purpose of demonstrating that Congress was
reasonably justified in attaching the condition as a prerequisite to the enjoyment of
the benefits which it had provided. As
already pointed out, however, it did not
give such beneficiaries the option of compliance or noncompliance. The result of
the congressional inquiry is summarized in
the Board's brief as follows:
' '. "Congress was not unaware that Com" munist officers of labor organizations sometimes effectively represent the economic
interests of members in collective bargaining, and in grievance adjustment, and that
to this extent their activities do tend to
effectuate the policies of the Act. But
Congress believed that whatever public
value Communist leadership of labor unions
might have in this respect was clearly outweighed by the danger that they might, on
other occasions, utilize their power and
influence for purposes inimical to the policies of the Act and to national security."
statute which creates such a situation,
especially considered in connection with
its vague and indefinite requirements, is
so arbitrarily discriminatory as to violate
the due process clause of the F i f t h Amendment. As was said in Hurtado v. California, 110 U.S. 516, 535, 4 S.Ct. I l l , 121,
292, 28 L.Ed. 232:
" I t is not every act, legislative in form,
that is law. Law is something more than
mere will exerted as an act of power. It
must be not a special rule for a particular
person or a particular case * * *."
See also Nichols v. Coolidgc, 274 U.S.
531, 47 S.Ct. 710, 71 L.Ed. 11SI, 52 A.L.R.
1081, and United States v. Lovett, 328 U.S.
303, 66 S.Ct. 1073, 90 L.Ed. 1252.
According to the Board's argument, the
congressional target was Communist-dominated Unions. The legislative fire, however, was not directed merely at those
whom it intended to disable. The range
included a scope of far greater area. It
encompassed what it recognized as good
Communists as well as the bad. And of
\ Thus, notwithstanding this congressional more importance it included countless parecognition that some labor organizations triotic employees and Union officials who
with Communist officials were willing and carried no taint of Communism. A l l alike
able to cooperate in effectuating the poli- were made to suffer the same fate and recies of the Act, it placed such Unions in quired to answer for the sins of a few,
thc same category with those whose officials even one. From a practical aspect, it is
'were unwilling to do so, and denied to not unlike throwing a barrel of apples in
each class alike the benefits and facilities the river in order to get rid of one that is
which Congresi; had provided. By the rotten. From a legal viewpoint, it has the
same token, the rights of loyal and patriotic effect of arbitrarily singling out for legislaemployees, as well as Union officials, were tive action a particular person or group
made to rest upon the affirmative act of because of the personal belief of their as. "each" officer of the Union. So, if em- sociates. As was said in Schneiderman v.
ployees of a bargaining unit are willing to United States, 320 U.S. 118, 136, 63 S.Ct.
• submit to thc pressure which f a r . (h) 1333, 1342, 87 L.Ed. 1796:
engenders and are fortunate enough to
" * * * under our traditions beliefs
• select a bargaining agent, each of whose
are personal and not a matter of mere asofficers will make the affidavit, such emsociation, and that men in adhering to a poployees receive the benefits of the Act.
litical party or other organization notoriEmployees, however, who insist on mainously do not subscribe unqualifiedly to all
• taining their fundamental right to select a
of its platforms or asserted principles."
bargaining agent, or who for any reason
That the section is void because of its
have not succeeded in selecting a bargain^ing agent "each" officer of which is willing vague and uncertain language appears
to comply, are deprived of the congres- plain. This is so both as to the persons
.••'k%f ? ' g n t . The same comparison may within its scope and thc subject matter of
y.'". .be made between competing Unions. One the required affidavit. "There must be as,v;.i^pnion is.permitted to represent its employ- certainable standards of guilt. Men of
i j l f r i i j ' ' and thc other is not. In my view, a common intelligence cannot be required to
;
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�170 FEDERAL REPORTER, 2d SERIES
guess at the meaning of the enactment.
The vagueness may be from uncertainty in
regard to persons within the scope of the
act, Lanzetta v. New Jersey, 306 U.S. 451,
59 S.Ct. 618, 83 L.Ed. 888, or in regard to
the applicable tests to ascertain guilt."
Winters v. New York, 333 U.S. 507, 515,
68 S.Ct. 665, 670.
I•
I' ''
I
II
would make the section unworkable. There
was a concurring and a dissenting opinion.
The point is that the Board itself had great
difficulty in deciding who were included in
the term "officer," and the decision when
made was by a divided Board. This emphasizes the difficult problem presented to
officers of a Union in attempting to deterThe section applies to "each officer of mine whether they arc within thc scope of
such labor organization and the officers of persons required to make thc affidavit.
any national or international labor organiThe facts required to be stated in the
zation." Such officers are neither enu- affidavit are of such an uncertain and inmerated nor defined, either in the section definite nature as to afford little more than
in controversy or otherwise in the Act. a fertile field for speculation and guess.
While the record does not purport to dis- What is meant by a "member of thc Comclose a list of such officers, it docs show munist party or affiliated with such party"?
that the agreement between the Union and How and when does a person become a
the Company was signed by six officials of member of that party, or any other party
the national organization, including Philip for that matter? And what does it mean
J. Murray, as president, and by nine officers to be "affiliated"? The Supreme Court, in
of the local Union. From the agreement Bridges v. Wixon, supra, devoted several
it is discernible that there are twenty mem- pages to the meaning to be attributed to thc
bers of the grievance committee with au- word "affiliation," as used in the deportathority to negotiate on the part of the tion statute. The court's discussion is conUnion, twenty assistant members of the vincing that its meaning would be quite begrievance committee, and a safety com- yond thc reach of the ordinary citizen. As
mittee of equal number authorized to rep- close as the court came to defining the
resent the Union in its dealings with the term was (326 U.S. at page 143, 65 S.Ct.
company concerning safety matters. I as- at page 1447), " I t imports, however, less
sume that there are hundreds of officers than membership but more than symbetween the bottom and the top of this vast pathy." Thc court pointed out that cooperlabor organization. The importance of the ation with Communist groups was not sufword "officer" is evident, particularly in ficient to show affiliation with the party.
view of the fact that "each officer" is given the power by refusal to make the affiWhat docs the word "supports" include?
davit to paralyze a Union and its members. Does a person by voting for the candidates
That those who come within the scope of a party or by attending its meetings and
of the word "officer" have been left in a making contributions, or by buying its litstate of uncertainty and doubt is well illus- erature or books, become a supporter theretrated by an opinion of the Labor Board, of? And how can thc ordinary person posIn The Matter of Northern Virginia sibly be expected to make an affidavit that
Broadcasters, Inc., etc., and Local Union he is not a member of any organization
No. 1215, in the National Brotherhood of that believes in or teaches the overthrow
Electrical Workers, page 11, volume 75, of the United States Government "by any
Decisions and Orders of the N.L.R.B. In illegal or unconstitutional methods''?
that case, the Regional Director, following These are matters which perplex thc Bench
instructions of thc General Counsel of the and thc Bar, and thc diversity of opinion
Labor Board, dismissed the proceeding for among Judges as to what is illegal and unfailure of compliance with Sec. 9(h) by constitutional often marks thc boundary
the American Federation of Labor, with line between majority and dissenting opinwhich the local Union was affiliated. Thc ions.
Board held that compliance by officials of
the national organization was not required,
on thc ground that such a construction
Sec the recent case of United States v.
Congress of Industrial Organization, 335
U.S. 106, 68 S.Ct. 1349 and particularly the
�INLAND STEEL CO.
v. NATIONAL LABOK RELATIONS BOARD
Cite as 170 F.2d
concurving opinion by four members of
the court, which held unconstitutional Sec.
313 of the Federal Corrupt Practices Act
of 1925) as amended by Sec. 304 of the instant Act, 2 U.S.C.A. § 251, because of the
vagueness and uncertainty of thc phrase,
"a contribution or expenditure in connection with any election * * *." The discussion is quite rehvant to the instant situation. On page 153 of 335 U.S., on page
1372 of 68 S.Ct. it is stated:
"Vagueness and uncertainty so vast and
all-pervasive.seeking to restrict or delimit
First Amendment freedoms are wholly at
war with the long-established constitutional principles surrounding their delimitation,
They, measure up neither to the requirement of narrow drafting to meet the precise evil sought to be curbed nor to the
one that conduct proscribed must be defined with sufficient specificity not to blanket
large areas of unforbidden conduct
with doubt and uncertainty of coverage.
In this respect the Amendment's policy
adds its own force to that of due process in
the definition of crime to forbid such consequences. * * * Only a master, if
any. could walk the perilous wire strung
by the section's criterion."
.. . The Board makes no serious argument
but that the section is vague and uncertain
as charged. I t attempts to excuse its in.. firmitics by contending (1) that its vagueness is cured bv Sec. 35-A of the Criminal
Code, now IS U.S.C.A. § 1001, and & that
. the rule against vagueness and uncertainty
.. is not applicable because the statute is not
.compulsory.
No authorities are cited
.. which sustain either proposition.
k'J.: The substance of the argument in favor
. of the first proposition is that an officer of
a Union need not be too much concerned
about the truthfulness of the affidavit
which he makes because he can only bewnv.ctcd under Sec. 35-A of the Criminal
Lode for knowingly and willfully makmg a false affidavit. In the Board s own
words, 'Clearly, no afiiant could suc' ccssfully be prosecuted under this section
•'ior filing a false affidavit under Sec. 9(h)
' unless it could be proved that he knowing,
lied in making the averments contained
' .''in his affidavit." This statement, so I think,
',j''%^ '^ k
d e concerning every prosccu0 U
e
m a
263
247
tion .for perjury. The Board makes the
further puerile suggestion that an affiant
need not be afraid of a groundless prosecution because "our law provides adequate
modes of redress to victims of malicious
prosecution."
To me, this argument is shocking and
should be repudiated in no uncertain terms.
Bluntly stated, it means that an officer of
the Union who makes the affidavit need not
be concerned with the sanctity of his oath
because of the unlikelihood of conviction
i case of a prosecution for perjury. He
need not be afraid because the only danger
which he assumes is the hazard of a prosecution which when unsuccessful leaves him
the possessor of a damage suit against
his accuser in an action for malicious prosecution.- This argument is a persuasive indication that the section should be invalidated because of its vagueness and uncertainty
'Sift
n
; £
a s
Neither do I think there is any merit in
thc suggestion that the authorities as to
vagueness and uncertainty are inapplicable
because the making of the affidavit is voluntary. In reality, the making of the affidavit is indispensable if the Union is to
survive and thc rights of its members protected. It is made at the invitation of Congress, and I can discern no reason why the
rule as to uncertainty and vagueness should
not be applied. The reason for the rule, as
thc authorities show, is that persons of
intelligence may not be required
if
%
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o r d i n a r y
to guess or speculate at the meaning of a
statute, and every reason of which I can
think which entitles the maker of a compulsory affidavit to such information exists
in thc instant situation. Thc need for this
information is emphasized from thc fact
that the section serves notice that one who
m;-.kcs a false affidavit is subject to prosecution for perjury.
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KERNER, Circuit Judge.
[1] I concur in Judge MAJOR'S opinion that thc Board properly determined that
pension and retirement plans constitute
part of thc subject matter of compulsory
'•I
�170 FEDKItAX. REPOltTER, 2d SERIES
204
collective bargaining under the Act, but I
am not persuaded that § 9(h) of the Act
is invalid.
The Union's principal contention is that
the condition imposed by the Board's order
and the Congressional policy embodied in
§ 9(h) which the order effectuates, invade
the right to freedom of speech and deny
freedom of political belief activity. I t insists that § 9(h) "is an attempt to restrict
freedom of belief"; that the section is
"primarily if not exclusively a restraint
upon opinion and belief," and that it "imposes sanctions for the alleged evil of harboring 'dangerous thoughts.'"
In support of its contention the Union
cites among others the cases appearing in
the margin. A study of these cases discloses that in them the court was concerned
with the effect of legislation, or judicial action, which imposed a prior restraint upon
speech, press or assembly, or which restricted the occasion for permissible exercise of speech, press or assembly, or which
punished the individuals for having published their views.
1
United States Government by force or by
any illegal or unconstitutional methods,
violated the Constitution.
It is to be remembered that neither belief,
nor speech, nor association is thc subject
matter of the policy of § 9(h) and that neither that section nor the Board's order imposes any limitation upon what any labor
leader may think or say, nor docs the order
or § 9(h) attempt to prohibit or restrain
anyone from joining or supporting any organization. Neither the order nor § 9(h)
denies to Communists thc right to speak
and to publish freely their views, beliefs
and opinions. They may speak as they
think. There is no invasion of political
rights. Communists are not denied the
right to continue to remain members of thc
Communist Party. Thc section does not
make such affiliation or beliefs punishable
cither criminally or by the imposition of
civil sanctions. In such a situation the
cases cited by the Union are inapplicable
and hence not controlling here, but as was
said in National Maritime Union v. Herzog, D.C, 78 F.Supp. 146, 163, " I t is therefore clearly wrong to say that § 9(h) impinges on a union officer's freedom of
speech."
It is to be borne in mind that the Act
was not passed because Congress disapproved of thc views and beliefs of Communists, but because Congress recognized
that the practices of persons who entertained the views presently to be discussed,
might not use thc powers and bencfits conferred by the Act for the purposes intended
by Congress, so, in my view, thc question
is whether Congress, by providing that the
facilities of the Board shall not be available to a labor organization unless each of
its officers shall file an affidavit with the
Board that he is not a member of thc Communist Party or affiliated with such party,
and that he does not believe in, does not
belong to, or support any organization believing in or teaching the overthrow of the
[2] It is unquestioned that Congress
may conclude that the policies of the Act,
i.e., stimulation of commerce ami the security interests of thc nation would be deterred by an extension of the bencfits of
the Act to labor organizations dominated
by officers who are Communists or supporters of organizations dominated by Communists, and that it may take steps to effectuate its conclusions. In fact the "congressional authority to protect interstate
commerce from burdens and obstructions is
not limited to transactions which can be
deemed to be an essential part of a 'flow'
of interstate or foreign commerce. Bur-
l Stromberg v. California, 283 U.S.
MD. 51 S.Ct. 5;:2, 75 L.Ed. 1117, 7,'5
A.L.R. 148J; De Joncc v. OroRoii, 2.09
U.S. o'S.'i, 57 S.Ct. 2r>5, 81 L.Ed. 27S;
nerndrm v. Lowry, SOI U.S. 242, 57 S.
Ot. 732, 81 L.Ed. 1000; Schneider v.
State, 308 U.S. 147, 60 S.Ct. 140, 84 L.
Ed. 155; CantwcU v. Connecticut, 310
U.S. 2»C, 00 S.Ct. «00, 84 L.Ed. 1213,
128 A.LR. 1352; Bridges v. Cnlifoi nin,
314 U.S. 252, <;2 S.Ct. 190. SG L.Ed. 102.
159 A.L.R. 1340; West ViiKiniu .Stuto
lioiird of Education v. Itnrnetto, 319 V.
S. 024, 03 S.Ct. 1178, 87 L.Ed. t(i2,S,
147 A.L.R. 074; Miirdotk v. P !iii.syJvnnin, 319 U.S. 105, 03 S.Ct. 870, 87
L.Ed. 12.92, 140 A.L.R. 81; Thoiuiis v.
Collins, 323 U.S. 510, 05 S.Ct. 315, 89
L.Ed. 4.';0: nnd Sniji v. New York, 334
U.S. 558, 08 S.Ct. 1148.
<
�INLAND STEEL CO. v. NATIONAL LABOR RELATIONS BOARD
205
Cite aa 170 F.2d 247
dens and obstructions may be due to injurious action springing from other
sources. Thc fundamental principle is that
the power to regulate commerce is thc power to enact 'all appropriate legislation'
• * *. That power is plenary and may
be exerted to protect interstate commerce
'ro matter what the source of thc dangers
which threaten i t . ' " National Labor Relations Board v. Jones & Laughlin Steel
Corp., 301 U.S. 1, 36. 57 S.Ct. 615, 81 L.Ed.
893, 103 A.L.R. 1352. Nevertheless, the
Union contends that § 9(h) contravenes the
gtiarantces of the Ninth and Tenth Amendments. It insists thai: the instant case involves more than a regulatory measure,
and it argues that if the statute is viewed
as one "restricting expression of advocacy," it fails to meet the clear and present danger test.
[3] While it is true that "a law applied
to deny a person a right to earn a living or
hold any job because of hostility to his particular race, religion, beliefs, or because
of any other reason having no rational relation to the regulated activities," cannot
be supported under the Constitution, Kotch
v. River Port Pilot Commissioners, 330 U .
S. 552, 556, 67 S.Ct. 910, 912, 91 L.Ed. 1093,
yet Congress has the power to withhold
benefits which it confers for the accomplishment of legitimate purposes within its constitutional powers from those who, it has
cause to believe, ma)' utilize those benefits
lior. directly opposite purposes. For example, in Turner v. Williams, 194 U.S. 279,
24 S.Ct. 719, 48 L.Ed. 979, it was held that
Congress could properly make the privilege
of immigration turn upon the political beHi.efs of the immigrant, and^in" United Pub•lie..Workers v. Mitchell, 330 U.S. 75, 67 S.
Ct. 556, 91 L.Ed. 754, it was held that in
the exercise of its power to promote the
efficiency of the public service, Congress
could properly bar from public employment
Persons who exercised their constitutional
ght to engage in political activity. And
'O.Oklahoma v. Unitod States Civil Service
Coinmission, 330 U.S. 127, 143, 67 S.Ct. 544,
5^3, 91 L.Ed. 794, it was held that Congress
'Jl.the exercise of its powers to "fix the
terrns upon which its money allotments to
I'ates shall be disbursed," could constitu•'l^f170 E.2d—17%
ri
m
tionally deny allotments to states which refuse to remove from their payrolls cmployees who engage in political activity,
See also I n re Summers, 325 U.S. 561, 65
S.Ct. 1307, 89 L.Ed. 1795; Hamilton v.
Board of Regents, 293 U.S. 245, 55 S.Ct.
197, 79 L.Ed. 343; Hawker v. New York,
170 U.S. 189, 18 S.Ct. 573, 42 L.Ed. 1002;
State of Ohio ex rel. Clarke v. Deckebach,
274 U.S. 392, 47 S.Ct. 630, 71 L.Ed. 1115;
and Kotch v. River Port Pilot Commissioners, supra. And where factors relevant to
the attainment of legitimate legislative policies are shown, their use as a basis for distinction is not to be condemned. Hirabayashi v. United States, 320 U.S. 81, 101, 63
S.Ct, 1375, 87 L.Ed. 1774. That being so, 1
think it well to inquire whether there are
factors reasonably related to the attainment
of the objectives which Congress sought
to promote.
[4] Unquestionably, the Labor Management Relations Act, 1947, 61 Stat. 136, was
designed to lessen industrial disputes. This
purpose is clearly shown in the declaration
of policy, § 1(b) of the Act, and in the
amendment to the findings and policies contained in § 1 of the National Labor Relations Act.
Prior to the passage of the National Labor Relations Act, employers were free to
discharge employees for joining labor organizations, and to refuse to bargain collcclively with labor organizations which represented their employees. And it is clear
that when Congress enacted that Act it
sought to minimize strikes in industries affecting commerce by promoting the process
of collective bargaining as a practice conducive to friendly adjustments of disputes
over wages, hours and working conditions
between employers and employees. In doing this, Congress imposed new obligations
upon employers and provided administrativc machinery for the enforcement of those
obligations, but it did not impose those dutics because it was under a constitutional
obligation to employees or labor organizations to do so. On the contrary, the statute
was enacted solely because Congress deemed
the imposition of those duties desirable as
a means of protecting thc public interest in
the free flow of commerce, but thc bencfits
;!
4
I
Hp
;§!
•ill
rip
�2(56
170 FEDERAL REPORTiSR, 2d SERIES
of the Act could not be extended to shield
concerted activities which Congress had not
intended to protect, National Labor Relations Board v. Fanstccl Metallurgical Corp.,
306 U.S. 240, 59 S.Ct. 490, 83 L.Ed. 627, 123
A.L.R. 599; Southern Steamship Co. v.
National Labor Relations Board, 316 U.S.
31, 62 S.Ct. 886, 86 L.Ed. 1246, and any benefit which employees or labor organizations
derived from thc enforcement of these public rights was entirely incidental to the public purposes which enforcement was designed to achieve. True, under the Act,
the Board acts in a public capacity, but not
for the adjudication of private rights; rather it exists to give effect to the declared
public policy of the Act to eliminate and
prevent obstructions to interstate commerce
by encouraging collective bargaining. The
entire scheme of the statute emphasizes
this point, and the Supreme Court has so
held, National Licorice Co. v. National Labor Relations Board, 309 U.S. 350/60 S.Ct.
569, 84 L.Ed. 799; Phelps Dodge Corp. v.
National Labor' Relations Board, 313 U.S.
177, 61 S.Ct. 845, 85 L.Ed 1271, 133 A.L.R.
1217; and National Labor Relations Board
v. Indiana & Michigan Electric. Co., 318
U.S. 9, 63 S.Ct. 394, 87 L.Ed. 579.
[5] Before the enactment of § 9(h),
hearings were conducted by Congressional
committees which showed that Communists
did not view labor unions primarily as instrumentalities for the attainment of legitimate economic aims; that certain practices
of some labor organizations whose officers
were members of or supporters of the Communist Party tended to foment industrial
unrest and strife; and that these practices
were inimical to the purposes for which the
protection of the Act had been granted.
From the evidence thus produced and considered Congress believed that Communists
and their supporters and persons who advocate thc violent overthrow of thc Government, when they attain positions of power
and leadership in a labor organization
might not practice collective bargaining as
a method of friendly adjustment of employer-employee disputes, but instead might use
their position as a vehicle for promoting
dissension and strife between employers and
employees, and that Communists and their
supporters and persons who advocate violent overthrow of the Government, if in
control of labor organizations, might provoke strikes disruptive of commerce, not for
the purpose of improving the economic lot
of union members, but to develop political
power to achieve political ends, and hence,
Congress, in the exercise of its discretion,
concluded that extension of the benefits of
the Act to such labor organizations would
not serve to promote the policies of the
Act, but might endanger national interests.
The reasonableness of that conclusion was
for Congress to determine, North American
Co. v. Securities & Exchange Commission,
327 U.S. 686, 708, 66 S.Ct. 785, 90. L.Ed. 945,
and since there existed a substantial basis
in fact for the conclusion reached by Congress, it seems to me that it was rational
for Congress to conclude that members of
the Communist Party or persons affiliated
with such party who believe in and teach
the overthrow of thc United States Government by force or by any illegal or unconstitutional methods were more likely than others to misuse the powers which inhere in
union office. Hence T conclude that Congress acted within its constitutional powers.
[6] The point is made that the section is
invalid because the phrases "any organization that believes in or teaches, the overthrow of thc United States Government by
force or by any illegal or unconstitutional
methods," "affiliated with," and the word
"supports" are vague and indefinite and
must fall before the First, Fourth and Fifth
Amemlments. For the reasons set forth in
National Maritime Union v. Herzog, supra,
I think the contention lacks merit. In addition, I believe that the statute is as specific
as thc nature of thc problem permits. Compare Dunne v. United States, 8 Cir., 138
F.2d 137, 143. Moreover, thc language is
not so vague that men of common intelligence would have to guess at its meaning
and differ as to its application. It requires
only that persons who knowingly engage
in the activities set forth in § 9(h), or who
knowingly believe in the enumerated doctrines, or who knowingly support organizations which disseminate such doctrines,
shall not obtain access to thc machinery
set up by Congress for the purpose of
�UNITED STATES v. MCCARTHY
2G7
Cite a» 170 F.2d 2G7
advancing a specific public policy; hence
if-, an affiant honestly believes that he is
not affiliated with the Communist Party,
ichat he docs not support any organization
which to his knowledge teaches the overthrow of the United States Government
by means which he knows to be illegal or
unconstitutional, such an affiant would be
in.no danger of conviction under Sec.
35(A) of the Criminal Code, now 18
U.S.C.A. § 1001. Compare United States
v. Gilliland, 312 U.S;. 86, 91, 61 S.Ct. 518,
85 L.Ed. 598; Screws v. United States,
325 U.S. 91, 101-105, 65 S.Ct. 1031, 89 L.Ed.
1495,. 162 A.L.R. 1330; See also United
States iv. Petrillo, 332 U.S. 1, 67 S.Ct.
1538, 91 L.Ed. 1877.
[7] . The point is; made that § 9(h) is
a bill of attainder, because, so it is said,
the section proceeds not by way of defining
a harmful activity and setting up sanctions
against such activity, but by way of a
legislative declaration of the guilt of individuals and groups with respect to engaging
in such activities.
[8,9]
In my opinion this contention is
unsound. A bill of attainder is a legislative
act which inflicts punishment without a
judicial trial. Cummings v. The State of
Missouri, 4 Wall. 277, 323, 71 U.S. 277,
323, 18 L.Ed. 356. Section 9(h) does not
rest upon any finding of guilt, but like the
disqualification of convicted felons from
medical practice in Hawker v. New York,
supra, and the disqualification of aliens
from operating poolrooms in State of Ohio
ex rel. Clarke v. Deckebach, supra, it
operates not to impose punishment but to
safeguard important: public interests against
potential evil. And as was said by Mr. Justice Murphy, "nothing in the Constitution
prevents Congress from acting in time to
prevent potential injury to the national
economy from becoming a reality." North
American Co. v. Securities & Exchange
Commission, supra, 327 U.S. at page 711,
66 S.Ct. at page 799.
UNITED STATES v. MCCARTHY.
No. 62, Docket 21091.
United States Court of Appeals
Second Circuit
Oct. 28, 1948.
1. Conspiracy <£=543(5)
An indictment for conspiracy to steal
goods from a shipment in interstate commerce was not defective merely because it
did not allege that a particular defendant
took part in overt acts relied on. IS U.S.
C.A. § 371.
2. Conspiracy <3=47
Embezzlement €=44(1)
Evidence that when another came to
get receipts showing proper delivery of
soap, dock boss told defendant that he had
received the money for the soap and that
thereupon the defendant made out a forged
receipt was sufficient to prove conspiracy
to steal goods from a shipment in interstate commerce and to prove at least that
the defendant was an accessory after the
fact to the embezzlement of property of
the United States. 18 U.S.C.A. § 371.
3. Criminal law <S=>I030(I, 3), 1056(1)
Where defendant's attorney at conclusion of judge's charge, not only made
no objection to what had been charged but
stated that he had neither exceptions to take
nor requests to make, no complaint could
be made on appeal concerning instructions given.
4. Criminal law <3=>l 171(1)
That prosecutor apparently in answer
to an argument based on failure of witness to identify the defendant, told the jury
that the reason might have been that defendant might assault thc witness if he
had done so, was not ground for reversal.
Appeal from the United States Distria
I conclude the petitions to set aside the Court, for thc Southern District of New
Board's order ought to be denied and the York.
request for its enforcement granted.
John J. McCarthy was convicted of em: . M I N T O N , Circuit Judge, concurs in this bezzling property of the United States and
opinion.
of a conspiracy to steal goods from a ship-
�(C) 1994 McGraw-Hill, I n c . - DOCUMENT 1 (OF 3)
CITATIONS TO: 170 F.2d 247
SERIES: Shepard's Federal Citations
DIVISION: Fed€:ral Reporter, 2d Series
COVERAGE: A l l Shepard's Citations Through 03/94 Supplement.
NUMBER ANALYSIS
1
2
3
4
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6
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9
10
11
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affirmed
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same case
same case
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same case
same case
same case
same case
CITING REFERENCE
(12
339
94
70
335
336
339
93
93
94
69
SYLLABUS/HEADNOTE
A.L.R.2d 240)
U.S. 382
L.Ed. 925
S.Ct. 674
U.S. 910
U.S. 960
U.S. 990
L.Ed. 443
L.Ed. 1112
L.Ed. 1391
S.Ct. 480
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Dublin Core
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Title
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Health Care Task Force Records
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White House Health Care Task Force
Is Part Of
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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Task Force on National Health Care
White House Health Care Task Force
Jason Solomon
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Box 38
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
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Clinton Presidential Records: White House Staff and Office Files
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42-t-12093764-20060885F-Seg2-038-002-2015
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MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/OHicc of Origin:
Health Care Task Force
Scries/StaIT Member:
Solomon, Jason
Subseries:
OA/ID Number:
3327
FolderlD:
Folder Title:
Work Memos 11]
Stack:
Row:
Section:
Shelf:
Position:
S
52
7
9
2
�V
REPRESENTATIVE COOPER'S MANAGED COMPETITION A C T :
The Lewin-VHI Analysis
Lewin Conclusion: "Overall, about 91 percent of the population would be insured. . . While nine
percent of Americans would remain uninsured, about 97 percent of all potentially
covered health spending would be covered by insurance [since those remaining
outside the system would be healthier and less likely to need expensive health care
services]."
Response:
• In its own conclusion, this independent health care consulting firm highlights the flaws inherent to
Representative Cooper's Managed Competition Act.
Flaw#l:
• According to the Lewin analysis, the Managed Competition Act "will still leave 22.4
million persons uninsured. These individuals are still at risk for incurring large
uncompensated care expenses which ultimately will be shifted to insured individuals in the
form of higher prices for health care. " [Lewin, p. 12]
•
The people who remain uninsured will still obtain care when they get sick or get in an
accident. But without insurance, their bills will continue to be shifted onto those with
pnvate insurance. The CBO has estimated that this "cost-shifting" amounts to $25 billion
each year ~ driving up premiums for businesses and families throughout the country.
Flaw #2:
• The Lewin study also said, "Moreover, allowing healthy individuals not to obtain insurance
coverage will tend to result in higher premiums for those who purchase insurance."
[Lewin, p. 12]
•
With half-measures, such as Cooper's, that fail to achieve universal coverage, health
insurance premiums for middle income Americans will rise. Why? Because the sickest, and
most costly, people will join Cooper's insurance pools, raising costs for all those that now
buy coverage. And CBO predicted that: "An upward spiral of premiums might result."
[C130, p. xiv]
•
•
Th is is based on the realization that the increased premiums resulting from Cooper's
proposal, rather than increasing coverage, will force people who have insurance today to
drop this coverage. "Premium charges are likely to result in increased coverage for higher
cost groups which probably would be offset by a reduction in coverage f o r lower cost
populations. " [Lewin, p. 4]
And, finally, the Lewin-VHI study does nothing to contradict CBO's conclusion that the Cooper
bill does not adequately fund the subsidies necessary to achieve even its incomplete level of
coverage. Paying for these subsidies would add almost $200 billion to the deficit in the first 5
years, with higher deficits of over $300 billion over 10 years. [CBO, p. 22]
�Moyniifian Lays Out Health Proposals
Continued From Page A3
but this faction is incfeasingly
As Senate Labor Panel Clears Its Billerage.
isolated by conservatives who would prefer
to force a veto confrontation with the
ocrats must abandon the mandate on em- president over a bare-bones bill offering
ployers if they are to win on the floor.
just modest insurance reforms.
Siaff fieporterj oj' T H E WALL STREET JOURNAL.
In fact, the liberal makeup of the Labor
Such a measure would do little for poor
WASHINGTON - Senate Finance Com- panel subtracts from the significance of and working-class families, who can't afthe
victory.
Emboldened
by
the
Demomittee Chairman Daniel Patrick Moynihan
ford coverage today, but would still resowants to more than double President Clin- crats' difficulties elsewhere, business in- nate with a middle-class constituency,
ton's proposed tobacco-tax increase while terests and conservative Republicans are important swing voters for Democrats this
taking: a more flexible approach to expand- bent on blocking any significant action
ing health-care coverage for employees of before November, when the GOP hopes to fall and for Mr. Clinton in 1996.
Tobacco taxes already have been emsmall businesses
add to its ranks in the midterm elections.
braced
by centrists on the panel, although
Mr. Clinton has threatened to veto
The New York Democrat outlined his
plan at meetings with Finance Committee legislation that stops short of providing not at the level sought by Mr. Moynihan.
members: last nifrht. the Senate Labor and health insurance for all Americans, but his But the 1% payroll tax proposed for large
Human Resources! Committee approved its goal is gradually being whittled away. In companies, which would raise about $50
own health-reform plan that incorporates the case of small business. Mr. Moynihan billion overfiveyears, faces strong opposiMany Republicans have pressed inmuch of the administration's proposals.
proposes a tough standard, demanding tion.
stead
for a cap on the current income-tax
Like the president, Sen. Moynihan that companies with 20 or fewer workers exclusion protecting health benefits, and
would require lan?e employers to pay as collectively achieve 97% coverage by the there has been a greater willingness by
much as 80% of their workers' insurance end of 1998 or face a more burdensome GOP moderates to delay their proposed
costs, but companies with 20 or fewer mandate requiring them to pay at the costly health deductions for the selfemployees could opt for a less burdensome same rate as larger firms. In fact, that will employed and individuals in order to
payroll tax if strict overall targets are met be hard to meet. A centrist coalition of stretch available revenue.
for coverage in late; 1988 and 2000.
Democrats and Republicans, including
Like the administration, Mr. Moynihan
To help finance his scheme, Sen. Moy- leading members of the Finance Commitnihan wants to raisu cigarette taxes to $2 a tee, have devised a scheme that uses a wouldrequireworkers to pay 20% of their
pack, an increase of $1.76 over the current benchmark of 96% coverage for all individ- insurance costs, but his subsidies appear
rate. The president has proposed a 75-cent uals by 2000. Some Southern conservatives less generous than the president's. Family
payments would be capped at 5% of annual
increase. The chairman also wants a have argued for a goal of 91% to 93%.
series of high-profile business taxes runFor Mr. Clinton, these compromisesincome up to $30,000, for example, comning from a beefed-up levy on handgun- pose an awkward dilemma. He doesn'tpared with 3.9% in the president's plan.
ammunition, sales to a 1% payroll tax on want to give up the goal of universal The Finance chairman's plan also
shows some effort to accommodate modercompanies with 500 or more workers.
coverage, but to hold firm on this standard
ate Democrats and Republicans who favor
may
mean
giving
up
the
chance
of
improvA new tax on health-insurance prea more market-oriented approach to cost
miums would be phased in, reaching 2.5% ing health care for many poor and workcontrols. The system he proposes would set
ing-class
families
on
a
more
incremental
by 1999, to help finance assistance to
annual
targets rather than the more oneracademic health centers and medical edu- basis. A small band of moderate Republicaps proposed by the president for
cation and research. In addition, Mr. Moy- cans, including Sen. John Chafee (R., ous
health insurance premiums.
nihan would seek to recover billions of R.I.), is still committed to expanding covdollars in Medicare subsidies that now go
Please Turn to Page Ak, Column 3 Mr. Moynihan includes a "deficit-control" apparatus to cut future subsidies, if
to the wealthy.
costs
exceed estimates. But his emphasis
Mr. Moynihan's ideas represent the
on taxes met immediate objections from
opening gambit of intense maneuvering
Mr. Packwood, who labeled the proposal a
expected on the panel for at least the next
"whopper." The Oregon Republican
several weeks. Much of the chairman's
quoted
preliminary estimates Indicating
plan appears to invite rejection, given
that
its
new taxes would outstrip savings
business opposition to both taxes and the
by
a
better
than 4-1 margin. And while
mandated employer payments sought by
moderates
have
proposed multiyear savthe administration. Hut by forcing his
ings
of
$152
billion
from Medicare and
fellow Democrats, as well as Republicans,
Medicaid.
Mr.
Moynihan's
bill falls far
to face these options. Mr. Moynihan could
short of that standard.
yet open the way to bipartisan discussions
Sen. Moynihan said last night that any
of what can be salvaged of health-care
action in his committee must await a final
reform this year.
cost analysis by the Congressional Budget
Mindful of the stakes, President Clinton
Office.
As seen across the Capitol at the
is seeking a meeting next week with the
House
Ways
and Means Committee yester-.
Sen. Moynihan and his Republican counday,
analyzing
health costs isn't easy. The
terpart. Sen. Bob Paclcwood of Oregon.
new
acting
chairman
of the House commitThere is growing concern in the White
tee.
Rep.
Sam
Gibbons,
has been forced to
House that health refonn. the centerpiece
issue
almost
daily
revisions
of his plan in
of the president's domestic agenda, is at
order
to
keep
pace
with
fluctuating
cost
risk of becoming a debacle.
estimates. But last night, the Florida DemIn the Labor Committee. Sen. James
ocrat said he felt assured of receiving CBO
Jeffords of Vermont was the sole Republiestimates today, from which the commitcan joining Democrats in the 11-6 vote,
tee can work next week.
which ended eight days of deliberations.
"We can't work from the back of an
"Today is an historic day," said Presienvelope,"
Mr. Gibbons said. And an undent Clinton in a statement last night
daunted House Majority Leader Richard
congratulating Chairman Kennedy. Mr.
Gephardt vowed with a smile, "Universal
Clinton sought to make thi> most of what he
coverage in our time."
saw as renewed "momen tum" in both the
"But you're young," a reporter said.
House and Senate. But Sen. David Duren"No I'm not." answered the 53-year-old
berger (R.. Minn.), who sits on both the i
Missouri Democrat, grinning.
Finance and Labor committees, said Dem- >
By DAVID ROGERS
And HILARY STOUT
�From: Ed Rothtohiid To: Jtton Solomon
.04/28/94
16:43
© 2 0 2 296 4054
Dato: 6/6/M Tlmo: 16:08:04
P«9*2of$
©001
CITIZEN ACTION
Citizen Action
1120 19th Street, N.W., Suite #630
Washington, D.C. 20036
(202)775-1530
(1\02) 296-40S4 (FAX)
For immediate release:
Wednesday , April 27, 1994
Press Release
For further information
Contact: Ed Rothschild
(202) 775-1580
Average Family to Pay $1,700 to $4,500 More Per Year
If Congress Forces Individuals to Pay Higher Percentage of
Health Insurance Premiums
Washington: In an analysis released today, Citizen Action, the nation's largest consumer organization,
estimates that the average American family could pay between $1,700 and $4,500 more per year if
Congress allows businesses to shift the cost of premium payments to individuals.
In a letter to Senate Majority Leader George Mitchell (D-ME), who has floated a 50-50 premium split
between businesses and employees, Citizen Action Executive Director Ira Arlook sharply criticized the
proposal and other proposals that would force individuals and families to bear the entire cost of health
insurance premium payments.
"Health car© proposals which place the entire burden on individuals wonlrl allow husinesses to avoid
any responsibility in paying for health care costs which could increase consumer costs by as much as
$1.5 trillion overfiveyears and by an average of $4,452 per year for a family of four," said Arlook.
As part of its letter to Senator Mitchell, Citizen Action released a state-by-state analysis of the impact
on both individuals and families of shifting from the proposed 80-20 split between employers and
workers to a 50-50 split or to a complete "individual mandate" as some members of Congress have
proposed.
According to the analysis, under a 50-50 split proposal, the increased annual premium cost for a single
ycisvu would be $630, $1,260 for a couple, $1,229 for a single parent with children and $1,670 for
two parent families. For a family earning $25,000 per year, the increase will mean paying between
2.5 % and 7 % more of their income on health care. Under an "individual mandate," where individuals
and families pay the entire annual health insurance premium, a single person would pay an additional
$1,680 pftr year, a couple would pay $3,360 more, a single parent would pay $3,276 more and a two
parent family would pay $4,452 more.
"When the public finds out how some members of Congress want to shift the bulk or the entire burden
of paying for health care from businesses, where it belongs, to individuals and famDles, there will be
an enormous and justified public outcry," said Arlook. "It is Qic height of political irresponsibility for
members of Congress to give their constituents less health care than those constituents provide them,"
commented Arlook.
�From: Ed Rothtohiid To: Jston Solomon
04/28/94
16:43
© 2 0 2 296 4054
D«t»: 6W«4 Tlmo: 16:08:46
CITIZEN ACTION
P»9» S of 8
®J<02_
The Impact of Increasing the
Health Insurance Burden on Employees
Congrtsss is currently debating proposals to shift the burden of paying for health care from business to
individuals. One proposal would increase the individual's responsibility from 20 percent to 50 percent of
premium ("fifty-fifty"). Another would put the entire burden on individuals ("individual mandate"). The purpose
of this report is to show the impact of these proposals on individuals and families on a state by state basis.
Table T shows the impact of increasing the employee responsibility from 20 percent to 50 percent. The
impact is shownforfour types of families: individuals, couples, single parents, and couples with children. The
figures given are for premiums based on the benefits package in the Health Security Act in 1994. The underlying
premiums used are those developed by the Congressional Budget Office in "An Analysis of the Administration's
Health Proposal." State specific impacts were developed using the State Health Spending Model (SHSM). The
model adjusts estimates of the national weighted average premium for each state primarily by accounting for state
price variation and the extent of cost shifting.
Table I shows, for example, that a couple with children in Rhode Island would have to pay $1,849 more
per year if their employer contributed 50 percent instead of SO percent of premiums. The $1,849 does not include
the 20 percent of the premium that the family would have to pay under either the fifty-fifty split or the eightytwenty split. In some instances, an employer might choose to pay more than 50 percent of the premium.
However, it is all but certain that those who work for employers who do not now provide insurance would have
to pay the ful'l 50 percent, and that over time, 50 percent could become a standard (hat encourages employers to
reduce their health insurance contribution.
Table II shows the impact of replacing the employer mandate with an individual mandate on four types
of families: individuals, couples, single parents and couples with children. Thefiguresare givenforthe Health
Security Act in 1994. The underlying premiums were developed by the Congressional Budget Office in "An
Analysis of die Administration's Health Proposal." State specific impacts were developed using the State Health
Spending Model (SHSM). The model adjusts estimates of the national weighted average premium for each state
primarily by accounting for state price variation and the extent of cost shifting.
Tablu IT shows,forexample, that a couple with children in Rhode Island would havetopay $4,931 more
per year if their employer contributes nothing instead of 80 percent. The $4,931 does not include the 20 percent
of the premium that the family would have to pay under either the individual mandate or the eighty-twenty split.
In some instmces, an employer might choose to pay more than 50 percent of the premium. However, it is all
but certain that those who work for employers who do not now provide insurance would have to pay the full 80
percent.
Table III shows the total potential shift from businesses to families over the period fiscal year 1998
throughfisciilyear 2002. Two important caveats must be considered. First, the exact state by state and national
impact will depend on the subsidy structure. For example, in a fifty-fifty proposal would the subsidies currently
slated for business go directly to individuals dollar for dollar? Would more funds be appropriated to soften the
significant impact either proposal would have on families? We basically ignore those questions and use the
Congressional Budget Office's estimates of employer premium payments under the Health Security Act. Second,
it is clear that especially in the short run, many employers who currently pay more than 50 percent will continue
to do so. In the longer am, it is not clear what the behavioral reaction of employers will be, especially if the
subsidy structure allows them to reduce their contributions without increasing their employees' burden, or if one
of these prcposals reduces the tax deductibility of health insurance premiums for business. Thus, the figures
in Table III merely illustrate the magnitude of the potential shiftfromemployers to employees if either proposal
is adopted. Proposals which shift premium costs to individuals must also address questions such as whether
additional subsidies would be provided to reduce impacts on families or whether subsidies currently slated for
business would go directly to individuals dollar for dollar.
�Prom: Ed Rottuohlld To: Jaion Solomon
04/28/94
16 :44
P»9* 4 of 8
Dtto: 6/6/04 Tlmo: 19:09:89
© 2 0 2 296 4054
0003
CITIZEN ACTION
Table I
«tste Specific Family Impact of "Frtty-Fifty" Employer Mandate on
f 'our Family Types. 1994
Families Earning $25,C
JUabama
;\rizona
•Vkansas
i^alifomia
iDolorado
Connecticut
Oelaware
Ditt df Coii.mb'ii
Rorida
Georgia
Hawaii
idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Mfsine
Maryiana
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampehire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South CsroHna
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
US, Average
Tun
Parent
Families
Single
Couple
Single
Couple
Singte
Parents
$598
8650
$558
$515
t617
5597
$705
$645
?T30
$629
$535
$651
$453
$651
$585
$611
$618
$561
$600
$54?
$1,195
$1,300
$1,116
$1,030
$1,234
$1,195
$1,409
$1,291
51.4*0
$1,259
$1,191
$1,302
$905
$1,301
$1,170
$1,777
$1,236
$1,121
$1,200
$1,084
$1,166
$1,268
$1,087
$1,004
$1,203
$1,165
$1,374
$1,258
?M2?
$1,227
$1,161
$1,269
$883
$1,269
$1,140
$1,191
$1,205
$1,093
$1,169
$1,057
$1,584
$1,722
$1,479
$1,365
$1,634
$1,583
$1,867
$1,710
$1.««4
$1,668
$1,578
$1,725
$1,199
$1,725
$1,550
$1,619
$1,638
$1,485
$1,589
$1,437
2.4%
2.6%
22%
2.1%
Z5%
24%
2.8%
26%
2.9%
2.5%
2.4%
26%
1.8%
26%
2.3%
24%
2.5%
22%
24%
2.2%
4.8%
5.2%
4.5%
4.1%
4.9%
4.8%
5.6%
52%
5.8%
5.0%
4.8%
5.2%
3.6%
52%
4.7%
4.9%
4.9%
4.5%
4.8%
4.3%
$815
$674
$639
$457
$645
$484
$588
$522
$610
$708
$532
$771
$506
$648
$1,630
$1,348
$1,278
5913
$1,290
$968
$1,175
$1,044
$1,220
$1,416
$1,063
$1,541
$1,012
$1,296
$1,285
$1,055
$1,OS3
$1,432
$1,396
$1,054
$1,140
$1,193
$1,086
$943
$1,034
$1,162
$1,170
$1,157
$1,246
$1,124
$1,260
$1,590
$1,315
$1,246
$891
$1,258
$944
$1,146
$1,017
$1,188
$1,380
$1,037
$1,502
$985
$1,263
$1,253
$1,028
$1,036
$1,396
$1,361
$1,028
$1,111
$1,163
$1,059
$925
$1,008
$1,133
$1,140
$1,128
$1,216
$1,096
$1,229
$2,160
$1,786
$1,694
$1,211
$1,709
$1,282
51,557
$1,383
$1,616
$1,876
$1,409
$2,042
$1,341
$1,716
$1,703
$1,397
$1,408
$1,898
$1,849
$1,397
$1,511
$1,580
$1,439
$1,257
$1,371
$1,540
$1,550
$1,532
$1,650
51,489
$1,670
3.3%
27%
2.6%
1.8%
26%
1.9%
2.4%
2.1%
2.4%
28%
21%
3.1%
2.0%
2.6%
2.6%
2.1%
2.1%
2.9%
28%
21%
2.3%
24%
22%
1.9%
21%
2.3%
2.3%
2.3%
25%
22%
25%
6.5%
5.4%
5.1%
3.7%
5.2%
3.9%
4.7%
4.2%
45%
5.7%
4.3%
6.2%
4.0%
5.2%
5.1%
4.2%
4.3%
5.7%
5.6%
42%
4.6%
4.8%
4.3%
3.8%
4.1%
4.6%
4.7%
4.6%
5.0%
4.5%
5.0%
Families Earning $50,000
Single
Parents
4.7%
5.1%
4.3%
4.0%
4.8%
4.7%
5.5%
5.0%
^7%
4.5%
4.6%
5.1%
3.5%
5.1%
4.6%
4.8%
4.8%
4.4%
4.7%
4.2%
Twr,
Parent
Families
Singte
Couple
6.3%
6.9%
5.9%
5.5%
6.5%
6.3%
7.5%
6.8%
7.7%
6.7%
6.3%
6.9%
4.8%
6.9%
6.2%
6.5%
6.6%
5.9%
6.4%
5.7%
1.2%
1.3%
1.1%
1.0%
1.2%
1.2%
1.4%
1.3%
1 fi%
1.3%
1.2%
1.3%
0.9%
1.3%
1.2%
1.2%
1.2%
1.1%
12%
1.1%
24%
26%
22%
2.1%
2.5%
24%
2,8%
26%
?q«it.
2.5%
2.4%
26%
1.8%
2.6%
2.3%
2.4%
2.5%
2.2%
24%
2.2%
8.6%
7.1%
6.8%
4.8%
6.8%
5.1%
6.2%
5.5%
6.5%
7.5%
5.6%
8.2%
5,4%
6.9%
6.8%
5.6%
5.6%
7.6%
7.4%
5.6%
6.0%
6.3%
5.8%
5.0%
5.5%
6.2%
6.2%
6.1%
6.6%
6.0%
6.7%
1.6%
1.3%
1.3%
0.9%
1.3%
1.0%
1.2%
1.0%
1.2%
1.4%
1.1%
1.5%
1.0%
1.3%
1.3%
1.1%
1.1%
1.4%
1.4%
1.1%
1.1%
1.2%
1.1%
0.9%
1.0%
1.2%
1.2%
1.2%
1.2%
1.1%
1.3%
3.3%
2.7%
2.6%
1.8%
26%
1.9%
2.4%
21%
2.4%
2.8%
2.1%
3.1%
2.0%
2.6%
2.6%
2.1%
21%
2.9%
2.8%
21%
2.3%
2.4%
2.2%
1.9%
21%
2.3%
2.3%
2.3%
2.5%
22%
2.5%
O.O-Jb
5543
$527
$531
$716
$698
$527
$570
$596
$543
$474
$517
$581
$578
$tiZJ
$562
$63C
Source: State Health Spending Model baaed on CBO Health Security Act Premiums
27.Apr^4
6.4%
5.3%
5.0%
3.6%
5.0%
3.8%
4.6%
4.1%
4 8%
5.5%
41%
6.0%
3,9%
5.1%
5.0%
4.1%
4.1%
5.6%
5.4%
4.1%
4.4%
4.7%
42%
3.7%
4.0%
4.5%
4.6%
4.5%
4.9%
4.4%
4.9%
Single
Parents
23%
25%
22%
2.0%
24%
2.3%
2,7%
25%
?R%
2.5%
2.3%
2.5%
1.8%
2.5%
2.3%
2.4%
24%
2.2%
23%
2.1%
^a*
3.2%
26%
25%
1.8%
2.5%
1.9%
2.3%
2.0%
24%
2.6%
2.1%
3.0%
2.0%
25%
2.5%
2.1%
21%
2.8%
27%
21%
2.2%
2.3%
21%
1.8%
2.0%
2.3%
2.3%
23%
2.4%
22%
2.5%
Twn
Parent
Families
3.2%
3.4%
3.0%
2.7%
3.3%
3.2%
3.7%
3.4%
3q%
3.3%
3.2%
3.4%
2.4%
3.4%
3.1%
3.2%
3.3%
3.0%
3.2%
2.9%
d./Tb
4.3%
3.6%
3.4%
24%
3.4%
2.6%
3.1%
2.8%
3.2%
3.8%
2.8%
4.1%
2.7%
3.4%
3.4%
2.8%
28%
3.8%
3.7%
2.8%
3.0%
3.2%
2.9%
2.5%
27%
3.1%
3.1%
3.1%
3.3%
3.0%
3.3%
�From: Ed Rdihtohlld To: Jason Solomon
04/28/94
16:44
©202
Paflo 6 ol 8
Dal*: m m Tlmo; 19:10:88
296
CITIZEN ACTION
4054
11004
Table II
Stata Specific Family Impact Of Individual Mandate on
Four Family Types, 1994
Families Earning $25,000
Two
Parent
Families
Alabama
Alaska
Arizona
Arkansas
eallfairikj
Colorado
Connecticut
Deiawaro
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indinna
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mi&nisAiprii
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
. North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermnnt
Virginia
Washington
West Virginia
Wisconsin
Wyoming
U.S. Average
$11,594
$1,733
$11,458
$•1,374
9 .844
$11,593
$'l.87 9
$'1,721
$•1,946
$1,678
$'1,588
$'1,736
$1,207
$1,736
t'I.EGO
$1,629
$1,648
$1,495
$1,599
$1,446
$1,884
52,174
$1,797
$1,704
S1.71R
$1,720
$1,290
$1,567
$1,391
$1,626
51,888
$1,418
$2,055
$1,350
$1,727
$1,714
$1,406
51,417
11,910
51,861
51.406
51.520
51,590
j;i,448
11,265
Jil.ffTfi
?i1,550
311,560
311,542
$1,661
511.498
1.1,680
,
$3,188
$3,467
$2976
$2,747
$3,290
$3,186
$3,758
$3,442
$3,892
$3,357
$3,177
$3,471
$2414
$3,470
$3,110
$3,257
$3,296
$2,990
$3,199
$2891
$3,769
$4,348
$3,596
$3,409
$3,441
$2581
$3,134
$2,783
$3,252
$3,778
$2836
$4,109
$2,688
$3,455
$3,428
$2812
$2,834
$3,818
$3,723
$2,811
$3,039
$3,181
$2895
$2,530
1i?7SR
$3,099
$3,113
$3,084
$3,322
$2,997
$3,360
$3,109
$3,380
$2,900
$2,879
$3,207
$3,106
$3,664
$3,356
$3,795
$3,273
$3,097
$3,385
$2,354
$3,384
«3.041
$3,176
$3,213
$2915
$3,119
$2,819
$3,674
$4,240
$3,506
$3,324
$??I7R
$3,355
$2517
$3,056
$2,713
$3,169
$3,681
$2765
$4,006
$2631
$3,369
$3,342
$2,742
$2,763
$3,723
53.629
$2,742
$2,963
$3,101
$2,823
$2,466
$7.fiRq
$3,021
$3,041
$3,008
$3,239
$2,922
$3,276
Families Earning $50,000
Two
Parent
Single
Couple
Single
Parents
6.4%
6.9%
6.0%
5.5%
e.fl%
6.4%
7.5%
6,9%
7.8%
6.7%
6.4%
6.9%
4.8%
6.9%
12.8%
13.9%
11.9%
11.0%
13.2%
127%
15.0%
13.8%
15.6%
13.4%
127%
13.9%
9.7%
13,9%
124%
13.5%
11.6%
10.7%
12.8%
124%
14.7%
13.4%
15.2%
13.1%
124%
13.5%
5.4%
13.5%
16.9%
18.4%
15.8%
14.6%
17.4%
16.9%
19.9%
18.2%
20.6%
17.8%
16.8%
18.4%
128%
18.4%
£4,134
G.2%
12.E%
12,2%
1C.C%
3.1%
$4,316
$4,367
$3,961
$4,238
$3,832
$4,994
$5,761
$4,763
$4,617
6.5%
6.6%
6.0%
6.4%
5.8%
7.5%
8.7%
7.2%
6.8%
4P%
6.9%
5.2%
6.3%
5.6%
6.5%
7.6%
5.7%
8.2%
5.4%
6.9%
6.9%
5.6%
5.7%
7,6%
7.4%
5.6%
6.1%
6.4%
5.8%
5.1%
13.0%
13.2%
120%
128%
11.6%
15.1%
17.4%
14.4%
13.6%
fl7%
13.8%
10.3%
125%
11,1%
13.0%
15.1%
11.3%
16.4%
10.8%
13.8%
13.7%
11.2%
11.3%
15.3%
14.9%
11.2%
122%
12.7%
11.6%
10.1%
11 n%
12.4%
125%
12.3%
13.3%
12.0%
13.4%
12.7%
129%
11.7%
125%
11.3%
14.7%
17,0%
14.0%
13.3%
A 5%
13.4%
10.1%
12.2%
10,9%
12.7%
14.7%
11.1%
16.0%
10.5%
13.5%
13.4%
11.0%
11.1%
14.9%
14.5%
11.0%
11.9%
12.4%
11.3%
9.9%
10 8%
121%
12.2%
120%
13.0%
11.7%
13.1%
17.3%
17.5%
15.8%
17.0%
15.3%
20.0%
23.0%
19.1%
18.1%
3.3%
3,3%
3.0%
3.2%
2.9%
3,8%
4.3%
3.6%
3.4%
1?P%
7 4%
18.2%
13.7%
16.6%
14.7%
17.2%
20.0%
15.0%
21.8%
14.3%
18.3%
18.2%
14.9%
15.0%
20.2%
19.7%
14.9%
16.1%
16.9%
15.3%
13.4%
14.fi%
16,4%
16.5%
16.3%
17.6%
15.9%
17.8%
3.4%
2.6%
3.1%
2.8%
3.3%
3.8%
2.8%
4.1%
2.7%
3.5%
3.4%
2.8%
28%
3.8%
3.7%
2.8%
3.0%
3.2%
2.9%
2.5%
78%
3.1%
3.1%
3.1%
3.3%
3.0%
3.4%
$4,224
$4,593
$3,943
$3,641
$4,SW
$4,222
$4,980
$4,560
$5,157
$4,447
$4,208
$4,599
$3,198
$4,599
$4,558
$3,420
$4,152
$3,687
$4,309
$5,003
$3,758
$5,445
$3,576
$4,576
$4,542
$3,726
$3,754
$5,060
$4,931
$3,726
$4,028
$4,215
$3,837
$3,353
$4,106
$4,134
$4,086
$4,401
$3,970
$4,452
6.2%
6.2%
8.2%
6.6%
6.0%
6.7%
Source: State Health Spending Model based on CBO Health Security Act Premiums
27-Apr-94
Families
Single
Couple
3.2%
3.5%
3.0%
27%
3.3%
3.2%
3.8%
3.4%
3.9%
3.4%
3.2%
3.5%
24%
3.5%
6.4%
6.9%
6.0%
5.5%
6.6%
6.4%
7.5%
6.9%
7.8%
6.7%
6.4%
6.9%
4.8%
6.9%
0.2%
6.5%
6.6%
6.0%
6.4%
5.8%
7.5%
8.7%
7.2%
6.8%
4n%
6.9%
5.2%
6.3%
5.6%
6.5%
7.6%
5.7%
8.2%
5.4%
6.9%
6.9%
5.6%
5.7%
7.6%
7.4%
5.6%
6.1%
6.4%
5.8%
5.1%
5.5%
6.2%
6.2%
6.2%
6.6%
6.0%
6.7%
Single
Parents
6.2%
6.8%
5.8%
5.4%
6.4%
6.2%
7.3%
6.7%
7.6%
6.5%
6.2%
6.8%
4.7%
8.8%
0.1%
6.4%
6.4%
5.8%
6.2%
5.6%
7.3%
8.5%
7.0%
6.6%
Two
Parent
Families
8.4%
9.2%
7.9%
7.3%
8.4%
10.0%
9.1%
10.3%
8.8%
8.4%
9.2%
6.4%
9.2%
0.0%
8.6%
8.7%
7.9%
8.5%
7.7%
10,0%
11.5%
9.5%
9.0%
4R%
RS%
6.7%
5.0%
6.1%
5.4%
6.3%
7.4%
5.5%
8.0%
5.3%
6.7%
6.7%
5.5%
5.5%
7.4%
7.3%
5.5%
5.9%
6.2%
5.6%
4.9%
5.4%
6.0%
61%
6.0%
6.5%
5.8%
6.6%
9.1%
6.8%
8.3%
7.4%
8.6%
10.0%
7.5%
10 9%
7.2%
9.2%
9.1%
7.5%
7,5%
10.1%
9.9%
7.5%
8.1%
8.4%
7.7%
6.7%
7.3%
8.2%
8.3%
8.2%
8.8%
7.9%
8.9%
�Fiem: Ed Rethtohlld To: Jaton Solomon
04/28/94
16:45
© 2 0 2 296 4054
Dato: 6/6/84 Tlmo: 16:11:88
CITIZEN ACTION
Tablelll
Total Potential Shift from Business to Individuals
Fiscal Years 1998 - 2002. Billions of Dollars
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
MasiaehuMtts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Ptinnsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Wcral liny luu
West Virginia
Wisconsin
Wyoming
U.S. Total
FflyFifty
Individual
Mandate
$7.6
$20.3
$3.1
$18.7
$11.2
$168.6
$20.3
$23.5
$4.5
$1.2
S7.0
$4.2
$63.2
$7.6
$8.8
$1.7
$1.3
$26.1
$12.8
$2.8
$1.6
$28.9
$12.8
$3.6
$69.6
$34.2
$7.5
$4.2
$77.1
$34.2
$5.8
$15.5
$5.4
$6.2
$7.4
$2.4
$13.0
$1G7
$23.5
$14.4
$16.6
$19.8
$6.4
$34.8
$44.4
$62.6
$27.8
$9.6
$35.3
$3,2
$8.8
$7.0
$7.5
$57.8
$7.0
$120.4
$33.7
$3.0
$69.6
$14.4
$15.5
$78.1
$6.4
$18.7
$3.1
$26.8
$87.8
$7.5
$2.9
$37.5
$27.8
$8.0
$31.0
$2.3
$1,474.0
$10.4
$3.6
$13.2
$1.2
$3.2
$2.6
$2.8
$21.7
$2.6
$45.2
$12.6
$1.1
$26.1
$5.4
$5.6
$29.3
$2.4
$7.0
. $1-2
$10.0
$32.9
$2.8
$11
$14.0
$10.4
$3.0
$11.6
$0.9
$5528
Source: State Health Spending Model based on CBO Health Security Act Premiums
27-Apr-94
Pag* 8 of 8
a 005.
�From: Ed Roth$ohlld To: Ji*on Solomon
04/28/94
18:45
© 2 0 2 298 4054
DM*: 6/6/94 Tim*: 16:12:91
CITIZEN ACTION
P*9* 7 ol 8
©0013
Citizen Action
1120 19th Street, N.W., Suite #630
Washington, D.C. 20036
(202) 775-1580
(202) 296-4054 (FAX)
April 27, 1994
The Honorable George Mitchell
Majority Leader
U.S. Senate
S-221 The Capitol
Washington, D.C. 20510
Dear Majority Leader Mitchell:
Congress is currently debating one of the most important issues facing this nation — the
establishment of a guarantee of affordable, comprehensive health care coverage to every
American. Citizen Action strongly supports that goal but believes it cannot be met by imposing
unaffordable burdens on the backs of middle-income Americans. For that reason, we oppose
proposals that would require individuals and families to pay 50 percent or even 100 percent of
premium costs as some members of Congress have proposed.
Recently, you correctly pointed out that members of Congress must resolve many thorny
issues in this debate, key among them the question of how tofinanceuniversal coverage. For
example, you mentioned that the 80%-20% premium split in the President's bill could be changed
to 50%-5056, meaning that individuals and families across the country would have to pay half
of the cost of coverage. Even if sufficient revenues were provided to fully protect low-income
individuals and families, that change would have significant impacts on the middle-class. To
assist you and other members of Congress in understanding those impacts, we would like to
provide you our state-by-state analysis of proposals to require a 50% family contribution and to
impose an individual mandate.
Under a 50% -50% proposal, the increased annual premium cost (above the requirements
under an 80%-20% split) for a single person would be $630, $1,260 for a couple, $1,229 for a
single parent with children and $1,670 for two-parent families. To give just one example of that
impact on family income, this would require that a two-parent family earning $25,000 pay an
additional 6.7% of income just for premium coverage.
Even more burdensome are individual mandate proposals that, would allow businesses to
avoid any responsibility in paying for health care costs, shifting costs to consumers on an even
more massive scale. Over five years, the cost to individuals would amount to $1.5 trillion.
Under an "individual mandate," where individuals and families pay the entire annual health
insurance premium, the additional annual costs would be $1,680 for a single person, $3,360 for
a couple, $3,276 for a single-payer family, and $4,452 for a two-parent family.
limit
I'll un r*«f:yi*.lr«1
(Afttt
�From: Ed Rothtohiid To: Jaton Solomon
04 ' 2S/ 94
liJ:46
© 2 0 2 296 4054
D««: 6WM Tlmo: 16:13:19
CITIZEN ACTION
9 «l«
Si 007
The attached tables demonstrate the increased costs to individuals and families within every state
from those two proposals. Obviously, the increased cost burden is far too costly to middle class
Amerioms. We recognize that this analysis represents the maximum possible impact, as it
assumes that all businesses shift costs to employees. Decisions by individual businesses to
continue coverage would mitigate the impact. While some businesses might continue to pay
employee health benefits, they would face severe competitive disadvantages that could force them
to reduce coverage. Not only could workers with employer coverage today lose that coverage,
but the high cost of premium coverage would do little make coverage affordable to uninsured
workers and their families.
This andysis may also overestimate the costs involved if there is a decision to retain the 3.9%
of income limit for individual and family premium contributions. This would still represent too
large of a burden for many middle-class families who would pay far less as a percentage of their
income under the 20% premium share in the Clinton proposal. But we are concerned that even
this proitection would be eliminated or substantially reduced because of its significant costs.
We will never achieve universal health care coverage if the burden for such coverage is shifted
from business directly onto individuals. For those reasons, Citizen Action calls on you to
express your support for affordable coverage by rejecting proposals which would require that
individuals and families pay more than 20 percent of premium costs.
As always, Citizen Action is anxious to be helpful to you as the Senate attempts to resolve this
and otluar critical health care issues. Please feelfreeto contact us at any time if we can be of
any assistance or respond to any questions you may have about this study.
Sincerely,
Ira Arlook
Executive Director
Enclosure
�June 2, 1994
MEMORANDUM FOR GENE SPERLING
FROM:
GREGORY E. LAWLER
SUBJECT:
Priorities For Data
\ J&J
Following up on our conversation last night, here is an attempt to prioritize the requests
based on what you've said about how long it takes to get some of the information we've
requested. To have materials available for Congress by the next recess (June 30), we need
to get working on this as soon as possible. There are two categories — information we need
early next week (the stuff that is more readily available) and information we need by midJune. Thanks for your help.
Next week:
Current estimates by Congressional District:
people who have pre-existing conditions
people with lifetime limits on their coverage
EITC beneficiaries/income-tax losers
Family and Medical Leave beneficiaries
Annual data for 1980-present, also by Congressional District
aggregate job growth
real disposable income
Mid-June;
Current estimates by Congressional District:
retraining beneficiaries
school-to-work beneficiaries
college education financing beneficiaries
homes refinanced
Annual data for 1980-present, also by Congressional District
manufacturing job loss
export job growth
unemployment
real wages
data as available on tax burden and income distribution
cc: Harold Ickes
Bob Rubin
�U
expundeij to other ;irt:;is. It now covers
Chicago ;inci
of Muryland: new drives
are under way in New York City and in
Texas. Humber said.
Humber said that the alliance, which
has 30,(1(10-40.000 members in Maryland,
recently generated about 3.000 letters to
that state's Labor and Industry Division,
protestim; a proposal to ban smoking in
enclosed norkplaccs.
In California, the alliance was active
earlier this year in collecting signatures
for an initiative—to be placed on the
election b;illot in November—that would
override about 270 local antisnioking
ordinances, replacing them with a lessstringent state law. (Separately. Philip
Morris has spent more than $50(1.000 to
support the initiative.)
Formei Rep. Guy Vander Jagt. RMieh.. whii is on the alliance's advisory
board, has signed a letter backing the
measure. The group's California chapter
is also trying to put together a coalition of
businesses ;:o support the initiative.
Antisnioking groups have charged that
many of the 607,000 people who signed
the petitions were led to believe that they
were supporting a measure to protect
nonsmokeis and youths. State officials
are investigating and have said that if they
find evidence of fraud the measure could
be removed from the ballot.
Meanwhile, the alliance is trying to line
up corporations to help finance its activities nationally. Althaus. the chairman,
said there are about 20 corporate sponsors, but he declined to name them.
The alliance has also recruited some
big names for its 27-member advisory
board, including Republican National
Committee co-chairwoman Jeanie Austin
and Peter G. Kelly, a prominent Democrat who's with the Alexandria (Va.)based lobbying firm of Black. Manafort.
Stone & Kelly Public Affairs Co.
Tobacco industry sources say that they
expect the alliance to bombard Ways and
Means Committee members with letters
and telephoiiE calls as the panel deliberates on a proposed 75 cents-a-pack increase in cigarette taxes. Humber declined to eemment on that subject,
although he scoffed at the suggestion that
the alliance's Chicago chapter was started
to target Rostenkowski.
Humber said that the proposed excise
tax "would be an onerous burden." But.
he said, "all issues involving discrimination against smokers are on the table.'' •
P
D
A
T
E
FROM THE K STREET CORRIDOR
T
he Health Insurance Association of America has struck a deal to put its
"Harry and Louise" advertisements into temporary retirement, but other
groups are filling the void. The Health Care Leadership Council, a group of
major pharmaceutical, insurance and hospital companies, began airing radio ads
at the end of April in nine states, aimed at persuading members of key congressional committees to oppose insurance price controls and health care spending
limits that President Clinton has proposed. "When it comes to how much [each
state] can spend on health care, do you trust the government in Washington and
only the government in Washington to make that decision?" the ad asks, before
providing a toll-free number that will patch callers through to their local Member of Congress. The council has budgeted $225,000 for the ads.
The American Medical Association, meanwhile, expects to spend about
$250,000 for a print advertising campaign aimed at opinion leaders in Washington and other metropolitan areas. The ads. headlined ''What You Don't Know
Can Hurt You, ' promote legislation devised by the AMA to make health maintenance organizations and other health plans disclose more about their coverage
and hiring practices. Sen. Paul Wellstone, D-Minn., a Labor and Human
Resources Committee member, has promised to offer various features of the bill
as amendments to other health reform legislation.
—Julie Kosterlitz
7
T
rade groups that oppose an employer mandate that would require employers
to help pay for their workers' health care coverage are being offered a chance
to demonstrate their grass-roots muscle.
Reps. J. Dennis Hasten, R-Ill., and W.J. (BUly) Tauzin, D-La.. have sponsored
a resolution that would allow Members to vote to strike employer mandate provisions from any health care reform bill that reaches the House floor. The two
lawmakers have enlisted the National Federation of Independent Business Inc.,
the National Restaurant Association and the National Association of WholesaleDistributors, all of which adamantly oppose a mandate, to gin up their members
to lobby for their proposal and help recruit co-sponsors.
"Anything we do, we need to have grass-roots support for," Hasten said. "This
is a very good test to see if it's there and to see how they would react." He said
that he hopes to get a vote on the resolution in June. If it wins big, he said, that
will be a signal to any committees still marking up reform legislation that they
shouldn't include a mandate.
—James A. Bames
S
tateside Associates Inc., an Arlington (Va.) public affairs firm that has prospered by guiding its Fortune 500 clients through the maze of state laws and
regulations, is gambling that activist local governments will soon be giving corporate executives major headaches. Earlier this month. Stateside announced that it
had purchased Local Government Services, a small company based in Sacramento, Calif., that keeps tabs on governmental actions in all of California's 1,500
cities and counties.
''Local governments are becoming increasingly more active in public policy
matters," said Constance Campanella, Stateside's president. The 25-person firm
already advises Mobil Corp. on local governmental actions in California, Florida
and New York.
But giving advice to its clients on state issues remains Stateside's forte. The
1.200-member National Association of Mutual Insurance Companies, an Indianapolis-based group of property and casualty insurers, recently hired the firm
to advise it on insurance matters, including workers' compensation, in all 50
states.
—W. John Moore
NATIONAL JOURNAL 5/2ti/y4 1245
�^ 1 .
u
expanded to oilier areas. It now covers
Chicago and all of Maryland; new drives
arc under way in New York City and in
Texas, I lumber said.
Humoer said that the alliance, which
has 3(U;00-41 ),0()0 members in Maryland,
recently generated about 3.000 letters to
that stale's Labor and Industry Division,
protesting a proposal to ban smoking in
enclosed workplaces.
In California, the alliance was active
earlier this year in collecting signatures
for an initiative—to be placed on the
election ballot in November—that would
override about 270 local antisnioking
ordinances, replacing them with a lessstringen; state law. (Separately. Philip
Morris has spent more than $500,000 to
support the initiative.)
Former Rep. Guy Vander Jagt. RMich.. who is on the alliance's advisory
board. h:is signed a letter backing the
measure. The group's California chapter
is also trying to put together a coalition of
businesses to support the initiative.
AiitisniLiking groups have charged that
many of the 607.0(10 people who signed
the petitions were led to believe that they
were supporting a measure to protect
nonsmokers and youths. State officials
are investigating and have said that if they
find evidence of fraud the measure could
be removed from the ballot.
Meanwhile, the alliance is trying to line
up corporations to help finance its activities nationally. Althaus. the chairman,
said there are about 20 corporate sponsors, but In; declined to name them.
The alliance has also recruited some
big names for its 27-member advisory
board, including Republican National
Committee co-chairwoman Jeanie Austin
and Peter G. Kelly, a prominent Democrat who's with the Alexandria (Va.)based lobbying firm of Black, Manafort.
Stone & Kdly Public Affairs Co.
Tobacco industry sources say that they
expect the alliance to bombard Ways and
Means Committee members with letters
and telephone calls as the panel deliberates on a proposed 75 cents-a-pack increase in cigarette taxes. Humber declined to comment on that subject,
although he scoffed at the suggestion that
the alliance's Chicago chapter was started
to target Rostenkowski.
Humber said that the proposed excise
tax "would be an onerous burden." But.
he said, "all issues involving discrimination aeainst smokers are on the table." •
FROM THE K STREET CORRIDOR
T
he Health Insurance Association of America has struck a deal to put its
"Harry and Louise" advertisements into temporary retirement, but other
groups are filling the void. The Health Care Leadership Council, a group of
major pharmaceutical, insurance and hospital companies, began airing radio ads
at the end of April in nine states, aimed at persuading members of key congressional committees to oppose insurance price controls and health care spending
limits that President Clinton has proposed. "When it comes to how much [each
state] can spend on health care, do you trust the government in Washington and
only the government in Washington to make that decision?" the ad asks, before
providing a toll-free number that will patch callers through to their local Member of Congress. The council has budgeted $225,000 for the ads.
The American Medical Association, meanwhile, expects to spend about
$250,000 for a print advertising campaign aimed at opinion leaders in Washington and other metropolitan areas. The ads, headlined 'What You Don't Know
Can Hurt You," promote legislation devised by the AMA to make health maintenance organizations and other health plans disclose more about their coverage
and hiring practices. Sen. Paul Wellstone, D-Minn., a Labor and Human
Resources Committee member, has promised to offer various features of the bill
as amendments to other health reform legislation.
—Julie Kosterlitz
T
rade groups that oppose an employer mandate that would require employers
to help pay for their workers' health care coverage are being offered a chance
to demonstrate their grass-roots muscle.
Reps. J. Dennis Hasten, R-III., and W.J. (Billy) Tauzin, D-La., have sponsored
a resolution that would allow Members to vote to strike employer mandate provisions from any health care refonn bill that reaches the House floor. The two
lawmakers have enlisted the National Federation of Independent Business Inc.,
the National Restaurant Association and the National Association of WholesaleDistributors, all of which adamantly oppose a mandate, to gin up their members
to lobby for their proposal and help recruit co-sponsors.
"Anything we do, we need to have grass-roots support for," Hastert said: "This
is a very good test to see if it's there and to see how they would react." He said
that he hopes to get a vote on the resolution in June. If it wins big, he said, that
will be a signal to any committees still marking up reform legislation that they'
shouldn't include a mandate.
—James A. Barnes
S
tateside Associates Inc., an Arlington (Va.) public affairs firm that has prospered by guiding its Fortune 500 clients through the maze of state laws and
regulations, is gambling that activist local governments will soon be giving corporate executives major headaches. Earlier this month. Stateside announced that it
had purchased Local Government Services, a small company based in Sacramento. Calif., that keeps tabs on governmental actions in all of California's 1,500
cities and counties.
"Local governments are becoming increasingly more active in public policy
matters," said Constance Campanella, Stateside's president. The 25-person firm
already advises Mobil Corp. on local governmental actions in California. Florida
and New York.
But giving advice to its clients on state issues remains Stateside's forte. The
1.200-member National Association of Mutual Insurance Companies, an Indianapolis-based group of property and casualty insurers, recently hired the firm
to advise it on insurance matters, including workers' compensation, in all 50
states.
—W. John Moore
NATIONAL JOURNAL 5/28/94 1245
�u
expanded to other areas. It now covers
Chicago and all of Maryland: new drives
are under way in New York City and in
Texas. Humber said.
Humber said that the alliance, which
has 30.01)0-40,1)()() members in Mar.-land,
recently generated about 3.000 letters to
that state's Labor and Industry Division,
protesting a proposal to ban smoking in
enclosed workplaces.
In California, the alliance was active
earlier this year in collecting signatures
for an initiative—to be placed on the
election ballot in November—that would
override about 270 local antisnioking
ordinances, replacing them with a lessstringent state law. (Separately. Philip
Morris has spent more than $500,000 to
support the initiative.)
Former Rep. Guy Vander Jagt. RMich.. who is on the alliance's advisoryboard, has signed a letter backing (he
measure. The group's California chapter
is also trying to put together a coalition of
businesses to support the initiative.
Antisnioking groups have charged that
many of the 607.000 people who signed
the petitions were led to believe that they
were supporting a measure to protect
nonsmokers and youths. State officials
are investigating and have said that if they
find evidence of fraud the measure could
be removed from the ballot.
Meanwhile, the alliance is trying to line
up corporations to help finance its activities nationally. Althaus. the chairman,
said there are about 20 corporate sponsors, but he declined to name them.
The alliance has also recruited some
big names for its 27-member advisory
board, including Republican National
Committee co-chairwoman Jeanie Austin
and Peter G. Kelly, a prominent Democrat who's with the Alexandria (Va.)bascd lobbying firm of Black. Manafort.
Stone & Kelly Public Affairs Co.
Tobacco industry sources say that they
expect the alliance to bombard Ways and
Means Committee members with letters
and telephone calls as the panel deliberates on a proposed 75 cents-a-pack increase in cigarette taxes. Humber declined to comment on that subject,
although he scoffed at the suggestion that
the alliance's Chicago chapter was started
to target Rostenkowski.
Humber said that the proposed excise
lax "would be an onerous burden." But.
he said, "all issties involving discrimination against smokers are on the table." •
FROM THE K STREET CORRIDOR
T
he Health Insurance Association of America has struck a deal to put its
"Harry and Louise" advertisements into temporary retirement, but other
groups are filling the void. The Health Care Leadership Council, a group of
major pharmaceutical, insurance and hospital companies, began airing radio ads
at the end of April in nine states, aimed at persuading members of key congressional committees to oppose insurance price controls and health care spending
limits that President Clinton has proposed. "When it comes to how much [each
state] can spend on health care, do you trust the government in Washington and
only the government in Washington to make that decision?" the ad asks, before
providing a toll-free number that will patch callers through to their local Member of Congress. The council has budgeted $225,000 for the ads.
The American Medical Association, meanwhile, expects to spend about
$250,000 for a print advertising campaign aimed at opinion leaders in Washington and other metropolitan areas. The ads, headlined "What You Don't Know
Can Hurt You," promote legislation devised by the AMA to make health maintenance organizations and other health plans disclose more about their coverage
and hiring practices. Sen. Paul Wellstone, D-Minn., a Labor and Human
Resources Committee member, has promised to offer various features of the bill
as amendments to other health reform legislation.
—Julie Kosterlitz
T
rade groups that oppose an employer mandate that would require employers
to help pay for their workers' health care coverage are being offered a chance
to demonstrate their grass-roots muscle.
Reps. J. Dennis Hastert, R-lll., and W.J. (Billy) Tauzin, D-La., have sponsored
a resolution that would allow Members to vote to strike employer mandate provisions from any health care refonn bill that reaches the House floor. The two
lawmakers have enlisted the National Federation of Independent Business Inc.,
the National Restaurant Association and the National Association of WholesaleDistributors, all of which adamantly oppose a mandate, to gin up their members
to lobby for their proposal and help recruit co-sponsors.
"Anything we do, we need to have grass-roots support for," Hastert said. "This
is a very good test to see if it's there and to see how they would react:" He said
that he hopes to get a vote on the resolution in June. If it wins big, he said, that
will be a signal to any committees still marking up reform legislation that they
shouldn't include a mandate.
—James A. Barnes
S
tateside Associates Inc., an Arlington (Va.) public affairs firm that has prospered by guiding its Fortune 500 clients through the maze of state laws and
regulations, is gambling that activist local governments will soon be giving corporate executives major headaches. Earlier this month. Stateside announced that it
had purchased Local Government Services, a small company based in Sacramento, Calif., that keeps tabs on governmental actions in all of California's 1,500
cities and counties.
"Local governments are becoming increasingly more active in public policy
matters," said Constance Campanella, Stateside's president. The 25-person firm
already advises Mobil Corp. on local governmental actions in California, Florida
and New York.
But giving advice to its clients on state issues remains Stateside's forte. The
1.200-member National Association of Mutual Insurance Companies, an Indianapolis-based group of property and casualty insurers, recently hired the firm
to advise it on insurance matters, including workers' compensation, in all 50
states.
—W. John Moore
NATIONAL JOURNAL 5/28/94 1245
�THE EROSION OF EMPLOYER-PROVIDED BENEFITS
If coverage under employer-provided health plans had remained at its 1979 level, an
additional 5.4 million workers (plus their families in many cases) would be covered
by their employer. (Dept. of Labor, May 1994)
�ELECTION '94:
DEBATING THE IMPACT OF HEALTH REFORM
P o l i t i c a l a n a l y s t C h a r l i e Cook on t h e impact of h e a l t h
r e f o r m on '94 Dem campaigns: "People want h e a l t h care r e f o r m ,
but t h e y ' r e not sure what t h e y want, so t h e r e ' s not a r e a l h i g h
e x p e c t a t i o n -- c e r t a i n l y not a demand -- f o r any s p e c i f i c t h i n g .
But f o r Democrats, t h e y need t o show t h a t Congress can work, t h a t
Congress i s not d y s f u n c t i o n a l . And I t h i n k Democrats i n Congress
r e a l l y f e e l t h e i m p e r a t i v e t o pass something t o prove t h a t
t h e y ' r e a b l e t o do something, t h a t t h e y have some v a l u e . And I
t h i n k t h a t ' s t h e pressure t o do something r i g h t now."
Political
a n a l y s t S t u a r t Rothenberg: " I t h i n k a l l incumbents want t o a c t
on h e a l t h c a r e . There seems t o be d i f f e r e n c e s i n o p i n i o n as t o
what a c t i n g means. I t h i n k p r o b a b l y the White House w i l l
u l t i m a t e l y c l a i m v i c t o r y no m a t t e r what. But I don't t h i n k
h e a l t h care i s l i k e l y t o be a b i g boon f o r the Democrats come
November" ( " I n s i d e P o l i t i c s , " CNN, 5/30). NBC's "Today" hosted
Dem c o n s u l t a n t Bob Squier and GOP c o n s u l t a n t Mary M a t a l i n .
Squier on t h e "rush" t o pass h e a l t h care t h i s year:
"The r u s h i s
v e r y s i m p l e , i f we don't get t h i s b i l l t h i s year, we may not get
t h i s b i l l . ... The f a c t i s t h a t we i n the Democratic p a r t y are
g o i n g t o have a hard time c a r r y i n g the U n i t e d S t a t e s Senate next
t i m e . ... [ C l i n t o n ] has got t o get a b i l l t h i s year because t h e
people t h a t are s a y i n g , 'Let's w a i t t i l l next year' are t h e
people t h a t are r e a l l y s a y i n g , 'Let's w a i t t i l l next year and
t h e n we're g o i n g t o k i l l t h i s t h i n g . ' " M a t a l i n p r e d i c t e d :
"We're g o i n g t o get a p l a n . I t ' s g o i n g t o be the Bush-Bentsen
p l a n . I t ' s g o i n g t o be t h e exact p l a n t h a t t h e Democrats
r e j e c t e d i n 1991 so Bush would not get c r e d i t f o r i t -- mark my
words" ( 5 / 3 1 ) .
=====
(c)
STATELINES
=====
The American P o l i t i c a l Network, I n c .
�TABLE (MATRIX) OUTLINES
Table
(matrix)
PI.
92.
P3.
P3A.
P4.
P5.
•?6.
?7.
:?8.
:?9.
Title
-- STF 3D
T o t a l number
o f data c e l l s
PERSONS(1)
Universe:
Persons
Total
UNWEIGHTED SAMPLE COUNT OF PERSONS(1)
Universe:
Persons
Total
10 0-PERCENT COUNT OF PERSONS(1)
Universe:
Persons
Total
PERCENT OF PERSONS I N SAMPLE(1)
Universe:
Persons
Total
FAMILIES(1)
Universe:
Families
Total
HOUSEHOLDS(1)
Universe:
Households
Total
URBAN AND RURAL (4)
Universe:
Persons
Urban:
I n s i d e u r b a n i z e d area
O u t s i d e u r b a n i z e d area
Rural:
Farm
Nonfarm
SEX(2)
Universe:
Persons
Male
Female
RACE (5)
Universe:
Persons
White
Black
American I n d i a n , Eskimo, o r A l e u t Asian o r P a c i f i c I s l a n d e r
Other race
RACE (25)
Universe:
Persons
White (800-869, 971)
Black (870-934, 972)
American I n d i a n , Eskimo, o r A l e u t (000-599, 935-970, 973-975):
American I n d i a n (000-599, 973)
Eskimo (935-940, 974)
A l e u t (941-970, 975)
A s i a n o r P a c i f i c I s l a n d e r (600-699, 976-985):
A s i a n (600-652, 976, 977, 979-982, 9 8 5 ) :
Chinese (605-607, 976)
F i l i p i n o (608, 977)
Japanese (611, 981)
A s i a n I n d i a n (600, 982)
Korean (612, 979)
Vietnamese (619, 980)
Cambodian (604)
Hmong (609)
L a o t i a n (613)
T h a i (618)
Other A s i a n (601-603, 610, 614-617, 620-652, 985)
P a c i f i c I s l a n d e r (653-699, 978, 983, 9 8 4 ) :
P o l y n e s i a n (653-659, 978, 9 8 3 ) :
Hawaiian (653, 654, 978)
Samoan (655, 983)
Tongan (657)
Other P o l y n e s i a n (656, 658, 659)
M i c r o n e s i a n (660-675, 9 8 4 ) :
Guamanian (660, 984)
Other M i c r o n e s i a n (661-675)
Melanesian (676-680)
P a c i f i c I s l a n d e r , n o t s p e c i f i e d (681-699)
Other race (700-799, 986-999)
1
1
1
1
1
1
4
2
5
25
�. P10.
PERSONS OF HISPANIC ORIGIN(1)
U n i v e r s e : Persons o f H i s p a n i c o r i g i n
Total
Pll.
HISPANIC ORIGIN(16)
Universe:
Persons
Not o f H i s p a n i c o r i g i n (000-001, 006-199)
H i s p a n i c o r i g i n (002-005, 200-999):
Mexican (002, 210-220)
Puerto Rican (003, 261-270)
Cuban (004, 271-274)
Other H i s p a n i c (005, 200-209, 221-260, 275-999):
Dominican (Dominican R e p u b l i c ) (275-289)
C e n t r a l American (221-230):
Guatemalan (222)
Honduran (223)
Nicaraguan (224)
Panamanian (225)
Salvadoran (226)
Other C e n t r a l American (221, 227-230)
South American (231-249):
Colombian (234)
Ecuadorian (235)
P e r u v i a n (237)
Other South American (231-233, 236, 238-249)
Other H i s p a n i c (005, 200-209, 250-260, 290-999)
P12.
HISPANIC ORIGIN(2) BY RACE(5)
Universe:
Persons
Not o f H i s p a n i c o r i g i n :
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
Hispanic o r i g i n :
(Repeat FACE)
P13.
AGE(31)
Universe:
Persons
Under 1 yesir
1 and 2 yesirs
3 and 4 yecirs
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 y e a r s
16 y e a r s
17 y e a r s
18 y e a r s
19 y e a r s
2 0 years
21 y e a r s
22 t o 24 y e a r s
25 t o 29 y e a r s
30 t o 34 y e a r s
35 t o 3 9 y e a r s
4 0 t o 44 y e a r s
45 t o 49 y e a r s
50 t o 54 y e a r s
55 t o 59 y e a r s
6 0 and 61 y e a r s
62 t o 64 y';ars
65 t o 69 y e a r s
70 t o 74 y e a r s
75 t o 79 y e a r s
80 t o 84 y e a r s
85 y e a r s and over
P14A. RACE(l) BY SEX(l) BY AGE(31)
U n i v e r s e : White males
White:
Male:
Under 1 y e a r
1 and 2 y e a r s
3 and 4 y e a r s
1
16
10
31
31
�5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 y e a r s
16 y e a r s
17 y e a r s
18 y e a r s
19 y e a r s
20 years
21 years
22 t o 24 y e a r s
25 t o 29 y e a r s
30 t o 34 years
35 t o 3 9 years
40 t o 44 years
45 t o 49 y e a r s
50 t o 54 y e a r s
55 t o 59 y e a r s
60 and 61 y e a r s
62 t o 64 y e a r s
65 t o 6 9 y e a r s
70 t o 74 y e a r s
75 t o 7 9 y e a r s
80 t o 84 y e a r s
85 y e a r s and over
P14B. RACE(l) BY SEX(l) BY AGE(31)
U n i v e r s e : White females
White:
Female:
Under 1 y e a r
1 and 2 y e a r s
3 and 4 years
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 y e a r s
16 y e a r s
17 years
18 y e a r s
19 y e a r s
2 0 years
21 y e a r s
22 t o ;.4 y e a r s
25 t o ;:9 y e a r s
3 0 t o 3 4 years
3 5 t o 2:9 years
40 t o '.-A years
45 t o <;9 y e a r s
50 t o 54 y e a r s
55 t o 59 years
6 0 and 61 years
62 t o 64 years
65 t o 69 years
70 t o 74 y e a r s
75 t o 79 y e a r s
80 t o 1)4 y e a r s
85 y e a r s and over
P14C. RACE(l) BY SEX(l) BY AGE(31)
U n i v e r s e : Black males
Black:
Male:
Under 1 y e a r
1 and 2 years
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
31
31
�14 y e a r s
15 y e a r s
16 yearsi
17 years:
18 years;
19 years:
20 years;
21 years:
22 t o 24. y e a r s
25 t o 25' y e a r s
30 t o 34 y e a r s
35 t o 3S' y e a r s
40 t o 44 y e a r s
45 t o 4<> y e a r s
50 t o 54: y e a r s
55 t o 5 Si y e a r s
60 and 61 y e a r s
62 t o 64: y e a r s
65 t o 6!i y e a r s
70 t o 74': y e a r s
75 t o 79 y e a r s
80 t o 84; y e a r s
85 years! and over
P14D. RACE(l) BY !;EX(1) BY AGE (31)
U n i v e r s e : Black females
Black:
Female:
Under 1 year
1 and 2 y e a r s
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 yeans
15 y e a r s
16 y e a r s
17 year.'S
18 year:;
19 y e a r s
20 years
21 y e a r s
22 t o 24 years
25 t o 29 y e a r s
30 t o 34 y e a r s
3 5 t o 39 y e a r s
4 0 t o 4 1 years
4 5 t o 4 9 years
50 t o 54 y e a r s
55 t o 59 y e a r s
60 and ; i years
62 t o 64 y e a r s
65 t o 6 9 y e a r s
70 t o 74 years
75 t o 7 9 years
80 t o 8 4 y e a r s
85 y e a r s and over
P14E. RACE(l) BY SEX(l) BY AGE(31)
U n i v e r s e : American I n d i a n , Eskimo, o r A l e u t males
American I n d i a n , Eskimo, o r A l e u t :
Male:
Under 1 y e a r
1 and 2 y e a r s
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 years
14 y e a r s
15 years
16 y e a r s
17 y e a r s
18 y e a r s
31
31
�19 y e a r s
20 y e a r s
21 y e a r s
22 t o 24 y e a r s
25 t o 29 years
30 t o 34 years
3 5 t o 3 9 years
40 t o 44 y e a r s
4 5 t o 4 9 years
50 t o 54 years
55 t o 59 years
60 and 61 y e a r s
62 t o 64 years
65 t o 69 years
70 t o 74 years
75 t o 79 years
80 t o 84 y e a r s
85 y e a r s and over
P14F. RACE(l) BY SEX(l) BY AGE(31)
U n i v e r s e : American I n d i a n , Eskimo, o r A l e u t
American I n d i a n , Eskimo, o r A l e u t :
Female:
Under 1 y e a r
1 and 2 y e a r s
3 and 4 years
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 years
15 y e a r s
16 y e a r s
17 y e a r s
18 y e a r s
19 years
20 years
21 years
22 t o 2 4years
25 t o 2 9 years
30 t o 34 years
35 t o 3 9 years
40 t o 44 years
45 t o 4 3 years
50 t o 51 years
55 t o 5:3 years
60 and o l y e a r s
62 t o 61 y e a r s
65 t o 6:3 y e a r s
70 t o 71 years
75 t o 7:9 years
80 t o 84 y e a r s
85 y e a r s and over
P14G. RACE(l) BY :3EX(1) BY AGE(31)
U n i v e r s e : A s i a n and P a c i f i c I s l a n d e r males
A s i a n and P a c i f i c I s l a n d e r :
Male:
Under 1 year
1 and 2 y e a r s
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 years
15 years
16 y e a r s
17 y e a r s
18 y e a r s
19 years
20 y e a r s
21 y e a r s
22 t o 24 y e a r s
25 t o 29 y e a r s
31
females
31
�3 0 t o 3 4 years
3 5 t o 3 9 years
4 0 t o 4 4 years
45 t o 4 9 y e a r s
50 t o 54 y e a r s
55 t o 59 y e a r s
60 and 51 years
62 t o 61 y e a r s
65 t o 69 years
70 t o 74 y e a r s
75 t o 79 y e a r s
80 t o 84 years
85 y e a r s and over
P14H. RACE(l) BY ;3EX(1) BY AGE (31)
U n i v e r s e : A s i a n and P a c i f i c I s l a n d e r
A s i a n and P a c i f i c I s l a n d e r :
Female:
Under 1 y e a r
1 and 2 y e a r s
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 year;;
16 y e a r s
17 year;;
18 years
19 yearii
31
females
20 year;!
21 year:!
22 t o 2<- years
25 t o 29 years
30 t o 34 y e a r s
3 5 t o 3 9 years
40 t o 4< y e a r s
45 t o 49 y e a r s
50 t o 54 y e a r s
5 5 t o 59 y e a r s
60 and 61 years
62 t o 64 years
65 t o 69 y e a r s
70 t o 74: y e a r s
75 t o 7S' y e a r s
80 t o 84: y e a r s
85 yearsi and over
P14I. RACE(l) BY £:EX(1) BY AGE(31)
U n i v e r s e : Cither race males
Other r a c e :
Male:
Under 1 year
1 and 2 y e a r s
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 years
14 years:
15 years;
16 years;
17 years:
18 years:
19 years
20 years:
21 years
22 t o 24 y e a r s
2 5 t o 2S years
30 t o 34 y e a r s
3 5 t o 3£ y e a r s
4 0 t o 4 4 years
45 t o 4S years
50 t o 54 y e a r s
;
:
31
�55 t o 5 5' y e a r s
60 and 61 y e a r s
62 t o 6<: y e a r s
65 t o 65' y e a r s
70 t o 7<: y e a r s
75 t o 7S' y e a r s
80 t o 84 y e a r s
8 5 years and over
P14J. RACE(l) BY £:EX(1) BY AGE (31)
U n i v e r s e : Other race females
Other r a c e :
Female:
Under 1 y e a r
1 and 2 y e a r s
3 and 4 years
5 years
6 years
7 t o 9 years
10 and I'.l y e a r s
12 and 13 y e a r s
14 year;;
15 y e a r s
16 y e a r u
17 years
18 y e a r s
19 y e a r s
20 y e a r s
21 y e a r s
22 t o 24 y e a r s
2 5 t o 2:5 y e a r s
30 t o 34 y e a r s
35 t o 3:3 y e a r s
40 t o 44 y e a r s
45 t o 4 9 y e a r s
50 t o 5 i y e a r s
55 t o 59 y e a r s
60 and SI y e a r s
62 t o 64 y e a r s
65 t o 6 9 y e a r s
70 t o 74 y e a r s
75 t o 79 y e a r s
80 t o 84 y e a r s
8 5 years and over
P15A. SEX(l) BY AGE(31)
U n i v e r s e : Males o f H i s p a n i c o r i g i n
Male:
Under 1 y e a r
1 and 2 years
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 years
15 y e a r s
16 y e a r s
17 years
18 y e a r s
19 years
20 y e a r s
21 years
22 t o 24 y e a r s
25 t o 2 9 y e a r s
30 t o 34 y e a r s
35 t o 3 9 y e a r s
40 t o 44 y e a r s
45 t o 49 y e a r s
50 t o 54 y e a r s
55 t o 59 y e a r s
60 and 6 L y e a r s
62 t o 64 y e a r s
65 t o 69 y e a r s
70 t o 74 y e a r s
75 t o 79 y e a r s
31
31
�P15B.
PI6 .
P17.
P18.
80 t o 84 y e a r s
85 y e a r s end over
SEX(l) BY AGE (31)
U n i v e r s e : females o f H i s p a n i c o r i g i n
Female:
Under 1 ye:ar
1 and 2 y e a r s
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 years
12 and 13 y e a r s
14 y e a r s
15 y e a r s
16 years
17 y e a r s
18 y e a r s
19 y e a r s
20 y e a r s
21 years
22 t o 24 y e a r s
25 t o 29 y e a r s
30 t o 34 y e a r s
35 t o 3 9 y e a r s
40 t o 44 y e a r s
45 t o 4 9 y e a r s
50 t o 54 y e a r s
55 t o 59 y e a r s
60 and 61 y e a r s
62 t o 64 y e a r s
65 t o 69 y e a r s
70 t o 74 y e a r s
75 t o 79 y e a r s
80 t o 84 years
85 y e a r s ;and over
PERSONS I N HOUSEHOLD(7)
U n i v e r s e : Households
1 person
2 persons
3 persons
4 persons
5 persons
6 persons
7 o r more persons
HOUSEHOLD TiTPE AND RELATIONSHIP (15)
Universe:
Persons
I n f a m i l y households:
Householder
Spouse
Child:
N a t u r a l - b o r n o r adopted
Step
Grandchild
Other r e l a t i v e s
Nonrelatives
I n n o n f a m i l y households:
Male householder:
L i v i n g alone
Not l i v i n g alone
Female householder:
L i v i n g alone
Not l i v i n g alone
Nonrelati.ves
I n group q u a r t e r s :
I n s t i t u t i o n a l i z e d persons
Other persons i n group q u a r t e r s
Filler
HOUSEHOLD TYPE AND RELATIONSHIP(12)
U n i v e r s e : Persons 65 years and over
I n f a m i l y households:
Householder
Spouse
Other r e l a t i v e s
Nonrelatives
31
15
12
�P19.
P20.
P21.
P22.
I n n o n f a m i l y households:
Male householder:
L i v i n g alone
Not l i v i n g alone
Female householder:
L i v i n g alone
Not l i v i n g alone
Nonrelatives
I n group q u a r t e r s :
I n s t i t u t i o n a l i z e d persons
Other persons i n group q u a r t e r s
Filler
HOUSEHOLD TYPE AND PRESENCE AND AGE OF CHILDREN(7)
U n i v e r s e : Households
Family households:
Married-couple family:
W i t h own c h i l d r e n under 18'years
No own c h i l d r e n under 18 years
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
W i t h own c h i l d r e n under 18 years
No own c h i l d r e n under 18 years
Female householder, no husband p r e s e n t :
W i t h own c h i l d r e n under 18 years
No own c h i l d r e n under 18 y e a r s
N o n f a m i l y households
RACE OF HOUSEHOLDER(5) BY HOUSEHOLD TYPE AND PRESENCE AND
AGE OF CHILDREN(7)
Universe:
households
White:
F a m i l y households:
Married-couple family:
W i t h own c h i l d r e n under 18 y e a r s
No owr.'. c h i l d r e n under 18 years
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
W i t h own c h i l d r e n under 18 years
No own c h i l d r e n under 18 y e a r s
Female householder, no husband p r e s e n t :
W i t h own c h i l d r e n under 18 y e a r s
No own c h i l d r e n under 18 years
N o n f a m i l y households
Black:
(Repeat HOUSEHOLD TYPE AND PRESENCE AND AGE OF CHILDREN)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat HOUSEHOLD TYPE AND PRESENCE AND AGE OF CHILDREN)
Asian o r P a c i f i c Islander:
(Repeat HOUSEHOLD TYPE AND PRESENCE AND AGE OF CHILDREN)
Other r a c e :
(Repeat HOUSEHOLD TYPE AND PRESENCE AND AGE OF CHILDREN)
HOUSEHOLD TYPE AND PRESENCE AND AGE OF CHILDREN(7)
U n i v e r s e : Households w i t h householder o f H i s p a n i c o r i g i n
F a m i l y households:
Married-couple f a m i l y :
W i t h own c h i l d r e n under 18 years
No own c h i l d r e n under 18 y e a r s
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
W i t h own c h i l d r e n under 18 years
No own c h i l d r e n under 18 y e a r s
Female householder, no husband p r e s e n t :
W i t h own c h i l d r e n under 18 years
No own c h i l d r e n under 18 years
N o n f a m i l y households
FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN(6)
Universe:
Families
Married-couple family:
W i t h c h i l d r e n 18 y e a r s and over
No c h i l d r e n 18 y e a r s and over
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
W i t h c h i l d r e n 18 y e a r s and over
No c h i l d r e n 18 y e a r s and over
Female householder, no husband p r e s e n t :
W i t h c h i l d r e n 18 y e a r s and over
7
35
7
6
�P23.
P24.
P2 5.
P26.
P2 7.
P28.
No c h i l d r e n 18 y e a r s and over
FAMILY TYPE AND AGE OF CHILDREN(21)
U n i v e r s e : Ov/n c h i l d r e n under 18 years
I n married-couple family:
Under 3 y e a r s
3 and 4 y e a r s
5 years
6 t o 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 t o 17 y e a r s
I n o t h e r fam:.ly:
Male householder, no w i f e p r e s e n t :
Under 3 y e a r s
3 and 4 y e a r s
5 years
6 t o 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 t o 17 y e a r s
Female householder, no husband p r e s e n t :
Under 3 y e a r s
3 and 4 y e a r s
5 years
S t o 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 t o 17 y e a r s
HOUSEHOLD TYPE(2) BY AGE OF HOUSEHOLDER(7)
U n i v e r s e : Households
Family households:
15 t o 24 y e a r s
25 t o 34 y e a r s
35 t o 44 y e a r s
45 t o 54 y e a r s
55 t o 64 y e a r s
65 t o 74 y e a r s
75 y e a r s and over
N o n f a m i l y households:
(Repeat AGE OF HOUSEHOLDER)
SUBFAMILY TYPE AND PRESENCE AND AGE OF CHILDREN(4)
Universe:
Subfamilies
Married-couple subfamily:
W i t h own c h i l d r e n under 18 years
No own c h i l d r e n under 18 years
Mother-child subfamily
Father-child subfamily
SUBFAMILY TYPE AND RELATIONSHIP(7)
U n i v e r s e : Persons i n s u b f a m i l i e s
Persons i n i r a r r i e d - c o u p l e s u b f a m i l y :
Reference person
Spouse
Child
Persons i n m o t h e r - c h i l d s u b f a m i l y :
Parent
Child
Persons i n f a t h e r - c h i l d s u b f a m i l y :
Parent
Child
SEX(2) BY MARITAL STATUS(6)
U n i v e r s e : Persons 15 y e a r s and over
Male:
Never m a r r i e d
Now m a r r i e d :
M a r r i e d , spouse p r e s e n t
M a r r i e d , spouse absent:
Separated
Other
Widowed
Divorced
Female:
(Repeat Mj\RITAL STATUS)
AGE (3) BY Li\NGUAGE SPOKEN AT HOME AND ABILITY TO SPEAK ENGLISH(IO)
U n i v e r s e : Persons 5 y e a r s and over
5 t o 17 y e a r s :
21
14
4
7
12
30
�Speak o n l y E n g l i s h
Speak Spanish:
Speak E n g l i s h " v e r y w e l l ' '
Speak E n g l i s h ~ " w e l l
Speak E n g l i s h ""not w e l l
o r ""not a t a l l
Speak Asian o r P a c i f i c I s l a n d language:
Speak E n g l i s h " " v e r y w e l l '
Speak E n g l i s h " " w e l l '
Speak E n g l i s h ""not w e l l ' ' o r ""not a t a l l ' '
Speak o t h e r language:
Speak E n g l i s h " " v e r y w e l l
Speak E n g l i s h " " w e l l
Speak E n g l i s h ""not w e l l
o r ""not a t a l l '
18 t o 64 y e a r s :
(Repeat LANGUAGE SPOKEN AT HOME AND ABILITY TO SPEAK ENGLISH)
65 y e a r s and o v e r :
(Repeat LANGUAGE SPOKEN AT HOME AND ABILITY TO SPEAK ENGLISH)
HOUSEHOLD LANGUAGE AND LINGUISTIC ISOLATION(7)
U n i v e r s e : Households
English
Spanish:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
A s i a n o r P a c i f i c I s l a n d language:
Linguisticcilly isolated
Not l i n g u i s i t i c a l l y i s o l a t e d
Other language:
Linguisticcilly isolated
Not l i n g u i E i t i c a l l y i s o l a t e d
AGE, LANGUAGE SPOKEN AT HOME, AND LINGUISTIC ISOLATION(33)
U n i v e r s e : Persons 5 y e a r s and over
Persons i n households:
5 t o 13 yecirs:
Speak o n l y E n g l i s h :
Linguistically isolated:
Spanish spoken i n household
A s i a n o r P a c i f i c I s l a n d language spoken i n household
Other language spoken i n household
Not l i n g u i s t i c a l l y i s o l a t e d
Speak Spanish:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
Speak A s i a n o r P a c i f i c I s l a n d language:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
Speak o t h e r language:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
14 t o 17 y e a r s :
Speak o n l y E n g l i s h
Speak Spanish:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
Speak A s i a n o r P a c i f i c I s l a n d language:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
Speak o t h e r language:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
18 t o 64 y e a r s :
Speak o n l y E n g l i s h
Speak Spanish:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
Speak A s i a n o r P a c i f i c I s l a n d language:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
Speak o t h e r language:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
65 y e a r s and over:
Speak o n l y E n g l i s h
Speak Spanish:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
1 1
1 1
1
1
1
1
1 1
1 1
1 1
P29.
P30.
1
7
33
�P31.
P3 2.
P33.
Speak A s i a n o r P a c i f i c I s l a n d language:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
Speak o t h e r language:
Linguistically isolated
Not l i n g u i s t i c a l l y i s o l a t e d
Persons i n group q u a r t e r s
Filler
LANGUAGE SPOKEN AT HOME(26)
26
U n i v e r s e : Persons 5 y e a r s and over
Speak o n l y E n g l i s h
German (607, 613)
Y i d d i s h (609)
Other West Germanic language (608, 610-612)
Scandinavian (614-618)
Greek (637)
I n d i e (662-678)
I t a l i a n (619)
French o r Freinch Creole (620-624)
Portuguese o r Portuguese Creole (629-630)
Spanish o r Sjianish C r e o l e (625, 627-628)
P o l i s h (645)
Russian (639)
South S l a v i c (647-652)
Other S l a v i c language (640-644, 646)
Other Indo-European language (601-606, 626, 631-636, 638, 653-661)
A r a b i c (777)
Tagalog (742)
Chinese (708-715)
Hungarian (6112)
Japanese (72:1)
Mon-Khmer (726)
Korean (724)
N a t i v e N o r t h American languages (800-955, 959-966, 977-982)
Vietnamese (728)
Other and u n s p e c i f i e d languages (679-681, 683-707, 716-722, 725,
727, 729-741,743-776, 778-799, 956-958, 967-976, 983-999)
ANCESTRY(4)
4
Universe:
Persons
Ancestry s p e c i f i e d :
Single ancestry
M u l t i p l e ancestry
Ancestry u n c l a s s i f i e d
Ancestry not reported
ANCESTRY(36)
36
Universe:
Persons
F i r s t a n c e s t r y r e p o r t e d (000-999) :
Arab (400-415, 417-418, 421-430, 435-481, 490-499)
A u s t r i a n (D03-004)
B e l g i a n (038-010)
Canadian (931-934)
Czech (111-114)
Danish (020, 023)
Dutch (021, 029)
E n g l i s h (015, 022)
F i n n i s h (024-025)
French (except Basque) (000-001, 016, 026-028, 083)
French Canadian (935-938)
German (032-045)
Greek (046-048)
Hungarian (125-126)
I r i s h (050, 081, 099)
I t a l i a n (030-031, 051-074)
L i t h u a n i a n (12 9)
Norwegian (082)
P o l i s h (142-143)
Portuguese (084-086)
Romanian (144-147)
Russian (148-151)
S c o t c h - I r i s h (087)
S c o t t i s h (088)
Slovak (IE 3)
Subsaharan A f r i c a n (500-599)
Swedish (089-090)
Swiss (091-096)
�P34.
P35.
U k r a i n i a n (L71-174)
U n i t e d S t a t e s o r A m e r i c a n (939-994)
Welsh (097)
West I n d i a n ( e x c l u d i n g H i s p a n i c o r i g i n g r o u p s ) ( 3 0 0 - 3 5 9 )
Y u g o s l a v i a n ( 1 5 2 , 154, 176-177)
Race o r H i s p a n i c o r i g i n g r o u p s ( 2 0 0 - 2 9 9 , 9 0 0 - 9 2 8 )
O t h e r g r o u p s ( 0 0 2 , 005-007, 011-014, 017-019, 049, 075-080,
098,
100-110, 115-124, 127-128, 130-141, 155-170, 175, 178-199,
3 6 0 - 3 9 9 , 4 1 6 , 4 1 9 - 4 2 0 , 4 3 1 - 4 3 4 , 4 8 2 - 4 8 9 , 6 0 0 - 8 6 2 , 9 2 9 - 9 3 0 , 998)
U n c l a s s i f i e d o r n o t r e p o r t e d ( 8 6 3 - 8 9 9 , 9 9 5 - 9 9 7 , 999)
ANCESTRY(36)
36
Universe:
Persons
Second a n c e s t r y r e p o r t e d ( 0 0 0 - 9 9 9 ) :
A r a b (400-415, 417-418, 421-430, 4 3 5 - 4 8 1 , 490-499)
A u s t r i a n (003-004)
B e l g i a n (008-010)
Canadian (931-934)
Czech (111-114)
D a n i s h ( 0 2 0 , 023)
D u t c h ( 0 2 1 , 029)
E n g l i s h ( 0 1 5 , 022)
F i n n i s h (024-025)
F r e n c h ( e x c e p t B a s q u e ) ( 0 0 0 - 0 0 1 , 0 1 6 , 0 2 6 - 0 2 8 , 083)
F r e n c h Canadian (935-938)
German ( 0 3 2 - 0 4 5 )
Greek (046-048)
H u n g a r i a n (125-126)
I r i s h ( 0 5 0 , 0 8 1 , 099)
I t a l i a n (030-031, 051-074)
L i t h u a n i a n (129)
Norwegian (082)
P o l i s h (142-143)
P o r t u g u e s e (084-086)
Romanian (144-147)
R u s s i a n (148-151)
S c o t c h - I r i s h (087)
S c o t t i s h (088)
Slovak (153)
Subsaharan A f r i c a n (500-599)
Swedish (089-090)
Swiss (091-096)
U k r a i n i a n (171-174)
U n i t e d S t a t e s o r A m e r i c a n (939-994)
Welsh (097)
West I n d i a n ( e x c l u d i n g H i s p a n i c o r i g i n g r o u p s ) ( 3 0 0 - 3 5 9 )
Y u g o s l a v i a r . ( 1 5 2 , 154, 176-177)
Race o r H i s p a n i c o r i g i n g r o u p s ( 2 0 0 - 2 9 9 , 9 0 0 - 9 2 8 )
O t h e r g r o u f s ( 0 0 2 , 005-007, 011-014, 017-019, 049, 075-080, 098,
100-110,115-124,127-128, 1 3 0 - 1 4 1 , 155-170, 175, 178-199, 360-399,
416,
4 1 9 - 4 2 0 , 4 3 1 - 4 3 4 , 4 8 2 - 4 8 9 , 6 0 0 - 8 6 2 , 9 2 9 - 9 3 0 , 998)
U n c l a s s i f i e d o r n o t r e p o r t e d ( 8 6 3 - 8 9 9 , 9 9 5 - 9 9 7 , 999)
ANCESTRY(37)
37
Universe:
Persons
R e p o r t e d s i n c i l e a n c e s t r y ( 0 0 0 - 8 6 2 , 9 0 0 - 9 9 4 , 998) :
A r a b (400-415, 417-418, 421-430, 435-481, 490-499)
A u s t r i a n (003-004)
B e l g i a n (008-010)
C a n a d i a n (£'31-934)
Czech (111-114)
D a n i s h ( 0 2 0 , 023)
D u t c h ( 0 2 1 , 029)
E n g l i s h (015, 022)
F i n n i s h (024-025)
F r e n c h ( e x c e p t B a s q u e ) ( 0 0 0 - 0 0 1 , 0 1 6 , 0 2 6 - 0 2 8 , 083)
French Canadian (935-938)
German (03:'.-045)
Greek (046-048)
H u n g a r i a n 1125-126)
I r i s h (050, 0 8 1 , 099)
I t a l i a n (0:10-031, 0 5 1 - 0 7 4 )
L i t h u a n i a n (129)
Norwegian (082)
P o l i s h (142-143)
Portuguese (084-086)
Romanian (144-147)
�E36.
Russian (148-151)
S c o t c h - I r i s i h (087)
S c o t t i s h (088)
Slovak (15;.)
Subsaharan A f r i c a n (500-599)
Swedish (0f:9-090)
Swiss (091-096)
U k r a i n i a n 1171-174)
U n i t e d Stat.es o r American (939-994)
Welsh (097)
West I n d i a n ( e x c l u d i n g H i s p a n i c o r i g i n groups) (300-359)
Y u g o s l a v i a n (152, 154, 176-177)
Race o r Hisipanic o r i g i n groups (200-299, 900-928)
Other groups (002, 005-007, 011-014, 017-019, 049, 075-080, 098,
100-110,115-124,127-128, 130-141, 155-170, 175, 178-199, 360-399,
416, 419-^20, 431-434,482-489,600-862, 929-930, 998)
Reported m u l t i p l e a n c e s t r y (000-998)
U n c l a s s i f i e d o r n o t r e p o r t e d (863-899, 995-997, 999)
YEAR OF ENTRY (10)
10
U n i v e r s e : F o r e i g n - b o r n persons
1987 t o 1990
1985 o r 19H6
1982 t o 1984
1980 o r 19111
1975 t o 1979
1970 t o 1974
1965 t o 1969
1960 t o 1964
1950 t o 19!i9
B e f o r e 1950
'
AGE (2) BY CITIZENSHIP (3)
6
U n i v e r s e : Persons
Under 18 y e a r s :
Native
Foreign born:
Naturalized citizen
Not a c i t i z e n
18 y e a r s and o v e r :
(Repeat CITIZENSHIP)
MARITAL STATUS(2) BY AGE(4)
8
U n i v e r s e : Females 15 y e a r s and over
Never m a r r i e d :
15 t o 24 y e a r s
25 t o 34 y e a r s
35 t o 44 y e a r s
4 5 y e a r s and over
Ever m a r r i e d :
(Repeat AGE)
AGGREGATE NUMBER OF CHILDREN EVER BORN(l) BY MARITAL STATUS(2)
BY AGE(4)
8
U n i v e r s e : Females 15 y e a r s and over
Total:
Never m a r r i e d :
15 t o 24 y e a r s
25 t o 34 y e a r s
35 t o 44 y e a r s
4 5 y e a r s and over
Ever m a r r i e d :
(Repeat AGE)
GROUP QUARTERS(10)
10
U n i v e r s e : Persons i n group q u a r t e r s
I n s t i t u t i o n a l i z e d persons (001-991):
C o r r e c t i o n a l i n s t i t u t i o n s (201-241, 271, 281, 951)
N u r s i n g homes (601-671)
Mental ( P s y c h i a t r i c ) h o s p i t a l s (451-481)
J u v e n i l e i n s t i t u t i o n s (011-051, 101-121, 151)
Other i n s t i t u t i o n s (001, 061-091, 131, 141, 161-191, 251, 261,
291-441, 4:91-591, 681-941, 961-991)
Other persons i n group q u a r t e r s (00N-99N):
C o l l e g e d o r m i t o r i e s (87N)
M i l i t a r y q u a r t e r s (96N-98N)
Emergency s h e l t e r s f o r homeless persons (82N, 83N)
V i s i b l e i n s t r e e t l o c a t i o n s (84N, 85N)
Other n o m . n s t i t u t i o n a l group q u a r t e r s (00N-81N,86N,88N-95N,99N)
GROUP QUARTERS(2) BY AGE(3)
6
y
I'37.
P3 8.
P39.
P4 0.
P41.
�P42.
P43.
P44 .
P4 5.
P46.
P4 7.
Universe:
Persons i n group q u a r t e r s
I n s t i t u t i o n a l i z e d persons:
Under 18 y e a r s
18 t o 64 y e a r s
65 y e a r s and over
Other persons i n group q u a r t e r s :
(Repeat AGE)
PLACE OF BIFTH(9)
9
U n i v e r s e : Persons
N a t i v e (001-099):
Born i n S t a t e o f r e s i d e n c e
Born i n o t h e r S t a t e i n t h e U n i t e d S t a t e s (001-059):
N o r t h e a s t (009, 023, 025, 033-034, 036, 042-044, 050)
Midwest (017-020, 026-027, 029, 031, 038-039, 046, 055)
South (001, 005, 010-014, 021-022, 024, 028, 037, 040, 045,
047-046:, 051-052, 054)
West (OC'2-004, 006-008, 015-016, 030, 032, 035, 041, 049,
053, 0E.6-059)
Born outsi.de t h e U n i t e d S t a t e s (060-099) :
Puerto F:ico (072-075)
U.S. o u t l y i n g area (060-071, 076-099)
Born abroad o f American p a r e n t ( s )
F o r e i g n b o r n (100-999)
RESIDENCE I N 1985--STATE AND COUNTY LEVEL(IO)
10
Universe:
E'ersons 5 years and over
Same house i n 1985
D i f f e r e n t house i n U n i t e d S t a t e s i n 1985:
Same c o u n t y
D i f f e r e n t county:
Same S t i i t e
D i f f e r e n t State:
Northeast
Midwest
South
West
Abroad i n 1985:
Puerto Rico
U.S. o u t l y i n g area
Foreign country
RESIDENCE I N 1985--MSA/PMSA LEVEL(12)
12
Universe:
Persons 5 years and over
L i v i n g i n an MSA/PMSA i n 1990:
Same house; i n 1985
D i f f e r e n t house i n U n i t e d S t a t e s i n 1985:
T h i s MSA/PMSA i n 1985:
Central c i t y
Remainder o f t h i s MSA/PMSA
D i f f e r e n t MSA/PMSA i n 1985:
Central c i t y
Remainder o f d i f f e r e n t MSA/PMSA
Not i n an MSA/PMSA i n 1985
Abroad i n 1985
Not l i v i n g :,n an MSA/PMSA i n 1990:
Same house i n 1985
D i f f e r e n t house i n U n i t e d S t a t e s i n 1985:
I n an MSA/PMSA i n 1985:
Central c i t y
Remainder o f MSA/PMSA
Not i n an MSA/PMSA i n 1985
Abroad i n 1985
PLACE OF WORK--STATE AND COUNTY LEVEL(3)
3
U n i v e r s e : Workers 16 years and over
Worked i n S t a t e o f r e s i d e n c e :
Worked i n county o f r e s i d e n c e
Worked o u t s i d e county o f r e s i d e n c e
Worked o u t s i d e S t a t e o f r e s i d e n c e
PLACE OF WORK--PLACE LEVEL(3)
3
U n i v e r s e : Workers 16 years and over
L i v i n g i n a place:
Worked i n p l a c e o f r e s i d e n c e
Worked o u t s i d e p l a c e o f r e s i d e n c e
Not l i v i n g i n a p l a c e
PLACE OF WO^K--MSA/PMSA LEVEL(8)
8
U n i v e r s e : Workers 16 years and over
L i v i n g i n a:i MSA/PMSA:
�P4 8.
P49.
IPSO.
P51.
?52.
Worked i n MSA/PMSA o f r e s i d e n c e :
Central c i t y
Remainder o f t h i s MSA/PMSA
Worked o u t s i d e MSA/PMSA o f r e s i d e n c e :
Worked i n a d i f f e r e n t MSA/PMSA:
Central c i t y
Remainder o f d i f f e r e n t MSA/PMSA
Worked o a t s i d e any MSA/PMSA
Not l i v i n g i n an MSA/PMSA:
Worked i n an MSA/PMSA:
Central c i t y
Remainder o f MSA/PMSA
Worked o u t s i d e any MSA/PMSA
PLACE OF WORK--MINOR CIVIL DIVISION LEVEL(3)
U n i v e r s e : Workers 16 y e a r s and over
Living i n the 9 Northeastern States:
Worked i n t h e minor c i v i l d i v i s i o n o f r e s i d e n c e
Worked o u t s i d e minor c i v i l d i v i s i o n o f r e s i d e n c e
Not l i v i n g i n t h e 9 N o r t h e a s t e r n S t a t e s
MEANS OF TRANSPORTATION TO WORK(13)
U n i v e r s e : Workers 16 y e a r s and over
Car, t r u c k , o r van:
Drove alone
Carpooled
Public t r a n s p o r t a t i o n :
Bus o r t r o l l e y bus
Streetcar or t r o l l e y car
Subway o r e l e v a t e d
Railroad
Ferryboat
Taxicab
Motorcycle
Bicycle
Walked
Other means
Worked a t home
TRAVEL TIME TO W0RK(13)
U n i v e r s e : Workers 16 y e a r s and over
Did n o t work a t home:
Less t h a n 5 minutes
5 t o 9 minutes
10 t o 14 minutes
15 t o 19 minutes
20 t o 24 minutes
25 t o 29 minutes
30 t o 34 minutes
35 t o 39 minutes
40 t o 44 minutes
45 t o 59 minutes
60 t o 89 minutes
90 o r more minutes
Worked a t home
AGGREGATE TRAVEL TIME TO WORK ( I N MINUTES)(1)
U n i v e r s e : Workers 16 y e a r s and over who d i d n o t work a t home
Total
TIME LEAVING HOME TO GO TO WORK(15)
U n i v e r s e : Workers 16 y e a r s and over
Did n o t work a t home:
12:00 a.. m. t o 4:59 a . m
5:00 a. m. t o 5 :29 a. m.
5:30 a. m. t o 5 :59 a. m.
6:00 a. m. t o 6 :29 a. m.
6:30 a. m. t o 6 : 59 a. m.
7 : 00a. m. t o 7 : 29 a. m.
7:30 a. m. t o 7 :59 a. m.
8:00 a. m. t o 8:29 a. m.
8:30 a. m. t o 8 :59 a. m.
9 : 00 a. m. t o 9 :59 a. m.
r
10 : 00
i a . rr. t o 10:59 a. m.
r
11: 00i a . rr.
. t o 11:59 a. m.
12:00 P . rr
. t o 3:59 P . m
4 : 00 P- m. t o 11:59 P . m
Worked at heme
PRIVATE VEHICLE OCCUPANCY(8)
Universe:
Viorkers 16 y e a r s and over
1
1
1
P53.
3
13
13
1
15
�P54.
P5 5.
P56.
P57.
P5 8.
P5 9.
Car, t r u c k , o r van:
Drove alone
I n 2-person c a r p o o l
I n 3-perscn c a r p o o l
I n 4-persan c a r p o o l
I n 5-perscn c a r p o o l
I n 6-perscn c a r p o o l
I n 7-or-more person c a r p o o l
Other means
SCHOOL ENROLLMENT AND TYPE OF SCHOOL(7)
Universe:
Persons 3 years and over
Enrolled i n preprimary school:
Public school
P r i v a t e school
E n r o l l e d i n elementary o r h i g h s c h o o l :
Public school
P r i v a t e school
Enrolled i n college:
Public school
P r i v a t e school
Not e n r o l l e d i n s c h o o l
RACE(5) BY SCHOOL ENROLLMENT(4)
Universe:
Persons 3 years and over
White:
E n r o l l e d i n p r e p r i m a r y school
E n r o l l e d i n elementary o r h i g h school
Enrolled i n college
Not e n r o l l e d i n s c h o o l
Black:
(Repeat SCHOOL ENROLLMENT)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat SCHOOL ENROLLMENT)
Asian o r P a c i f i c I s l a n d e r :
(Repeat SCHOOL ENROLLMENT)
Other r a c e :
(Repeat SCHOOL ENROLLMENT)
SCHOOL ENROLLMENT(4)
Universe:
Eersons o f H i s p a n i c o r i g i n 3 years and over
E n r o l l e d i n p r e p r i m a r y school
E n r o l l e d i n elementary o r h i g h school
Enrolled i n college
Not e n r o l l e d i n s c h o o l
EDUCATIONAL ATTAINMENT(7)
Universe:
E'ersons 25 years and over
Less t h a n 9t.h grade
9 t h t o 1 2 t h grade, no diploma
High s c h o o l g r a d u a t e ( i n c l u d e s e q u i v a l e n c y )
Some college:, no degree
A s s o c i a t e de:gree
Bachelor's degree
Graduate o r p r o f e s s i o n a l degree
RACE (5) BY EDUCATIONAL ATTAINMENT (7)
Universe:
Persons 25 years and over
White:
Less t h a n 9 t h grade
9 t h t o 1 2 t h grade, no diploma
High s c h o o l graduate ( i n c l u d e s e q u i v a l e n c y )
Some c o l l e g e , no degree
A s s o c i a t e degree
Bachelor's degree
Graduate o r p r o f e s s i o n a l degree
Black:
(Repeat EDUCATIONAL ATTAINMENT)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat EDUCATIONAL ATTAINMENT)
Asian o r P a c i f i c I s l a n d e r :
(Repeat EDUCATIONAL ATTAINMENT)
Other race:
(Repeat EDUCATIONAL ATTAINMENT)
EDUCATIONAL ATTAINMENT(7)
Universe:
Persons o f H i s p a n i c o r i g i n 25 years and over
Less than 9 t h grade
9 t h t o 1 2 t h grade, no diploma
High s c h o o l graduate ( i n c l u d e s e q u i v a l e n c y )
Some c o l l e g e , no degree
7
20
4
7
35
7
�P60.
P61.
P62.
P63.
A s s o c i a t e degree
Bachelor's degree
Graduate o r p r o f e s s i o n a l degree
EDUCATIONAL ATTAINMENT (7)
Universe:
Persons 18 years and over
Less than 9 t h grade
9 t h t o 1 2 t h grade, no diploma
High s c h o o l g r a d u a t e ( i n c l u d e s e q u i v a l e n c y )
Some college:, no degree
A s s o c i a t e decree
Bachelor's degree
Graduate o r p r o f e s s i o n a l degree
SCHOOL ENROLLMENT, EDUCATIONAL ATTAINMENT, AND EMPLOYMENT
STATUS (13)
Universe:
Persons 16 t o 19 years
I n Armed For ces:
Enrolled i n school:
High s c h o o l graduate
Not h i g h s c h o o l graduate
Not e n r o l l e d i n s c h o o l :
High s c h o o l graduate
Not high, s c h o o l graduate
Civilian:
Enrolled i n school:
Employed.
Unemployed
Not i n l a b o r f o r c e
Not e n r o l l e d i n s c h o o l :
High sch.ool g r a d u a t e :
Employed
Unemployed
Not i r . l a b o r f o r c e
Not h i g h s c h o o l g r a d u a t e :
Employed
Unemployed
Not i n l a b o r f o r c e
RACE(5) BY SCHOOL ENROLLMENT, EDUCATIONAL ATTAINMENT, AND
EMPLOYMENT STATUS(13)
Universe:
Persons 16 t o 19 years
White:
I n Armed Forces:
Enrolled, i n s c h o o l :
High s c h o o l graduate
Not h i g h s c h o o l graduate
Not e n r o l l e d i n s c h o o l :
High s c h o o l graduate
Not h i g h s c h o o l graduate
Civilian:
Enrolled: i n s c h o o l :
Employed
Unemployed
Not i r . l a b o r f o r c e
Not e n r o l l e d i n s c h o o l :
High s c h o o l g r a d u a t e :
Employed
Uneitiployed
Not i n l a b o r f o r c e
Not h i g h s c h o o l g r a d u a t e :
Employed
Unemployed
Not i r . l a b o r f o r c e
Black:
(Repeat SCHOOL ENROLLMENT, EDUCATIONAL ATTAINMENT, AND
EMPLOYME:NT STATUS)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat SCEOOL ENROLLMENT, EDUCATIONAL ATTAINMENT, AND
EMPLOYMENT STATUS)
Asian o r P a c i f i c I s l a n d e r :
(Repeat SCKOOL ENROLLMENT, EDUCATIONAL ATTAINMENT, AND
EMPLOYMENT STATUS)
Other r a c e :
(Repeat SCHOOL ENROLLMENT, EDUCATIONAL ATTAINMENT, AND
. EMPLOYMENT STATUS)
SCHOOL ENROLLMENT, EDUCATIONAL ATTAINMENT, AND
EMPLOYMENT STATUS(13)
7
13
65
13
�P64.
P65.
P66.
P67.
U n i v e r s e : Persons o f H i s p a n i c o r i g i n 16 t o 19 years
I n Armed Forces:
Enrolled i n school:
High s c h o o l g r a d u a t e
Not h i g h s c h o o l graduate
Not e n r o l l e d i n s c h o o l :
High s c h o o l g r a d u a t e
Not h i g h s c h o o l g r a d u a t e
Civilian:
Enrolled i n school:
Employed
Unemployed
Not i n l a b o r f o r c e
Not e n r o l l e d i n s c h o o l :
High s c h o o l g r a d u a t e :
Employed
Unemployed
Not i n l a b o r f o r c e
Not h i g h s c h o o l g r a d u a t e :
Employed
Unemployed
Not i n l a b o r f o r c e
SEX(2) BY AGE(2) BY VETERAN STATUS(3)
12
U n i v e r s e : Persons 16 y e a r s and over
Male:
16 t o 64 y e a r s :
I n Armed Forces
Civilian:
Vetera:.!
Nonveteran
6 5 y e a r s and o v e r :
(Repeat VETERAN STATUS)
Female:
(Repeat AGE By VETERAN STATUS)
PERIOD OF MILITARY SERVICE(13)
13
U n i v e r s e : C i v i l i a n v e t e r a n s 16 y e a r s and over
May 1975 o r l a t e r o n l y :
September 1980 o r l a t e r o n l y :
With less than 2 years o f service
W i t h 2 o r more y e a r s o f s e r v i c e
May 1975 t o August 1980 o n l y
Both, May 1975 t o August 1980 and September 1980 o r l a t e r
Vietnam e r a , no Korean c o n f l i c t n o r World War I I
Vietnam e r a and Korean c o n f l i c t , no World War I I
Vietnam e r a , Korean c o n f l i c t , and World War I I
February 1955 t o J u l y 1964 o n l y
Korean c o n f l i c t , no Vietnam e r a n o r World War I I
Korean c o n f l i c t and World War I I , no Vietnam e r a
World War I I , no Korean c o n f l i c t n o r Vietnam e r a
World War I
Other s e r v i c e
' SEX (2) BY AGE (2) BY WORK DISABILITY STATUS AND EMPLOYMENT
STATUS(7)
28
U n i v e r s e : C i v i l i a n n o n i n s t i t u t i o n a l i z e d persons 16 years and over
Male:
16 t o 64 y e a r s :
W i t h a work d i s a b i l i t y :
In labor force:
Employed
Unemployed
Not i n l a b o r f o r c e :
Prevented from w o r k i n g
Not p r e v e n t e d from w o r k i n g
No work d i s a b i l i t y :
In labor force:
Employed
Unemployed
Not i n l a b o r f o r c e
65 y e a r s and o v e r :
(Repeat WORK DISABILITY STATUS AND EMPLOYMENT STATUS)
Female:
(Repeat AGE By WORK DISABILITY STATUS AND EMPLOYMENT STATUS)
SEX(2) BY AGE(2) BY MOBILITY LIMITATION STATUS(2) BY
EMPLOYMENT STATUS(3)
24
U n i v e r s e : C i v i l i a n n o n i n s t i t u t i o n a l i z e d persons 16 years and over
�P68.
•969.
P70.
P71.
Male:
16 t o 64 y e a r s :
With a m o b i l i t y l i m i t a t i o n :
In labor force:
Employed
Unemployed
Not i n l a b o r f o r c e
No m o b i l i t y l i m i t a t i o n :
(Repeat EMPLOYMENT STATUS)
65 y e a r s and o v e r :
(Repeat MOBILITY LIMITATION STATUS By EMPLOYMENT STATUS)
Female:
(Repeat AGE By MOBILITY LIMITATION STATUS By EMPLOYMENT STATUS)
SEX(2) BY AGS(2) BY WORK DISABILITY STATUS(2) BY MOBILITY AND
SELF-CARE LIMITATION STATUS(2)
16
U n i v e r s e : C i v i l i a n n o n i n s t i t u t i o n a l i z e d persons 16 years and over
Male:
16 t o 64 y e a r s :
W i t h a work d i s a b i l i t y :
With a m o b i l i t y o r s e l f - c a r e l i m i t a t i o n
No m o b i l i t y o r s e l f - c a r e l i m i t a t i o n
No work d i s a b i l i t y :
(Repeat MOBILITY AND SELF-CARE LIMITATION STATUS)
65 y e a r s and o v e r :
(Repeat WORK DISABILITY STATUS By MOBILITY AND SELF-CARE
LIMITATION STATUS)
Female:
(Repeat AGE By WORK DISABILITY STATUS By MOBILITY
AND SELF-CARE LIMITATION STATUS)
SEX(2) BY AGE (3) BY MOBILITY AND SELF-CARE LIMITATION STATUS(4)
24
U n i v e r s e : C i v i l i a n n o n i n s t i t u t i o n a l i z e d persons 16 years and over
Male:
16 t o 64 y e a r s :
With a m o b i l i t y o r self-care l i m i t a t i o n :
M o b i l i t y l i m i t a t i o n only
Self-care l i m i t a t i o n only
M o b i l i t y and s e l f - c a r e l i m i t a t i o n
No m o b i l i t y o r s e l f - c a r e l i m i t a t i o n
65 t o 74 y e a r s :
(Repeat NOBILITY AND SELF-CARE LIMITATION STATUS)
75 y e a r s and o v e r :
(Repeat MOBILITY AND SELF-CARE LIMITATION STATUS)
Female:
(Repeat AGE By MOBILITY AND SELF-CARE LIMITATION STATUS)
SEX(2) BY EMPLOYMENT STATUS(4)
8
U n i v e r s e : E'ersons 16 y e a r s and over
Male:
In labor force:
I n Armed Forces
Civilian:
Employed
Unemployed
Not i n l a b o r f o r c e
Female:
(Repeat EMPLOYMENT STATUS)
RACE(5) BY SEX(2) BY EMPLOYMENT STATUS(4)
40
U n i v e r s e : Persons 16 years and over
White:
Male:
In labor force:
I n Armed Forces
Civilian:
Employed
Unemployed
Not i n l a b o r f o r c e
Female:
(Repeat EMPLOYMENT STATUS)
Black:
(Repeat SEX By EMPLOYMENT STATUS)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat SEX By EMPLOYMENT STATUS)
Asian o r P a c i f i c Islander:
(Repeat SEX By EMPLOYMENT STATUS)
Other race:
(Repeat SEX By EMPLOYMENT STATUS)
�,
I 72.
P73.
P74.
:?75.
P76.
SEX (2) BY EMPLOYMENT STATUS (4)
8
U n i v e r s e : Persons o f H i s p a n i c o r i g i n IS years and over
Male:
In labor force :
I n Armed Forces
Civilian:
Employed
Unemployed
Not i n l a b o r f o r c e
Female:
(Repeat EMPLOYMENT STATUS)
PRESENCE AND AGE OF CHILDREN AND EMPLOYMENT STATUS(12)
12
U n i v e r s e : Females 16 y e a r s and over
W i t h own c h i l d r e n under 18 y e a r s :
Under 6 y e a r s o n l y :
In labor force:
Employed o r i n Armed Forces
Unemployed
Not i n l a b o r f o r c e
6 t o 17 y e a r s o n l y :
In labor force:
Employed o r i n Armed Forces
Unemployed
Not i n l a b o r f o r c e
Under 6 y e a r s and 6 t o 17 y e a r s :
In labor force:
Employed o r i n Armed Forces
Unemployed
Not i n l a b o r f o r c e
No own c h i l d r e n under 18 y e a r s :
In labor force:
Employed o r i n Armed Forces
Unemployed
Not i n l a b o r f o r c e
PRESENCE AND AGE OF CHILDREN(2) BY EMPLOYMENT STATUS OF
PARENTS(8)
16
U n i v e r s e : Own c h i l d r e n under 18 years i n f a m i l i e s and s u b f a m i l i e s
Under 6 y e a r s :
L i v i n g w i t h two p a r e n t s :
Both p a r e n t s i n l a b o r f o r c e
Father o n l y i n labor force
Mother o n l y i n l a b o r f o r c e
N e i t h e r parent i n l a b o r f o r c e
L i v i n g w i t h one p a r e n t :
Living with father:
In labor force
Not i n l a b o r f o r c e
L i v i n g w i t h mother:
In labor force
Not i n l a b o r f o r c e
6 t o 17 y e a r s :
(Repeat EMPLOYMENT STATUS OF PARENTS)
SEX (2) BY WORK STATUS I N 1989 (2)
4
U n i v e r s e : Persons 16 y e a r s and over
Male:
Worked i n 1989
Did n o t work i n 1989
Female:
(Repeat WORK STATUS I N 1989)
SEX(2) BY WCRK STATUS I N 1989, USUAL HOURS WORKED PER WEEK IN
1989, AND WEEKS WORKED I N 1989(19)
38
U n i v e r s e : Persons 16 y e a r s and over
Male:
Worked i n 1989:
U s u a l l y worked 35 o r more hours p e r week:
50 t o 52 weeks
48 t o 49 weeks
40 t o 47 weeks
2 7 t o 3 9 weeks
14 t o 26 weeks
1 t o 13 weeks
U s u a l l y worked 15 t o 34 hours p e r week:
50 t o 52 weeks
48 t o 49 weeks
40 t o 47 weeks
�P77.
P78.
P7 9.
F80.
27 t o 39 weeks
14 t o 26 weeks
1 t o 13 weeks
U s u a l l y worked 1 t o 14 hours p e r week:
50 t o 52 weeks
4 8 t o 4 9 weeks
40 t o 4 7 weeks
27 t o 39 weeks
14 t o 26 weeks
1 t o 13 weeks
Did n o t work i n 1989
Female:
(Repeat WORK STATUS I N 1989, USUAL HOURS WORKED PER WEEK I N
1989, AND WEEKS WORKED I N 1989)
INDUSTRY(17)
17
U n i v e r s e : Employed persons 16 y e a r s and over
A g r i c u l t u r e , f o r e s t r y , and f i s h e r i e s (000-039)
M i n i n g (040-059)
C o n s t r u c t i o n (060-099)
M a n u f a c t u r i n g , nondurable goods (100-229)
M a n u f a c t u r i n g , d u r a b l e goods (230-399)
T r a n s p o r t a t i o n (400-439)
Communications and o t h e r p u b l i c u t i l i t i e s (440-499)
Wholesale t r a d e (500-579)
R e t a i l t r a d e (580-699)
Finance, i n s u r a n c e , and r e a l e s t a t e (700-720)
Business and r e p a i r s e r v i c e s (721-760)
Personal s e r v i c e s (761-799)
E n t e r t a i n m e n t and r e c r e a t i o n s e r v i c e s (800-811)
P r o f e s s i o n a l and r e l a t e d s e r v i c e s (812-899):
H e a l t h s e r v i c e s (812-840)
E d u c a t i o n a l s e r v i c e s (842-860)
Other p r o f e s s i o n a l and r e l a t e d s e r v i c e s (841, 861-899)
P u b l i c a d m i n i s t r a t i o n (900-939)
OCCUPATION(13)
13
U n i v e r s e : Employed persons 16 years and over
M a n a g e r i a l and p r o f e s s i o n a l s p e c i a l t y o c c u p a t i o n s (000-202):
E x e c u t i v e , a d m i n i s t r a t i v e , and m a n a g e r i a l o c c u p a t i o n s (000-042)
P r o f e s s i o n a l s p e c i a l t y o c c u p a t i o n s (043-202)
T e c h n i c a l , s a l e s , and a d m i n i s t r a t i v e s u p p o r t o c c u p a t i o n s (203-402):
Technicianis and r e l a t e d s u p p o r t o c c u p a t i o n s (203-242)
Sales o c c u p a t i o n s (243-302)
A d m i n i s t r a t i v e s u p p o r t o c c u p a t i o n s , i n c l u d i n g c l e r i c a l (303-402)
S e r v i c e o c c u p a t i o n s (403-472):
P r i v a t e household o c c u p a t i o n s (403-412)
P r o t e c t i v e s e r v i c e o c c u p a t i o n s (413-432)
S e r v i c e o c c u p a t i o n s , except p r o t e c t i v e and household (433-472)
Farming, f o r e s t r y , and f i s h i n g o c c u p a t i o n s (473-502)
P r e c i s i o n p r o d u c t i o n , c r a f t , and r e p a i r o c c u p a t i o n s (503-702)
O p e r a t o r s , f a b r i c a t o r s , and l a b o r e r s (703-902):
Machine o p e r a t o r s , assemblers, and i n s p e c t o r s (703-802)
T r a n s p o r t a t i o n and m a t e r i a l moving o c c u p a t i o n s (803-863)
Handlers, equipment c l e a n e r s , h e l p e r s , and l a b o r e r s (864-902)
CLASS OF WORKER(7)
7
U n i v e r s e : Enployed persons 16 years and over
P r i v a t e f o r p r o f i t wage and s a l a r y workers
P r i v a t e n o t - i i o r - p r o f i t wage and s a l a r y workers
L o c a l government workers
S t a t e governrient workers
F e d e r a l government workers
Self-employed workers
Unpaid f a m i l y workers
HOUSEHOLD INCOME I N 1989(25)
25
Universe:
Households
Less t h a n $5,000
$5,000 t o $9,999
$10,000 t o $j.2,499
$12,500 t o $14,999
$15,000 t o $17,499
$17, 500 t o $:.9, 999
$20,000 t o $22,499
$22,500 t o $2.4,999
$25,000 t o $27,499
$27,500 t o $29,999
$30,000 t o $::2,499
�H63.
H64.
H6 5.
H66.
H67.
H68.
H6 9.
K70.
H71.
W i t h a mortgage
Not mortgaged
AGGREGATE HOUSEHOLD INCOME IN 1989(1) BY TENURE AND MORTGAGE
STATUS (3 )
3
U n i v e r s e : Occupied h o u s i n g u n i t s
Total:
Owner o c c u p i e d :
W i t h a mortgage
Not mortgaged
Renter o c c u p i e d
PLUMBING FACILITIES(2)
2
U n i v e r s e : Housing u n i t s
Complete p l u n b i n g f a c i l i t i e s
L a c k i n g complete plumbing f a c i l i t i e s
PLUMBING FACILITIES(2)
2
U n i v e r s e : Vacant h o u s i n g u n i t s
Complete p l u n b i n g f a c i l i t i e s
L a c k i n g complete plumbing f a c i l i t i e s
RACE OF HOUSEHOLDER (5) BY PLUMBING FACILITIES (2)
10
U n i v e r s e : Occupied h o u s i n g u n i t s
White:
Complete p l u m b i n g f a c i l i t i e s
L a c k i n g c o n p l e t e plumbing f a c i l i t i e s
Black:
(Repeat PLUMBING FACILITIES)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat PLUMBING FACILITIES)
Asian o r P a c i f i c I s l a n d e r :
(Repeat PLUMBING FACILITIES)
Other r a c e :
(Repeat PLUMBING FACILITIES)
PLUMBING FACILITIES(2)
2
U n i v e r s e : Occupied h o u s i n g u n i t s w i t h householder o f H i s p a n i c o r i g i n
Complete p l u n b i n g f a c i l i t i e s
L a c k i n g complete plumbing f a c i l i t i e s
AGE OF HOUSEHOLDER(2) BY PLUMBING FACILITIES(2)
4
U n i v e r s e : Occupied h o u s i n g u n i t s
15 t o 64 y e a r s :
Complete p l u m b i n g f a c i l i t i e s
L a c k i n g c o n p l e t e plumbing f a c i l i t i e s
6 5 y e a r s and o v e r :
(Repeat PLUMBING FACILITIES)
TENURE(2) BY PLUMBING FACILITIES(2) BY PERSONS PER ROOM(3)
12
U n i v e r s e : Occupied housing u n i t s
Owner o c c u p i e d :
Complete p l u m b i n g f a c i l i t i e s :
1.00 o r l e s s
1.01 t o 1.50
1.51 o r nore
L a c k i n g c o n p l e t e plumbing f a c i l i t i e s :
(Repeat PERSONS PER ROOM)
Renter o c c u p i e d :
(Repeat PLUMBING FACILITIES By PERSONS PER ROOM)
PLUMBING FACILITIES(2) BY UNITS I N STRUCTURE(10)
20
U n i v e r s e : Housing u n i t s
Complete p l u n b i n g f a c i l i t i e s :
1, detached
1, a t t a c h e d
2
3 or 4
5 to 9
10 t o 19
20 t o 49
50 o r more
M o b i l e home o r t r a i l e r
Other
L a c k i n g complete plumbing f a c i l i t i e s :
(Repeat UNITS I N STRUCTURE)
PLUMBING' FACILITIES(2) BY PERSONS PER R00M(2) BY YEAR STRUCTURE
BUILT(2)
8
U n i v e r s e : Occupied housing u n i t s
Complete p l u m b i n g f a c i l i t i e s :
1.00 o r l e s s :
1940 t o March 1990
1939 o r e a r l i e r
�H''2.
H73.
H74.
H75.
H76.
H77.
H78.
H79.
H80.
H81.
H82.
H83.
H84.
H85.
H86.
H87.
H88.
H8 9.
l . O i o r more:
(Repeat YEAR STRUCTURE BUILT)
L a c k i n g complete plumbing f a c i l i t i e s :
(Repeat PERSONS PER ROOM By YEAR STRUCTURE BUILT)
IMPUTATION OF HOUSING ITEMS (2)
U n i v e r s e : Housing u n i t s
No items a l l o c a t e d
One o r more items a l l o c a t e d
IMPUTATION OF CONDOMINIUM STATUS(2)
U n i v e r s e : Housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF PLUMBING FACILITIES(2)
U n i v e r s e : Housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF SOURCE OF WATER(2)
U n i v e r s e : Housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF SEWAGE DISPOSAL(2)
U n i v e r s e : Housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF YEAR STRUCTURE BUILT(2)
U n i v e r s e : Housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF YEAR HOUSEHOLDER MOVED INTO UNIT(2)
U n i v e r s e : Occupied h o u s i n g u n i t s
Allocated
Not a l l o c a t e d !
IMPUTATION OF HOUSE HEATING FUEL(2)
U n i v e r s e : Occupied h o u s i n g u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF KITCHEN FACILITIES(2)
U n i v e r s e : Housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF BEDROOMS(2)
U n i v e r s e : Housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF TELEPHONE I N HOUSING UNIT(2)
Universe:
Occupied h o u s i n g u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF VEHICLES AVAILABLE(2)
U n i v e r s e : Occupied h o u s i n g u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF MORTGAGE STATUS(2)
Universe:
S p e c i f i e d owner-occupied h o u s i n g u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION 0!? TENURE (2)
U n i v e r s e : Occupied h o u s i n g u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION O? VACANCY STATUS(2)
U n i v e r s e : Vacant h o u s i n g u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF ROOMS(2)
U n i v e r s e : Housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF UNITS I N STRUCTURE(2)
U n i v e r s e : Housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF VALUE(2)
Universe:
S p e c i f i e d owner-occupied housing u n i t s
Allocated
�H90.
H91.
H92.
Not a l l o c a t e i i
IMPUTATION 01? MEALS INCLUDED IN RENT (2)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing u n i t s p a y i n g cash r e n t
Allocated
Not a l l o c a t e d
IMPUTATION OF GROSS RENT(2)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing u n i t s
Allocated
Not a l l o c a t e d
IMPUTATION OF MORTGAGE STATUS AND SELECTED MONTHLY OWNER COSTS(4)
U n i v e r s e : S p e c i f i e d owner-occupied housing u n i t s
w i t h a mortgsige:
Allocated
Not a l l o c a t e d
Not mortgaged:
Allocated
Not a l l o c a t e d
�$32,500 t o $34,999
$35,000 t o $37,499
$37,500 t o $39,999
$40,000 t o $42,499
$42,500 t o ?44,999
$45,000 t o $47,499
$47,500 t o $49,999
$50,000 t o $54,999
$55,000 t o $59,999
$60,000 t o $74,999
$75,000 t o $99,999
$100,000 t o $124,999
$125,000 t o $149,999
$150,000 o r more
P80A. MEDIAN HOUSEHOLD INCOME I N 1989(1)
U n i v e r s e : Households
Median household income i n 1989
P81.
AGGREGATE HOUSEHOLD INCOME I N 1989(2)
U n i v e r s e : Households
Total:
Less t h a n $150,000
$150,000 o r more
P82. RACE OF HOUSEHOLDER(5) BY HOUSEHOLD INCOME I N 1989(9)
U n i v e r s e : Households
White:
Less t h a n $5,000
$5,000 t o $9,999
$10,000 t o $14,999
$15,000 t o $24,999
$25,000 t o $34,999
$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t c $99,999
$100,000 c r more
Black:
(Repeat HOUSEHOLD INCOME I N 1989)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat HOUSEHOLD INCOME I N 1989)
Asian o r P a c i f i c Islander:
(Repeat HOUSEHOLD INCOME I N 1989)
Other r a c e :
(Repeat HOUSEHOLD INCOME I N 1989)
)?83. HOUSEHOLD INCOME I N 1989(9)
U n i v e r s e : Households w i t h householder o f H i s p a n i c o r i g i n
Less t h a n $5,000
$5,000 t o $9,999
$10,000 t o $14,999
$15,000 t o $24,999
$25,000 t o $34,999
$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t o $59,999
$100,000 o r more
P84. AGGREGATE HOUSEHOLD INCOME I N 1989(1) BY RACE OF HOUSEHOLDER(5)
U n i v e r s e : Households
Total:
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
P85. AGGREGATE HOUSEHOLD INCOME I N 1989(1)
U n i v e r s e : Households w i t h householder o f H i s p a n i c o r i g i n
Total
PSe. AGE OF HOUSEHOLDER(7) BY HOUSEHOLD INCOME IN 1989(9)
U n i v e r s e : Households
Under 2 5 y e a r s :
Less t h a n :;5,000
$5,000 t o i;9,999
$10,000 t o $14,999
$15,000 t o $24,999
$25,000 t o $34,999
$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t o $99,999
1
2
45
9
5
1
63
�$100, 000 o;r more
25 t o 34 yea:rs:
(Repeat HOUSEHOLD INCOME I N 1989)
35 t o 44 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
45 t o 54 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
55 t o 64 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
65 t o 74 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
75 years and over:
(Repeat HOUSEHOLD INCOME IN 1989)
P87A. RACE OF HOUSEHOLDER(1) BY AGE OF HOUSEHOLDER(7) BY HOUSEHOLD
INCOME I N 1989(9)
U n i v e r s e : White households
White:
Under 2 5 y e a r s :
Less t h a n $5,000
$5,000 t o $9,999
$10,000 t o $14,999
$15,000 t o $24,999
$25,000 t o $34,999
$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t o $99,999
$100,000 o r more
25 t o 34 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
3 5 t o 44 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
45 t o 54 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
55 t o 64 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
65 t o 74 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
7 5 years and over:
(Repeat HOUSEHOLD INCOME I N 1989)
P87B. RACE OF HOUSEHOLDER (1) BY AGE OF HOUSEHOLDER (7) BY HOUSEHOLD
INCOME I N :L989 (9)
Universe:
Black households
Black:
Under 25 y e a r s :
Less t h a n $5,000
$5, 000 i;o $9, 999
$10,000 t o $14,999
$15,000 t o $24,999
$25,000 t o $34,999
$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t o $99,999
$100,000 o r more
25 t o 34 years:
(Repeat HOUSEHOLD INCOME I N 1989)
35 t o 44 years:
(Repeat HOUSEHOLD INCOME IN 1989)
45 t o 54 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
55 t o 64 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
65 t o 74 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
75 years and over:
(Repeat HOUSEHOLD INCOME IN 1989)
P87C. RACE OF HOUSEHOLDER(1) BY AGE OF HOUSEHOLDER(7) BY HOUSEHOLD
INCOME I N 1989(9)
63
U n i v e r s e : American I n d i a n , Eskimo, o r A l e u t households
American I n d i a n , Eskimo, o r A l e u t :
Under 25 y e a r s :
Less t h a n $5,000
$5,000 t o $9,999
$10,000 t o $14,999
$15,000 t o $24,999
$25,000 t o $34,999
63
63
�$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t o $99,999
$100,000 o r more
25 t o 34 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
3 5 t o 44 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
45 t o 54 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
55 t o 64 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
65 t o 74 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
75 y e a r s and over:
(Repeat HOUSEHOLD INCOME I N 198 9)
P87D. RACE OF HOUSEHOLDER(1) BY AGE OF HOUSEHOLDER(7) BY HOUSEHOLD
INCOME I N 1389(9)
U n i v e r s e : A s i a n and P a c i f i c I s l a n d e r households
A s i a n and P a c i f i c I s l a n d e r :
Under 25 y e a r s :
Less t h a n $5,000
$5,000 t o $9,999
$10,000 t o $14,999
$15,000 t o $24,999
$25,000 t o $34,999
$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t o $99,999
$100,000 o r more
25 t o 34 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
35 t o 44 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
45 t o 54 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
55 t o 64 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
65 t o 74 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
75 y e a r s Eind over:
(Repeat HOUSEHOLD INCOME I N 1989)
P87E. RACE OF HOUSEHOLDER (1) BY AGE OF HOUSEHOLDER (7) BY HOUSEHOLD
INCOME I N 1989(9)
U n i v e r s e : Other race households
Other r a c e :
Under 2 5 y e a r s :
Less t h a n $5,000
$5,000 t o $9,999
$10,000 t o $14,999
$15,000 t o $24,999
$25,000 t o $34,999
$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t o $99,999
$100,000 o r more
25 t o 34 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
35 t o 44 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
4 5 t o 54 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
55 t o 64 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
65 t o 74 / e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
75 y e a r s and over:
(Repeat HOUSEHOLD INCOME I N 1989)
P88. AGE OF HOUSEHOLDER(7) BY HOUSEHOLD INCOME IN 1989(9)
U n i v e r s e : Households w i t h householder o f H i s p a n i c o r i g i n
Under 2 5 y e a r s :
Less than $5,000
$5,000 t c $9,999
$10,000 t o $14,999
$15,000 t o $24,999
63
63
63
�$ 5 , 0 0 0 t o $9,999
$10,000 t o $14,999
$15,000 t o $24,999
$25,000 t o $34,999
$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t o $99,999
$ 1 0 0 , 0 0 0 o r more
5 t o 34 years:
( R e p e a t HOUSEHOLD INCOME I N 1 9 8 9 )
5 t o 44 y e a r s :
( R e p e a t HOUSEHOLD INCOME I N 1 9 8 9 )
�P89.
P90.
P91.
P92.
P93.
P94.
P95.
P96.
P97.
P98.
]?99.
P100.
P101.
P102.
P103.
P104.
P105.
$25,000 t o $34,999
$35,000 t o $49,999
$50,000 t o $74,999
$75,000 t o $99,999
$100,000 o r more
25 t o 34 y e a r s :
(Repeat HOUSEHOLD INCOME IN 1989)
3 5 t o 44 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
45 t o 54 y e a r s :
(Repeat HOUSEHOLD INCOME I N 1989)
55 t o 64 yecirs:
(Repeat HOUSEHOLD INCOME I N 1989)
65 t o 74 yecirs:
(Repeat HOUSEHOLD INCOME IN 1989)
7 5 y e a r s and over:
(Repeat HOUSEHOLD INCOME IN 1989)
EARNINGS I N 1989(2)
Universe:
Households
With earninqs
No e a r n i n g s
WAGE OR SALARY INCOME I N 1989(2)
Universe:
Households
With wage o r s a l a r y income
No wage o r s a l a r y income
NONFARM SELF-EMPLOYMENT INCOME I N 1989(2)
Universe:
Households
With nonfarn: self-employment income
No nonfarm self-employment income
FARM SELF-EMPLOYMENT INCOME I N 1989(2)
Universe:
Households
W i t h farm self-employment income
No farm self-employment income
INTEREST, DIVIDEND, OR NET RENTAL INCOME IN 1989(2)
Universe:
Households
W i t h i n t e r e s t , d i v i d e n d , o r n e t r e n t a l income
No i n t e r e s t , d i v i d e n d , o r n e t r e n t a l income
SOCIAL SECURITY INCOME IN 1989(2)
Universe:
Households
W i t h S o c i a l S e c u r i t y income
No S o c i a l S e c u r i t y income
PUBLIC ASSISTANCE INCOME IN 1989(2)
Universe:
Households
W i t h p u b l i c a s s i s t a n c e income
No p u b l i c a s s i s t a n c e income
RETIREMENT INCOME I N 1989(2)
Universe:
Households
W i t h r e t i r e m e n t income
No r e t i r e m e n t income
OTHER TYPE OF INCOME I N 1989(2)
Universe:
Households
W i t h o t h e r income
No o t h e r income
AGGREGATE WAGE OR SALARY INCOME I N 1989(1)
Universe:
Households
Total
AGGREGATE NONFARM SELF-EMPLOYMENT INCOME I N 1989 (1)
Universe:
Households
Total
AGGREGATE FARM SELF-EMPLOYMENT INCOME I N 1989(1)
Universe:
Households
Total
AGGREGATE INTEREST, DIVIDEND, OR NET RENTAL INCOME I N 1989(1)
Universe:
Households
Total
AGGREGATE SOCIAL SECURITY INCOME I N 1989(1)
Universe:
Households
Total
AGGREGATE PUBLIC ASSISTANCE INCOME IN 1989(1)
Universe:
Households
Total
AGGREGATE RETIREMENT INCOME I N 1989(1)
Universe:
Households
Total
AGGREGATE OTHER TYPE OF INCOME IN 1989(1)
�Universe:
Households
Total
P106. AGGREGATE PERSONS I N HOUSEHOLDS(1) BY PUBLIC ASSISTANCE INCOME
I N 1989(2) 3Y AGE(3)
U n i v e r s e : Persons i n households
Total:
W i t h p u b l i c a s s i s t a n c e income:
Under 15 y e a r s
15 t o 64 y e a r s
65 y e a r s and over
No p u b l i c a s s i s t a n c e income:
(Repeat AGE)
P107. FAMILY INCOME I N 1989(25)
Universe:
Families
Less t h a n $5,000
$5,000 t o $9,999
$10,000 t o $12,499
$12,500 t o $14,999
$15,000 t o $17,499
$17,500 t o $19,999
$20,000 t o $22,499
$22,500 t o $24,999
$25,000 t o $27,499
$27,500 t o $29,999
$30,000 t o $32,499
$32,500 t o $34,999
$35,000 t o $37,499
$37,500 t o $39,999
$40,000 t o $42,499
$42,500 t o $44,999
$45,000 t o $47,499
$47,500 t o $49,999
$50,000 t o $54,999
$55,000 t o $59,999
$60,000 t o $74,999
$75,000 t o $99,999
$100,000 t o $124,999
$125,000 t o $149,999
$150,000 o r more
P107A.MEDIAN FAMILY INCOME I N 1989(1)
Universe:
Families
Median f a m i l y income i n 1989
P108. AGGREGATE FAMILY INCOME IN 1989(1) BY FAMILY INCOME IN 1989(2)
U n i v e r s e : E'amilies
Total:
Less t h a n $150,000
$150,000 o r more
P109. AGGREGATE FIMILY INCOME I N 1989(1) BY FAMILY TYPE AND PRESENCE
AND AGE OF CHILDREN(6)
Universe:
Families
Total:
Married-couple family:
W i t h own c h i l d r e n under 18 years
No own c h i l d r e n under 18 y e a r s
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
W i t h own c h i l d r e n under 18 y e a r s
No own c h i l d r e n under 18 years
Female householder, no husband p r e s e n t :
W i t h own c h i l d r e n under 18 years
No own c h i l d r e n under 18 years
P110. NONFAMILY HOUSEHOLD INCOME IN 1989(25)
U n i v e r s e : N o n f a m i l y households
Less t h a n $5,000
$5,000 t o $9,999
$10,000 t o $12,499
$12,500 t o $14,999
$15,000 t o $17,499
$17,500 to-$19,999
$20,000 t o $22,499
$22,500 t o $24,999
$25,000 t o $27,499
$27,500 t o $29,999
$30,000 t o $32,499
$32,500 t o $34,999
6
25
1
2
6
25
�$35,000 t o $37,499
$37,500 t o $39,999
$40,000 t o $42,499
$42,500 t o $44,999
$45,000 t o $47,499
$47,500 t o $49,999
$50,000 t o $54,999
$55,000 t o $59,999
$50,000 t o $''4,999
$75,000 t o $99,999
$100,000 t o :;i24,999
$125,000 t o :;149,999
$150, 000 o r r.iore
PllOA.MEDIAN NONFAMILY HOUSEHOLD INCOME IN 1989(1)
U n i v e r s e : N o n f a m i l y households
Median n o n f a m i l y household, income i n 1989
P i l l . AGGREGATE NONFAMILY HOUSEHOLD INCOME I N 1989(1) BY NONFAMILY
HOUSEHOLD INCOME I N 1989(2)
U n i v e r s e : N o n f a m i l y households
Total:
Less t h a n ;;i50,ooo
$150,000 o r more
P112. WORKERS I N FAMILY I N 1989(4)
Universe:
Families
No workers
1 worker
2 workers
3 o r more workers
P113. AGGREGATE FAMILY INCOME I N 1989(1) BY WORKERS IN FAMILY I N
1989(4)
Universe:
Families
Total:
No workers
1 worker
2 workers
3 o r more workers
P114. AGGREGATE INCOME I N 1989(1) BY GROUP QUARTERS(3)
U n i v e r s e : Persons 15 y e a r s and over
Total:
I n households
I n group q u a r t e r s :
I n s t i t u t i o n a l i z e d persons
Other persons i n group q u a r t e r s
Filler
P114A.PER CAPITA INCOME I N 1989(1)
Universe:
Persons
Per c a p i t a income i n 1989
£'1148 . PER CAPITA INCOME I N 1989(1) BY GROUP QUARTERS (3)
Universe:
Persons
Per c a p i t a income i n 1989:
I n households
I n group q u a r t e r s :
I n s t i t u t i o n a l i z e d persons
Other persons i n group q u a r t e r s
Filler
P115. AGGREGATE INCOME I N 1989(1) BY.RACE(5)
U n i v e r s e : Persons 15 y e a r s and over
Total:
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
P115A.PER CAPITA INCOME I N 1989(1) BY RACE(5)
Universe:
Persons
Per c a p i t a income i n 1989:
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
P11G. AGGREGATE INCOME I N 1989(1)
Universe: Persons o f H i s p a n i c o r i g i n 15 years and over
Total
P116A.
PER CAPITA INCOME I N 1989(1)
�U n i v e r s e : Persons o f H i s p a n i c o r i g i n
Per c a p i t a income i n 1989
P117. POVERTY STATUS I N 1989(2) BY AGE(12)
U n i v e r s e : Persons f o r whom p o v e r t y s t a t u s i s determined
Income i n 19 39 above p o v e r t y l e v e l :
Under 5 y e a r s
5 years
6 t o 11 y e a r s
12 t o 17 y e a r s
18 t o 24 y e a r s
2 5 t o 3 4 years
3 5 t o 44 y e a r s
45 t o 54 y e a r s
55 t o 59 y e a r s
60 t o 64 y e a r s
65 t o 74 y e a r s
75 y e a r s and over
Income i n 19 39 below p o v e r t y l e v e l :
(Repeat AGE)
P118. POVERTY STATUS I N 1989(2) BY SEX(2) BY AGE(7)
U n i v e r s e : Persons f o r whom p o v e r t y s t a t u s i s determined
Income i n 1939 above p o v e r t y l e v e l :
Male:
Under 5 y e a r s
5 years
6 t o 11 y e a r s
12 t o 17 y e a r s
18 t o 64 y e a r s
65 t o 74 y e a r s
75 y e a r s and over
Female:
(Repeat AGE)
Income i n 1989 below p o v e r t y l e v e l :
(Repeat SEX By AGE)
P119. POVERTY STATUS I N 1989(2) BY RACE(5) BY AGE(7)
U n i v e r s e : Persons f o r whom p o v e r t y s t a t u s i s determined
Income i n 1989 above p o v e r t y l e v e l :
White:
Under 5 years
5 years
6 t o 11 years
12 t o 17 y e a r s
18 t o 64 y e a r s
65 t o 74 y e a r s
7 5 y e a r s and over
Black:
(Repeat AGE)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat AGE)
Asian o r P a c i f i c I s l a n d e r :
(Repeat AGE)
Other r a c e :
(Repeat AGE)
Income i n 1989 below p o v e r t y l e v e l :
(Repeat RACE By AGE)
P120. POVERTY STATUS I N 1989(2) BY AGE(7)
U n i v e r s e : Eersons o f H i s p a n i c o r i g i n f o r whom p o v e r t y s t a t u s
i s determined
Income i n 19 89 above p o v e r t y l e v e l :
Under 5 y e a r s
5 years
6 t o 11 y e a r s
12 t o 17 y e a r s
18 t o 64 y e a r s
65 t o 74 y e a r s
75 y e a r s c.nd over
Income i n 1S'89 below p o v e r t y l e v e l :
(Repeat AGE)
P121. RATIO OF INCOME I N 1989 TO POVERTY LEVEL(9)
U n i v e r s e : Persons f o r whom p o v e r t y s t a t u s i s determined
Under .50
.50 t o .74
.75 t o .99
1.00 tO 1.24:
1.25 t o 1.49
24
28
70
14
9
�1.50 t o 1.74
1.75 t o 1.84
1.85 t o 1.99
2.00 and over
P122. POVERTY STATUS I N 1989(2) BY AGE (3) BY HOUSEHOLD TYPE AND
RELATIONSHIP(9)
U n i v e r s e : Persons f o r whom p o v e r t y s t a t u s i s determined
Income i n 1989 above p o v e r t y l e v e l :
Under 65 y e a r s :
I n married-couple family
In other family:
Male householder, no w i f e p r e s e n t
Female householder, no husband p r e s e n t
Unrelated i n d i v i d u a l s :
I n f a m i l y households
I n n o n f a m i l y households:
Householder:
L i v i n g alone
Not l i v i n g alone
Nonrelatives
I n group q u a r t e r s
Filler
65 t o 74 y e a r s :
(Repeat HOUSEHOLD TYPE AND RELATIONSHIP)
75 y e a r s and over:
(Repeat HOUSEHOLD TYPE AND RELATIONSHIP)
Income i n 1989 below p o v e r t y l e v e l :
(Repeat AGE By HOUSEHOLD TYPE AND RELATIONSHIP)
P123. POVERTY STATUS I N 1989(2) BY FAMILY TYPE AND PRESENCE AND
AGE OF CHILDREN(12)
Universe: Families
Income i n 1989 above p o v e r t y l e v e l :
Married-couple family:
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 y e a r s
No r e l a t e d c h i l d r e n under 18 years
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 y e a r s
No r e l a t e d c h i l d r e n under 18 y e a r s
Female householder, no husband p r e s e n t :
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 y e a r s
No r e l a t e d c h i l d r e n under 18 y e a r s
Income i n 1989 below p o v e r t y l e v e l :
(Repeat FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN)
P124A.POVERTY STATUS I N 1989(1) BY RACE OF HOUSEHOLDER(5) BY FAMILY
TYPE AND PRESENCE AND AGE OF CHILDREN(12)
U n i v e r s e : F a m i l i e s w i t h income i n 1989 above p o v e r t y l e v e l
Income i n 1989 above p o v e r t y l e v e l :
White:
Married-couple family:
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 y e a r s
No r e l a t e d c h i l d r e n under 18 y e a r s
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 y e a r s
No r e l a t e d c h i l d r e n under 18 y e a r s
Female householder, no husband p r e s e n t :
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
54
24
60
�Under 5 y e a r s and 5 t o 17 years
No r e l a t e d c h i l d r e n under 18 y e a r s
Black:
(Repeat FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN)
Asian o r P a c i f i c Islander:
(Repeat FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN)
Other r a c e :
(Repeat FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN)
P124B.POVERTY STATUS I N 1989(1) BY RACE OF HOUSEHOLDER(5) BY FAMILY
TYPE AND PRESENCE AND AGE OF CHILDREN (12)
U n i v e r s e : F a m i l i e s w i t h income i n 1989 below p o v e r t y l e v e l
Income i n 1989 above p o v e r t y l e v e l :
White:
Married-couple family:
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 years
No r e l a t e d c h i l d r e n under 18 years
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t.o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 years
No r e l a t e d c h i l d r e n under 18 y e a r s
Female householder, no husband p r e s e n t :
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 years
No r e l a t e d c h i l d r e n under 18 years
Black:
(Repeat FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN)
Asian o r P a c i f i c Islander:
(Repeat FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN)
Other r a c e :
(Repeat FAMILY TYPE AND PRESENCE AND AGE OF CHILDREN)
P125. POVERTY STATUS I N 1989(2) BY FAMILY TYPE AND PRESENCE AND
AGE OF CHILDREN(12)
U n i v e r s e : F a m i l i e s w i t h householder o f H i s p a n i c o r i g i n
Income i n 1989 above p o v e r t y l e v e l :
Married-couple family:
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 y e a r s
No r e l a t e d c h i l d r e n under 18 y e a r s
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 y e a r s
No r e l a t e d c h i l d r e n under 18 y e a r s
Female householder, no husband p r e s e n t :
W i t h r e l a t e d c h i l d r e n under 18 y e a r s :
Under 5 y e a r s o n l y
5 t o 17 y e a r s o n l y
Under 5 y e a r s and 5 t o 17 years
No r e l a t e d c h i l d r e n under 18 y e a r s
Income i n 1989 below p o v e r t y l e v e l :
(Repeat F.M1ILY TYPE AND PRESENCE AND AGE OF CHILDREN)
P126. POVERTY STATUS I N 1989(2) BY FAMILY TYPE AND AGE(9)
Universe:
R e l a t e d c h i l d r e n under 18 years
Income i n 1989 above p o v e r t y l e v e l :
I n married-couple family:
Under 5 y e a r s
5 years
6 t o 17 y e a r s
In other family:
60
24
18
�P127.
P128.
P129.
P13 0.
P131.
P132.
P133.
P134.
P135.
P136.
P137.
Male householder, no w i f e p r e s e n t :
Under 5 y e a r s
5 years
6 t o 11 y e a r s
Female householder, no husband p r e s e n t :
Under 5 y e a r s
5 years
G t o 17 y e a r s
Income i n 19E9 below p o v e r t y l e v e l :
(Repeat FAMILY TYPE AND AGE)
POVERTY STATUS I N 1989(2) BY AGE OF HOUSEHOLDER(3) BY
HOUSEHOLD TYPE(5)
U n i v e r s e : Households
Income i n 19f;9 above p o v e r t y l e v e l :
Householder 15 t o 64 y e a r s :
Married-couple f a m i l y
Other f a m i l y :
Male householder, no w i f e p r e s e n t
Female householder, no husband p r e s e n t
N o n f a m i l y households:
Householder l i v i n g alone
Householder n o t l i v i n g alone
Householder 65 t o 74 y e a r s :
(Repeat HOUSEHOLD TYPE)
Householder 75 y e a r s and over:
(Repeat HOUSEHOLD TYPE)
Income i n 1939 below p o v e r t y l e v e l :
(Repeat AGE OF HOUSEHOLDER By HOUSEHOLD TYPE)
IMPUTATION OF POPULATION ITEMS(3)
U n i v e r s e : Persons
No i t e m s a l l o c a t e d
One o r mora i t e m s a l l o c a t e d
Filler
IMPUTATION OF RELATIONSHIP(2)
U n i v e r s e : Persons i n households
Allocated
Not a l l o c a t e d
IMPUTATION OF SEX(3)
Universe:
Persons
Allocated
Not a l l o c a t e d
Filler
IMPUTATION CF AGE(3)
U n i v e r s e : Eersons
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF RACE(3)
U n i v e r s e : Persons
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF MARITAL STATUS(3)
U n i v e r s e : Persons 15 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF HISPANIC ORIGIN(3)
U n i v e r s e : Persons
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF GROUP QUARTERS(2)
Universe:
Persons i n group q u a r t e r s
Allocated
Not a l l o c a t e d
IMPUTATION DF PLACE OF BIRTH(3)
Universe:
Persons
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF CITIZENSHIP(3)
U n i v e r s e : Persons
Allocated
Not a l l o c a t e d
30
3
2
3
3
3
3
3
2
3
3
�Filler
P13 8. IMPUTATION OF YEAR OF ENTRY(3)
U n i v e r s e : F o r e i g n - b o r n persons
Allocated
Not a l l o c a t e d
Filler
P13 9. IMPUTATION OF SCHOOL ENROLLMENT(3)
U n i v e r s e : Persons 3 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
P140. IMPUTATION OF EDUCATIONAL ATTAINMENT(3)
U n i v e r s e : Persons 18 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
P141. IMPUTATION OF EDUCATIONAL ATTAINMENT(3)
U n i v e r s e : Persons 25 years and over
Allocated
Not a l l o c a - e d
Filler
P142. IMPUTATION OF ANCESTRY(3)
U n i v e r s e : Persons
Allocated
Not a l l o c a t e d
Filler
P143. IMPUTATION OF MOBILITY STATUS(3)
U n i v e r s e : Persons 5 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
P144. IMPUTATION OF RESIDENCE IN 1985(5)
U n i v e r s e : Eersons 5 y e a r s and over
D i f f e r e n t house i n 1985:
Allocated:
One o r more b u t n o t a l l geographic p a r t s a l l o c a t e d
A l l geographic p a r t s a l l o c a t e d
Not a l l o c a t e d
Filler
Same house i n 1985
P145. IMPUTATION OF LANGUAGE STATUS(3)
U n i v e r s e : Persons 5 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
P146. IMPUTATION OF LANGUAGE SPOKEN AT HOME(4)
,
Universe:
Persons 5 y e a r s and over
Speak o n l y E n g l i s h
Speak o t h e r language:
Allocated
Not a l l o c a t e d
Filler
P147. IMPUTATION OF ABILITY TO SPEAK ENGLISH(4)
U n i v e r s e : Persons 5 y e a r s and over
Speak o n l y E n g l i s h
Speak o t h e r language:
Allocated
Not a l l o c a t e d
Filler
P148. IMPUTATION OF VETERAN STATUS(2)
U n i v e r s e : Persons IS y e a r s and over
Allocated
Not a l l o c a t e d
Filler
P149. IMPUTATION OF PERIOD OF MILITARY SERVICE(3)
U n i v e r s e : C i v i l i a n v e t e r a n s 16 years and over
Allocated
Not a l l o c a t e d
Filler
P150. IMPUTATION OF WORK DISABILITY STATUS(3)
U n i v e r s e : C i v i l i a n n o n i n s t i t u t i o n a l i z e d persons 16 years and over
Allocated
Not a l l o c a t e d
Filler
P151. IMPUTATION OF MOBILITY LIMITATION STATUS(3)
3
3
3
3
3
3
5
3
4
4
2
3
3
3
�P152.
P153.
P154.
P155.
P156.
P157.
P158.
P159.
P160.
P1G1.
P162.
P163.
U n i v e r s e : C i v i l i a n n o n i n s t i t u t i o n a l i z e d persons 16 years and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF SELF-CARE LIMITATION STATUS(3)
3
U n i v e r s e : C i v i l i a n n o n i n s t i t u t i o n a l i z e d persons 16 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF CHILDREN EVER B0RN(3)
3
U n i v e r s e : Ftmales 15 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF PLACE OF W0RK(4)
4
U n i v e r s e : Workers 16 y e a r s and over
Allocated:
One o r more b u t n o t a l l geographic p a r t s a l l o c a t e d
A l l geographic p a r t s a l l o c a t e d
Not a l l o c a t e d
Filler
IMPUTATION 0'.? MEANS OF TRANSPORTATION TO WORK (3)
3
U n i v e r s e : Workers 16 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF PRIVATE VEHICLE OCCUPANCY(4)
4
U n i v e r s e : Workers 16 y e a r s and over
Car, t r u c k , o r van:
Allocated
Not a l l o c a t e d
Filler
Other means
IMPUTATION OF TIME LEAVING HOME TO GO TO WORK(4)
4
U n i v e r s e : Workers 16 y e a r s and over
D i d n o t work a t home:
Allocated
Not a l l o c a t e d
Filler
Worked a t heme
IMPUTATION OF TRAVEL TIME TO W0RK(4)
4
U n i v e r s e : Workers 16 y e a r s and over
Did n o t work a t home:
Allocated
Not a l l o c a t e d
Filler
Worked a t home
IMPUTATION OF EMPLOYMENT STATUS(3)
3
U n i v e r s e : Persons 16 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF WORK STATUS I N 1989(3)
3
U n i v e r s e : Persons 16 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF USUAL HOURS WORKED PER WEEK I N 1989(4)
4
U n i v e r s e : Persons 16 y e a r s and over
Worked i n 1989:
Allocated
Not a l l o c a t e d
Filler
D i d n o t work i n 1989
IMPUTATION OF WEEKS WORKED I N 1989(4)
4
U n i v e r s e : Persons 16 y e a r s and over
Worked i n 1989:
Allocated
Not a l l o c a t e d
Filler
D i d n o t work i n 1989
IMPUTATION OF INDUSTRY(3)
3
U n i v e r s e : Employed persons 16 years and over
Allocated
Not a l l o c a t e d
�P164.
P165.
P166.
P167.
P168.
P169.
P170.
HI.
H2.
H3.
H3A.
H4.
H5.
H6.
H7.
H8.
Filler
IMPUTATION OF OCCUPATION(3)
U n i v e r s e : Employed persons 16 years and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF CLASS OF WORKER(3)
U n i v e r s e : Employed persons 16 years and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF INCOME I N 1989(3)
Universe:
Persons 15 y e a r s and over
Allocated
Not a l l o c a t e d
Filler
IMPUTATION OF HOUSEHOLD INCOME I N 1989(2)
Universe:
Households
Allocated
Not a l l o c a t e d
IMPUTATION OF FAMILY INCOME I N 1989(2)
Universe:
Families
Allocated
Not a l l o c a t e d
IMPUTATION OF NONFAMILY HOUSEHOLD INCOME IN 1989(2)
U n i v e r s e : N o n f a m i l y households a l l o c a t e d
Not a l l o c s i t e d
IMPUTATION OF POVERTY STATUS I N 1989(3)
U n i v e r s e : Persons f o r whom p o v e r t y s t a t u s i s determined
Filler
Allocated
Not a l l o c a t e d
HOUSING UNMTS(1)
U n i v e r s e : Housing u n i t s
Total
UNWEIGHTED SAMPLE COUNT OF HOUSING UNITS(1)
U n i v e r s e : Housing u n i t s
Total
10 0-PERCENT COUNT OF HOUSING UNITS(1)
U n i v e r s e : Housing u n i t s
Total
PERCENT OF HOUSING UNITS I N SAMPLE(1)
U n i v e r s e : Housing u n i t s
Total
OCCUPANCY STATUS(2)
U n i v e r s e : Housing u n i t s
Occupied
Vacant
URBAN AND RURAL(4)
U n i v e r s e : Housing u n i t s
Urban:
I n s i d e u r b a n i z e d area
O u t s i d e u r b a n i z e d area
Rural:
Farm
Nonfarm
CONDOMINIUM STATUS(2) BY VACANCY STATUS(4)
U n i v e r s e : Vacant h o u s i n g u n i t s
Condominium:
For rent:
For s a l e o n l y
For s e a s o n a l , r e c r e a t i o n a l , o r o c c a s i o n a l use
A l l other vacants
Not condominium:
(Repeat VACANCY STATUS)
CONDOMINIUM STATUS(2) BY TENURE AND MORTGAGE STATUS(3)
U n i v e r s e : Occupied h o u s i n g u n i t s
Condominium:
Owner o c c u p i e d :
W i t h a mortgage
Not mortgaged
Renter o c c u p i e d
Not condcminium:
(Repeat TENURE AND MORTGAGE STATUS)
TENURE(2)
�H9.
H10.
Hll.
H12.
H13.
H14.
HIS.
H16.
U n i v e r s e : Occupied housing u n i t s
Owner o c c u p i e d
Renter o c c u p i e d
RACE OF HOUSEHOLDER(5)
5
U n i v e r s e : Occupied housing u n i t s
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
TENURE(2) BY RACE OF HOUSEHOLDER(5)
10
U n i v e r s e : Occupied housing u n i t s
Owner o c c u p i e d :
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
Renter o c c u p i e d :
(Repeat RACE OF HOUSEHOLDER)
HISPANIC ORIGIN OF HOUSEHOLDER(2) BY RACE OF HOUSEHOLDER(5)
10
U n i v e r s e : Occupied housing u n i t s
Not o f H i s p a n i c o r i g i n :
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
Hispanic o r i g i n :
(Repeat FACE OF HOUSEHOLDER)
TENURE(2) BY RACE OF HOUSEHOLDER(5)
10
U n i v e r s e : Occupied housing u n i t s w i t h householder o f H i s p a n i c o r i g i n
Owner o c c u p i e d :
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
Renter o c c u p i e d :
(Repeat RACE OF HOUSEHOLDER)
TENURE(2) BY AGE OF HOUSEHOLDER(7)
14
U n i v e r s e : Occupied housing u n i t s
Owner o c c u p i e d :
15 t o 24 y e a r s
25 t o 34 y e a r s
35 t o 44 y e a r s
45 t o 54 y e a r s
55 t o 64 y e a r s
65 t o 74 y e a r s
75 years and over
Renter o c c u p i e d :
(Repeat AGE OF HOUSEHOLDER)
AGGREGATE PERSONS(1) BY TENURE(2) BY RACE OF HOUSEHOLDER(5)
10
U n i v e r s e : Persons i n o c c u p i e d housing u n i t s
Total:
Owner o c c u p i e d :
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other reice
Renter o c c u p i e d :
(Repeat RACE OF HOUSEHOLDER)
AGGREGATE PERSONS(1) BY TENURE(2)
2
U n i v e r s e : Persons i n occupied housing u n i t s w i t h householder o f
Hispanic o r i g i n
Total:
Owner o c c u p i e d
Renter o c c u p i e d
ROOMS(9)
9
U n i v e r s e : Housing u n i t s
1 room
2 rooms
3 rooms
4 rooms
�Other means
YEAR STRUCTURE BUILT(8)
U n i v e r s e : Housing u n i t s
1989 t o March 1990
1985 t o 1983
1980 t o 1981
1970 t o 1979
1960 t o 1969
1950 t o 1959
1940 t o 194 9
1939 o r e a r l i e r
H2 5A. MEDIAN YEAR STRUCTURE BUILT(1)
U n i v e r s e : Housing u n i t s
Median y e a r s t r u c t u r e b u i l t
H26. YEAR STRUCTURE BUILT(8)
U n i v e r s e : Vacant h o u s i n g u n i t s
1989 t o March 1990
1985 t o 1988
1980 t o 1984
1970 t o 1979
1960 t o 1969
1950 t o 1959
1940 t o 1949
1939 o r e a r l i e r
H2 7.
TENURE(2) BY YEAR STRUCTURE BUILT(8)
U n i v e r s e : Occupied h o u s i n g u n i t s
Owner o c c u p i e d :
1989 t o March 1990
1985 t o 1988
1980 t o 1984
1970 t o 1979
1960 t o 1969
1950 t o 1959
1940 t o 1949
1939 o r e a r l i e r
Renter o c c u p i e d :
(Repeat YEAR STRUCTURE BUILT)
H2 8.
YEAR HOUSEHOLDER MOVED INTO UNIT(6)
U n i v e r s e : Occupied h o u s i n g u n i t s
1989 t o March 1990
1985 t o 19£:8
1980 t o 19£:4
1970 t o 1979
1960 t o 1969
1959 o r e a r l i e r
H29.
TENURE(2) BY YEAR HOUSEHOLDER MOVED INTO UNIT(6)
U n i v e r s e : Occupied h o u s i n g u n i t s
Owner o c c u p i e d :
1989 t o March 1990
1985 t o :.988
1980 t o :'.984
1970 t o 1979
1960 t o 1969
1959 o r e a r l i e r
Renter o c c u p i e d :
(Repeat YEAR HOUSEHOLDER MOVED INTO UNIT)
H30.
HOUSE HEATING FUEL(9)
U n i v e r s e : Occupied h o u s i n g u n i t s
U t i l i t y gas
B o t t l e d , t a n k , o r LP gas
Electricity
Fuel o i l , kerosene, e t c .
Coal o r coxe
Wood
S o l a r energy
Other f u e l
No f u e l used
H31. BEDROOMS(6)
U n i v e r s e : Housing u n i t s
No bedroom
1 bedroom
2 bedrooms
3 bedrooms
4 bedrooms
5 o r more bedrooms
H25.
8
1
8
16
6
12
9
6
�H32.
H33.
H3 4.
H35.
H36.
H37.
H3 8.
H39.
BEDROOMS(6)
U n i v e r s e : Vacant housing u n i t s
No bedroom
1 bedroom
2 bedrooms
3 bedrooms
4 bedrooms
5 o r more bedrooms
TENURE(2) BY BEDROOMS(6)
U n i v e r s e : Occupied housing u n i t s
Owner o c c u p i e d :
No bedroom
1 bedroom
2 bedrooms
3 bedrooms
4 bedrooms
5 o r more bedrooms
Renter o c c u p i e d :
(Repeat BEDROOMS)
BEDROOMS(4) BY GROSS RENT(7)
Universe:
S p e c i f i e d r e n t e r - o c c u p i e d housing u n i t s
No bedroom:
W i t h cash r e n t :
Less t h a n $200
$200 t o $299
$300 t o $499
$500 t o $749
$750 t o $999
$1,000 o r more
No cash r e n t
1 bedroom:
(Repeat GROSS RENT)
2 bedrooms:
(Repeat GROSS RENT)
3 o r more bedrooms:
(Repeat GROSS RENT)
TENURE(2) BY TELEPHONE I N HOUSING UNIT(2)
U n i v e r s e : Occupied housing u n i t s
Owner o c c u p i e d :
With telephone
No t e l e p h o n e
Renter o c c u p i e d :
(Repeat TELEPHONE I N HOUSING UNIT)
AGE OF HOUSEHOLDER(4) BY TELEPHONE IN HOUSING UNIT(2)
U n i v e r s e : Occupied housing u n i t s
15 t o 59 y e a r s :
With telephone
No t e l e p h o n e
SO t o 64 y e a r s :
(Repeat TELEPHONE I N HOUSING UNIT)
65 t o 74 y e a r s :
(Repeat TELEPHONE I N HOUSING UNIT)
75 years a r d over:
(Repeat TELEPHONE I N HOUSING UNIT)
TENURE (2) E'.Y VEHICLES AVAILABLE (6)
U n i v e r s e : Occupied housing u n i t s
Owner o c c u p i e d :
None
l
2
3
4
5 o r more
Renter o c c u p i e d :
(Repeat: VEHICLES AVAILABLE)
AGGREGATE VEHICLES AVAILABLE(1) BY TENURE(2)
U n i v e r s e : Occupied housing u n i t s
T o t a l .Owner o c c u p i e d
Renter o c c u p i e d
RACE OF HOUSEHOLDER(5) BY VEHICLES AVAILABLE(2)
U n i v e r s e : Occupied housing u n i t s
White:
None
1 o r more
6
12
28
4
8
12
2
10
�Not mortgaged:
Less t h a n $100
$100 t o $149
$150 t o $199
$200 t o $249
$250 t o $299
$300 t o $::49
$350 t o $J99
$400 o r more
H52A. MEDIAN SELECTED MONTHLY OWNER COSTS AND MORTGAGE STATUS(2)
2
U n i v e r s e : S p e c i f i e d owner-occupied h o u s i n g u n i t s
W i t h a mortgage
Not mortgagfid
H53. AGGREGATE SELECTED MONTHLY OWNER COSTS(1) BY MORTGAGE STATUS(2)
2
U n i v e r s e : S p e c i f i e d owner-occupied h o u s i n g u n i t s
Total:
W i t h a mortgage
Not mortgaged
H54. RACE OF HOUSEHOLDER(5) BY MORTGAGE STATUS AND SELECTED MONTHLY
OWNER COSTS(11)
55
U n i v e r s e : S p e c i f i e d owner-occupied housing u n i t s
White:
W i t h a mortgage:
Less t h a n $300
$300 t o $499
$500 t o $699
$700 t o $999
$1,000 t o $1,499
$1,500 o r more
Not mortgaged:
Less t h a n $100
$100 t o $199
$200 t o $299
$300 t o $399
$400 o r more
Black:
(Repeat MORTGAGE STATUS AND SELECTED MONTHLY OWNER COSTS)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat MORTGAGE STATUS AND SELECTED MONTHLY OWNER COSTS)
Asian o r P a c i f i c Islander:
(Repeat MORTGAGE STATUS AND SELECTED MONTHLY OWNER COSTS)
Other r a c e :
(Repeat MORTGAGE STATUS AND SELECTED MONTHLY OWNER COSTS)
H55. MORTGAGE STATUS AND SELECTED MONTHLY OWNER COSTS(11)
11
U n i v e r s e : .Specified owner-occupied housing u n i t s w i t h householder o f
Hispanic o r i g i n
W i t h a mortgage:
Less t h a n $300
$300 t o $499
$500 t o $699
$700 t o $999
$1,000 t o $1,499
$1,500 o r more
Not mortgaged:
Less t h a n $100
$100 t o $199
$200 t o $299
$300 t o $399
$4 0 0 o r more
H56. AGGREGATE SELECTED MONTHLY OWNER COSTS(1) BY MORTGAGE STATUS(2)
2
U n i v e r s e : Owner-occupied m o b i l e homes o r t r a i l e r s
Total:
W i t h a mortgage
Not mortgaged
H5 7. AGGREGATE SELECTED MONTHLY OWNER COSTS(1) BY MORTGAGE STATUS(2)
2
U n i v e r s e : Owner-occupied condominium housing u n i t s
Total:
W i t h a mortgage
Not mortgaged
H58. MORTGAGE STATUS(2) BY SELECTED MONTHLY OWNER COSTS AS A
PERCENTAGE OF HOUSEHOLD INCOME I N 1989(6)
12
U n i v e r s e : S p e c i f i e d owner-occupied housing u n i t s
W i t h a mortgage:
Less t h a n 20 p e r c e n t
20 t o 24 p e r c e n t
�25 t o 29 p e r c e n t
30 t o 34 p e r c e n t
3 5 p e r c e n t , o r more
Not computed
N o t mortgage:d:
( R e p e a t SELECTED MONTHLY OWNER COSTS AS A PERCENTAGE OF HOUSEHOLD
INCOME I N 1 9 8 9 )
H5 8A.
MEDIAN SELEICTED MONTHLY OWNER COSTS AS A PERCENTAGE OF
HOUSEHOLD INCOME I N 19 8 9 AND MORTGAGE STATUS(2)
2
Universe:
S p e c i f i e d owner-occupied
housing u n i t s
W i t h a mortciage
Not m o r t g a g e d
H59.
HOUSEHOLD INCOME I N 1 9 8 9 ( 5 ) BY SELECTED MONTHLY OWNER COSTS AS A
PERCENTAGE OF HOUSEHOLD INCOME I N 1 9 8 9 ( 6 )
30
Universe:
S p e c i f i e d owner-occupied
housing u n i t s
Less t h a n $10,000:
L e s s t h a n 20 p e r c e n t
20 t o 24 p e r c e n t
25 t o 29 p e r c e n t
30 t o 34 p e r c e n t
3 5 percent: o r more
Not computed
$ 1 0 , 0 0 0 t o :;19,999:
( R e p e a t SELECTED MONTHLY OWNER COSTS AS A PERCENTAGE OF
HOUSEHOLD INCOME I N 198 9)
$20,000 t o $34,999:
( R e p e a t SELECTED MONTHLY OWNER COSTS AS A PERCENTAGE OF
HOUSEHOLD INCOME I N 1 9 8 9 )
$35,000 t o $49,999:
( R e p e a t SELECTED MONTHLY OWNER COSTS AS A PERCENTAGE OF
HOUSEHOLD INCOME I N 1 9 8 9 )
$50,000 o r more:
( R e p e a t SELECTED MONTHLY OWNER COSTS AS A PERCENTAGE OF
HOUSEHOLD INCOME I N 1 9 8 9 )
H60.
AGE OF HOUSEHOLDER(2) BY SELECTED MONTHLY OWNER COSTS AS A
PERCENTAGE OF HOUSEHOLD INCOME I N 1 9 8 9 ( 6 )
12
Universe:
S p e c i f i e d owner-occupied
housing u n i t s
15 t o 64 y e a r s :
Less t h a n 2 0 p e r c e n t
20 t o 24 p e r c e n t
25 t o 29 p e r c e n t
30 t o 34 [ p e r c e n t
3 5 p e r c e n t o r more
Not computed
65 y e a r s a n d o v e r :
( R e p e a t SELECTED MONTHLY OWNER COSTS AS A PERCENTAGE OF
HOUSEHOLD INCOME I N 1 9 8 9 )
H61.
VALUE(20)
20
Universe:
S p e c i f i e d owner-occupied
housing u n i t s
Less t h a n $15,000
$15,000 t o $19,999
$20,000 t o $24,999
$25,000 t o $29,999
$30,000 t o $34,999
$35,000 t o $39,999
$40,000 t o $44,999
$45,000 t o $49,999
$50,000 t o $ 5 9 , 9 9 9
$60,000 t o $74,999
$75,000 t o $99,999
$100,000 t o $124,999
$125,000 t c $149,999
$150,000 t c $174,999
$175,000 t c $199,999
$200,000 t c $249,999
$250,000 t o $299,999
$300,000 t o $399,999
$400,000 t c $499,999
$500,000 o r more
H61A. MEDIAN VALUE(1)
1
Universe:
S p e c i f i e d owner-occupied
housing u n i t s
Median v a l u e
H6 2.
AGGREGATE VALUE(1) BY MORTGAGE STATUS(2)
2
Universe:
S p e c i f i e d owner-occupied
housing u n i t s
Total:
�TABLE (MATRIX) OUTLINES -- STF ID
Table
(matrix)
Title
PI.
Persons(1)
U n i v e r s e : Persons
Total
P2.
Families(1)
U n i v e r s e : E'amilies
Total
P3.
Households(1)
Universe:
Households
Total
P4.
Urban and R u r a l ( 4 )
Universe:
Persons
Urban:
I n s i d e u r b a n i z e d area
Outside u r b a n i z e d area
Rural
Not d e f i n e d f o r t h i s f i l e
P5 .
Sex (2)
Universe:
Male
Female
Persons
P6.
Race(5)
Universe:
Persons
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r PEicific I s l a n d e r
Other race
P7.
Race(25)
Universe:
Persons
White (800-869, 971)
Black (870-934, 972)
American I n d i a n , Eskimo, o r A l e u t (000-599, 935-970,
American I n d i a n (000-599, 973)
Eskimo (335-940, 974)
A l e u t (941-970, 975)
A s i a n o r P a c i f i c I s l a n d e r (600-699, 976-985) :
A s i a n (600-652, 976, 977, 979-982, 9 8 5 ) :
Chinese (605-607, 976)
F i l i p i n o (608, 977)
Japanese (611, 981)
A s i a n I n d i a n (600, 982)
Korean (612, 979)
Vietnamese (619, 980)
Cambodicn (604)
Hmong (609)
L a o t i a n (613)
Thai (618)
Other A s i a n (601-603, 610, 614-617, 620-652, 985)
P a c i f i c I s l a n d e r (653-699, 978, 983, 9 8 4 ) :
P o l y n e s i a n (653-659, 978, 9 8 3 ) :
Hawaiian (653, 654, 978)
Samoan (655, 983)
Tongan (657)
Other P o l y n e s i a n (656, 658, 659)
M i c r o n e s i a n (660-675, 984) :
Guamanian (660, 9 84)
Other M i c r o n e s i a n (661-675)
Melanesian (676-680)
P a c i f i c I s l a n d e r , n o t s p e c i f i e d (681-699)
Other race (700-799, 986-999)
P8.
T o t a l number
o f data c e l l s
Persons o f H i s p a n i c O r i g i n ( 1 )
U n i v e r s e : Persons o f H i s p a n i c o r i g i n
25
973-975)
�Total
P9.
Hispanic OriijintS)
Universe:
Persons
Not o f H i s p a n i c o r i g i n
Hispanic o r i g i n :
Mexican
Puerto Rican
Cuban
Other H i s p a n i c
5
P10.
H i s p a n i c O r i g i n ( 2 ) by Race(5)
Universe:
Persons
Not o f H i s p a n i c o r i g i n :
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
Hispanic o r i g i n :
(Repeat RE:ce)
10
Pll.
Age(31)
Universe:
Persons
Under 1 y e a r
1 and 2 y e a r s
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 t o 24 y e a r s
2 5 t o 2 9 years
3 0 t o 34 y e a r s
3 5 t o 3 9 ye:ars
4 0 t o 44 ye:ars
4 5 t o 4 9 years
50 t o 54 years
55 t o 59 y e a r s
60 and 61 y e a r s
62 t o 64 y e a r s
65 t o 69 y e a r s
70 t o 74 y e a r s
75 t o 79 y e a r s
80 t o 84 y e a r s
85 years a i d over
31
P12.
Race(5) b y S e x ( 2 ) b y A g e ( 3 1 )
Universe:
Persons
White:
Male :
Under 1 y e a r
1 and 2 years
3 and 4 years
5 years
6 years
7 t o S years
10 and 11 years
12 and 13 years
14 years
15 y e a r s
16 y e a r s
17 y e a r s
18 y e a r s
19 y e a r s
20 y e a r s
310
�21 y e a r s
22 t o 24 y e a r s
25 t o 29 y e a r s
30 t o 34 y e a r s
35 t o 3 9 y e a r s
40 t o 44 y e a r s
45 t o 49 y e a r s
50 t o 54 y e a r s
55 t o 59 y e a r s
60 and 61 y e a r s
62 t o 64 y e a r s
65 t o 69 y e a r s
70 t o 74 y e a r s
75 t o 79 y e a r s
80 t o 84 y e a r s
85 y e a r s and over
Female:
(Repeat Age)
Black:
(Repeat Sex by Age)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat Se:x by Age)
Asian or P a c i f i c Islander:
(Repeat Seix by Age)
Other r a c e :
(Repeat Sex by Age)
P13.
Sex(2) by Age(31)
U n i v e r s e : Persons o f H i s p a n i c o r i g i n
Male:
Under 1 y e a r
1 and 2 y e a r s
3 and 4 y e a r s
5 years
6 years
7 t o 9 years
10 and 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 y e a r s
16 y e a r s
17 y e a r s
18 y e a r s
19 y e a r s
20 y e a r s
21 y e a r s
22 t o 24 y e a r s
25 t o 29 y e a r s
30 t o 34 y e a r s
3 5 t o 3 9 years
40 t o 44 y e a r s
45 t o 49 y e a r s
50 t o 54 y e a r s
55 t o 59 y e a r s
60 and 61 y e a r s
62 t o 64 y e a r s
65 t o 69 y e a r s
70 t o 74 y e a r s
75 t o 79 y e a r s
80 t o 84 y e a r s
8 5 y e a r s and over
Female:
(Repeat Age)
62
P14.
Sex(2) by M a r i t a l S t a t u s ( 5 )
U n i v e r s e : Persons 15 y e a r s and over
Male:
Never meirried
Now m a r i i e d , except s e p a r a t e d
Separated
Widowed
Divorced
Female:
(Repeat M a r i t a l S t a t u s )
10
�P15.
Household T^pe and R e l a t i o n s h i p ( 1 3 )
Universe:
Persons
I n f a m i l y households:
Householdeir
. Spouse
Child:
N a t u r a l - b o r n o r adopted
Step
Grandchild
Other r e l s i t i v e s
Nonrelatives
I n n o n f a m i l y households:
Householder l i v i n g alone
Householdeir n o t l i v i n g alone
Nonrelatives
I n group q u s i r t e r s :
I n s t i t u t i o n a l i z e d persons
Other persons i n group q u a r t e r s
13
P16.
Household s i z e and Household Type(10)
Universe:
Households
1 person:
Male householder
Female householder
2 o r more pe:rsons:
F a m i l y households:
Married-couple family:
With r e l a t e d c h i l d r e n
No r e l a t e d c h i l d r e n
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
With r e l a t e d c h i l d r e n
No r e l a t e d c h i l d r e n
Female householder, no husband p r e s e n t :
With r e l a t e d c h i l d r e n
No r e l a t e d c h i l d r e n
N o n f a m i l y households:
Male householder
Female householder
10
P17.
Persons i n F a m i l i e s ( 1 )
U n i v e r s e : Persons i n f a m i l i e s
Total
1
P17A.
Persons p e r F a m i l y ( 1 )
Universe:
Families
Persons p e r f a m i l y
1
P18.
Age o f Household Members(2) by Household Type(5)
Universe:
Households
Households w i t h 1 o r more persons under 18 y e a r s :
F a m i l y households:
Married-couple f a m i l y
Other f a m i l y :
Male householder, no w i f e p r e s e n t
Female householder, no husband p r e s e n t
N o n f a m i l y households:
Male householder
Female householder
Households w i t h no persons under 18 y e a r s :
(Repeat Household Type)
10
P19.
Race o f Householder(5) by Household Type(8)
Universe:
Households
White:
F a m i l y households:
Married-couple family:
With r e l a t e d c h i l d r e n
No r e l a t e d c h i l d r e n
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
With r e l a t e d c h i l d r e n
No r e l a t e d c h i l d r e n
Female householder, no husband p r e s e n t :
40
Filler
�With r e l a t e d c h i l d r e n
No r e l a t e d c h i l d r e n
N o n f a m i l y households:
Householder l i v i n g alone
Householder n o t l i v i n g alone
Black:
(Repeat Household Type)
American I n d i a n , Eskimo, o r A l e u t :
(Repeat Household Type)
Asian or P a c i f i c I s l a n d e r :
(Repeat Household Type)
Other r a c e :
(Repeat Household Type)
P2 0.
Household Type(8)
U n i v e r s e : Households w i t h householder o f H i s p a n i c o r i g i n
F a m i l y households:
Married-couple family:
With r e l a t e d c h i l d r e n
No r e l a t e d c h i l d r e n
Other f a m i l y :
Male householder, no w i f e p r e s e n t :
With r e l a t e d c h i l d r e n
No r e l a t e d c h i l d r e n
Female householder, no husband p r e s e n t :
With r e l a t e d c h i l d r e n
No r e l a t e d c h i l d r e n
N o n f a m i l y households:
Householder l i v i n g alone
Householder n o t l i v i n g alone
8
P21.
Household Type and R e l a t i o n s h i p ( 9 )
U n i v e r s e : Persons under 18 y e a r s
I n households:
Householder o r spouse
Own c h i l d :
I n married-couple family
In other family:
Male householder, no w i f e p r e s e n t
Female householder, no husband p r e s e n t
Other r e l a t i v e s
Nonrelatives
I n group q u a r t e r s :
I n s t i t u t i o n a l i z e d persons
Other persons i n group q u a r t e r s
9
Filler
P22.
R e l a t i o n s h i p and Age(37)
U n i v e r s e : Persons under 18 y e a r s
I n households:
Householder o r spouse
Related c h i l d :
Own c h i l d :
Under 3 y e a r s
3 and 4 y e a r s
5 years
6 t o 11 y e a r s
12 and. 13 y e a r s
14 y e a r s
15 t o 17 y e a r s
Other r e l a t i v e s :
Under 3 y e a r s
3 and 4 y e a r s
5 years
6 t o l l years
12 and 13 y e a r s
14 yec.rs
15 t o 17 y e a r s
Nonrelatives:
Under 3 y e a r s
3 and 4 y e a r s
5 years
G t o 11 y e a r s
12 ancl 13 y e a r s
14 yeeirs
37
�15 t o 17 y e a r s
I n group q u a r t e r s :
I n s t i t u t i o n a l i z e d persons:
Under 3 y e a r s
3 and 4 y e a r s
5 years
G t o 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 t o 17 y e a r s
Other persons i n group q u a r t e r s :
Under 3 y e a r s
3 and 4 y e a r s
5 years
6 t o 11 y e a r s
12 and 13 y e a r s
14 y e a r s
15 t o 17 y e a r s
Filler
P23.
Household Type and R e l a t i o n s h i p ( 1 2 )
U n i v e r s e : Persons 6 5 y e a r s and over
I n f a m i l y households:
Householder
Spouse
Other r e l a t i v e s
Nonrelatives
I n n o n f a m i l y households:
Male householder:
L i v i n g alone
Not l i v i n g alone
Female householder:
L i v i n g E.lone
Not l i v i n g alone
Nonrelatives
I n group qua.rters:
I n s t i t u t i o n a l i z e d persons
Other persons i n group q u a r t e r s
12
Filler
P24.
P25.
Age o f Houseihold Members (2) by Household Size
and Household Type(3)
U n i v e r s e : Households
Households w i t h 1 o r more persons 60 years and over:
1 person
2 o r more persons:
Family households
N o n f a m i l y households
Households w i t h no persons 60 years and over:
(Repeat Household Size and Household Type)
Age o f Household Members(2) by Household Size and
Household Type(3)
U n i v e r s e : Households
Households w i t h 1 o r more persons 65 years and over:
1 person
2 o r more persons:
F a m i l y households
N o n f a m i l y households
Households w i t h no persons 65 y e a r s and over:
(Repeat Household Size and Household Type)
6
6
P26.
Household Type(2)
U n i v e r s e : Households
Households w i t h 1 o r more n o n r e l a t i v e s
Households w i t h no n o n r e l a t i v e s
2
P27.
Household Type and Household Size(13)
U n i v e r s e : Households
F a m i l y households:
2 persons
3 persons
4 persons
5 persons
6 persons
13
�7 or more persons
Nonfamily households:
1 person
2 persons
3 persons
4 persons
5 persons
6 persons
7 o r more persons
P28.
Group Q u a r t e r s ( 1 0 )
U n i v e r s e : Persons i n group q u a r t e r s
I n s t i t u t i o n a l i z e d persons (001-991):
C o r r e c t i o n a l i n s t i t u t i o n s (201-241, 271, 281,
951)
N u r s i n g homes (601-671)
Mental ( P s y c h i a t r i c ) h o s p i t a l s (451-481)
J u v e n i l e i n s t i t u t i o n s (011-051, 101-121, 151)
Other i n s t i t u t i o n s (001, 061-091, 131, 141, 161-191,
261, 291-441, 491-591, 681-941, 961-991)
Other persons i n group q u a r t e r s (00N-99N):
College d o r m i t o r i e s
(87N)
M i l i t a r y q u a r t e r s (96N-98N)
Emergency s h e l t e r s f o r homeless (82N,
83N)
V i s i b l e i n s t r e e t l o c a t i o n s (84N,
85N)
Other n o n i n s c i t u t i o n a l group q u a r t e r s (00N-81N, 86N,
88N-95N, 93N)
10
251,
P29.
Persons S u b s t i t u t e d ( 3 )
U n i v e r s e : Persons
Not s u b s t i t u t e d
Substituted for:
Noninterview
Filler
3
P30.
Imputation of Population Items(2)
U n i v e r s e : Persons not s u b s t i t u t e d
No i t e m s a l l o c a t e d
One or more i t e m s a l l o c a t e d
2
P31.
Imputation of Relationship(2)
U n i v e r s e : Persons not s u b s t i t u t e d
Allocated
Not a l l o c a t e d
2
P32.
I m p u t a t i o n o f Sex(2)
U n i v e r s e : Persons not
Allocated
Not a l l o c a t e d
2
P33.
I m p u t a t i o n c f Age(2)
U n i v e r s e : Persons not
Allocated
Not a l l o c a t e d
substituted
2
substituted
P34.
I m p u t a t i o n o f Race(2)
U n i v e r s e : Persons not s u b s t i t u t e d
Allocated
Not a l l o c a t e i d
2
P35.
Imputation of Hispanic O r i g i n ( 2 )
U n i v e r s e : Persons not s u b s t i t u t e d
Allocated
Not a l l o c a t e d
2
P36.
I m p u t a t i o n of M a r i t a l S t a t u s ( 3 )
U n i v e r s e : Persons 15 y e a r s and over
Substituted
Not s u b s t i t u t e d :
Allocated
Not a l l o c a t e d
3
HI.
Housing U n i t s ( 1 )
U n i v e r s e : Housing u n i t s
Total
1
�H2.
Occupancy S t a t u s ( 2 )
Universe: Housing u n i t s
Occupied
Vacant
2
H3 .
Tenure (2)
U n i v e r s e : Occupied h o u s i n g u n i t s
Owner o c c u p i e d
Renter o c c u p i e d
2
H4.
Urban and R u r a l (4)
U n i v e r s e : Hcusing u n i t s
Urban:
I n s i d e u r b a n i z e d area
O u t s i d e u r b a n i z e d area
Rural
Not d e f i n e d f o r t h i s f i l e
4
H5.
Vacancy S t a t u s ( 6 )
U n i v e r s e : Vacant h o u s i n g u n i t s
For r e n t
For s a l e o n l y
Rented o r s o l d , n o t o c c u p i e d
For seasonal, r e c r e a t i o n a l , o r o c c a s i o n a l use
For m i g r a n t workers
Other vacant
6
HS.
Boarded-up S t a t u s ( 2 )
U n i v e r s e : Vacant h o u s i n g u n i t s
Boarded up
Not boarded up
2
HI.
Usual Home Elsewhere(2)
U n i v e r s e : Vacant h o u s i n g u n i t s
Vacant, u s u a l home elsewhere
A l l other vacants
2
H8.
Race o f Householder(5)
U n i v e r s e : Occupied housing u n i t s
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
5
H9.
Tenure(2) by Race o f Householder(5)
U n i v e r s e : Occupied h o u s i n g u n i t s
Owner o c c u p i e d :
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
Other race
Renter o c c u p i e d :
(Repeat Race o f Householder)
10
H10.
H i s p a n i c O r i g i n o f Householder(2) by Race o f Householder(5)
U n i v e r s e : Occupied housing u n i t s
Not o f Hispa.nic o r i g i n :
White
Black
American I n d i a n , Eskimo, o r A l e u t
A s i a n o r E'acific I s l a n d e r
Other race:
Hispanic o r i g i n :
(Repeat Raice o f Householder)
10
Hll.
Tenure(2) by Race o f Householder(5)
U n i v e r s e : Occupied housing u n i t s w i t h householder
of H i s p a n i c o r i g i n
Owner o c c u p i e d :
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c Islander
10
�Other race
Renter o c c u p i e d :
(Repeat Race o f Householder)
H12.
Tenure(2) by Age o f Householder(7)
U n i v e r s e : Occupied h o u s i n g u n i t s
Owner o c c u p i e d :
15 t o 24 y e a r s
25 t o 34 y e a r s
35 t o 44 y e a r s
45 t o 54 y e a r s
55 t o 64 y e a r s
65 t o 74 y e a r s
75 y e a r s and over
Renter o c c u p i e d :
(Repeat Age o f Householder)
14
H13.
Rooms(9)
U n i v e r s e : Housing u n i t s
1 room
2 rooms
3 rooms
4 rooms
5 rooms
6 rooms
7 rooms
8 rooms
9 o r more rooms
9
H14.
Aggregate Rooms (1)
U n i v e r s e : Housing u n i t s
Total
1
H15.
Aggregate Rooms(1) by Tenure(2)
U n i v e r s e : Occupied h o u s i n g u n i t s
Total:
Owner o c c u p i e d
Renter o c c u p i e d
2
H16.
Aggregate Rooms(1) by Vacancy S t a t u s ( 6 )
U n i v e r s e : Vacant h o u s i n g u n i t s
Total:
For r e n t
For s a l e o n l y
Rented o r s o l d , n o t o c c u p i e d
For s e a s o n a l , r e c r e a t i o n a l , o r o c c a s i o n a l use
For m i g r a n t workers
Other v a c a n t
6
H17 . Persons i n U n i t ( 7 )
U n i v e r s e : Occupied h o u s i n g u n i t s
1 person
2 persons
3 persons
4 persons
5 persons
6 persons
7 o r more persons
7
H17A. Persons p e r Occupied Housing U n i t ( l )
U n i v e r s e : Occupied h o u s i n g u n i t s
Persons p e r o c c u p i e d h o u s i n g u n i t
1
H18.
Tenure(2) by Persons i n U n i t ( 7 )
U n i v e r s e : Occupied h o u s i n g u n i t s
Owner o c c u p i e d :
1 person
2 persons
3 persons
4 persons
5 persons
6 persons
7 o r more persons
Renter o c c u p i e d :
(Repeat Persons i n U n i t )
14
�H18A. Persons p e r Occupied Housing U n i t by Tenure(2)
Universe: Occupied housing u n i t s
Owner o c c u p i e d
Renter o c c u p i e d
H19.
Aggregate Persons(1)
U n i v e r s e : Persons i n occupied housing u n i t s
Total
1
H2 0.
Aggregate Persons(1) by Tenure(2)
U n i v e r s e : Persons i n o c c u p i e d housing u n i t s
Total:
Owner o c c u p i e d
Renter o c c u p i e d
2
H21.
Persons p e r Room(5)
U n i v e r s e : Occupied h o u s i n g u n i t s
0.50 o r l e s s
0.51 t o 1.00
1.01 t o 1.50
1.51 t o 2.00
2.01 o r more
5
H22.
Tenure(2) by Persons p e r Room(5)
U n i v e r s e : Occupied h o u s i n g u n i t s
Owner o c c u p i e d :
0.50 o r lesis
0.51 t o 1.00
1.01 t o 1.50
1.51 t o 2.00
2.01 o r moire
Renter o c c u p i e d :
(Repeat Persons p e r Room)
10
H23.
Value(20)
U n i v e r s e : S p e c i f i e d owner-occupied housing u n i t s
Less t h a n $15,000
$15,000 t o $19,999
$20,000 t o $24,999
$25,000 t o $29,999
$30,000 t o $34,999
$35,000 t o $39,999
$40,000 t o $44,999
$45,000 t o $49,999
$50,000 t o $59,999
$60,000 t o $74,999
$75,000 t o $99,999
$100,000 t o $124,999
$125,000 t o $149,999
$150,000 t o $174,999
$175,000 t o $199,999
$200,000 t o $249,999
$250,000 t o $299,999
$300,000 t o $399,999
$400,000 t o ?499,999
$500,000 o r more
20
H23A. Lower Value Q u a r t i l e U )
U n i v e r s e : S p e c i f i e d owner-occupied housing u n i t s
Lower v a l u e q u a r t i l e
1
H23B. Median V a l u e d )
Universe: S p e c i f i e d
Median v a l u e
1
owner-occupied housing u n i t s
H23C. Upper Value Q u a r t i l e ( l )
U n i v e r s e : S p e c i f i e d owner-occupied housing u n i t s
Upper v a l u e q u a r t i l e
1
H24 . Aggregate V a l u e d )
Universe: S p e c i f i e d
Total
1
H25.
owner-occupied housing u n i t s
Race o f Householder(5)
5
�U n i v e r s e : S p e c i f i e d owner-occupied housing
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian or P a c i f i c I s l a n d e r
Other race
units
H26.
Aggregate V a l u e d ) by Race o f Householder (5)
U n i v e r s e : S p e c i f i e d owner-occupied housing u n i t s
Total:
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian o r P a c i f i c I s l a n d e r
Other race
5
H27.
H i s p a n i c O r i g i n o f Householder(2)
U n i v e r s e : S p e c i f i e d owner-occupied
Not o f H i s p a n i c o r i g i n
Hispanic o r i g i n
2
housing
units
H28.
Aggregate V a l u e d ) by H i s p a n i c O r i g i n o f Householder(2)
U n i v e r s e : S p e c i f i e d owner-occupied housing u n i t s
Total:
Not o f H i s p a n i c o r i g i n
Hispanic o r i g i n
2
H2 9.
Aggregate V a l u e ( 1 ) by U n i t s i n S t r u c t u r e ( 6 )
U n i v e r s e : Owner-occupied housing u n i t s
Total:
1, detached
1, a t t a c h e d
2
3 o r more
Mobile home o r t r a i l e r
Other
6
H3 0.
Vacancy S t a t u s ( 3 )
U n i v e r s e : Vacant housing u n i t s
S p e c i f i e d vacant f o r r e n t
S p e c i f i e d vacant f o r sale o n l y
A l l o t h e r vacants
3
H31.
Aggregate P r i c e Asked(1)
U n i v e r s e : S p e c i f i e d v a c a n t - f o r - s a l e - o n l y housing
Total
H32.
C o n t r a c t Rent(17)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing
W i t h cash r e n t :
Less t h a n $100
$100 t o $149
$150 t o $199
$200 t o $249
$250 t o $299
$300 t o $349
$350 t o $399
$400 t o $449
$450 t o $499
$500 t o $549
$550 t o $599
$eoo t o $649
$650 t o $699
$700 t o $749
$750 t o $S99
$1,000 o r more
No cash r e n t
H32A. Lower Contrs.ct Rent Q u a r t i l e (1)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing
p a y i n g ca£:h r e n t
Lower c o n t r a c t r e n t q u a r t i l e
H32B. Median C o n t r a c t R e n t d )
U n i v e r s e : S f i e c i f i e d r e n t e r - o c c u p i e d housing
1
units
17
units
units
units
�p a y i n g cash r e n t
Median c o n t r c i c t r e n t
H.32C. Upper C o n t r a c t Rent Q u a r t i l e (1)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing
p a y i n g cash r e n t
Upper c o n t r a c t r e n t q u a r t i l e
H33.
H34.
Aggregate C o n t r a c t R e n t d )
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing
p a y i n g cash r e n t
Total
Race o f Householder(5)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing
p a y i n g cash r e n t
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian or P a c i f i c I s l a n d e r
Other race
1
units
1
units
5
units
H35.
Aggregate C o n t r a c t R e n t d ) by Race o f Householder(5)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing u n i t s
p a y i n g cash r e n t
Total:
White
Black
American I n d i a n , Eskimo, o r A l e u t
Asian or P a c i f i c I s l a n d e r
Other race
5
IBS.
H i s p a n i c O r i g i n o f Householder (2)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing
p a y i n g cash r e n t
Not o f H i s p a n i c o r i g i n
Hispanic o r i g i n
2
H37.
H3 8.
units
Aggregate C o n t r a c t R e n t ( l ) by H i s p a n i c O r i g i n of
Householder(2)
•
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing u n i t s
p a y i n g cash r e n t
Total:
Not of H i s p a n i c o r i g i n
Hispanic o r i g i n
Aggregate Rent Asked(1)
U n i v e r s e : S p e c i f i e d v a c a n t - f o r - r e n t housing
Total
2
1
units
H3 9.
Age of Householder(2) by Meals I n c l u d e d i n Rent(3)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing u n i t s
Under 6 5 y e a r s :
W i t h cash r e n t :
Meals i n c l u d e d i n r e n t
No meals i n c l u d e d i n r e n t
No cash r e n t
65 years and over:
(Repeat M£:als I n c l u d e d i n Rent)
6
H4 0.
Vacancy S t a t u s ( 3 ) by D u r a t i o n o f Vacancy(3)
U n i v e r s e : Vcicant housing u n i t s
For r e n t :
Less t h a n 2 months
2 up t o 6 months
6 o r more months
For s a l e o n l y :
(Repeat D u r a t i o n o f Vacancy)
A l l other vacants:
(Repeat D u r a t i o n o f Vacancy)
9
H41.
Units i n Structure(10)
U n i v e r s e : Housing u n i t s
1, detached
1, a t t a c h e d
'
10
�2
3 or 4
5 to 9
10 t o 19
20 t o 49
50 o r more
Mobile home o r t r a i l e r
Other
H42.
Units i n Structure(10)
Universe: Vacant h o u s i n g u n i t s
1, detached
1, a t t a c h e d
2
3 or 4
5 to 9
10 t o 19
20 t o 49
50 o r more
Mobile home o r t r a i l e r
Other
10
H43.
Tenure(2) by U n i t s i n S t r u c t u r e ( 1 0 )
Universe: Occupied h o u s i n g u n i t s
Owner occupied:
1, detached
l , attached
2
3 or 4
5 to 9
10 t o 19
20 t o 49
5 0 o r more
Mobile home o r t r a i l e r
Other
Renter occupied:
(Repeat U n i t s i n S t r u c t u r e )
20
H44.
Aggregate Pe:rsons(l) by Tenure (2) by U n i t s i n S t r u c t u r e (10)
Universe: Persons i n occupied housing u n i t s
Total:
Owner occupied:
1, detached
1, a t t a c h e d
2
3 or 4
5 to 9
10 t o IS
20 t o 45
50 o r more
Mobile home o r t r a i l e r
Other
Renter occupied:
(Repeat U n i t s i n S t r u c t u r e )
'
20
H45.
Housing U n i t s S u b s t i t u t e d ( 2 )
Universe: Housing u n i t s
Substituted
Not s u b s t i t u t e d
2
H46.
I m p u t a t i o n o f Housing Items(2)
Universe: Housing u n i t s n o t s u b s t i t u t e d
No items a l l o c a t e d
One o r more items a l l o c a t e d
2
H47.
I m p u t a t i o n o f Vacancy S t a t u s ( 3 )
Universe: Vcicant h o u s i n g u n i t s
Substituted
Not s u b s t i t u t e d :
Allocated
Not a l l o c a t e d
3
H4 8.
I m p u t a t i o n o f D u r a t i o n o f Vacancy(3)
Universe: Vacant h o u s i n g u n i t s
Substituted
3
�Not s u b s t i t u t e d :
Allocated
Not a l l o c a t e d
H49.
I m p u t a t i o n oJ: U n i t s i n S t r u c t u r e (2)
U n i v e r s e : Housing u n i t s not s u b s t i t u t e d
Allocated
Not a l l o c a t e d
HBO.
I m p u t a t i o n oi: Rooms (2)
Universe: Housing u n i t s not
Allocated
Not a l l o c a t e d
substituted
H51.
I m p u t a t i o n oi: Tenure (3)
U n i v e r s e : Occupied housing u n i t s
Substituted
Not s u b s t i t u t e d :
Allocated
Not a l l o c a t e d
H52.
I m p u t a t i o n ol: Value (3)
U n i v e r s e : S p e c i f i e d owner-occupied housing u n i t s
Substituted
Not s u b s t i t u t e d :
Allocated
Not a l l o c a t e d
H53.
I m p u t a t i o n or P r i c e Asked(3)
Universe: S p e c i f i e d v a c a n t - f o r - s a l e - o n l y
Substituted
Not s u b s t i t u t e d :
Allocated
Not a l l o c a t e d
H54.
H55.
I m p u t a t i o n or C o n t r a c t Rent(4)
Universe: S p e c i f i e d renter-occupied
W i t h cash r e n t :
Substituted
Not s u b s t i t u t e d :
Allocated
Not a l l o c a t e d
No cash r e n t
housing u n i t s
housing u n i t s
I m p u t a t i o n o f Meals I n c l u d e d i n Rent(4)
U n i v e r s e : S p e c i f i e d r e n t e r - o c c u p i e d housing u n i t s
W i t h cash r e n t :
Substitutei
Not s u b s t i t u t e d :
Allocated
Not a l l o c a t e d
No cash r e n t
�PAGE
LEVEL 1 - 1 OF 1 STORY
C o p y r i g h t 1994 The Washington Post
The Washington Post
February
25, 1994, F r i d a y , F i n a l E d i t i o n
SECTION: EDITORIAL; PAGE A21
LENGTH: 84 5 words
HEADLINE: Why Employer Mandates?
\^CG(j
SERIES: O c c a s i o n a l
BYLINE:
Roger
C.
Altman
BODY:
Amid b u s i n e s s c o m p l a i n t s and f r e s h c o n t r o v e r s y over t h e h e a l t h care numbers,
a s s o r t e d commentators have d e c l a r e d t h e p r e s i d e n t ' s h e a l t h care r e f o r m p l a n
dead. T h i s i s r i d i c u l o u s . The o u t l o o k i s a c t u a l l y v e r y good.
That's because t h e .heart o f our p l a n i s guaranteed p r i v a t e h e a l t h i n s u r a n c e .
E i g h t y p e r c e n t o f Americans want t h i s . The e n t i r e c o n g r e s s i o n a l l e a d e r s h i p says
i t does t o o . But some s e l f - s t y l e d r e f o r m e r s i n Congress pay o n l y l i p s e r v i c e t o
t h i s concept. The c e n t r a l q u e s t i o n i s whether Congress w i l l back a mechanism t o
ensure i t .
The p r e s i d e n t has proposed b u i l d i n g upon t h e p r e s e n t system t h r o u g h an
employer mandate. Businesses would be r e q u i r e d t o h e l p pay f o r coverage, and
employees would have t o pay t h e i r share. Today, n i n e o f 10 Americans w i t h
p r i v a t e covera.ge r e c e i v e i t t h i s way.
There a r e o n l y two o t h e r ways t o do i t .
One i s a government program i n which government would r a i s e t h e money t o pay
a l l t h e b i l l s . T h i s i s t o o much c e n t r a l i z a t i o n , t o o much t a x , and t o o much
government.
The second i s an i n d i v i d u a l mandate. A l l Americans would be r e q u i r e d t o buy
coverage, b u t would be on t h e i r own i n d o i n g so, w i t h o u t t h e b e n e f i t o f group
rates.
What those p u s h i n g an i n d i v i d u a l mandate don't say i s t h a t many employers
would no l o n g e r have an i n c e n t i v e t o p r o v i d e coverage. Why s h o u l d t h e y , when
t h e i r employees would end up w i t h i t anyway? So, many employers c o u l d drop i t ,
and t h a t would undermine t h e bedrock o f today's system.
/
I t i s a l s o d o u b t f u l whether an i n d i v i d u a l mandate would b r i n g a r e d u c t i o n i n
" L h e a l t h care i n f l a t i o n , which i s v i t a l t o t r u e r e f o r m . Our employer-based
/ p r o p o s a l would have a l l companies b u y i n g i n volume and b e n e f i t i n g from lower
(^prices.
Some say an i n d i v i d u a l mandate would be e a s i e r t o a d m i n i s t e r . But i n f a c t i t
would i n v o l v e r e f u n d a b l e t a x c r e d i t s f o r much o f America. T h i s would have t h e
IRS s e e k i n g o u t m i l l i o n s who a r e n o t now on t h e t a x r o l l s . Who wants t h a t ?
�PAGE
2
The Washington Post, February 25, 1994
Then t h e r e a r e t h e myths c i r c u l a t i n g about t h e impact o f an employer mandate./
They s h o u l d be exposed f o r what t h e y a r e -- f l a t wrong, m i s l e a d i n g , o r r e d
j
herrings.
One i s t h a t i t would cost j o b s . Numerous independent s t u d i e s , i n c l u d i n g work
by t h e n o n p a r t i s a n C o n g r e s s i o n a l Budget O f f i c e , conclude t h e j o b impact would be
small.
Some c l a i m t h e mandate would cost businesses money. For t h e m a j o r i t y o f
businesses t h a t a l r e a d y p r o v i d e coverage f o r t h e i r employees, t h a t i s wrong. The
CBO has now a f f i r m e d t h a t o u r p l a n would produce major savings i n n a t i o n a l
h e a l t h spending - - a s much as $ 150 b i l l i o n a n n u a l l y by 2004. Since so much o f
t h a t spending i s u n d e r w r i t t e n by businesses, t h e y w i l l r e a l i z e p a r t i c u l a r l y
large savings.
We're s u f f i c i e n t l y c o n f i d e n t o f t h i s t o have proposed an o u t r i g h t cap on
business spending f o r h e a l t h c a r e . Most l a r g e r businesses today spend 10 percent
t o 11 p e r c e n t o f p a y r o l l on i t . We would cap t h a t a t 7.9 p e r c e n t .
A t h i r d myth i s t h a t t h e mandate would c r u s h s m a l l b u s i n e s s . Here, t h e r e i s
an acute m i s u n d e r s t a n d i n g . Those who oppose an employer mandate don't want you
t o know t h a t a m a j o r i t y o f s m a l l businesses a l r e a d y o f f e r coverage. That's
r i g h t . A p p r o x i m a t e l y h a l f o f Americans employed by businesses w i t h fewer t h a n
500 employees are a l r e a d y covered.
These a r e t h e v e r y businesses v i c t i m i z e d by t h e p r e s e n t system. They don't
have t h e p u r c h a s i n g power o f l a r g e f i r m s , and must pay t h r o u g h t h e nose f o r
coverage; on average, t h e y pay 3 5 p e r c e n t more. Our p l a n g i v e s them t h e volume
p u r c h a s i n g power o f b i g g e r businesses. Small business i s one o f t h e b i g g e s t
winners under t h e C l i n t o n p l a n .
What about those s m a l l businesses t h a t don't cover t h e i r people now and would
have t o do so i n t h e f u t u r e ? Won't t h e y be c r i p p l e d ? I n a word, no. The average
wage among f i r m s t h a t don't p r o v i d e coverage today i s v e r y low -- $ 7,400 a
year. Under o u r p l a n , t h e c o s t o f c o v e r i n g t h a t average worker would be 70 cents
a day. I t ' s t h a t low because we would s h a r p l y d i s c o u n t t h e c o s t o f i n s u r a n c e
premiums t o such s m a l l employers. T h i s e x t r a cost i s s u r e l y n o t n e g l i g i b l e , but
i t s not crushing e i t h e r .
Another canard i s t h a t t h e r e q u i r e d b e n e f i t s package i s a " C a d i l l a c p l a n " -too generous t o employees. I n r e a l i t y , i t ' s o n l y s l i g h t l y more generous t h a n
what most l a r g e employers now o f f e r . B e n e f i t s w i l l be s l i g h t l y expanded f o r most
workers, and t h e y w i l l have, f o r t h e f i r s t t i m e , t h e s e c u r i t y o n l y guaranteed
coverage can p r o v i d e .
F i n a l l y , some say an employer mandate amounts t o a g i a n t p a y r o l l t a x . No one
in. my memory has ever c a l l e d a payment f o r p r i v a t e i n s u r a n c e between two p r i v a t e
p a r t i e s a t a x . CBO has concluded i t i s n o t a t a x b u t a m i s c e l l a n e o u s r e c e i p t
l i k e a f i n e , a p e n a l t y o r f o r f e i t u r e . We don't agree even on t h i s budget
t r e a t m e n t , and these d i f f e r e n c e s can be e a s i l y r e s o l v e d by s l i g h t adjustments on
our s i d e .
The employer mandate i s t h e best approach t o b u i l d on t h e p r e s e n t system,
ensure n a t i o n a l and business s a v i n g s , and a v o i d an a d m i n i s t r a t i v e n i g h t m a r e .
That's why we chose i t and why we hope Congress w i l l s u p p o r t i t .
�PAGE
The Washington Post, February 25, 1994
The w r i t e r i s deputy secretary of the Treasury.
LANGUAGE: ENGLISH
LOAD-DATE-MDC: February 2 5, 1994
�•J ^
Double Sword
For President
Whose Health Is No. 1,
Businesses or Workers?
By ERIK ECKHOLM
For months it was a steeper issue in
the health care debate. But last week,
after President Clinton's initial sales
pitch for his plan-in-prog ress, his proposal that all employers be required to
pay for health coverage
News
cnergcd
one of the
. , most fiercely contested as»y
pectt.
The employer mandate,
as it is known, presenui Mr. Clinton
with a dilemma. Thla President certainly does not want ta harm the hundreds of thousandi of MiMUMiuftiarf
owners who say, with bKfciQi from
economista, that the prcpOMl would j
cause job hwaes and bankirvptdM. And
he hardly wants to hand the Repubbcana a convenient dub for attacking
his propoaala.
Yet the mandate la a airaentOM of
his moat cherished foal, the one that
may earn him his plac» to history:
guaranteeing health conmrage for all
the country's citizens.
Alteraathm U Man Tana
Mr. Clinton needs the una of Wiltons
of extra dollars that componlea would
be forced to pay toward the coat of
covering mora than 37 million uninsured people, most of whom aro work'
era and their famiUea. As it is, the
White House la stnig|(Un| to find
sources for the tens of Wlliona of additional dollars It would neisd to subaidl
threatened companies und cover the
unemployed.
Without the large neiv contribution
from employers, the Administration
would have to come up with mora
money itself — almost certainly
through even higher Lutes tbaa the
proposal already requiiea. Politically.
A M
, t a
1
Continued on Page A». Cotunui I
that may be more dangerous than thei
wrath of small business.
But Mr. Clinton's dilemma is one
faced by his Republican critics as well.
If they do not support an employer
health care requirement, they either
have to come up with other revenue
sources, not an appealing prospect, or
back away from universal coverage.
This may explain why critics like Senator Bob Dole of Kan.sas, the Senate
minority leader, were careful to leave
negotiating room on the mandate question.
In his speech to governors last week,
Mr. Clinton spoke of a 'shared responsibility of employer and employee,
building on the system we have now"
as the only practical rcute to universal
coverage. His aides say he will propose
that employers be required to pay at
I least 80 percent of tht; cost of premiiums, with employees paying the rest.
To Be Phased In
But Mr. Clinton also stressed the
need to phase in the requirement gradually and to limit the obligations of
struggling small or low-wage businesses. Officials have discussed putting a
cap on the contributions of vulnerable
companies to 3.5 percent of payroll,
with the Government paying the rest.
They have not yet determined the criteria for awarding subsidies, a task
that could be an administrative nightmare.
Administration officials also note
that if subsidies were offered to uninsured workers without a general employer requirement, many companies
that now offer insurance might stop
doing so, knowing the Government
would fill the gap, and the entire
system would unravel.
The debate assumes that the nation
will base most health financing on the
workplace. The chief alternatives — a
Government takeover of all medical
payments, favored by some liberals, or
a shift to individual responsibility, favored by some conservatives — have
so far been judged as either undesirable or unrealistic by the President and
majorities in Congress.
Expanding employer coverage "is
the most pragmatic and least disruptive way to go,"'said Karen Davis, an
expert on health policy and executive
of the Commonwealth Fund, a private
foundation in New York.
System Emerged 50 Yean Ago
The
employer-based
system
emerged during World War II, when
companies offered health coverage in
lieu of raises, which were prohibited by
wage controls. Today, a majority of
employers help pay for worker coverage, but many smaller companies, as
well as larger companies like' retail
and fast-food chains that pay low
wages, offer few benefits If any, especially to entry-level employees.
The first prominent proposal for
mandating employer coverage came
not from the Democrats but from President Richard M. Nixon in the early
IQTO's. His health plan died along with
his Presidency, but similar mandates
were later proposed by President Jimmy Carter and a succession of Democrats in Congress.
About three-fourths of the nation's
workers are already covered by employers, either directly or through a
working spouse. But a majority of companies with fewer than 100 employees
do not offer health benefits, said William Custer of the Employee Benefit
Research Institute in Washington.
The debate has been hampered by
disagreement over cost estimates. The
Administration estimates that in 1993
the nation's companies and workers
will spend $275 billion on health premiums. Simply extending the current
system to all workers would require
additional outlays of close to $70 billion,
which would be paid by employers,
workers and Government through its
subsidies.
But the new system will save such
large sums through reduced administration and other changes that the cost
of covering all workers will be far less
than that, said Kenneth Thorpe, an
official in the Department of Health
and Human Services and an architect
of the Clinton plan. Costly emergencyroom visits for routine care by people
with no insurance or doctor will also
decline, he said. But Mr. Thorpe refused to disclose the Administration's
working estimate of the ultimate costs.
The politics of the employer mandate are more convoluted than the
chorus of attacks on Mr. Clinton last
week would suggest. Leading Republicans In the Senate, where the battle
over the health plan may be closest,!
have voiced deep concern about the;
mandate, but they have also been careful, as John H. Chafee of Rhode Island
put it, "to avoid drawing lines in the
sand."
Senator Dole, when asked whether
he supported universal coverage, said,
"I think that's our goal, but I'm not
certain how quickly we can achieve it."
Asked how this could be financed
without an employer requirement he
said: "I'm not sure we have an alternative yet. There may be other ways to
finance it." But Mr. Dole also said of
Mr. Clinton's plan, to be unveiled more
Clinton's choice:
forcing small
business to pay
or raising taxes.
fully next month, "Let's see what he
has to offer before taking shots at it."
What Business Prefers
As an alternative to guaranteed universal coverage, some Republicans
and other critics have discussed a
more decentralized approach involving
expanded public clinics, rules to reduce
insurance costs and tax incentives to
help the uninsured find coverage.
That is the approach of the National
Federation of Independent Business,
which lobbies on behalf of 600,000 small
businesses and Is leading the campaign
against a mandate. "What we say is
universal access."" said Michael
Roush, chief Senate lobbyist for the
federation.
The federation is implacably opposed to a mandate, with or without
subsidies, which, Mr. Roush said, "will
only at best mitigate the bad effects."
A majority of the federation's members actually do offer health coverage
�-
lh
A
—
J^E_NEyy
YORK TIMES
—
\
y cA
v
Who's Covered In the Workplace
Health insurance status of workers aged 18-64 employed In each
to some employees, out in some cases
sizefirm.Percentages.*
it is less generous than what Mr. Clinton would require. Even many owners
who now offer costly benefits tend to
oppose any new Government requirement.
Still, Mr. Clinton will find considerable support for the mandate within
the business community. The United
States Chamber of Commerce, for example, which represents businesses of
Covered by spouse's
various sizes supports a mandate proemployer
vided it is accompanied by adequate
subsidies for small business.
Covered by
"The chamber's view is that unless
everybody in the health system is playemployer
ing by the same rules, this nation is
never going to get a grip on runaway
health costs," said Kristin Bass, manSizeofflmr.
ager of human resources with the organization. She noted that as hospitals
and doctors make up the costs of treat%ofaiwori»er»
ing uninsured patients through excess
aged 1944
charges to the insured, smaller compaempioyadln .
nies that offer twnefits are being penaleach siza UrnK
ized.
Large corpc rations, almost all of
which provide health benefits, may
'Figures may not add to 100, because tome \
provide the strongest support of all.
than one aouroa of Insurance andtor roundngu^
These businesses say they are not only
forced to help pay for the uninsured but
Sbuctc Fmpfeyv* Srafli AMMNS JnttfUt * •: ,.' ^£'8
also are unfairly saddled with the
The Him York Tlmti
health costs of entire families when the
spouse has a job without benefits.
"If it's goinf; to be the policy of this lower. Businessmen there say the man- tacked and won a delay of the plan until •
country to rely on employers to finance date has sometimes caused hardship 1999. Opponenu are expected to make,
health care, then it's got to be all but that in general employers have another push to delay or kill the plan.
employers," stiid Walter B. Maher, di- adjusted well. A recent study by state Oregon passed an employer manrector of Federal relations for the officials asserts that business has not date that was originally scheduled to
suffered and notes that unemployment take effect in 1999. But as in MassachuChrysler Corporation.
in Hawaii has fallen steadily since the setts, business opposition has grown,
1970's while small businesses have and thla month the Legislature voted to
The Hawaii Example
The experience of individual states thrived. But critics question Hawaii's defer the requirement until 1997. "If
provides ammunition to both sides. So relevance, given its isolation and the economy turns sour I think the
mandate could disappear," said Courtfar, only Hawaii has required insur- strong economy.
On the mainland, the first state to ney S. Campbell, a medical ethlcist at
ance payments by employers, and only
Hawaii has achieved near-total health vote for a mandate was Massachusetts, Oregon State University.
in 1988. But as the economy soured and Earlier thla year Washington State
coverage of its; population.
Hawaii passed its mandate in 1974, a a Republican Governor took office, also passed an employer mandate but
time when health costs were much small-business owners counterat- it will not ba in full effect until 1999.
�HEALTH BENEFITS GUARANTEED AT WORK
FACT SHEET
THE PRESIDENT'S APPROACH BUILDS ON CURRENT SYSTEM:
• Nine out of ten Americans with private health insurance receive their coverage
through the workplace.
1
•
On average, employers who provide coverage today pay 80% of the cost of their
employees' premiums.
2
•
Yet, right now, eight out of ten people who do not have health insurance are in
working families -- workers or dependents of workers.
3
SMALL BUSINESSES WILL BENEFIT MOST FROM REFORM:
• The Wall Street Journal wrote: "For many small businesses, saddled with
escalating health-care costs, President Clinton's health-care package comes
as an unexpected windfall."
4
PLAN PROVIDES DISCOUNTS TO HELP SMALLEST BUSINESSES:
• With the President's approach, many small low-wage businesses will receive
substantial discounts on the insurance they provide for their employees. In fact,
the smallest businesses will receive discounts of between 25 and 85 percent -bringing affordable insurance into reach for America's smallest companies.
5
REFORM SAVES MONEY FOR FIRMS THAT NOW PROVIDE:
• In 1991, companies that covered their employees spent more than $26 billion to
cover members of the families of their workers, simply because other firms did
not provide insurance.
6
•
Under the President's plan, American businesses will save $90 billion in the
next ten years, even when spending from businesses that currently don't provide
health care is included, according to the Congressional Budget Office.
7
JOBS: EXPERTS SA Y IMPACT OF PRESIDENT'S PLAN NEGLIGIBLE:
• The CBO analysis states clearly that the President's approach will have a
negligible net effect on employment. "The Clinton plan, [CBO] concluded, would
not significantly slow the economy or result in the loss ofjobs, as many critics
have charged."
8
Employee Benefit Research Institute with 1993 Current Population Survey data, January 1994
1991 data; Urban Institute, Analysis of March 1992 Current Population Survey and HIAA data
Employee Benefits Research Institute, 1994
(emphasiji added) "Small Business Sees Burdens Getting Lighter." Wall Street Journal. 9/13/93
HHS analysis
National .Association of Manufacturers, "Employer Cost-Shifting Expenditures," prepared by
Lewin-ICF, December 1991.
CBO Analysis, 2/9/94.
Pearlstein and Broder, Washington Post, 2/9/94.
2
3
4
5
6
7
8
�Health Benefits Guaranteed at Work:
The Key Points
Every job should come with health
benefits. Most jobs do today. And
yet 8 out of 10 Americans who
have no insurance are in working
families.
We want everyone to have health
benefits guaranteed at work. The
government will provide discounts
for small businesses and help cover
the unemployed.
Today, people who work but don't
have health coverage pay taxes for
the health coverage of people on
welfare. That's not right, and health
reform should guarantee everyone
health coverage that can never be
taken away.
The vast majority of businesses
provide insurance. Even among the
smallest companies, more than half
provide coverage and many of the
rest say they would if they could
afford it.
Small businesses will be among the
biggest winners under reform.
They'll be able to get insurance at
the same rate as big businesses and
government. And insurance
company abuses that hurt small
businesses ~ like raising rates when
one worker gets sick — will be
outlawed.
Health Benefits Guaranteed at Work
Did you know....
...Since Hawaii began asking all employers
to provide insurance for their employees in
1974: the unemployment rate has dropped
to one of the lowest in the nation, and
small business creation rates have remained
high.
...Major corporations like PepsiCo — which
owns Pizza Hut, Kentucky Fried Chicken,
and Taco Bell — help pay for workers'
health insurance in foreign countries but
don't help pay for their workers in
American restaurants.
...Kerry Kennedy, owner of a small
furniture store in Titusville, Florida, was
recently forced to drop coverage for two
employees because the insurance company
decided they were too old to cover. Those
employees were Kerry Kennedy's parents.
...When her husband came down with a
serious illness and lost his insurance,
Sheryl Brown of Madison, Wisconsin, had
to leave her job and go on welfare to get
the benefits she needed. Then, when she
got off welfare, and went back to work,
her family lost their benefits.
...President Nixon proposed extending the
employer-based health insurance system to
all employees in 1971 with employers
paying 75% of the premium and employees
paying 25%. As he said, "we should
guarantee that all workers will receive
adequate health insurance protection. "
�HEALTH BENEFITS GUARANTEED AT WORK
SUMMAllY:
The President's bottom line is guaranteed private health insurance
for every American. In order to achieve this, the President chose to
build upon the current system and ask all businesses to do what the
most successful American companies do today -- provide health
coverage for their employees. The critics' claim that this will lead to
job loss has been disputed by independent economists -- and a
number of studies have concluded that the plan will create jobs.
BUILDS ON CURRENT
SYSTEM:
•
Nine out of ten (88%) Americans with private health insurance receive their
coverage through an employer-sponsored plan.
1
•
Excluding the very smallest companies - those with less than 5 employees the vast m a j o r i t y of businesses provide insurance. Even among the
smallest companies, more than half provide coverage and many of the rest
say they would if they could afford i t . And the most competitive American
businesses -- including nearly every company on the Fortune 500 list -provide medical coverage to their employees.
2
3
4
5
CONSERVATIVE APPROACH PROPOSED BY NIXON 20 YEARS AGO:
•
I n 1971, President Nixon first proposed extending the employer-based health
insurance system to all employees. Nixon's proposal was one of shared
responsibility between employers and employees - with the employer paying
75% of the premium and the employee paying 25%.
6
•
In support of his employer mandate, President Nixon said: "In the past, we
have taken similar actions to assure workers a minimum wage, to provide
them with disability and retirement benefits, and to set occupational health
and safety standards. Now we should go one step further and guarantee that
all workers will receive adequate health insurance protection." The costs
would be "shared by employers and employees, much as they are today under
most collective bargaining agreements. ^
SHARED RESPONSIBILITY-EMPLOYERS,
FAMILIES,
GOVERNMENT:
•
Under the President's approach, employers will contribute 80% of the
average cost health insurance plan in an area. Employees will pay the
difference between this contribution and the plan they choose.
�H E A L T H B E N E F I T S G U A R A N T E E D AT WORK
Page 2
•
The P resident's approach ensures affordable health care by providing
significant discounts to both employers and families. For all firms, except
those that choose to form their own alliances, premiums would be capped at
7.9% of payroll and would be as low as 3.5% for the smallest businesses.
•
According to a Washington Post survey, 73% of Americans support an
employer requirement for full-time workers and 69% for part-time employees.
A Wall Street Journal poll found that 65% of Americans support shared
responsibility for small firms.
8
PROVIDES DISCOUNTS TO HELP SMALLEST
BUSINESSES:
•
Many small businesses - those with fewer than 75 employees and ah average
wage of under $24,000 - will be eligible for substantial discounts on the cost
of the insurance they provide their employees. In many cases, contributions
for health coverage will be a little over $1 a day per employee for the small
employer whose average worker earns minimum wage.
9
•
The non-partisan Congressional Budget Office concluded that: "[The
proposal] would benefit smaller firms that typically pay much higher
premiums than larger firms. This leveling of costs could benefit all small
businesses - not just those that provide insurance
today. With access to
more affordable insurance, small businesses would be better able to attract
workers who now demand health insurance as a condition of employment."
10
NO COST-SHIFT SAVES MONEY FOR FIRMS THAT NOW PROVIDE:
•
Right now, eight out o f t e n people who do not have health insurance are in
working families - workers or dependents of workers.
11
•
When all employers take responsibility, costs will be substantially
reduced
for businesses that currently provide insurance. The CBO confirmed that:
"Universal coverage would mean that those firms that now offer insurance
would not longer need to pay indirectly through higher doctor and hospital
bills for the care given to uninsured workers and their families. On the other
hand, firms that do not now provide insurance could no longer ride free. "
l2
•
I n 1991, employers who took responsibility for their employees' insurance
paid an additional $10.8 billion in premiums to cover uncompensated
hospital care - nearly half of which was provided to workers, or dependents
of workers, in firms that didn't provide coverage. I n addition, those same
employers spent $26.5 billion that year to cover dependents who are
employed by firms that did not offer insurance.
13
�H E A L T H B E N E F I T S G U A R A N T E E D AT WORK
Page 3
•
A recent study found that f r o m one quarter to one t h i r d of premiums
currently paid by employers who provide coverage for employees and
dependents goes to cover the shortfall resulting from companies who do not
cover their employees and the dependents of their employees.
14
•
This is why the Wall Street Journal wrote: "For many small businesses,
saddled with escalating health-care costs, President Clinton's
health-care
package comes as an unexpected
windfall"
and Henry Aaron of the
Brookings Institution said that "Successful implementation of health care
reform is one of the best pieces of news American business could receive."
15
16
E V E N W H I L E COVERING EVERYONE, BUSINESSES SAVE B I L L I O N S :
•
Even when new spending from those businesses that do not now provide
insurance is included, CBO concluded that American businesses as a whole
see dramatic savings under reform. "Overall, businesses' costs for health
insurance would be significantly reduced by the proposal. Businesses'
insurance premiums for active workers would drop by about $90 billion below
our baseline level in the year 2004 . . . "
17
JOBS - EXPERTS SAY NEGLIGIBLE IMPACT OR NET CREATION:
•
The CBO analysis states clearly that the President's approach will have a
negligible net effect on employment. "The Clinton plan, [CBO] concluded,
would not significantly slow the economy or result in the loss of jobs, as many
critics have charged."
18
•
I n fact, some experts say there will be job creation. Two independent
studies -- one from the Economic Policy Institute and one from the Employee
Benefit Research Institute -- predict that health reform will cause a net
increase in American jobs. The EPI projects that 258,000 manufacturing jobs
will be created over the next decade. And the Employee Benefit Research
Institute predicts that the President's proposal could produce as many as
660,000 jobs.
19
20
•
For exa mple, the health care sector should produce a significant number of
new jobs. One health expert at the Brookings Institution predicted that the
plan will create 750,000 home health care jobs alone.
21
�HEALTH BENEFITS GUARANTEED AT WORK
Page 4
HAWAII PROVES IT WON'T COST JOBS:
•
Hawaii's real world experience suggests that required employer contributions
do not necessarily have adverse economic or employment effects. Since
Hawaii began asking all employers to provide insurance for their employees
in 1974:
•
The unemployment rate has dropped to one of the lowest in the nation;
•
Small business creation rates have remained high;
•
The rate of business failures has been less than half the national rate;
•
In addition, Hawaii's "rainy day" fund, which set up to assist the small
businesses provide insurance, has only been used 5 times over 19
years.
22
SOURCES:
Employee Benefit Research Institute with 1993 Current Population Survey data, January 1994.
"HeaUh Care Coverage and Costs in Small and Large Businesses", Lewin-ICF Retirement Plan
Survey for SBA Office of Advocacy, 6/92.
"Small Business and the National Health Reform Debate", Jennifer Edwards, et al, Data Watch.
Spring 1992.
''"SmaZZ Business and Health Care: Results of A Survey", Charles Hall and John Kuder, NFIB, 1990.
"'Daily Labor Report, 3/1/94.
S. 2970 "Comprehensive Health Insurance Act of 1974", Congressional Record (p. 2291). February 6,
1974.
"Special Message to the Congress on Health Care," President Nixon, Public Papers of the President,
3/2/72.
ABC/Washington Post. 2/24 - 27/94; Wall Street Journal, 12/93
" I n Clinton Plan, Economic Result Rests on How We Spend Health Savings; Unambiguously Positive
Results Predicted for Manufacturing, Exports and Trade Balance," Edie Rasell, Roll Call. 2/21/94.
[emphasis added] "An Analysis of the Administration's Health Proposal", CBO, 2/9/94, p. 54.
Employee Benefits Research Institute, 1994.
Reischauer Testimony, Senate Finance Committee, 2/9/94.
National Association of Manufacturers, "Employer Cost-Shifting Expenditures," prepared by
Lewin-ICF, December 1991.
-' 'How Would Business React to an Employer Mandate," Hewitt Associates, January 1994.
[emphasis added] Small Business Sees Burdens Getting Lishter." Wall Street Journal. 9/13/93.
CBS News.
Analysis of the Administration's Health Proposal", CBO, 2/9/94.
Pearlstein and Broder, Washington Post. 2/9/94.
"The Impact of the Clinton Health Care Plan on Jobs, Investment, Wages, Productivity and
Exports," Economic Policy Institute, November 1993.
" A n Employer Mandate: What's Known and What Isn't," Employee Benefits Research Institute,
November 1993.
Reuters, 9/17/93.
The Hawaii Department of Health, June 8, 1993.
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[I:\DATA\HLTHCARE\MANDATE2.PRS; 05/09/94 07:08 AM]
�6^
Health Reform:
How It Works
�HEALTH REFORM:
THE PRESIDENT'S APPROACH
Here's how the President's health reform works:
Guaranteed private insurance. We want to guarantee private insurance
coverage to every American. Comprehensive coverage that can never be
taken away.
Ch oice. We want everyone to have therightto choose their own doctor and
their own health plan. We want to make sure you get high-quality care by
giving you the choice, not your boss or insurance compaiiy.
Outlaw unfair insurance practices. We want to make it illegal for
insurance companies to: drop coverage or cut benefits; jack up your rates if
you get sick; use lifetime limits to cut off your benefits; or charge older
people more than younger. That's how you'll get affordable insurance you
can depend on.
Preserve Medicare. We will protect and strengthen Medicare. Older
Americans have a right to count on Medicare and choose their doctor. We
also want to cover prescription drugs under Medicare, and give new options
for long- term care in the home and community.
Health benefits guaranteed at work. Every job should come with health
benefits. Most jobs do today. And yet 8 out of 10 Americans who have no
insurance are in working families. We want everyone to have health benefits
guiiranteed at work. The government will provide discounts for small
businesses and help cover the unemployed.
�THE PRESIDENT'S HEALTH CARE REFORM:
How It Works
I. Introduction: The Health Care Crisis
II. A Vision of Health Security
L Guaranteed private insurance for everyone
2. Choice of doctor and health plan
3. Outlaw unfair insurance practices
4. Preserve Medicare
5. Health benefits guaranteed at work
III. Conclusion: The President's Reform Works For You
�Introduction: The Health Care Crisis
1. They say there's no crisis, but they're wrong. [Chart 1]
A. Even if you have good insurance today, you can lose
it tomorrow.
58 million Americans go without insurance at some
point during the year. 2 million Americans a month
lose their insurance.
B. Your benefits are threatened by insurance company
fine print.
81 million Americans have "pre-existing conditions"
that insurers can use to raise rates or deny coverage.
3 out of 4 insurance policies — that's 133 million
people -- have lifetime limits that cut off benefits
when you need them most.
C.
You're paying more, and your choices are declining.
The President's reform will protect you and your
family from a future of being squeezed — getting
lower-quality care, fewer choices and higher bills.
2. America faces 3 choices: [Chart 2]
•
government insurance
•
guaranteed private insurance (the President's approach)
•
no guarantee of coverage
3. The bottom line: the President wants to strengthen what's
right about our health care system and fix what's wrong.
�A Vision of Health Security
Here's how the President's health reform will work. [Chart 3]
Guaranteed private insurance
The President's proposal will guarantee every American
private health insurance. Comprehensive coverage that can
never be taken away.
Under the President's approach, everyone will get a Health
Security card that will guarantee: [hold up card]
•
Benefits as good as what America's biggest companies
offer and as good as what members of Congress get.
Your benefits will include prescription drugs and
preventive care ~ things often not covered today.
•
Protection against the devastating costs of serious illness.
That means a low deductible and no lifetime limits on
your benefits.
�Choice of doctor and health plan
You will: [Chart 4]
•
choose your doctor
and
choose your health plan.
We want to make sure you get high-quality care by giving you
the choice, not your boss or insurance company.
If we do nothing, rising costs will force more and more
employers to limit your choice of plan and doctor.
With your Health Security card, you'll be able to follow your
doctor to any plan you choose:
•
a plan where you can see any doctor in your community
- they call these "fee for service" plans
a network of doctors and hospitals
or an HMO
Let's be clear: we're against forcing people into HMOs. That's
why the President's approach expands your choices.
�Outlaw unfair insurance practices
We need a system of coverage that guarantees affordable
insurance people can depend on.
That's why the President's reform makes sure that insurance
company premiums don't continue to skyrocket. [Chart 5]
And it will be illegal for insurance companies to:
1) drop coverage or cut benefits
2) jack up your rates if you get sick
3) use lifetime limits to cut off your benefits
4) charge older people more than younger
If we do nothing, you will continue to be at the mercy of the
insurance companies. And continue to pay more and get less.
Insurance ought to mean what it used to mean. You pay a fair
price for security, and when you're sick, your health care is
there for you — no matter what.
�Protect Medicare
The President believes very strongly that the true test of health
reform is whether it's good for older Americans. That's why
his proposal preserves and protects Medicare. [Chart 6]
The American Association of Retired Persons (AARP) says
that the President's approach is the "best option for senior
citizens."
Older Americans will have:
•
the right to choose their doctor
•
new prescription drug coverage
•
some long term care protection
The President wants to make sure that every penny of
Medicare money is used for seniors. But others want to take
Medicare money away from seniors.
�Health benefits guaranteed at work
We want everyone who works to get health insurance at work,
with employers and employees each paying part of the cost.
This is the easiest, simplest way to make sure everyone has
coverage because:
That's where the vast majority of Americans with private
insurance get it today.
•
Eight out of ten people without insurance are in working
families.
Today people on welfare get guaranteed health insurance,
while people with jobs may or may not be covered. That's
wrong. People who work should have health insurance.
[Chart 7]
So anyone who works will get coverage at work. Employers
will be asked to contribute, as will employees. Small
businesses will get discounted insurance. The government will
cover the unemployed, and will continue to cover older
Americans with Medicare. That's how we make sure that
everyone is covered.
�Conclusion: The President's Reform Works For You
1) The President's reform works for you and your doctor.
That's why the doctors, the nurses, the people on the front
lines - including America's largest associations of family
physicians, pediatricians, nurses and pharmacists — support it
and believe it will work.
2) Opponents will try to confuse the issue by making it seem
more complicated, but it's really pretty simple:
•
You'll get a Health Security card, you'll pick any doctor
you want, fill out one form, and know exactly what's
covered. And your health security can never be taken
away.
3) So that's how the President's reform works. [Chart 8]
Guaranteed private insurance.
Choice of doctor and health plan.
Outlaw unfair insurance practices.
Preserve Medicare.
Health benefits guaranteed at work.
4) The insurance companies don't like the President's reform.
But the President didn't design his reform for the insurance
companies ~ he designed it for you.
5) Now it's up to us to stand with the President against the
special interests. This is the right thing to do, and with your
help, it's going to happen this year.
�HEALTH CARE SPEECH
Introduction
F'resident Clinton has been in office for just over a year now, and we have already
seen him move our economy in the right direction, start to restore our sense of security and
begin to renew America's spirit.
This President is dedicated to the proposition that people that work hard and play by
the rules should be rewarded for their work.
That's why he introduced a reemployment initiative to help people get good jobs with
growing incomes. That's why he passed the Family and Medical Leave Act so good workers
can be good parents. That's why he expanded the earned income tax credit to reward work
over welfare.
And that's why he's dedicating himself to fixing this health care system -- to provide
hard-working families with the health security they deserve.
This year we have a magic moment. After 60 years of false starts and obstruction, we
have an opportunity to give every American health security. This is an opportunity we must
seize.
Opponents of reform are trying to tell you there's no health care crisis, but they're
wrong. [Chart 1]
The fact is: Even if you have good health insurance today, you can lose it tomorrow.
Two million Americans a month lose their insurance. And fifty-eight million Americans find
themselves without insurance at some point during the year.
Your benefits are threatened by insurance company fine print. Eighty-one million
American:; have "pre-existing conditions" that insurers can use to raise rates or deny coverage.
And three out of four insurance policies -- that's 133 million people — have lifetime limits
that cut off benefits when you need them most.
Even if you've got insurance, you know you're paying more and getting less. And your
choices ars declining. I'm here to tell you how the President's reform will protect you and
your family from a future of being squeezed - getting lower-quality care, fewer choices and
higher bills.
[Chart 2]
America faces three choices: government insurance for everybody, no guarantee of
coverage for anybody, and guaranteed private insurance — which is the President's approach.
And the President has told the Congress he will veto a bill which doesn't cover everybody —
because without guaranteed private insurance for everyone, it's not real reform.
�The bottom line is this: the President wants to strengthen what's right about our health
care system and fix what's wrong.
We know the system is broken. We know that all of us are at risk of losing our
coverage at any time. Here's how we want to fix it.
We want to guarantee private health insurance for every American;
We want to protect your right to choose your own doctor and health plan, and
improve the quality of your health care;
We want to outlaw insurance company abuses;
We want to protect and dramatically improve Medicare;
We want to guarantee health benefits through the workplace, because that's the
best way to cover everyone.
Guaranteed Private Insurance For AH
[Chart 3]
The President believes that everyone must be covered. Always. That's the only way
to guarantee security. As long as any of us at any time can be denied coverage or dropped
from coverage — none of us is secure. And as long as Americans who have insurance pay the
price for those who don't have insurance, we'll never get costs under control.
He's also said that the benefits package must be comprehensive, [hold up Health
Security card] Under the President's proposal, every American will get a Health Security card
that will guarantee benefits as good as what America's biggest companies offer ~ as good as
what members of Congress get. Plus preventive care ~ immunizations, mammograms,
physicals — and prescription drugs. We must keep our people healthy, not just treat them
after they get sick.
And Americans must have protection against the devastating costs of serious illness.
That means low deductibles and no lifetime limits on your benefits. People must have the
peace of mind of knowing that no matter what happens, their health care can never be taken
away.
�Choices Preserved and Expanded
[Chart 4]
The President wants to preserve and expand your choice of doctor and health plan,
because that's the best way to guarantee high quality health care.
But choice and quality are threatened today. I f we do nothing, rising costs will force
more and more employers to limit your choice of plan and doctor.
Under the President's approach, your Health Security card guarantees your choice of
doctor. Once you get your card, you — not your boss or insurance company — choose your
doctor ard health plan. It can be a plan that lets you use any doctor or hospital that you
want. Or it can be a plan that lets you use a network of doctors or hospitals. Or, you can
join an HMO. It's your choice.
The special interests are trying to scare you on this issue in order to block reform. But
remember that they're trying to preserve their profits. And don't let them stand in the way of
your health security.
Outlaw Insurance Company Abuses
[Chart 5]
We want to guarantee affordable insurance that people can depend on. The President's
approach would make it illegal for insurance companies to raise your rates unreasonably... to
drop your coverage or take away your benefits... to increase your rates i f you get sick... to use
"lifetime limits" to cut off your benefits... or, to charge you more simply because you are
older or have a pre-existing condition.
If we do nothing, or worse, pretend to do reform, you will continue to be at the mercy
of the insurance companies. And you'll continue to pay more and get less.
Insurance ought to mean what it used to mean. No more fine print. No more insurance
company abuses. You pay a fair price for security, and when you're sick, your health care
benefits are there for you — no matter what.
�Protecting and Expanding Medicare
[Chart 6]
The President believes very strongly that the true test of health reform is whether it's
good for older' Americans. That's why his proposal preserves and dramatically improves
Medicare. And the American Association of Retired Persons (AARP) says that the President's
approach is the "best option for senior citizens."
Under the President's approach, if you get Medicare you keep it. You keep your
doctor i f that's your choice. Plus, your benefits are expanded. People receiving Medicare will
get coverage for prescription drugs, which costs older Americans more than anything today.
And we zdso begin to provide coverage for long term care at home or in your community.
The President wants to make sure that every penny of Medicare money is used for
seniors. Some want to take Medicare money away from seniors and spend it on other things.
That's why we must fight with the President for health care reform that protects Medicare and
older Americans.
Insurance Through The Workplace
Finally, if we're going to cover everybody, the best way to do it is to guarantee health
benefits at work. Every job should come with health benefits. Most jobs do today. And yet 8
out of 10 Americans who have no insurance are in working families.
[Chart 7]
We want everyone to have health benefits guaranteed at work, with the government
providing discounts for small businesses and the unemployed. This approach builds on what
works. And it's the easiest and simplest way to accomplish our goal of guaranteed private
insurance for everyone.
Providing health benefits at work not only makes sense; it's also the right thing to do.
Today people on welfare get guaranteed health insurance while people with jobs may or may
not be covered. That's wrong. People who work should have health insurance.
If we are to guarantee this, we must protect small businesses — and the President's
approach does just that. The President wants to provide discounts for small businesses, and
full tax deductibility for people who work for themselves.
That's how we make sure that everyone is covered. Anyone who works will get
coverage at work. Employers will be asked to contribute, as will employees. The government
will cover those between jobs, and will continue to cover older Americans with Medicare.
�Conclusion: The President's Reform Works For You
The President's reform works for you and your doctor. That's why the people on the
front lines — America's largest associations of family physicians, pediatricians, nurses and
pharmacists ~ support it and believe it will work.
Opponents are trying to confuse the issue by making it seem more complicated, but it's
really pretty simple. You'll get a Health Security card, you'll pick any doctor you want, fill
out one form, and know exactly what's covered. And your health security can never be taken
away.
[Chart 8]
Guarantee everyone private insurance. Keep your choice of doctor. Outlaw
unfair insurance company abuses. Protect Medicare. And guarantee health benefits at
work. That's the approach. And this is our opportunity.
No wonder the special interests - the people who profit off today's crazy system ~ are
out in full force. One group of health insurers has already spent $14 million — money from
your insurance premiums — on TV ads to scare you about reform.
But the President didn't design health reform for the insurance companies — he
designed it for you. And we must not let the insurance companies stand in the way of real
reform.
Presidents from FDR to Harry Truman to Nixon to Carter have tried to guarantee
insurance to every American, but none have succeeded — because special interest groups have
been just ioo powerful to overcome. But this time, if we work together, I am convinced things
will be different.
This time, we will make history and guarantee private insurance to every American. I
ask you tc join with me and help do what is right for America. Thank you.
�QUESTIONS AND ANSWERS
1) Doesn't the Clinton plan add more layers of government
bureaucracy?
No. The President specifically rejected a government-run system in favor
of guaranteed private insurance. America basically faces 3 choices:
government insurance for everybody
guaranteed private insurance (the President's approach)
leaving people without insurance
The President's approach is guaranteed private insurance. Everyone will
have comprehensive coverage that can never be taken away;
2) But what about these so-called "alliances"?
The purpose of them is very simple -- to give bargaining power to small
businesses and individuals and take it awayfromthe insurance companies.
Today, the deck is stacked against small businesses and individuals. Small
businesses are paying 35% more than big business for the same insurance,
and individuals pay even more.
So we have these consumer-controlled alliances to allow people and small
businesses to band together and get more consumer clout in the
marketplace. Consumer-controlled ~ that's the President's idea, not
government-controlled.
Now Congress willfigureout exactly how they should be structured, but
this is an idea that has bipartisan support. The insurance companies don't
like it because it means they have less power, but that's what alliances are
intended to do. And that's why the insurance industry is spending millions
to weaken or destroy the idea.
:
3) One of those TV ads says that the President's plan will limit my
choice of doctor. Is that true?
No, it's not. You'll be able to choose your own doctor and health plan.
In fact, to make sure that you get the high-quality care you deserve, the
President's approach actually increases the choices most consumers will
have. Because you will choose your doctor and health plan — your boss
�won't and the insurance company won't. So you can choose any doctor
and health plan in your community. Remember who's paying for these
ads: the insurance companies ~ who are trying to scare you and preserve
their profits.
4) Won't this plan mean that I'll pay more and get less?
No. In fact, the independent Congressional Budget Office (CBO) analysis
that the Republicans praised said that the President's plan would cost
Americans less money and give them more health benefits. Young,
healthy people may pay a little more ~ but that's because we're
prohibiting the insurance companies from charging older people more than
younger people.
Under the President's approach, you'll be guaranteed affordable insurance
you can depend on. We'll make it illegal for insurance companies to jack
up your rates or drop you if you get sick, use lifetime limits to cut off
your benefits, or take away your benefits. The insurance companies won't
be allowed to bleed you dry.
And ilie President's proposal calls for comprehensive benefits, including
preventive care and prescription drugs. Under the President's approach, no
one -• not your boss, not your insurance company - can take those
benefits away.
5) Won't your employer mandate cause massive job loss and cause
thous ands of small businesses to go bankrupt?
There is no credible evidence to support that claim. The independent
Congressional Budget Office (CBO) analysis that the Republicans praised
said that the Clinton plan would not result in the loss of jobs, and would
benefit all small businesses.
Studies predict that there will, in fact, be job gains as a result of the plan.
The Economic Policy Institute predicts 258,000 manufacturing jobs
created over the next decade, Lewin-VHI, a widely-respected, bipartisan
firm, predicts over one million jobs created by providing long-term care,
and the Employee Benefit Research Institute predicts that the President's
proposal could produce as many as 660,000 jobs.
�The President specifically designed his proposal to help small businesses - the biggest victims of today's health care crisis. Small business owners
will be able to get rock-solid, comprehensive coverage for their families
and employees. And no longer will they be subject to insurers jacking up
their rates- or dropping their coverage when one employee gets sick.
Because those insurance company abuses will be illegal.
6) Why do we need an employer mandate anyway?
If we want to guarantee every American health insurance, we've got to
figure out how to achieve that goal. The President believes every job
should come with health benefits. Most jobs do today because most
employers accept this responsibility to provide worker health benefits.
And yet 8 out of 10 Americans who have no insurance are in working
families. We want everyone to have health benefits guaranteed at work.
And under the President's approach, the government will provide
discounts for small businesses, help cover the unemployed, and continue
Medicare for older Americans. That's how we'll cover everybody.
7) When you try to cut costs and limit the amount premiums can
rise, won't that just lead to rationing?
Absolutely not. The key to this is insurance company premiums can't
continue to rise unchecked. Your money will go to buying you the highest
quality of care and service, not padding the insurance company red tape.
That's why there's a limit on how much insurance companies can raise
your rates. In fact, it will be illegal for insurance companies to drop your
coverage or take away your benefits. You'll be guaranteed affordable
insurance you can depend on.
The F'resident's approach is all about keeping you healthy. You'll have the
right i:o choose your own doctor and health plan. We want to make sure
you get high-quality care by giving you the choice, not your boss or
insurance company.
8) I've got good insurance. What's in this plan for me?
First — and most important -- you'll get something that no amount of
money can buy in today's insurance market: guaranteed private insurance.
Comprehensive coverage that can never be taken away. Second, you, not
�your boss or insurance company, have the choice of doctor and health
plan to make sure you get the high-quality care you deserve.
Third, unfair insurance company practices will be outlawed. 3 out of 4
insurance policies - that's 133 million people -- have these lifetime limits
which mean that your coverage could be cut out just when someone in
your family is sickest. No more. No more jacking up prices when you get
sick. You'll have affordable insurance you can depend on. Fourth, we
protect Medicare. We'll cover prescription drugs under Medicare, and give
new options for long-term care in the home and community. And fifth,
everyone will have health benefits guaranteed at work, with the
govemment providing discounts to small businesses and the unemployed.
Even if you lose your job, you will never have to worry about losing
benefits or being forced to change doctors.
9) Is it true that my doctor can be fined $10,000 for treating me
outside the system?
A: No, that's not true. You can see any doctor you want and pay for any
procedure or treatment. The $10,000finerefers to the President's
crackdown on insurance companyfraud.Fly-by-night insurance companies
will befinedif they try to dupe you by selling you "supplemental"
benefits that you're already guaranteed by law.
[Note: By law, you'll be guaranteed therightto pay to see any doctor in
the country, even if you are in an HMO.]
10) What's going to happen to my Medicare benefits?
A: Older Americans who receive Medicare will continue to receive all the
benefits you do today. And you'll keep the doctor you now have. In
addition, we'll strengthen Medicare by adding prescription drug coverage.
Older Americans will also benefitfromnew long-term care options in
their homes and communities, where they want to receive care.
11) What happens if the money runs out?
A: Today, when insurance companies go out of business, patients get
struck without health care, and doctors don't get paid. The President's
approach prevents that. It bans fly-by-night insurers, forcing the insurance
industry to set aside funds to protect against bankruptcy or failure.
�T H E CRISIS
People Without Insurance Each Year
58 million
People With Pre-existing Conditions
81 million
People With Lifetime Limits On Coverage
133 million
�GUARANTEED PRIVATE
INSURANCE
Comprehensive Benefits
No Lifetime Limits
Insurance That Can't Be
Taken Away
�CHOICE
You choose your doctor
You choose high-quality plan
Employers won't pick your plan
Insurance companies can't deny
you coverage
�R E A L INSURANCE
REFORM
Illegal for insurers to:
• Drop coverage or cut benefits
• Increase your rates if you get sick
• Use lifetime limits to cut off
your benefits
• Charge older people more
�P R E S E R V E MEDICARE
Protect Choice of Doctor
Cover Prescription Drugs
Begin Long Term Care
�AMERICA'S CHOICE
• Government Insurance
llfGuaranteed Private
Insurance
• No Guarantee of Coverage
�HEALTH BENEFITS
GUARANTEED AT WORK
Employed: Covered at Work
Small Business: Discounts
on Insurance
Unemployed: Help from
Govemment
�How REFORM WORKS
Guaranteed Private Insurance
Choice of Doctor
Real Insurance Reform
Medicare Preserved
Health Benefits Guaranteed
At Work
�BACKUP FACT SHEET
People Without Insurance Each Year
58 Million
THE FACT:
"The Bureau of the Census calculated that 50 million Americans
lacked health insurance for at least 1 month during 1987.
Lewin/VHI updated the census estimate, calculating that 58
million people were uninsured for at least 1 month in 1992."
THE SOURCE:
"Dynamics of People Without Health Insurance: Don't Let the
Numbers Fool You" Journal of the American Medical Association
(JAMA). January 5, 1994
People W i t h Pre-Existing Conditions
81 Million
THE FACT:
An estimated 81 million Americans under age 65 have medical
problems for which insurance companies can charge higher
premiums, exclude coverage or deny coverage altogether.
THE SOURCE:
"Health Insurance at Risk - The Seven Warning Signs", Citizens
Fund, June 1991 [with data from National Center for Health Statistics
"Health Interview Survey", further datafromthe Health Insurance Association
of America "Source Book", and the latest Department of the Census "Current
Population Surveys"]
People With Lifetime Limits on Coverage
133 Million
THE FACT:
The Bureau of Labor Statistics 1991 Survey of Medium and Large
Private Establishments reports that only 1 out of 4 people have
insurance policies without lifetime limits.
THE SOURCE:
Table 45 -- Medical Care Benefits: "Employee Benefits in Medium
and Large Private Establishments", Bureau of Labor Statistics,
1991
CALCULATION: In 1992, 177.5 million Americans had private insurance, according
to the Employee Benefit Research Institute analysis of the March
1993 CPS. Seventy-five percent of 177.5 million is 133 million.
�
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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Work Memos [1]
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Task Force on National Health Care
White House Health Care Task Force
Jason Solomon
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2006-0885-F Segment 2
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Box 38
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093764" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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2/6/2015
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42-t-12093764-20060885F-Seg2-038-001-2015
12093764
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https://clinton.presidentiallibraries.us/files/original/02de58771fde2e4f2fbfa54480da3da1.pdf
611e4b045d10b05c22e4b786615fdef2
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Collcetion/Reeord Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Solomon, Jason
Subseries:
3327
OA/11) Number:
FolderlD:
Folder Title:
[Miscellaneous] Q&As
Staek:
Row:
Seetion:
Shelf:
Position:
s
52
7
9
2
�- \
il
E X E C U T I V E
O F F I C E
30-Jun-1994
OF
T H E
P R E S I D E
09:10am
TO:
(See
Below)
FROM:
Kathy McKiernan
O f f i c e o f t h e Press S e c r e t a r y
SUBJECT:
Fact Sheet f o r Press on P r e s i d e n t ' s H e a l t h Care Eve
PRESIDENT CLINTON ADDRESSES SMALL BUSINESS OWNERS IN
SUPPORT OF UNIVERSAL HEALTH CARE COVERAGE FOR EVERY
AMERICAN
Thursday, June 30, 1994
P r e s i d e n t C l i n t o n w i l l r e i t e r a t e h i s commitment t o
guaranteed u n i v e r s a l h e a l t h care f o r every American
t o d a y i n an address t o America's l a r g e s t c o a l i t i o n o f
s m a l l business owners, t h e Small Business C o a l i t i o n f o r
H e a l t h Care Reform. The c o a l i t i o n today announced i t s
s t r o n g s u p p o r t f o r u n i v e r s a l h e a l t h care coverage and
f o r employer mandates as t h e best way t o achieve t h i s
important goal.
The Small Business C o a l i t i o n f o r H e a l t h Care
Reform i s composed o f 29 n a t i o n a l o r g a n i z a t i o n s which
r e p r e s e n t more t h a n 626,000 s m a l l businesses employing
more t h a n 5.6 m i l l i o n workers. The c o a l i t i o n has
doubled i n s i z e s i n c e i t s f o r m a t i o n May 3, 1994 and i s
now l a r g e r t h a n t h e N a t i o n a l F e d e r a t i o n o f Independent
Businesses (NFIB).
I n a d d i t i o n t o today's support from s m a l l
b u s i n e s s , r e c e n t p o l l s have shown t h a t Americans i n
g e n e r a l o v e r w h e l m i n g l y support t h e P r e s i d e n t ' s g o a l o f
u n i v e r s a l coverage ( 7 8 % ) , as w e l l as employer mandates
(75%) as a means o f a c h i e v i n g t h a t g o a l .
A l e t t e r from The Small Business C o a l i t i o n f o r
H e a l t h Care Reform and f a c t sheets on s m a l l business
and t h e P r e s i d e n t ' s p l a n f o r h e a l t h care r e f o r m , as
w e l l as r e c e n t p o l l s on u n i v e r s a l coverage and employer
mandates a r e a v a i l a b l e i n t h e lower press o f f i c e .
�More t h a n 350 s m a l l business owners and 51 Members
of t h e House o f R e p r e s e n t a t i v e s a r e expected t o be i n
the audience f o r t h e P r e s i d e n t ' s remarks. On stage w i t h
the P r e s i d e n t w i l l be t h e F i r s t Lady, Small Business
A d m i n i s t r a t o r E r s k i n e Bowles, t h e Honorable B u t l e r
D e r r i c k (D-SC), C h i e f Deputy M a j o r i t y Whip, and Mr.
B r i a n McCarthy, Owner, McCarthy Flowers o f Scranton,
P e n n s y l v a n i a . Mr. McCarthy, who w i l l be speaking on
b e h a l f o f t h e c o a l i t i o n , can o n l y a f f o r d t o i n s u r e a
p o r t i o n o f h i s employees under today's system. Under
u n i v e r s a l coverage, w i t h a l l employers p r o v i d i n g
i n s u r a n c e , he would be a b l e t o i n s u r e a l l o f h i s
employees and t h e i r f a m i l i e s .
Speaking f i r s t a t today's event w i l l be t h e F i r s t
Lady, f o l l o w e d by SBA A d m i n i s t r a t o r Bowles and Rep.
D e r r i c k , who w i l l i n t r o d u c e two s m a l l business owners:
�M i c h a e l Oakley, Vice P r e s i d e n t , Oakley I n d u s t r i e s of
C l i n t o n Township, Michigan and M i c k i Schneider,
S p i r a l s , of Palo A l t o , C a l i f o r n i a .
Mr. Oakley c u r r e n t l y i n s u r e s a l l of h i s employees,
but h i s r a t e s c o n t i n u e t o r i s e . He b e l i e v e s t h a t
w i t h o u t u n i v e r s a l coverage, w i t h a l l employers
p r o v i d i n g insurance t o t h e i r employees, r a t e s w i l l
never be c o n t r o l l a b l e .
M i c k i Schneider has looked and been unable t o
o b t a i n a f f o r d a b l e insurance f o r her employees. She
b e l i e v e s s t r o n g l y t h a t i f a l l employers p r o v i d e d
coverage t o t h e i r employees and u n i v e r s a l coverage was
o b t a i n e d , she would be able t o purchase the insurance
she wants t o p r o v i d e .
A f t e r t h e i r remarks, A d m i n i s t r a t o r Bowles w i l l
i n t r o d u c e B r i a n McCarthy who w i l l speak and i n t r o d u c e
the P r e s i d e n t .
-30-30-30-
Distribution:
TO
TO
TO
TO
TO
TO
TO
TO
TO
TO
David B. Anderson
K e i t h O. Boykin
J e f f r e y L. E l l e r
Ernest D. Gibble
Jonathan P. G i l l
Kukis, H e i d i
Joseph W. C e r r e l l
Payne, J u l i a M.
L i s a Mortman
Rica F. Rodman
�WITHOUT UNIVERSAL C O V E R A G E ,
RESPONSIBLE SMALL BUSINESSES PAY T H E B I L L S
TODAY:
Billions Are Shifted Onto Small Businesses
Small businesses get charged higher prices in today's market because don't have enough
employees to give them strong purchasing power. Large businesses and the government use
their bargaining power to demand the lowest rates, and then insurance companies charge
small businesses higher rates to make up the difference.
And, more and more often, small businesses watch their premiums skyrocket ~ or see their
coverage dropped altogether - if just one employee gets sick.
•
"Pre-existing condition exclusion — particularly excluding an entire firm because of one
employee's health status -- is a practice almost exclusively reservedf o r small businesses."
[D.Stone, 1990]
And millions of dollars are shifted onto the small businesses that provide their employees
with insurance when they are forced to pay for those businesses who do not.
A recent study found that from one quarter to one third of premiums currently paid by
employers who provide coverage goes to pay for employees and dependents at companies who
do not provide coverage! [Hewitt Associates, 1/94]
WITHOUT UNIVERSAL COVERAGE:
Small businesses will pay an even larger share as
more health costs are shifted onto them
"By using their clout with health care providers to demand lower costs, big employers help squeeze
out inefficiencies . . . Those costs won't disappear, however. As big companies shed them,
insurance premiums f o r smaller employers will be forced up." [Wall Street Journal. 6/27/94]
The high cost of insurance is expected to cause 30% of small businesses currently providing
insurance to drop coverage in the years ahead. This will further raise premiums for the smallest
companies that do provide. [Health Affairs. Spring 1992]
WTTH UNIVERSAL COVERAGE:
Everyone will pay a fair price and small businesses
will no longer get stuck with the bill
That's why the non-partisan Congressional Budget Office concluded that universal coverage "would
benefit smaller firms that typically pay much higher premiums than larger firms. This leveling of
costs could benefit all small businesses - not just those that provide insurance today." [CBO, 2/9/94]
�Community-Rated Health Plans Prove Popular,
But Success May Depend on Universal Coverage
By HILAKY STOUT
T , p . ) • •
THE
WALL
STUECT
Rating the Proposals
JOL RN *L
- It's the health-care
:'r:p'.'Sa! everyone loves: the notion that
nsurance companies shouldn't be allowed
[IJ jack up rates for sick people or others at
rsk of piling up big medical bills.
So attractive is the concept, known as
community rating.' that even many Republicans and conservative Democrats say
Congress should go ahead and enact it.
ilong with a set of other insurance-market
revisions, and forget about universal
health coverage for now. A new GOP
television advertising campaign pushes
tor bipartisan insurance-market reforms
to ' fix health care. '
There s just one problem with the idea,
experts insist and real-life evidence shows.
!; probably won t work without universal
coverage. Indeed, several of the insurance
''han^es that reformers are clamoring ' T
may depend for their success on bringir-i
nearly erybody into the insurance pool.
Fcr '.he pas; year New York state has
;r:ed L.jmmunity rating without a law
re'iuirmg everyone to have health insur.ince. The result has been a rise in insurj.nce premiums for younger, healthier
pr>ple .md a drop in rates for older, sicker
.ndividuais Consequently, young people
' have bailed out of the system, figuring
they e.ther won't need coverage or they'll
be ible to get it at a reasonable price when
'•/.ASHINGTON
:he> do.
Older. Sicker People
Now. insurers are raising prices again
n -rder to cover the medical needs of those
Ider sicker people left in the pool. State
.nsuran^e department figures show that as
:' I
!. nine months after the new law
is -t'fect. l i A " fewer people had health
•i.vinnce individually or in small'yer ^"ups. Tha; s a l.."' decline.
The ,nly way to avoid this chain reaction, many experts say. is to set up a
v-tern where people can't drop out. Owe
Kcmnardt. a Princeton University health
v.onomist. says that when he heard Republican calls to enact insurance market
reforms alone as a way to vastly improve
the current system he reacted with total
disbelief. Community rating without universal coverage wiU trigger the wont
kind of behavior among insurers and patients. " he says.
If you can go in and out of a system at
will, then the only people who will buy
insurance are those who need it." says
Barbara Ragle, legal counsel at Central
Reserve Life Insurance Co.
Nor is community rating the only popu/ lar insurance reform that would be nearly
impossible without universal coverage.
The same thing is true of proposals to
outlaw the common industry practice of
refusing to cover people with known medical problems, so-called pre-existing conditions. Most health bills that stop short of
universal coverage, such as the bipartisan
Managed Competition Act championed by
Democratic Rep. Jim Cooper of Tennessee,
allow insurance companies to exclude coverage of a pre-existing condition for up to
six months unless the prospective policy
holder is switching from one policy to
another. Again, the reason is that if
the government requires companies to
cover pre-existing conditions without re
quiring everyone to have insurance, people
will buy policies only when they expect
high medical expenses.
Seeing the Insurer's Side
Even Gail Shearer, who as manager of
policy analysis for Consumers Union is
usually no friend of insurance companies,
says: You can understand why the insurers want protection."
In a pure community-rated insurance
system, everyone in a region would pay the
same premium for the same package of
health benefits, regardless of age. sex.
medical history, lifestyle or place of resi:ence. lesmte cancer or severe disabil-
r
-y.-i n ~i.c -•edi!P--*'c—
:ej: .-. - -•;
• CLINTON: No c-e- ^ . y :
ano-.ved
age -ec cai siaius geog•aor.y of ifesive Se:a-'a:e sees
acco'r.-g :o *a<"-- >• <••*
3
o r s
• SENATE LABOR AND HUMAN RESOURCES
(approved June 9): Sa-e as C".-ton
erased n over 'o-.' /ears
• CHAFEE:
o ^ s — s : otter a
~od.i ec
:, '3 e premium 'o
:eoo!e a.-: "L.5.cesses of .rcer 1QQ
.•,0'<e'S .vno Duy nswrarce throi.gr a
ou-cnasi-g rbcoeratcve
;
r
• HOUSE WAYS AND MEANS (currently
under consideration): Co^nunir/ rating
Some supporters of community rating
are pushing to allow some adjustments,
such as for age and habits that affect
bealth. like smoking. And for all the rhetoric embracing community rating, most
of '.he actual bills under consideration in
Congress would adopt only a modified
version of the concept.
" Nobody is proposing pure community
rating," says Henry Aaron, an economist
at the Brookings Institution in Washington. Even the sweeping Clinton proposal
would allow four different types of regional
risk pools, based on family type - for individuals, for single parents with children,
for couples and for two-parent families
with children.
The House Ways and Means Committee, under pressure from the insurance
industry, is considering a bill with five
different market sectors, based largely on
a person's employer Each sector would be
community rated, but insurers wouldn't
have to sell policies in every sector. The
leading Senate Republican bill, written by
John Chafee of Rhode Island, allows insurers to adjust for age and geography in
some markets.
In fact, many people argue that the only
legislation that guarantees a true community-rated approach are bills establishing a
"single-payer" health system, where the
government pays people's medical bills
with tax revenues.
Other things that make community
ratings work are also opposed by supporters of the concept. A successful community-rated system requires a bureaucratic structure to oversee it. Yet many of
the people calling for insurance-market
reforms are the same ones decrying the
large regional health alliances that President Clinton has proposed.
The alliances, which would be set up by
the states, would include employees of all
businesses with fewer than 5.000 workers.
The White House says they were conceived
to establish a large pool over which to
spread insurance risks. And they are also
intended to take care of a difficult but
critical job known as risk adjusting.
Community rating violates basic actuarial principles." says Princeton's Prof.
Reinhardt. "A community-rated system
forces a competing private insurer to look
THt * ^hh-^—
"
sesa-ate
s
enoioyers . v f - c e - 3 ..-v.^-^
associabor : 3-s .rc -nr.- 1 a-ces
I SENATE FINANCE (currently under consideration):
.3 3: :-s
acco-^-g -o ' 3 - % ;e •;•;•:<;• 12-. 3-:
age ^ g-es; age-jci-.s:?':
-a.- "e -c ~c--e - a r
ce --. :
3ge-aCjLs:ed s.-em.LI COOPER-BREAUX: Nc ac:cs:-e-s
allowed 'or medicai status or - ~ : e ' ;•'
bast "medical ciaims. DremnjTs can :e
.•a ed accordtng to gecg^b" ,- r c "o
so^e degree age
J
ri
1
at a deathly ill patient, seeing i SlOO.OV
'
bill, and cheerfully enroll :n.it person for
S2.000. It goes against human nature. So :n
order to overcome nornid: .- ..man nature
you need some coercion.
That means that while everyone pavs
the same amount into a commumtv rated
system, a mechanism must be set up so
insurance companies receive varying
amounts, depending on the risk levels of
their beneficiary pools. Otherwise, a plan
that for some reason was chosen by a
disproportionate number of. say, HIV positive people, would be in bad financial
shape. Ultimately, health plans overloaded
with bad risks who pay low premiums
could collapse. Risk-adjusting basically
requires plans with better risk po-.is to
subsidize those with worse risk pools
The administration proposed heiitn alliances to accomplish that task. H< 'Aever. 1
most of the people pushing insurance re- •
forms are balking at alliances. Consequently, large mandatory alliances are
all but dead in Congress.
Alliances aren't the only entities that ,
could perform such functions. It could be i
done through state insurance regulation, j
says Mr. Aaron. The virtue of alliances. :
Prof. Reinhardt points out, is that they also <
would collect the health-insurance premiums. and could then turn around and
pay money out to plans in the form of a
nsk-adjusted premium." He says,
"That's a lot different than having to go in
there and fight with their lawyers
�lo:
I n c i a tnnghl
(Tom: Ht^LIH L'AKb UtLlVtKY HOW
b-^"J-y4 biU^ptn
p. Z
THE WHITE HOUSE
Office of the Press Secretary
For Immediate Release
June 23,1994
STATEMENT BY T H E PRESIDENT
Under the leadership of Chainnan Ford, the decisive action by tlie Members of the House
Education and Labor Committee has brought us one step closer to achieving our goal of universal
coverage - guaranteed private insurance for even- American that can never be taken away.
Chainnan Ford has had a long, distinguished career in Congress and his guidance throughout the
health cai e reform process - and his commitment to universal coverage - will help us ensure that all
Americans have the health security they want and desen-e.
With today's action, for the first time ever, a committee in each house of Congress has reported a
bill that guarantees universal coverage. They have broken the chokehold of special interests, and by
choosing to cover even-one, have stood up instead for millions of hard working middle class
.Americans.
.As we continue to move forward, and as momentum for refonn builds, this committee action
sends a clear signal to the .American people that Congress is well on its way to making health cai e
histon- this vear .
-30-30-30-
of Z
�GO
.P
. . IN THE HOUSE
TRYN
IG TO BLOCK
HEALTH CARE B
THE
N
EVV YORK TIMES.
Continued From Page Al
cans by requiring employers to pay
most of the cost of premiums for their
workers and by creating a new form
of Medicare, the existing health proGINGRICH LEADING FIGHT gram for the elderly, to include the
unemployed and others not reached
through employment
is no point in improving it
He Says Republicans Should so' "There
it will pass," Mr. Gingrich said.
'^It's a-bad bill, and it's wrong." He
Oppose Any Plan to Widen skid the bill would cause "bigger government, bigger bureaucracy and
Support for Proposal
Higher taxes for worse health care."
; Mr. Gingrich, who is all but certain
tb become minority leader after the
November elections, confirmed a
By ADAM CLYMER
Special to The New Vurk Times
qomplaint made on Wednesday by
WASHINGTON, June 16 - At the Pred Grandy, an Iowa Republican. In
urging of Representative Newt Ging- the committee meeting. Representarich, their deputy leader, House Re- tive Grandy said Mr. Gingrich had
that an amendment suggested
publicans are trying to keep health urged
tiy Mr. Grandy not be offered because
care legislation from reaching the the taxes it involved might be used
House floor in a form that could pass. against Republican candidates.
Despite criticism from Democrats : Mr. Grandy agreed not to propose
and even from one Republican who the amendment in the committee
accused Mr. Gingrich of putting par- Meeting, but he said today. "To see
tisan pr.uics first. Mr. Gingrich said health care pre-empted by politics,
today •hat Republicans should vote ^ven in the short run, is unsettling."
against amendments that might r Senators have not made similar
broaden the support for a bill that thercomplaints in public. But if they are
House Ways and Means Committee is/ guaranteed anonymity some senaconsidering.
in both parties say that PresidenA few hours later. Republican com- irs
al politics and a desire to deny Mr.
mittee members followed that pre Clinton success have driven Republiscription; all 14 opposed an amend cans to oppose compromising on
ment to soften the bill's impact on fcealth care.
small business by providing tax cred
Others insist that they merely feel
its to offset their new insurance costs. tery strongly that Mr. Clinton's proBul Mr Gingrich's hardball strat- posal for national health insurance
egy backfired when previously divid- and the spinoffs offered by Mr. Gibed Democrats closed ranks and voted sons and Senators Edward M. Kenunanimously for a series of amend- nedy of Massachusetts and Daniel
ments, even though some made it Patrick Moynihan of New York,
clear that they did not like them, and would be bad for the country They
focus on the damage to small
might alter some later. Several said jsually
wsiness they foresee if employers
that Mr. Gingrich s moves had uni- re required to buy insurance for
fied them.
leir workers — an element these
Mr. Gingrich's comments con- ills have in common.
firmed in part accusations of obstrucUnity Above All
tionism that Democrats have leveled -» But at least one important player,
at Republican leaders, saying they Senator Bob Packwood of Oregon,
were muzzling moderates in their Cited Republican unity as a reason for
party and blocking compromise on ioing against his own preference. Mr.
any health care bill. But they have Packwood, the senior Republican on
JWr. Moynihan's Finance Committee,
never provided specifics.
"It's becoming clearer and clearer $aid today that while he personally
that they are interested in frustrating
action," Representative Richard A.
Gephardt of Missouri, the Democratic leader, said today. While Republicans often claimed that they wanted
bipartisan cooperation, he said,
"Their real intention is to, unfortunately, not do anything." He said Republicans were acting like "robots."
In an interview today, Mr. Gingrich, of Georgia, responded, " I think
it is very sad to see Gephardt reduced
to a Clinton level of dishonesty." He
said Republicans had repeatedly offered to work with Democrats on
health care legislation, but "what
they mean by bipartisan is us caving
in." He said members of his party
were resisting "selling out your principles to pass one bill."
Mr. Gingrich said he told Republican members of the House Ways and
Means Committee that "they should
do what they think is effective in
minimizing the prospect that the Gibbons bill will pass." The committee's
bill was proposed by its acting chairman, Representative Sam M. Gibbons of Florida.
The Gibbons bill would seek to provide health insurance for all Ameri-
S
t
Continued on Page AM. Column /
FRIDAY.
JUNE
17. 1994
Democrats unite
against a Gingrich
strategy.
favored an employer mandate, for
example, he would not vote for one
"If you're going to go against your
party, you do it either out of "conscience or constituency," he said.
"You do not do It over a matter of
convenience." He said that he thought
requiring contributions from employers would enable the nation to insure
all Americans, but that it could be
done, though more slowly, without
that requirement. Republican unity
was worth a little delay, he said
But a group of Democrats held a
news conference today to try to rally
support for Mr. Clinton's call for universal insurance coverage and required-employer
payments
to
achieve it. Senator Kennedy, chairman of the Labor and Human Resources Committee, said he was confident the full Senate would support
employer payments once it had debated the issue, because "You don't
get to universal coverage without an
employer contribution."
Senator George J. Mitchell of
(Maine told reporters this morning,
"We will be on the Senate floor with a
health care bill in July." He said he
was not dismayed by the disagreements that had stalled action in the
Finance Committee. "I've been
through dozens and dozens of bills
where you start with disagreement
and end up with agreemenL"
The embattled Finance Committee
held two closed meetings today, discussing what benefits should be included under any national health insurance plan. It also discussed what
sort of national board should deal
with changes in the package. It will
meet, again in a closed meeting, next
Tuesday.
Grandy Would Tax Benefits
The Grandy amendment that started the House dispute is actually one
that Democratic leaders like Mr.
Gephardt oppose bitterly, though
some of the members in both parties
like the idea. Its would tax health
care benefits above those in a mmimum insurance plan, both to discourage wasteful use of health care resources and to raise money to subsidize insurance for the poor. Labor
unions have made the defeat of any
version of this idea a top priority.
Mr. Gingrich told Mr. Grandy that
has amendment could hurt Republican candidates, because Democrats
could label it a tax increase on the
middle class. Mr. Grandy said he
understood, though he was disappointed.
But this afternoon the commiltee s
Democrats, who were bickering last
night over a patchwork amendment
that would reduce proposed tobacco
taxes, give tax credits to small businesses and delay the availability of
long-term care benefits, stood together and voted without dissent for each
of them.
In a caucus this morning. Democrats encouraged each other to stand
against the Republican enemy. Mr
Gingrich's title is Republican whip,
which means he is supposed to keep
Republicans united.
But Representative Jim McDermott, a Washington Democrat who
swallowed his unhappiness with details of the amendments and voted for
them, said that Democratic antagonism toward the Republican leader
meant that "Mr. Gingrich was our
whip today."
\
�Rx, Durenberger and Wellstone: Tranquilizer
do nc: think it serves anyone's interest to
By Tom Htmbor^w
respond to such a charge other than to wy that
Wftstsinfton Bumu Chief
I regret that we cannot keep the debate on a
higher piar.e." While not berating eaca other,
Washington, D.C.
Capitol Hill turns s^rioui-y to the knotty the senator? pushed their brands of reform in
question of healthreform,tempers flare and several fonms arc und the ciry. Both have
re!auoa*hip» Cray Aik Mirresou's senator*, ihowT. a wiLLngness to compromise.
whote Icnftime diwirtemect cti health policy
»piUed over the bcund* of Senate decorvm Durenberser met with Pr^idret Cinton late
Thunday. It was the second meeting between
ThurKlay.
the two men in a wtefc Ginton seeks suppon
It happened after Republicas Dive D-jrehber-- firorr. moderate Republicans on the Senate Figer accused Democrat Paul Wellstone of pro-,, nance Conuninee.Purenberger uid the'discustnounf the "Kaawi quo" in his apprcach to . sion was phibscphicel as . Lie two men discussed the definition of "universai coverage"
hadlh reform.
and •'msunmce.'.' No conclusions or agreements
were reached. •
- •. - ••• '•:
: That may no: sound so rouah. But to a commu-.
rjty acth-st and lortitime reformer juch asWelhtone, ihcse art tfthtinj words. He fired . For his part. Wellstone joined a group of Senate
ofT a - news releaie acoinii*. [>urenbertcr cf Dexomu in a ne^ conference to urge Chnbeing in the pockt. of- the healui insaraace toa to hold the line. "We are ail here today to
iodiiitrv ard detaiJed the senior senator's cam--v"say thatiV^ ^ill not' let, health, carereform-,
efforts be hracked." • WfListonet'said. He and •
paiip contribuiions,.'-'.:
• '\
Sens. Edward-. Kennedy',' ^oni^Daschle. Jay
• DurccbCTfir.'.made;the; accusation - because.'-Rockefeller, 'and -E^t_ Graham said-Corgress ..
. .Wdistone. d-o«n't"-shire Jns^eatiusiym^for^ cannot icttlit foi.incretnenu! heaJth reform and ••>:
^mujt insist on. coverage for ail citizenirr ^-^^'/^
"changes, in the ra^cal.'marl«i,!sucfe''a»-..thev.''.
''f-r- •• V'-j; t r i .--.y*.^ ^ v . - " . .,
' rapid sluf. 'to managed:c£_-e. Wells'tone'advoi-.-*:
cates a- Canadian-style.-national' health insur-.;', liter in tbe day,, the Democratic sehaicrs met
ance-system;..Dure^berge.- prefers market-re- .'- with doctors, D'arvs and-oths-. representatives. ;
fjrTrjs to proT.y* competiuon apong' heaith fro.T. Minhesoti-bascd healU: maintenance or-"'
gamzations who spent th? da;-: visiting men- .
D .V.S
- .. '•. . .
•/ •
--, .••
be.-j of C.'r.gr-.-s: prc.Triiiife tht ii-:z of rrar..
I Late ir. iht day Dur.c.-.berg'er s'aici: "I have neve: aged c^r:
! 'Dc::.r-; b*e:-...ac;-se:_by er.\:r.i of 3.-.-:ir:s rr.y
i
Je: a:--..ie ir''. : f my cc.'.s^ucs. snd I Scutors cor.-ir.ued :n pti: '.-'^
1
-
3
:
,
neanncare
v
Don't
give up on universal coverage
Now oomc Sens Daniel Moynihan and
It's fundamental
to health care reform
for moral, economic
and social reasons.
Robert Packwood to tell Presideat Clinton thu Senate Fmance Committee
won't requite employers to provide
heallii care coverage for workers. Given
thai pragmatic appraisal, Clinton properly urged Moynihan and Packwood to
explore possible compromises. But
Clmlon alio was _ngh| to repeat his
insistence-that health" cafc reform be finds a way to require all Americans lo
bu;:'. ground universal coverage.
ensure they are onvered individually —
mandates arc the sures; and quickest
Coverage for all Vmericaus is funda- method to get to uni versa! coverage.
mcrUal .o health caie reform for moral, They're also a proven method, since
economic and sodal reasons. Morally, most Amencar. workers already enjoy
mo.-a Amn-icans bave come to believe tax-free health-care benefits prindpally
simr.gly Utat everyone should have ac- financed by their employers.
cess to high-quality, basic bealth care.
Eronoioically, universal coverage U es- Opponents of mandated benefits —
sential to bringing health cart cost'in- mostly Republicans — ihus oppose the
creases; under xontrul; so long as mil^ idea of attending to unprotected worklions of Americans remain underin-' \ers — mostly lower-paid people ui
sumi and uninsured, cost shifting will fcmai] businesses — benehis that bettercontinue, Jeavinp. a mechanism for uo ulf Amencaiis have enjoyed for dr^
warranted pnet inflation in heallb care. attes It brings io mind efforts early in
this tintury to md child labor, to reguSicial.'y, universal coverage is essential late hours and wages, and to ensure
to achieve Clinton's goal nf ending worker safety. Those efforts also
"welfare as we know i t " Concern about sparked powerful oppoMtion from peolosing health care benefits is the single ple with a vested intnest in the unreamost iniportam lolluence that eniices sonable exploitation of their fellow hu
people to remain on public assistance man beings.
longer thai) they should. Ob wellare,
they and their families get Medicaid Perhaps Moynihan and Pacirwood cau
cuv^race; off welfare and in low-paying avoid employer mandates and still
jol*. most don't get any health benefits achieve universal coverage withm a reaai all, fror mruiy pcopie. that make:: the sonable period of time Bui if the senarhoiic Minplc. Without universal health tors fail, Clinton should stand with
"care to vt rage, Clinton can kiss effective House Democrats and tbeir strong supwelfare reform goodbye. '
port for employer mandates. Chnton
has indicated a remarkable willingness
Emplbycr mandates hnd universal cov- to compromise Bul he cannot yieid on
erage, are not synonymouji. But unless u.-jversal coverage, without which there
the- nati'-n moves to a tax-lltiancpd,
_
esc be ao health fire refornri deserving
singlivpaycr s>st<-m like Canada's
OT
of the nan s.
f
liJ
�o
C l i n t o n says u n i v e r s a l h e a l t h coverage must "phased i n o v e r a p e r i o d
of j u s t a few y e a r s . " T h i s morning, P r e s i d e n t C l i n t o n was asked
about Democratic Senator Moynihan's statement y e s t e r d a y t h a t t h e r e
was no chance t h a t Congress w i l l pass a h e a l t h care p l a n t h a t w i l l
g i v e a l l Americans immediate i n s u r a n c e coverage. Responded C l i n t o n :
"The r i g h t t h i n g f o r America's v a l u e s , f o r work, f o r f a m i l y , i s t o
p r o v i d e h e a l t h care f o r a l l Americans.
I t doesn't have t o be done
tomorrow.
I t ought t o be phased i n over a p e r i o d o f j u s t a few
y e a r s . But we ought n o t t o walk away w i t h o u t a b i l l t h a t p r o v i d e s
h e a l t h c a r e t o a l l Americans."
Added C l i n t o n :
"Our p l a n r e q u i r e d a p h a s e - i n . I t ' s g o i n g t o
t a k e some t i m e f o r t h e s t a t e s and f o r o t h e r s who would have t o
p r o v i d e t h e i n s u r a n c e who don't now t o phase i t i n . But I t h i n k t h e
i m p o r t a n t t h i n g i s t h a t we s h o u l d n o t walk away from t h i s Congress
w i t h o u t a commitment t o cover everyone. The s o - c a l l e d 91 p e r c e n t
s o l u t i o n , i f i t ' s a permanent s o l u t i o n , e s s e n t i a l l y would guarantee
what we have now. The poor would g e t h e a l t h c a r e . The w e a l t h y
would g e t h e a l t h c a r e . The middle c l a s s would be a t r i s k o f l o s i n g
i t . ... The s i t u a t i o n i n terms o f coverage i s g e t t i n g worse; more
and more m i d d l e - c l a s s Americans a t r i s k . " Added C l i n t o n :
"Now, I
admit t h a t we needed t o make some changes i n o u r o r i g i n a l p r o p o s a l .
I always s a i d we would. We want i t now t o be l e s s b u r e a u c r a t i c and
Press RETURN t o c o n t i n u e , GOLD MENU f o r o p t i o n s o r EXIT t o c a n c e l
�l e s s r e g u l a t o r y , and t h e p r o p o s a l s a r e . They r e f l e c t some changes
t h a t we have agreed t o . But we have t o cover a l l Americans, and
t h a t ' s the r e a l issue."
Asked i f he would v e t o a b i l l which p r o v i d e s coverage f o r o n l y
91 p e r c e n t o f Americans, C l i n t o n dodged the q u e s t i o n , r e p l y i n g :
"What I'm s a y i n g i s I don't t h i n k i t w i l l come t o my desk f o r t h e
simple reason t h a t i f you l o o k a t what t h e b i l l does, t h e b i l l t h a t
covers 91 p e r c e n t o f Americans, the p r o p o s a l would c o s t m i d d l e - c l a s s
t a x p a y e r s more t a x money, e s s e n t i a l l y s u b s i d i z e low-income people,
and l e a v e m i d d l e - c l a s s workers e i t h e r w i t h o u t h e a l t h i n s u r a n c e o r a t
r i s k o f l o s i n g i t because o f a l l the problems we have i n t h e system
today. So I r e a l l y don't b e l i e v e i t i s a s o l u t i o n . "
C l i n t o n made
h i s comments d u r i n g an appearance t h i s morning on NBC t e l e v i s i o n .
T h i s morning, C l i n t o n h e a l t h care a d v i s o r I r a Magaziner was
o p t i m i s t i c Congress would move ahead on a f a s t schedule, s a y i n g : " I
t h i n k t h e committees are moving ahead, and we're h o p e f u l t h a t a l l
f i v e o f t h e major committees t h a t have t o c o n s i d e r h e a l t h care
r e f o r m l e g i s l a t i o n w i l l be f i n i s h e d w i t h t h e i r work, g i v e o r t a k e ,
around J u l y 4 t h . And then w e ' l l move on t o t h e f l o o r o f b o t h Houses
i n J u l y . Both M a j o r i t y Leader M i t c h e l l and M a j o r i t y Leader Gephardt
have i n d i c a t e d t h a t t h e y w i l l move t o the f l o o r w i t h b i l l s i n J u l y . "
Magaziner a l s o s a i d t h e l e g i s l a t i v e approach b e i n g advocated by
Press RETURN t o c o n t i n u e , GOLD MENU f o r o p t i o n s o r EXIT t o c a n c e l
�on" C l i n t o n ' s meetings w i t h Finance Cmte. members. Senate a i d e s
say Moynihan "welcomes t h e p a r t i c i p a t i o n o f t h e e x p e r i e n c e d
Bentsen." One WH a i d e :
"He i n j e c t s a l i t t l e r e a l i t y i n t o t h e
White House" (6/27 i s s u e ) .
SHALALA: HHS Sec. Donna S h a l a l a , asked i f GOPers "are
s e r i o u s " about h e a l t h care r e f o r m t h i s year: " I a c t u a l l y t h i n k
t h a t t h e Republicans want h e a l t h care r e f o r m as much as we do.
... I suppose t h e r e are some Republicans t h a t would l i k e t o throw
a monkey wrench and use i t , b u t I cannot b e l i e v e t h e l e a d e r s h i p
o f t h e R e p u b l i c a n P a r t y doesn't care as much about w o r k i n g
Americans as Democrats do" ("Evans & Novak," CNN, 6/18).
HEALTH-SPEAK: Penn p r o f . K a t h l e e n H a l l Jamieson w r i t e s , "To
t h e l e g i s l a t o r s bent on expanding h e a l t h coverage, E n g l i s h seems
t o be a second language. ... E n t i r e swaths o f t h e debate can be
t e l e g r a p h e d i n b a r e l y i n t e l l i g i b l e a l t e r n a t i v e s such as u n i v e r s a l
coverage v s . u n i v e r s a l access. Both are m i s l e a d i n g i n what t h e y
o m i t . ... A l l t h i s would be c o n f u s i n g enough even i f advocates
s t a n d a r d i z e d t h e i r symbols. But as t h e debate has e v o l v e d so t o o
have t h e phrases d e f i n i n g t h e problem, t h e p l a n s and t h e i r
p u t a t i v e e f f e c t s " (PHILA. INQUIRER, 6/20) .
(c) The American P o l i t i c a l Network, I n c .
Press RETURN t o c o n t i n u e , GOLD MENU f o r o p t i o n s o r EXIT t o c a n c e l
�THE REPUBLICAN PLANS: AN EMPTY PROMISE OF "PORTABILITY"
"I have great trouble seeing how you get portability without universal coverage. "
— Senator John H. Chafee
When il comes to health care reform, many Republicans talk a good game ~ portability, continuous
coverage, no more denials for pre-e.xisling conditions — but when you look al the fine print, their plans
don't deliver. Under their plans, every American would still risk losing their coverage, and nearly 40
million people would remain uninsured. No one would be secure. Everyone would be at risk.
Without universal coverage, it is next lo impossible to enact real and lasting insurance reforms such as
portability. As the Wall Street Journal noted "experts insist and real-life evidence shows: it [insurance
reform] probably won't work without universal coverage. " [WSJ 6/15/94]
The
Republican
ads
sav:
"We can make insurance portable now... Congress simply needs to change the laws so if you lose your job,
you won't lose your coverage."
But
the
facts
are:
There is a big difference between portability and security. "Portability" means that you can take with you
benefits you were given at your old job ~ provided you can assume the full cost yourself. It's like saying
lhat if you leave a job with a company car, you can take your car with you ~ if you're prepared to buy it
from the company.
But insurance already costs more than many families can afibrd, and paying Ihe full cost -- up lo $12,000
a year for some families — would be impossible.
The only way lo make insurance iruly secure is lo guarantee that every job comes with insurance, and thai
people who arc between jobs or otherwise unemployed don't lose their coverage, even if they lose their
ability to pay for it. The incremenlal Republican plans don't pass that test. Under their plans:
•
You could slill lose your coverage when you change your job.
•
You could slill be denied coverage for a prc-cxisling condition.
•
You could be dropped from your plan if you can't afford the premium.
•
If you lose your job, your new insurance company could wail six months before ihey begin covering
you.
Insurance reforms are not the answer -- they don't give you real securitv. If Republicans are serious about
health care reform they'll give the American people what they've got -- guaranteed private insurance on
the job that can never be taken away.
�/
/
tried. President Nixon tried. President Carter tried. Every time
the special interests were powerful enough to defeat them. But not
this time. (Applause.)
I know that facing up to these interests will require courage. It
will raise critical questions about the way we finance our campaigns
and how lobbyists yield their influence. The work of change,
frankly, will never get any easier until we limit the influence of
well-financed interest who profit from this current system. So I
also must now to call on you to finish the job both Houses began last
year by passing tough and meaningful campaign finance reform and
lobby reform legislation this year. (Applause.)
You know, my fellow Americans, this is really a test for all of us.
The American people provide those of us in government service with
terrific health care benefits at reasonable costs. We have health
care that's always there. I think we need to give every hardworking, tax-paying American the same health care security they have
already given to us. (Applause.)
I want to make this very clear. I am open, as I have said
repeatedly, to the best ideas of concerned members of both parties.
I have no special brief for any specific approach, even in our own
bill, except this: If you send me legislation that does not
guarantee every American private health insurance that can never be
taken away, you will force me to take this pen, veto the legislation,
and we'll come right back here and start all over again. (Applause.)
But I don't think that's going to happen. I think we're ready to act
now. I believe that you're ready to act now. And if you're ready to
guarantee every American the same health care that you have, health
care that can never be taken away, now — not next year or the year
after — now is the time to stand with the people who sent us here.
Now. (Applause.)
As we take these steps together to renew our strength at home, we
cannot turn away from our obligation to renew our leadership abroad.
This is a promising moment. Because of the agreements we have
reached this year, last year, Russia's strategic nuclear missiles
soon will no longer be pointed at the United States, nor will we
point ours at them. (Applause.) Instead of building weapons in
space, Russian scientists will help us to build the international
space station. (Applause.)
Of course, there are still dangers in the world —rampant arms
proliferation, bitter regional conflicts, ethnic and nationalist
tensions in many new democracies, severe environmental degradation
the world over, and fanatics who seek to cripple the world's cities
with terror. As the world's greatest power, we must, therefore,
maintain our defenses and our responsibilities.
This year, we secured indictments against terrorists and sanctions
�THE WHITE HOUSE
January 25, 1994
STATE OF THE UNION ADDRESS
BY THE PRESIDENT
The House of Representatives
THE PRESIDENT: Thank you very much. Mr. Speaker, Mr. President,
members of the 103 rd Congress, my fellow Americans:
I'm not at all sure what speech is in the TelePrompter tonight —
(laughter) -- but I hope we can talk about the state of the Union.
1
I ask you to begin by recalling the memory of the giant who presided
over this Chamber with such force and grace. Tip O'Neill like to
call himself "a man of the House." And he surely was that. But,
even more, he was a man of the people, a bricklayer's son who helped
to build the great American middle class. Tip O'Neill never forgot
who he was, where he came from, or who sent him here. Tonight he's
smiling down on us for the first time from the Lord's Gallery. But
in his honor, may we, too, always remember who we are, where we come
from, and who sent us here. (Applause.)
If we do that we will return over and over again to the principle
that if we simply give ordinary people equal opportunity, quality
education, and a fair shot at the American Dream, they will do
extraordinary things.
We gather tonight in a world of changes so profound and rapid that
all nations are tested. Our American heritage has always been to
master such change, to use it to expand opportunity at home and our
leadership abroad. But for too long, and in too many ways, that
heritage was abandoned, and our country drifted.
For 30 years, family life in America has been breaking down. For 20
years, the wages of working people have been stagnant or declining.
For the 12 years of trickle-down economics, we built a false
prosperity on a hollow base as our national debt quadrupled. From
1989 to 1992, we experienced the slowest growth in a half century.
For too many families, even when both parents were working, the
American Dream has been slipping away.
In 1992, the American people demanded that we change. A year ago I
asked all of you to join me in accepting responsibility for the
future of our country. Well, we did. We replaced drift and deadlock
with renewal and reform. And I want to thank every one of you here
who heard the American people, who broke gridlock, who gave them the
most successful teamwork between a President and a Congress in 30
years. (Applause.)
�Community-Rated Health Plans Prove Popular,
But Success May Depend on Universal Coverage
By HILAHY STOLT
X
p . :. - J- T H E W A L L S T R E E T
Rating the Proposals
JOLRN^L
A AiHINGTON - It's the health-care
vrop.'iai everyone loves: the notion that
p.iurjnce companies shouldn t be allowed
tu jack up rates for sick people or others at
risk of piling up big medical bills.
So attractive is the concept, known as
community rating." that even many Republicans and conservative Democrats say
Congress should go ahead and enact it.
along with a set of other insurance-market
revisions, and forget about universal
health coverage for now. A new GOP
television advertising campaign pushes
tor bipartisan insurance-market reforms
to - fix health care.''
There s just one problem with the idea,
experts insist and real-life evidence shows.
It probably won t work without universal
coverage. Indeed, several of the insurance
•.hinges that reformers are clamoring f.>r
may depend or their success on bringing
nearlv e-.erybody into the insurance pool.
Fur the pas; year New York state has
;r:ed Lummunity rating without a law
requiring everyone to have health insur.mce. The result has been a rise in insuri.-ue premiums for younger, healthier
pe-ple .md a drop in rates for older, sicker
:n- .;v:duais Consequently, young, people
Have bailed out of the system.' figuring
•.he> e.ther won't need coverage or they'll
iv ible to get it at a reasonable price wlien
-cv; re -^a.c -ea!:r--?'c-r. z r \ :ea: •. •- •
• CLINTON: Nc : e~ ^ .a^ator-s
aiio'.vea'o-age -ec cai status geog-ao^y or ifestyie Se:a a:e ice's
accQ'r.-g to 'af- , s
"
ietta'ate : ;•; s
t - j . e . e - s .'.
;
:
^
er-ioioyers .vn ~o-» ~y : • : ..-y.-.-s
jssociat'oc :-a-s r c -fa-:- • a-ces
I SENATE FINANCE (currently under consideration): = -•?- ^r- . j 3: ; -5
accotC'-g :Q 'a.- 3 :e geeg--]:-. rc
age gnes: age-ac^s ?::
' a / :e -.0
:-ar ce - f :
age-aciustec
• SENATE LABOR AND HUMAN RESOURCES
(approved June 9): Sa^e as C""ton Dut
crasea n over 'o^r ears.
(
u
• CHAFEE: "eaif. r-ans -"JS: o«ter a
-ec.f ec :o "' "-":.. 'ate tyem-um tor
^eoDie a-c juSiresses ot ^r.aer lOO
«0'<e's .vno ouy nsi.r3r.ce mrougr. a
Durciasing ccooerative
r
i
2-:5C-
1
-
I COOPER-BREAUX: ^Jc ac .s ^e -s
anowea 'or mecKai status or - j - i e ' v
Gast -^ed'cai cairns, preniums tan ;e
.•a ed accordirg to gecg-3G.v a-.c to
sor^e :eg ?e age
• HOUSE WAYS AND MEANS (currently
under consideration): Community ratirg
ri
n
r
f
H
:be> di>.
*
Older. Sicker People
Now. insurers are raising prices again
.n i'rder to cover the medical needs of those
•Ider. sicker people left in the pool. State
.nsurance department figures show that as
: t-n. i. nine months after the new law
-f'ect. J.Vt": 'ewer people had health
'oiiriiice individually or in small•••
'wr -T'lips Tha; s a 1.2'". decline.
The univ way to avoid this chain reaction, many experts say. is to set up a
.>;em where people can t drop out. Uwe
r.c-mnardt. a Princeton University health
- .onumist. says that when he heard Repubiican calls to enact insurance market
reforms alone as a way to vastly improve
the current system he reacted with total
disbelief Community rating without universal coverage will trireer the worst
kind of behavior among insurers and patients." he says.
If you can go in and out of a system at
will, then the only people who will buy
insurance are those who need it." says
Barbara Ragle, legal counsel at Central
Reserve Life Insurance Co.
Nor is community rating the only popular insurance reform that would be nearly
impossible without universal coverage.
The same thing is true of proposals to
outlaw the common industry practice of
refusing to cover people with known medical problems, so-called pre-existing conditions. Most health bills that stop short of
universal coverage, such as the bipartisan
Managed Competition Act championed by
Democratic Rep. Jim Cooper of Tennessee,
allow insurance companies to exclude coverage of a pre-existing condition for up to
six months unless the prospective policy
holder is switching from one policy to
another. Again, the reason is that if
the government requires companies to
cover pre-existing conditions without requiring everyone to have insurance, people
will buy policies only when they expect
high medical expenses.
;
Some supporters of community rating
are pushing to allow some adjustments. •
such as for age and habits that affect '
bealth, like smoking. And for all the rhetoric embracing community rating, most
of the actual bills under consideration in ;
Congress would adopt only a modified
version of the concept.
Nobody is proposing pure community
rating." says Henry Aaron, an economist
at the Brookings Institution in Washington. Even the sweeping Clinton proposal
would allow four different types of regional
risk pools, based on family type - for individuals, for single parents with children,
for couples and for two-parent families \
with children.
The House Ways and Means Commit- |
tee. under pressure from the insurance ;
industry, is considering a bill wuh five
different market sectors, based largely on
a person s employer. Each sector would be
community rated, but insurers wouldn't !
have to sell policies in every sector. The
leading Senate Republican bill, written by
John Chafee of Rhode Island, allows insurers to adjust for age and geography in
some markets.
In fact, many people argue that the only
legislation that guarantees a true community-rated approach are bills establishing a
"single-payer health system, where the
government pays people's medical bills
with tax revenues.
Other things that make community
ratings work are also opposed by supporters of the concept. A successful community-rated system requires a bureaucratic structure to oversee it. Yet many of
the people calling for insurance-market
reforms are the same ones decrying the
large regional health alliances that President Clinton has proposed.
The alliances, which would be set up by
the states, would include employees of all
businesses with fewer than 5.000 workers.
The White House says they were conceived
to establish a large pool over which to
spread insurance risks. And they are also
intended to take care of a difficult but
critical job known as risk adjusting.
Community rating violates basic actuarial principles.'' says Princeton's Prof.
Reinhardt. "A community-rated system
forces a competing private insun*/ to look
1
at a deathly ill patient, mv.r.i i SIOOOIVI
bill, and cheerfully enroll t.-.^t person for
$2,000. It goes against human nature So m
order to overcome norma: y.-.min nature
you need some coercion.
That means that while everyone pavs
the same amount into a community rated
system, a mechanism must be set up so
insurance companies receive varvng
amounts, depending on the risk level's of
their beneficiary pools. Otherwise, a plan
that for some reason was chosen by a
disproportionate numberof. sav, HIV positive people, would be in bad financial
shape. Ultimately, health plans overloaded
with bad risks who pay low premiums
could collapse. Risk-adjusting basically
requires plans with better risk po..is to
:
subsidize those with worse risk puvis
The administration proposed he.ntn uliances to accomplish that task. H- w^ver. ,
most of the people pushing insurance reforms are balking at alliances •;.,nsequently. large mandatory allian.vs are :
ail but dead in Congress.
Alliances aren't the only entities that |
could perfonn such functions. It could be i
done through state insurance regulation, j
says Mr. Aaron. The virtue of alhances. :
Prof. Reinhardt points out. is that they also i
would collect the health-insurance pre- ;
miums. and could then turn around and
pay money out to plans in the form of a
risk-adjusted premium.
He says,
"That's a lot different than having to go in
there and fight with their lawyers
Seeing the Insurer's Side
Even Gail Shearer, who as manager of
policy analysis for Consumers Union is
usually no friend of insurance companies,
says: You can understand why the insurers want protection."
In a pure community-rated insurance
system, everyone in a region would pay the
same premium for the same package of
health benefits, regardless of age, sex,
medical history, lifestyle or place of resi:ence. desoite cancer ir severe disabil-
V99A
THt
�Community'Rated Health Plans Prove Popular,
But Success May Depend on Universal Coverage
By HILAAY STOLT
';. p . . i
Rating the Proposals
T H E W A L L S T H E U T JOI-R> »L
-A \SHINGTON' - It's the health-care
nx-pvsal everyone loves: the notion that
.r:nce companies shouldn't be allowed
to jack up rates for sick people or others it
r:sk of piling up big medical bills.
So attractive is the concept, known is
community rating.'' that even many Republicans and conservative Democrats say
Congress should go ahead and enact it.
along with a set of other insurance-market
revisions, and forget about universal
health coverage for now. A new GOP
television advertising campaign pushes
for bipartisan insurance-market reforms
to " fix nealth care."
There's just one problem with the idea,
experts insist and real-life evidence shows.
I; probably won't work without universal
coverage. Indeed, several of the insurance
'.'hinges that reformers are clamoring '-T
may depend for their success on bringing
nearlv e'.erybody into the insurance pool.
For the pas; year New York state has
tried community rating without a law
requiring everyone to have health insurance. The result has been a rise in insuri.nce premiums for younger, healthier
pe' >ple .md a drop in rates for older, sicker
•n.Jtv.duais Consequently, young people
Have billed 'jut of the system, figuring
:he> e.ther won't need coverage or they'll
be ible to get it at a reasonable price when
they ao.
Older. Sicker People
Now. insurers are raising prices again
.n "rder to cover the medical needs of those
ider. -icker people left in the pool. State
.nsurance department figures show that as
•:'
!. nine months after the new law
'••••k -t'fect. J j . r : fewer people had health
-oiir trice individually or in small-ver iT'>ijps. That's a
decline.
Tbe vniy way to avoid this chain reaction, manv experts say. is to set up a
-;.-tern where people can t drop out. Uwe
Reinnardt. a Princeton University health
e . nomist. says that when he heard Republican calls to enact insurance market
reforms alone as a way to vastly improve
the current system he reacted with "total
disbelief Community rating without universal coverage "will trigger the worst
kind of behavior among insurers and patients." he says.
If you can go in and out of a system at
will, then the only people who will buy
insurance are those who need it." says
Barbara Ragle, legal counsel at Central
Reserve Life Insurance Co.
Nor is community rating the only popu/ lar insurance reform that would be nearly
impossible without universal coverage.
The same thing is true of proposals to
outlaw the common industry practice of
refusing to cover people with known medical problems, so-called pre-existing conditions. Most health bills that stop short of
universal coverage, such as the bipartisan
Managed Competition Act championed by
Democratic Rep. Jim Cooper of Tennessee,
allow insurance companies to exclude coverage of a pre-existing condition for up to
six months unless the prospective policy
holder is switching from one policy to
another. Again, the reason is that if
the government requires companies to
cover pre-existing conditions without requiring everyone to have insurance, people
will buy policies only when they expect
high medical expenses.
-o-.v t-e
-eai:r-'»'c— c-j— :ei! .-. •- •
• CLINTON: No : e - ^ .2'r.Q-s
aiicvea ' c age ~$c cai status geog-aory or -ifestye Se:ara:e pecs
acco'r ng to 'a^- . s.:e
"
s ": .
;
eno'Oyers .v r ~o-e r y I M
e--,
assoc anon ; a"? r c --.yr y a-ces
I SENATE FINANCE (currently under consideration): - ^
a a: ;~s
acco-ci-g'o'a-3
;e gecg-ac", rc
age * gres: age-3C.-s:ec
- a ; ce --c -c-e -"an ce t'e ; .-.es
age-aciLStea
• SENATE LABOR AND HUMAN RESOURCES
(approved June 9): Sar-e as Cnnon Out
erased n ove' 'o„: .ears.
• CHAFEE: ^eac^-. ^ - s ---st oner a
- o c ec C C - T ' a r e cewum ror
ceooie anc easinesses or jncer 100
:.o <e s .-.no Duy nsLrarce tnroLgn a
r
sesa-ate
-
I COOPER-BREAUX: Nc ac us ^e ts
anowea tor medicai status or -j.-oe'
cast "ned'cai claims oremiurrs ;3n ce
.•a"efl according to gecg-aony anc to
so^e cegee age
r
Ourcnasing ccoDeraiive
• HOUSE WAYS AND MEANS (currently
under consideration): Comnunity rating
r
:
Some supporters of community rating
are pushing to allow some adjustments, j
such as for age and habits that affect '
bealth. like smoking. And for all the rhetoric embracing community rating, most
of the actual bills under consideration in ;
Congress would adopt only a modified
version of the concept.
Nobody is proposing pure community
rating." says Henry Aaron, an economist
at the Brookings Institution in Washington. Even the sweeping Clinton proposal
would allow four different types of regional
risk pools, based on family type - for individuals, for single parents with children,
for couples and for two-parent families
with children.
The House Ways and Means Committee, under pressure from the insurance
industry, is considering a bill with five
different market sectors, based largely on
a person s employer Each sector would be
community rated, but insurers wouldn t
have to sell policies in every sector. The
leading Senate Republican bill, written by
John Chafee of Rhode Island, allows insurers to adjust for age and geography in
some markets.
In fact, many people argue that the only
legislation that guarantees a true community-rated approach are bills establishing a
"single-payer" health system, where the
government pays people's medical bills
with tax revenues.
Other things that make community
ratings work are also opposed by supporters of the concept. A successful community-rated system requires a bureaucratic structure to oversee it. Yet many of
the people calling for insurance-market
reforms are the same ones decrying the
large regional health alliances that President Clinton has proposed.
The alliances, which would be set up by
the states, would include employees of all
businesses with fewer than 5.000 workers.
The White House says they were conceived
to establish a large pool over which to
spread insurance risks. And they are also
intended to take care of a difficult but
critical job known as risk adjusting.
Community rating violates basic actuarial principles,'' says Princeton's Prof.
Reinhardt. "A community-rated system
forces a competing private insurer to look
:
at a deathly ill patient, seeing 1 Sioo.oori
bill, and cheerfully enroll tb^t person for
$2.i)00. It goes against human nature. So :n
order to overcome norma: numan nature,
you need some coercion
That means that while everyone pays
the same amount into a community rated
system, a mechanism must be set up so
insurance companies receive varying
amounts, depending on the risk levels of
their beneficiary pools. Otherwise, a plan
that for some reason was chosen by a
disproportionate numberof. say, HIV-positive people, would be in bad financial
shape. Ultimately, health plans overloaded
with bad risks who pay low premiums
could collapse. Risk-adjusting basically
requires plans with better risk pools to
subsidize those with worse risk pools
The administration proposed health alliances to accomplish that task. However,
most of the people pushing insurance reforms are balking at alliances Consequently, large mandatory alliances are
all but dead in Congress.
Alliances aren t the only entities that
could perform such functions. "It could be
done through state insurance regulation,
says Mr. Aaron. The virtue of alliances.
Prof. Reinhardt points out. is that they also
would collect the health-insurance premiums, and could then turn around and
pay money out to plans in the form of a
risk-adjusted premium.
He says,
"That's a lot different than having to go in
there and fight with their lawyers
Seeing the Insurer's Side
Even Gail Shearer, who as manager of
policy analysis for Consumers Union is
usually no fnend of insurance companies,
says: You can understand why the insurers want protection."
In a pure community-rated insurance
system, everyone in a region would pay the
same premium for the same package of
health benefits, regardless of age, sex.
medical history, lifestyle or place of resitence. lesoite cancer or severe disabil
1994
�Community-Rated Health Plans Prove Popular,
But Success May Depend on Universal Coverage
By HiLAKY STOLT
.
:
•
.;,
D
)
•
:
T H E W A U . S T K C C T J O I R.N AL
WASHINGTON - It's the health-care
:-r:.-pi..sal everyone loves: the notion that
insurance companies shouldn't be allowed
to jack up rates for sick people or others at
risk of piling up big medical bills.
So attractive is the concept, known is
community rating, that even many Republicans and conservative Democrats say
Congress should go ahead and enact it.
along with a set of other insurance-market
revisions, and forget about universal
health coverage for now. A new GOP
television advertising campaign pushes
for bipartisan .nsurance market reforms
to - fix bealth care.''
There's just one problem with the idea,
experts insist and real-life evidence shows.
probably won t work without universal
coverage.Indeed, several of the insurance
changes that reformers are clamoring '.T
may depend for their success on bringing
nearly e-.erybudy into the insurance pool.
Fcr tbe p.is; year New York state has
tried c.-mmunity rating without a law
requiring everyone to have health insurjnce. The result bas been a rise in insuri.nce premiums for younger, healthier
people and a drop in rates for older, sicker
individuals. .Consequently, yo.ung people
have bailed ...ut of the system, figuring
:bes e.ther won't need coverage or they'll
be ible to get it at a reasonable price when
tbey do.
Older. Sicker People
Now. insurers are raising prices again
n .rder to cover the medical needs of those
ider. <icker people left in the pool. State
."Mirince department figures show that as
: .:.'i. i. nine months after the new law
O.-K -tfect. J~>.t:: fewer people had health
nMinnce .ndividually or in small••••ii'-iover groups That s a l..": decline.
Tbe only way to avoid this chain reaction, many experts say. is to set up a
v .~;eni uhere people can't drop out. Uwe
Reinnardt. a Princeton University health
- .nomist. says that when he heard Republican calls to enact insurance market
reforms alone as a way to vastly improve
the current system hereactedwith total
disoelief. Community rating without universal coverage will trigger the worst
kind of behavior among insurers and patients." he says.
If you can go in and out of a system at
will, then the only people who will buy
insurance are those who need it," says
Barbara Ragle, legal counsel at Central
Reserve Life Insurance Co.
Nor is community rating the only popular insurance reform that would be nearly
impossible without universal coverage.
The same thing is true of proposals to
outlaw the common industry practice of
refusing to cover people with known medical problems, so-called pre-existing conditions. Most health bills that stop short of
universal coverage, such as the bipartisan
v Managed Competition Act championed by
Democratic Rep. Jim Cooper of Tennessee,
allow insurance companies to exclude coverage of a pre-existing condition for up to
six months unless the prospective policy
holder is switching from one policy to
another. Again, the reason is that if
the government requires companies to
cover pre-existing conditions without requiring everyone to have insurance, people
will buy policies only when they expect
high medical expenses.
Seeing the Insurer's Side
Even Gail Shearer, who as manager of
policy analysis for Consumers Union is
usually no fnend of insurance companies,
says: You can understand why the insurers want protection."
In a pure community-rated insurance
system, everyone in a region would pay the
same premium for the same package of
health benefits, regardless of age, sex,
medical history, lifestyle or place of resi:er,ce. desoite cancer ir severe disabil;
Rating tbe Proposals
• CUMTON-.Nc : e - j ^ - a ato-s
aiicv.-eo'c age ~eccais;a us geog•aony or I'estye Secarate pccis
3cco':.-g to 'a'**- y s -e
- •:•„• sec-a'ate
s
-
• SENATE LABOR AND HUMAN RESOURCES
(approved June 9): Sa-e as Ci.nton
:rasea n over 'o^r years.
• CHAFEE: -e.i - o'ans ^ . s : o^er a
-03 t ec ror-.-j*.:. -ate crem.um 'or
ceoce an- D^s-nesses ot jn.aer iQG
.•.O'He's .-.no ouy ns1_r3n.ce througr. a
burcnasi.ng ccoDeratc-e
• HOUSE WAYS AND MEANS (currently
under consideration): Community rating
Some supporters of community rating
are pushing to allow some adjustments,
such as for age and habits that affect
bealth. like smoking. And for all the rhetoric embracing community rating, most
of the actual bills under consideration in
Congress would adopt only a modified
version of the concept.
Nobody is proposing pure community
rating," says Henry Aaron, an economist
at the Brookings Institution in Washington. Even the sweeping Clinton proposal
would allow four different types of regional
risk pools, based on family type - for individuals, for single parents with children,
for couples and for rwo-parent families
with children.
The House Ways and Means Committee, under pressure from the insurance
industry, is considering a bill with five
different market sectors, based largely on
a person's employer. Each sector would be
community rated, but insurers wouldn't
have to sell policies in every sector. The
leading Senate Republican bill, written by
John Chafee of Rhode Island, allows insurers to adjust for age and geography in
some markets.
In fact, many people argue that the only
legislation that guarantees a true community-rated approach are bills establishing a
"single-payer health system, where the
government pays people's medical bills
with tax revenues.
Other things that make community
ratings work are also opposed by supporters of the concept. A successful community-rated system requires a bureaucratic structure to oversee it. Yet many of
the people calling for insurance-market
reforms are the same ones decrying the
large regional health alliances that President Clinton has proposed.
The alliances, which would be set up by
the states, would include employees of all
businesses with fewer than 5,000 workers.
The White House says they were conceived
to establish a large pool over which to
spread insurance nsks. And they are also
intended to take care of a difficult but
critical job known asriskadjusting.
Community rating violates basic actuarial principles.'' says Princeton's Prof.
Reinhardt. "A community-rated system
forces a competing private insuirr to look
r
emoioyes .v n - c e - r Iv. .•.-•«e-;
association :-3-5 a"C ' - . i - , - \- a-ces
I SENATE FINANCE (currently under consideration):
.a- a: :--s
acco-C'-g to 'a- ••. 3 ;e gecg-a:-. a--:
age ^ gnes: age-3C:-.ste;
..~
-a/ "e -0
: an ce --. •: .•.es:
age-aaiLStec z^.-^r_
I COOPER-BREAUX: Nc ac .s - e s
anowec tor mecicai status or " m:-e
cast med.cai ciaims. premiums can ce
.a-'ed according to gecg-aony anc to
so^e cegee age
r
J
r
at a deathly ill patient, seeing 1 SIIJI)..)IVI
bill, and cheerfully enroll that person lor
$2,000. It goes against human nature. So in
order to overcome norma, n .man nature,
you need some coercion
That means that while everyone pavs
the same amount into a commumtv rated
system, a mechanism must be set up so
insurance companies receive varvng
amounts, depending on the risk levels of
their beneficiary pools. Otherwise, a plan
that for some reason was chosen bv a
disproportionate number of, say, HIV-positive people, would be in bad financial
shape. Ultimately, health plans overloaded
with bad nsks who pay low premiums
could collapse. Risk-adjusting basically
requires plans with better risk pools to
subsidize those with worse risk pools
The administration proposed health iiliances to accomplish that task. H. wever. 1
most of the people pushing insurance reforms are balking at alliances .' .nsequently. large mandatory alliances are •
all but dead in Congress.
Alliances aren't the only entities that ;
could perform such functions. It could be i
done through state insurance regulation, j
says Mr. Aaron. The virtue of alhances. :
Prof. Reinhardt points out. is that they also 1
would collect the health-insurance premiums. and could then turn around and
pay money out to plans in the form of a
"risk-adjusted premium." He says,
That's a lot different than having to go in
there and fight with their lawyers
1
. NESD
ED
�Community-Rated Health Plans Prove Popular,
But Success May Depend on Universal Coverage
O .
U . t
.OX.-
—
By HIL.\JIY STOLT
:
. ;.p
.-:..
r
they Jo.
A'
*
Older. Sicker People
Now. insurers are raising prices again
m "rder to cover the medical needs of those
Ider. -ncker people left in the pool. State
.nsurance department figures show that as
: tan. I. nine months after the new law
"ffect. J'JJ" fewer people had health
nvirmce individually or in small.y-?r ..T'ups. That s a 1 2'" decline.
Ttie only way to avoid this chain reaction, many experts say. is to set up a
v-nem where people can t drop out. Uwe
Reinnardt. a Princeton University health
economist, says that when he heard Republican calls to enact insurance market
reforms alone as a way to vastly improve
the current system he meted with "total
disbelief. Community rating without universal coverage "will trigger the worst
kind of behavior among insurers and patients." he says.
If you can go in and out of a system at
will, then the only people who will buy
insurance are those who need it." says
Barbara Ragle, legal counsel at Central
Reserve Life Insurance Co.
Nor is community rating the only popular insurance reform that would be nearly
impossible without universal coverage.
The same thing is true of proposals to
outlaw the common industry practice of
refusing to cover people with known medical problems, so-called pre-existing conditions. Most health bills that stop short of
universal coverage, such as the bipartisan
. Managed Competition Act championed by
Democratic Rep. Jim Cooper of Tennessee,
allow insurance companies to exclude coverage of a pre-existing condition for up to
six months unless the prospective policy
holder is switching from one policy to
another. Again, the reason is that if
the government requires companies to
cover pre-existing conditions without requiring everyone to have insurance, people
will buy policies only when they expect
high medical expenses.
Seeing the Insurer's Side
Even Gail Shearer, who as manager of
policy analysis for Consumers Union is
usually no fnend of insurance companies,
says: You can understand why the insurers want protection."
In a pure community-rated insurance
system, everyone in a region would pay the
same premium for the same package of
health benefits, regardless of age. sex,
medical history, lifestyle or place of resilence. lesoite cancer or severe disabil
^
—
^
^
—
—
^
^
.
.
Rating the Proposals
n THE WALL STRICT JOVRN^L
WASHINGTON - It's the healthcare
rropc'Sal everyone loves: the notion that
.nsurance companies shouldn't be allowed
to jack up rates for sick people or others at
risk of piling up big medical bills.
So attractive is the concept, known is
community rating.'' that even many Republicans and conservative Democrats say
Congress should go ahead and enact it.
along with a set of other insurance-market
revisions, and forget about universal
health coverage for now. A new GOP
television advertising campaign pushes
for bipartisan insurance-market reforms
to fix bealth care."
There's just one problem with the idea,
experts insist and real-life evidence shows.
It probably won't work without universal
coverage. Indeed, several of the insurance
changes that reformers are clamoring ' T
ma> Jeoend for their success on bringing
nearK e-.erybudy into the insurance pool.
Fur the pas; year New York state has
tried community rating without a law
requiring everyone to have health insurance The result has been a rise in insur
ance premiums for younger, healthier
people and a drop in rates for older, sicker
.nd^iduais. Consequently, young people
bave sailed out of the system, figuring
thes e.ther won't need coverage or they'll
be ible to get it at a reasonable price when
^
-•y:. t-e
-,ei,:p.-at, -~ , j - 5
:
:
I CLIMTOW: He :-e~ ^ . y a' o-s
anowea ' c age -ec cai status geog-aony or 'ifestye 3e:a'a:e pec's
acco'r.-g to ' a ^ . ; s-:e
I SENATE LABOR AND HUMAN RESOURCES
(approved June 9): Sa^e as Ci nton Out
cr-asea n over 'o-r ,ears
I CHAFEE: " w - c'a^s -us: otter a
-03 f ec c c — j - . t . -ate crem-um -or
ceoce anc Ci-s.resses of jncer iQQ
/.o-'e-s .vno ouy ns^ance througr a
ourcnasmg :cooerative
I HOUSE WAYS AND MEANS (currently
under consideration): Community ratmg
Some supporters of community rating
are pushing to allow some adjustments,
such as for age and habits that affect
bealth, like smoking. And for all the rhetoric embracing community rating, most
of the actual bills under consideration in
Congress would adopt only a modified
version of the concept.
Nobody is proposing pure community
rating," says Henry Aaron, an economist
at the Brookings Institution in Washington. Even the sweeping Clinton proposal
would allow four different types of regional
risk pools, based on family type - for individuals, for single parents with children,
for couples and for two-parent families
with children.
The House Ways and Means Committee, under pressure from the insurance
industry, is considenng a bill with five
different market sectors, based largely on
a person s employer. Each sector would be
community rated, but insurers wouldn't
have to sell policies in every sector. The
leading Senate Republican bill, written by
John Chafee of Rhode Island, allows insurers to adjust for age and geography in
some markets.
In fact, many people argue that the only
legislation that guarantees a true community-rated approach are bills establishing a
"single-payer' health system, where the
government pays people's medical bills
with tax revenues.
Other things that make community
ratings work are also opposed by supporters of the concept. A successful community-rated system requires a bureaucratic structure to oversee it. Yet many of
the people calling for insurance-market
reforms are the same ones decrying the
large regional health alliances that President Clinton has proposed.
The alliances, which would be set up by
the states, would include employees of all
businesses with fewer than 5,000 workers.
The White House says they were conceived
to establish a large pool over which to
spread insurance nsks. And they are also
intended to take care of a difficult but
critical job known as nsk adjusting.
Community rating violates basic actuarial principles," says Princeton's Prof.
Reinhardt. "A community-rated system
forces a competing pnvate insunr to look
" -y.r seca-ate z:-:s
r
emoiov?s
-o-e : - r
e-s
association c a-s j - c -ejc.- y a-,
:e5
I SENATE FINANCE (currently under consideration):
^m . j - j ; ; -5
accc-ci-g to ' a - s:e gecg-ac, r c
age ^ gnes; age-aci-stee c e - _~
- a , ce -c - c e t-ar ce
cesage-aciustec cem^m
I COOPER-BREAUX: ^Jc ac .st-e ;s
anowea !or medcai status o- -..-ce' :
cast med'cai daims. Dremnjms ran ce
/a"ed according to gecg'3c v a-c to
some degree, age
;
n
at a deathly ill patient, seeing i SIOO.'XIO
bill, and cheerfully enroll teat person for
$2,000. It goes against human nature. So m
order to overcome norma, cuman nature,
you need some coercion
That means that while everyone pavs
the same amount into a community rated
system, a mechanism must be set up so
insurance companies receive varying
amounts, depending on the nsk level's of
their beneficiary pools. Otherwise, a plan
that for some reason was chosen by a
disproportionate number of, say, HIV positive people, would be in bad financial
shape. Ultimately, health plans overloaded
with bad risks who pay low premiums
could collapse. Risk-adjusting basically
requires plans with better risk pools to
subsidize those with worse risk pools.
The administration proposed health alliances to accomplish that task. However, i
most of the people pushing insurance reforms are balking at alliances Consequently, large mandatory alliances are ;
all but dead in Congress.
Alliances aren't the only entities that |
could perform such functions. "It could be
done through state insurance regulation,
says Mr. Aaron. The virtue of alliances.
Prof. Reinhardt points out. is that they also i
would collect the health-insurance premiums, and could then turn around and
pay money out to plans in the form of a
risk-adjusted premium." He says.
"That's a lot different than having to go in
there and fight with their lawyers.
ED
S E S D A*-
�Community-Rated Health Plans Prove Popular,
But Success May Depend on Universal Coverage
By HILAHY STOLT
;.p
Rating the Proposals
)' T H E W A L L S n i c t T J U L R N A L
A
' AiHlNGTON - It's the health-care
iTop'jsai everyone loves: the notion that
—3v.-na,c neaitn-'e'c " c.j-s :9a: . - . - - J
nsurance companies shouldn't be allowed
•
CLINTON: Mo z-er. ^ . r
-• 'Our seca-ate
s •: . ;.as
to jack up rates for sick people or others at
allowed
'0' age ^ec cai status geoge-ce.e's
2-25C- i~z ~. ees
risk of piling up big medical bills.
-aon-y or ifesty e Seca'a'e pcois
So attractive is the concept, known is
employers .vn ~o-e r a - 2:0 ..o-.e-s
community rating.' that even many Reaccof-:.-.g to 'a^:-, s :e
association c-a-s anc -eac- \- a-ces
publicans and conservative Democrats say
•
SENATE FINANCE (currently under con•
SENATE
LABOR
AND
HUMAN
RESOURCES
Congress should go ahead and enact it.
sideration):
S-e- ^m a; a;..-5
(approved
June
9):
Same
as
Cnnton
out
along with a set of other insurance-market
acco'dng to-am.'-,, s ;e gecg-ac". r c
cr-aseo n over 'oc ,ears.
revisions, and forget about universal
age H-gnes: age-aci-.stec
health coverage for now. A new GOP
• CHAFEE: "ea;^ o ^ s m-s: otter a
ma/ Ce no m.;;.-j -r^r
ce " - . c.-.fs:
television advertising campaign pushes
~ca.t ec :o 'mj-.t,- -ate premium 'or
age-aciustec ;Kem:um.
for bipartisan insurance-market reforms
ceoo'e anc businesses ot raer iQQ
to •fix health care.''
• COOPER-BREAUX: Nc ac ust-e-s
•vote's -vno cuy nsurance through a
There s just one problem with the idea,
anowea for medicai status or -j.-ce' r
ourcnasmg "operative
experts insist and real-life evidence shows.
cast medical daims. premiums can ce
It probablv won t work without universal
• HOUSE WAYS AND MEANS (currently
'.•'a'ed accorcmg to gecg'acny anc to
coverage. Indeed, several of the insurance
under consideration): Community ratmg
some degee age
changes that reformers are clamoring f 'r
may depend for their success on bringing
Some supporters of community rating
nearly e-.erybudy into the insurance pool.
at a deathly ill patient, seeing a SlOO oim
are pushing to allow some adjustments,
Fcr tbe past year New York state bas
bill, and cheerfully enroll tbat person for
such
as
for
age
and
habits
that
affect
tried community rating without a law$2,000.
It goes against human nature. So m
bealth. like smoking. And for all the rhetorequiring everyone to have health insurorder to overcome norma: human nature,
ric
embracing
community
rating,
most
ance. The result has been a rise in insurof the actual bills under consideration in you need some coercion.
i.nce premiums for younger, healthier
That means that while everyone pays
people and a drop in rates for older, sicker Congress would adopt only a modified
the same amount into a community-rated
version
of
the
concept.
.nd;\'.duals Consequently, young people
" Nobody is proposing pure community system, a mechanism must be set up so
bave nailed out of the system, figuring
insurance companies receive varying
rating,"
says Henry Aaron, an economist
thev e.ther won't need coverage or they'll
amounts,
depending on the nsk level's of
be able to get it at a reasonable price wlien at the Brookings Institution in Washing- their beneficiary pools. Otherwise, a plan
ton.
Even
the
sweeping
CUnton
proposal
;he> Jo.
would allow four different types of regional that for some reason was chosen by a
Older. Sicker People
risk pools, based on family type - for indi- disproportionate numberof. say. HIV-posiNow. insurers are raising.pnces again
viduals, for single parents with children, tive people, would be in bad financial
.n order to cover the medical needs of those
for couples and for rwo-parent families shape. Ultimately, health plans overloaded
•Ider. sicker people left in the pool. State
with bad nsks who pay low premiums
with children.
.nsurance department figures show that as
could
collapse. Risk-adjusting basically
The House Ways and Means Commit:' 'an. I. nine months after the new law tee, under pressure from the insurance requires plans with better risk pools to
K -tfect. 'Ji.r: fewer people had health
industry, is considenng a bill with five
i».ir ir.ce individually or in smallsubsidize those with worse risk pools.
different market sectors, based largely on
>ver »r»ups. That s a 1 decline.
The administration proposed health ala person s employer. Each sector would be
Tbe onl;. way to avoid this chain reaccommunity rated, but insurers wouldn t liances to accomplish that task. However,
tion, many experts say. is to set up a
most of the people pushing insurance rehave to sell policies in every sector. The
-tern where people can't drop out. Uwe leading Senate Republican bill, written by forms are balking at alliances. ConseReinhardt. a Princeton University health
John Chafee of Rhode Island, allows in- quently, large mandatory alliances are
-' cnomist. says that when he heard Resurers to adjust for age and geography in all but dead in Congress.
publican calls to enact insurance market
some markets.
Alliances aren't the only entities that
reforms alone as a way to vastly improve
In fact, many people argue that the only could perform such functions. It could be
the current system he reacted with total
legislation that guarantees a true commu- done through state insurance regulation,
disbelief. Community rating without uninity-rated approach are bills establishing a says Mr. Aaron. The virtue of alliances.
versal coverage will trigger the worst
"single-payer health system, where the Prof. Reinhardt points out. is that they also
kind of behavior among insurers and pagovernment pays people's medical bills would collect the health-insurance pretients." he says.
with tax revenues.
miums, and could then turn around and
If you can go in and out of a system at
Other things that make community pay money out to plans in the form of a
will, then the only people who will buy
ratings work are also opposed by suprisk-adjusted premium." He says.
insurance are those who need it." says porters of the concept. A successful comThat's a lot different than having to go in
Barbara Ragle, legal counsel at Central
munity-rated system requires a bureau- there and fight with their lawyers
Reserve Life Insurance Co.
cratic structure to oversee it. Yet many of
Nor is community rating the only popu- the people calling for insurance-market
lar insurance reform that would be nearly reforms are the same ones decrying the
impossible without universal coverage.
large regional health alliances that PresiThe same thing is true of proposals to
dent Clinton has proposed.
outlaw the common industry practice of
The alliances, which would be set up by
refusing to cover people with known medi- the states, would include employees of all
cal problems, so-called pre-existing condibusinesses with fewer than 5.000 workers.
tions. Most health bills that stop short of
The White House says they were conceived
universal coverage, such as the bipartisan
to establish a large pool over which to
'v Managed Competition Act championed by spread insurance nsks. And they are also
Democratic Rep. Jim Cooper of Tennessee,
intended to take care of a difficult but
allow insurance companies to exclude cov- critical job known asriskadjusting.
erage of a pre-existing condition for up to
Community rating violates basic actusix months unless the prospective policy
arial principles,'' says Princeton's Prof.
holder is switching from one policy to
Reinhardt. A community-rated system
another. Again, the reason is that if
forces a competing private insurer to look
the government requires companies to
cover pre-existing conditions without requiring everyone to have insurance, people
will buy policies only when they expect
high medical expenses.
Seeing the Insurer's Side
r
1
3
a ; ; ( r s
:
r
,
r
Even Gail Shearer, who as manager of
policy analysis for Consumers Union is
usually no friend of insurance companies,
says: You can understand why the insurers want protection."
In a pure community-rated insurance
system, everyone in a region would pay the
same premium for the same package of
health benefits, regardless of age. sex.
medical history, lifestyle or place of resilence. desoite cancer or severe disabil
v
tUNEVj^
�Community-Rated Health Plans Prove Popular,
But Success May Depend on Universal Coverage
By HILAKY STOLT
-
Rating the Proposals
7 . p . - - . . ' i; T H E W A U . S T K C C T JOVH.NAL
WASHINGTON - It's the health-care
rr.-posal everyone loves: the notion that
.nsurance companies shouldn't be allowed
to jack up rates for sick people or others at
risk of piling up big medical bills.
So attractive is the concept, known as
community rating.' that even many Republicans and conservative Democrats say
Congress should go ahead and enact it.
along with a set of other insurance-market
revisions, and forget about universal
health coverage for now. A new GOP
television advertising campaign pushes
for bipartisan insurance-market reforms
to fix health care."
There's just one problem with the idea,
experts insist and real-life evidence shows.
It probably won't work without universal
coverage.Indeed, several of the insurance
changes that reformers are clamoring'T
may depend for their success on bringing
nearly everybody into the insurance pool.
For tbe pas; year New York state has
tried community rating without a law
requiring everyone to have health insurance The result has been a rise in insurance premiums for younger, healthier
people and a drop in rates for older, sicker
.ndmduais. Consequently, young people
bave sailed out of the system.' figuring
:he> e.ther won't need coverage or they'll
ne able to get it at a reasonable price when
they do.
Older. Sicker People
Now. insurers are raising prices again
n • Tder to cover the medical needs of those
ider. sicker people left in the pool. State
.nsurance department figures show that as
: '.:'.}. i. nine months after the new law
is "ffect. . ' i . * : : fewer people had health
nMirince individually or in small•••••pi'iyer groups. That s a l.." decline.
Tbe only way to avoid this chain reaction, many experts say. is to set up a
v.item.where people can t drop out. Uwe
Kemnardt. a Princeton University health
economist, says that when he heard Republican calls to enact insurance market
reforms alone as a way to vastly improve
the current system he reacted with "total
disbelief Community rating without universal coverage "will trigger the worst
kind of behavior among insurers and patients." he says.
If you can go in and out of a system at
will, then the only people who will buy
insurance are those who need it." says
Barbara Ragle, legal counsel at Central
Reserve Life Insurance Co.
Nor is community rating the only popu/ lar insurance reform that would be nearly
impossible without universal coverage.
The same thing is true of proposals to
outlaw the common industry practice of
refusing to cover people with known medical problems, so-called pre-existing conditions. Most health bills that stop short of
universal coverage, such as the bipartisan
Managed Competition Act championed by
Democratic Rep. Jim Cooper of Tennessee,
allow insurance companies to exclude coverage of a pre-existing condition for up to
six months unless the prospective policy
holder is switching from one policy to
another. Again, the reason is that if
the government requires companies to
cover pre-existing conditions without requiring everyone to have insurance, people
will buy policies only when they expect
high medical expenses.
,
-Ow tne •~ a,cr neaitn--e'C'-n
^eai •'. f
• CLINTON: No c e - j m ^ a t o - s
aUowed'0'age ^ec cai status geog•aony or cfestyie Secarate pecis
accor-:,.-g to 'a^.y s^e
•• 'ou sepa-ate
s - : . :.a i
employers . m .-o.-e - r CM
e-s
association c-a-s r c -eac- a- a-ces
I SENATE FINANCE (currently under consideration): = ••»- ^m ,3- 3: ;,-5
acco ci~g to 'agecg-ac-, a-c
age ^gnes; age-accstec ce- a ; ce -o ~c'e :-ar
ce
;
age-aciustea o
• SENATE LABOR AND HUMAN RESOURCES
(approved June 9): Same as Cnnton ou
erased n over 'ou years.
r
• CHAFEE: "eaitn nia^s m^s; otfpr a
~ C 0 ' ' ec c o m m ^ - . ; , . -jrp oremiLiTi 'or
ceocie anc businesses of jnaer 100
.•.0'<e'S .vno cuy nsurance througr a
burcnasmg ccoDerative
I COOPER-BREAUX: Nc ac us -e s
anoweo lor medicai status or -..~ce :
cast med'cai claims, premiums can ce
/a"ed according to gecg-aonv anc to
so^e degree age
r
• HOUSE WAYS AND MEANS (currently
under consideration): Community rating
1
Some supporters of community rating
are pushing to allow some adjustments, j
such as for age and habits that affect
bealth. like smoking. And for all the rhetoric embracing community rating, most
of the actual bills under consideration in j
Congress would adopt only a modified
version of the concept.
Nobody is proposing pure community
rating," says Henry Aaron, an economist
at the Brookings Institution in Washington. Even the sweeping Clinton proposal
would allow four different types of regional
risk pools, based on family type - for individuals, for single parents with children,
for couples and for two-parent families j
with children.
The House Ways and Means Commit- |
tee, under pressure from the insurance j
industry, is considenng a bill with five
different market sectors, based largely on
a person s employer. Each sector would be
community rated, but insurers wouldn t I
have to sell policies in every sector. The
leading Senate Republican bill, written by
John Chafee of Rhode Island, allows insurers to adjust for age and geography in
some markets.
In fact, many people argue that the only
legislation that guarantees a true community-rated approach are bills establishing a
"single-payer health system, where the
government pays people's medical bills
with tax revenues.
Other things that make community
ratings work are also opposed by supporters of the concept. A successful community-rated system requires a bureaucratic structure to oversee it. Yet many of
the people calling for insurance-market
reforms are the same ones decrying the
large regional health alliances that President Clinton has proposed.
The alliances, which would be set up by
the states, would include employees of all
businesses with fewer than 5,000 workers.
The White House says they were conceived
to establish a large pool over which to
spread insurance risks. And they are also
intended to take care of a difficult but
critical job known as risk adjusting.
Community rating violates basic actuarial principles." says Princeton's Prof.
Reinhardt. "A community-rated system
forces a competing private insurer to look
1
Seeing the Insurer's Side
Even Gail Shearer, who as manager of
policy analysis for Consumen Union is
usually no fnend of insurance companies,
says: You can understand why the insurers want protection."
In a pure community-rated insurance
system, everyone in a region would pay the
same premium for the same package of
health benefits, regardless of age. sex,
medical history, lifestyle or place of resilence. desoite cancer or severe disabil
"e
iTKE^T
at a deathly ill patient, seeing i Sioo.ooo
bill, and cheerfully enroll t.n.it person for
$2,000. It goes against human nature. So m
order to overcome norma: human nature
you need some coercion.
That means that while everyone pavs
the same amount into a community rated
system, a mechanism must be set up so
insurance companies receive varying
amounts, depending on the risk levels of
their beneficiary pools. Otherwise, a plan
that for some reason was chosen bv a
disproportionate numberof, say, HIV-positive people, would be in bad financial
shape. Ultimately, health plans overloaded
with bad risks who pay low premiums
could collapse. Risk-adjusting basically
requires plans with better risk pools to
subsidize those with worse risk pools
The administration proposed heaith alliances to accomplish that task. H wever.
most of the people pushing insurance reforms are balking at alliances .'onsequently. large mandatory alliances are
all but dead in Congress.
Alliances aren t the only entities that
could perform such functions. "It could be
done through state insurance regulation,
says Mr. Aaron. The virtue of alliances.
Prof. Reinhardt points out. is that they also
would collect the health-insurance premiums. and could then turn around and
pay money out to plans in the form of a
risk-adjusted premium.
He says.
'That's a lot different than having to go in
there and fight with their lawyers
i
:
;
;
!
j
;
i
!
�Community'Rated Health Plans Prove Popular,
But Success May Depend on Universal Coverage
By HILARY STOLT
. •;•
/
.;.p.
i:' T H E W A L L S T * K E T
Rating tbe Proposals
JOI.R.N*L
•A AiHlNGTON - It's the health-care
"n.'P'.'sal everyone loves: the notion that
.nsurance companies shouldn't be allowed
to jack up rates for sick people or others at
risk of piling up big medical bills.
So attractive is the concept, known as
community rating.' that even many Republicans and conservative Democrats say
Congress should go ahead and enact it.
along with a set of other insurance-market
revisions, and forget about universal
health coverage for now. A new GOP
television advertising campaign pushes
for bipartisan insurance-market reforms
to fix bealth care."
There's just one problem with the idea,
experts insist and real-life evidence shows.
It probably won't work without universal
coverage. Indeed, several of the insurance
changes that reformers are clamoring W
may depend for their success on bringing
nearly e.ervbudy into the insurance pool.
For the pas; year New York state bas
tried community rating without a law
requiring everyone to have health insurjnce. The result has been a rise in insurince premiums for younger, healthier
people and a drop in rates for older, sicker
individuals. Consequently, young people
bave bailed out of the system, figuring
they e.ther won't need coverage or they'll
be able to get it at a reasonable price when
they do.
Older. Sicker People
Now. insurers are raising prices again
.n "rder to cover the medical needs of those
•Ider. sicker people left in the pool. State
.nsurance department figures show that as
c lan I. nine months after the new law
o-'k -ffect. J3.r" fewer people had health
tiMir ince individually or in small••i-ii'.iover iToups That's a i.T* decline.
Tbe .'nly way to avoid this chain reac•ion. many experts say. is to set up a
system where people can't drop out. Uwe
Reinhardt. a Princeton University health
economist, says that when he heard Republican calls to enact insurance market
reforms alone as a way to vastly improve
the current system he reacted with "total
disoelief. Community rating without universal coverage will trigger the worst
kind of behavior among insurers and patients." he says.
"If you can go in and out of a system at
will, then the only people who will buy
insurance are those who need it." says
Barbara Ragle, legal counsel at Central
Reserve Life Insurance Co.
Nor is community rating the only popular insurance reform that would be nearly
impossible without universal coverage.
The same thing is true of proposals to
outlaw the common industry practice of
refusing to cover people with known medical problems, so-called pre-existing conditions. Most health bills that stop short of
universal coverage, such as the bipartisan
Managed Competition Act championed by
Democratic Rep. Jim Cooper of Tennessee,
allow insurance companies to exclude coverage of a pre-existing condition for up to
six months unless the prospective policy
holder is switching from one policy to
another. Again, the reason is that if
the government requires companies to
cover pre-existing conditions without requiring everyone to have insurance, people
will buy policies only when they expect
high medical expenses.
;
-o-.v t-e -a.C' neai:n--eo-n-. c-a-s :ea: . - . • CLINTON: Nc : e~ ^ .y at o-s
allowed ' c age ~ic cai sta'us geog-aony jr Mesty'e Se:a a:e pools
acco'c-.g to 'am -y s-ie
r
-
I SENATE FINANCE (currently under consideration): e~ .m .3- 3; ;rs
accorsrg 'o 'am .,- ; ; e geog-ac-, a-c
age ^gnes: ag?-3Custec c e - ^~
-ay ce no --ce t-ar
ce :-e
age-aciustea ore-'um
• SENATE LABOR AND HUMAN RESOURCES
(approved June 9): Same as Clinton ou
erased n ove 'ou /ears
3
r
i
• CHAFEE: "eaitn 3:3^5 m-si otter a
"c-Cii ec c c - r j - . f , -ate cremium 'or
ceooie anc c-usmesses of .-noer iQQ
r,
I COOPER-BREAUX: Nc ac.ius-e-ts
aHowea for medicai status or "j~;-e r
cast medical claims, premiums can ce
•.-a"ed according to gecg-aoT..- anc tc
some deg^e age
r
.•.O <eS .vno Duy nsurance througr a
r
ourcnasmg -ccoDeratcve
• HOUSE WAYS AND MEANS (currently
under consideration): Community ratmg
Some supporters of community rating ;
are pushing to allow some adjustments, j
such as for age and habits that affect
health, like smoking. And for all the rheto- !
nc embracing community rating, most
of the actual bills under consideration in ;
Congress would adopt only a modified
version of the concept.
Nobody is proposing pure communityrating, " says Henry Aaron, an economist
at the Brookings Institution in Washington. Even the sweeping Clinton proposal
would allow four different types of regional
risk pools, based on family type - for individuals, for single parents with children,
for couples and for two-parent families
with children.
The House Ways and Means Committee, under pressure from the insurance
industry, is considenng a bill with five
different market sectors, based largely on
a person s employer. Each sector would be
community rated, but insurers wouldn t
have to sell policies in every sector. The
leading Senate Republican bill, written by
John Chafee of Rhode Island, allows insurers to adjust for age and geography in
some markets.
In fact, many people argue that the only
legislation that guarantees a true community-rated approach are bills establishing a
"single-payer health system, where the
government pays people's medical bills
with tax revenues.
Other things that make community
ratings work are also opposed by supporters of the concept. A successful community-rated system requires a bureaucratic structure to oversee it. Yet many of
the people calling for insurance-market
reforms are the same ones decrying the
large regional health alliances that President Clinton has proposed.
The alliances, which would be set up by
the states, would include employees of all
businesses with fewer than 5.000 workers.
The White House says they were conceived
to establish a large pool over which to
spread insurance nsks. And they are also
intended to take care of a difficult but
critical job known as risk adjusting.
Community rating violates basic actuarial principles," says Princeton's Prof.
Reinhardt. "A community-rated system
forces a competing private insurrr to look
1
Seeing the Insurer's Side
Even Gail Shearer, who as manager of
policy analysis for Consumers Union is
usually no fnend of insurance companies,
says: You can undersund why the insurers want protection."
In a pure community-rated insurance
system, everyone in a region would pay the
same premium for the same package of
health benefits, regardless of age, sex.
medical history, lifestyle or place of residence, desoite cancer or severe disabil
- 'bur seca-ate
s
e-o-o.ei-s ••.2-150 i ~ z : .ees
employers .vp mo-e -.3- 0:0J-S
3ssooa:'on c-a-s a-c -eac. a- a-ces
THEWXLLi
at a deathly ill patient, seeing a ^ijo.aoii
bill, and cheerfully enroll tbat person for
$2,000. It goes against human nature So in
order to overcome norma: numan nature,
you need some coercion.
That means that while everyone pays
the same amount into a community rated
system, a mechanism must be set up so
insurance companies receive varvng
amounts, depending on the risk level's of
their beneficiary pools. Otherwise, a plan
that for some reason was chosen by a
disproportionate numberof. say, HIV positive people, would be in bad financial
shape. Ultimately, health plans overloaded
with bad risks who pay low premiums
could collapse. Risk-adjusting basically
requires plans with better risk pools to
subsidize those with worse risk pools.
The administration proposed health alliances to accomplish that task. However,
most of the people pushing insurance reforms are balking at alliances Consequently, large mandatory alliances are
ail but dead in Congress.
Alliances aren't the only entities that
could perform such functions. It could be
done through state insurance regulation,
says Mr. Aaron. The virtue of alliances.
Prof. Reinhardt points out. is that they also
would collect the health-insurance premiums, and could then turn around and
pay money out to plans in the form of a
"risk-adjusted premium.
He says.
That's a lot different than having to go in
there and fight with their lawyers
i
:
|
i
j
!
<
1
1
�Community-Rated Health Plans Prove Popular,
But Success May Depend on Universal Coverage
By HILAHY STOLT
-
.:
op
- v
Rating the Proposals
>.• T H E W A L L S T R C E T J O L R S . < L
A
' \iHINGTijN - It's the health-care
rr.pusal everyone loves: the notion that
.nsurance companies shouldn't be allowed
tu jack up rates for sick people or others at
risk of piling up big medical bills.
So attractive is the concept, known as
community rating.' that even many Republicans and conservative Democrats say
Congress should go ahead and enact it.
along with a set of other insurance-market
revisions, and forget about universal
bealth coverage for now. A new GOP
television advertising campaign pushes
for bipartisan msurance-market reforms
to fix health care."
There s just one problem with the idea,
experts insist and real-life evidence shows.
It probably won't work without universal
coverage. Indeed, several of the insurance
changes tbat reformers are clamoring 'or
may depend for their success on bringing
nearly e'.erybody into the insurance pool.
For the pas; year New York state has
tried community rating without a law
requiring everyone to have health insurjnce. The result has been a rise in insurince premiums for younger, healthier
people and a drop in rates for older, sicker
individuals. Consequently, young people
have bailed out of the system, figuring
tbey either won't need coverage or they'll
be able to get it at a reasonable price when
r
I CLINTON: No ;-e~ ^ .a a:-ors
aiicved '0' age ^ec cai status gecg-aony or 'ifestye Se:a ate pools
acco :'-g to 'an-.... s-^e
- -cu seca-ate
s - : . ;.a s
e-o-c-.e-s .-. •- 2-25'Z -. 'z :.r?5
empiovers .VP -o.-e f j - CMe-s
association c a--s a-c -eac- a -a-ces
r
r
I SENATE LABOR AND HUMAN RESOURCES
(approved June 9): Same as Cunton out
erased n over 'ou /ears.
I CHAFEE: " W - c^ans mjs: otter a
"-oo.tec co'-f'j-.f.- -ate cem'um -or
ceoce anc CLS.nesses of r.aer 100
.•.o-'e-s .vno cuy nsurance mrougn a
ourcnasmg ccoDeratcve
I SENATE FINANCE (currently under consideration): - e~ ^m a a: -rs
acco C!-g '-o 'am .» 3 ;e geog-ac-, r c
age H-gnes: age-aciustec c e -ay ce "o --ce t-ar ce :-e
age-aciustea orem^m
r
I COOPER-BREAUX: Nc acicst-e--ts
anoweo for medicai status or -j.-ce' •:'
cast mea'cai claims, oremiums can ce
.a"ed according to geog-aonv anc to
some ceg ee. age
I HOUSE WAYS AND MEANS (currently
under consideration): Community ratmg
r
Some supporters of community rating
are pushing to allow some adjustments, j at a deathly ill patient, seeing a $100.OH)
bill, and cheerfully enroll tn.u person for
such as for age and habits that affect
$2,000. It goes against human nature. So :n
bealth. like smoking. And for all the rheto- • order
to overcome norma: human nature,
nc embracing community rating, most
you need some coercion.
of the actual bills under consideration in !
That means that wtnle everyone pavs
Congress would adopt only a modified
the
same amount into a community rated
version of the concept.
Nobody is proposing pure community system, a mechanism must be set up so
insurance companies receive varvng
rating," says Henry Aaron, an economist
at the Brookings Institution in Washing- amounts, depending on the nsk levels of
their beneficiary pools. Otherwise, a plan
tbey do.
ton. Even the sweeping Clinton proposal
would allow four different types of regional that for some reason was chosen by a
Older. Sicker People
risk pools, based on family type - for indi- disproportionate number of. say, HI V posiNow. insurers are raising prices again
viduals, for single parents with children, tive people, would be in bad financial
.n order to cover the medical needs of those for couples and for two-parent families j shape. Ultimately, health plans overloaded
with bad risks who pay low premiums
Ider. -iicker people left in the pool. State
with children.
could
collapse. Risk-adjusting basically
.nsurance department figures show that as
The House Ways and Means Commit- |
; i.i.n. l. nine months after the new law tee. under pressure from the insurance requires plans with better risk pools to
•.••ok -ffect. .'5.r" fewer people had health
industry, is considenng a bill with five •
-Mir mce individually or in smalldifferent market sectors, based largely on subsidize those with worse risk pools
•••••.:•.!•.>>er »Ti>ups. That's a i.T. decline.
The administration proposed health ala person s employer Each sector would be
The only way to avoid this chain reaccommunity rated, but insurers wouldn t I liances to accomplish that task. H wever. 1
tion, many experts say. is to set up a
most of the people pushing insurance re
have to sell policies in every sector. The
sy .^em where people can t drop out. Uwe leading Senate Republican bill, written by forms are balking at alliances JonseReinhardt. a Princeton University health
John Chafee of Rhode Island, allows in- quently, large mandatory alliances are \
economist, says that when he heard Resurers to adjust for age and geography in ail but dead in Congress.
publican calls to enact insurance market
Alliances aren't the only entities that ;
some markets.
reforms alone as a way to vastly improve
In fact, many people argue that the only could perform such functions. "It could be j
the current system he reacted with total
legislation that guarantees a true commu- done through state insurance regulation, j
disbelief. Community rating without uninity-rated approach are bills establishing a says Mr. Aaron. The virtue of alliances.
versal coverage 'will trigger the worst
Prof. Reinhardt points out. is that they also 1
"single-payer" health system, where the
kind of behavior among insurers and pagovernment pays people's medical bills would collect the health-insurance pretients." he says.
miums. and could then turn around and
with tax revenues.
If you can go in and out of a system at
pay money out to plans in the form of a
Other things that make community
will, then the only people who will buy
risk-adjusted premium.
He says.
ratings work are also opposed by supinsurance are those who need it." says
That's a lot different than having to go in
porters of the concept. A successful comBarbara Ragle, legal counsel at Central
munity-rated system requires a bureau- there and fight with their lawyers
Reserve Life Insurance Co.
cratic structure to oversee it. Yet many of
Nor is community rating the only popu- the people calling for insurance-market
lar insurance reform that would be nearly
reforms are the same ones decrying the
impossible without universal coverage.
large regional health alliances that PresiThe same thing is true of proposals to
dent Clinton has proposed.
outlaw the common industry practice of
The alliances, which would be set up by
refusing to cover people with known medi- the states, would include employees of all
cal problems, so-called pre-existing condibusinesses with fewer than 5.000 workers.
tions. Most health bills that stop short of
The White House says they were conceived
universal coverage, such as the bipartisan
co establish a large pool over which to
v Managed Competition Act championed by spread insurance risks. And they are also
Democratic Rep. Jim Cooper of Tennessee, intended to take care of a difficult but
allow insurance companies to exclude cov- critical job known asriskadjusting.
erage of a pre-existing condition for up to
Community rating violates basic actusix months unless the prospective policy
arial principles.' says Princeton's Prof.
holder is switching from one policy to
Reinhardt. "A community-rated system
another. Again, the reason is that if
forces a competing private insurrj" to look
the government requires companies to
cover pre-existing conditions without requiring everyone to have insurance, people
will buy policies only when they expect
high medical expenses.
Seeing the Insurer's Side
1
1
1
lb
1
Even Gail Shearer, who as manager of
policy analysis for Consumers Union is
usually no fnend of insurance companies,
says: You can undersund why the insurers want protection. "
In a pure community-rated insurance
system, everyone in a region would pay the
same premium for the same package of
health benefits, regardless of age. sex,
medical history, lifestyle or place of resilence. lesmte cancer or severe disabil-
v
t V N E V ^
�SOCIALIZED MEDICINE: THE SAME OLD SCARE TACTIC
TODAY:
-
Senator Robert Dole (R-KS): "The President's idea is to put a mountain of
bureaucrats between you and your doctor." [Wall Street Journal. 1/26/94; New
York Times, 2/1/94]
-
Senator Phil Gramm (R-TX): ". . . good old-fashioned socialized medicine
with the government running the health system . . . " [Reuters. 10/13/93]
Representative Newt Gingrich (R-GA): " . . . it has got to be the most
destructively big government plan ever proposed. . . "["Meet the Press", in
Washington Times. 10/4/93]
SOUND FAMILIAR?
•
If these arguments sound familiar, it is because they are the same, exaggerated,
emotional "big brother" arguments that have been used time and time again to
defeat health reform proposals.
1949
Opposition to President Truman's Health Reform Proposal:
Do You Want the Government to Come Between You and Your
Doctor?" Full-page ad in 30 national magazines. [Campion, Frank. The AMA
and U.S. Health Policy Since 1940, Chicago, IL]
"Who is for Compulsory Insurance?" opponents asked and answered, "All
Who Seriously Believe in a Socialist State." [Campion]
1961
Opposition to President Kennedy's Medicare proposal:
American Medical Association: "We fight because the administration's
medical care proposal, if enacted would certainly represent the first
major, irreversible step toward the complete socialization of medical
care." [Campion, p. 256]
1965
Opposition to President Johnson's Medicare proposal: Representative
Hall (R-MO) — "Consequently, we cannot stand idly by now, as the
Nation is urged to embark on an ill-conceived adventure in Government
medicine, the end of which no one can see andfromwhich the patient is
certain to be the ultimate sufferer. " [Congressional Record, House, 4/8/65]
Senator Cunningham (R-NE) - "This legislation could eventually lead
us to socialized medicine. Make no mistake about that. It takes no more
than a quick glance at a history book, and a little common sense, to come
to this conclusion. " [Congressional Record, Senate, 3/3/65]
�Partial reform does not help the middle class
Millions left uninsured under current system v. "91%" reform by income category
"91%" Reforms Insure Many of the Poor...
But do not help the middle class
In Poverty
150-200% ($23-30k)
300-400% ($46-61 k)
100-150% ($15-23k)
200-300% {$30-46k)
400% + ($61 k +)
Current System •
Source: CBO, 5/94; Tables 4-1,2
Incomes categorized by percentage of poverty; dollar ranges shown
for family of four.
"91%" Reform
�Health views that elected Wofford
in '91 could oust him in November
By J Jennings Moss
THt WASHINGTON TIMES
7^
When Harris Wofford beat the
odds and upset Dick Thomburgh
for a Senate seat from Pennsylvania three years ago, the buzz that
swept through political circles,
amplified in newspaper and television coverage, was that he had
done it with adroit use of "health
care" as the driving issue.
Mr. Wofford, a Democrat who
had never before held elective office, is up for re-election in November, and health care is an issue
once more. Only this time, his opponent — Republican Rep. Rick
Santorum — is trying to use it
against him.
"This issue, the health care reform debate currently in the Congress is probably the most important debate we will have in my
lifetime, because it is a debate that
really focuses on who we will be as
a country," Mr. Santorum said in a
speech last week. He promised it
would "be probably the biggest issue in the campaign."
Mr. Wofford's 1991 strategy
came to be seen as a blueprint for
other Democrats, notably Bill
Clin too, who has made health care
reform his top legislative priority.
But he has seen it battered on and
off Capitol Hill and by both parties.
Probably more than any other
election this year, analysts will
look to the Pennsylvania contest to
determine the salience of health
care as an issue, and whether
Democrats were wise to thrust it
onto the national stage. Mr. Wofford advocates a significant
restructuring of the health care
system, with more government involvement. Mr. Santorum wants to
give individuals more responsibility for their health choices.
Some Pennsylvanians see it as
an important issue, but not the
transcending one. G. Tferry Madonna, a political analyst and pollsee WOFFORD, page A 7
Americans to keep their health
plan when they leave a job. They
also back medical malpractice reforms, although the details of their
From page A1
reform plans differ.
Political observers in Pennsylster at Millersville University,
vania say the burden is on Mr. Wofsays health care was only one of
the decisive issues in 1991, and ford to prove his plan is right. At
others, like the poor economy and the same time, some analysts arMr. Thomburgh's role in the Bush gue that he must not link himself
administration, were important as too closely with Mr. Clinton beweU.
cause the president's favorable
"What Wofford is doing is up- rating hovers not far above 40 perping the ante of the health care cent.
"It's not exaggerated to say
thing by making it a centerpiece of
his re-election effort, and you have [health care] is symbiotically conto ask if that's going to work," Mr. nected with Wofford's persona,"
Madonna says. "Pennsylvania has says Michael Young, director of
backed off their support of that." the Penn State Center for Survey
He notes a February poll that Research.
showed only 5 percent of the pubMr. Wofford breaks from the
lic viewed health care as the most norm of federal lawmakers from
important issue. Ahead of it were Pennsylvania, who traditionally
unemployment, crime and taxes.
avoid being linked to a single issue,
Mr. Wofford is not worried about instead concentrating on conhis choice of issue. "We're on the stituent services.
eve of battle right now," the senator
According to Mr. Young, Mr.
says in an interview, referring to Wofford has "tied himself to a bed
the fact that key congressional ... whether it's a bed of roses or a
committees have started to draft a bed of nails, we'll see."
bill.
Mr. Santorum also is unique. Re"The skepticism about govern- publicans running statewide hisment in general is very high and torically have been moderate to
for many people it has gone over to b be ral in the mold of Sen. Arlen
cynicism, and that affects the Specter and the late Sen. John
health care issue," Mr. Wofford Heinz, whom Mr. Wofford sucsays. "Secondly, the Clinton bill ceeded after Mr. Heinz was killed
has been tied to the roller-coaster in a plane crash. Mr. Santorum, a
ride of Clinton's own standing."
two-term House member, is linked
In 1991, the Wofford theme was to the conservative wing of the
that if accused criminals have a GOP
right to a lawyer, then sick AmerMuch of Mr. Santorum's camicans have the right to a doctor. paign platform revolves around
This year, his pitch is that Amer- social issues — he is a key Repubicans should have the wide range hcan player for welfare reform, a
of choices in doctors and health topic he raises often on the stump.
plans that members of Congress But it is with health care that he
and federal workers have through draws the biggest distinction bethe Federal Employee Health
tween himself and Mr. Wofford.
Benefits Program.
On health care, Mr. Wofford says
Mr. Wofford's views on health his opponent "is in a very vulnercare track closely with Mr. Clin- able spot. He has a bill, he has an
ton's. He backs a mandate for em- approach, and it can be measured
ployers to pay for most of their and I think punctured. I think it's
workers' health care premiums, a balloon that can be punctured
believes government must play a pretty fast."
role in controlling health care
He cites a study by the chaircosts and argues that long-term man of Blue Cross-Blue Shield of
care must be included in health Ohio that concluded that Medical )
reform.
Savings Accounts would create
Mr. Santorum thinks the empha- large federal deficits that would
sis should be on the individual. He make it difficult to care for the
would like to give Americans the neediest.
opportunity to have a Medical SavThe Santorum camp has at its
ings Account, from which they disposal the results of several
would pay for health expenses and analyses from critics of the Clinbe allowed to use what's left over ton health care model, which conhowever they wish. While he would clude the plan would lead to the
like to see employer contributions loss of jobs and higher health costs
go into the account, bosses would for some Americans.
not be required to pay their work"Harris Wofford may claim to
ers' health care premiums.
have started the engine on health
Both men agree the insurance care but the people of Pennsylvaindustry should be reformed, nia know that he is sitting behind
chiefly by stopping discrimination the wheel of an Edsel," says Mr.
against those with existing medi- Santorum's campaign manager,
cal conditions and by allowing Ed Hodges.
WOFFORD
�WHY UNIVERSAL COVERAGE IS IMPORTANT
We must guarantee health security — no matter what
Real health security means comprehensive health benefits that can never be taken
away - that is possible only with universal coverage. We need to be able to say to
people who work hard and play by the rules that they will never lose their insurance.
If you lose your job. If you start a small business. If you get sick. If your child gets
sick. No matter what « you're covered. It's time to give the American people freedom
from the fear that they could lose their health coverage and be denied care when they
or their children need it most.
Universal coverage is essential to controlling costs.
Without universal coverage, too many will continue to get carefromemergency
rooms instead of doctors' offices « because they couldn't afford preventive care or a
doctor visit, and their illnesses became more severe. The costs end up being overly
expensive in the emergency room, and each of us pays higher premiums and taxes to
make up for those who don't pay. One health policv expert writes that "only with
Hnivcrsaiity gap
diminaie the practice of making patients with insurange pay the
medical costs of those without it." In general, health policv experts agree that "cost
control becomes easier when the plan is universal, not harder."
Today, some low-wage workers go on welfare just to get health benefits. Universal
co\ erage will put an end to this practice, reducing what we spend on welfare. One
study suggests that universal coverage could reduce welfare cases by up to 25 percent.
Universal coverage is necessan to simplify the system.
Savings from simplify ing and reducing the bureaucracy can't be realized without
universal coverage. For example, a single claims form doesn't work unless eveiyone
is in the system and following the same rules. And the simplicity and savingsfroma
Health Security card won't happen unless evervone is guaranteed benefits that can
never be taken away.
In a changing job market, people need security'.
With American workers changing jobs so often they'll hold an average of eight jobs in
a lifetime and more and more companies using temporary or part-time workers, we
need universal coverage to make sure no one will ever lose their health insurance.
Even if people are without insurance for just a few months, during that time, they are
an illness or injury away from financial catastrophe.
�HEALTH CARE SPEECH
Introduction
President Clinton has been in office for just over a year now, and we have already
seen him move our economy in the right direction, start to restore our sense of security and
begin to renew America's spirit.
This President is dedicated to the proposition that people that work hard and play by
the rules should be rewarded for their work.
That's why he introduced a reemployment initiative to help people get good jobs with
growing incomes. That's why he passed the Family and Medical Leave Act so good workers
can be good parents. That's why he expanded the earned income tax credit to reward work
over welfare.
And that's why he's dedicating himself to fixing this health care system ~ to provide
hard-working families with the health security they deserve.
This year we have a magic moment. After 60 years of false starts and obstruction, we
have an opportunity to give every American health security. This is an opportunity we must
seize.
Opponents of reform are trying to tell you there's no health care crisis, but theyVe
wrong. [Chart 1]
The fact is: Even if you have good health insurance today, you can lose it tomorrow.
Two million Americans a month lose their insurance. And fifty-eight million Americans find
themselves without insurance at some point during the year.
Your benefits are threatened by insurance company fine print. Eighty-one million
Americans have "pre-existing conditions" that insurers can use to raise rates or deny coverage.
And three out of four insurance policies — that's 133 million people -- have lifetime limits
that cut off benefits when you need them most.
Even if you've got insurance, you know you're paying more and getting less. And your
choices are declining. I'm here to tell you how the President's reform will protect you and
your family from a future of being squeezed ~ getting lower-quality care, fewer choices and
higher bills.
[Chart 2]
America faces three choices: government insurance for everybody, no guarantee of
coverage for anybody, and guaranteed private insurance — which is the President's approach.
And the President has told the Congress he will veto a bill which doesn't cover everybody ~
because without guaranteed private insurance for everyone, it's not real reform.
�The bottom line is this: the President wants to strengthen what's right about our health
care system and fix what's wrong.
We know the system is broken. We know that all of us are at risk of losing our
coverage at any time. Here's how we want to fix it.
We want to guarantee private health insurance for every American;
We want to protect your right to choose your own doctor and health plan, and
improve the quality of your health care;
We want to outlaw insurance company abuses;
We want to protect and dramatically improve Medicare;
We want to guarantee health benefits through the workplace, because that's the
best way to cover everyone.
Guaranteed Private Insurance For AH
[Chart 3]
The President believes that everyone must be covered. Always. That's the only way
to guarantee security. As long as any of us at any time can be denied coverage or dropped
from coverage — none of us is secure. And as long as Americans who have insurance pay the
price for those who don't have insurance, we'll never get costs under control.
He's also said that the benefits package must be comprehensive, [hold up Health
Security card] Under the President's proposal, every American will get a Health Security card
that will guarantee benefits as good as what America's biggest companies offer - as good as
what members of Congress get. Plus preventive care ~ immunizations, mammograms,
physicals — and prescription drugs. We must keep our people healthy, not just treat them
after they get sick.
And Americans must have protection against the devastating costs of serious illness.
That means low deductibles and no lifetime limits on your benefits. People must have the
peace of mind of knowing that no matter what happens, their health care can never be taken
away.
�Choices Preserved and Expanded
[Chan 4]
The President wants to preserve and expand your choice of doctor and health plan,
because that's the best way to guarantee high quality health care.
But choice and quality are threatened today. I f we do nothing, rising costs will force
more and more employers to limit your choice of plan and doctor.
Under the President's approach, your Health Security card guarantees your choice of
doctor. Once you get your card, you — not your boss or insurance company - choose your
doctor and health plan. It can be a plan that lets you use any doctor or hospital that you
want. Or it can be a plan that lets you use a network of doctors or hospitals. Or, you can
join an HMO. It's your choice.
The special interests are trying to scare you on this issue in order to block reform. But
remember that they're trying to preserve their profits. And don't let them stand in the way of
your health security.
Outlaw Insurance Company Abuses
[Chart 5]
We want to guarantee affordable insurance that people can depend on. The President's
approach would make it illegal for insurance companies to raise your rates unreasonably... to
drop your coverage or take away your benefits... to increase your rates if you get sick... to use
"lifetime limits" to cut off your benefits... or, to charge you more simply because you are
older or have a pre-existing condition.
If we do nothing, or worse, pretend to do reform, you will continue to be at the mercy
of the insurance companies. And you'll continue to pay more and get less.
Insurance ought to mean what it used to mean. No more fine print. No more insurance
company abuses. You pay a fair price for security, and when you're sick, your health care
benefits are there for you — no matter what.
�Protecting and Expanding Medicare
[Chart 6]
The President believes very strongly that the true test of health reform is whether it's
good for older Americans. That's why his proposal preserves and dramatically improves
Medicare. And the American Association of Retired Persons (AARP) says that the President's
approach is the "best option for senior citizens."
Under the President's approach, if you get Medicare you keep it. You keep your
doctor i f that's your choice. Plus, your benefits are expanded. People receiving Medicare will
get coverage for prescription drugs, which costs older Americans more than anything today.
And we also begin to provide coverage for long term care at home or in your community.
The President wants to make sure that every penny of Medicare money is used for
seniors. Some want to take Medicare money away from seniors and spend it on other things.
That's why we must fight with the President for health care reform that protects Medicare and
older Americans.
Insurance Through The Workplace
Finally, if we're going to cover everybody, the best way to do it is to guarantee health
benefits at work. Every job should come with heaJth benefits. Most jobs do today. And yet 8
out of 10 Americans who have no insurance are in working families.
[Chart 7]
We want everyone to have health benefits guaranteed at work, with the government
providing discounts for small businesses and the unemployed. This approach builds on what
works. And it's the easiest and simplest way to accomplish our goal of guaranteed private
insurance for everyone.
Providing health benefits at work not only makes sense; it's also the right thing to do.
Today people on welfare get guaranteed health insurance while people with jobs may or may
not be covered. That's wrong. People who work should have health insurance.
If we are to guarantee this, we must protect small businesses - and the President's
approach does just that. The President wants to provide discounts for small businesses, and
full tax deductibility for people who work for themselves.
That's how we make sure that everyone is covered. Anyone who works will get
coverage at work. Employers will be asked to contribute, as will employees. The government
will cover those between jobs, and will continue to cover older Americans with Medicare.
�Conclusion: The President's Reform Works For You
The President's reform works for you and your doctor. That's why the people on the
front lines - America's largest associations of family physicians, pediatricians, nurses and
pharmacists — support it and believe it will work.
Opponents are trying to confuse the issue by making it seem more complicated, but it's
really pretty simple. You'll get a Health Security card, you'll pick any doctor you want, fill
out one form, and know exactly what's covered. And your health security can never be taken
away.
[Chart 8]
Guarantee everyone private insurance. Keep your choice of doctor. Outlaw
unfair insurance company abuses. Protect Medicare. And guarantee health benefits at
work. That's the approach. And this is our opportunity.
No wonder the special interests — the people who profit off today's crazy system ~ are
out in full force. One group of health insurers has already spent $14 million — money from
your insurance premiums — on TV ads to scare you about reform.
But the President didn't design health reform for the insurance companies ~ he
designed it for you. And we must not let the insurance companies stand in the way of real
reform.
Presidents from FDR to Hany Truman to Nixon to Carter have tried to guarantee
insurance to every American, but none have succeeded - because special interest groups have
been just too powerful to overcome. But this time, if we work together, I am convinced things
will be different.
This time, we will make history and guarantee private insurance to every American. I
ask you to join with me and help do what is right for America. Thank you.
�LARGE EMPLOYERS
THE PROBLEM
RISING HEALTH CARE COSTS BURDEN AMERICA'S
EMPLOYERS:
•
In 1992, American businesses paid almost $4,000 for health care for each
employee - more than twice as much as they paid eight years before.
[Christian Science Monitor. 11/21/91]
•
For the first time in American history, health care costs exceed business
after-tax profits. [Health Care Finance Review. Winter 1991]
RISING HEALTH COSTS HURT AMERICAN
COMPETITIVENESS:
•
In 1990, GM spent $3.2 billion in medical coverage for its 1.9 million
employees and retirees. This was more than the company spent on
Steel. [TIME. 11/25/92]
•
Health care costs add $1,100 to the price of every car made in America double the cost added to Japanese imports. [University of Michigan, 1990]
FIRMS THAT TAKE RESPONSIBILITY
PAY FOR THOSE THAT DON'T:
•
Some experts estimate that $25 billion in health care costs are shifted onto
people with private insurance each year. [CBO, May 1993]
•
A recent study found that from one quarter to one t h i r d of premiums
currently paid by jmployers who provide coverage for employees and
dependents goes tc cover the shortfall resulting from companies who do not
cover their employees and the dependents of their employees. ["How Would
Business React to an Employer Mandate,' Hewitt Associates, January 1994]
BUSINESSES BURDENED BY RISING COSTS OF EARLY RETIREES:
•
A recent Foster Higgins survey said that business costs of covering early
retires rose by 11% last year -- almost four times the inflation rate. The
study concluded that "many employers have simply concluded they can no
longer afford to provide retiree health care coverage . . . as many firms are
paying premiums for early retirees that are twice as high as those for active
workers. " [The Washington Post. 12/13/93]
[bigbiz2 brf, 04/13/94 04:52 PM]
�LARGE EMPLOYERS AND HEALTH CARE
"Successful implementation of health care reform is one of the best
pieces of news American business could receive."
[Henry Aaron, Brookings Institution, CBS , 9/28/93]
SUMMARY:
Over the last eight years, per worker health care costs for American
businesses have almost doubled. But most American corporations
agree that every job should come with health benefits, and they have
continued to provide coverage for their workers and families, despite
ever-rising costs. In today's system however, businesses that cover
their worker's and their worker's families pay for those companies
that don't •• shifting up to $25 billion dollars each year onto those
with private insurance. Rising health care costs are also eroding the
ability of U.S. companies to compete in the global marketplace, and
siphoning dollars away from new capital investments. The
President's approach will get business health spending under control
by increasing employees' incentives to reduce costs, cutting
administrative waste and imposing discipline on both private and
public health care spending.
I.
THE PRESIDENT'S APPROACH
1.
•
REAL, ENFORCEABLE COST CONTROL
Market Forces
The Health Security act will aggressively control costs by bringing market
forces to bear in the health care system. Corporate alliances will continue
using the innovative cost control strategies they've found successful, and
regional alliances will build on those same strategies of pooling purchasing
power and bargaining for better rates.
•
Administrative Savings
The Health Security act will streamline the burdensome and costly
regulation that eats up at least 15 cents of every health care dollar. By
replacing today's thousands of insurance policies with a comprehensive
benefits package and standard claim forms, more money will go to benefits
and less to underwriters and marketers.
•
Premium Caps: Back-up Measure for Cost Containment
While there is ample evidence that lower cost growth will be driven by
competition and increased efficiency, the Health Security plan will build in a
back-up measure to cost containment: premium caps. These caps will limit
the growth in what businesses and individuals pay for the comprehensive
�benefits package. The President believes that if businesses are going to be
asked to contribute to the cost of health care, they must be guaranteed that
increases in their payments will stay within reasonable bounds.
2.
•
FAIR, EQUITABLE FINANCING
Shared Responsibility - Employers, Employees, Government:
Under the President's approach, employers will contribute 80% of the
average cost health insurance plan in an area. Employees will pay the
difference between this contribution and the plan they choose. Employers
who cover 100 percent of employee health costs may continue to do so; all
employers will pay 80 percent of an average price plan.
•
Businesses Protected by Caps at a Percentage of Payroll
Under Health Security, employers in a health alliance will pay no more than
7.9 percent of their payroll for health care. Many employers today spend
more than 10 percent of their payroll for health insurance.
•
Preserves the Tax Deductibility of Health Insurance
Under reform, premium payments will continue to be fully tax deductible for
employers and will not be included in employee's taxable income. The
President's reform does not tax any employer, ever, for any health benefit
they provide. Any employer contributions -- either toward covering the
employee share of premium^, co-paymen 8 or deductibles - is never taxed,
either for the employer or er ployee. Starting in the year 2004, services
beyond the comprehensive benefits in the reform -- such as cosmetic face lifts
-- will no longer be excluded from taxable income for employees.
f
3.
RELIEF FOR THE COSTS OF RETIREE HEALTH CARE
•
The Health Security Act will allow our businesses, and particularly the
nation's largest manufacturers, to better compete in global markets.
Subsidizing the employer share of early retiree premiums will relieve many
of our nation's largest employers of the significant financial burden of
covering health care costs for retired workers.
4.
•
REFORMS HEALTH PORTION OF WORKER'S COMPENSATION:
Injured workers will obtain treatment through their health plans, just as
they would for other injuries or illnesses. This will end unnecessary
duplication of services, help workers get back to work quickly, and reduce
costs for employers. Workers' compensation insurers will continue to provide
coverage and reimburse the worker's health plan according to a fee schedule.
�5.
•
BUSINESSES WILL HAVE AN ACTIVE LOCAL ROLE
Businesses will have a strong voice in the health plans set up to serve their
workers. Companies, Taft-Hartley plans, or rural cooperatives with more
than 5,000 employees will be able to operate their own alliance, allowing
them to enhance the many cost control innovations offered by self insured
plans today. Employers will be represented on the boards of all regional
health alliances.
II.
WHAT THIS MEANS FOR AMERICA'S BUSINESSES:
LEADING CEOS SAY REFORM WILL HELP COMPETITIVENESS:
•
Prominent business leaders expressing support for the Clinton plan include
the CEO's of USX, Bethlehem Steel, American Airlines, Archer Daniels
Midland, Food For Less, Drummond and Company, Anheiser Busch, Ford,
Chrysler, McDonnell Douglas, and General Motors.
SLOWER GROWTH IN COSTS FOR AMERICAN COMPANIES:
•
Firms that do not provide insurance will pay more, but at a much lower cost
than they currently face when they try to purchase insurance. While
guaranteed private insurance will mean that an initial increase in business
spending under reform, lower costs will lead to lower aggregate business
spending on health care by the end of the decade.
ELIMINATING COST-SHIFTING SAVES FIRMS THAT NOW PROVIDE:
•
When all employers take responsibility, costs will be substantially reduced
for businesses that currently provide insurance. The non-partisan
Congressional Budget Office confirmed that: "Universal coverage would mean
that those firms that now offer insurance would not longer need to pay
indirectly through higher doctor and hospital bills for the care given to
uninsured workers and their families. On the other hand, firms that do not
now provide insurance could no longer ride free. ^
NO MORE CORPORATE "FREE RIDERS"- EVEN PLAYING FIELD:
•
The Health Security Act will make businesses more efficient by eliminating
"corporate free riders" - the millions of Americans who are insured through a
spouse's policy. Employers of both spouses will contribute to coverage,
further lowering costs for business that currently provide coverage. For
example in 1991, employers spent $26.5 billion to cover dependents who are
employed by firms that did not ofifer insurance.
2
Reischauer Testimony, Senate Finance Committee, 2/9/94
National Association of Manufacturers, 'Employer Cost-Shifting Expenditures,'' prepared by
Lewin-ICF, December 1991.
2
�SMALL BUSINESS AND HEALTH REFORM
THE PROBLEM
SMALL BUSINESS FACES HIGHER HEALTH COSTS:
•
Small busmesses are charged an average of 35% more than large businesses
for the same insurance. [Hay Huggins survey]
SMALL BUSINESS' HEALTH COSTS RISE FASTER:
•
Small business has experienced annual health care cost increases of 20 to 50
percent recently. In 1991, 33% of small business owners experienced health
care cost increases of more than 25 percent and 7% experienced cost
increases of 50 - 100 percent. fWash. Post. 1/26/93; Arthur Andersen, 7/92]
•
During 1988, health care costs for firms with fewer than 25 employees
increased by 33 percent - a rate of increase 1 1/2 times the rate experienced
by the nation's largest firms. [GAO, July 1991]
•
The high cost of insurance is expected to cause 30% of small businesses
currently providing insurance to drop coverage in the years ahead.. [Health
Affairs. Spring 1992]
SMALL BUSINESSES WANT TO PROVIDE
INSURANCE:
•
A recent study prepared for the NFIB said that 64 percent of small business
owners would lite to provide some or better insurance to their v orkers.
When asked why they do not offer insurance, the most common i. eason -stated by 65 percent of small business owners -- is that premiums are too
high. And 92 percent of small business owners agree that the ''ost of health
insurance is a serious business problem. [Charles Hall and John Kuder, Small
Business and Heallh Care: Results of A Survey, The NFIB Foundation. 1990]
INSURANCE COS DISCRIMINATE AGAINST SMALL BUSINESS:
•
Not all firms that want to provide insurance have the option to do so.
Internal insurance documents confirm that insurance companies "blacklist"
large sectors of the small business market -• such as grocery stores,
hairdressers, bartenders and medical offices and refuse to sell insurance to
these small businesses at anv price. fNew York Tim^. 2/5/90]
•
" . . . Preexisting condition exclusion • particularly excluding an entire firm
because of one employee's health status - is a practice almost exclusively
reserved for small businesses." [D.Stone, Chronic Disease and Disability: Beyond
the Acute Medical Model, 1990]
�SMALL BUSINESS AND HEALTH REFORM
SUMMARY:
Today, small businesses are threatened by a health care system that
is stacked against them. Their health coverage costs more and offers
less than policies that large companies negotiate. Despite these
obstacles, many small businesses want to provide health care
coverage to their employees and a majority do. But today, the
businesses that provide insurance are paying for the ones that do
not. The Health Security Act will end this unfair "cost-shifting" lowering costs for most small businesses and ensuring that no one
gets a free ride. And it will pool small businesses together to give
them the bargaining power that only large employers get today.
MOST SMALL BUSINESSES PROVIDE, AND MOST OF REST WANT TO:
•
A recent study surveying only small businesses found that even among the
very smallest companies (1-5 employees), more than half provide coverage.
And, 75% of all businesses with between 6 and 25 employees provided
coverage to their employees. 90% of all businesses with between 26 and 100
employees provided coverage.
•
According to the NFIB's chief lobbyist, "two out of three of those who don't
would like to do it." A recent study prepared for the NFIB said that 64
percent of small business owners would like to provide some or better
insurance to their workers.
GUARANTEES AFFORDABLE INSURANCE FOR SMALL BUSINESS:
•
By allowing small businesses and consumers to pool their purchasing power,
the President's approach will help small businesses negotiate the same deals
that big businesses get today. It will consolidate the administrative burden
for all businesses -- managing benefits, enrolling employees, negotiating and
renewing coverage, and bargaining for insurance prices with health plans.
•
Our plan will lower health care costs for the majority of small businesses that
now take responsibility -- which is why the Wall Street Journal called the
Clinton plan "an unexpected windfall" for small business.
•
The non-partisan Congressional Budget Office concluded that the President's
plan "would benefit smaller firms that typically pay much higher premiums
than larger firms. This leveling of costs could benefit all small
businesses — not just those that provide insurance today. With access to
more affordable insurance, small businesses would be better able to attract
workers who now demand health insurance as a condition of employment."
�There will be a limit on how much insurance companies can raise their
premiums - to protect small business and prevent their premiums from
increasing at several times the rate of inflation as they have recently. This
limit, combined with new bargaining power, will mean substantially lower
insurance prices.
SMALL BUSINESSES THAT NOW PROVIDE PAY LESS UNDER REFORM:
•
Small businesses that currently provide health benefits will likely pay less
immediately under reform due to a smaller administrative burden and lower
premium rates. For example, premiums are excepted to be 10.5 percent
lower under reform when all companies take responsibility and costs are no
longer shifted from firms who don't provide to those who do.
•
That's why the Wall Street Journal wrote: "For many small
businesses, saddled with escalating health care costs, President
Clinton's health care package comes as an unexpected windfall." [WaU
Street Journal Small Business Sees Burdens Getting Lighter", 9/13/93)
•
In fact, firms with fewer than 25 workers that currently provide insurance
will experience the largest savings under the Health Security Act. They will
pay almost 3% less of their payroll on premiums after reform -• saving $771
p e r w o r k e r . ["The Health Security Act: A Financial and Distribution Analysis,"p. 31]
PROVIDES DISCOUNTS FOR THE SMALLEST LOW-WAGE BUSINESSES:
•
Many small businesses -- those with less than 75 employees and an average
wage of no more than $24,000 - will be eligible for substantial discounts on
the cost of the insurance they provide their employees. I n fact, 75 percent
of the discounts going to businesses w i l l go to small firms.
ENDS INSURANCE INDUSTRY ABUSES OF SMALL
BUSINESSES:
•
Today, small businesses often see their premiums skyrocket -- or have their
coverage immediately dropped - when just one of their employees gets sick.
Often entire industries are denied insurance because they are considered
"high risk". The Health Security Act will outlaw these practices and ensure
that small businesses get the same deals as big businesses.
•
Under reform, health plans must charge small businesses the same premium
as large businesses in the same region for the comprehensive package of
benefits.
�REFORMS THE HEALTH PORTION OF WORKER'S COMPENSATION:
•
Injured worken will obtain treatment through their health plans, just as
they would for other injuries or illnesses. This will end unnecessary
duplication of services, help workers get back to work quickly, and reduce
costs for employers. Workers' compensation insurers will continue to provide
coverage and reimburse the worker's health plan according to a fee schedule.
100 PERCENT TAX DEDUCTION FOR SELF-EMPLOYED:
•
Today, the self-employed are discriminated against by the federal tax system,
as they are also able to deduct only 25% of health care costs from their taxes,
rather than the 100% that other businesses do. After reform, the selfemployed and independent contractors will be able to deduct 100% of the cost
of the comprehensive benefits package from their income taxes.
HAWAII EXPERIENCE PROVES SMALL BUSINESSES WILL BENEFIT:
•
Experience shows that the Health Security plan will create a better climate
for small businesses to grow and prosper. Since Hawaii asked all employers
to provide insurance for their employees in 1974:
• the unemployment rate dropped to one of the lowest in the nation (2.8% in
1991);
• small business creation rates remained high - with the number of
employers growing almost 200%from1970 to 1991, and
• the rate of business failures in Hawaii was less than half the national
average.
• In addition, Hawaii's "rainy day" fund - set up to help the smallest
businesses provide insurance •- has only been used 5 times in 19 years.
[The Hawaii Department of Health, June 8, 1993)
�Watching my mother die
Her lingering death, with great pain and cost, teaches a health-care lesson
For every American family,
health care is an intensely personal issue.
Usually, it is about a ba^ic
decision like which doctor to
rely on. Sometimes, it is more
complicated — weighing between diagnoses, treatments or
hospitals.
And too often these days, it is
also a b o u t
the h e a r t wrenching
c h o i c e between paying for costly
care and aff o r d i n g necessities
such as rent,
heat
and
food.
By Sen. Jay
Just
as Rockefeller,
these health- D-W.Va.
care deci—
—
sions are personal and private
matters for millions of families, my efforts to fix our
health-care system are motivated by similar feeling and
worries.
About a year and a half ago,
my mother died from Alzheimer's disease. Dying from
Alzheimer's is about the worst,
most humiliating way you can
die. It is not painful in the way
cancer is, but even as you are
watching yourself, your brain
cells begin to die. You lose control of yourself; you lose control over your actions; you become somebody else.
I watched this over a period
of almost eight yenre with my
mother. She would get up at 2
o'clock in the morning, put on
two dresses, and go into the
kitchen for breakfast. Somebody would take her gently by
the hand ;ind put her back to
bed, and an hour later she
wrmM do the snmf* IhinR She
had no idea she was doing it.
I would go to New York to
visit her as often as I could. I
am her only son, and I would
sit with her and Just sob. I
would look into her eyes and
she would be looking away
from me. I am convinced —
and nobody will ever convince
me otherwise — that she was
humiliated by what was happening to her and could not
look back at me because she
knew she was a different person and was ashamed.
My three sisters and I were
fortunate enough to have all
the resources in the world to
give her the best care at home
that she could get In New
Y o r k C i t y , a t r a i n e d Alzheimer's nurse, working an
eight-hour daily shift, costs
$50,000 per year. My mother
was a big woman — 5-feet-10
and strong There Is a period
when you have Alzheimer's in
which you grow violent Everyone goes through it. You hit,
you throw food and plates, you
just pound on people; it is just a
phase of Alzheimer's. But because of my mother's strength
and size, one person could never handle her safely.
So we n e e d e d t w o Alzh e i m e r ' s nurses. And Alzheimer's does not end at 5
o'clock or work in eight-hour
shifts. It's 24 hours a day. Those
A l z h e i m e r ' s nurses — at
$50,000 per year each — got
very expensive, very fast
My family had the resources
to give my mother whatever
care and attention she needed.
But it did not hurt any less for
me and my three sisters to
watch our mother — a good,
caring warm, wonderful woman — die like that
What makes me so angry
and whnt Is so unfair Is that
x
c
JO
O
>
-<
CD
c
OO
J>
By Web Bryant. USA TODAY
there are 4 million people in
A m e r i c a today w i t h Alzheimer's disease, and millions
more suffering with cancer,
heart disease and other fatal,
debilitating illnesses. T h e i r
families do not have the luck
my sisters and I have. Even after paying insurance premiums year alter year or saving
money for an emergency, they
still cannot afford a $50,000
nurse for eight hours a day.
So what are they doing?
They are at home giving care
themselves. They are awake at
all hours. They get physically,
psychologically and financially
exhausted. They quit Jobs. The
money for a child's college tuition gets used up. All because
Ihey are unable to get or afford
health insurance, or because
the insurance they do have is
Inadequate.
President Clinton's health-
care reform plan will change
all that In addition to guaranteed private insurance for every American that can never
be lost or taken away, it offers
long-term care at home, where
my mother wanted to be and
where she wanted to die. It
makes c e r t a i n a l l f a m i l i e s
have the ability to get the
health care they need and give
the care their grandparents,
parents and children deserve.
So sure, I have personal reasons for caring passionately
about health-care reform and I
will not apologize for them.
What my family experienced
during my mother's Illness is
being played out in homes
across America, and the burdens weigh more and more
heavily on families every day.
Congress will soon have to
make the hard vote on healthcare reform and defy the criti-
cism from special interests, political action committees and
the press; but that is precisely
what Congress is sent to Washington to do.
If Congress has the political
will — the plain old guts — to
take charge and take on those
now determined to block reform, then Just watch: With the
good blueprint provided by the
president. Congress will guarantee health-care security and
peace of mind to every American before the year Is out
Sen. Jay Rockefeller is a
member of the Senate Finance
Committee, chairman of ifs
subcommittee on Medicare
and long-term care, and a
member of the subcommittee
on health for famUies and the
uninsured.
• Health care, 4A
o
D
J>
-<
�JUNE 6 - JUNE 13
Day/Dept
Scheduling
Principals
Press Office
Public Liaison
Pa per/Research
[incl. data book]
I ntergovernmental/
Congressional
Cabinet, Surrogates
-Status of Issue Days
-FLOTUS and LoWV??
Thursday
June 9
Ed board mailing
Friday
June 10
Release of Radio Address
Text?
Weekend
June 11-12
Misc./Mgt
Prz: Radio Address
Altman Public Affairs
Council
Continue work on CEOs
breakfast
Prep for Waihee Issue Day
Shore up Gleason Charts
-League of Women Voters paper
to HRC?
-Nurses paper to HRC?
-CEO breakfast paper due
-Reno rdtble paper due?
-Deficit argument 1 pager
-Radio address paper
Health Care Sabbath
-VP rdtble briefing paper due
-Status of HI issue day?
Invites for Waihee Issue
Day [?]
Locked-in on Issue Day?
[and future days on the scope?]
HRC Nurses spch
Misc.
Status of Hollywood mtg.
Status of pundit program
June 10. 1994 9:42 am
Page 1
�JUNE 13 - JUNE 20
Day/Dept
Scheduling
Press Office
Public Liaison
Principals
Cabinet, Surrogates
Monday
6/13
VP Press Rdtble
League, if no HRC
Tuesday
6/14
HRC: League [?]
Wed.
6/15
HRC: Lehman Bros
Stem fraud briefing
[with whom?]
Bentsen: CEO brkfst ?
•Press paper for Issue Day
Bentsen Business breakfast
Thursday
6/16
HRC: farmers' call [?]
•Issue Day: Bowles and
Gov. Waihee [?]
Regional Media for Farmers'
call
[Wash. State/Cost
Containment Issue Day
prep]
VP Press Rdtble [any
handouts ready]
Paper/Research
[incl. data book]
Congressional/
Intergovernmental
Misc.
•Farm call paper ready
[Susannah, Simone, Julia]
•Paper for FLOTUS Lehman Bros
ready
•Jerry Stern paper ready
-Bensten CEO breakfast paper
•Stem paper cleared with
lower press, etc.
Welfare Reform
•Issue day paper [Univ. Cvg]: [?]
-bkgd, q&a, Waihee
•paper for Rivlin/Rubin rdtble
Race for the Cure paper to
VP/MEG?
Invites out to members
re: Washington State
Issue Day
Reich Businesses
Dumped Briefing
Rubin/Rivlin roundtable
Friday
6/17
Weekend
6/18-6/19
VP/MEG: Race for
the Cure
Letter writers component of dbase due
•Panetta speech draft help
•letter writers bkgd for HRC event
Misc/
,
Questions
June 10, 1994 9:42 am
Page 2
�JUNE 20 - JUNE 26
Day/Dept
Scheduling
Principals
Press OfFice
Public Liaison
Paper/Research
[incl. data book]
Families USA small biz
study
Freeh Testimony prep assistance
Congressional/
Intergovernmental
Misc.
Clear Freeh testimony
-BRT
-NBC special
Cabinet, Surrogates
Monday
6/20
Panetta Speech
Bowles/Families event
re: study [move to Thu?]
Tuesday
6/21
Reno/Shalala rdtble
Reno/Shalala rdtble
Wed.
6/22
Prep for Q/C forum
Freeh: Schumer hearing
on Fraud [maybe move
to Thurs?]
Thursday
6/23
Invites out for Q/C
forum
Friday
6/24
Weekend
6/25-6/26
MEG whistlestops in
the NW?
Misc./
Questions
HRC letter writers
MEG adult day care
•Gore family: seniors
event
•Teaching hosp?
t
•Panetta spch TuesAVed
Cost Control Issue Day
with Wash. St.
•Natl. AG's Conf, [WedFri]
Chain Drug Conf
[Sun-Wedj
•Panetta/Rivlin roundtable
Press handout for issue day
Wash. St. Issue Day
Quality/choice prep
Issue day paper [charts/etc]
•letter writers bkgd
Panetta speech draft help
-Cost Control Issue
Day
June 10, 1994 9:42 am
Page 3
�JUNE 27 - JULY 2
Day/Dept
Scheduling
Principals
Monday
6/27
Firefighters:
Prez: Hoboken
HRC: Detroit?
VP: local
MEG: Out West?
Tuesday
6/28
VP: Seniors speech?
HRC: D C. Economic
Club
Cabinet, Surrogates
Press Office
Public Liaison
Paper/Research
[incl. data book]
Congressional/
Intergovernmental
Misc.
*
Wed.
6/29
Thursday
6/30
Friday
7/1
Weekend
7/2-7/3
Misc./
Questions
HRC quality/choice
rdtble [?]
Fleming/Lee
quality/choice rdtble
Prz: s/t with
committees?
Qaulity/Choice Issue
Day
•Quality/Choice rdtble with
Fleming/Lee
•handout for Issue Day
•Qlty/Choice Issue Day paper
•Seniors paper for Gores
June 10. 1994 9:42 am
Page 4
�THE ftswNCTw Post TIESO»V, M«
24.1994
E. J. Dionne Jr.
Health Care
Turning Point
The health c.ire deb.ite is not ne.irlv ,i> > <>mplk\ited
as it lojks. Oh yes. the lier.iils can yet immeiwlv i ')niplex—and getting the details wrong could cost dearly
But what's causing all the turmoil are a few krv
choices. Once those choices are made, the details begin
to fall into place.
The biggest choice is whether or not the United
States wants a system assuring every Aniencan health
insurance. This issue passes under the name universal
coverage." Universal coverage is irmnensely popular
not only among those who are uninsured but alxj
among those who currently have insurance but fear
they will lose it or see their coverage eroded as employers face ever-higher costs.
So popular is universal coverage that few politicians
will say they're against it. But guaranteeing everyone
health coverage will cost money. There are only so many
ways to raise the money. Congress could simply raise
taxes. Or it could require individuals to pick up the tab.
Or it can require employers to pay part or most of the
costs, as so many already do now.
President Clinton's plan puts most but not all of the
burden on employers. All employers, with the exception
of some of the smallest, would have to pay 80 percent of
the health insurance costs for their employees, individuals 20 percent. That roughly matches the current split at
companies that insure their employees.
You wouldn't know it from the cowering in Congress
over the dread "employer mandate." as it's known, but
requiring companies to insure their employees is immensely popular. That ought not be surprising. Most
people are employees, not employers. And most people
think that if they hold down a job—or, as is the case with
so many families, two jobs—health coverage ought to be
part of the deal.
But it is a sign of how skewed the debate is in Washington toward various buamess lobbies that the employer
mandate has become the main sticking point in the discussion. Many Republicans and some conservative Democrats say they'll kill any health bill that includes one.
Yet most of these politicians will then turn around and
also say no to new taxes, no to individual mandates, no to
anything that would actually guarantee universal coverage. A courageous exception is Sen. John Chafee (R-R.I.)
who favors requiring individuals to buy health insurance.
As Chafee noted on "Meet the Press" on Sunday, "to
have universal coverage and to have the reforms that we
need . . . we've got to have some kind of mandate." For
his candor, Chafee has gotten nothing but grief from the
Repubbcan nght. which wants to use the mandate issue
to stop universal coverage.
What scares the Republicans about Chafee's position
is that if they concede the reality that only mandates or
taxes lead to universality, the Democrats who favor employer mandates suddenly have the political high ground.
Senate Republican Lender Bob Dole is very shrewd
about this. "I can already see the iiO-second television
spots.'' Dole told The Post's Dana Pnest." 'Well, the Republicans didn't want your boss to pay for it, they want
you to pay for it'." Clinton ought to hire Dole as a media
consultant.
Some former opponents of the mandate among Democrats have begun to understand what Dole already knows.
The conversion of Sen. John Breaux (D-La.) from tirm opposition to open-muidedness about an employer mandate
may be seen later as the turning point in the debate.
There are some legitimate worries about the impact of
a mandate on job creation. If an employer adds health insurance costs to the salaries of low-paid employees, his
costs go up a lot because health msumnce is so expensive.
That's why Sen. Edward Kennedy's latest modification of the Clinton plan is so important. Clinton's plan, in
a bow to the small business lobby, gives large subsidies
Thoughts on World Trade
The Post's "Sovereignty and the
WTO" |e(iitori.il. May 10) is a useful
contribution on an important topic.
L<.-t me just add three points to your
an.ilysis.
hr-t. having a one-nation, one-vote
nici h.iniMii in which Rwanda equals
the United States or Antigua and
Macao could combine to out-vote the
United States is at best questionable
and at worst dangerous.
Second, having the United States
pay more than 20 percent of the
budget (based on its share of world
trade) while getting less than one
percent of the vote is just wrong.
Third, Vice President Al Gore's
speech at the GATT plenary session
proposed an agenda of labor and envi-
ronmental issues that
a dram it
expansion of the World Trade Orgrn
zation from what the editorial
scribed as "a technical oryanizanoii.
I favor bigger market- and fr<trade. I hope we can pass the GAT
agreement. However, a brand ne
World Trade Organisation deserv!
tough scrutiny, careful analysis ai
thorough hearings.
After we have learned all the d.
tails and thought through all the n
plications for the United States. 1 w
be prepared to help write GATT n
plementation language.
NEWTGINGRIC
to small employers to help them buy insurance for their
workers. Kennedy would still give special help to smaller
businesses, but he would subsidize only the purchase of
insurance for lower-wage workers. He does this by limiting how much an employer will have to pqy for health insurance to a percentage of a worker's salary: This sharply reduces the ch.uices that heaJth care refonn would
force employers to lay off low-paid workers. Kennedy's
proposal may not be perfect, but it illustrates how reasonable objections to the Clinton plan can be met without
sacrificing universal coverage.
Opponents of large-scale reform have taken to arguing
that there is no need for a universal program now and
that slower, piecemeal action makes more sense on a
problem this complicated. This view has intuitive appeal,
but may be dead wrong on health care. As Hilary Stout
and David Rogers pointed out in the Wall Street Journal
last week, the cost per person of providing coverage
generally drops when more people are covered in larger
insurance pools. Piecemeal refonn could be more expensive, not less. And real cost containment is only possible
once everyone is in the system. Otherwise, the providers
of health care wil) keep shifting costs from the uninsured
or the poorly insured to the well insured.
The point with health reform is that you either really
do it or you don't, and the key to whether it gets done is
Sen. Daniel Patnck Moynihan, the chainnan of the Senate Finance Committee. Moynihan's discomfort with the
Clinton plan is often ascribed to prickly personal relations
with the White House, with Senate Majonty Leader
George Mitchell and the like. But instead of psychoanalyzing Moymhan, supporters of health reform would do
well to pay attention to what he's written about social
policy over the years—for example, in his 1988 volume,
"Came the Revolution."
Two themes are central to Moynihan's view. One is
the hubns of social reformers. Speaking of government's
exertions in the l%0s. Moymhan says that "we should
not exaggerate what we knew or what would come of
what we undertook." What scared Moynihan initially
about Clinton's health undertaking was his plan's complexity and the impression some Clintomtes gave that
they thought they had unlocked all the mystenes of
health policy.
But Moynihan also has an immense respect for what
government can do. "Government." he says, "can embrace great causes and do great things."
CUnton's central task is to convince Moymhan—and
with him the country—that universal health coverage as
conceived by the administration is not an act of hubris
but a practical next step in a great cause that began with
Social Secunty and the New Deal—and that has worked
out pretty well.
Mm
I S. k pi.. .. •
l
•.
'k-'.
WashmgK
�If we don't pass health care this year.
American families will pay more for health care with less secure benefits and diminishing
choices. Many workers will continue to trade wage increases or stay locked in jobs that don't suit
them just to hang on to the health benefits they've got.
•
Health care spending per worker will be over $7,000 in 1994. By the year 2000, health care
spending per worker will rise to $12,386, or 25 percent of compensation.
•
Without reform, by the year 2000, American workers will lose almost $600 in wages each
year just to keep their health benefits [Commerce Department]
American businesses will drop or pare back coverage, or continue to pay more for employee
health benefits.
•
One and a half million fewer full-time workers receive health benefits directly through an
e m p l o y e r today, compared to 1988. [University of North Carolina, 8/92]
•
In the future, 30 percent of small businesses currently providing insurance will drop their
insurance coverage because of the high cost. FHealth Affairs. Spring 1992]
Choices will decline for those with insurance, as employers try to stem rising costs by switching
to managed care plans with a small number of "approved" doctors. And as more families find
themselves without insurance, those with any history of illness will join the 81 million
Americans labeled as having "pre-existing conditions".
•
In 1988 , 89% of employers offered indemnity (fee-for-service) plans. In 1993, only 65% of
e m p l o y e r s o f f e r e d such plans. ["Health Benefits in 1993", KPMG Peat Marwick]
•
Up to 30% of employees report that they are afraid to leave their job for fear of losing
continuous health insurance coverage.
Doctors will have less and less control over their practices and the care they provide their
patients, as people at insurance companies without medical degrees second-guess medical
decisions and dictate "necessary care".
The federal budget will be overwhelmed by health care spending on Medicare and Medicaid.
This will add to the deficit, raising the pressure to cut back on benefits in those programs. State
budgets will also be increasingly eaten up by Medicaid, cutting back spending on other programs.
•
•
Two-thirds of the growth in federal spending between 1993 and 1996 will be accounted for
by health care spending.
In 1992, Medicaid spending totaled $102 billion, a 33% increase over 1991. By 1995,
M e d i c a i d Spending is expected tO reach $198 b i l l i o n . (National Association of Budget Officers)
•
In 1993, for the first time, states spent more money on health care than they did on taxf i n a n c e d higher education. (National Association ol'Stale Legislatures)
�V J
SAMPLE OP-ED/LETTER TO THE EDITOR ON HEALTH REFORM
We have a health care crisis in America, and it's time we faced up to the
challenge before us.
The opponents of reform say there's no health care crisis, but they ignore the
facts. That even if you have good insurance today, you can lose it tomorrow. In
fact, new Census Bureau data indicates that one in four Americans have already
lost or will lose their insurance for some period of time.
And your benefits are threatened by insurance company fine print. 81 million
Americans have "pre-existing conditions" that insurers can use to raise rates or deny
coverage. And 3 out of 4 insurance policies — that accounts for 133 million people
- have lifetime limits that cut off benefits when you need them most. In other
words, chances are your insurance plan is great ~ until you get sick.
Even if we have insurance, we're paying more, we're getting less, our choices
are declining, and our worries are increasing. If we don't act now, we face a future
of lower-quality care, fewer choices and higher bills.
America faces three choices: The first option is government insurance for
everybody, which would require a broad-based tax. The second option is no
guarantee of coverage for anybody, which is what we're doing today. And the third
option is guaranteed private insurance, which is the President's approach. It's an
approach that builds on the existing system because the bottom line is this: reform
must strengthen what's right about our health care system and fix what's wrong.
I support the President's approach because it consists of five key elements
central to real health reform:
Guaranteed private insurance. Every American should be guaranteed
private health insurance. That means comprehensive benefits that can never
be taken away.
Choice. Everyone should have the right to choose their own doctor and their
own health plan. To make sure we get high-quality care we can depend on,
the choices should be made by us, not by employers or insurance companies.
Outlaw unfair insurance practices: It will be illegal for insurance
companies to: drop coverage or cut benefits; jack up your rates i f you get
�sick; use lifetime limits to cut off your benefits; or charge older people more
than younger. That's how everyone will get affordable insurance we can
depend on.
•
Preserve Medicare. The President's approach also protects and strengthens
Medicare. Older Americans have a right to count on Medicare and choose
their doctor. The President's approach also covers prescription drugs under
Medicare, and give new options for long- term care in the home and
community.
Health benefits guaranteed at work. Every job should come with health
benefits. Most jobs do today. And yet 8 out of 10 Americans who have no
insurance are in working families. Everyone should have health benefits
guaranteed at work — that's the President's approach. The government will
provide discounts for small businesses and help cover the unemployed.
How do we know that the President's reform will work for us and our
doctor? Because doctors, nurses, and other people on the front lines ~ including
America's largest associations of family physicians, pediatricians, nurses and
pharmacists — support it and believe it will work.
Now it's up to our members of Congress to make the President's reform a
reality. And it's time we let our representatives know what we need ~ health
security for the rest of our lives.
Opponents of reform are trying to confuse the issue by making it seem more
complicated, but it's really pretty simple: When the President's reform passes, we'll
get a Health Security card, be able to pick any doctor we want, fill out one form,
and know exactly what's covered. And we'll all know that our health security can
never be taken away.
In the coming months, we'll hear plenty of TV and radio ads opposing the
President's reform. Many of the insurance companies who pay for these ads don't
like the President's reform ~ we know that. But the President's reform isn't
designed for the insurance companies —it's designed for the American people.
Now it's up to us to stand with the President against the special interests.
This is the right thing to do, and if we make our voices heard, we can help pass
health care reform this year.
�MEMORANDUM
TO:
FROM:
RE:
DATE:
Distribution
Health Care Message Team
Congressional response
February 22, 1994
As Congressional committees move forward in considering health reform legislation, we
expect that you will be asked to comment or make predictions on various developments. We
should avoid any commentary on specific Congressional actions and let the process take its
course. Our response:
The ball is now in Congress' court.
We're pleased that the committees are o f f to a fast start and are taking steps on
the road to guaranteeing private insurance for every American.
As Congress moves forward on health reform, we expect ups and downs as we
wrestle with the challenge of health reform. That's what always happens. There
are people on Capitol Hill and around this country who have been working on
these issues for decades, and we expect they will pursue their ideas.
No one can predict exactly where Congress will end up. But the important
question will not be how much the mechanics have changed, but whether the
legislation reaches the President's bottom line: providing guaranteed private
insurance to every American.
We are pleased that Congress is moving ahead and confident that, when all is
said and done, it will pass a bill that will meet the President's commitment to
giving every American health care that can never be taken away.
�THE PRESIDENT'S APPROACH TO HEALTH REFORM
A Consumer's Point of View
We must return our health care system to the people who should be in the driver's seat
- consumers and their doctors. And the President's approach does that by outlawing the
insurance company discrimination that is so common today. It will be illegal for the insurance
companies to decide who gets coverage. Illegal to charge people more if they're older or sick.
Illegal to put lifetime limits on coverage.
Small businesses and individuals will be able to get insurance at the same affordable
rates that only big business and government can get today. And each individual ~ not their
employer, not a bureaucrat ~ will have a choice of health plans and doctors.
We want to phase in reform over a few years to make sure it's done right. But when
we're done, insurance ought to mean what it used to mean. You pay a fair price for security,
and when you get sick, health care's always there, no matter what.
The President's goal is this: guaranteed private insurance to every American. And let's
be clear about what that means because there's a lot of misinformation out there.
Most people will get insurance the same way they do today, through their employer.
Once you've picked a plan, if you need to go to the doctor for a check-up or get sick, you'll
simply take your Health Security card, show it at the doctor's office or the hospital, and get
the care you need. Most of you will go to the same doctor you see today, the same hospital if
you become seriously ill. And if you live in an urban or rural area, it will be easier for you to
get the care you need when you need it.
The President's approach would guarantee that every American has comprehensive
benefits including coverage for preventive care and prescription drugs. And the President's
approach also protects older Americans by preserving Medicare and by adding new coverage
for prescription drugs and some long-term care.
Most important, the President's approach provides every American with the peace of
mind of knowing that their health care will always be there for them when they need it.
�Q: IVe got a good job with good insurance. Why should I support reform?
That's an excellent question. There are many people in your position who are lucky enough to
have good coverage ~ but know that they have no guarantee that they will have that same,
good coverage at this time next year.
What's Happening Today
Let's look at what's happening to people's health insurance today. Right now, insurance
companies are raising premiums every year. Businesses ~ faced with rising costs — are
responding by forcing employees into managed care, cutting your benefits, increasing what
you have to pay for insurance, or dropping your coverage altogether. Whichever way you cut
it, you're the one getting squeezed.
Insurance Company Control
The problem is this: Insurance companies have too much control over your health care. They
pick and choose whom they cover. They charge you more if you're older. And they drop you
when you get sick.
They're constantly coming up with new ways to deny you the benefits you need. If you're
sick or had a past illness, they'll single you out and refuse you coverage for that "preexisting
condition." 81 million Americans have a preexisting condition which may cause them to pay
more or be denied coverage. And hidden in the fine print of three out of four insurance
policies are "lifetime limits" ~ which cancel your insurance when your bills run too high.
If you get sick or have a past illness...if you own or work in a small business or are selfemployed...if you switch jobs or lose your job...you could find yourself denied coverage or
have insurance priced out of your reach at any time.
So today, you're at the mercy of the insurance companies. The President's approach reduces
insurance company control over the system, and gives people and small businesses the
choices and the power to get high-quality care at an affordable cost.
That's the context of this debate. But I understand the bottom line is: you've got good
insurance now — what do you personally stand to gain from reform?
What You'll Gain From Reform
Guaranteed Security. You'll get comprehensive benefits that can never be taken away - no
matter what. No employer or insurance company will be able to take away your benefits —
because they will be guaranteed in law. If you lose your job, you're covered. If you switch
jobs, you're covered. If you start a small business, you're covered.
Lifetime limits in insurance policies will be illegal, and it will be illegal to drop you when
you get sick. Your health care will always be there.
�Guaranteed Affordability. Rest assured that insurance will be affordable for you and your
family. Because first of all, there will be a limit on how much insurance companies can raise
your premiums year to year. Second, your employer or insurance company will never be able
to make you pay more than 20% of the average-cost health plan where you live. And your
employer can continue to pay 100% of the cost of your insurance if they so choose.
Increased Wages. Middle-class wages have been stagnant for 20 years, in no small part
because workers have had to trade wage increases just to keep good benefits. With guaranteed
benefits, that will change, and workers will have their first chance at wage increases in years.
In fact, the Congressional Budget Office (CBO) analysis says definitively that "the proposal
would increase the cash wages of U.S. workers . . . "
Increased Choices. In today's system, your choices are dictated by your employer or
insurance company. Your boss usually picks your plan, and your plan often limits what
doctors you can see. Under reform, you have your choice of doctor and health plan — just
like members of Congress do. The law will require that there be at least one traditional "feefor-service" plan - where you have unlimited choice of doctor - in every region of the
country. And all health plans ~ even HMOs - must give you the option of seeing doctors
outside the plan, even if you have to pay a slightly higher copay and deductible to do so.
The overall effect of reform on American families was best described by CBO Director
Reischauer after completing the most comprehensive analysis of our proposal to date:
"The Clinton plan, when compared to today's system, would cost average Americans less
money, give them more health benefits and more choice of physicians and medical care,
[Reischauer] said." [ Washington Post. 2/9/94]
That is why middle-class American families like yours ~ even those with good insurance —
stand to gain from reform. You'll see a "surprisingly simple" world, according to the
Washington Post. You'll get comprehensive benefits at an affordable price ~ and something
that no amount of today's money can buy. The peace of mind that comes with knowing that
your health coverage can never be taken away ~ no matter what.
�America's Health Care Crisis
Today's system is rigged against families and small businesses, and the
insurance companies are in charge. They pick and choose whom they cover.
They use "lifetime limits" and loopholes to cut off your benefits. And then they
drop you when you get sick. Here's what happens to American families and
small businesses when insurance companies control our health care system.
Last year, 58 million Americans were without health insurance for some
period of time. These people are left unprotected against the threat of
illness. And up to 30% of people report they are afraid to leave their
current job for fear of losing health insurance, uoumai ot the American Medicai Attociaiion.
1/5/94; 1993 Economic Report to the President. Council of llconomic Advisers)
/
Every month. 2 million Americans lose their insurance for some period of
time. If someone in the family comes down with a serious illness during
that time, the family's savings could be wiped out. In fact, over 100,000
middle-class American families declare bankruptcy every year because of
a S e r i o U S i l l n e S S O r i n j u r y . (Families USA. Idizabcth Warren. Penn Law School, forthcoming report 1994)
•
The meaning of the word "insurance" has been lost. Most Americans do
have insurance right now, but three out of four (76%^ of those insurance
policies have "lifetime limits" — cutting off your benefits when you get
really sick. 69% of private insurance policies refuse to cover pre-existing
conditions -- denying benefits to those who need them most. And an
estimated 81 million Americans under age 65 have medical problems for
which insurance companies charge higher premiums, exclude coverage, or
deny
COVerage altogether.
(Bureau ot l abor Sialisti^. rosier Higgins 1991 survey: Citizens Fund)
Paying rising health care bills is the fastest-growing contributor to our
federal deficit. (Entitlement Spending A Fact Sheet. Congressional Research Service. 4/16/93)
In 1980, Americans were being charged $2,600 per family for health care.
This year, between prescription drug costs, premium payments, Medicare
taxes and other health costs, we're being charged $8,000 per family.
("Skyrocketing Health Innation." Families USA report. November I99.t)
•
Small businesses are charged an average of 35% more than big businesses
for the same insurance. And the high cost of insurance is expected to
cause 30% of small businesses to drop coverage in the years ahead. (Hay
Huggins survey; "Small Business and the National Health C are Retorm Debate." Heallh Affairs, Spring 1992)
�ANALYSIS OF ALTERNATE PLANS
TABLE OF CONTENTS
I.
CHAFEE BILL
•
Some Concerns
•
Questions to Pose
II.
COOPER BILL
•
Some Concerns
•
Questions to Pose
III.
GRAMM / MCCAIN
•
Some Concerns
•
Questions to Pose
IV.
SINGLE-PAYER
•
Some Concerns
•
Questions to Pose
�The Republican Health Care Task Force Proposal- Some Concerns
The Republican Health Care Task Force has proposed a health care
system based on mandating that all individuals buy health insurance. It
would set up a government program to pay for health insurance for poor
people, and pay for it with Medicare and Medicaid savings. Employers
would decide whether their workers got a choice of plans, and whether or not
to buy coverage through a health alliance. The plan would control costs by
encouraging competition among plans within the alliances, and by taxing
individuals and employers who buy benefits that cost more than the
established cap. The plan also includes measures to reduce administration
and bureaucracy, and reforms malpractice laws.
The proposal they have put forth indicates that we are closer than ever
before to a bi-partisan approach to comprehensive health care reform. For the
first time, 23 Republican Senators have committed themselves to
guaranteeing comprehensive coverage for all Americans, and have put forth a
serious proposal. We agree with much of their approach. We agree that
coverage for all Americans is the first and most important goal of health
reform. We agree that market forces and changed incentives can bring down
health care costs, and that competing health plans and health alliances will
make it happen . We agree that individuals should take responsibility and
contribute toward their care.
But we cannot support the Republican plan because it does not go far
enough. It says that individuals have an obligation to buy health insurance,
but that the companies they work for don't need to contribute. It says that
small businesses and individuals deserve the better bargaining power ofa
health alliance, but doesn't guarantee they'll get that clout. It says that
comprehensive benefits are a must, but fails to say what's covered. It limits
spending for public programs, but has no similar protections on the private
side. It says that we can slow spending in Medicare and Medicaid, but
doesn't use that money to buy new benefits for seniors. This plan is like a car
that heads down the right road, but runs out of gas halfway there.
Does not achieve universal coverage this century.
The Chafee proposal promises universal coverage for comprehensive
benefits by the year 2000
if. If the savings they project
materialize. If savings don't come as quickly, they' will extend
coverage more slowly, leaving more people without coverage for longer.
DRAFT
�Does not guarantee a defined set of comprehensive benefits.
The proposal promises that the benefits package will cover a broad
range of services
ijf If the Commission the Republican plan sets
up decides those benefits are affordable. And if costs go up faster than
they expect, the benefits could be cut back. These are big ifs. People
need the security of knowing what's covered, and knowing that those
services won't be watered down over time.
Shifts costs to businesses and individuals.
The Chafee proposal controls costs by pooling small businesses into
regional purchasing cooperatives and forcing plans to compete on
quality and price. The evidence suggests that competition and better
incentives will control costs-- but it doesn't guarantee it. By contrast,
public sector savings are guaranteed in this proposal-it caps Medicare
and Medicaid growth at 7%, from a projected 12%.
Capping the growth of pubhc programs with no control on the private
side will continue the same "cost shift" we have today, where prices go
up slower in the Medicare and Medicaid programs, and doctors and
hospitals raise prices higher and faster in the private sector to make
up for it. Individuals and businesses will keep paying more,
weakening the cost-slowing effects of competition.
No guaranteed bargaining leverage for small businesses.
By making purchasing aUiances both small and voluntary, this
proposal significantly weakens the bargaining muscle of the alhance,
and their effectiveness in bargaining with plans.
And what's worse, it keeps in-place an insurance system which avoids
risk by "cherry picking" firms with young healthy employees and
rewarding them with lower rates. Any group that can get a better deal
outside the aUiance will stay outside. This approach pools vulnerable
small businesses with the poor and uninsured, and will almost
certainly mean that premiums in the aUiances are higher than outside.
That's no help at aU to smaU businesses.
Continuous Disruption for many Americans
The average person changes jobs 10 times in a lifetime, more for
people in smaU firms. If the pools are voluntary, workers wiU be in
and out of different plans based on their employer, and may lose their
work-based plan if they lose their job.
�Allows huge variations among states
It's one thing to give states flexibihty, it's another thing to tell them
they can set up a whole different system than their neighbors. The
Chafee plan tells lets set up basically whatever kind of system they
want as long as they meet certain federal rules. That could mean a
single-payer program in Vermont, an individual mandate in New
Hampshire, pay-br-play in Massachusetts, an employer mandate in
Rhode Island, and Med-Save accounts in Connecticut. Such vastly
different approaches in such close proximity could guide business
decisions and other factors that skew economic development and have
differing effects on state economies. And states that want to build on
the current system through an employer requirement can't do so
without worrying that businesses could move to the state across the
border -- tieing the hands of governors who support employer-based
reforms.
�QUESTIONS ABOUT THE REPUBLICAN TASK FORCE PROPOSAL
1.
Do you think its fair to put the full burden of insurance on American
families, without asking the companies they work for to chip in?
2.
Aren't you worried that many companies will drop their workers'
coverage if your refonn is passed'.'
3.
What exactly is covered in your benefits package? What's left out?
I f you're not going to say what's covered, how can we know what your
program will cost?
4.
How much will insurance premiums be, on average, under your plan?
5.
Can you guarantee that health care costs won't keep going up and up?
6.
Why do you think the federal ^ovornment's spending on health care
should be contained, hut that spending by individuals and businesses
should be open-ended? Doesn't that just lead to a "cost-shift"?
7.
Under your proposal, do people covered by employer-sponsored plans
lose that coverage when they lose their job?
8.
Your plan calls for saving about $200 billion inthe Medicare and
Medicaid programs over 5 years. Don't you think we owe to to older
Americans to spend some of that money on benefits to seniors? Why
should the elderly bear the full cost of your reform?
9.
Doesn't your "tax cap' amount to a new tax on the milhons of
Americans who have given up wage increases for good health benefits?
10.
Is there anything in your plan that would give help to businesses who
want to provide insurance, but can't now afford it?
11.
Aren't you concerned that by letting states set up whatever type of
system they want, you'll have huge variations across states, skewing
economic development and causing a mess for large firms? What
would happen when people move? What if someone saved money in a
MedSave account in Tennessee, and moved to Kentucky, which had a
single payer system? How would that work?
1
DRAFT
�"THE MANAGED COMPETITION ACT OF 1993":
SOME CONCERNS
There are many components of this approach we completely agree with. Like
Congressman Cooper, we believe community rating returns insurance to a community
responsibility, not an exercise in profit making and risk avoidance. Like Congressman
Cooper, we believe that an increased emphasis on competition will promote efficiency,
reduce waste, and lower costs. And finally, like Congressman Cooper, we believe
increased cost-consciousness is an important aspect of health care reform, and a
necessary ingredient for cost control.
But we cannot support the Cooper bill because it does not provide health security for all
Americans. We believe all Americans need and deserve health care security; this plan
just doesn't provide that. We believe that comprehensive benefits should be spelled out
and guaranteed; this plan doesn't provide that. We believe choice of doctor is a right;
this plan considers choice a taxable luxury. We believe HMOs are one alternative; this
plan believes HMOs are for everyone.
The Cooper plan must get a failing grade as it does not meet five of the six principles the
President has set forth for comprehensive health reform.
1. It does nol provide the security of a comprehensive package of benefits that can never
be taken away.
2. It does not provide increased choices for consumers.
3. It does not provide a simpler system.
4. It does not guarantee savings — it continues the cost shift and raises the deficit.
5. And it asks responsibility from no one. In fact it gives no one any reason to be
responsible.
COOPER.
"[The plan does not/ compel employers to pay the health plan premiums
of their employees."
Translation: In fact, the Cooper plan doesn't require anyone — not employers, not
individuals, not the government — to take responsibility for health
care. Therefore, it doesn't provide heaith care coverage for everyone
and guarantees no one security.
There are only a few ways to guarantee coverage for all Americans. One is
to raise a broad-based tax, and have the governmentfinanceand deliver
health care The second is to require employers to contribute to coverage
for all of their workers. The third is to require all individuals to purchase
insurance for themselves Whether it's the government, employers,
individuals, or some combination... for everyone to have coverage,
someone has to pay.
DRAFT
�T H E MANAGED C O M P E T I T I O N A C T O F 1993
Page 2
The Cooper plan assumes that between better incentives and government
help for the poor, more Americans will be covered. But individuals can
still decide that health care isn't their responsibility- it's yours and mine.
They can still go without coverage, show up at the emergency room, and
shift the cost to those with coverage. Employers can continue to drop
workers who are costly, or not cover any of their workforce. In fact, this
plan encourages employers with low wage workers to drop the coverage
they now provide- and let the government pick up their care. The result?
After Cooper-style health reform, 22 million Americans will still be
uncovered. [Congressional Budget Office. July 1993]
In fact, the Cooper plan provides incentives for employers to drop
coverage for many workers leading CBO to warn of 6 million newly
uninsured Americans.
By providing government vouchers for low-income workers who now have
coverage through the workplace, this plan could encourage some
employers to drop their workers coverage, knowing the workers would be
picked up by the government program. According to the Congressional
Budget Office, "Enactment of the law is likely to cause a few employers to
drop their health insurance plan and allow the government to assume the
cost of covering their low income workers." [CBO, "Estimates of Health Care
Proposals from the 102nd Congress " p. 52, 7/931
COOPER:
"If an individual loses his job, he can remain in the HPPC and pay
premiums himself "
Translation: For millions, when you lose your job, you lose your coverage.
•
If you lose your job, this plan does not guarantee you any
protection at all. *
•
If you're locked into a job because you don't want to lose benefits,
you're still trapped
�T H E MANAGED C O M P E T I T I O N A C T O F 1993
Page 3
COOPER::
"A national commission will establish a uniform set of effective health
benefits."
Translation: This plan does not even specify — much less guarantee - a
comprehensive set of benefits, nor does it protect American families
from exorbitant out-of-pocket costs.
The Cooper proposal shifts the responsibility for defining the benefits
package to a National Board ~ to be determined after the legislation has
passed and become law. How can the public be asked to support a bill
when they don't know what health care they'll receive? The millions of
Americans who want and need health care reform have made clear that
health care reform must mean comprehensive benefits.
This approach does not answer a single important question about benefits:
Which services will covered, and which will be denied'?
Are preventive services fully covered? which ones?
How much is a family liable for in a given year?
Is mental health care covered?
What about lifetime limits?
No American consumer would pay up front for a new car, only to have the
dealership decide later on the type of engine in the car, on the features that
were included, or what kind of warrantee the car came with. There are
certain things the American people have a right to know up front,
guaranteed, spelled out benefits are one of them.
COOPER:
"... to discourage inflationary "Rolls Royce" health policies, which
don't control costs, the bill caps tax deductibility at the cost of the lowest
price AHP p l a n . . . "
Translation: You could be penalized if you pick your own doctor and pay a "choice
tax" to belong to certain plans or see certain doctors.
This proposal doesn't just target the "Roll Royce", it targets the family
station wagon. Millions of Americans will pay new taxes for the same
benefits. By trying to reward consumers for choosing tightly managed,
cost-efficient plans like HMOs, the proposal punishes individuals and their
employers for any other choices. If you want to continue to get health care
the way you do now - or to see the same doctor you've always seen
outside of an HMO — you get taxed.
�T H E MANAGED C O M P E T I T I O N A C T O F 1993
Page 4
If you choose not to go into an HMO or HMO-type organization, you and
your employer both pay new taxes on your health care premiums. HMOs
are afinealternative for many Americans, but they are not for everyone.
Free choice of doctor is an American tradition, and is the only type of
health care delivery in many areas of the country. The "one-size-fits-all"
approach doesn't work for health care, and HMOs are not the bestfitfor
many people who don't want to see such major change in their health care.
Under this plan:
•
Those who currently have restricted choices will find their choice is
still limited or more limited.
•
Those who currently have a free choice of doctor will lose that
choice, or pay a tax to maintain it.
COOPER:
"Employers will be allowed to deduct the cost of the most efficient health
plans but not the cost of excess benefits or wasteful spending. "
Translation: The Cooper plan encourages employers to reduce benefits by levying
tax penalties on employers that give their workers comprehensive
coverage.
Does Congressman Cooper consider prescription drugs "excessive
benefits"? Does he consider investments in mental health and long-term
care "wasteful spending"?
Today employers can deduct the cost of any and all health benefits as a
business expense. The Cooper proposal would set a "tax cap" at the
lowest cost plan in the area - a plan with benefits that are less generous
than what most people have today.
So even though this plan says that "individuals would choose", employers
would have every incentive to force their workers into only one plan ~ the
cheapest plan. This trend exists today, .workers are increasingly locked
into one plan by their employer, forcing them to give up relationships with
doctors they trust.
�T H E MANAGED C O M P E T I T I O N A C T O F 1993
Page 6
COOPER:
". . . does not include price controls, nor does it include global budgets."
Translation: This plan does not guarantee cost control, nor does it protect
individuals and families from insurance premiums that skyrocket year
after year.
Competition will go a long way to slow runaway health care spending, to
be sure. But today skyrocketing health care costs are threatening
American families, American businesses and the health of our economy
itself. But what if competition takes too long? What if it doesn't work
everywhere?
In addition, this proposal does nothing to guarantee that rising health costs
will no longer wipe out our families and businesses. Controlling the
increase in premiums that individuals and businesses pay is the only way to
protect the private sector from being bankrupted by health care.
Under this plan:
•
The practice of "cost shifting" -- squeezing down on the public side
and pushing costs higher on the private side— will continue
unchanged.
•
Individuals and families now unprotected from skyrocketing costs
have no greater protection.
•
Costs will still rise at the projected rate— or faster: "CBO estimates
that, after a few years, H.R. 5936 wouid leave national health
expenditures only a little higher than they would otherwise be."
[CBO, "Estimates of Health Care Proposals from the 102nd Congress" p. 58,
July 1993 |
COOPER:
". . . the bill uses strong tax incentives . . . "
Translation: This plan is an administrative nightmare; it might as well be called
"the IRS full employment bill".
This plan significantly expands the reach of government bureaucracies and
government involvement in the workplace. It requires the IRS to
determine and monitor the low-cost plan in every HPPC region, and match
that against spending on health care by every employer for every employee.
And this adds a tremendous new administrative burden for businesses particularly small businesses who now suffer tremendous administrative
�THE MANAGED COMPETITION ACT OF 1993
Page 7
burdens -- by forcing them to keep on top of the "lowest cost plan" the
way an investor would follow changes in the stock market.
COOPER:
"Deficit: [1995] $14 Billion; [1996] $22 Billion; [1997] $17 Billion;
[1998] $12 Billion; [1999] $5 Billion"
Translation: The Cooper Plan increases the deficit by $70 billion.
This proposal doesn't even pay for itself. In fact, the CBO/Joint Tax
Committee analysis of the plan found that it increases the deficit by $70
billion in the first 5 years alone.
COOPER:
"The states will gradually assume responsibility for long-term care, with
greater flexibility to try innovative approaches. "
Translation: The Cooper plan does not address long term care other than shifting
enormous federal costs onto the states.
The fastest growing item in most state budgets is Medicaid, outstripping
state's abilities to pay for other needed services like education and public
safety. And more and more of those Medicaid dollars go to the mounting
costs of long-term care. As our population ages and more and more
Americans live longer, these costs add increasing burden on both federal
and state governments.
Today, the federal government contributes at least 50 cents of every dollar
states spend on Medicaid long-term care; in some cases, up to 75 cents.
The Cooper plan says that states should bear those costs completely on
their own, a proposition that would bankrupt many states.
�QUESTIONS TO ASK REPRESENTATIVE COOPER
1.
Does the Cooper plan guarantee coverage to all Americans?
What secunty does the Cooper plan offer the American people
• when they are not guaranteed health coverage
• when they are not guaranteed comprehensive benefits,
and
• when there is no lifetime limit on what they can spend?
2.
Doesn't the Cooper Plan penalize employers that now provide their
employees with comprehensive benefits?
3.
Doesn't the Cooper Plan give employers incentives to drop their
employees' health coverage or drastically reduce their employees' health
benefits?
4.
Doesn't the Cooper plan have a "choice tax" -- where Americans are
taxed for choosing their own doctors unless their doctor is in the lowest
cost plan?
5.
When you read between the lines, isn't this just a National HMO plan?
Don't employers have every incentive to just force their employees into
the cheapest cost plan?
6.
Couldn't this be called the "IRS full employment bill" because it is such
an administrative nightmare requiring the IRS to monitor the lowest
cost plan in every region in the country?
7.
Isn't it true that if you're one of the tens of millions of workers whose
employer doesn't cover you today, this plan does nothing to encourage
them to cover you tomorrow?
8.
Didn't the CBO/Joint Tax Cominittee assessment of this same plan last
year show it running a deficit of $70 billion in its first 5 years?
9.
Isn't it true that if you lose your job today, this plan does nothing to
keep you from losing your entire life savings and everything you've ever
worked for?
10. The major advocates of Managed Competition -- such as Enthoven and
EUwood -- support an employer mandate because they believe that there
much be universal coverage for Managed Competition to work. Why do
you beheve your plan will work without universal coverage when the
people who invented Managed Competition disagree?
�"THE C O M P R E H E N S I V E F A M I L Y H E A L T H A C C E S S
AND SAVINGS ACT" (GRAMM-MCCAIN):
SOME C O N C E R N S
Under the Gramm-McCain plan, responsibility for health care would shift
from employers to individuals. It calls for the creation of tax-free "Medisave"
accounts, medical accounts along the lines of Individual Retirement Accounts, to
encourage individuals to put money away to cover small medical bills. State
requirements for minimum insurance benefits would be eliminated to create a market
for catastrophic health plans that would cover only major medical expenses. Tax
incentives would encourage consumers to purchase such plans. Individuals would
pay for routine care and deductibles out of their Medisave accounts, using insurance
only for more serious medical problems. TJiey would retain whatever funds they did
not use from their accounts, creating an incentive for them to keep their health care
use down.
There are some components of even this proposal with which we can find
common ground. Like Senators Gramm and McCain, we believe that relying on
consumers to make informed choices should be the centerpiece of our health care
system. Like Senators Gramm and McCain, we believe that consumers should share
in the financial responsibility for purchasing their insurance coverage and paying for
their care in order to make these decisions sensitive to cost.
But we cannot support the Gramm-McCain bill because it does not provide
security for all Americans - in fact it puts Americans at even greater risk than are
today. This plan leaves insurance companies in the driver's seat - free to drop people
or raise their rates for any reason. And it actually encourages them to jack up your
rates if you get sick or have a pre-existing condition.
The Comprehensive Family Health Access and Savings Act is guilty of false
advertising. It is not comprehensive. 'It does not improve access. And it does not
provide any savings.
Encourages "Bare-Bones" Coverage
We believe that all Americans should be guaranteed a comprehensive
package of benefits that can never be taken a away. Not only does this bill
not provide comprehensive benefits, it encourages everyone to purchase bare
bones policies which cover only catastrophic health care costs. Every time
you see your doctor means draining your savings. In fact, the only
comprehensive thing about this bill is the word in its title.
DRAFT
�Discourages Cost-Effective Preventive Care
We believe our health care system should encourage prevention to keep
people healthy rather than treating them when they get sick. This plan
encourages people to avoid seeking preventive care altogether and to wait
until they are really sick before seeing their doctor when treating them will
be much more expensive.
Tells Consumers to Go it Alone
We beheve that by having individuals and small businesses join together
they will be able to bargain for good coverage at affordable rates- just like
big companies do today. Under this plan its everyone for themselves
bargaining with doctors and hospitals for discounts. This plan expects that
everyone will have the medical knowledge of C. Everett Koop, the financial
sense of J.P. Morgan and the negotiating skill of Henry Kissinger.
Sacrifices Quality
This plan has no quality standards, eliminates basic protections for
insurance plans and provides no information to consumers on the quahty of
plans or the effectiveness of treatments. It puts the burden on consumers to
make choices about their treatment but gives them no tools to do so. This
plan is not the least bit concerned about people's health or the quahty of care
received as long as it costs less.
"The Bureaucracy and Paperwork Preservation Act"
We believe that health care reform should simplify the system for doctors and
patients by reducing paperwork and administrative redtape that are choking
our health care system; they believe that confusing insurance policy fine
print and mountains of forms are nothing we need to worry about and that its
fine for us to spend our money, billions of dollars, on waste, fraud, and other
things which do nothing to make us healthier.
�QUESTIONS ABOUT THE GRAMM/MCCAIN BILL
1.
Both the President's plan and the Chafee/Dole plan guarantee that every
American will have health insurance. Does yours?
2.
Your proposal assures access to insurance for every American, it just doesn't
guarantee coverage. Isn't that a little hke saying that every American has
access to an education, but we can't promise they'll be able to go to school?
3.
This sounds to me hke the "swiss cheese" health care plan -- more holes
than anything else. What protection does a $3,000 deductible offer the
average American family?
4.
Most people beheve that preventive care saves money. Doesn't your plan
discourage people from getting less expensive care in doctor's offices, and
further the incentives toward high-cost care in hospitals?
5.
Doesn't this plan let insurance companies continue to pick and choose who to
cover and who to deny, how much to charge, and what conditions to exclude?
Is it really fair for people to pay more just because they've once been sick?
6.
Nearly every other plan before the Congress bans pre-existing conditions.
Even the insurance industry lobby supports that. Why doesn't your plan?
7.
No consumer group supports this plan. The NFIB does not support this plan.
Who besides some insurers - who will directly benefit under the plan support it?
8.
The theory behind Medical Savings Accounts is that they they control costs
by making people more aware of prices and encouraging them to bargain.
People know what health care costs, and they think that's the problem.
What new powers are you giving consumers to help them get better prices?
9.
What assurances can we give the American pubhc that their costs won't keep
skyrocketing under your plan?
DRAFT
�SINGLE PAYER:
SOME CONCERNS
Under single payer proposals the government would take full responsibility as
the sole purchaser of health care services. The government would increase taxes on
individuals and businesses, including payroll taxes and income taxes, replacing all
private health insurance premiums today. The government would also establish
payment rates for all physicians and other providers and prohibit them from billing
patients for covered services. All legal residents would be eligible for comprehensive
health benefits with no out-of-pocket payments and choose their own doctors. Total
spending would be strictly limited by a national health budget, which would grow
no more rapidly than the economy.
Many elements of the single payer bills are central features of our plan. For
example, both plans guarantee a comprehensive package of benefits for all
Americans. Both simplify administration and reduce paperwork. We also agree on
the need to control costs. We also provide states with the flexibility to adopt a single
payer plan for their citizens.
But we cannot support the single payer health care proposal because, among
other reasons, it would require raising and redistributing as much as half a trillion
dollars in new federal taxes. Not only would this approach add further strain to our
recovering economy, but it doesn't make sense to change our health care system so
radically when it is possible to build on our current system - to take the finest
private health care system in the world and make it work better.
A New Half A Trillion Dollar Tax
Of the Americans that are covered under today's system, 90% receive their
coverage through the workplace. While we agree there are major problems with the
current system that need to be addressed that there are many positive aspects as
well. We beheve that our goal should be to change what's wrong while preserving
what's right. Our plan is uniquely American plan rooted in the private sector.
Asking Americans to support a half a trillion dollar tax hike to support a system
whose costs are already out of control is unfair. Without an effective mechanism for
containing costs, their plan would compromise the quahty of American health care
and would hmit consumer choices.
DRAFT
�A One Size Fits All Approach
Their plan is based on the premise that "one size fits all" -- that a single
health plan would meet everyone's health needs and work as well everywhere. Our
plan recognizes the unique differences of our states. What works in New York, may
not work in New Mexico. Our plan allows states the flexibihty to tailor their reform
plan to meet the needs of the citizens of their state.
Government Dream? Providers Nightmare?
While they claim that their system would be simpler, providers say that our
current government programs are a bureaucratic nightmare. They must deal with
an ever-growing set of regulation, a blizzard of paperwork and multiple layers of
reviews, inspections and oversight. In their government-run health care system
without competition, there are no incentives to increase efficiency, to develop
systems that works better and improves quahty.
We beheve that the government should set standards, guarantee security
then get out of the way. It will simplify the system, reduce paperwork, and
streamhne government oversight. Doctors and nurses will be able to spend less
time filling out forms and fighting bureaucrats and more time taking care of
patients.
Ineffective Cost Control
Their plan contains costs by setting fee schedules -- controlling the cost by
controlhng the payment rates for doctors and other providers. Under this approach,
its easy for providers to game the system by ordering more tests and more
procedures. Canada's health care costs are rising as fast as ours. We do not
beheve that Americans should be asked to spend their money on a system with
skyrocketing costs with a containment mechanism that is ineffective.
Our plan is based on proven approaches - here and around the world -- that
are successful in containing costs here and around the world. Costs will be
controlled by bringing competition to the health care marketplace, strengthening
the buying power of consumers and businesses by pooling them into large groups to
bargain for lower prices. It will put consumers in the driver's seat by providing
them with the information they need to choose plans on price and quahty
�QUESTIONS ABOUT SINGLE-PAYER LEGISLATION
1.
How can you justify -- and do you believe that a majority of Americans would
support -- a $500 bilhon tax hike to pay for a health care system that is
already out-of-control?
2.
The first job of the President is finding the right combination of provisions
that guarantees coverage, contains costs, assures quahty and choice, and that
WILL PASS THE CONGRESS. Are there any well-respected political
analysts who beheve that a single-payer bill can or will pass the Congress?
3.
Different approaches are working well in different states. Why should we
enact a one-size fits all health care solution?
4.
Canada's health care costs are rising as fast as ours. Why do you think your
plan based on the Canadian system would do any better in this country?
5.
Canada and other single payer nations control costs by controlling the
payment rate for doctors and other providers. Studies on this approach have
found that providers find it easy to game the system through higher
utilization of services. Doctors just order more tests. Why should we rely on
failed cost containment mechanisms for our health reform?
6.
Most Americans associate a single payer system with a large, Governmentrun bureaucracy. Do you believeithat a single payer bill could really shed
this image and gain the confidence and trust of the American pubhc and the
Congress?
7.
Single-payer supporters claim they are supporting a simpler and less
bureaucratic system, but most doctors and hospitals, and many consumers,
say our current Government programs, Medicare and Medicaid, are
bureaucratic nightmares. How do you respond to the criticism that a
Government run single-payer plan would combine the "compassion of the IRS
with the efficiency of the Post Office?"
DRAFT
�..-/
HEALTH CARE REFORM UPDATE
1. There is a health care crisis in America and the American people know it They feel it
Last year, 58 million Americans were without health insurance for some period of
time. These people were left unprotected against the threat of illness. Up to 30% of
people report they are afraid to leave their current job for fear of losing health
insurance. (Journal of the American Medical Association, 1/5/94; 1993 Economic
Report to the President, Council of Economic Advisers)
•
The meaning of the word "insurance" has been lost. Most Americans do have
insurance right now, but three out of four (76%) of those insurance policies have
"lifetime limits" ~ cutting off your benefits when you get really sick. And an
estimated 81 million Americans under age 65 have medical problems for which
insurance companies charge higher premiums, exclude coverage, or deny coverage
altogether. (Bureau of Labor Statistics; Foster Higgins 1991 survey; Citizens Fund)
•
A Newsweek poll released this week indicates that the American people recognize the
seriousness of the problem. Nearly eight in ten Americans, 79 percent, agree with the
President that there is a health care crisis in the United States. (Newsweek, 2/14/94)
2. The Congressional Budget Office confirms that the financing of the President's proposal
will guarantee private insurance to eveiy American and bring down the deficit in the long-run.
Sen. Geoige Mitchell (D-ME):
"Am I correct in my understanding that your report supports the President's conclusions as to
those principal objectives . . . So that all Americans would be insured, the deficit would be
going down, health care spending as a percentage of the Gross Domestic Product would be
going down, and the wages of American workers would be increased by up to or close to $90
billion a year. Is that correct?"
Mr. Robert Reischauer (CBO Director) : "That is the judgment that we reached."
[CBO Testimony, Senate Finance Committee, 2/9/94]
The President's approach will guarantee eveiy American health insurance and control costs.
-
-
"The CBO credited the administration with coming up with a framework that
appears to reconcile what many had considered irreconcilable: extending health
care to all Americans while at the same time slowing the growth of medical
costs, which threaten to consumer 20 percent of the nation's economic output
by the end of the decade." [Pearlstein and Broder, Washington Post. 2/9/94]
"[The CBO analysis] is a significant acknowledgment that health reform can do what
is necessary; that is, provide health coverage for all Americans while containing
sky-rocketing health-care costs." [USA Today. 2/9/94]
�American families will benefit from the President's approach.
~
"The Clinton plan, when compared to today's system, would cost average
Americans less money, give them more health benefits and more choice of
physicians and medical care, [Reischauer] said. " [Priest and Rich, Washington
PosL 2/9/94]
The President's approach will lead to deficit reduction.
— "[CBO Chairman Reischauer said] significant deficit reduction will be achieved by
2004." [UPI, 2/9/94]
American workers will get higher wages from the President's approach.
— ". . . the lion's share of those savings would be relumed to workers in the form of
higher cash wages. . . " [CBO. 2/9/94, p. 35]
— "First, the proposal would increase the cash wages of U.S. workers ..." ["An
Analysis of the Administration's Health Proposal", CBO. 2/9/94, p. 51]
National health expenditures will be "significantly"reducedunder the President's approach.
~
"Thus, CBO projects that national health expenditures would fall $30 billion below
the current CBO baseline by calendar year 2000, and would be $150 billion (7
percent) below that baseline in 2004." ["An Analysis of the Administration's
Health Proposal", CBO. 2/9/94, p. xii]
~
"Once the administration's proposal was fully implemented it would significantly
reduce the projected growth of national health expenditures." [CBO. 2/9/94, p.
26]
Businesses large and small will save substantially under the President's approach.
— "[The President's proposal] would sharply reduce the growth of employer spending
for health insurance. By 2004, employers would save about $90 billion for
active workers and more than $15 billion for early retirees... " ["Analysis of the
Administration's Health Proposed", CBO. 2/9/94]
-- "[The proposal] would benefit smaller firms that typically pay much higher
premiums than larger firms. This leveling of costs could benefit all small
businesses — not just those that provide insurance today. " ["An Analysis of the
Administration's Health Proposal", CBO. 2/9/94, p. 54]
This CBO report echoes what was already confirmed by the independent health
policy consulting firm Lewin-VHI in December.
�\
\
CBO REFUTES ATTACKS ON HEALTH REFORM:
WHAT DO OPPONENTS
HAVE LEFT TO SAY?
Representative Dick Armey has hailed the CBO report as " . . . a victory for
good government and honest bookkeeping." [AP, 2/9/94] We agree. For over a
year now -- as the President has prepared and introduced the most
comprehensive health reform proposal in American history -- the American
people have been subject to a litany of charges from guardians of the status
quo. I n an attempt protect their own vested interests, these opponents of
reform have terrified hardworking Americans -- claiming that the President's
approach will hurt families, reduce choices, destroy jobs, raise federal
deficits, drive up spending, bankrupt businesses, ruin small entrepreneurs,
etc., etc., etc.
But now the experts have spoken. The Congressional Budget Office's
analysis strips away their smoke screen, directly refuting each of their
charges -- one by one.
CBO ANAL YSIS VALIDATES P R E S I D E N T ' S A P P R O A C H . . .
•
About American families. Senator Phil Gramm (R-TX)
claimed:
"Under Clinton's plan, [my constituents] will end up paying more and
getting less. " [USA Today. 9/7/93]
B u t CBO said that: "The Clinton plan . . . would cost average
Americans less money, give them more health benefits and more choice
of physicians and medical care . ." [Priest and Rich, Washington Post. 2/9/94]
About choice. Senator Robert Dole (R-KS) claimed: "More cost.
Less choice . . . That's what the President's government-run plan is
likely to give you. " [USA Today. 1/26/94]
B u t CBO said that: The President plan "willprovide insurance
coverage for all Americans, raise wages for employees, offer a greater
choice of doctors . . . " [USA Today. 2/10/94]
About job loss. Representative
Dick Armey (R-TX)
claimed:
"We're likely to lose 3.1 million jobs under this plan. Tlie plan is really
a Dr. Kevorkian prescription for the jobs of the Americans working men
and women. " [New York Times, 9/28/93]
�CBO R E F U T E S A T T A C K S ON P R E S I D E N T ' S PROPOSAL
Page 2
B u t CBO said that: "The Clinton plan . . . would not significantly
slow the economy or result in the loss of jobs, as many critics have
charged." [Pearlstein and Broder, Washington Post. 2/9/94
About the federal deficit. Representative Dick Armey (R-TX)
claimed: ". . . massive increases in the federal d e f i c i t . . . " ILos Angeles
Times, 1/22/94]
B u t CBO said t h a t : "[CBO Chairman Reischauer said[ significant
deficit reduction will be achieved by 2004." [UPI, 2/9/94]
About worker's wages. Senator Bob Dole (R-KS): claimed: "... the
employer is going to have to take it out of future wage increases of the
employee, so it's really going to be the low-income employee who's going
to suffer. . . " [Face the Nation. 9/22/93]
B u t CBO said that: "First, the proposal would increase the cash
wages of U.S. workers . . . " ["An Analysis of the Administration's Health
Proposal", CBO. 2/9/94, p. 51]
About h e a l t h care spending, the House Republican Conference
claimed: "It won't shave a penny from skyrocketing health care costs."
["White Paper: An Analysis of the Clinton Approach to Health Care," 8/25/93]
B u t CBO said that: "Once the administration's proposal was fully
implemented, it would significantly reduce the projected growth of
national health expenditures." [CBO, 2/9/94, p. 26]
About effects on business. Jack Kemp claimed: "If you go out there
with this employer mandate . . . you go out there and put many people
out of business. " [BNA Pensions & Benefits Daily, 8/18/93]
B u t CBO said t h a t : "[The President's proposal] would sharply reduce
the growth of employer spending for health insurance. By 2004,
employers would save about $90 billion for active workers and more
than $15 billion for early retirees... " ["Analysis of the Administration's Health
Proposal", CBO. 2/9/94]
�CBO REFUTES ATTACKS ON PRESIDENT'S PROPOSAL
Page 3
•
About small business. Representative Dick Armey (R-TX)
claimed: "Small employers can't afford [employer mandates]. How
have you served employees and the small mom and pop entrepreneur
when you've driven them out of business?" {Wall Street Journal, 9/5/93]
But CBO said that: "[The proposal] would benefit smaller firms that
typically pay much higher premiums than larger firms. This leveling of
costs could benefit all small businesses - not just those that provide
i n s u r a n c e today. " ["An Analysis of the Administration's Health Proposal", CBO,
2/9/94, p. 54]
SO WHAT'S LEFT?
•
Now that the Congressional Budget Office has stripped away all of the
accusations that the opponents of reform have been throwing in the
path of the President's proposal, what do these people have left to say?
Senator Robert Dole (R-KS): 'The President's idea is to put a
mountain of bureaucrats between you and your doctor." [Wall
Street Journal. 1/26/94: New York Times. 2/1/94]
-
Senator Phil Gramm (R-TX): ". . . good old-fashioned socialized
medicine with the government running the health system . . . "
[Reuters. 10/13/93]
Representative
Newt Gingrich (R-GA): "... it has got to be the
most destructively big government plan ever proposed . . . " ["Meet the
Press", in Washington Times, 10/4/93]
SOUND FAMILIAR?
•
If these arguments sound familiar, it is because they are the same,
exaggerated, emotional "big brother" arguments that have been used
time and time again to defeat health reform proposals.
1949
Do You Want the Government to Come Between You and
Your Doctor?" -- Full-page ad picturing a doctor sitting at the
bedside of an obviously sick child, looking very concerned sponsored by opponents of President Truman's health reform
proposal. [Campion, Frank D. The AMA and U.S. Health Policy Since 1940,
Chicago, IL]
"Who is for Compulsory Insurance?" opponents asked and
answered, "All Who Seriously Believe in a Socialist State."
[Campion]
�CBO REFUTES ATTACKS ON PRESIDENT'S PROPOSAL
Page 4
1961
Opposition to President Kennedy's Medicare proposal: "We fight
because the administration's medical care proposal, if enacted
would certainly represent the first major, irreversible step
toward the complete socialization of medical care. "
[Campion, p. 256]
1965
Representative Hall (R-MO) on the Medicare proposal:
"Consequently, we cannot stand idly by now, as the Nation is
urged to embark on an ill-conceived adventure in
Government medicine, the end of which no one can see and
from which the patient is certain to be the ultimate sufferer."
[Congressional Record, House, 4/8/65]
Senator Cunningham (R-NE) on the Medicare Proposal:
"This legislation could eventually lead us to socialized
medicine. Make no mistake about that. It takes no more than a
quick glance at a history book, and a little common sense, to come
to this conclusion. " [Congressional Record, Senate, 3/3/65]
NOT THIS TIME!
•
As the old saying goes, "Fool me once, shame on you. Fool me twice,
shame on me." These people have been allowed to fool the American
people for too long. We too should "make no mistake about it." It
takes "no more than a quick glance at a history book and a httle
common sense." We've seen the pattern. It won't happen again.
�A 'Whipping Boy' Shines in California
Amid criticism of health care alliances, one purchasing group has lots of happy clients
In the debate over health care
reform, health care "alliances," or
group purchasing pools, have become
one of the favorite whipping boys in
Washington. Under President Clinton's health care reform plan, a
health care alliance would be a government-established regional agency; as a patient-doctor go-between it
would negotiate for the best prices for
medical services.
These alliances, a key part of the
Clinton plan, have been denounced as
the vehicles by which government
would dictate how often a patient saw
a physician and which physician the
patient saw. Such alliances, opponents maintain, would prove to be
prototypes of government bureaucracy run amok.
However, it doesn't have to be that
way, and it's not that way for 40,000
workers who are members of the
nation's first working alliance. It's
called the Health Insurance Plan of
California, and Times staff writer
Robert A. Rosenblatt has found the
little-known program to have a lot of
happy customers.
There are key differences between
the HIPC alliance and what Clinton
proposes: The HIPC is voluntary and
privately run. Thus the m^or objections to Clinton's version of health
alliances are removed. And while the
HIPC doesn't have the political baggage of the Clinton alliances, it still
retains the msgor advantage: Through
it, consumers can negotiate better
prices by virtue of having banding
together in a large purchasing group.
Here's how it works. In Los Angeles County, a worker whose company
has joined the HIPC can choose
among 15 health insurance plans,
including health maintenance organizations. Monthly fees vary, with the
company paying at least half of the
cost of the lowest-priced plan. The
worker pays the rest Rates are 10%
to 15% lower than many comparable
conventional plans. In one dramatic
example, an instrument repair firm in
Van Nuys was quoted a premium of
$2,500 a month for seven workers;
last summer it joined the HIPC and
now pays only $780 a month.
Ironically, it was in part the fear
that the government would mandate
health care alliances that gave impetus to the creation of voluntary
programs. In Florida, where a voluntary alliance will start in May, Gov. ;
Lawton Chiles admitted that the
President's plan was a tremendous '
incentive to get moving.
The President's plan, which by
Clinton's own admission has virtually
no chance of remaining intact as it |
moves through the legislative process, indeed needs revision. But the
important lesson offered by the impressive California experience so far
is that labels alone mean nothing.
Health care alliances, or purchasing
pools, are not inherently evil. As a
matter of fact, when set up properly
they can work quite well.
�£o0 Atiaetee ®tme0
SUNDAY, APRIL 3,1994
COPYRIGHT I f W / T H E TIMES MIRROR OOMPANV/CCT/JT3 FACES
Key Facets of Clinton's
Health Plan Still Intact
• Medicine: Despite dire assessments, the White House
sees developments so far as reasons to remain optimistic.
Although Administration officials
are loath to discuss areas of
TIMES STAFF WRITER
compromise publicly, they privately refer to such potential comproWASHINGTON-Weeks after
mises as "transitional" instead of
independent-minded members of
Congress began crafting their own - "structural"—a telling distinction
health care reform plans, the key: underscoring that Clinton remains
committed to the goal of universal
structural elements of President
coverage even if his proposed
Clinton's agenda remain very
much alive—confounding critics means are modified.
who months ago pronounced them
That view was validated recentdead on arrival.
ly as two House panels developed
With growing confidence, the
Please see HEALTH, A13
White House is counting on mandatory, work-based health insurance, cost controls and the creation
of insurance-purchasing alliances
to become the foundations of a
revamped health care system.
"As people try to pull "our plan
apart, they'll see that you can't
achieve the goals that so many of
us agree on—lifetime universal
coverage with comprehensive benefits—without doing what the
President has proposed," one presidential adviser said.
The White House is leaving
plenty of room for compromise. But
rather than jettison any of the
By EDWIN CHEN
NEWS ANALYSIS
major elements, it is becoming
clear that the President is willing
to let Congress scale back, stretch
out and even drastically alter the
employer mandate, the cap on
insurance premiums and the na. lure of the alliances.
There is also a distinct possibility
that Clinton ultimately will agree
to delay universal coverage , beyond his stated goal of 1998 and to
defer certain elements of a standard benefits package, especially
coverage for mental health and
long-term care.
�HEALTH: Key Elements of Clinton's Plan Are Still Focus of Debate
COBHBUMI from A l
their own proposals and both
ibiiuined the major principles in
Clinton's plan.
"The legislative process, of
course, is never entirely predictable, and that is all the more true in
thp attempted restructuring of
on^-seventh of the U.S. economy.
A» the President noted during a
March 24 press conference: "There
wUl be lots of twists and turns in
Jhe legislative process. . .
' i . And with the bulk of the work
VUU ahead, there is plenty of time
tar Clinton's plan to come unglued.
"^appreciate their desperation for
hanging on. Otherwise, their plan
truly, falls apart," said critic Gail
Wilensky, a top health care adviser
in the George Bush Administration.
tiU. for all the pronouncements
by Republicans and even some
Democrats that Clinton's plan is
dead, the key elements of his
1.342-page Health Security Act
continue to dominate the public
diafcgue and set the congressional
agenda.
Moreover, many of the President's other proposals—a cigarette
tax Juke, administrative streamlining, abolition of discriminatory insurance practices, prescription
drug coverage—are so widely embraced that they are barely even
debated.
The centerpiece of Clinton's
overhaul agenda calls for employers to pay at least 80% of workers'
premiums, with employees paying
thft'rest. No big firm would have to
pay more than 7.9% of its payroll.
Sm^ll companies with low-wage
earners would receive subsidies
while having their premium payments capped at 3.5% of payroll.
The President's plan would also
force companies with fewer than
5,000 workers to Join the regional
insurance-buying alliances, which
pool consumers to enhance their
purchasing power. The alliances
would select from provider groups
a variety of insurance plans from
which consumers could choose annually.
To ensure that his experiment
with "managed competition" slows
the' rale of growth in heallh care
speeding. Clinton would limit the
ambnnt that insurance premiums
may grow. This may prove to be
the most intractable element in
Clinton's agenda, for many members of Congress appear to be
S
unalterably opposed to any price
controls—just as the White House
devoutly believes that controls are
essential.
"That's a tough one." one senior
Administration analyst said. "You
need to control costs, or else providing universal coverage would
be unaffordable. And we are unwilling to stake things on market
forces."
Still, there may be room for
compromise—perhaps by setting
"targets" rather than absolute
caps.
On the employer mandate, there
seems to be more leeway for compromise.
To lessen the burden to businesses, the President may well
agree to reduce the employer requirement to, say, 70% of premiums instead of 80%—and perhaps
even delay its implementation, especially as applied to small businesses.
But the lower the share paid by
the employer, the greater the
number of individuals who will
need federal subsidies, warned
Paul Starr, a Princeton University
analyst who helped the Administration develop its proposals last
year.
espite considerable business
resistance to the mandate.
Administration officials insist that
no other politically feasible alternatives exist.
"While no one likes the idea of
added employer responsibility, no
one can come up with a better way
of achieving the goal of universal
coverage," House Ways and Means
Committee Chairman Dan Rostenkowski (D-Ill.) said recently.
"People have got to understand
the trade-offs, and that's just beginning to happen," said John
Rother, director of legislation, research and policy for the American
Assn. of Retired Persons. "If you're
not going to have the employer
mandate, then taxes have to be a
lot higher."
Clinton chose the mandate because it builds on the current
system, in which most Americans
get their insurance through the
workplace. Moreover, an employer
mandate would cover 80% of the
38 million uninsured who are already jobholders or dependents of
jobholders.
On the health care alliances, the
President has all but declared his
D
willingness to allow them to become voluntary rather lhan mandatory cooperatives and lo invest
in ihem far fewer regulatory functions—which "can probably be
done some other place," as he told
California Medical Assn. leaders
during a satellite teleconference
last month. Clinton also may agree
to allow for competing alliances in
the same regions.
" I think it'll all be debated in
Congress and I'm certainly flexible
on it," the President said, implying,
nevertheless, that some alliance
structure may be needed.
"Without alliances, there's not a
sufficient pooling mechanism to
group people into large risk pools,"
Rother said. "These things are not
Ihere just to look good. They are
actually there to solve problems."
Given ihe President's bottomline goal of universal coverage, the
broad rationale of his complex
proposal is beginning to dawn on
members of Congress.
After divisive wrangling, the
House Ways and Means health
subcommittee produced a bill that
contains an employer mandate and
tough cost controls.
The bill would require all em-
ployers with more than 100 workers to provide insurance by Jan. 1,
1996. Firms with fewer lhan 100
employees would get a two-year
grace period. The bill would also
impose federal cost controls on the
fees of private doctors, hospitals
and insurance companies. And it
conuins a $1.25-per-pack increase
in the federal cigarette lax, 50
cents more than Clinton's proposal.
A
separate proposal, crafted by
House Energy and Commerce
Chairman John D. Dingell (DMich.), also would retain the employer mandate. It too eases the
burden on small business by exempting firms with 10 or fewer
workers. The plan also would scale
back the minimum benefits package and make participation in alliances voluntary.
"The plan's not bad, is it? Things
are really getting Interesting," a
top Clinton adviser said.
An Administration health analyst said: " I wouldn't say it's 80%
of the President's plan, but ifs
close."
Meanwhile, some moderate
Democrats on the Ways and Means
Committee are circulating a pro-
posal that would give firms with
fewer than 100 employees a chance
lo phase in Ihe employer mandate
over four years, starting with a
50% contribution and reaching
80% only by the fourth year.
Such transitional compromises
may well win the support of smallbusiness owners, as several of
them said In testimony before the
Senate Finance Commiltee last
month.
With such encouraging words
from ihe most implacable opponents of Clinton's agenda to date,
no wonder CUnton and his heallh
care leam are so upbeat. That
became apparent on a recent
spring afternoon as the President.
First Lady Hillary Rodham Clinton, Vice President Al Gore and his
wife. Tipper, spoke at a health care
pep rally on the White House
South Lawn.
Clinton clapped his hands in
delight when Sister Bernice Coreil,
a SL Louis hospital administrator,
told him not to be discouraged by
exaggerated reports of his plan's
demise.
"D.E.A.D.." she said, "sunds for
'Don't Expect A Defeat' "
�aca
Commentary/by Aaron Bernstein
WHY UNIVERSAL HEALTH COVERAGE IS SMART MEDICINE
I
n early February, United Airlines
Inc. decided to stop providing medical insurance for new hires. By
mid-March, the carrier had added 450
reservations agents and other nonunion
employees who agreed to forgo coverage. United isn't alone. In recent years,
thousands of employers have cut out
coverage for new workers or yanked it
from current ones. Many startups,
meanwhile, simply don't offer a plan at
all. As a result, millions of families are
now uninsured—unless their breadwinners are blind, disabled, or on welfare, and thus qualify for Medicaid,
the government program that provides
health care for the indigent.
The retreat of employers from health
insurance spotlights a central issue in
the health-care debate: Should every
citizen have medical insurance, as President Clinton insists? Or is this admirable goal simply too expensive? The
answer: Universal coverage is essential—and not just because it's the right
thing to do. It also is virtually impossible to achieve the other primary goal
of reform—cost control—without bringing everyone into the system.
COIPORATI CASTorrs. "We don't let
people bleed on the street. So we're
paying for the uninsured anyway," says
William S. Custer, the research director at the Employee Benefit Research
Institute (EBRI), a nonprofit Washington
group that doesn't endorse a particular
health-care bill. "Also, as employers
ivilm-e thi.' number of people in the
risk pool, the pool gets riskier, und
premiums go up for everyone still paying for insurance."
The problem is evident in the figures on employer coverage. Companies and other employers provided primary health insurance for 55.6% of
Americans in 1992, the latest year
available, down from 59.7% in 1988,
according to EBRI'S tabulations of Census Bureau statistics (chart). That represents more than 10 million workers
and dependents who either lost coverage or didn't get it when they started a new job. The actual figure is even
higher, because EBRI includes some 3.6
million workers who get coverage
through their employers but must pay
the entire cost themselves.
Taxpayers and those who remain insured pick up the tab for these corpo-
Tenn.I, wouldn't have much impact on
rate castoffs. Some oi the uninsured
its cost either. "There's a strong reason
have sought refuge in Medicaid, where
to move to universal coverage: to get
the number of recipients soared 40%
rid of the cross-subsidies and other inbetween 1988 and 1992, to 20.5 million
efficiencies," says C. Eugene Steuerle. a
people, according to EBRI. Part of the
health expert at the Urban Institute, a
increase occurred because Congress
Washington think tank that hasn't eneased Medicaid's eligibility rules. But
dorsed any health-care bill.
some of those left stranded by companies—such as part-timers making low
So far. Congress isn't rushing to
wages—joined up as well, experts say.
embrace coverage for everyone. Only
Add in continuing medical inflation,
two of the reform initiatives swirling
and taxpayers' bill for Medicaid has
around the Capitol insist on universal
jumped 159% since 1988, to $140 billion
coverage: Clinton's and one from Replast year.
resentative Jim McDermott (D-Wash.)
Most of the other
HEALTH-CARE CRUNCH
that calls for a Canapeople abandoned by
dian-style system.
employers have no
AS EMPLOYER-PROVIDED
HOIY MIKL Most othcoverage at all. The
so — COVERAGE SHRINKS...
er reformers object
ranks of uninsured
to the projected exhave risen by 15%
7
pense for insuring 39
since 1988, to 38.8
million extra people:
million, according to
It ranges from $25
EBRI. But as Custer
billion to $60 billion
says, taxpayers foot
a year, depending on
the bill for them, too.
assumptions about
Experts aren't sure
how many health-care
how much health care
dollars the uninsured
the uninsured get
already use. That
from public health
translates into about
clinics, city ambu$260 to $625 a year
lances, and hospital
per household. Clinemergency
rooms.
...THE UNINSURED
ton expects most of
Rut the estimates
ARE INCREASING...
this to be offset by
range from about half
the slowdown in medto two-thirds of what
ical cost hikes his
the insured get. The
plan envisions. But
funds for such sermost polls show that
vices either come
...AND SO ARE
taxpayers may be
from public colters or
MEDICAID RECIPIENTS
willing to pony up
are rolled into healtheven if that doesn't
care providers' prices
happen. For instance,
for everyone else.
a 1993 EBRI poll found
Given the highly
that 76% of Ameri'88
'89
'90
'91
97
inefficient nature of
A HIIIIOM of mm
;
cans want Washingemergency care, unton to provide health
checked growth in
the numbers of uninsured could negate
insurance to everyone, even if it means
the various cost-control ideas being
a tax hike. On average, respondents
considered in Washington. Preventive
said they would pay $169 a year more
care, which usually is cheaper than
in taxes.
waiting for an emergency, is virtually
It makes no sense, in short, to leave
nonexistent for these people. Also,
the uninsured out of the equation. If
most of the managed-care cost-control
that happens, any reform plan will face
measures employers are applying to
a never-ending battle to rein in the
the insured don't work in hospital
runaway costs created as employers
emergency rooms. And since the poor
abandon health insurance.
aren't paying for their care, the market
competition envisioned by reformers,
Bernstein is BUSINESS WEEK'S Worksuch as Representative Jim Cooper (Dplace editor.
BUSINESS WEEK/MARCH 28, 1994 171
�C A IM T A L
GAINS
Health Reform: The Missing Story
Critics in fright wigs mislead you about the Clinton plan
BY
JANE
BRYANT
Q U I N N
you anv doctor you want. In 1988. S9 percent of the employees in
health care, where would you start'' You'd sprok the public company plans could choose fee-for-service. KPMG Peat MarI with ghost stories, hoping to scare them away from retorm. wick reports (its survey covered medium-size tirms and up). By
1092. that number had shrunk to 65 percent. Left to itself, the
That's what's happening now, as rumormoniiers in tright
I wigs sponsor TV ads and make the rounds of the op-ed market will eventually hmit you to staff doctors at a healthpages. If they get enough voters to back awav. health-care re- majntenanee organization (HMO) or the network of doctors in
form—if it passes at all —will reflect the interests of the medical- a preferred-provider organization (PPO)
industrial complex, not yours. Doctors and health and insurance
Ironically, the Clinton plan — which critics claim will wipe out
execs, along with their political-action committees (PACs). in- doctor choice —might actually preserve it beyond its likely freevested S8.3 million in Congress during the tirst 10 months of market life span, says John Holahan of the Urban Institute. Your
1993, up 22 percent from 1991. reports Citizen Action, a Wash- choices, Clinton says, must include at least one fee-for-service
ington consumer group. The drumbeat of disinformation has plan, giving you access to almost any doctor with such a practice,
been pounding away on four major issues:
and one HMO with a "point of service" option.
1. Who's uninsured? The shoulder-shruygers say that those
Point-of-service HMO plans are proliferating. Those who
without coverage are mainly young workers who could buy choose them will normally see the docs at their HMO. But they
health insurance but don't, or people between jobs who will can also visit an outside doctor. This privilege is expensive.
come under another plan soon. Even if that truly
Today, you might pay an extra 20 percent premium,
described the problem (and it doesn't), I don't see
plus an annual $300 deductible, plus 30 percent of
why their lack of coverage is OK. The uninsured see
each outside doctor's remaining bill, with a cap of
doctors less often than the rest of us. are more apt to
$3,000 on your spending. But for the well-to-do, the
need hospitalization for illnesses that could have
choice makes HMOs more appealing. If they doubt
been treated at home, go to the hospital in worse
a diagnosis, they can get another opinion.
shape and die there more often. The cost of their
At present, most employers don't offer both of
treatment comes partly from taxes and partly from
these doctor-choice plans. And none of the Conhigher charges to everyone else.
gress's managed-care bills requires companies to
have them. So although the president draws the fire,
The uninsured are counted by the Census Buhis bill should open more doors than it closes. What
In a year,
reau's annual population survey, which numbered
the docs don't like is that Clinton would restrict their
them last March at 37.4 million. That's up from
one in four
fees, while most of the other bills let them charge
2.6 million in 1988. with most of the losses fallw hatever they want.
ing on small-business workers and the self-emmay lose
ployed. But many more probably lacked coverage
3. Can you pick the best coverage for your family?
coverage. The Clinton would group most people into purchasing
during at least part of the year, reports Lewin-VHI,
a health-care research-and-consulting firm that
co-ops (alliances). Once a year you'd get a booklet
rest are a
develops data for government and business clients.
containing details on the plans in your region. MemThe total uninsured at some point during 1993 prob- pink slip away.
bers could choose the one they liked. Every plan
ably reached more than 51 million—almost one in
would cover the same things, so you'd pick based
four Americans under 65. The rest are only a pink slip away. on competitive factors like quality, convenience and price.
The Health Insurance Association of America (HIAA) has
Fewer than two out of 10 of the uninsured are young people 18
to 24. Most of the rest are working adults (plus their spouses and been sponsoring TV ads suggesting that the better plans won't be
children) who have no employee plan. Only 28 percent are on your alliance's list. But the only plans it could refuse are those
officially classified as poor. Nearly 60 percent earn low to middle costing 20 percent more than average (although there must be a
incomes; for a family of four, that means S14.300 to S57.300, fee-for-service plan, regardless ot price). So these ads mislead.
pretax. The cost of family coverage can easily run from S6.000 to There would, however, be many fewer health insurers, which
S11.000 a year. So even at the high end. insurance isn't an easy explains the HIAA's concern.
buy. Around 3 percent lack policies because of an illness insurers
4. Why not just cover the uninsured and leave everyone else
won't cover. Only 7 percent go bare by choice.
alone? It doesn't work. If Congress created subsidized pools for
More than half of the uninsured depend on small firms or are the uninsured, thousands of small businesses would drop their
self-employed. The voluntary health plan proposed by Rep. Jim own plans and toss their lower-income workers onto the public.
Cooper assumes that competition will cut health-insurance costs Other mini-reforms have drawbacks, too. Say, for example, that
by so much that employers will choose to help workers buy Congress left the insurers untouched except to require them to
policies. But according to a 1991 Harris poll, more than half of take all comers regardless of health. The insurers could still
small-business owners aren't likely to purchase coverage even if avoid many high risks by not hiring agents in low-income areas.
the price drops by 50 percent.
Clinton's plan can't pass as written; there are serious ques2. Can you pick your own doctor? Without health reform, the tions of cost and reach. But tinkering just preserves the status
answer is increasingly no. Cost-conscious health plans are rapid- quo. which is what the critics in fright wigs want.
Reporter T E M M A E H B E N F E L D
ly smothering fee-for-service medicine, where insurers allow
j F VOU WANTED TO FOIL THE CLINTON It-AN FOR CNIVCRSAL
I
58 N E W S W E E K
M A R C H 2 1 . 1994
�WCRACKSSHOW
IN THEO
- PPOSITION
TO HEALTH PLAN
THE
NEW YORK TIMES, MONDAY, MAY 23, 1994
SMALL BUTCRUCIALSHIFTS
Movement Is Seen on Issues
of Universal Coverage and
How to Control Costs
By ADAM CLYMER
Special io The Nev York Timet
WASHINGTON, May 22 - For the
first time since President Clinton proposed a national health insurance
plan in September, some of his opponents are giving ground.
Not necessarily a lot. "It's a very
narrow strip of ground," said Senator
Daniel R. Coats, the Indiana Republican who last Thursday suspended his
all-out opposition to anything resembling the Clinton proposal. He did so
just long enough to join a unanimous
Senate Labor Committee vote for a
cost-control plan that involved major
concessions by both sides.
And last week's shifts among Labor Committee Republicans and by
Senator John B. Breaux, the Louisiana Democrat on the Finance Committee who decided that he could support requiring most employers to pay
for their workers' insurance, hardly
opened a floodgate.
StiU, there was important movement on the most crucial issue, how
to pay (or any universal insurance
system. There was also a meeting of
minds on cost control, one of dozens
of complicated issues that Democrats
have committed themselves to clearing away over the next few weeks, a
necessity if Congress is to redesign
the nation's health care system this
year.
Labor Committee Republicans,
plainly uncomfortable in the role of
naysayers that their party's leaders
assigned, may make more deals this
week on subjects like the degree of
bureaucracy needed to supervise a
new health system. That would be
another measure of opposition flexibility, comparable to the on the costcontrol issue. Until last week, it was
only Mr. CUnton's allies who were
offering deals as they trolled for
votes.
Republicans wanted any benefits
program defined by an independent
board, not by Congress, which they
said wouid give away the store. Democrats said Congress had to level with
the public about just what medical
care would be covered in a new
system. So on Thursday they cut a
deal, wuh Congress establishing the
system and a board having a great
deal of power to cut it back if costs
soared.
Mr. Breaux's shift on employer
payments was less decisive. He is,
after all, one senator, not a political
faction. But he moved on health
care's toughest political issue, and his
seat on the Finance Committee gives
him influence.
Republicans have been louder, but
conservative Democrats have joined
in their antagonism to making employers pay. When Mr. Breaux said
he could support such a requirement
if it left employers of 10 or fewer
workers free not to insure, that was a
major break in the opposition ranks.
On the other side of the Capitol,
Representative Richard A. Gephardt
of Missouri, the majority leader, said
Cracks Show in Opposition
To the Health Care Overhaul
ConUnued From Page Al
Mr. Breaux's shift had altered the
political situation in the House. "It
means conservative Democrats can
start talking about ideas that embrace universal coverage," he said.
He also said there was a lot uf
House interest in the bill that the
Senate Labor Committee was considering, a modification of the CUnton
plan put forward by Senator Edward
M. Kennedy that would soften its impact on very small businesses and
enable any American to join the Federal Employees Health Benefits Plan
and thus be offered the same insurance choices that members of Congress here and Government file
clerks everywhere now have.
In the Senate, too, the movement by
Mr. Breaux suggested that Democrats could get the bill out of the
Finance Committee without Republican help if they have to. If they can
solidify their own 11 votes, that may
be the surest way to attract some
support from the 9 Republicans.
Today one of those Republicans,
Senator John H. Chafee of Rhode Island, predicted that the committee
and Congress would adopt a universal
insurance bill. He insisted on the NBC
News program "Meet the Press" that
universal coverage and the savings it
should generate, were unattainable
without requiring either individuals
or employers to buy insurance.
The public shifts'were not the only
important developments in Congress.
The Finance Committee, one member reported, decided not to wait until
the Congressional Budget Office
measures Mr. Chafee's bill, which
would require individuals to buy their
own insurance, before it starts voting.
And it decided that the voting would
begin in early June.
But even that decision was a reminder of a failure — the certain
failure of all committees except,
probably, Mr. Kennedy's to meet the
Memorial Day deadline they had announced, perhaps imprudently. That
failure underlined the critical importance of June, of the four weeks until
the real drop-dead deadline of the
July 4 vacation period. If the five
major committees have not finished
by then, sweeping change will be almost impossible this year.
A Year for Change?
And the Democrats seem convinced that this is the year for sweeping change, perhaps in part because
they expect to have fewer Democrats
around if they have to try again in
1995. They cite everything they can
think of in support of this timetable,
from the remembered words of Har-
ry S. Truman to, as Senator paui
Wellstone of Minnesota put it, "the
pricklings in my fingertips" that tell
him this is the time to move forward.
While the Democrats edged toward
common ground, the Republican position was less coherent. The Republicans sought to portray themselves as
taking a clear stand with some new,
television ads, curiously labeled "a
bipartisan message." But the issue
they chose, making insurance coverage portable from job to job, is both a
second-tier question and much more
complicated than their ad suggested.
Republicans on the Labor Committee alternated between cooperation
and invective, offering amendments
they sometimes seemed not to understand. One amendment, by Senator
Judd Gregg of New Hampshire, a
fierce opponent of requiring employers to pay for workers' insurance,
appeared to do exactly what he want-'
ed to prevent: It attempted to guarantee every American the right vo
keep the insurance he or she has now,
which would mean that employers
that now provide insurance would
have to continue to do so.
Weighing the Costs
And they offered cautionary arguments. Replying to Mr. Kennedy's
insistence that "the American people
expect us to act, and it is our responsibility to deliver," Senator David F.
Durenberger of Minnesota said, "The
cost of not doing it right is greater
than the cost of not doing it now."
Republicans also struggled to find
arguments to marginalize Mr. Kennedy, saying that the Finance Committee — where they are stronger —
was a better forum for action. But it
was no clearer in Finance than in
Labor or in the partisan bickering of
the House Ways and Means Committee what the Republicans wanted to
do; indeed, they seemed to be backing away from a bill sponsored by one
of their own, Mr. Chafee. The Republicans' unwillingness to coalesce
seemed to be uniting the Democrats.
This creaky, disorganized legislative process has a long way to go
before it succeeds or fails. June will
be pivotal, but only in making July
and August floor action possible.
Senator Harris Wofford, "the Pennsylvania Democrat who rode the
health care issue to an upset victory
in 1991 and has assumed a growing
role in the Labor Committee's search
for compromises, said, "No legislation of this magnitude could move
forward without tough and probing
debate." Comparing the effort to
reach agreement to a family reunion,
he said that while it isn't "the Waltons, it also isn't the Hatfields and
McCoys."
�Clinton's Health Plan: Not as Dead as It Looks
suppon for M i . Climon's approach. Km I ho
Prcsidcm's bill, for all the hours and 1 Q
points lhal went into it, has always been
more of .1 compass lhan a roadmap. and
mosl of all a prod lo uul sei ions aboul health
care.
Al Ihe v i i y Icasl, the sulx o mini I lee's ac
turn was a sale passage anions shoals And
heallh caiv is going lo need a lol of lhal kind
of navigalion l.asl week, lhe plan's suppoilers in lIK; Senalc heal back cffoi Is lo snalch
up Medicare and Medicaid savings earmarked by the Admiiiislralioii for heallh
care and diverl Ihem lo olher purposes
By ADAM CLYMER
WASHINGTON
P
4-
RESIDENT CLINTON'S health care
bill got nowhere in Congress last
week. But his cause of health insurance for all Americans made substantial progress. The difference lies in the
way Congress works, and underscores the
danger of treating the governmenl and the
President as one and the same!
If major health care legislation is passed,
ii w i l l be a long, slogging fight. It will take
compromises piled on compromises, and it
will take patience. That is the way, major
legislation gets enacted.
But much of Washington likes to keep
score, and prefers scoring the President to
rating anything else. When nobody on the
House Ways and Means Subcommittee on
Health would vote last week for his bill in the
f o r m that it was Introduced last fall, approving a more modest plan instead, Mr. Clinton
was said by the scorekeepers to have suffered an embarrassing setback- Similarly,
when Representative John D. Dingell of
Michigan floated a substitute proposal thai
had businesses paying less and consumers
paying more, and nobody required to join
those cdtnplicated insurance alliances, that
could have been read as another slight
But no one above the grade of junior White
House staffer ever thought the 1,342-page bill
would become law much the way it was
introduced. In fact both of Mr. Clinton's point
losses in the House ultimately make it more,
rather than less, likely lhat Congress will
ultimately pass legislation that promises private heaJth insurance . tp a l l Americans,
guarantees that the insurance cannot be canceled, curbsnhe mo$t flagrant practices of
the insurance industry, makes a serious eff o r t to restrain the sharply rising costs of
health care, and probably makes employers
pay a large share of the cost.
And thai, after all, is a pretty good description o^the Clinton bill, without its mechanics.
The mechanics matter, of course. A key
N3
Votes to Spare
The While Hoiue/Associalcd Prcbi
B i l l and H i l l a r y C l i n t o n i n a send-up of the H a r r y and Louise television commercials,
w h i c h oppose the C l i n t o n health plan, seen at the G r i d i r o n C l u b dinner last weekend.
purpose of those alliances that lawmakers
love to hate is to hold down insurance rates
and make sure everybody gets charged the
same. Scrap or weaken alliances and other
tools will be needed to reach those goals.
It is easy to exaggerate the significance of
the subcommittee's action. "The first big
,/iurdle has been overcome," said Representative Richard A. Gephardt of Missouri, the
House m a j o n t y leader Representative Dan
Rostenkowski of Illinois, chairman of the full
Ways and Means Committee, said, "We have
won an im|M)ilant bailie in a legislative war
lhal wil! -II- our focus for Ihe remainder of
this year "
To Republicans like Representative Bill
Thomas of California, the action was e^ially
momentous, he said ii proved ihere was no
Beyond lhal. Hie Demnerals showed ihey
could make deals, ciimprumise, and even
vole "aye'' while holding ilieir noses. 'Ihey
got b mil ol Ihe 7 Uemni iais on ihe subeoin
milll-e lo go along with Ihe allernalive No
Republicans voted wuh Ihem. If Kcpuhlicaii^
provide no voles in ihe full House i-nher, ih.ii
is just aboul exactly ihe level of parly support the Democrals musl have- lo pass a bill
That ralio would gel Ihem TH) Democralic
voles on Ihe floor, or Iwn lu spare.
The Dingell inilialive was even mure nn
porlanl lo the fighl for a heallh-caic plan. No
other player in (his coniesi has been ai il as
long as the chairman of Ihe House Energy
and Commerce Commiliee Prcsidenl Clinton came lo his commilmenl lo nalion.il
health insurance sometime during the 1992
campaign. Mr Dingell learned il al the family dinner lable in ihe 1940's from his father,
who introduced the first national health insurance bill in Congress in 1943.
Nothing means as much lo Mr. Dingell as
fulfilling his father's dream. And lo do lhal,
he has lo gel a bill oul of the closely divided
Commerce Commitlee. So when he showed a
few of his cards, offering ihe son of ( IMM essions he thought could bring unceiiain mem
bers along, il was nol a casual gesluic. He
was noi < laiming vielory, but the waverers
started leaning his way
Mr. Dingell s elfui ls are represent,il ive of
What seemed like a
bad week in the House
may have been a
rehearsal for an
ultimate victory.
^
sofneihmg else, mo He and Mr Rostenkow-. .
ski are ihe most effective committee chair-., ,
men in Ihe House. Ihey sometimes scrap.
Hul here ihey are togeihei, and, as M r . .
(iephardi said, "1 have never seen them a$
inlelleciually and eniulionally c o m m i t t e d . "
And Ihose House bulls are only two of thq',, .
very serious and very powerful lawmakers in,,.
Congress who see this as a chance to make ..
history those ranks also include, al a m m l ^
mum. Mr. Gcphardl and Speaker Thomas S.
I oley, and Seualors Edward M. Kennedy o^.,,
Massat huselis, (ieorge .1. Mitchell of Maine,
Darnel Palrick Moymhan of New York and, ,,
Bob Dole of Kansas, the Kepublican leader.,
Firepower like (hat counls for a lot.
l.asl week shed liitle light on ihe Senate,.,,',
where some bipai t isanslup will ultimately be
necessary. Mr. Moynihan would like to cut i ' . / i
deal wuh Mr. Dole and bring a lot of Republicans along. Olher Demoi p als ihink Ihey can. ..
sphl a few of Ihe moderaies off and get their,,!,
majority with or without Mr. IXile. Of course,
neither approach rnighi work. The Senata,,,
could fail lo agree on a bill.
And so could the House But as Ihe Repre- ,.
sentatives head home fur spring break, M r ,
Clinton's suppoi lei s are increasingly o p t i - .
mislic The I'resideni sounded lhat way, toaJ,'i,
when he said (hat Ihe House hill, while not as
good as his. was good enough lhat he would .•
sign il After all, lie lias been insisting f o r
monihs that he woui;l compromise on j u s f V
aboul any detail
A
:
0 l
�Panel's Vote Gives Health-Care Bill Momentu
But Deliberations Reveal Difficult Task Ahead
By HILARY STOLT
And DAVID ROGERS
Staff Repontrs of T m
W A I X STREET JOURNAL
WASHINGTON - The House Ways and
Means health subcommittee's narrow approval of a health-care bill Wednesday
injected critically needed momentum into
the movement to overhaul the U.S. medical
system.
But the panel's deliberations serve-as a
cold lesson in the political realities lawmakers face as they work on health care
legislation.
To get a bill through even the liberalleaning subcommittee, lawmakers had to
trim benefits proposed by President Clinton. They also had to push back their chairman's proposed effective date for requiring that all employers pay part of their
workers' heilth insurance. Even then, the
package nearly fell apart in a fractious
debate over financing.
Arduous Process
The panel's 6-5 vote was but one step in
a long and arduous process. But it seems
increasingly clear, judging from the subcommittee s deliberations and the closeddoor discussions of other congressional
panels, that Congress is moving toward a
less ambitious scheme than the president's
package. Specifically, it appears that:
• President Clinton's bottom line, health
insurance for all Americans, still appears
on track. But the guaranteed benefits
package almost certainly will be scaled
back. It's possible that more benefits could
be phased in over time.
• The large, mandatory health insurance purchasing cooperatives that Mr.
Clinton would require all employers with
fewer than 5.000 workers to join won t
survive. Instead, a system of voluntary
"health alliances" to help give small businesses clout in the health-care market is
likely to be adopted. States are likely to be
given the option of setting up a mandatory
alliance system if they wish, however.
• The Clinton "employer mandate" requiring all companies generally to pay 80%
of their workers' health insurance premiums will be rewritten to impose less
stringent requirements on small businesses than large companies. A possible
alternative is a hybrid system, in which
the employer mandate will apply to larger
companies while workers in smaller companies would have to acquire insurance on
their own, with help from the government.
• The idea of establishing some govemment-run option for unemployed and
lower-wage workers-the Ways and Means
subcommittee proposed a new arm of
Medicare-may be gaining support.
• To grapple with the gnawing issues of
cost, changes in the health system will
likely be phased in over a longer period
than President Clinton suggested. The
Ways and Means subcommittee's deliberations this week showed there is a strong
distaste in both parties for broad based four already look doubtful: Rep. Mike
taxes; the subcommittee's working major- Andrews of Texas opposed the Stark bill in
ity of six Democrats almost fell apart when the subcommittee vote; Rep. L.F. Payne, a
Rep. Sander Levin (D., Mich.) refused to Virginia Democrat, will have trouble with
vote for a new, 0.8% payroll tax to pay for its proposal to raise cigarette taxes $1.25
the bill. To keep their deliberations from a pack: Rep. Bill Brewster of Oklahoma
breaking down, the Democrats ultimately is a conservative, and Nebraska Rep.
agreed to a 17c payroll levy only for Peter Hoagland has big insurance compacompanies with more than 1,000 workers. nies in his district. Mr. Hoagland has
organized a group of undecided Democrats
Aiming for Price Stability
on the Ways and Means panel, which is
An issue sure to come up again and circulating a compromise proposal that
again is the idea of capping the tax bene- includes, among other things, voluntary
fits granted employer-paid health benefits. alliances and an 80% employer mandate
This concept is embraced by numerous with both a four-year phase-in period and
Republicans and conservative Democrats subsidies for small businesses.
because it aims to make consumers of
President Clinton, for one, said the
medical services more price-conscious,
Stark
subcommittee's bill would meet his
thereby helping to stabilize prices. It also
is attractive to some Democrats because it minimum requirements. "Certainly if it
could yield a lot of revenue to cover the were to be enacted by the U.S. Congress, I
would sign it because it meets the funda
uninsured.
Labor groups fiercely oppose the idea, mental criteria I laid out of covering all
and many liberal Democrats denounce it Americans with health care." he said in a
as a tax on working Americans. But even nationally televised press conference. But
some who have opposed it in the past say it Mr. Clinton said he doubted the bill would
should be revisited. Rep. Pete Stark (D., be as successful as his plan in controlling
Calif.), the chainnan of the Ways and medical costs.
For all of Rep. Stark's liberal creden
Means health subcommittee and the primary author of the bill that passed the tials, his bill is more conservative than a
panel this week, has discussed the idea of plan introduced by Ways and Means Com
phasing out the tax benefits at higher mittee Chairman Dan Rostenkowski (D .
income levels while keeping it for most Ul.) in 1991. The fact that the Chicago
Democrat is now saying the subcommittee
blue-collar and middle-class people.
be scaled back shows how he and
The White House was eager to fortify bill must
Democrats are trimming their sails
support for health-care overhaul and give other
lawmakers a sense of momentum before this year.
like a palm tree these days, swing
they return to their home districts this ing "I'm
back
and forth." said Mr. Rosteweekend for a two-week recess. President kowski, making
light of assorted state
Clinton. Vice President Al Gore and Hil- ments he has made
on the prospects for
lary Rodham Clinton all attended a Senate health-care legislation.
The Chicago Dem
Democratic luncheon on Capitol Hill yesterday, where Sen. Bob Kerrey (D., Neb.) Ii ocrat agreed that the subcommittee om
bluntly warned that administration's bill • draws on major portions of his own past
didn't have 35 votes in the Senate and told proposals. He seems driven by an almost
them they must begin to seek some com- territorial imperative to keep the White
House away while he works his panel. I
promise.
i
don't
want them commenting on everv
"I'm still optimistic but we have got to
start writing," said Mr. Kerrey later. "The thing." he said.
Meanwhile, in the House Energy and
time for generalized arguments is over."
Committee, Chairman John
Shortly after lawmakers return to Commerce
Dingell
(D..
Mich.)
and health subcommit
Washington in mid-April, the five principal
Chainnan Henry Waxman ID., Calif. >
committees with jurisdiction over health tee
have been working on a compromise that
legislation hope to begin drafting bills. would
retain an employer mandate, but
While President Clinton's 1,342-page pro- place less
of a burden on small firms.
posal has been serving as a framework for "We're getting
Mr. Dingell said
committee discussions, only two panels- yesterday of his closer."
efforts to get votes.
the Senate Labor and Human Resources
Mr. Dingell asserted that business inCommittee, headed by Sen. Edward Kennedy (D., Mass.), and the House Education terests find the compromise plan's proand Labor Committee, run by Rep. Wil- : posed 1% payroll tax on firms with more
liam Ford (D.. Mich.) - are likely to ap- than 1.000 workers "acceptable," given
prove a bill that bears strong resem- what is in the bill "as a whole." "We're
going to save them money by the reforms.
blance to the White House plan.
he said.
1
Doubtful Support
Counting oa Finance Panel
In the Senate. Finance Committee
In the full Ways and Means Committee,
Democrats have a 24-14 majority. With no Chainnan Daniel Patrick Moynihan has
Republican support likely, they can afford acknowledged that changes must be made
to lose only four of their members. And in the administration's package. But he
took heart from a 63-35 Senate vote yester
day killing a budget proposal that would
have prevented the use of proposed sav
ings in Medicare for the health-care initia
tive. "Good." said the New Yorker. We
have 63 votes for health reform."
Many observers are counting on the
THE WALL STREET JOURNAL FRIDAY, MARCH 25. 1994 Finance Committee, whose membership
includes the leaders of both parties and has
an 11-9 Democratic majority, to draft the
compromise that can ultimately clear Congress. In a speech yesterday. Sen. John
Chafee (R.. R.I.), a Finance Committee
member and the author of a leading Republican alternative bill, predicted: "In
April, the Senate Finance Committee-and
I believe we are the centrists - will be
getting together with the leadership and
drafting a bipartisan bill."
�Leader in House
Proposes Trims
On Health Plan
By ADAM CLYMER
Special 10 The New York Times
WASHINGTON, March 21 — A pow- Hillary, were urgently selling the his
The approximately 15 million workerful House committee chairman is plan today to thousands of retirees in ers in these small firms would have to
sun
hats
at
Deerfield
Beach,
Fla.
"Uncirculating a scaled-back alternative to
buy their own insurance, but would be
President Clinton's health care bill. It der our approach, you get more," Mr. I heavily subsidized by the Government,
would maintain his goal of health insur- Clinton told them. At the first event of a j Regardless of income, they would have
ance for all Americans while cutting weeklong White House health cam- I to pay no more than 3.9 percent of their
the bureaucracy to administer it, re- paign, Mr. Clinton also said that he now J income for coverage. Under the Clinton
had three Republican Senators who
ducing the cost to small business and had promised him their votes. Only proposal all employers would have to
promising not to increase the Federal senator James M. Jeffords of Vermont pay a minimum of 3.9 percent of payroll for workers' health insurance.
deficit.
has made his commitment public, and
The money to pay for those subsidies
The plan, being put forward by Rep- Vhite House aides would not say who
would come mainly from two changes
resentative John D. Dingell, the Michi- else Mr. Clinton was referring to.
in what individuals would pav for mediOn Capitol Hill, a subcommittee of cal care. While the Clinton "bill would
gan Democrat who heads the Energy
another
House
committee
voted
to
conand Commerce Committee, is the first
require them to pay 20 percent of the
significant movement by Mr. Clinton's trol pnvate health spending by setting cost of most services, up to an annual
supporters to trim the President's plan limits on payments to doctors and hos- limit of $1,500, the Dingell plan would
in the hope of getting enough votes to pitals in any state that exceeds spend- make that 25 percent, up to a limit of
ing goals to be set by the Federal $2,500.
pass it.
Government.
The bill would copy the Clinton measUnlike the Clinton plan, the draft
As the health subcommittee of the
would raise the cost to individuals to House Ways and Means Committee ure in guaranteeing the renewal of
make up for decreased revenue from plodded ahead in writing its version of health insurance, requiring that coverbusiness. In addition, it would maintain the bill, it also voted to limit awards for age be portable when a person changes
and prohibiting exclusions for preMr. Clinton's goals of making coverage "pam and suffering" in malpractice jobs
existing medical conditions.
cases
to
$350,000,
even
though
Republipermanent and cutting costs while doThe Dingell proposal would require
ing away with a main element of his cans wanted a lower amount.
states to set up insurance purchasing
plan: the notion of insurance-purchasalliances and offer various types of
Some Blanks Stay Blank
ing alliances that all employers but the
biggest would be required to join. But - In addition, the subcommittee autho- plans, including the traditional fee-forservice method. But no one would be
that proposal has seemed dead for rized the Federal Government to set required to buy insurance through allipriorities
for
the
training
of
doctors.
weeks anyway.
ances, although everyone except emThe proposal is labeled a "staff Washington could require 53 percent of ployers of 1,000 or more could do so. In
medical residents to be trained as in, draft," but there is no question that it is ternists, family practitioners, obstetri- the Clinton plan, all employers except
j Mr. Dingell's concept for getting a cians and gynecologists. Only 33 per- those of more than 5,000 workers are
j health care proposal out of his commit- cent of new doctors are now trained in required to use alliances.
tee, whose 44 members closely mirror such primary care specialties. The
the whole House in ideology and party subcommittee's work could be modibalance.
fied by the full Ways and Means ComThe White House had no comment on mittee.
The Dingell plan, which was passed
the substance of the plan, although
Lorrie McHugh, a spokeswoman, said, out in draft form to Commerce Com"We are glad that the committee is miltee members today, did not specifically mention another benefit that
moving forward."
would be provided by the Clinton plan,
White House officials said they had the Federal assumption of most health
been kept informed of the direction Mr. insurance costs for early retirees and
others from the age of 55 to 64 without
insurance. This idea has been widely
Continued From Page Al
criticized, especially by Senate Republicans, as a windfall for big manufacDingell was taking, and there was no turers, But Mr. Dingell has said that he
regards it as a major element in changindication that they objected.
- While Mr. Dingell was not available ing health care, as well as a benefit to
toukomment, one of his subcommittee the automobile industry, so in some
chairmen, Representative Philip R. form, it is likely to survive in his comSharp of Indiana, said he believed the mittee.
The draft concentrated on three macommittee, with 27 Democrats and 17
Republicans, would approve this plan jor sources of concern about the Clinor something close to it after the Eas- ton bill that Mr. Dingell had encounter recess, which ends on April 11. If all tered in his committee. They were its
Republicans vote against it, Mr. Din- requirement that small business, along
gell would need the votes of 23 of the 27 with other employers, pay most of the
Democrats to get it through the com- cost of workers health care, the concern that the revisions would end up
mittee.
increasing the budget deficit rather
The Toughest Test
than curbing it as Mr. Clinton hoped
In many ways, the committee pro- and the concern about the alliances
vides the toughest test health care that employers would have to join.
legislation will face in the House. Its
The Dingell plan would, allow the
member include not only solidly op- smallest employers, those with 10 or
posed Republicans, but also several fewer workers, to choose not to buy
Democrats who have been critical of workers' insurance, though it would
tlw Clinton plan, as well as two who require those with up to 5 workers to
h£ve proposed slimmer alternatives, make a "minimum employer contribuRepresentatives Jim Cooper of Ten- tion of 1 percent of payroll." Those with
nessee and J. Roy Rowland of Georgia, 6 to 10 workers would start at one
admired family doctor.
percent and eventually pay 2 percent.
Zlhe Dingell draft says generally that
tttt provisions not mentioned in its seven pages "are generally maintained."
TJjat suggests, but does not guarantee,
that he would preserve the Clinton
pfen's additional benefits for the eldTHE NEW YORK TIMES. TUESDAY. MARCH 22, 1994
eSJy, coverage for prescription drugs
ajfjl a start on coverage of long-term
care.
TThe President himself and his wife,
V
2
�\
THE BOSTON SUNDAY GLOBE » APRIL 17,1994
Health alliance plans
become focus of fears
Finl in an occasional series on the institution.
most controversial elements in the
Unpopular or not, alliances or
health care debate.
something very similar to them are
• so central to the Clinton health plan
By Peter G.GoeseBn
.
- and to many of the alternative pro-;
GLOBE STAFF
posals now making the Washington
WASHINGTON - You would be rounds - thaf. they may prove hard
;
hard-pressed to find anything that • to dispense with.
As Congress tries to fashion a
plays quite so thoroughly to America's fear of bureaucracy health care compromise this spring;
health alliances, the alliances are one Of a handful of is
THE as
purchasing cooperatives sues that will crop up at each stage
HEALTH through which President of debate. How lawmakers handle
CARE Clinton would like al- them could ultimately determine
DEBATE most everybody to buy whether more than two years of public clamor over health results in a
their medical coverage.
They don't even exist, and yet dramatic, perhaps drastic, overhaul
they already seem to be neck and of the nation's medical delivery sysneck with the Internal Revenue Ser- tem or only minor adjustment.
vice as the nation's most unpopular
HEALTH, Page 27
j
�Central to many plans, but still murky, they stir fears of bureaucracy
• JfeALTH
Conllnued from Page 1
job besides keeping insurers honest,
namely to continue the shift of medical costs from the indigent to the relatively affluent, which many thought
would end with health reform. .
According to a soon-to-be released study for the nonpartisan
Kaiser Family Foundation, the net
new cost of the shift to American
employers would total $33 billion in
1998 alone. In addition, the president's plan would lock in another $19
Yes
Yes
billion a year in charges that employers now bear because Medicaid
underpays health providers who
Voluntary.
Mandatory.
Businesses and
The plan would
raise their prices for paying customIndividuals could
require certain
ers to make up the difference.
choose
to
Joi
n
groups of
Administration officials defend
the purchasing
businesses and
the cross-subsidy and cost shift as
groups.
Individuals to
the only way to assure health coverjoin a purchasing
group.
age for all at uniformratesin an era
when most Americans seem unwillAbout 40% of
the same 40%
ing to raise taxes. But the arrangeAmorfcsns,
of Americans es
Including those In under Cooper
ment leaves the White House with
firms of under
would be
much less maneuvering room on alli100, Individuals,. eligible to Join.
ances than Is generally appreciated.
the unemployed,, Even those
and Medicaid • :-> . could buy a <
For example, if alliances are
dropped altogether - aa some Republians and Democrats advocate the administration would have to
come up with an extra $217 billion
between now and the end of the decade, according to the Kaiser study.
GLOSESTVFCHWr
If they are trimmed to the size of the
purchasing groups in proposals like
in Washington on need for such a
shift, at least In some cases. But that Chafee's, it would still need an extra
does not mean there is wide support $70 billion.
"If you can't spread the coat
for Clinton's version of alliances.
That's because, in putting togeth- across big alliances, somebody is goer their proposal, the president and ing to havetopay the bill," said Denhis planners substantially expanded nis Beatrice, the Kaiser vice presithe notion of a community rate to in- dent who supervised the study. That,
clude huge subsidies for the poor, or the president is going to have to
disabled and unemployed. In doing start cutting back some of his most
so, they assigned alliances a second ambitious goals for reform.
% Hearth alliance: v a ^ o i i s ^ n a theme- ^
We can't do proper reform without Jalliances. It's impossible," said
Sen; John D. Rockefeller 4th, a West ^SlIlarua^M purchasing grbupv^
Virginia Democrat and ardent supporter.
All they're going to do is add a
costly new level of bureaucracy and
red tape," argued Rep. Nancy L.
JohSson, a Connecticut Republican Mi • Would the plan
ancC adamant opponent. Congress |'j create alliances
Yes
woiCt approve them, she predicted.
fc3 or purchasing
A look at how alliances would j$! groups?
wor* Illustrates some of the compli- fe' • Would
Mandatory.
cated problems lawmakers must
membership be Ttie plan would
solw before they can pass legislarequire most
mandatory or
tion: And the nature of the public
businesses and
voluntary?
Individuals to Join
canD>algn for and against them sugalliances.
gests why the national health debate
gives so many Americans a headache; most of the arguments on both i
sides have almost nothing to do with
• Who would
About 80% of
the Issue.
belong?
Americans,
Including those In
"It's no wonder people are confirms of under
fused," said Henry Akron, a respect5,000 woitera, ,
ed health economist with the Brookunaffiliated
ings^ Institution. "The debate about
Individuals, the |
alliances has been all about symbol- .
Um) not about what they'd do."
One thing that everyone agrees
alliances would not do is provide
medical care directly. Instead, they
would act as middlemen between
consumers and providers, signing
people up for health coverage, collecting insurance premiumsfromin- "experience rates" that allowed
dividuals and companies, and issuing healthy, usually young, people who
repbrt cards on how doctors and hos- are unlikely to need coverage to pay
pitals are performing. Where the de- less, while demanding that older, ofbate begins to veer off course is over ten sicker, people pay more, or leave
why more middlemen are needed the group altogether.
and what side effects would come of
Almost everybody involved In the
adding them.
health debate agrees that the perUntil recently, the administra- verse result of experience rating is
tion Insisted that the principal pur- that the more you need insurance,
posfe of alliances was to give Ameri- the less likely you will be able to afcans the clout to drive a hard bar- ford it, at least without a public
gain with health providers. The only program like Medicare or Medicaid.
problem is that the bill it submitted Most favorreturningto some kind of
to Congress gave them almost no community-rated system. But that is
lee*ay to bargain. Except in rare in- easier said than done because of the
stances, alliances can't dicker over fantastic concentration of health care
pri£8.niey have almost nothing to spending on a few, sick people.
- sJly aWut services. They can't even
Statistics show that in any given
threaten to oust a provider in order year just 5 percent of the population,
to win a concession.
about 13 million people, account for
"If you can't bargain over wheth- fully half the nation's health care bill.
er somebody's In or out, there's not As a result, insurers have an enorexactly a lot you can bargain over," mous incentive to try to spot those
conceded White House health advis- people ahead of time and refuse to
cover them.
er Walter Zelman.
But if the administration's arguThey're like the queen of spades
ments for alliances have been less, in the card game of hearts," which
than crystal clear, opponents' argu- costs you points if you have it at the
ments against them have been end of the game, said Harvard
equally murky. Nearly all warn that health economist joseph P. New"fyhe proposed institutions would re- house. "Everybody devotes considsult in a vast new government bu- erable effort to trying to stick other
reaucracy. What most fail to note is players with them."
that most of their alternative proposThe administration plan and
als .would also require new bureauc- many of its competitors propose to
racies or the expansion of old ones.
stop the "sticking" process by order"Everybody's pregnant on this ing insurers to offer a standard
one," said Christine Ferguson, depu- package of benefits and charge at a
ty chief of staff for Republican Sen. community, rather than experience,
John H. Chafee of Rhode Island, rate.
who has advanced his own health
But few believe such rules alone
plan. "We can argue about more bu- would be enough because insurers
reaucracy versus less, or new bu- could still decide whom to offer the
reaucracy versus old. But we can't package to and whom to avoid, and
argue about bureaucracy versus no they could easily mask doing so. As
bureaucracy."
an example, Alain Enthoven, a StanSo what is the real purpose of ford economist who is credited with
alliances and what are the argu- many of the ideas at the center of
mehts for and against them? The an- the current debate, cited the case of
swer has to do with one of the cen- an insurer that located its enrolltral goals of the overhaul that has ment offices on the upperfloorsof a
largely been lost In the debate over walk-up building, a sure-flre means
specifics: the effort to reassemble of attracting only healthy people
what many people have come to view who can climb stairs.
as a Humpty Dumpty of a health in"The technology of making yoursurance system.
self unavailable is advancing rapidThe problem and proposed solu- ly," Enthoven said. So rapidly, in
tion require a little explanation.
fact, that administration policy mak
The basic idea of health insur- ers and many others think the job of
ance Is that a group of people pay distributing Insurance coverage can
into a common pot in return for the no longer be entrusted to Insurance
promise that each can draw on the companies, but must be shifted to a
money if sick As originally con- separate organization: the alliances.
ceived and operated In this country, In effect, they would take over from
everyone paid about the same so- the companies' marketing departrailed conununity rate.
ments.
But beginning in the 1970s and
Given the implicit criticism of
accelerating since, insurance com- free markets and private business,
panies changed the rules by offering there is surprisingly wide agreement
1
tt
0i
Z
J1
" ^•••- '^ -^-^
�xVIany Dop't Realize It's Clinton
Plan thev Like '
* Bykn^xY STOUT
stiff Rmfwr •/ Tw WiOJ. *nm* JOUHM.
YORK. Pt. - Jtbu BUMT Uoew't Ute
President CUnton s he*ltft-art plin. Ste
thlnJu It's too confuslnf. tod conpiex tM
Health-Care Satisfaction
probablv too expensive.
what aoout a plan uut wouid |uar*ntee a itaodard prlTit* bMtt bwflti
package to all Amertcani. try to promote
compention in the medical industry, include some government regulation to Keep
pnces under control and require all employers to buy health insurance (or their
workers with the promise ::' rrvernre'
subsidies to help the smallest compames
It sound! good.'' says Mrs. Bastur. i
43-year-old stcretary and mother of seven.
Employen may pick up a lot of the
burden, but if the employer can't afford it.
the government wtll subsidise. So you're
going to have the employer, the government and the insurance companies wont
ing together."
Actually, that plan (5 the Ointon plan
Mr. Clinton is losing the pattie to define
nis owhTiialtn-care Sill. In :r.e cacopr.or.
of negative television aas ana sniping oy
POLL
rr.tir<ifnjft art raising aouSts aoout trie
-Hprnnj^n fgttpr man tne nrfsident ana
ments. "If the White House had had access
to these people in York, what it would
HTITIarvRodhftm Clinton can exniain ;: Congress didn't pass a plan this year.
The White House snould find tmsrecognize
Do:is they have to be able to
satisfymg ana sooenng. savs Mr. Har.
pajo:
confusion, the outlook for
simplify their message, to say this is what
Satisfying oecause the basic ideas which
we re doing: A. B and C." he says. "Tbey
^InTT^Hflft^T til" IS 1"
in to be able to get out there and talk
AnewWall Street Journal/NBC News theyve drawn up are the nght ideas have
about it. day in and day out"
poll shows that public suppon for the view of many people, he says. Bu:
riintonhealth plan" is eroding Yetjht sobenng because they clearly have com-\
Everyone in the York group also agrees
mumcated very little to the public, ana
thatir.^
health-care refonn means coverafe
theS
ert Teeter and Democrat Peter H&n. that respect have ceded too much to (or
every Amencan. No one ia theroonis
J willing to accept a eorapromise of anything
showTDgraddni for the banc provisions interest groups."
To funher test pubhc sentiment in the <less. We've got to have universal health
in the president's plan ts satyr
qf ATti»nr«n< nnw ny health-care debate, the WaU Street Journal care, whether you make a milUoo bucks or
TrraiF
:
says Ma. ML
itimyT™*** ninrnn run, vp '*m ^ asked Mr. Han to convene a smaU group ofooching."
people in York, a medlum-olsed city in the In the Journal/NBC poU. 33% of Ameri—rrr^vQllg mil *r"" "'
alter the president outlined the plan in southern pan of Pennsylvania. Everyone cans rank universal coverage as the most
a televised address to Congress. in tne group - including a woman whose important goal of health-care refonn. the
Thirty-seven percent of those surveyed family lost tu health corenge when her highest for any of the suggested chotces.
favoHhe Clinton program, downfrom471 husband lost his job and a union member Lower medical rates and capping cosu
with a plan that "coven everything you placed second, with 18%.
n January and Si'^m September.
. —BuTwHr- rrnri a iHinrn^n nf rflr can imagine - believes the U.S. heaith
In contrast to the sentimenu of the
\ ' rraiofprovTsions of the White House bill- svstem is badly broken and needs to people in York, though, the poll found some
\: ^unniii i-ltnu mg v - ''^ T ^ P - be overhauled to guarantee health cover- wtUingneu to accept a bill that doan t
/ ^ firmuay » Mt tnm* "i i n v rt-il of age (or everyone.
guarantee corerafstareveryone. Ia tbe
r^pgeaFlJjEJJjBie-appeaL'' That is far
But no one expresses suppon for Mr. new pod. 43% of Americans say Mr. Ointon
-^^Setter than th* response to desalpuons of Clinton's sweeping proposal. In fact, no should refuse to sign a bUl that doesn't
four other congressional prapoutt:
one can explain it. "I think nobody in this guarantee universal coverage; 43% says be
oom realizes where Ointon s coming from shouldn t refuse.
A descnpoon of a plan by mode Islandrwith
plan, and it doesn t speak
When the people in York discuss their
Sen. John Chafee and other moderate clearly,his complains
Keith Beatty. wno own health care, tbey reflect the feeling
Republicans, which would require ail indi- runs a local youth-care
program.
among many Americans about the precanviduals to obtain health coverage and
Yet
when
the
group
is
read
a
descnn
provide financial assistance to low-income tion of the Clinton bill i without identifvtnc ousness of medical coverage in the U.S.
people, appeals to 4&t of tnose surveyed. A:t as th? president s plan) and of the four tooav Of the 12 people, seven have
aim by Democratic Rep. Jim Cooper o: otner leading proposals in Coneress. tne oeen without health insurance at some
time in the past five yean. Another. Linda
Tennessee that has oipartisan oacKing ana
plan is the lint choice of everyone Lutner Baumer. who worts pan-tune,
would require employers to offer - but notClinton
in the room. Refemng to (he unidentified worries that she'll lose her coverage when
pay for-coverage for their workers and Clinton
proposal. Mr. Beattv aeciares
"•r niisoand retires in the next year or two
seek to control prices tnrourn market Wun tne
plan you just presented, it
fcither 1 ve got to get a fuUtune job that
compeution gets a 34^ approval rating, A speaks clearly."
provides beneftu or - we don't know what
plan by conservative GOP Sen. Phil
Gramm of Texas mat would allow people to Most memoen of the group say they get we re going to do." the says.
Fred Bingamaa. a
set up tax-free savings accounts for medi-their informauon about health care from
cal expenses gets 47"t approval. And a television and newspapen. To many, the representative, recerres coverage for bis
govemment-mn. taxpayer-funded system most memorable source has been health- family through his employer in retuni for a
pushed by Rep. Jim McDermott of Wash insurance-industry commercials strongly S37.96 weekly contribution. He's satisfied
ington and some other liberal Democrats cnocuinf elements of the CUnton plan, with his bealth oorerage now. but figures
including the famous Harry and Louise'' I may not be m good shape tomorrow-or
appeals to 31%.
ads that depict an 'ordinary couple'' wor- an hour from now."
Forty percent of those surveyed say rying about the White HOUM bUl.
While the people la Yortt worry about
requiring employers to pay for their
Yet the Pennsytvamans insist they
nsing
health COM. they ail say tbey
worken' health coverage, a corn entone odon't
t
place much stock in such messages would pay something to ensure umvenal
the Clinton plan, is the best way to achitv- Robin Doll, a 4-1 year-old financial special coverage - if the svstem is fair. "I don t
umvenal health coverage. This compare, ist (or York County who hu a Blue
pay now. but I'd be wtUWf to pay an equal
wi th ZPt who favor requiring individuals to
Cross/Blue Shield health plan paid for bv percentage u everyone else." says Mr.
purcnue their own coverage, and 18% whoher emptoyer. says she sees critical adver- Renael. the steetworten representative
pack having the government collect moneytisements from the health-insurance intnrouBn taxes ana use it to :;y nedici. ausin constantly. But she declares,
in* *tii wrttf jmrnmuHtt mm wm •mm OMM tt.
mm. Moreover, oy Stfi to 34?. Amtncani 'they're in it to make MlUooa. so who s
say the government should set oootrati oo gouf to beUere tben?"
SMf
health prices. The CUnton pita wouM place
lU.l.fQr
Nevertheless, the people tn this group
caps on the annual increase in ortvsf
health insurance premiums. Plans oein seem to be taking away the ads messar
pushed by RepuhUcaos ud tome other and are waiting (or Mr. dlnloa to respond
more dearly about hfr ptaa. Tdttktto
Dtmocnts wouidnt.
now nactty how tt's r * * io wort." says
SurprtHnfty, despite the push for fist k
Debbie
RudlsiU. a sudooery-storv sales
action on health-care overhaul. Americanswoman wtth
health coverage. "One day
by 60% to 35% say it would be acceptableheifsays this, no
one day he says that. "
Mr. Han says the admimstraoon could
leam a valuable lesson from such com
rtnuht
,aw
g
K
1
r
(
k
<
<
<
z
s
u.
X
H
y.
<
i
�4? HEALTH: State Alliance Gives Clout to Smaller Companies
State Alliance ' ^
How the Health Alliance Works
Give&Wbrkers
Health Clout
By ROBERT A. ROSENBLATT
TIMCS S T A t t W a i T C *
WASHINGTON-Forty thouund workt n ml amall California businesaes will get
an extraordinary piece of good news on
TUeeday: At a lime when health insurance
cotu are climbing by 6% to 8% a year,
their premiume will actually be reduced for
the year tuning July 1.
Theee fortunate few are memben of the
sute's unheralded health alliance, a purchasing agency lhat gives companies with
five to SO workers an opportunity to band
together and achieve the same buying
clout In the health care markei as giant
corporations.
Even as Preaidenl Clinton's proposal for
alliance* covering every citizen is being
denounced in Washington as a bluepnnl for
a menacing new bureaucracy, a staff of just
13 slale workers in Sacramento has put
together a working alliance, the firsl iii the
nation. And its customers seem delighted.
"It was heartbreaking to warn lo gel
insurance for your workers and nol be able
to afford it." said Cynthia Chauvie of Van
Nuys. whose precision instrument repair
firm was once quoted an impossible $2,500a-month premium for tu seven workers.
Last July she joined the new sute health
alliance, and now she pays $780 a month for
Ihe whole office.
"It's a great relief to have coverage now
for all of us." she said.
The alliance, formally called the Health
Insurance Plan of California, offers something never before available for employees
of small companies; a wide choice of
different insurance programs, with workers—nol management—making the stltcP U S M sat H E A L T H . I T
Cvaiiawd fnai B i
Iran
In l-ot A n j r l r s County, for e i amplr. d matktr w h o * (mall romptny h u ioiMd (he H I P C u n
rhoosr j m o n f IS p U i M - 1 2 tttlllh
m j i n t r n ^ n r r o r g a n i u i i o n * and
Itin-r prrforrrd providrr organitaiiont-inrluding w e l l wHI-known
nanwi »
K a i w r . Artna. P H P .
Hrallhnrt anil Prucar* T h a i differadramjiK-allr (ram I h f conv«nllonal •iiiulHin in which l h * company m « k * « a v a l l a b l t one or
perhaps two hrallh plana
A
ll plana mual offer lha aam*
brnrfiia. but tha docton and
h a p i l i l i ara mor* dartrabl* In
M M than o t h a r * MonUdy
I—
n n c * fram I M to I I 7 1 U for a
S S - y t a r - o l d w o r k a r a n d from
S M 2 J 0 a month i s I S N / M for a
35- y a a r - o l d a m p l o y M with a
^ o u H and chiMran. T h t company
muat pay an amount equal lo at
leaat half of the coal of Utt lowtalpnred plan, the worker paya tha
mt
" V o u s e t one monthly bill
whriher you have 13 empioyeea In
one health network or In 13 differant networka." aaid Dtane Bouraaaa. office manager for Telenetworka. a aofiware firm In P e u l u ma "It'a a great variety of choice*
and avoidi a tremendoua admlnia
u a u v e lood on amall companiea
like ua. where typically you have
one peraon running the officr."
Ratea are 10% to l i % below
many comparable plana In Ihe
' conventional Inaurance m a r k e i .
acoordli^ to a n c e n t atudy by a
' H I P C board mamber. T k e reaasnr
P r o v i d e n are willing to offer dimc o u n u to gain accaaa to aa many aa
40.000 rustomera.
' T h e r e ' a no myatary hart." aald
' John Ramey. the H I P C a eaacuUva
director. "We're trying to got a
large-volume deal for our amall
employen."
In May. Florida will become the
arcond atale u> try voluntary altianeea when it begina enrolling
email buaineaaea in a voluntary
purchasing group called the Community Heallh Purchaaing Alliance*
Tht California and Florida aipa, nances may offer soma dlracUon
for lha incraaaiiigty txuar national
dabau aver health can
raform.
CltMan's plan la being torn apart in
Washlnfton by partlian
Republicans and skrpucal Democrala. with
tnihuaiaatir lobbying by business
r« l^ra^
mrvi
imAl\
Cakfornta and Florida officials
are betting that their voluntary
apprvacfc will be a giant M p
toward CUnton a goala of providing
Inauraaca prouctioa lar avaryom
while controUw
of medleafcare
Byofferln,
prtem. they hope
t a matu
raa*lft
l h a raakasf t h a i
among the n e w l y 4 S r
teana wiihowl c o v t n g t . afcom S 0 »
a r t full-time,
i h e k spouaesa
Clinton w a n U ta n q u l r r all e w ptaytra l a artar msursncr and pay
S O * of Uta Mat af an average.
i M . H a a t e wanta l a
wtth n e r * than 5 M 0
i l o enroll m koelUi aJHi that woufc* negntlaie on thru
bthaif w M i Inaurance companKa.
htalth mainunance orfaniaationa
i of htalth c a n
providers.
national
l ? e a r af a co
1 iwagiam of alliancas made it
eaater for all factlona In F l o r i d * buainttata. Insurers and politid a m — t o work together for a voluntary program C o v . L a w t o n
Chile* aaid he waa grateful that the
Pteaidtnt'a plan prodded everyone
to get down to work.
Ftonda officiala aay they hope to
gel prteta down simply by publishing tht bids offered by Inauren lo
amall firms through l h a alliance
S i d e - b y - a l d a com p a r i sons w i l l
make bualnoaaea aggreaalva in
eetktng better daala and force tha
high priced I m u r a n to bring iheir
pneaa down, ihey say
.-A M af what wa da In Florida
wfll saad a aaaaaga to lha nation. "
a d d Loma K W a k . chairwoman et
l h a alHanoa lor Dada Counly - T h e
eondarfUl U d ^ Florida haa la
choica.But CaUfomia took a bigger step.
Republican Cov. P t u Wllaon and
the Democrat-eontrallcd Leglalal u r t decided to give I M health
alliance real muaelt by granung it
the authority to negotiate rales
wlih inauren.
When U M ftrat act of bida came
In laat yaar. lha H I P C gave tha
companies 4S hour* lo lower
r a t e * - a n d many of ihem did
On Tuaaday. lha H I P C board will
approve l u aacond rata achadule.
the figures covering «0000 people
from 2J00 employen for ihe I I
monihs aurting July I. The H I P C
• M o may paiHrfrara? F i n a a w u h five to Ml w o r k e n .
m m m daaa N aMarT S u i t w M a . a choice of I S health maintenance
organiiationa and three pi cft n e d provider networka. T w e l v e of tht
HMOs and all Ihree PPOs operate in Loa A n g r l r s . fewer ara
a v a i l s * ^ m other p a n s of tha a u l a .
• What da « « MMOa t e e t T F b r w o r k e n in the standard plan,
co-paypiema of S I S prr doctor's office n a i l . 1100 per hoapiul
admiation and f 10 per generic drug prcacnption
For f t o r k e n tn the prefrrrtd plan, c o - p a y m e m i of tr. per doctor's
of f m lialt. M I ro payment far h a ^ i u l admiaaion* and t!i fur genenc
d n g s and I I P for brand namaa.
T h t HMO pay* if it refe n tnrallaa* to out ante apeciafiats
MaJdmum out-of pocket coal per year. UjOOO for individuala and
SfOOq lar famlliaa under boOi plana
a «MM« da t k a P P O a a a o l t A S 0 « co-payment l o r o f n c t v M U t o
nat work docton and hospitala and « « l o outaMara
F o r w o r k e n In theatandard plan, a WOO yearly daducUbls par
For w o r k e n in tht prtftrrad plan, a SSSO ytarly deductible par
peraon
PreacriptiMi drug co • p a y m t n U of 30% for generics and 3 0 * for
brand name*.
Maamum yearly out-of -pocket p a y m e n u af tUBOOper peraon
and 14.000 per family in the network, and (5.000per peraon and
110.000 per family outaide tha nat work.
• Haw c a a I d p i apT Call your inaurance agent or tht H I P C
directly at I 100 44T Z93T.
wtll announce lhat tht average
inaurance premium will decline in
price, a teatamenl to Ihe negoualing skills of the organ.ulton and
the desires of the insurance companies to crack Ihe important
amall group markei.
The average company now e n rolled m lha H I P C haa 10 w o r k e n .
Campaniea with aa few aa four
aoiployaaa will ba able to join aa of
July I. and U M Ihnahoid wiU drop
10 three a yaar later About i h r a t q u a r t a n of ihe employ a n In tha
H I P C bought their c o v e r a g e
ihro««h Inaurance agenia. a tact
lhat has made agents friendly
n l h a r than anlagomsuc toward
the alliance.
H I P C membership ahould douMe
In the coming year and could grow
even fatter aa word ^ r t a d s . R a mey and hia staff eatimau.
Beyond that, the competitive
Impact of ihe H I P C ia being felt in
Ihe rest of the s u i t ' s sprawling
Insurance msrket. where companiea ara offering more choice* and
trying to slow Ihe rale uf increase
In premiums
The H I P C la the "sundard by
which every other heallh plan'*
offerings and p n c e i t r * c o m pared, aaid Mark Weinberg. ex*cuiivr vice president al Blua O o a s
of California, which cover* J mil
Uon California- and dominatca the
email - group maiket
"If anything, we are h a v i i ^ lo ba
mart competilive than ever to
compete with Ihe H I P C . " he aaid It
w a * "no coincldtncc." he added,
thai a alowdown In Calforma Inaurance mfUlion began laat July
when tht H I P C opened for t x a l
At Uw beginning of U M decade.
CaUfomia w a * g r a p p l b * with Uw
aaoM thing tha Pi s u d s n i and P i n t
L a d y Hillary Rodham C l l n u n . who
I the AdmbuttraUon'e health
c a r t reform u a k force, denounce
again and again In spaachsa a l locking inaurance companies t h *
specter of sick people crying in
vain for help and uninsured families ruined by coaUy medical bills.
Many I m u r a n eitftfed In "cherry-picking"—inmnng the healthy
but not Ihoac who ware likely to
fact big medical bills T h i * meant
aetktng oui firm* with young, educated w o r k e n In whiU-collar fob*
and giving i h t m bargain raiaa If
thair medical Mil* ware higher
than e i p e c l e d . I neur ers' rata*
would go up or ihe firm * coverage
might be canceled without aiptanaiion.
Soma industries were to be
avoided Inauren didnt l.k.- to
write policies for renauranis brcauae many cooks, butboyt. waner* and w a i l r e a s n were t r a i m r m s
T h e y avoided l a w y e r s brrause
ihey might sue and docton be
cauat Ihey would demand * lot of
high-coat cart.
Addrcaaing this protdein. the
Caltfamia law guarantees lhat no
Individual or company could be
u f u a i d coverage for any rraaon.
Any tneurane* product must be
available to all c uai o m m
I I iwliaaa may vary wuh the
a e * . famUy [ • • p o a i l n n and geo
graphic lacaUan af tha maurad An
m a u m M y aak a SO-year old u
pay • • * ( • than i s m i n n s who la 3 a
a a w r t a d a i a u a whh Uira* chUthan a ( t o f l *
hieh. «a pay
whoHvaamUkiah
B
a y a u k e only
n u tn rata* u
tonpanaaU l a r dWarant health
oondhlona If the coal of I
lor a typical g n > » of five people la
1100 a M M h . the tneurer cannot
c h a r f * a u r a lhan 1120 for a groiq»
of Ave paapl* In which two have
cancer, taro ha v ^ heart diaeaa* and
t h * fifth auffen from d i a h e m A
group of lour marathon r u n n e n in
perfect haalth cannot get a rale
Thaae ground rule* enable I h t
H I P C to avoid becoming U M dumpmg grmmd tor inmpaiilis wipi nek
trurkara wbo eotddn't get coverage
atoawhere. T h a H I P C * aggreaalve ly lew rataa and broad aalertion of
I It attractive for healthy
aa w*U aa high-nsk group* of
wiakeia
At L Q T W B b l g i n a e n In C O M
Maaa. far example. U M M.D00 a
aMnth premium under Ihe H I P C
i t p n a s n u a ssvtng* of aa much aa
3 0 * from t h * firm'* old insurance
plan.
The range of choice* is welcome.
If a Ml tntimidaling; Marilyn Hall,
lha firm i vice presideni. says the
45 w o r k e n have enroll ^ in I I
Mtarorka
"Some employee* come u> ma
and sayi Which o n * •hould I
•hoaae. M a r i l y n ' I «ay. If you hava
a doctor, find oul which network
ba b*longs to.' Ones thty understand It, people love the choice* "
Btfora U M H I P C . Sltv,- L e v i n * ,
who own* an ad agtncy 11 Venice,
got asvaral call* * w i c k from
peoplr Irving to sell him insurance
"I would tell them I'm a diabetic
who had a kidney transplant, and
Ihe phone would go c l i c k . " he
said
l i e paid tl.UOU a iiiiMiih lur
tnwrance for the four w o r k e r * at
his agency, plus I I . W O out of h u
own pocket lor aprcial drugs to
ensure lhat h i * body did not r e j r c l
Uw kidney.
Now a M M M J T Mil of SBSI from
ihe H I P C c o v e n both L e v i n * and
hia employees—and d r u g * a r t p a n
of tht package
T h e a l a u haa kept down coma
and avoided building a n e w b u reaucracy by hiring a private firm
l a act aa the H I P C a aalta agent,
record-keeper and adaauuauaior
Ihe contract and e a l l e c u a fee lor
each p e n o n fftralletf. T n e compe•
ny « u t « * d with I S aalta repreacfitaUvaa and now. anticipating a
boom yaar. haa 30
" W e have forced the market to
rupond." aaid Kirk Rothrock. e a ecutive v m presi da nt of t h a H I P C .
talking sfcout the alliance s inOue n c * far beyond i h t comparaiively
email number of people enrolled
A l l i a n c e b a c k e r s in F l o r i d a
agree. "Vou don't m t a s u r t aucceaa
by tht number of (mall buatntaaca
Ihey Uwurt but by t h * impact they
h a v * on Ihe market." aaid BUI
Hirrit. a Florida btmneaa lobbywt- V o u Invent ihem u> bring heallh
care pricca down."
n w alliance* u l u m a i d y could
fall (hart of b r i n g i i * m s u r a n c e l a
everyone After all. they a r a v o l untary and employen remain free
u rafuaa lo spend money on health
T h r e e - q u a n t n of U M H I P C a
aarollaaa already h a d c o v e r a g e
ale«wh*i«i only one-quarter C O M
from the rank* of t h t unimurad.
California still haa a i i a g g e r t i * « 3
million unlnaurad people under age
SS. and S 3 * of ihem are workera
and their dependents, according lo
Richard Brown, director of the
U C L A Center for H e a l l h Policy
Research
"We will need a national health
care plan to complete the >ot>."
Chile* aaid.
Although he aatd he ia conhdeni
ihe voluniary approach will make
pragroaa In hia a u t * . I don't want
u oacond-gitcm t h * Preaidenr- on
t h * call for mandatury coverage
and compulaory alliance*.
"I've got my hand io play and he
'haa h u . " he aaid.
�^ HEALTH: State Alliance Gives Clout to Smaller Companies
State Alliance '^
How the Health Alliance Works
Gives Workers
Health Clout
Cvailaiwtf Itmm BS
lion
In 1*1 AngrlM Counly. (or n jmplr. d worker whoa* unall company h u yxnrd the H I P C can
chooac among IS plana—12 hrallh
m a i n i r n j n r c organixaiiona and
ihr.-r prrforrrd provider o r g a n i u tiont-mrluding such well-known
names as Kaiser. Aetna. P H P .
Hrallhnei and Pnicare. T h a i differs dranutirjilly from Ihe conventional aiitMlKm in which the company makes available one or
perhapa iwo heallh plan*.
By ROBERT A. ROSENBLATT
T I M t J S T A F F WRITER
WASHINGTON-Forty thousand workers at small California businesses wall get
an extraordinary piece of good news on
Tuesday: At a time when health insurance
cosu are climbing by 6% to 8% a year,
their premiums will actually be reduced for
the year starting July I.
These fortunate few are memben of the
sute's unheralded health alliance, a purchasing agency that gives companies with
five to 50 workers an opportunity to band
together and achieve the same buying
clout in the health care market as giant
corporations.
Even as President Clinton's proposal for
alliances covering every citizen is being
denounced in Washington as a blueprint for
a menacing new bureaucracy, a sUff of just
13 sute workers in Sacramento has put
together a working alliance, the first iii the
nation. And its customers seem delighted.
"It was heartbreaking to want to get
insurance for your workers and not be able
to afford it." said Cynthia Chauvie of Van
Nuys. whose precision-instrument repair
firm was once quoted an impossible $2,500a- month premium for its seven workera.
Last July she joined the new stale heaJth
alliance, and now she pays 1780 a month for
the whole office.
"It's a great relief lo have coverage now
for all of us." she said.
The alliance, formally called the Health
Insurance Plan of California, offers something never before available for employees
of small companies: a wide choice of
different insurance programs, with workers—not management—making the selecPleas* sac H E A L T H . BT
A
ll plans must offer the same
benrfite. but t h * doctor* and
hoapiuls are more dedrabl* In
• o m * lhan o t h e n . Monthly faaa
range from tS4 lo SI73.14 for a
2 5 - y e a r - o l d w o r k e r a n d from
S M 2 J 0 a month lo U n * A * lot a
3 5 - y e a r - o l d e m p l o y e * with a
spouse and children. T h e company
musl pey an amount equal lo at
leaat half of the coat of the lowaatpneed plan: the worker pay* lha
rest
" V o u get one monthly bill
whether you have 13 employee* In
one health network or In 13 different networka." aaid Diane Boura*aa. office manager for Telenetworka. a aofiware firm in Petaluma. "It'a a great variety of choice*
and avoida a iremendou* admlniatrative load on small eompaniee
like ua. where typically you have
one penon running the office."
R a m are 10% to 15% below
many convarable plana In Ihe
' conventional Inaurance market,
according to a recent nudy by •
H I P C board membei. T h e reaaonr
P r o v i d e n are willing lo offer discounta to gain s e c t * * lo ae many aa
' 40.000 cuatomcra.
"There'a no m y n a r y hare." aald
' John Ramey. the H I P C * exacutive
director "We're trying lo gal a
large-volume deal for our • n u l l
employen."
In May. Florida will become the
arcond aute lo try v o l u n u r y alliance* when it begin* enrolling
•mall buainenes in • voluntary
purchasing group called Ihe Communily Heallh Purchasing Allian1
. cn
The California and Florida expa, nences may offer aom* dlractlan
for lha Inrreaaiiigly biuar national
dsbali over heallh c a r * refonn.
C U n u n ' * plan la being torn apart in
Washington by panlaan Republicana and akrpucal Democrala. with
enthusiastic lobbying by businesse i large and small
Cafifomia and Florida officials
ara betting thai their voluniary
approach will be a giant n t p
toward Clinton'* goala of providing
inaurance protection far everyone
whU* c o n t r o l l i i * ihe aoartng coata
of medical ear*.
B y offcrtat wide choice and low
pHcaa. they hope l a woo enough
buiiMMce to make dgallfcam Inroad* in t h * rank* t t l h a Mtaaurcd:
among the nearly 40 adlHon Amertrana without coverage, about R0%
are full-time, low-wage w o r k e n .
thair spouae* and children.
Clinton wants to require all emp l o y e n to offer Inaurance and pay
80% of l h a coat af an averageH a alao w a n u u
In Dnaa with mare than 6.000
empioyeea to enroll l a heallh allii that m o M negotlau on then
behalf wtth Inaurance companies,
health maintenance oeganliation*
and other networka of heallh care
provfdm.
F
ear of a compulaory national
program of alliance* made il
easier for all factlona In F l o r i d a buaineaaea. Inaurart and politician*—to work together for * voluntary program. C o v . L a w t o n
Chile* u i d he w a * grateful lhat the
President'* plan prodded everyone
to get down to work.
Florida official* aay ihey hope lo
gel prices down dmply by publishing t h * bid* offered by Inauren lo
•mall firma through lha alliance.
S i d e - b y - t i d e comparlaona w i l l
make buaineaaea aggreaalva in
•ceking better daala and force Ihe
high-priced Inauren to bring their
pricee d o w a ihey aay.
.-A lot af what we do In Florida
will aend a n u i a ^ i lo the nation."
• U d L y r m Klalak. chairwoman of
Ihe aUUnoe lor Dade County "The
wonderful thing Florida haa la
choica"
But California look a bigger (UpRepublican Cov. P e U W i l n n and
ihe Democrat-controlled LegUlature decided to give t M health
alliance rati muscle by granting it
t h * authority U> negotiate r a m
with inauren.
When Ihe first act of bids came
In laat y * * r . lha H I P C gave the
c e m p a n l a * 4S h o u r * lo lower
n t c s - a n d many af them did.
On Tuaaday. U M H I P C board will
approve I U second r s u ichadula.
U M n g u r w eovarlng 40.000 people
from 2 J 0 0 employen for the 12
month* itarting July I. T h e H I P C
F i r m * with five to 50 w o r k e n .
i N aflert S u t e w i d e . a choice of I S heallh maintenance
organiialion* and three p t c f e i n d piovidet network*. T w e l v e of t h *
HMO* and all three PPOs operate In Loa A n g r l r s . fewer are
a v a i l s ' ) ^ in other p a r u of lha t u U .
• What da Ihe MSOe aaatT F o r arorken in the s u n d a r d pUn.
co- payjnenu of 115 per docior's office v w t . S100 per hospiul
admisa^on and f 10 per genenc drug preaenptmn.
For f r o r k r n in the preferred plan, co- p a y m e n u of Vt per docior's
office viaii. no ro - payment for haaplul admuuuons and t S fur genenc
druga and S I 0 for brand namca
T h e HMO pay* if il refers <
i to outaide tpcciaf l * u .
Mudmum out -of pocket coat per year. $2,000 for tndi vidua Is and
I4.00q far tamlllae under both plana.
a What da M a PPOa aoott A 30% co-payment for office v w u to
network docton and hoapiul* and 40% lo o u t a i d m .
F o r w o r t e n In the aumdard plan, a S&00 yearly deductible per
For workera in Ihe pre n a d plan, a S250 yearly (
peraon.
Preacription drug co p a y m e n u of 20% for genetic* and 30% for
brand name*.
Manmum yearly oul of - pocket p a y m e n u of \1SXX> per p e n o n
and $4,000 per family in the network, and $5,000 per p e n o n and
$10,000 per family outside the network
a Haw c a a I alga a p t Call your inaunnce agent or the H I P C
directly at I 800 447 2937
will announce lhal the average
Insurance premium will decline in
price, a l e s u m e n l U> the negotiating skills of the orgtmution and
the desires of the insurance companiea lo crack the important
small - group market.
T h e average company now e n rolled in U M H I P C haa 10 w o r k e n .
Osmpaniae with aa few ae four
empioyeea will be able to join a * of
July I. and U M threshold will drop
tp three a year later About thraeq u a r t a n af the employen l a Ihe
H I P C bought t h e i r c o v e r a g e
through inaurance agenia. a fact
l h a l h a * m a d * agent* friendly
rather than anlagonitiie toward
the alliance.
H I P C mcmbenhlp ihould doubt*
In the coming yaar and could grow
even las ler a * word spread*. R a mey and hia n a f f eatimau.
Beyond lhal. ihe competitive
impact of the H I P C ia being fell in
the r e d of the ( U l c ' s sprawling
Inaurance markei. where companle* ar* offering more choice* and
trying lo (low ihe rait uf increase
In premiume
T h e H I P C t* the sundard by
which every other health plan'i
offering* and prices a r e c o m pared.'' said Mark Weinberg, executive vtce preaidenl at Blua Croat
of California, which c o v e n 5 milUon California- and domlnaua the
amall - group ma. keL
"If anything, we ara having to be
more competitive lhan aver lo
compete with the H I P C . " he aaid II
w a * "no cmnctdence." he added,
that a slowdown in Cali'omia i n aurance Inflalion began laat July
when the H I P C opened for b w i At U M beginning af U M decade.
California waa frippllng with U M
tame thing U M Preaidenl and F l m
Lady Hillary Rodham Clinton, who
headed the Admlmsuailon'* health
care reform task force, denounce
again and again In tpaech** attacking insurance companln- the
specter of tick people crying In
vain for help and uninsured famllice ruined by costly medical bilta
Many Inaurera engaged in "cherry-picking"—Inmuing l h * healthy
but not ihoae who were likely to
face big medical bills. T h i * meant
•ceking oul firm* with young, educated w o r k e n in w h i u - c o l l a r Job*
and giving Ihem bargain rataa If
their medical Mil* ware higher
lhan eipecled. inturert' rst*s
would go up ar l h * firm's coverage
might be canceled without explanation.
Some induttriet were to be
avoided. I n t u r e n didn't like to
wrile poiiciea for r e t u u r a n u became many rooks, buiboys. wan e n and w a i l r e n e * were t r a n u r m s
T h e y avoided l a w y e r * b r r a u s e
Ihey might aue and doctors be
cause ihey would demand a lot of
high-coal care.
A d d r e n i n g this problem, the
California law guarantees thai no
Individual or company could be
u f u * « d coveragt for any reaion.
Any Inaunnce product musl be
• v a i l a b l * lo all c u d o m r n .
ITamlums amy vary with the
age. family compoaition and geographic lacaUan af U M Maured A n
msural « a y aril a 80-year old lo
pay a u r a than eainiMM who la 30.
a married a t w i n w k h three c h l l -
high, io pay mare than
who Uvea In Uklah.
B
•a I m u r a n may a u k * only
e d h w m t n u in rate* u
cusapentau far different health
candlilena U tha coal of Inaurance
for a typical g r m v of five people ia
$100 a amnth. l h a Inaurar cannot
charge a u r a than $120 for a g r o t *
ef flva people In which two have
cancer, lam hav^-heart diaeaee and
the M l h auffen from d i a b e m . A
group of four marathon runners In
perfect health cannot get a r a U
lower than $80.
T h a a * ground rules enable Ihe
H I P C lo avoid bacatning l h * dumping grotaid far eompaniee with rick
workera who couldn't get coverage
ela*where. T h e H I P C * aggre«atvc ly low rataa and bread eeleelion of
plan* a u k * II attraciive for healthy
ae well aa hlgh-nak group* of
weekm.
At L O S W B E n g i n a e n In C O M *
Maaa. for example. U M M.OOO-amanth premium under the H I P C
reptaaenu a savings of as much aa
30% from the firm's old inaurance
pUn.
T h e range of choices it welcome,
tf a hit Intimidating; Marilyn Hall,
lha firm'* vie* preiidem. says the
45 worker* have enrolh-d in 11
networka.
"Some empioyeea come to me
and aay. 'Which one should I
aheaee. Marilyn.' I aay. If you hava
a doc lor, find oul which network
h * belong* io.' Once they underHand It. people love ihe c h m c e t "
M a n U u H I P C . Slev,- L e v i n * ,
who ownt an ad agency 11 Venice,
got aeveral call* a wtek from
people Irving to sell him insurance
"I would lell them I'm a diabetic "
who had a kidney I r a n s p U n l . and
the phone would go click. " he
said
l i e paid $1,000 a nu.mh lor
Inaurance for the four workers at
his agency, plus $1,500 oul of his
own pocket for apecial druga to
ensure that his body did not reiecl
the kidney.
Now a monthly bill of SSSI from
the H I P C c o v e n both L e v i n e and
his employeee—and d r u g * are part
of the package.
The a u u haa kept down c o a u
and avoided building a new b u reaucracy by hiring a private firm
io act a * the H I P C a aalca agent,
record-keeper and administralor
B m p l o j t n Heallh Inaurance won
Ihe contract and c o l l e c u a fee for
each peraon enrolled. T h e company t u r t a d wtth I S tales reprceenU t i v n and now. anticipating a
boom yaar. haa 30.
"We h a r e farced the market to
respond." said K i r k Rothrock. ex
ecuUve vice preaident of the H I P C .
talking aboul U M a l l u n c e * mHuence far beyond the comparatively
email number ot people enrolled
A l l i a n c e b a c k e r * in F l o r i d a
agree. " Y o u don't measure success
by the number of small businesaes
Ihey insure but by the impact they
have on U u market." aaid Bill
H i n i e . a Florida bunneat tobbynt.
"You Invent them to bring health
care prices down
T h e alliance* ulumately could
(all ahort of bringing inaurance to
everyone. After all. ihey are v o l untary and e m p l o y e n remain free
lo ref uee lo spend money on health
T h r e e - q u a r t e n of U M H I P C a
• n r o l l a a e already h a d c o v e r a g e
elaawherai only one-quarter come
from the rank* of the uninsured.
CallfomU (till haa a •taggering 6 1
million uninsured people under age
SS. and 8 3 % of ihem are workera
and their dependenu. according to
Richard Brown, director of the
U C L A C e m e r for Health Policy
Research
"We will need a national health
care plan to complete the )ob."
Chileamid.
Alihough he aaid he ta confident
the voluntary approach will make
program In hit t u t * . "I don't want
U aacond-gueaa the Preaident" on
the call for mandatury coverage
• n d compulaory a l l u n c e * .
"I've goi my hand to play and he
W h u . " he and
�Mandy Grunwald
'Untruth in Packaging?^
THt_
'. The Post attacked me Ust week in an
editorial ("Untruth in Packaging." Feb.
17) for "willfully twisdn^ Gov. CarroU
Campbell's comments about whether or
not there is a health care crisis, in an ad
I produced for the Democratic National
Committee. The ad included Gov.
Campbell saying "there is not a crisis" in
a series of video clips of other Republicans—Bob Dole, Jack Kemp, Dick Cheney—making similar comments.
I regret not induding Gov. Campbell's full sentence, "There is not a crisis
in the entire medical system of America.", but I do not think that would have
altered the essential fairness of including
Kristol warns that the president's
health care refonn fight is "a serious
pdituuii threat to the Republican party."
Passage of Cbnton's health care refonn.
Knstol wrote, would revive the Democratic Party's reputation "as the generous
protector at middle class interests. And it
will at the same ome strike a punishing
blow against Repubhcan daims to defend
the middle class by restraining government"
Those Republicans, no matter how
they qualified their positions, who chose to
say that there is no health care crisis,
chose an intentional politxal strategy. The
Post s reporter and others noted that
strategy. Oir ad for the Democratic Party
did as well.
Perhaps Gov. Campbell's recent attempts to distance himself from the "no
crisis" camp of the Repubbcan Party will
him, as many journalists did, with other lead to the Republicans' full repudiation
"no crisis" Republicans and conserva- of a failed political strategy to deny the
tives.
problem rather than work with DemoThe essence of The Post's concern crats to solve it
appears to be that the editing of Campbell's comments was "misleading" and The writer ts a Democratic media
that it was wrong to include him in the consultant
ad at all The governor, in the interview
t I excerpted, in statements at a National
Governors Association press conference, and to the Conservative Political
Action Committee,firstdelineated those
' areas where he saw a crisis and then
conducted that there was no crisis in the
whoie health care system.
Was it fair to categorize this as a "no
crisis" position comparable to Bob
Dole's, Jack Kemp's and Dick Cheney's?
Reasonable people who listened to his
comments did just that Who do I think
is reasonable? Reporters from National
Public Radio. Reuters and The Washing• ton Post. Yes, The Washington Post.
Amid business complaints and fresh
Each reporter considered Campbell's
controversy over the health care numfuD remarks and edited them or characbers, assorted commentators have deterized them as a "no health care crisis"
clared the president's health care reposition, drawing no distinction between
form plan dead. This isridiculoiis.The
Campbell's statements and those of othoutlook is actually very good.
er Republicans:
That's because the heart of our plan
• NPRreported:"Campbell says there
is guaranteed private health msurance.
is no crisis in the nation's health care
Eighty percent of Americans want
system. The South Carolina governor is
this. The entire congressional leaderjoining the Senate Republican leader.
ship says it does too. But some selfstyled reformers in Congress pay only
Bob Dole, in that assessment"
lip service to this concept The central
• Reuters wrote: "Only two days ago,
question is whether Congress wiU back
{CampbeU) challenged the central asa mechanism to ensure it.
sertion of Clinton's health refonn
The president has proposed building
plan—that there was a crisis in the
upon the present system through an
nation's health care system which
employer mandate. Businesses would
needed fixing. '1 do not bebeve there is
be required to help pay for coverage,
a crisis in the entire system,' Campbell
and employees would have to pay their
said Saturday...."
share. Today, nine of 10 Americans
• • The Washington Post wrote, and I
with private coverage receive it this
" quote in full "Joining a number of conway.
servative critics of the Clinton adminisThere are only two other ways to do
tration's health care initiative, CampbeU
it.
argued that 'the cure they conjured up'
One is a government program in
is being driven by the 'cnsis they conwhich government would raise the
. jured up.... There is not a crisis m the
money to pay all the bills. Thia is too
- entire system of heaJth care. We still
much centralization, too much tax, and
- have the best system in the world' "
too much government
" If Gov. Campbell considered any of
The second is an individual manthese news stones a distortion of his
date. All Americans would be required
position, why didn't he call the reporters
to buy coverage, but would be on their
to protest' Why didn't he critjcae Bob
own m doing so, without the benefit of
Dole or Jack Kemp or Dick Cheney for
group rates.
their position, as some Republicans did?
What those pushing an individual
And if distortion in the heaith care
mandate don't say is that many emdebate is so tioubting to him. why did he
ployers would no longer have an injjse the same interview that I excerpted
centive to provide coverage. Why
to smear the president's plan for guarshould they, when their empioyeea
anteed private insurance as a "grand
would end up with it anyway? So, many
sodabst scheme?
employers could drop it, and that
Why? Because the attempt by some
would undermine the bedrock of toRepublicans to deny that America has a
day's system.
health care crisis is not merely a rheIt is abo doubtful whether an inditorical disagreement in a complex devidual mandate would bring a reducbate but a conscious political strategy.
tion in health care inflation, which is
If you knk at Bill Knstol's original
vital to true reform. Our employermemo tmplormg Republicans to deny
based proposal would have aO compathat America has a health care crisis,
nies buying in volume and benefiting
you wiD see that he argued that "any
from lower prices.
Republican urge to negotiate" with the
Some say an individual mandkte
president should be "resisted" and "dewould be easier to administer. But jb
fact it would involve refundable tax
feating the Clinton plan outright" must
credits for much of America. This
bethegoaL
Taking Exception
Roger C. Altman
Why v/'
Employer
Mandates?
(
lions who are not now on the tax rolls.
Who wants that'
Then there are the myths circulating about the impact of an employer
mandate. They should be exposed for
what they are—Qat wrong, misleading, or red herrings.
One is that it would cost jobs. Numerous independent studies, induding
work by the nonpartisan CongressionaJ
Budget Office, conclude the job impact
would be small.
Some claim the mandate would cost
businesses money. For the majonty of
businesses that already provide coverage for their employees, that is
wrong. The CBO has now affirmH
that our plan would produce major
savings in national health spending—
as much as $150 billion annually by
2004. Since so much of that spending
is underwritten by businesses, they
will realize particularly large sawigv
We're sufficiently confident of this
to have proposed an outright cap on
business spending for health care
Most larger businesses today spend 10
percent to 11 percent of payroll on it
We would cap that at 7 .9 percent
A third myth is that the mandate
would crush small business. Here,
there is an acute misunderstanding.
Those who oppose an employer mandate don't want you to know that a
majority of small businesses already
offer coverage. That's right Apprtnomately half of Americans employed by
businesses with fewer than 500 employees are already covered.
These are the very businesses victimized by the present system. They
don't have the purchasing power of
large firms, and must pay through the
nose for coverage; on avenge, they
pay 35 percent more. Our plan gives
them the volume purchasing power of
bigger businesses. Small business a
one of the biggest winners under the
Clinton plan.
What about those small busmesses
that don't cover their people now and
would have to do so in the future
Won't they be crippled? In a word, na
The avenge wage among firms thai
don't provide coverage today is very
low—$7,400 a year. Under our plan,
the cost of covering that average
worker would be 70 cents a day It t
that low because we would sharply
discount the cost of insurance premiums to such small employers. Thu
extra cost is surely not negligible, but
its not crushing either.
Another canard is that the required
benefits package is a "Cadillac plan'—
too generous to employees. In realiry
it's only slightly more generous than
what most large employers now otfer
Benefits will be slightly expanded for
most workera, and they will have.
the first time, the security only guaranteed coverage can provide.
Finally, some say an employer mandate amounts to a giant payroll tax. No
one in my memory has ever called a
payment for private insurance between two pnvate parties a tax. CBO
has concluded it is not a tax but a
miscellaneous receipt like a fine, a
penalty or forfeiture. We don't agree
even oo this budget treatment, and
these differences can be easily resolved by slight adjustments on our
side.
The employer mandate a the best
approach to build on the present system, ensure national and business savings, and avoid an administrauve
nightmare. That's why we chose it and
why we hope Congress will support i t
1
ThtwriUrudtputysicniaryoftk*
Treasury.
�-r
J
r- • 7 • •„
i ^1
rr.uisional checkerboard, for there are five major committees
doing the initial work almost simultaneously.
Wuhmjton Post Sutf Wnto
Most of this work is being done in private, in the chairmen's
It's a blustery autumn day and President Clinton, trailed by persona] offices or some hard-to-find cubbyhole in the Capitol.
There are hundreds of phone calls, between staff and staff and
30 ofliciais in dark suits and a couple of bright dresses, steps into
between chairmen, members and evolving coalitions of memthe Rose Garden for a bill-signing ceremony. First Lady Hillary
Rodham Ointon is at his elbow, beaming. In a tight formationbers within each committee and across each committee. After
stand the leaders of Congress, administration officials and a the Memorial Day recess—the very unofficial deadline for
passing committee bills—the leadership in each house will try
handful cf doctors, nurses, labor leaders and senior citizens. Afteran effusive speech, the president sits down at a table and talusto combine its committee bills into a single proposal. Over the
summer members of the House and Senate will debate the two
out apen. The cameras zoom in.
plans and eventually vote on them.
i all goes as the administration hopes, the country will
Then, a conference of House and Senate leaders will tie the
have a health care plan enacted this year. But will Clinton two versions together and the separate houses will vote on the
be able to claim victory or will the Health Security Act of
compromise plan once again. If the proposal gains majorities, it
1994 actually fall short of his promises? Jost how compre- will be sent to the president for his signature.
hensive it may be—or whether it will pass—is not known.
"The business of legislating is tofindout what you can do and
Public and congressional skepticism notwithstanding, the
what you can't do," said Energy and Commerce Chairman Rep.
prospect for significant change in the medical system is strongJohn Dingell (D-Mich.), who is trying to gamer the needed 23
er than it has been since President Ointon first assigned the
members to back the bill he's crafting.
First Lady and hundreds of policy experts to develop what beThe October deadline to pass a bill Ms a month short of the
came the longest piece of legislation in White House history.
November elections. In the Senate, 16 members up for reelecBut there's one important catch.
tion face tight races. In the House about 70 Democrats and 40
The Clinton plan, per se, is no longer the center of attention.
Republicans are looking at tight races. Unless there is a major
The 1.364-page Health Security Act and the 34 thick White
shift in public opinion, most lawmakers say that the failure to
House binders that back it up have become the ultimate referenact health care legislation by that time would greatly fuel the
ence manual, an encyclopedia for the lawmakers on Capitol HiU,
voters' anti-incumbent feeling that Congress is stalled by gridwho have taken over the show and, for the moment, seem delock.
termined to produce a health care bill by mid-October.
Clinton can claim credit for putting health care on the politFor the next six weeks or so, the action takes place in conical agenda. The ability of the president to take his message to
gressional committees, which are beginning to write their own
the people :s one of the most powerful tools of the office. In the
bills. Ultimately, the work of at least 16 committees will be
past
year, r.e Clintons have attended more than 90 health care
melded into one bill by the congressional leadership and the
events.
Dunng the latest two-week congressional recess in
committee chairmen with the aim of being able to get 218
April,
the
Clintons, Vice President Al Gore and his wife Tipper,
votes in the House and 60 in the Senate.
"Forget which plan is up or down, forget whether it's the
Cabinet officials and other top administration members traveled
Clinton plan or something else," said Sen. Harris Wofford (Dto 25 states and participated in more than 80 events, according
Pa.) whose 1991 upset election gave health care a national poto the White House.
litical appeal. "We're getting down to the building blocks and
But as Harry Forest, a 76-year-old retired worker in Constarting to move them around to get the results we want."
necticut, commented after Clinton visited his hometown, "he's
The main questions lawmakers are trying to answer in their
only one man."
bills are the following:
Each step of the congressional process is an opportunity for
groups and individuals to try to influence the debate. Each step
• How to pay for health care for all Americans.
is also a window on where Congress might be heading,
• How to bnng down the exploding cost of care for individuals
yet few feel confident to predict thefinaldestination.
and businesses and in two government programs—Medicaid
Recalling the apprehension lawmakers had about enactfor the poor and disabled and Medicare for the elderly.
ing Social Security legislation in 1937, Ways and Means
• How to regulate health msurance companies so that they
Chairman Dan Rostenkowski (D-IU.) told doctors and medcannot deny insurance to sick people or charge them high rates.
ical students at the Harvard School of Public Health recent• How to guarantee Amencans some independence in choosly: "Health will require a similar leap of faith, and we can
ing physicians.
onlv hope that the result will be smularlv positive."
To follow the process on a daily basis would require a five-diSee KEY ISSUES. Page 12
By Dana Priest
I
THE U ASHINCTO> POST TUESDAY. MAY
3.1994
�COVER STORY
\
The Debate Centers on Four Key Issues
Covering the Uninsured
A
bout 39 million people do not have health
insurance at a given time dunng the year, a
number expected to increase each year. When
people without health insurance get sick, they
forgo care or pay for the care themselves or someone else
pays for them indirectly—either in higher insurance
premiums or higher hospital charges, for example.
The Clinton plan would cover most of the uninsured by
requiring employers to pay 80 percent of their workers'
insurance premiums and individuals to pay the other 20
percent. Government subsidies would be available to
certain small firms and self-employed peopie. Medicaid
would continue to cover the poor; Medicare would remain
the main coverage for people at least 65 years old.
5i
<
5
a
•—•
CO
2.
Z
O
X
Currently all congressional committee chairmen are
working on variations of the Clinton "employer mandateapproach. They are concerned that the mandate could
threaten the economic health of some companies. They are
also worried about the cost of subsidies to protect small
companies and certain individuals. Under debate are ways
to lower the overall economic burden of the health plan by
exempting small firms altogether, changing the 80-20 split
so the employee bears a greater share, or scaling back the
standard benefit package.
Some committee chairmen, including House Ways and
Means Chairman Dan Rostenkowski (D-Ill.), who heads the
House's tax-writing committee, believe there may have to
be broad-based taxes—perhaps a payroll tax or a
surcharge on income—to pay for the subsidies.
Rostenkowski has proposed expanding Medicare, in which
the federal government sets hospital and doctor fees, to
cover people in small firms and the uninsured. He calls this
Medicare Part C.
I
Single-payer advocates would empower the federal
government to levy payroll, income and other taxes and use
that money to pay for people's medical bills. This approach
12 L would eliminate the need for insurance companies and
employer-provided insurance. Instead, all legal residenU could
go to the doctor or hospital and the government would pay the
bill, at prices the government established.
Meanwhile, the "individual mandate" approach, as in the
Chafee-Thomas bill, is gaming ground. As with auto
insurance, all individuals would be required to purchase
health insurance.
Some lawmakers advocate a mixed, individual-employer
requirement with an individual mandate on employees in
small firms, say under 25 workers, and an employer
mandate on all others. Many others do not favor requiring
anyone to pay for health insurance. Supporters of the
Cooper-Breaux bill believe that if insurance is less
expensive and easy to obtain, people will buy it. Instead
they favor trying to bring down the cost of health msurance
and would require that insurance companies sell policies to
anyone who wants to buy them at relatively the same
rates. Under the Cooper-Breaux bill, small firms with
fewer than 100 employees would have to pool together to
buy insurance.
In another approach, employers would pay for policies
that cover catastrophic illnesses. These medical savings
accounts tend to have high out-of-pocket costs and
individuals can be required to pay thousands of dollars
themselves in any given year before the policy kicks in.
The proposal would ask employers to set aside other
money in an individual's medical savings account. The
money could be used for medical care in any given year,
rolled over into the account for the next year, or spent on
something else at the end of the year (Michel/Lott and
Steams/Nickles). Incremental approaches (Michel/Lott)
would ask employers to offer, but not pay for. insurance
policies and would make some changes in insurance rules
so that small firms or individuals would have an easier time
buying insurance.
Controlling Costs
C
urbing the cost of health care, which is rising at
three times the rate of inflation, is key to most
legislators. Lawmakers also agree that if they
impose new requirements on employers or
individuals to buy insurance, there would be increased
pressure to control how much insurance will cost. The
health industry opposes any limits placed on what they can
charge. Many others in Congress are philosophically
opposed to allowing the government to set prices. Chnton
proposes to control spending by limiting the annual
increase in insurance premiums.
Advocates of expanding Medicare or implementing a
single payer system would have the government set the
price of doctor and hospital services, with variations for
regional differences.
Supporters of the "managed competition" approach
(Cooper/Breaux) bebeve that imposing a tax on some
portion of people's health benefits will drive down the price
of care. These benefits are not now taxed. Most experts
agree that this kind of cost control would favor organized
health care systems—so-called "managed care" health
plans such as health maintenance organizations.
Standard Benefit Package
M
any lawmakers agree that insurers should be
required to sell policies that contain a
minimum set of benefits, something the
federal government or a natwoal health board
would establish. This would level the playingfieldfor
insurance companies, so that they could compete for
consumers' business based on the quality of their services
rather than using caveats in small-print that lower the cost
of policies by excluding coverage of certain medically
necessary services.
The Clinton plan's benefit package is fairlycomprehensive—including medically necessary patient
care, hospital services, family planning and
pregancy-related care, preventive and hospice care,
prescription drug coverage, ambulance services, outpatient
laboratory, radiology and diagnostic services, eyeglasses
and dental care for children under age 18. It also includes
some mental health and long-term care benefits. It limits
annual out-of-pocket costs for individuals or families and
prohibits insurers from imposing lifetime hmits on services,
which many insurance policies currently contain.
The alternatives that lawmakers are discussing vary
(Treatly; from catastrophic coverage to leaner versions of
the Clinton bill, with mental health and long-term care
being the most likely candidates for cuts.
New Insurance Laws
L
awmakers generally favor imposing a set of new
rules on insurance companies. They are looking at
laws that would prohibit insurers from denying
coverage to people with pre-existing conditions or
when they change jobs. Many believe insurers should live
by "community rating"—charging everyone in a given
region the same rate. Others believe companies should
have the ability to vary prices, with some limits, according
to a person's risk. (Older people, women in childbearing
years and people who work in hazardous professions are
some examples of high risks.)
While it seems like a simple concept, enforcing
community rating is one of the great policy challenges. The
"health alliances" proposed by Clinton are one approach,
but it has little support in Congress. Insurance companies
are concerned that they would end up with an unusuallylarge and costly number of sick people.
^
�FMANCWe H E U m INSURANCE FOR A U
Possible sources of money per year
Taxing some
health benefits
$20 billion
75-cents-a-pack
cigarette tan
$10 billion
5% value added
tax (VAT)
$8 billion
Alcohol—$16 per
proof gallon
$4.5 billion
Guns and
bullets
$200 million
"•/"'• ?V
•••• '• •
Mandatory
premiiHTt ftn^nts
household
premium
payments
$94 billion
SOURCES Baseo o- es;'rra:c-s v o -
Congressior.3> BuOget 0«'ce: White Houst: Senate Finance Commitree
THE PAY OF SPECIALISTS AND PRIMARY CARE DOCTORS
O n e of the aims of health care reform is to channel more doctors into the
I
fields of primary care, instead of specialties From a purely economic
standpoint, doctors who are specialists make more money. This is evident in an
American Medical Association phone survey of about 4,000 physicians, in
which they gave their incomes after expenses but before taxes.
DOCTORS' AVERAGE ANNUAL SALARIES IN THOUSANDS • 1992 B 1991
ALL PHYSICIANS
$177.4
Radiologists
S253.3
$229.8
Surgeons
$244.6
$233.8
Anesthesiologists
$228.5
Obstetricians-gynecologists
$215.1
Pathologists
$189.8
Internists
$159.3
Psychiatrists
$130.7
Pediatricians
General or family practice
$111.8
SOURCE AMA Socioeconomic
Moritoring S/stem. 1993
�2. COMMITTEE BILLS
MAJOR BILLS INTRODUCED
O
Membership of two committees, Senate Labor and Human Resources and House Education and
Labor, is more liberal than their respective full chambers. These committees are expected to pass bills
dose to the Clinton plan and the tax-financed, Canadian-style system. The other three committees are
more reflective of the general membership of each house. They are split in dozens of ways. Strong
leadership is needed to pull members together and cut the deals necessary to support legislation.
•Presklent Clinton's bill, the Health Security Act,
introduced by Rep Richard A. Gephardt (D-Mo.)
and Sen George J Mitchell (D-Maine)
•Single-payer bill, sponsored by Rep. Jim
MrDennott (D-Wash ) and Sen Paul Wellstone
(D Minn.)
•Managed competition bill, sponsored by Rep.
Jim Conper (D Tenn ) and Sen John Breaux
(D-La )
Wajfi and M M I M
Rep. Dan Rostenkowski (D-Ill ), chairman
•Moderate Republican, individual mandate bill,
sponsoied by Rep. Bill Thomas (R-Calil) and
Sen John Chafee (R-R.I )
Has publidy pledged to get a bill out with
universal coverage; personally favors
expanding Medicare to cover the poor and
uninsured.
• M a i n House Republican alternative, an
incremental reform plan, sponsored by Rep. Bob
Michel (R-lli.) and Sen Trent Lott (R-Miss.)
•Another incremental bill sponsored by Rep.
Clitlord Stearns (R Fla.) and Sen Don Nickles
(R-Okla.)
MELDING THE BILLS
Leading Democrats, including committee
chairmen and select subcommittee members
meet in private to forge a single proposal in each
chamber. This is the time of real deal making to
honor promises made by committee chairmen.
Fights are expected over which committees will
have control over new health initiatives.
Edacatfan and Labor
Rep. William D. Ford (D-Mich ).
chairman
9-
Expected to pass both a Clinton-style
bill and a tax-financed, single-payer
one.
Enwnr aad C o s s w r c e
Rep John D. Dingell ID-Mich ). chairman
Committees that also makn
recommendations to loaders:
Has introduced his father's tax financed,
health care for all bill every year since
1955.
• Armed Senrket
• Vetwani'affairs
• Post Office
•Judkiary
•Government Operations
• Natural Resources
House Specter Thomas S. Foiay (D-Wash ),
left, is committed to the presidents health care
goals Mafeftty L—d«r K c h M * A. Beptunft
(D-Mo.) tried for several years to unite Ihe
Democrats behind a bill that would gua'anice
insurance to all Americans.
THE REPUBLICANS
Finance
Sen Daniel Patrick Moynihan (D-N.Y). chairman
Heac/s ode ol the most unpredictable
commiflees Three Democralic and three
Republican members are planning to retire and
may leet unencumbered by reelection concerns.
Senate Minority leader Robert Dole (R Kan ), left.
ts tiynif; In f-v^inHi a compromise between
mnflPMi"'. ..orh .ir, Sen. John Chafee (R-R I.),
CCMIIO'. .mil [ I T i.i.vty's conservative wing, whose
VIPWS mo iplloclPil hv HOUM Minority Leader
Robert Michel (R-lll.l, right
MUM
labor and Human Resources
Sen Edward M. Kennedy (D-Mass.). chainnan
T
ESEBS
Has favored national health care coverage, for
many years. He is expected to play a major
role in melding the Senate bills and. later, in
conference in shaping the final proposal
Committees that also make
recommendations to /carters
• Armed Senrfces
• Veterans' Affain
• Governmental Affairs
• ludklary
• Indian Affairs
Senate Majority Leader Georfe J. MKcbeN (D-Maine)
A firm believer m CUnton style reform He pl.iys crucial
role in shepheitf'ng Icgi^l.ilicn thmnf h Cc"iR''''i,s.
a.
�A
FLOOR VOTE
* In each chamber, members will
debate and amend respective bills and pass
or reject the proposals in part or in whole
Hie White House believes it must get 60
votes in the Senate, the number needed to
break a filibuster, and 218 m the House
5. CONFERENCE
If bills pass in each chamber,
Democrat and Republican leaders from the
House and Senate meet in private to combine
the two proposals into one plan. All essential
promises are integrated in the final deal.
g
V
CONGRESS VOTES
r
Senate and House both vote on final
"conference report" bill A simple majority is
needed.
. i i f s - H O U M wrtes on a
final "conference
report" version.
BILL TO PRESIDENT
, « H O U M debates MB.
^ ' r A f f ^ i ^ - - ' - Suhstitiitrs may ho
offered.
Clinton signs or vetoes.
•v
House/Senate conference
twmdtteo reconciles
differences and sends final
version back to each chamber.
"II you send me legislation
that does not guarantee
everv American private
health insurance (hat can
never hr taken away, you
will force mc to take this
pen. veto Ihe legislation,
and we'll come right back
heie and start all over
again."
—PrtsMent Cftiten
Jan 25. 199J
Senate debates bHI.
Substitutes may be
offered.
Senate wites on a
'V'V
final "conference V ^ ' ^ l . ' w
report" version.
�Many Dop't Realize It's Clinton
Br HIIAIY STOUT
Staff HapTtar 0/ Tm WAIX Bnwmr J
YORK. Pa. - Jaban Bathir doem't Uta
President Clinton's health-care plan. She
thinks it's too confusing, too complex and
Health-Care Satisfaction
probablv too expensive.
What about a plan that would guarantee a standard private health benefits
package to all Americans, try to promote
competition in the medical industry, include some government regulation to keep
prices under control and require all employers to buy health insurance for their
workers with the promise rovernmer.
subsidies to help the smallest compames.
"It sounds good.'' says Mrs. Bashir. a
43-year-old secretary and mother of seven.
"Employers may pick up a lot of the
burden, but If the employer can't afford it,
the government will subsidize. So you're
going to have the employer, the government and the insurance companies working together."
~:K:..- :.
-••yri
Actually, that plan is the Clinton plan. • .i
Mr. ninton Is losing the battle to define
his owri~Kealth-care bill. In the cacophony
of negative television ads and sniping by
rritirs__fnps are raisingfloubtsabout the THI WILL Sinn «JIEAL/»»e MMS KU.
-nTntmTjjnin fAstor than the nresirient and
ments. "If the White House had had access
-ffinarvRbdham Clinton can_expiain it. Congress didn't pass a plan this year.
to these people in York, what it would
• ^ f f p ^ j f t ^ p||ntnnc r a n T n T t h m n g h thp
"The White House should find this bor recognize is they have to be able to
confusion, the outlook for passage of maior satisfying and sobenng,• says Mr. Han. simplify their message, to say this is what
-^Wnflj nf th>tr bill is in doubt.
Satisfying because the basic ideas which we're doing: A. B and C," he says. "They
Anew Wall Street Journal/NBC News they ve drawn up are therightideas" in have to be able to get out there and talk
poll shows that public support for "the the view of many people, he says. Bu: about it. day in and day out."
Clinton health plan" is eroding. Yet the. "sobering because they clearly have comEveryone in the York group also agrees
samTEoirTamducted bv R^puhhran Rnh- municated very little to the public, and ir ! that health-care reform means coverage
ert Teeter and Democrat Peter Hart. that respect have ceded too much to the for every American. No one in the room is
shows that backing for the basic pnmsiQns interest groups. "
willing to accept a compromise of anything
fn the president's plan is strong.
To further test public sentiment in the less. "We've got to have universal health
lh tflfi POll. 45^ fff Amprir«n<= nnw car health-care debate, the Wall Street Journal care, whether you make a million bucks or
asked Mr. Hart to convene a small group of nothing," says Ms. Doll.
^"YTP"" *hc fi) "'"" P"", "P
—jTr-rariMary gprt 1*7- In Spptamhnr jmt people in York, a medium-sized dty in the
In the Journal/NBC poll. 33% of AmeriaTfeFThe president outlined the plan in southern part of Pennsylvania. Everyone cans rank universal coverage as the most
a televised address to Congress. in the group - including a woman whose important goal of health-care refonn, the
Thirty-seven percent of those surveyed family lost its health coverage when her highest for any of the suggested choices.
favor tne Clinton program, down from fFi husband lost hts job and a union member Lower medicai rates and capping costs
with a plan that "covers everything you placed second, with 18%.
in Januajy^M^Linseptemoer.
—BuTwhe'-rPBri a descriptinn nf tb? can imagine" - believes the U.S. health
In contrast to the sentiments of the
ma'jofprovisions of the White House bill- system is badly broken and needs to people in York, though, the poll found some
^ithnni ifWnti nag it - 76Pe of tho rospon. be overhauled to guarantee health cover- willingness to accept a bill that doesn't
jrimsay It hsi •ttim "i gru* iitsi of age for everyone.
guarantee coverage for everyone. In the
But no one expresses support for Mr. new poll. 43% of Americans say Mr. Clinton
PEf'" or "Hfi""* "pp""' " That is far
"Setter than th* response to descriptions of Clinton s sweeping proposal. In fact, no should refuse to sign a bill that doesn't
one can explain it. "I think nobody in this guarantee universal coverage; 43% says he
four other congressional proposals:
oom realizes where Clinton's coming fromI shouldn t refuse.
A description of a plan by Rhode Islandrwith
plan, and it doesn't speak
When the people in York discuss their
Sen. John Chafee and other moderate clearly,his complains
Keith Beatty. who own health care, they reflect the feeling
Republicans, which would require all indi- runs a local youth-care
program.
among many Americans about the precarividuals to obtain health coverage and
Yet
when
the
group
is read a descrm ousness of medical coverage in the U.S.
provide financial assistance to low-income uon of the Clinton bill (without
today Of the 12 people, seven have
people, appeals to 4STc of tnose surveyed. Ait as th? president's plan) and ofidentifyinc
the four oeen wuhoui health insurance at some
plan by Democratic Rep. Jim Cooper o: otner leading proposals in Congress,
tnu ume in the past five years. Another, Linda
Tennessee that has bipartisan backing andClinton plan is the first choice of everyone
would require employers to offer - but notin the room. Referrinp to the unidentified Luther Baumer. who works part-time,
worries that she'll lose her coverage when
pay for-coverage for their workers and
proposal. Mr. Beatty declareshor husband retires In the next yearor two.
seek to control prices throuen markei Clinton
"With the plan you just presented, it
Either I ve got to get a fulltime job that
competition gets a 34'7 approval rating, A speaks
clearly . "
provides benefits or - we don't know what
plan by conservative GOP Sen. Phil
Gramm of Texas that would allow people to Most members of the group say they get we re going to do." she says.
Fred Bingaman. a customer service
set up tax-free savings accounts for medi-their information about health care from
cal expenses gets 42^ approval. And a television and newspapers. To many, the representative, receives coverage for his
government-run, taxpayer-funded system most memorable source has been health- familv through his employer in return for a
pushed by Rep. Jim McDermott of Wash- insurance-industry commercials strongly $37.96 weekly contribution. He's satisfied
ington and some other liberal Democrats criticizing elements of the Clinton plan, with his health coverage now. but figures
including the famous "Harry and Louise" "I may not be in good shape tomorrow - or
appeals to 31%.
ads that depict an "ordinary couple" wor- an hour from now."
Forty percent of those surveyed say rying about the White House bill.
While the people in York worry about
requiring employers to pay for their
Yet the Pennsylvanians insist they
nsmg health costs, they all say they
workers' health coverage, a cornerstone oldon't
much stock in such messages would pay something to ensure universal
the Clinton plan, is the best way to achiev- Robinplace
Doll,
44-year-old financial special coverage - if the system is fair. "I don i
universal health coverage. This compare^ ist for Yorka County
who has a Blue
pay now. but I'd be willing to pay an equal
with 22% who favor requiring individuals tCross/Blue
o
Shield
health
plan
paid
for
bv
percentage
as everyone else." says Mr.
purchase their own coverage, and 18% whoher employer, says she sees critical adverback having the government collect moneytisements from the health-insurance in- Rentzel. the steelworkers representative.
through taxes and use it to pay medic- austry constantly." But, she declares,
Tnt «an sirttt journii/NBC Ncmooii WMOMMOT,
t M t r n m o * I M Mum canaucM
bills. Moreover, by SSft to 34%. Americans
FrMiv
t r r o u * Tundev ev M M M W orwMuttani oi
"they're in it to make billions, so who's
say the government should set controli on going
to believe them?"
Tht wmeM wm M M M m JU
health prices. The CUnton plan would place Nevertheless,
OTOVMMC aoMt tn mt eannnwitil U .S. EKtiraetonw«>
the
people
in
this
group
rtsrfMmM
in Braaartun to Its oaeuistion. HouMflotn
caps on the annual increase in privaf seem to be taking away the ads' message
•*r» t t I K < M Dv • mttnoo nut etvt an ttitonont num.
health insurance premiums. Plans beini, and are waiting for Mr. Ointon to respond otn,
intM and U M M M , an aouat cnanea ot DaMe mpushed by Republicans and some other more dearly about his plan. "I'd like to
Ona aaun. n n t n ar o u r . M i laiicua I
Democrats wouldn't.
know exactly how It's going to work," says
. Tteraaumstfttarvev
Surprisingly, despite the push for fast Debbie Rudisill, a stationery-store sales•et ana an » anure mat tht
action on health-care overhaul. Americanswoman with no health coverage. "One day Ctitncatart It o»» mat It all
In
by 60% to 35% say it would be acceptable he
if says this, one day he says that. "
mtcsminantaiu.S
dtfttr tram m a t eati rtaum ov ne nure man 14 eareantoomti in m m M r m t a i A N m l M numaw « • • » Mr. Hart says the administration oould aet
ttanamrtattadof nattmeaamoit: for meat, tnt mtroin
ot trror Mat I t otrttmagt eoinn. Tnt marein tor any
leam a valuable lesson from such com
1
3!
1
C
uogrous aouM oaotno an ma v n ot mat grouc
x
<
Q
4
1
O
v.
mi
tc
X
�Todays
HEALTH-CARE REFORM
: Don't compromise on
universal health coverage
. That is called a "hard trigger".because it
dictates specific action. "Soft tnggers."
which have also cropped up in some compromise proposals, tell Congress it must do \
something but don't say specifically what.
Hard or soft, a tngger is a cop-out ReAccording to the hnest tea leaves avail- member the Gramm-Rudman-Hollings
able, at least three congressional commit- deficit-control act of 1985? That contained
tees will soon vote for health-care reform "hard triggers" and, after passing it. Conlegislation thatrequiresemployers to pro- gress spentfiveyears enacting laws to avoid
them. Triggers don't guarantee Congress
vide insurance for their workers.
It's a rosy prophesy. An employer man- will do what's nght only what's easy.
If the tnggers aren't enforced, what's left
date means that every
of
health-care reform? I n the most recently
full-time worker in the
publicized proposal to hit the Finance
country gets health inCommittee, the answer is. principally, resurance, bringing
forms of the insurance industry.
health care to millions
But watch out These changes alone can't
of Amencans who do
guarantee coverage. Last year. New York
not now have it
state ordered insurers to accept all appliSadly, the Senate Ficants at essentially a single price — -"comnance Committee,
munity rating" The result was disastrous.
from which a Senate
Premiums rose, which drove healthy concompromise is most
sumers away, which left insurers with highlikely to emerge, isn't one of those three. In er-risk consumere. which forced premiums
Finance, lawmakers are considering a com- higher still. In the end. fewer people were
promise that would abort such universal covered at greater cost
coverage before it ever draws a breath.
Mandating coverage avoids such probIn the compromise. Congress would en- lems, but moderates from both parties fear
act market reforms to make insurance the idea will look like another tax. Substicheaper and more accessible. Lawmakers tuting triggers lets them claim to have votalso would pass incentives and subsidies ed for universal coverage but against emfor employers to insure their workers. And ployer mandates.
Congress would set a series of deadlines
Don't fall for it. Our health-care system
and targets. If too many Americans remainis a costly mess, and only universal coveruninsured after a certain number of years, age can put it nght If the process requires
then a full employer mandate would be im- some compromise, it also requires manposed automatically.
dates — more so, andrightfrom the start
I Congress could barOUR VIEW i gain itselfrightout
of covering the people who need
coverage most.
Tl
05
ao
LU
Z
D
5
•Q
on
LU
z
Q
>
<
Q
O
<
3
�TheWorkpiace
Commentary/by Aaron Bernstein
WHY UNIVERSAL HEALTH COVERAGE IS SMART MEDKINI
I
n early February.,Unitad Airlines
Inc. decided to stop providing medical insurance for new hires. By
mid-March, the carrier had added 450
reservations agents and other nonunion
employees who agreed to foryo coverage. United isn't alone. In recent years,
thousands 'of employers have cut out
coverage for new worken or yanked it
from current ones. Many startups,
meanwhile, simply don't offer a plan at
all. As a result, millions of families are
now uninsured-unless their breadwinners are blind, disabled, or on welfare, and thus qualify for Medicaid,
the ifovemment program that provides
health care for the indigent.
The retreat of employers from health
insurance spotlights a central issue in
the health-care, debate: Should every
citizen have medical insurance, as President Clinton insists? Or is this admirable ?oal simply too expensive? The
answer: Universal coverage is essential—and not just because it's the right
thing to do. It also is virtually impossible to achieve the other primary goul
of reform—cost control—without bringing everyone into the system.
coapoaAH CAJTom. "We don't let
people bleed on the street. So we're
paying for the uninsured anywsy," says
U'illiam S. Custer, the research director ut the tmployee Benefit Research
Institute IEBRII. a nonprofit Washington
group that doesa't endorse a particular
health-care bill. "Also, as employen
n-'liu-y tho numbor of people in the
risk pool, iht- pool xots riskier, und
premiums go up for everyone still paying for insurance."
The problem is evident in the figures on employer coverage. Companiea and other employen provided primary health insurance for 55.6% of
Americans in 1992. the latest year
available, down from 59.7% ia 1988.
according to EBRl's tabulations of Census Bureau statistics IchartL That represents more than 10 million worken
and dependents who either lost coverage or didn't get it when they started a new job. The actualfigureis even
higher, because EBRI includes some 3.6
million worken who get coverage
through their employen but must pay
the entire cost themselves.
Taxpayers and those who remain insured pick up the tab for these corpo>
rate cusiotfs.-Some oi the uninsured Tenn.). wouldn't have much impact on
have sought refuge in Medicaid, where its cost either. There's a strong reason
the number of recipients soared 40% to move to universal coverage: to get
between 1988 and 1992. to 20.5 million rid of the cross-subsidies and other inpeople, according to EBRI. Part of the efficiencies." says C. Eugene Steuerie. a
increase occurred because Congress health expert at the Urban Institute, a
eased Medicaid's eligibility rules. But Washington think tank that hasn't ensome of those left stranded by com- dorsed any health-care bill.
panies—such as part-timers making low
So far. Congress isn't rushing to
wages—joined up as well, experts say. embrace coverage for everyone. Only
Add in continuing medical inflation, two of the reform initiatives swirling
and taxpayers' bill for Medicaid has around the Capitol insist on universal
jumped 159% since 1988. to 1140 billion coverage: Clinton's and one from Rep.
last year.
resenutive Jim McMosi of. the other
Dermott ID-Wash. I
HEALTH-ORE
CRUNCH
people abandoned by
that calls for a Canaemployers have no
dian-style system.
AS
CMPLOTIR
PROVIOI0
coverage at all. The "
COVERACI SHRINKS
ranks of uninsured
er reformers object
have risen by 15%
to the projected exsince 1988. to 38.8
pense for insuring 39
million, according to
million extra people;
EBRI. But as Custer
It ranges from t2S
says, '-axpayers foot
billion to S60 billion
the bill for them. too.
a year, depending on
Experts aren't sure
assumption* about
how much health care
how many haaUKve
the uninsured get
dollars the uninsured
from public health
already use That
clinics, city ambutranslates into about
lances, and hospital
1280 to 1625 a year
emergency rooms.
per household. ClinRut the estimates
THE UNIKSURID
ton expect! moat of
ARE INCREASING...
range trom about half
thia to be offset by
to two-thirds of what
the slowdown ia mad'
the insured get. The
ical coat hikaa his
funds for such serplaa enviaiooa. But
vices either come
most polls show that
...AND SO ABE
from public coffers or
taxpayen may he
MEDICAID RECIPIflfTS
are rolled into healthwilling to pony up
care providen' prices
even if that doaan't
for everyone else.
happen. For instanoa.
a 1998 EBRI poll found
Given the highly
that 76% ol Ameriinefficient nature of
caaa want Washingemergency care, unton to provide haalth
checked growth in
the numbers of uninsured could negate insunnee to everyone, even if it
the various cost-control ideas being a tax hike. On average, respondents
considered in Washington. Preventive said they would pay 1169 a year
care, which usually is cheaper than in
waiting for an emergency, is virtually
It makes no sense, ia short, to leava
nonexistent for these people. Also, the uninsured out of th* equation. If
most of the managed-care cost-control that happen*, aay reform plaa wiU face
measures employen are applying to a never-ending battle to rein ia th*
the insured don't work in hospital runaway costa created as employen
emergency rooms. And since the poor abandon health insurance.
aren't paying for their care, the market
competition envisioned by reformers,
Benuttim it BUSINESS WOK'* Worfcsuch as Representativa Jim Cooper ID- plact editor.
M N I S S wfat/MAam 211»*4 i n
�White House Hopeful on Health
Key Reform Are on Course in Congress, Officials Say
falo on Wednesday that Ickes and Magaxmer
dted as one cause for optimism, told a state
Democratic, parry meeting that waa nominatWhite House officials, in an opttmisuc as-ing him for reelection. "In this Congress, as
sessment of President Clinton's prospecu Finance Committee chairman, my health
for achieving his key health reform goals thiscare mission is clear—get the president hia
year, said yesterday that "a great deal of bill."
progress has been made" in Cong ess in the
Moyruhan recalled that he had co^pon^
past 10 to 11 weeks.
sored
a Canadian-style government health
-On balaaoa we an on target, the committees are on target,* said Deputy Chief of insurance proposal with Sen. Bob Kerrey (D*
Staff Harold Ickes at a briefing with report-Neb.) in 1992. but said such a biHTua no
ers. "We expect virtually all commit:ees" to chance of passing the United Sates Senate."
report out legislation "by the end of the though he favors giving each sute aa option
month." despite some gloomy polls and pre-to create such a system within its own bordictions in the press. He said the president'sders. He noted that he is a principal sponsor
key goals include passing legislation to assure universal health insurance coverage and of the president's bill.
In a May 26 letter to a Brooklyn. N.Y.,
' "to get it done thu year."
Ickes. accompanied by Ira Magaziner. health official Moynihan wrote. "I support—
White House senior adviser for policy devel-indeed I insist—that we must have universal
opment and a principal author of Clinton's coverage. I support an employer mandate
health plan, said that of five committees withand will oppose the taxation of benefits. I abjurisdiction to work on developing major solutely support long-term care."
health plans, two—the House and Senate la- In a telephone interview from Oregon yesbor committees—are on track to report billsterday, Sen. Bob Packwood (R-Ore.). said he
this month achieving many of the president'smight support a requirement that euipkiyan
major goals. They said work was underwayhelp
pay for heahh msurance for their wortan
m the House Ways and Means Committee
that
w
ould not become effective i
and that Senate Finance Committee Chairman Daniel Patnck Moynihan (D-N.Y.) had but would be triggered automatxally if i
made clear he will begin legislative action ul health insunnee covenge were net
achieved by some future date tpwiftrd ia the
A major sticking point for the president iaUw. But Packwood, the senior Repubboa oa
Congress, particularly in the Finance Com- the Finance Committee, uid whether he
mittee, is his propoaal that en-jioyen be re-would do so would depend on the specific
quired to pay part of the premiums for healthterms aad whether the rest of thefailis accare for their employees. Ta s "employer ceptable.mandate" isfiercelyopposed by small bus*
nesaes and moat Republicans. Ickea said that A triggenng mechanism soch as that d^
on the Finance Comnuttee tad elsewhere scribed by Packwood. it bemf pushed by
"there are Repuhiicana who are ia favor efSea. John Breaux (D-La.). . a Finaace Comuiuvenal coven (a aad real reform." and he mittee member, as a compmntao between
believes that ii the ead. It is my sense thereClinton's demand that employen help pay
will be somefarmof employer mandate/ for premiums and Republican demanda that
Meanwhile. Moymhan. in a speech in Buf-any employer mandate be dropped.
BySpnccrRidi
THE f A<Hi>cTr)N POST
Finuv, JIM 3.1994
�AN Health Reforn,550
White House Says Clinton S t i l l Demands Universal Health Coverage
Eds: Note California angle in 4th graf
By CHRISTOPHER COlTHELL" Associated Press WriterWASHINGTON (AP) White House officials sought to throw cold water Thursday
on any suggestion that President Clinton would settle for a health reform b i l l
that left millions of Americans uninsured.
Deputy White House Chief of Staff Harold Ickes also said
a great deal of
progress has been made" despite slumping public support for health reforms
and problems in some key committees.
He predicted most, i f npt a l l , of the five major panels would approve
b i l l s by the end of June.
Meanwhile, Sen. Dianne Feinstein, D-Calif., quietly has withdrawn her
sponsorship of Clinton's plan. Feinstein, one of 30 original Senate sponsors,
took her name off the b i l l last week.
Feinstein, who i s running for re-election, said in a statement, " " I stand
vith the president on the need for health care reform, but i t i s now clear his
b i l l w i l l be substantially reworked in both the Senate and the House. '
Ickes and I r a Magaziner, a senior domestic policy adviser, told health
reporters at a briefing that universal coverage to Clinton means " a l l
Americans.•'
,
Some lawmakers are pushing a managed competition b i l l to broaden coverage
without government mandates. The Congressional Budget Office recently
concluded that approach would help 15 million Americans get coverage, but
leave 24 million uninsured.
I f tens of millions of people are s t i l l left uncovered, " " i t ' s hard to
claim that you've got a l l Americans private insurance that can't be taken
away, said Magaziner, an architect of the Clinton proposal.
Ickes, who joined the White House in January to captain the team pushing
for passage of health reform, said, ""The Clinton plan as we know i t took a
real beating. We don't deny t h a t . "
But " a great deal of progress has been made' in the past 12 weeks, he
said.
"""We expect that virtually a l l the committees w i l l be reporting out b i l l s
by the end of this month,'• setting the stage for floor debate in July on
b i l l s put together by House and Senate leaders, he said.
He shrugged off recent polls that show health reform receding as an issue
behind jobs and crime. Surveys have also found increasing skepticism about
Clinton's prescriptions.
Ickes predicted the final compromise w i l l include some requirement that
employers pay for workers' health insurance with workers required to kick in,
too, and ""substantial discounts to small businesses."
He and Magaziner declined to say whether the president could accept a
proposal floated by Sen. John Breaux, D-La., to phase in an employer mandate
over three to five years only i f market reforms failed to cover at least
three-quarters of th* uninsured.
""We're not prepared to bargain against ourselves at this point," said
Ickes.
He said Rep. Dan Rostenkowski, D - I l l . , forced to step down as chairman of
Ways and Means after his indictment Tuesday on corruption charges, ""obviously
w i l l be missed," but he predicted that Rep. Sam Gibbons, D-Fla., the acting
chairman, w i l l push a b i l l through Ways and Means this month.
While Republican votes may be hard to come by on the f i r s t round in the
House and Senate, Ickes said, " " I suspect we may see much more Republican
support" for the compromise that ultimately emerges from a House-Senate
conference.
1
11
1
****
filed by:APW-(CA) on 06/02/94 at 17:57EDT ****
**** printed by:WHPR(LMCH) on 06/02/94 at 18:02EDT ****
�M CRACKS SHOW
IN THE4PPOSITION
TO HEALTH PLAN
THE NEW YORK TIMES. MONDAY, MAY 23, 1994
SMALL BUTCRUCIALSHIFTS
Movement Is Seen on Issues
of Universal Coverage and
How to Control Costs
By ADAM CLYMER
SPKIII ia Tht N«« York TIIDM
WASHINGTON, May 22 - For the
first time since President Clinton proposed a national health msurance
plan in September, some of his opponents are giving ground.
Not necessarily a lot "It's a very
narrow strip of ground," said Senator
Daniel R. Coats, the Indiana Republican who last Thursday suspended his
all-out opposition to anything resembling the Clinton proposal. He did so
just long enough to join a unanimous
Senate Labor Committee vote for a
cost-control plan that involved major
concessions by both sides.
And last week's shifts among Labor Committee Republicans and by
Senator John B. Breaux the Louisiana Democrat on the Finance Committee who decided that he could support requiring most employers to pay
for their workers' insurance, hardly
opened a floodgate.
Still, there was important movement on the most crucial issue, how
to pay for any universal insurance
system. There was also a meeting of
minds on cost control, one of dozens
of complicated issues that Democrats
have committed themselves to clearing away over the next few weeks, a
necessity if Congress ts to redesign
the nation's health care system this
year.
Labor Committee Republicans,
plainly uncomfortaMe In the role of
naysayers that their party's lesders
assigned, may make more deals this
week on subjects like the degree of
bureaucracy needed to supervise a
new health system. That would be
another measure of opposition flexibility, comparable to the on the costcontrol issue. Until last week, it was
only Mr. Climon's allies who were
offering deals as they trolled for
votes.
Republicans wanted any benefits
program defined by an independent
board, not by Congress, which they
said would give away the store. Democrats said Congress had to level with
the public about just what medical
care would be covered in a new
system. So on Thursday they cut a
deal, with Congress'establishing the
system and a board having a great
deal of power to icut it back if costs
soared.
Mr. Breaux's shift on employer
payments was less decisive. He is.
after all. one senator, not a political
faction. But he moved on health
care's toughest political issue, and his
seat on the Finance Committee gives
him influence.
Republicans have been louder, but
conservative Democrats have joined
in their antagonism to making employers pay. When Mr.' Breaux said
he could suppon such a requirement
if it left employers of 10 or fewer
workers free not to insure, that was a
major break in the opposition ranks.
On the other side of the Capitol,
Representative Richard A. Gephardt
of Missouri, the majonty leader, said
1
Cracks Show in Opposition
To the Health Care Overhaul
ry S. Truman to. as Senator paui
Wellstone of Minnesota put it, "the
pricklings in my fingertips" that tell
Mr. Breaux's shift had altered the him this is the time to move forward.
While the Democrats edged toward
political situation in the House, "it
means conservative Democrats can common ground, the Republican posistart talking about ideas that em- tion was less coherent The Republicans sought to portray themselves ss
brace universal coverage." he said.
He also said there was a lot of taking a clear stand with some new,
House interest in the bill that the television ads, curiously labeled "a
Senate Labor Committee was consid- bipartisan message." But the issue
ering, a modification of the Clinton they chose, making insurance coverplan put forward by Senator Edward age portable from job to job, Is both a:
M. Kennedy that would soften its im- second-tier question and much more
pact on very small busmesses and complicated than their ad suggested.
enable any American to join the FedRepublicans on the Labor Commit-:
eral Employees Health Benefits Plan tee alternated between cooperation
and thus be offered the same insur- and invective, offering amendmenu
snce choices that members of Con- they sometimes seemed not to undergress here and Government file stand. One amendment, by Senator
clerks everywhere now hsve.
Judd Gregg of New Hampshire, a
In the Senate, too, the movement by fierce opponent of requiring employMr. Breaux suggested that Demo- ers to pay for workers' insurance,
crats could get the bill out of the appeared to do exactly what he want-,
Finance Committee without Republi- ed to prevent: It attempted to guarcan help If they have ta If they can antee every Amencan the nght to
solidify their own 11 votes, that may keep the insurance he or she has now,
be the surest wsy to attract some which would mean that employers
that now provide insurance would
support from the 9 Republicans.
Today one of those Republicans, have to continue to do sa.
Senator John H. Chafee of Rhode IsWeighing the Costs
land, predicted that the committee
And they offered cautionary arguand Congress would adopt a universal ments.
Replying to Mr. Kennedy's
insurance bill. He insisted on the NBC insistence
that "the American people
News program "Meet the Press" that expect us to
act, and it is our responuniversal coverage and the savings it sibility to deliver,"
Senator David F.
'
should generate, were unattainable Durenberger of Minnesota
said, "The
without requiring either individuals cost of not doing it right is
greater
or employers to buy insurance.
than
the
cost
of
not
doing
it
now."
The public shifts were not the only
Republicans also struggled to find
important developments in Congress. arguments
marginalize Mr. KenThe Finance Committee,, one mem- nedy, sayingtothat
the Finance Comber reported, decided not to wait until mittee — where they
stronger —
the Congressional Budget Office was a better forum forare
action.
But it
measures Mr. Chafee's bill, which
no clearer in Finance than in
would require individuals to buy their was
Labor or in the panisan bickering of
own insurance, before it starts voting the
Ways and Means CommitAnd it decided that the voting would tee House
what the Republicans wanted to
begin in early June
indeed, they seemed to be backBut even that decision was a re- do;
ing
away
from a bill sponsored by one
minder of a failure — the certain
their own, Mr. Chafee. The Repubfailure of all committees except, of
unwillingness to coalesce
probably, Mr. Kennedys to meet the licans'
Memorial Day deadline they had an- seemed to be uniting the Democrats.
This creaky, disorganized legislanounced, perhaps imprudently. That
failure underlined the critical impor- tive process has a long way to go
tance of June, of the four weeks until before it succeeds or fails. June will
the real drop-dead deadline of the be pivoul, but only in making July
July 4 vacation period. If the five and August floor action possible.
major committees have not finished
Senator Harris Wofford, "the Pennby then, sweeping change will be al- sylvania Democrat who rode the
most impossible this year.
heallh care issue to an upset victory
in 1991 and has assumed a growing
A Year for Change?
role in the Labor Committee's search
And the Democrats seem con- for compromises, said. "No legislavinced that this is the year for sweep- tion of this magnitude could move
ing change, perhaps in part because forward without tough and probing
they expect to have fewer Democrats debate." Comparing the effort to
around if they hsve to try again in reach agreement tb a family reunion,
1995. They cite everything they can he said that while it isn't "the Walthink of in support of this timetable, tons, it also isn't the Hatfields and
from the remembered words of Har- McCoys."
Continued From Page Al
�Hawau is a Heaith Care .Lab
As Employers Buy Insurance
Don Moore, who runs the hardware
store in Kula, on the Island of Maul,
said scornfully, "They keep adding
bells and whistles."
Teena Rasmussen, a wholesale
By ADA* CLYMER
flower grower who produces leis and
Siwrni 10 Thr Hem Vor* Timn
bouquets in Kula, said the combinaHONOLULU, May 3 — The lough: A prrnxiic report on national
tion of new mandates and heallh care
est question in the heallh care debate heallh issues.
inflation "was not something the emis whether to require employers to
ployer had any method of covering
buy insurance for iheir workers.
1980's, and it has not happened in the except by lowering the coverage."
But if members of Congress could last few years, when insurance pre- She said foreign competition preventher from raising her pnces. While
overcome their fears of being ac- mium inflation occasionally, reached ed
she
once voluntarily helped cover
double
digits.
cused of lunketeering and actually
workers' families, she does so no
Full-Time Worken Covered
visit Hawaii, they would find compelling evidence about how such a
Part-time workers under 20 hours
system actually works, and they s week need not be insured, but no
would noi have to rely on a range of matter how small a company is, it
must cover all its other workers —
absolute, if uninformed, opinion. .
Aboul 96 percent of Hawaiians and without subsidies of the kind that
President Clinton's proposal would
have health insurance. Employers, provide.
A report earlier this year by
regardless of the size of their work the General Accouniing Office, the
force, must pay for most of it. None- investigative arm of Congress, said,
theless, they have thrived, despite "We found no evidence thai the emfrustration over expanding benefits ; ployer mandate resulted in large disruptions in Hawaii's small-business
and rising.costs.
Moreover, Hawaiians seem health- sector. •'
But a different, less shrill concern
ier than other Americans. Recent
small business that is heard in longer and is buying the cheapest
surveys by both the Northwestern of
Washington does echo here. Some coverage she can find for her nine
National Life Insurance Company business owners on the mainland conand the American Public Heallh As- cede that Congress may, include full-time employees. But there is no
revolt. "Employers are very
sociation have rated overall heallh in enough exemptions and subsidies so business
resigned
to it over here," she said
Hawaii better than in any other state. that the impact of required insurance
'Hardly Worth If
The Federal Centers for Disease Con- is bearable when it takes effect. Bul
Mr
Moore
certainly fills thai bill.
they
do
not
trust
government
to
keep
trol and Prevention ranked Hawaii at
"There are costs in any business," he
or near the top in low infant mortal- it bearable.
That has been problem in Hawaii. said, "and certainly health insurance
ity, longevity and early death from
As
Bene latum, state director of the is one of them. It's pretty consistent
heart and lung disease and cancer.
National Federation of Independent that it goes up, but I wouldn't say that
Hawaii is the only state where a Business, pui it outside the Hawaii it has gotten out of hand." He could
recent United States Chamber of Legislature the other day. "Subsidies deduct a total $200.85 from his nine
Commerce survey of us members, come and go; mandates last for- insured workers every two weeks.
But, he added: "The 1.5 percent is
who are mostly engaged in small ever.".
business, found a majority backing
There is no doubt that Hawaii's hardly worth it You've got an emcompulsory payments. Hawaii is also system is quite a bit tougher on em- ployee relationship to maintain."
One more local business gripe ts a
the only state with experience with ployers now than when it was encounterpart of the widespread doubts
acted.
that system.
that Congress will subject itself and
Limits on Worker Premiums
It is a little-used laboratory. Only
Federal workers to the same terms tt
Over the years, Hawaiian officials imposes on the rest of the nstioa
one Congressional subcommittee has
come here this year to hold a hearing. have been prevented by Federal law Consider the way sute government
Nor is there significant academic re- from raising the ceiling on Worker treats itself here. It pays 60 percent of
search, even by the University of contributions to health care that the the cost of insurance and requires
state law set in 1974. It is limited to 1.5 workers to pay 40 percent It also
Hawaii.
percent of a worker's salary, and no does not cover Its "emergency
Yet 20 years of Hawaiian experi- more than half the premium. For a
ai all, even if their tenures
ence does offer suppon for requiring minimum-wage worker in 1975, the workers
retch well beyond the 30 days after
employers to pay, as President Clin- limit of S5.20 a month was nearly a -,t
a private employer would have
ton has urged, but also for some of the third of that year's $18.62 monthly which
to insure a worker.
fears that the proposal raises among cost of basic health msurance.
Big business has less trouble with
But health insurance costs have the system. Of the 17 percent of Hasmall businesses.
grown
much
faster
than
the
miniIt ts clear that the "employer manwaiians in 1974 who lacked insurance
mum wage, which was $2.00 in 1975 that would cover both doctor and hosdate," as the requirement to buy and
is
$5.25
here
now,
or
$910
a
month
workers insurance is known here and based on a 40-hour week. The most pital bills, most worked for small
in Washington, has succeeded in lhat can be deducted from a mini- :ompanies in small factories, shops,
bringing Hawaii to the threshold of mum-wage worker now is $13.65 per restaurants and similar businesses.
universal health insurance coverage. month, such a small share of the This is a heavily unionized state, and
That seems to have helped restrain $131.02 premium for a worker s basic most union contracts had ample
health care inflation, a serious prob- coverage that many, perhaps mosi. nealth insurance 20 years ago. But
big businesses, io compete for
lem here but less critical than on the employers do not bother to collect it. jther
workers,
matched that benefit
mainland: health insurance premiThough Federal law blocked HaPutting
Theory to Work
ums are about 30 percent cheaper waii from requiring workers to pay a
. here, while almost everything else in bigger share of their insurance prePeter Lewis, vice president of HaHawaii is more expensive lhan on the miums, Hawaii's lawmakers ingen- waiian Electric, the islands' domiiously found a way around the law io nant power company, said: "Probamainland.
benefiis. .
bly speaking for most big businesses,
The state health director, John C. add
Barred from amending their 1974 we support the idea of the Prepaid
Lewm. argues lhat the system has Prepaid
Care Act. Hawaiian Health Care Act. As a company, we
done more than that. "By emphasiz- legislatorsHealth
changed the basic insur- are very much focused on the prevening primary care, u has improved the ance laws, requiring
all health insur- tive end. In the long run. it will save
heallh status of the people of Ha- ers and Health Maintenance
Organi- us money."
waii," he said. As one example, he zations to add mental heallh and
drug
said, early detection of breast cancer and alcohol coverage, mammograms
There is no question that Hawaii
— despite a high rate of it on Hawaii and more well-baby care and, in the was
a favorable site io experiment 20
— had enabled the state to achieve example lhat business loves to hate, vears ago. Primary-care doctors outthe nation's lowest rate of mortality in vitro fertilization.
numbered specialists. There was s
from the disease.
relatively high level of insurance covYet Hawaiians seem rather bias*
More Benefits, But Low Cost
erage and a paternalistic tradition of
about the fact that they have someMarvin Hall, president of the Ha- looking after workers. Moreover,
thing unique. So they may not notice waii Medical Service Association, the businesses thai hated the system
being free of the mainland fears that local Blue Cross-Blue Shield group :ould not move across a state line.
their employers will cancel a health that covers just over half of HawaiCommercial insurers, denied the
plan, or that pre-existing medical ians, insists that those additions
conditions will either keep them "have noi added significantly to the :hance to avoid unhealthy clients,
. locked m their jobs, force up their cost of heallh care:" He says they quicklv dropped out of the markei,
rates or deny them insurance alto- amount to less than 10 percent of the ind the H.M.H.A.. the Blue Cross carrier, with about half the markei, has
gether.
premium. And Dr. Philip I. MacNa- rompeted ever since with Kaiser PerNor is there any echo of the intense mee, a fertility specialist, argues manente, whose H.M.O.'s have about
lobbyists' argument in Washington plausibly that all insured in vitro fer- i fifth of ihe markei. "Die compeution
thai compelling most employers to tilizations cost Hawaiians about a dol- nas kepi prices down and encouraged
pay for insurance will cost millions of lar a year in insurance.
the son of preventive care that
jobs and force thousands ot compameans a slightly above-average rate
Beyond
the
cost,
the
fact
that
the
nies out of business. That did hot changes were shoved down its throat jf doctor visits yearly but also lower
happen when Hawaii's mandate took rankles small business, along with a nospiializauon rates, shorter hospital
effect in 1975. it did not happen during general
disaffection from the heavily stays and less frequent surgery.
the worst of the recession of the Democratic
pro-labor Legislature
The Basics of Care
C
1
A health plan that
seems workable
for business and
workers.
t;
u
Z
�DON RilOU. MlCMWAH
G l M H J . M I T C H I U . M A M I . CMAH
THO U A I A. O A S C N U . SOUTH OAKOTA. C » C H A I I I M A N
OANIIL PATRICK MonmtAN. N I W ' Y O R K
PAUL S. S A R I A N H . MAKYLAND. VIM-CHAIUMAN
JOHN O. ROCKIMUIR IV. W i r r ViaomiA
C M A H U I s . R O M . VMOIMIA. victCMAMMM
OANIIL AKAKA. HAWAII
J I M BINGAMAN. N I W M U K O . VICI-CMAIIIMAN
JOHN GLENN. OHIO. V I C K M A I I I M A N
ERNIST F. HOLUNOS, SOUTH CAROLINA
Wimtth State* Senate
Bemocrattc $olicp Committee
C L A I I O R N I P I U . RHOOI ISLAND
O A U B U M M R « . ARKANSAI
HOWILL HIIUM. ALAIAMA ,
BTRON L OOROAN. NORTH DAKOTA
B I N NIGHTHORSI C A M P R I U . COLORADO
CAROL M O I I U Y - B R A U N . ILUNOII
RufiiLL 0. FEINGOLO. WISCONSIN
W I N D I L L H. FORD, KINTUCKY. EX Officio
(AS WHIP)
HiaJtJinffton. 3BC 20510-7050
FRANK R. U U T I N I I R O . N I W J I R I I T
DAVID PRYOR. ARKANSAS. E X Officio
(AS SICRITARY Of CONflRINCI)
(202) 224-8561
For Release:
Media Contacts:
Wednesday, June 8, 1994
Debra Silimeo, (202) 224-3232
Mary Ana Hill (202) 224-2939
MORE THAN 1,300 GROUPS AND BUSINESSES
ENDORSE EMPLOYER-BASED HEALTH CARE REFORM
More than 1,300 organizations and.businesses across the country formally endorsed
an employer-based approach to health care refonn. Senate Majority Leader George J.
Mitchell announced today. Groups and businesses, representing over 93 million Americans,
signed a letter to Congress calling for comprehensive health care reform and supporting
guaranteed coverage through the workplace as the best approach.
The letter, sent to Senator Mitchell by the Health Care Reform Project, says "We
believe that an employer mandate is a fair, effective and practical means for achieving
universal coverage. We therefore urge its adoption."
"What this letter shows is that the political clout of the forces supporting
comprehensive reform is formidable.. These forces, representing over 93 million Americans
- 155 times the membership of the NFIB ~ are standing up to let their voices be heard in
this debate," said Senator Mitchell.
Thousands of American businesses are among those endorsing an employer mandate.
Over 340,000 small businesses and 100 of America's largest corporations including Heinz,
Westinghouse, GM, Ford, Georgia Pacific and others, have endorsed an employer-based
system of shared responsibility as the best way to achieve comprehensive health care reform.
In addition, well over 300 small businesses have independently signed on to the letter.
The more than 150 national groups and 630 state groups, who have signed the letter,
represent nearly every senior citizen in America, millions of American workers, farmers, .
health care providers, and consumers advocates.
The letter shows continuing and growing support for real reform, providing health
care security for all Americans, through shared responsibility, this year.
-- 30 -
�Debate update
WHAT TO WATCH FOR
IN HEAITH REFORM
A guide
to the key
issues
facing
consumers.
H
everaJ bills to "refom"
the U.S. health-care system were making their
way through committees
in the House of Representatives at.
the end of April. Their next stop: the
House Qoor, where Representatives
will vote on a bill to send to the
Senate. What sort of law will emerge
at the end of the process isn't known
at this writing. But to qualify as true
reform, any law must include the following key attributes: universal
insurance coverage, comprehensive
benefits, cost controls, adequate financing, and public accountability.
They are the signposts to watch as
the debate progresses.
Universal (overage
What's ideal: Guaranteed insurance coverage for all Americans
regardless of where they work, their
financial circumstances, or their
health status. Ideally, such coverage
should be provided through a system
of national health insurance.
What's under discussion: The
notion that all Americans should
have health . coverage has won
greater acceptance in this round of
health-reform deliberations than at
any other time in the last 50 years.
StiU, that view is not shared by everyone. Whether the U.S. will join the
rest of the industrialized world and
provide coverage for all its people is
still very much in doubt Indeed,
Republican strategist William Kristol,
chief of staff for former vice president Dan Quayle, has sent a letter to
Republican leaders urging them to
oppose universal coverage and "be
proud to oppose iL"
Kristol exhorts them to discard
even the relatively new concept of
universal access, widely promoted by
Rep. Jim Cooper, a. Tennessee
Democrat, who appears to be serving
as the point man for business and
insurance interests that want to see
the status quo as undisturbed as possible. Unlike universal coverage,
which provides a mechanism for giving all Americans insurance protection, universal access simply means
396
everyone would have a chance to
buy insurance if they could afford it
Cooper's bill would not require
employers to pay for coverage for
their workers, as, for example, President Clinton's plan would do. Nor
would it call for cost-containment
measures beyond the normal workings of the marketplace. The Congressional Budget Office has found
that Cooper's bill would leave some
25 million people uninsured.
Dr. Alain Enthoven, a i member
,of the Jackson Hole group, the confederation of insurance companies,
health-care providers, politicians, and
academics that has forged the,
"managed-competition" approach to
reform, provides a convenient parallel for those promoting access rather
than coverage. He says that the U.S.
should set its, goal for coverage at
something less than 100 percent of
the population, just as the term "full
employment" means that something
less than 100 percent of the workforce is actually employed. "Any private health insurance system may
not be able to ensure every citizen
gets covered," Enthoven told Congress in mid-March. In other words.
"full insurance" might mean coverage for 90 percent or even 85 percent
of the population that is currently
uninsured. That is an unacceptable
proposition, in our view.
Universal access might help the
million or so Americans who can
afford insurance but can't obtain it
because of health problems. But it
would do little for the remaining 38
million uninsured Americans. Ifs not
even clear, that universal access
would be of much help to those who
are sick.. A number of proposals in
Congress, advanced primarily by
conservative Republicans and Democrats, retain pre-existing<onditions
requirements that would nmfrom6
to 12 months, depending on the bilk
That means people who obtain n A ;
insurance after a period withe^
insurance would have to wait half a'
year or more before their existing
health problems were covered.
We'd prefer to see universal coverage provided through a national
health-insurance system similar to
' that found in Canada, where a single
payer pays health-care providers to
deliver services under an agreed-on
budget The payer could be a state or
IN BLACK AND WHITE
CONSUMER REPORTS JUNE 1994
�leral agency, as ioCanada, or one
more companies working under a
public contract. What's more likely to
become law is an "employer mandate," which would require all employers to provide insurance coverage
for their workers, or an "individual
mandate," which would require all
individuals to buy coverage on their
own, leaving employers' contributions voluntary, as they are today.
Even with an employer mandate,
people without jobs would have to
buy their own policies, presumably
with some sort of Government subsidies or discounts for those who
couldn't afford the premiums.
An employer mandate is the better
of the last two options. More than
half of the 39 million uninsured are
in families headed by a full-time
worker who has been employed the
entire year. One third are in families
headed by a part-time worker or a
full-time worker who was employed
for less than the whole year. Given
those statistics, requiring employers
to provide coverage makes sense. An
individual mandate, on the other
hand, would require heavy subsidies
in order for all people to purchase
verage and would require a comcated enforcement mechanism to
make sure they buy it
O
Comprehensive benefits
Whafs ideal: A comprehensive
package of benefits for all Americans
that includes all medically necessary
care, preventive services, and some
long-term care for the elderly and
disabled. Those benefits should be
guaranteed in any legislation.
money. If such tax disincentives
Whafs under discussion: Many
force employers .and employees to
of the current bills (except for the
Clinton proposal and the single-payer choose the cheapest plans (ones that
would probably offer minimal beneplan) do not define a guaranteed
package of benefits, but instead give fits), the theory goes that people
would use fewer medical services,
a health commission authority to
decide just what would be included.. saving money for the system. These
dubious measures threaten to leave
If that happens, cost pressures and
special-interest group demands could • all but the most prosperous Americans with third-rate coverage.
compel the commission to change
the package in ways that may not be
Cost controls
in the public interest.
Furthermore, some proposals tinWhat's ideal: Strong cost-control
ker with the meaning of "insured."
measures, including global budgets
They would count among the in- . that set limits on how much the U.S.
sured anyone who buys a policy that as a whole can spend on medical
covers only catastrophic illness, say
care and fee schedules that prescribe
one with a deductible of $2000,
what doctors and other providers get
$3000, or more. Such policies would paid. Every industrialized country
almost certainly discourage people
with a national health-care system
from seeking early treatment and
has a mechanism for controlling
preventive care—important goals of
health-care expenditures. Given the
health refonn.
rapid escalation of medical costs over
the last few years and the fact that
Some politicians and interest
the U.S. spends more than any other
groups would also use the tax system to reduce the benefits many peo- nation—some 14 percent of its gross
domestic product—on health care,
ple currently have. They have procost controls are essential. The govposed taxing any premiums paid by
ernment already pays for about oneemployers that exceed the cost of
third of. the country's medical bills
the lowest-priced plan in a healththrough the Medicare and Medicaid
care alliance (a large insurance-purprograms and controls the fees it
chasing cooperative, called for in the
pays to those providers. The same
President's plan, among others).
control must be placed on providers
Other proposals would change the
in the private sector.
law so that some of the premiums
paid by employers would be considWhat's under discussion: So
ered taxable income to employees.
far, the kind of cost control most
Those proposals are designed to
often under discussion is market
eliminate the so-called "Cadillac" or
competition, which up to this point
"gold plated" plans that provide ben- has a less-than-stellar record for conefits such as mental-health or pretaining costs. For example, competiscription-drug coverage and suppostion among hospitals has resulted
edly cost the system too much
not in cost savings but in expensive
f
�duplication of services, especially of
new technology.
President Clinton's plan envisions
the creation of regional alliances that
would pool premiums paid by employers and individuals to buy coverage. Health plans eager to sell
through alliances would compete to
offer the lowest-priced services. To
achieve that, they would have to
pressure providers in their networks
to keep fees down. The Clinton plan
also calls for limits on increases in
insurance premiums.
. But the now-famous, or infamous,
"Harry and Louise" commercials
aired by the Health Insurance Association of America, plus the strong
lobbying efforts of the American
Medical Association and other provider organizations, have created so
much public anxiety that effoi^s to
control costs through limits on insurance premiums or through health
alliances face growing opposition in
Congress. For alliances to have
enough leverage to control costs, virtually all employers and individuals
would have to buy coverage through
them. But if groups of providers and
individuals remain outside the costcontrol mechanism, putting a brake
on health-care costs will be difficult, '
if not impossible. If legislation calls
for voluntary alliances, they would
probably be ineffective.
More effective cost-control measures, such as global budgets and
provider fee schedules, are receiving
little serious attention. They are
anathema to the insurance industry
and medical providers.
Without them, though, the pernicious cycle of cost shifting from the
cost-controlled Medicare and Medicaid programs to uncontrolled privately insured patients will continue.
Such cost shifting is partly responsible for therapidescalation of premium rates. As Government programs
further slash provider fees in an
attempt to control costs, there's also
a danger that beneficiaries will have
a harder timefindingdoctors to treat
them. If cost controls are to work.
1
Up and away
The percentage
of U.S. gross
domestic
product spent
on health care
has risen dramatically in
recent years.
Figures for 1995
and later are
estimates that
assume the
system remains
unchanged.
1980. 9.2%
1985 ....10.5
1990 ....12.2
1992 ....14.0
1995 ....15.7
2000 ....18.9
2004 ....20.0
Source:
Congressional
Budget Oifica •
they must be applied equally to pri-'
vate as well as public payers. Indeed,
it would be best to eventually integrate the Medicare and Medicaid
programs into a single system with
one overall budget
I
So far, there's little consensus
how to" pay for those subsidies, oi
side of increasing cigarette taxes, a
move that will raise just afractionof
the amount needed. Most proposals
also call for cutting payments to doctors and other providers under the
Adequate finaming
Medicare program as a way to raise
What's ideal: A broad-based, pro- money to pay for the uninsured.
gressive income or payroll tax that
That's likely to. encounter serious
would generate enough revenue to
opposition from the American
cover not only the currently unin- Hospital Association, which says
sured but everyone else as well. That Medicare payments to its member
would eliminate the need for employ- hospitals are already too low, and
ers and. increasingly, employees to
from retiree groups, such as the
shoulder the burden for health-care
American Association of Retired
premiums.
Persons, which fear further cuts to
Whafs under discussion: Aldoctors might mean less service for
though income or payroll-tax inMedicare beneficiaries.
creases would in large measure
While CU would prefer to see a
merely replace the insurers' premi- broad-based tax pay for everyone's
ums that now come out of incomes
coverage, the employer mandate,
and payroll, few politicians have the
which (under the Presidenfs procourage even to speak of a broad tax. posal) requires employers to pay at
Instead, variousfinancingmeasures
least 80 percent of the premium
to provide subsidies to the uninsured costs for their workers, is the next
and to . small businesses are on the best approach. Some employers and
table. Subsidies are essential if the
their trade associations, particularly
uninsured are required to buy insurthe National Federation of Indepenance. A study by the Kaiser Family
dent Business, arefightinghard
Foundation/Commonwealth Fund re- against any /employer mandates.
ported that 59 percent of uninsured
Unless employers are required
adults have no insurance simply bepay a large portion of the premiu
cause they can't afford it Thafs not however, workers will have to shou?
surprising, since the typical family der more of the cost themselves.
health-insurance premium now runs That would create a big incentive for
about $5000 a year.
them to go uninsured—a poor idea
Such subsidies will be necessary
both for the individuals concerned
whether an employer or an individu- and for the system.
al mandate is chosen. In fact with an
Publk accountability
individual mandate, more subsidies
Sorely lackingfromthe debate at
would be needed, since employers
that now offer, and pay for coverage this point is arecognitionof the need
might decide td shift the entire cost for public accountability. The bills
to individuals, some of whom would under discussion would almost inthen have trouble paying premiums. variably. leave decisions about the
Low-income people would also need treatment patients could receive tb
additional help in the form of limits the very businesses with a financial
on how much they could be required incentivefordenying care: insurance
to spend for coverage. Without such companies and managed-care orgalimits, a family of four with an in- nizations, such as HMOs. That, ip
fact, is the direction the U.S. fis
come, say, 50 percent above the
poverty level (that is, about $21,500) already taking. True refonn would
would spend more than 20 percent of reverse that unhealthy trend and put
patients above profits.
•
its income for health insurance.
CONSUMER REPORTS JUNE 1994
�Healtli Reform: The Missing Story
Critics in fright wigs mislead you about the Clinton plan
BY J A N E
BRYANT
QUINN
r YOU WANTED TO FOIL THE CLINTON Pt.\N TOR LMVFRSAL vou any doctoryou want. In 1988.89 percent of the employees in
health care, where would you start' You d spook the public companv plans could choose tee-for-service. KPMG Peat Marwith ghost stories, hoping to scare them away from retorm wick reports (its survey covered medium-size firms and up». Bv
That's what's happening now, as rumormontters m rn^ht Vi'i-l. that number had shrunk to 35 percent. Lett to itself, the
wigs sponsor TV' ads and make the rounds o; the op-ed m-irket will eventually Lmit you to stalf docton at a healthpages. If they get enough voters to back a^ay. health-care re- maintenance organization iHMO) or the network of docton m
form-if it passes at all-wiU reflect the interests ot'the msdical- a preferred-provider organization (PPO).
. industrial complex, not yours. Docton and health and insurance Ironically, the Clinton plan-which critics claim will wipe out
execs, along with their political-action committees • PACsi. in- doctor choice-might actually preserve it beyond its likely freevested S8.3 million in Congress during the tirst 10 months ot market life span, says John Holahan of the Urban Institute. Your
1993. up 22 percentfrom1991. reports Citizen Action, a Wash- choices. Clinton says, must include at least one fee-for-service
ington consumer'group. The drumbeat ot dismiormation has plan, giving you access to almost any doctor with such a practice,
been pounding away on four major issues:
and one HMO with a "point of Jervice'' option.
1. Who's uninsured? The shoulder-shruiigers say :hat those
Point-ot-service HMO plans are proliferating. Those who
without coverage are mainly young workers who could buy choose them will normally see the docs at their HMO But they
health insurance but don t. or people berween jobs who will can also visit an outside doctor. This privilege is expensive.
come under another plan soon. Even if that truly
—:
, Today, you might pay an extra 20 percent premium.
described the problem (and it doesn t). I don't ;ee
plus an annual S300 deductible, plus 50 percent of
why their lack of coverage is OK. The uninsured see
each outside doctor'sremainingbiU. with a cap of
docton less otten than the rest of us. are more apt to
S3.000 on your spending. Butforthe well-to-do, the
need hospitalization for illnesses that could have
choice makes HMOs more appealing If they doubt
been treated at home, go to the hospital in worse
a diagnosis, they can get another opinion.
shape uid die there more often. The cost of their
At present moat employen don't offer both of
treatment comes partlyfromtaxes and partly from
these doctor-choice plans. And none of the Conhigher charges to everyone else.
gress's managed-care billsrequirescompanies to
have them. So although the president draws tho fire,
The uninsured are counted by the Census Buhis bill should open more doors than it doses. What
reau's annual population survey, which numbered
In a year,
the docs don't like is that CUnton wouldrestricttheir
'hem last March at 37.4 million. That's up from
one in four fees, while most of the other bills let then charge
2.6 million in 1988. with most of the losses fallwhatever they waaL
ing on small-business workers and the self-emmay lose
ployed. But many more probably lacked coverage
S. Caa yea pick the beat eeverataf* year fmlyT
during at least part of the year,reportsLewin-VHI. coverage. The Clinton would group most people into purchasing
a health-careresearch-and-consultinghrm that
co-ops (alliances). Once a year you'd (rt a booklet
rest are a
develops data for government and business clients.
containing details oo the plana in yourregion.MemThe total uninsured at some point during 1993 prob- pink slip away. bers could choose the ooe they liked. Eveiy plan
ably reached more than 51 million—almost one ia
^ would covar the same things, so you'd pick based
four Americans under 65. The rest are only a pink slip awiy. on competitive facton like quality, coovenienca and price.
Fewer than two out of 10 of the uninsured an young people 18 The Health Insurance Assodatko df America (HIAA) has
to. 24. Most of the rssl are woridng adults (plus their spouses andbeen sponsoring TV ads sugpsting that tho better plans won't be
children) who have ao eaployee plaa. Only 28 percent are on your alliance's list But the only plans it could muse are those
officially clsssifiad as pose Neariy 60 pereent earn low to middlecosting 20 percent more thaa averafi (although there must be a
incomes:fora (aatif of but that means S14.300 to SS7.300. fee-for-service plan, regardless of price). So these ads mislead.
pretax. The cost of M^flOMngi can easily runfrom$6,000 to There would, however. , be many invar bealth insuron. which
S11.000 a year. So evwat the high end. insurance isn't an easy explains the HIAA's concern.
buy. Around 3 poreeat lack policies because of an illness insurers 4. Why net Just cower the n
won't covar. Only 7 percent go bare by choica.
Doner It doesn't work. If Conym created substdiad pools for
More than half of the uninsured depend on small firms or are the uninsured, thousands of small businesses would drop their
self-employed. The voluntary health plan proposed by Rep. Jim own plans and toss their lower-income workers onto the public.
Cooper assumes that competition will cut health-insurance costs Other miw-refonns hava drawbacks, too. Say,foresaaipfe. that
by so much that employen will choose to help workers buy Congress left the insuren untouched except torequirethem to
policies. But according to a 1991 Harris poll more than half of take all comenregardlessof health. The insuren could still
s mail-business owners aren't likely to purchase coverage even if avoid many highrisksby not hiring agents in low-income areas.
the price drop* by SO percent
Clinton's plan can't pass as written: there are serious ques1 Can lea pick yoar om doctor? Without health reform, the tions of cost and reach. But tinkering just preserves the status
answer is increasingly no. Cost-conscious health plans are rapid-quo. which is what the critics infrightwigs want
ttiprnw. TIMMA EmtitrtLO
ly smothering fee-for-service medicine, where insuren allow
I
NCWSWCCK
M A I C H . s i . 1994
�Truth Lands in Intensive Care Unit as NewAd&
Seek to Etemonize Clintons Health-Reform Plan
9
By RICK WAKTZM.AN
.SIJ-' R.-portf o ' ' T H E W » L L STRF.rT J.JVRNAL
WASHINGTON. - The baby's scream is
anguished, the mother's voice desperate.
Please.'' she pleads into the phone, as she
seeks help for her sick child.
We're sorry, the government, healthcare center is now closed." says the recording at the other end of the line.
However, if this is an emergency, you
may call 1-SOO-Govemment." Her baby
still wailing, she tries it. only to be greeted
by another recording: We're sorry, all
health-carc representatives are busy now.
Please stay on the line and our first
available..."
Why did they let the government take
over?" she asks plaintively. " I need my
family doctor back."
The only problem with the radio spot,
produced by a Washington-based group
called Amencans for Tax Reform, is that it
isn't true. Neither the Clinton health-care
bill nor any of the alternatives on Capitol
Hill would force people to call for government approval before visiting a doctor or
rushing to the hospital. "It scares people,
and that irritates the dickens out of
me," says Democratic Rep. Jim Slattery. a
critical vote on the House Energy and
Commerce Committee whose eastern
Kansas district was a target of the ad.
Battle Heating Up
Such fear mongering is rampant as
Congress moves forward on compromise
health-care legislation. The complexity of
the Clinton proposal and the fact that the
issue affects every American have resulted
in a flood of alarmist propaganda that
makes Harry and Louise, the health-insurance industry's fictitious Clinton cntics,
look like Ozzie and Harriet.
Some of the horror stories stem from
ideological differences. Many of the groups
twisting the facts are hard-line conservatives, bent on stopping any government
presence in health care.. But clearly there
are other motives as well. Some groups, in
issuing direct-mail warnings about healthcare reform, are soliciting money to help
their cause.
Americans for Tax Refonn. which
claims 60,000 memben. makes no apologies for the I-SOO-Goverament ad. "Is it
frightening? Yes. Do I think we oversute
the case? No." insists Grover Norquist. the
president of the group, which is perhaps
best known for asking lawmakers to sign a
pledge opposing all income-tax increases.
Yet even some of the toughest cntics of
the Clinton health-care proposal, upon
hearing the ad. condemn it. " I think it's
unnecessary to use scare tactics." says the
Manhattan
Institute's
Elizabeth
McCaughey. whose own attack on the
Clinton plan in The New Republic magazine was denounced by the White House
and its allies.
Ms. McCaughey. who defends her critique by noting that it cites specific passages in the Clinton bill, rinds all sides of
the debate guilty of playing: to people's
emotions. That, she says, includes the
administration and its supporters, who
eagerly recount stories about peopie who
lose their health insurance, get sick and
are then financially wiped out "That's a
kind of scare tactic, too.'' she says.
Still, some groups have taken the tent-,
fying images to a different level, serving
up wholly fictional accounts of people
denied the most basic care by a heartless
bureaucracy.
Citizens for a Sound Economy, a conservative group that gets about half of la
$8 million budget from corporate and foundation sponsors and half from individuals
who send in contributions averaging about
$20. has also run radio ads in key congressional districts featuring a distraught
mother on the phone. This time, she's
trying to visit "Dr. Murray" so her son's
earache can be treated.
\.\J1 nmmr.H
How Mrfc O r t o n . Heakh d r e l
Rcrfbnn ptmt wil rffcrt you:!
A l t a i »* •»*«• b (WM* « • »• »
I t * mwmmm •» r o * t m • » • * ! - aa r a u d
k j x - sal h o •»»
m. f l r a r i <ak
n t >Arr* * j M on* t t rftr unit kmwm. bmt
fnfimurm t n t i i l — i kkidm >m tk* Prtsidtat'f
mrM hMBk n n n f e m 0 M . Tkntpn*ru—i t n
lUMariiad in l U 4mtnctm Ctmmil i m*m
romiiawr'i faidtbMfc. HttlH Cirr Mrform I ,
Tin Ooaonl. M uoa u I rttnvt yoar biUM. I ll
KJJO» von r» mt»r*»t*d. Mini r n * r m your /rer
lardtbuek ba htiltk ctr* r.furw.
American Council for Htalth Cart Rtform s dirtct mail litaraturt
You will not see Dr. Murray.'' the
government gatekeeper" replies. "Dr.
Johnson will see your son next week. . . .
Under health reform all Amencans, and
that includes you and your son. will have to
go through government health alliances
with gatekeepers like me. We will decide
who. when, or even if you need to see a
doctor."
Brent Bahler of Citizens for a Sound
Economy claims that "what we're presenting is a likely outcome" if legislation like
the Clinton bill is passed. But that's impossible. None of the health-care proposals on
the table, including the president's, has a
"government gatekeeper."
Some opponents of the Clinton bill
worry that such spurious claims could
backfire. "It becomes all too easy to fault
anyone who has legitimate criticism."
says Pam Bailey, president of the Healthcare Leadership Council, a coalition of
medical Industry representatives that is
lobbying against the Clinton plan.
Sometimes, the fabrications are bora of
real concerns. Many experts worry that
the Clinton bill, with its regional insurance-buying pools and a National Health
Board to oversee the system, would give
too much power to the government.
Moreover, many believe the Clinton
plan would hasten the already fast-growing trend of "managed care," where a
person's choice of doctors is limited and
physician "gatekeepers" often decide
whether a certain treatment is appropriate. Some analysts caution that because of
strict health-care spending caps in the
Clinton bill, rationing is possible.
The groups taking the hardest line
against the Clinton plan tend to oppose the
president's goal of guaranteeing comprehensive health coverage for every American. Many favor instead a more limited
scheme that Includes tax-free savings accounts from which people could pay their
medical expenses.
Under Investigation
Americans for Tax Refonn. for one. is
In a coalition called Gtizens Against Rationing Health that backs such an approach. Another member is the United
Seniors Associatioa, which says It is a
hree-market advocate for older Americans,
but which was accused by lawmakers
during a 1992 congressional hearing of
preying on the elderly for their money.
United Seniors was founded by conservative direct-mail pioneer Richard Viguene. though he is no longer associated
with it. The organization is under criminal
investigation by the Postal pspection
Service and theiFederal Bureau of Investigation, according to postal inspector Larry
Fryer. The association, which says it
hasn't heard from any federal investiga;
tors since October, complains it's the victim of a political witch hunt. "It's frustrating." says United Seniors spokesman Steven Allen, a former Senate aide.
Another of the big canards about the
Clinton plan is that people face "5-year's
in jail if you buy extra care." as the
American Council for Health Care Reform,
an Arlington. Va,. group, puts it in a
direct-mail package it has sent out to
millions of people. The council, which
according to tax records had revenue of
S302.2S9 in 1993, was founded 11 years ago
to get, the government out of health care.
"We aren't being alarmist," says the
group's Christopher Manion. "We think
the Clinton bill is alarming."
But in fact, while there is an antibribery provision in the Clinton proposal, the
bill explicitly says that people are free to
purchase "any health care services" they
want out of their own pockets.
"I don't see anybody going tb jail on a
liver-transplant rap." says John Shells, a
vice president at health-care consulting
firm Lewin-VHI Inc. "'They're trying tc
scare little old ladies."
THE WALL STREET JOURNAL FRIDAY. APRIL 29, 1994
�THE WALL STREET JOURNAL.
MARKETPLACE
Many Don't Realize It's Clinton Plan They Like
By HILARY STOUT
Slaff Reporter of T H E W A L L S T R E E T JOURNAL
YORK, Pa. - Jahan Bashir doesn't like
President Clinton's health-care plan. She
thinks it's too confusing, too complex and
probably too expensive.
What about a plan that would guarantee a standard private health benefits
package to all Americans, try to promote
competition in the medical industry, include some government regulation to keep
prices under control and require all employers to buy health insurance for their
workers with the promise of government
subsidies to help the smallest companies?
"It sounds good," says Mrs. Bashir, a
43-year-old secretary and mother of seven.
"Employers may pick up a lot of the
burden, but if the employer can't afford it,
the government will subsidize. So you're
going to have the employer, the government and the insurance companies working together."
Actually, that plan is the Clinton plan.
THURSDAY. MARCH 10, 1994
�THE WALL STREET JOURNAL.
Health-Care Satisfaction
With the U.S. hemcan system:
11%!
Very
satisfied
30% 1
Somewhat
satisfied
Somewhat
dissatisfied
30%
dissatisfied
26%
With your own medical care and
health coverage:
40%
3%^ Not sure j l %
THE WALL STKEEf MHSAL./WBC WfWS PtDU
In the poll, 45% of Americans now say
they oppose the Clinton plan, up from 39%
in January and 18% in September, just
after the president outlined the plan In
A new Wall Street Journal/NBC News a televised address to Congress.
poll shows that public support for "the Thirty-seven percent of those surveyed
Clinton health plan" is eroding. Yet the favor the Clinton program, down from 42%
same poll, conducted by Republican Rob- in January and 51% in September.
ert Teeter and Democrat Peter Hart,
But when read a description of the
shows that backing for the basic provisionsmajor provisions of the White House billin the president's plan is strong.
without identifying it - 76% of the respondents say it has either "a great deal of
appeal" or "some appeal."
THURSDAY. MARCH 10. 1994
�JUN-27-9 4
TUE
P.e1
10:25
Mind of the Manager
Why Us?
T
' hat was my first reaction to the idea of hoving businesses—esperioly small businesses—fund the nation's health
core. Then I ran the numbers for my company' • By Judy Wicks
business taxes and properly taxes—the list set-ms endless.
5 a restaurant owner who loves the business,
Then I thought of Keith and how most of out staff memI'rn getting tired of having our employees say
bers are not covered by health insurance, Jea.mie, one of our
to us, "It's time for mc to go oui ind get A real,
cooks, insures her two children under a welfare plan, but she
job." ^.Vhy aren't jobs in the restaurant busidoes not qualify- herself because she works. She is typical oi
ness considsred real jobs? Ask employees, and
the people not covered by health insurance: employee or
the most likely response wi!! be "Health-insmall businesses who cam afford coverage tor themselves and
surance benefits."
whose employers don't provide it. Eighty-eight perarit of
Take Keith, a young man who walked into my restaurant
people with private insurance are covered through tbe works few yeare ago looking for a job as a waiter. Keith was a litplace; the majority of those not covered live in families
tle rough around die edges at first, but after he had several
headed by working people like Jeannic and Keith.
:nonr.Ki of training and experience, customers were requesting Kim. He learned the job of rrskirg people feel cared for
It's no secret that most business organizaiions, including
and happy. His cheerful suggestions gave him a high average
the National Restaurant Association, have come out against
check per customer, while his efficiency got those table.?
the Clinton plan. I've been hearing wild stories about how a
turned for a third seating, with just the right timing to keep
pizza would cost 537 if the plan were passed and how the
customers from feeling rushed.
restaurant industry would be forcsd to lay off more than
Before long Keith becatne one of the top salespeople in a
800,000 workers. So I decided to take a closer look to find
company grossing
million, He got good tips. Everyone
out exactly how the plan would affect the White Dog Cafe,
/.'as happy- And then the other day Keith showed mc pictures
Through a formula that takes into consideration rhe
of his young daughter and explained that a second child was
number of employer;: in a business and the average wage
on nhe wa)-. I knew what was coming next,
earned, the proposed plan caps the amounv
because I had heird it .so often during my 22
a small business must pay at 3-5% to 7-9%
years in the business: "Time for me to go out
of total payroll. We currently pay ar. aversnd get a real job-" Keith is now headed for
age of around $30,000 in annual health ina big hotel chain where He can get full
surance to cover 15 employees. Under the
health-insurance benefits for his family,
Clinton plan, in which our cap would be
something we could never afford to offer.
set at 3.5% of payroll, our costs would inMy restauRor, the White Dog Cafe, in
crease to around $60,000 to insure ali 96
Philadelphia, employs % people, including
employees. The additional 530,000 ex•.he srafFof our adjoining gift shop, the Black
pense could be covered by increasing our
Cat. Like m.any small businesses, we're proprices by less than 1%. Covering all 96 emviding just what the economy needs. We
ploytes under the current system, even with
employ lots or people-, many are low-skilled
a 20% employee contribution, would cost
and at entry level. But as in other restauus S 140,000, Opponents of the plan call it
Judy V/klcs cgree-. wifh Hiilory
rants, profit matgins are slim, and the cona new payroll tax; I call it a bargain. Here's
Rodhoiv, Clinton.
cepi of providing health insurance for all
an opportunity to insure all our employees
jus: doesn't compute, It's not that wc don't want to do so. We
at an affordable rate, something we cannot do under the
believe that al! our staff should, be covered, but under the
present system. We increase onr capacity to attract and
current system we can afford to cover only IS psople.
maintain valuable employees. I can. sec some sense in bigWTien I heard that the Clinton healdi-caie-reform plan
business opposition to the plan, bm how can small busimandated that ai! employers provide health insurance, my
nesses not sec the benefit?
first reaction was, "Why us?" We're already burdened with
Our office spends hours researching health-plan options,
the enormous task of collecting income and sales taxe.*, matchand we know that as a small business we cannot get the same
ing social security, and paying unemployrner.r taxes and
rates that are available to large companies. Some sort of purworkers' compensation, .'.et alone cuy, state, and federal
chasing-alliance system would give us a competitive bargainlu.'y Wkks is the co-owner of tht While Dog Cufe, in Philadelpliia.
i i; .v E r g o 4 I N C . 25
�.JUH-27-94
T U E1 0 : 2 5
P . 0 2
Mind
ing position and eliminate the hours wc
spend not only in researching plans but
also in collecting employee contributions,
both of which would be handled by the
alliances. We currently offer two healthplan options to our employees; the proposed plan would offer three. .Another
thing our office hates to do is send checks
for workers' compensadon insurance,
which cost us more than 550,000 last
year, to piovide medical coverage for a
tew minor cuts and burns. The Clinton
plan suggests transferring thefinancial,responsibility for all medical benefits, including those under workers' comp and
auto insurance, to the new universal
heaJth system..
Under the cunent system, we cannot
change insurers for a better plan, because
one of our employees with a preexisting
health condition //ould lose his coverage
(something we're not willing io ler happen). The Clinton plan prohibits insurance companies from refusing or dropping coverage because of poor health.
Thar is an experience many employers
with a smp.il employee pool have run up
against and one of the main reasons we a I
ai
tho
Managur
prices we pay. So why shouldn't our employees get the same coverage?
Small companies like mine wouid
I've been hearing wild stories
greatly benefit by offering health insurabout how a pizzo would cost $3/ance to all employees, because it would
make us more competitive with big busiif the Clinton plan were passed andness in tbe labor market. For so long,
restaurant workcxs have been like sechow ihe restaurant industry would ond-class citizens in this economy. The
face of the matter is, unlike other indusbe forced to lay off more than tries, we small testaurants have never
charged our customers what it reilly
800,000 workers.
costs to run our businesses; which
should include the cost ot health insurance for all our workers. And the proseem to be tn agreement that universal posed plan presents an opportunity TO
coverage rs the fair and practical solution. provide full health-care coverage for ail
The argument is about who's going to our employees at such a low cost that we
pay, but the way I see it, we're all going to would vave to raise prices only slightly.
pay one way cr the other—either through All restaurants could make that increase
the government widi increased taxes or without losing business; after all, we're
through tlie workplace with increased not an industry chat is losing its cusprices. Currently, we small-business peo- tomers to Mexico.
ple are paying tor generous full-coverage
Right now Our worn' is more about
health benefits for government workers losing our best workers to big compathrough the taxes we pay, and we're pay- nies. I want to be able to call Keith up
ing for those same benefits for big-busi- and say, "Come back to the White Dog.
ness employees through the consumer We have a real job for you." a
There's no reason to keep the two apart any longer. Gold Crown Club Internationa', points
re now worth more than v*r before, Best Western staya. American Airlines tickets. Avis car rental*,
Carmvai Cruises snd U.S. Savings Bonds are Just the beginning. To show you we mean businesu, we've mvaat*
more than a billion dollars in the past few years to upgrade our properties, guaranteeing you lha quality you've
tem9 to expect from Best Western. Just call l-SOMJSS-GOLD to join. Vour memberslilp is good at over 3,000
P^t Western locatione around the world. You take care of business now, and well take oare of the fun later.
t
9
C A L L 1-800*526-1234 Q R Y O U R TRAVEL A G E N T F O B RESERVATIONS. YOUR B E S T B E T I S A B E S T W E S T E R N .
�July 1, 1994
To: Distribution
From: Lynn Margherio
SUBJ: Medicare/Social Security voting history
Attached is a chronology and a quote about the voting history on Medicare and Social
Security.
Both Social Security and Medicare drew partisan votes during the committee process - with
Democrats voting in favor and Republicans voting against. This turned when they went to
the floor.
�JUN-30-1994
17:35
FROM
TO
9456555?
P.02
MEDICARE CHRONOLOGY — HOUSE
1964
— Ways and Means Committee reports b i l l on p a r t y l i n e vote
(D: 17-0) (R: 0-8)
— Republican Amendment t o gut the b i l l and replace i t w i t h
a v o l u n t a r y program f a i l s 191 t o 236 (D: 63-226) (R:128-10)
— House approves Medicare w i t h strong b i p a r t i s a n support,
313-115 (D: 248-42) (R: 65-73)
— House approves conference r e p o r t 307-116 w i t h a m a j o r i t y
of Republicans (Dt 237-48) (Rt 70-68)
MEDICARE CHRONOLOGY — SENATE
1960:
Sen. C l i n t o n Anderson's Amendment F a i l e d 44-51 (D: 4319); (R:l-32)
1962:
Sen. C l i n t o n Anderson's Amendment Tabled 52-48 (D: 2 1 43); (R: 31-5)
1964:
Sen. A l b e r t Gore's Medicare Amendment Adopted 49-44 (D:
44-16); (R: 5 - 28) — Died i n Conference
1965
Medicare Adopted 68-21 (D: 55-7); (R: 13-14)
1965
Conference Report Adopted 70-24 (D:57-7); (R: 13-17)
�JUN-30-1994 17:35 FROM
TO
94565557
P.03
SOCIAL SECURITY CHRONOLOGY — HOUSE
On A p r i l 5, 1935
Ways and Means Committee reports the Social S e c u r i t y
Act without a s i n g l e Republican vote (D: 16-0; 1
absent) (R: 7 "Present")
On A p r i l 19, 1935:
House r e j e c t s motion t o recommit the b i l l t o Ways and
Means ( o f f e r e d by Treadway - R, MA) 149-253 (D:45-252)
(R:95-l)
House approves Social Security 372-33 (D:288-13) (R:77.
18) (1:7-2)
On August 8, 1935
House approves conference r e p o r t by voice vote
SOCIAL SECURITY CHRONOLOGY — SENATE
On June 19, 1935
Accepted an amendment t o exempt f i r m s o f f e r i n g p r i v a t e
pensions 51-35 (D:35-30) (R:16-3) — dropped i n
conference
Rejected an amendment t o s t r i k e old-age b e n e f i t s was
r e j e c t e d 15-63 (D:3-54) (R:12-7)
Passed the b i l l 77-6 (D:60-l) (R:15-5) (1:2-0)
On August 8, 1935
Adopted Conference report by voice vote
�JUN-30-1994
17:36
FRUH
IU
vnoaoozx
r.KJt
"It was an open secret on the hill
that many Republicans were not in
sympathy with the measure drafted,
but dared not be recorded against it
for fear they would be snowed under
at the next election."
"G.O.P. Crushed as House Votes Pensions, 372-33."
The Washington Post. (Douglas Warrenfels, April 20, 1935, p.l).
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Miscellaneous] Q and A’s
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Jason Solomon
Identifier
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2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 37
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093764" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Preservation-Reproduction-Reference
Date Created
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2/6/2015
Source
A related resource from which the described resource is derived
42-t-12093764-20060885F-Seg2-037-010-2015
12093764
-
https://clinton.presidentiallibraries.us/files/original/e741b7fc58e5b94fe983d6745a96a61d.pdf
0cbc0db387436d6dacebc9e7379dac35
PDF Text
Text
FOIA Number:
2006-0885-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Solomon
Subseries:
OA/ID Number:
3327
FolderlD:
Folder Title:
Letters
Stack:
Row:
Section:
Shelf:
Position:
S
52
7
9
2
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
SUBJECT/TITLE
DATE
RESTRICTION
001. letter
Constituent to POTUS; re: No Insurance (partial) (1 page)
02/08/1994
P6/b(6)
002a. story
re: Monthly Premiums (partial) (1 page)
n.d.
P6/b(6)
002b. stories
re: Health Care (partial) (1 page)
n.d.
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Jason Solomon
OA/Box Number:
3327
FOLDER TITLE:
Letters
2006-0885-F
ip2773
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - 15 U.S.C. 552(b)]
PI National Security Classified Information |(a)(]) of the PRA|
P2 Relating to the appointment to Federal office |(aX2) of the PRA]
P3 Release would violate a Federal statute 1(a)(3) of the PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute |(bX3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions [(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�;
- t
February 8, 1994
Dear Mr. President:
1 am a 28 year old nurse with no i n s u r e
diseaseT 1" ~ Was" d iij'gnp s^_wjlJi_.Rod g V in' s d i &e a se (cancer) in May
1987. After diagnosis, 1 received radiation therapy everyday for
four (4) months. 1 have also been through four (4) surgeries and
bone marrows which were all pain beyond belief.
My insurance paid well and 1 decided to work through treatments.
As sick as I was, I would go to work at 5 am, work until 11 am, go
get radiated and go back to work after treatment. 1 was laid off from
that job in 1992 after 8 years of service.
Shortly after being laid off, I started a new job ancl
later I had a reoccurrence of cancer. I had a COBRA
previous job and a limited amount of insurance left.
beyond my control. 1 had given that company 150%
was what they gave me in return.
three (3) months
policy from my
The lay off was
and a lay off
After being diagnosed, I received chemotherapy and radiation again.
I had to work through these two (2) cancer treatments to help pay
for the bills that my insurance did not pay. Chemotherapy was
$1300.00 every two (2) weeks and we had to pay what my insurance
wouldn't. The cost would usually be $150 - $200 every two (2)
weeks plus anti-nausea medicines which are very expensive. The
bills were overwhelming. I went to work at Sam until noon on
Friday and then went to chemotherapy. After treatment 1 stayed
sick on the couch until Monday morning and went to work at 4am
sick, nauseated and vomiting.
I was taking care of dialysis patients who were healthier than I and
who had insurance paid by the state. I was radiating next to
prisoners who had free insurance and 1 was unable to pay jujy bills.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
Constituent to POTUS; re: No Insurance (partial) (1 page)
02/08/1994
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Jason Solomon
OA/Box Number: 3327
FOLDER TITLE:
Letters
2006-0885-F
IP
2773
RESTRICTION CODES
Presidential Records Act - (44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA|
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA|
P3 Release would violate a Federal statute |(aX3) of the PRA|
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute |(bX3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�I raiLout of insurance in October of 1993 when no one would cover
me because of an illness I never asked for or deserved. My God I'm
"only "28 and 1 have minimal coverage. My insurance will not cover
CAT scans, blood work, chest x-rays or doctor visits. What am I to
do?
r.
I am not asking for anything free. All I want is to pay a fair price for
decent coverage. Not free, just what I pay for. 1 not only have to
worry about if the cancer will come back but how will ] pay for any
treatments.
I refuse to leave my family and husband with bills incurred because
of me. My parents retirement was meant for retirement and not for
my unpaid medical bills. I would rather not take treatment and die
than leave medical bills for my family to deal with. 1 think it's time
you do something for the hard working people of this country, who
arc willing to pay for insurance, but are uninsurable.
I voted for you because you seem to be very people oriented. Please
look after me and people like me. You are our only hope. No one but
you. My life depends on it.
Yours truly.
V
.
P6/(b)(6) ;.
'
i C L ^ ' ^ W ^
.
, < P6/(b)(6).
•
<;
t:
i••i ^:;^^ .: '•^•t'.'
v
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002a. story
SUBJECT/TITLE
DATE
re: Monthly Premiums (partial) (1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Jason Solomon
OA/Box Number: 3327
FOLDER TITLE:
Letters
2006-0885-F
IP
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)]
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute |(bX3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIA]
National Security Classified Information [(a)(1) of the PRA]
Relating to the appointment to Federal office 1(a)(2) of the PRA)
Release would violate a Federal statute 1(a)(3) of the PRA]
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
2 7 7 3
�—-MOLA, KANSAS
I am 59 years old. My husband is 61. We own a small retail garden shop in a
small town in Southeast Kansas. We have had Blue Cross/Blue Shield since
1989. Our monthly premium in 1989 was $243.00. In 1990 it rose to $433. In
1991 it was $558. And last year it had more than tripled to $900 per month.
The only hospital stay during this entire time was a two day stay for minor
surgery. There was some outpatient testing as I have a history of bladder
tumors. My husband also had a caterac removedfromhis eye.
As our annual income is modest, it is needless to say when the premiums went
up to $900 per month, we werefinanciallyforced to make changes in our
coverage. I have since found new coverage for myself which has a $2500
deductible. This has forced me to stop outpatient testing on an annual basis for
bladder tumors. I was unable tofindanother insurance company which would
cover my husband because of preexisting conditions, so he has had to stay with
BC/BS with a larger deductible. Our combined coverage is still costing over
$500 a month. We are both on prescription drugs which cost $95 per month.
At this time in my life I have decided that whatever happens to me that is health
related is up to God as I can no longer afford the medical profession. My
concern now is for my children and grandchildren and sincerely hope that our
government can do something about this run away nightmare of a problem.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002b. stories
SUBJECT/TITLE
DATE
re: Health Care (partial) (1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Jason Solomon
OA/Box Number:
3327
FOLDER TITLE:
Letters
2006-0885-F
ip2773
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act - 15 U.S.C. 552(b)]
PI
P2
P3
P4
b(l) National security classified information |(bXl) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute |(bX3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA]
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells |(bX9) of the FOIA]
National Security Classified Information 1(a)(1) of the PRA]
Relating to the appointment to Federal office 1(a)(2) of the PRA]
Release would violate a Federal statute 1(a)(3) of the PRA]
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�^ ^ ^ ^ ^ ^ ^ H ^ ^ f e i i " Respite her graduate school education, she was
unable to get a job because it would mean losing her disability benefits which
are necessary for her to survive with her liver disease.
- when her two year old son was diagnosed with a
terminal illness, she thought she had seen the worst that life had to offer. A
year later, when her husband lost his high paying job, and her son's insurance
coverage went with it, she realized things could indeed get much worse. They
were forced to sell their home and go on welfare to provide medical benefits for
her sick son.
V , .'; , .;p6^b)(6);..
is stuck in a job that she is very overqualified for
because she is afraid to lose her insurance. She has multiple sclerosis, and she
knows that she will never be able to find insurance again if she takes another
job.
; i
P6/(bX6).
" She wrote a year ago to say that because of her rising
premium, she was going to have to drop her insurance coverage. "What ever
happens to me now is up to God because I can no longer afford the medical
profession". She died six months later because the cancer that was growing in
her body was undetected until it had reached the terminal stage.
?i/^af^^^i4^:^l - She is a nurse caringforboth her elderly parents at home.
Her mother is bed ridden and her father is mentally ill. The cost of caring for
her parents at home is rapidly depleting their savings, but health insurance
won't pay for a home health aid to take some of the burden offfe^jj) 'f/^Kejis
also struggling to raise her 2 small children.
-1 think you know her story, and she might be good to
hicludeT She los her job and her insurance and couldn't afford to see a surgeon
to get a biopsy when she found a lump in her breast. She had to suffer 6
months not knowing if she had breast cancer, or a benign lump.
�
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Health Care Task Force Records
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White House Health Care Task Force
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<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
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<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
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William J. Clinton Presidential Library & Museum
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2006-0885-F
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Letters
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Task Force on National Health Care
White House Health Care Task Force
Jason Solomon
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2006-0885-F Segment 2
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Box 37
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093764" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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2/6/2015
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42-t-12093764-20060885F-Seg2-037-009-2015
12093764
-
https://clinton.presidentiallibraries.us/files/original/424c1b7417471bc9dc37413381136634.pdf
9469d753c63475ab217961d4147c34f1
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2006-0885-F
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This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Solomon
Subseries:
3327
OA/ID Number:
FolderlD:
Folder Title:
[Democratic Policy Committee]
Stack:
Row:
Section:
Shelf:
Position:
s
52
7
9
2
�I
Fact Sheet No. 1
DPC Health Care Reform Fact Sheet
In an effort to keep debate focused on policy and set
the record straight, the DPC is examining charges
made about Democratic proposals and providing
factual information on the issues in question.
Thursday, August 11,1994
MYTH:
FACT:
Senator Dole: 'The key issue in the debate is whether we will trade in a health
care system based on individual freedom for one based on government control."
(Washington Post, 8/10/94)
Senator Mitchell's bill builds on the existing, private sector system. The
Washington Post said that "the governmental role would be kept to a minimum
[in the Mitchell bill]." {Washington Post, 8/3/94)
The bill eliminates the acute care portion of Medicaid, one of the largest
government programs, and integrates millions of recipients into private health
insurance plans. • ..
.
'
MYTH:
FACT:
Senator Wallop: "It's really a job killing payroll tax." (Press re/ease, 8/11/94)
Any number of independent studies—from the Employee Benefits Research
Institute to the Economic Policy Institute—have found that the employer mandate would have a negligible or slightly positive job impact. Hawaii's experience
, proves that you can have strong economic growth with shared employeremployee responsibility. The GOP charges against health care reform today
sound a lot like the ones they made a year ago about the deficit reduction plan..
Those charges were proved wrong and millions of new jobs have been created.
MYTH:
FACT:
Senator Gregg: ""This bill... includes 18 new taxes." {Press release, 8/11/94)
When in doubt, it seems the Republicans have to fall back on tired and false tax
charges.' The Washington Post said that the Mitchell bill is "hardly tax heavy."
(Washington Post, 8/8/94) In fact, the Mitchell bill contains more tax cuts than
provisions which raise revenue. The bill is financed almost entirely by cuts in.
spending.
MYTH:
Senator Dole: [Quoting a constituent letter forwarded to him by Senator Gregg]
"In the scheme of things that the President proposed, we would not have been
able to send our son to Boston [to see a specialist].' The penalty for.'going
against the plan' would be a $10,000 fine, and possible.jail sentence." (Senate
floor debate, 8/10/94)
Opponents of health care reform are using scare tactics. In fact, the Mitchell bill
greatly expands the options consumers have to choose different doctors and
different health plans. The Mitchell bill guarantees you the choice of. at least
three health plans, including a fee-for-service plan that allows you to see whatever doctor you want. (Section 1301)
FACT:
Democratic Policy Committee • United States Senate • Washington, D.C.'20510 • (202) 224-3232
�MYTH:
Senator Packwood: "What does the Clinton-Mitchell bill promise? ...less freedom of choice." {Senate floor debate, 8/10/94)
FACT:
The Mitchell bill guarantees more choices of plans and doctors than most people
have under the current system, and certainly more than the Republican incremental bills. The Mitchell bill guarantees every individual the choice of at least
' three health plans, including one fee-for-seryice plan which allow patients to see
any doctor they want.
MYTH:
Senator Chafee: 'The Mitchell bill involves pure community rating." {Senate
floor debate, 8/10/94) .
FACT: . We gladly admit that under the Mitchell proposal, insurers may not charge people
more for being high-risk, having a history of illness, or having a pre-existing
condition. This provision is known as community rating. But Senator Chafee's
attack is. inaccurate because the Mitchell proposal does allow for age-adjusted
premiums as the legislation is phased in. However, over time, age rating phases
out..
.
•
' We challenge the Republicans to explain to older Americans why they should be
charged four times as much for premiums as other Americans, as in the Dole
bill. (Section 1116)
MYTH:
Senator Durenberger: 'The Mitchell bill takes away incentives for groups, to
. negotiate [with insurers]." (Senate floor debate, 8/10/94)
FACT:
Wrong. The Mitchell bill increases the purchasing power of firms and groups by
allowing them to form voluntary, competing purchasing cooperatives, which will
give individuals and small and medium-sized employers the bargaining power
they don't have under the current system.
MYTH: . Senator Durenberger: "The Mitchell bill increases,cost shifting." (Senate floor
debate, 8/10/94)
FACT:
Unlike the Republican bills, which shift the health care costs of tens of millions of
uninsured Americans onto businesses and individuals with coverage, the Mitchell
bill dramatically reduces the number of uninsured—dramatically reducing cost
shifting in the system.
MYTH:
Senator Domenici: "Benefits for the mental health conditions are not treated
with parity in the Mitchell bill." (Senate floor debate, 8/10/94)
FACT:
That's a distortion. The Mitchell bill instructs the^National Benefits Board to treat
mental illness exactly as other illnesses: are treated—for example, the same
cost shares and deductibles would be applied-. In fact, the Mitchell bill is the first:
national health insurance bill which treats mental illness with parity. If the Board
finds that reaching parity creates undue cost sharing burdens on all services,
then the Board is given explicit instructions'on ways to bring costs in line.. By
contrast, the Dole plan provides no certainty, that mental health services will be
covered at all. •
-
�I
Fact Sheet No. 2
DPC Health Care Reform FACT SHEET
In an effort to keep debate focused on policy and set
the record straight, the DPC is examining charges
made about Democratic proposals and providing
factual information on the issues in question.
Friday, August 12,1994
Mitchell Bill Protects Good Benefits
CHARGE: Senator Gramm: "If you have a provision'in your health insurance that you want
but the Mitchell bill does not want you to have it, there is up to a 66 percent tax on
that benefit." (Congressional Record, 8/11/94, p. S11197)
,
FACT:
Like so many charges by opponents, the attack is simply not true. The Mitchell
proposal protects people who have fought hard and sacrificed wage increases for
good benefits. Current tax treatment, which lexcludes health benefits from taxation, will continue for the entire range of benefits in the standard benefits package, as well as for unlimited cost-sharing supplements, vision and dental benefits. The bill provides that beginning in the year 2004, the exclusion for health
care benefits will be limited so that extraordinary health benefit protections do not
remain tax subsidized.^ Elaborate health benefits for such things as cosmetic
surgery will no longer be tax-favored.
Mitchell Bill Discourages Skyrocketing Premium Increases
CHARGE: Senator Gramm: "If you have an insurance policy and the cost of your insurance
goes up by more than 2 percent in real terms, the Government taxes your policy
and the increase with a 25 percent tax." (Congressional Record, 8/11/94,
P: S11197)
FACT:
This provision affects insurance companies who excessively raise premiums—
not American families. The Mitchell bill discourages insurers from excessively
raising rates and protects American families and businesses. Insurance companies that increase premiums in excess of a target amount are subject to a
25 percent assessment on that excessive growth. The 25 percent assessment
applies only to the excess, not to the entire premium. If costs exceed the growth
limit by 2 percent, the amount assessed against the insurance company is
0.5 percent. Insurance companies can raise' their rates 5 percent a year without
being subject to any assessment. The assessment does not affect supplemental
benefits.
Democratic Policy Committee • United States Senate • Washington, D.C. 20510 • (202) 224-3232
�Mitchell Bill Eliminates Pre-existing Condition Exclusions
i
CHARGE: Senator Doie: "Under Dole/Packwood bill, insurers would not be allowed to deny
coverage because of preexisting conditions.'' (Congressional Record, 8/11/94, p.
S11246)
FACT:
The Dole plan limits, but does not eliminate, the ability of insurance companies to
forestall coverage for preexisting conditions for up to a year. While all agree
preexisting bonditions limitations are a necessary transition tool to universal coverage, the exclusions under the Dole bill never go away.
The Mitchell plan eliminates the ability of insurance companies to deny coverage
for pre-existing conditions.
'
Mitchell Bill Streamlines Private System—Eliminates Bureaucracy
CHARGE: Senator Kassebaum: "The Mitchell bill woulid complicate rather than simplify the
administration of health care, ...and add nevy bureaucracy, red tape and government regulation." (Washington Post, 8/10/94). Senator Gramm: Forty different
new government agencies and bureaucracies. Senator Specter: 170 new agencies boards and programs.
FACT:
The fact is that the Mitchell plan streamlines ithe private health insurance system.
Health care would be simpler, more affordable and more secure. The Dole plan
would leave much of the existing bureaucracy in place, and would add new bureaucracy to administer the plan, with little reduction in the number of uninsured.
The legislation eliminates the acute care portion of Medicaid, a major government insurance program, and allows beneficiaries to enroll in private health plans.
instead. As a result, about 20 million people will enroll in private insurance, instead of getting their coverage through the government. (Department-of Health
and Human Services)
All serious approaches to health care reform require administration and over^
sight. In its report on the Senate Finance Committee bill, the Congressional Budget Office said: "For the proposed system to function effectively, new data would
have to be collected, new procedures and adjustment mechanisms developed,
and new institutions and administratively capabilities created."
Mitchell Bill Phases-ln Voluntary System
CHARGE: Senator Packwood: "Mandatory cooperatives appear to be back." (Congressional Record, 8/11/94, p. S11200)
FACT:
The Mitchell plan assists Americans in voluntarily purchasing private insurance
as it phases in universal coverage. The Mitchell bill increases the purchasing
power of firms and groups by allowing them to form voluntary, competing purchasing cooperatives, which will give them the bargaining power they don't have
under the current system. Employers will have a choice of competing voluntary
purchasing alliances, Employers and families will be able to choose which one
they wish to join. These cooperatives guarantee that American families have a
choice of plans so that they—npt their employers, not the government—can choose
the plan that best suits their needs.
�I
Fact Sheet No. 5
!
DPC Health Care Reform FACT SHEET
i •
In an effort to keep debate focused, on policy and set
the record straight, the DPC is examining charges
made about Democratic proposals and providing
factual information on the issues in question.
Tuesday, August 16,1994
FACT OF THE DAY: The Mitchell bill will extend private health care coverage to as many as
9 million uninsured children by 1997— 8 million children, will be eligible for premium assistance to purchase private health insurance. (Department of Health and Human Services)
Unfair insurance practices — denials for pre-existing conditions, refusal of coverage, and
other abuses — will be outlawed, enabling middle class families to afford private insurance
for their children.
1
More than 6 million children will be eligible for full piemium subsidies to purchase private
health insurance. An additional 1.8 million children will beleligible for premium subsidies on a
sliding scale. (Department of Health and Human Services)
REPUBLICAN DELAY: Since Senator Dodd (D-CT) introduced his children's amendment,
. there have been over 30 hours of debate. During that time, more than 28,000 children (15.7
per minute) have lost their health insurance. (Families USA, 8/16/94)
f
The Mitchell Bill Protects Consumers and Strengthens Choice
t
CHARGE:
"You can keep your plan, unless your plan is less generous... or unless your
plan is more generous. On page 145, sec. 1,309, this bill states that if your plan
does not conform to the benefit package mandated by the Clinton-Mitchell bill,
employers will be subject to civil penalties of $10,000 per employee." (Press
Release, Office of Senator Don Nickles (R-OK), 8/16/94) .
FACT:
Protecting consumers from insurance policies that are long on fine print and
short on benefits is one of the most important elements of reform. Like both
Democratic and Republican insurance market reform bills, the Mitchell bill provides for a standard benefits package to help consumers choose between competing health plans, based on price and quality. Consumers are guaranteed a
choice of plans. Employers will provide a choice of at least three health plans,
including a traditional fee-for-service plan.
Employers and individuals are free to purchase more generous coverage through
supplemental insurance that offers more benefits and lower cost-sharing.
Individuals also may purchase an alternative standard benefit package with higher
deductibles and a lower actuarial value.
The $10,000 civil penalty provision in section 1309 that Republicans cite is a
general enforcement sanction on employers who violate the requirements of
the bill — i.e., fail to offer a choice of . plans or discriminate against certain
employees.
'
.
Democratic Policy Committee • United States Senate * Washington, D.C. 20510 • (202) 224-3232
�I
Mitchell Proposal Prevents Abuse and Discrimination
f
CHARGE:
FACT:
Republicans have charged that employers will be subjected to a 35 percent tax
if they give employees more than the defined benefits package.
This is a complete distortion of the truth. Under the Mitchell proposal, employers are free to offer all employees more benefits, or pay the full premium for their
employees, if they so choose. An anti-abuse provision protects taxpayers'
dollars by preventing employers from selectively denying benefits to low-income
workers, based upon their eligibility for subsidies. Employers who discriminate
against workers by giving some employees more benefits than others have violated the anti-discrimination provision and are subject to a penalty. ,
�V
fr
Health Care Reform
Iseue Sheet No. 2
August 12,1994
DPC Health Care Reform ISSUE SHEET:
The Mitchell Proposal—
A Private Health Care System
Charge:
Republicans claim that the Mitchell proposal creates a massive new government-run program. They used the same rhetoric in the Medicare debate. The
Republicans are pulling out the old, tirod rhetoric about bureaucracy that they
have used for decades to block health care refpmn.
Response:
Nothing could be further from the truth. The Mitchell proposal streamlines
and consolidates a duplicative and chaotic system of health care into one that
will be far more responsive to the needs of American families.
A Private System, the Mitchell proposal retains the private health insurance
structure and provides a guarantee to middle class Americans that they cannot
lose the hoalth insurance they have now. Instead of a hew government program,
the Mitchell proposal provides subsidies to Americans to assist them in purchas. ing private health insurance.
Eliminates Government Program. The legislation eliminates the acute care
portion of Medicaid for AFDC and non-cash recipients, a major government insurance program, and allows beneficiaries to enroll in private health plans instead. As a result, about 20 million people will enroll in private insurance, instead
of getting their coverage through the government.
Accountability. A key goal of the Mitchell proposal is to eliminate bureaucracy .
and increase the power of consumers to demand accountability from their heaith
plans.
Streamlines System. The Mitchell proposal streamlines the health care system
through the use of purchasing cooperatives. Purchasing cooperatives increase
the power of the working American and the small business owner to obtain a
better deal from insurance companies. They allow thousands of Americans to
band together to negotiate better rates from insurance companies. They reduce
the high administrative costs in today's system and reduce wasteful paperwork.
1
Administrative Simplification. The Mitchell proposal will reduce paperwork .
and administrative waste in the current system. Electronic claims processing
and national standards for automation of insurance transactions will help eliminate much of the administrative waste in the current system.
hpmnnratic Policv Committeo • United States Senate • Washington DC 20510 • (202) 224-3232
�•I
Bureaucracy in the Current System
!
• The number of health administrators and bureaucrats has increased by
300 percent during the past decade. At the same time, the number of physicians grew by only 18 percent.
1
• Massachusetts Blue Cross employs more bureaucrats to insure 2.7 million
subscribers than Canada employs to insure 25 million people.
2
• Private insurance carriers and insurance agents employ more than 2.4 million
(1990) — more than the number of employees in all the legislative, judicial and
nondefense executive agencies of the American federal government including
postal workers.
3
• Children's Hospital in Washington, D.C. reports that it spends more than
$2 million a year filing out forms that have nothing to do with the treatment of
patients.
4
The number of hospital administrators is growing at four times the rate that the
number of doctors is growing .
1 5
Insurance overhead accounts for nearly 25 percent of total spending. By contrast, administrative costs in other industrialized countries total 11 percent or
less.
6
'Health Security: The President's Report to the American People,'p.'SO.
^"Wasted Health Care Dollars," Consumer Reported June 1992.
'DPC Special Report, "Health Care Questions Most Often Asked," SR-26 Health, November 20,
1990.
•ibid.
'
,
'Health Security: The President's Report to the American People, p.60.
ii i c rwjrtmant of Commerce. U.S: Industrial Outlook, 1994, January 1994.
�J
Fact Sheet No. 6
DPC Health Care Reform FACT SHEET
In an effort to keep debate focused on policy and set
the record straight, the DPC is examining charges
made about Democratic proposals and providing
factual information on the issues in question.
Wednesday, August 17,1994
FACT OF THE DAY:
The Mitchell proposal outlaws "lifetime limits." Seventy-six
percent (76%) of privately insured Americans have policies with life,time limits.
1
Over the past few days, Republicans have engaged in an effort to portray the Mitchell bill as
anti-choice and anti-consumer, when in fact, the opposite,is true.
Today's DPC Health Care Reform FACTSHEETprov\<ies information on important consumer
protections in the Mitchell proposal.
The Mitchell Proposal Protects Consumers From "Lemon" Insurance Policies
FACT:
Protecting consumers from insurance policies that are long on fine print and
short on benefits is one of the most important elements of reform.
Like other Democratic and Republican insurance market reform bills that have
been proposed, the Mitchell proposal provides for a standard benefits package
to protect consumers from fine print, and to help consumers choose between
competing private health insurance plans, based on price and quality. '
A standard package of benefits protects consumers by preventing insurance
companies from selling "lemon" policies which include such things as "lifetime
limits," which cut off coverage when consumers need it the most.
Lifetime limits are the insurance companies' Insurance policy. Lifetime limits
allow insurance companies to stop paying medicail costs, if a person with an
expensive illness or injury, uses up a certain dollar amount of coverage^ They
protect insurance companies, not consumers, from financial loss.
' "Employees in Medium and Large Private Establishments," Bureau of Labor Statistics, 1991.
Democratic Policy Committee • United States Senate • Washington, D.C. 20510 • (202) 224-3232
�The Mitchell Bill Expands Choice
CHARGE:
"You can keep your plan, unless your plan is less generous... [or unless your
plan is more generous.] On page 145,,sec. 1309, this bill states that if your plan
does not conform to the benefit package mandated by the Clinton-Mitchell bill,
employers will be subject to civil penalties of $10,000 per employee." (Press
Release, Office of Senator Don Nickles (ROK), 8n 6/94)
FACT:
The opposite is true. No one is forced to give up coverage that they like. Period.
Today, only 16 percent of employers who offer insurance offer a choice of insurance. Under the Mitchell proposal, all consumers are guaranteed choice of
private health insurance.
1
•
Employers must offer their employees at least three choices of private insurance, including a traditional fee-for-service plan.
•
Purchasing cooperatives provide an array of private health insurance plans
to everyone in a,community.
Consumers choose the amount of private insurance they want.
•
Employers and families can purchase a guaranteed standard benefits package, and know what they are covered for in advance.
•
Employers and families can purchase more generous supplemental policies
with more benefits and lower cost sharing.
•
Individuals can purchase a less generous policy by choosing an alternative
standard benefits package with higher deductibles and copayments, and lower
cost.
[
•
The Mitchell bill is a voluntary system. No one is required to purchase
insurance.
Kaiser Family Foundation, KPMG Peat Marwick survey, 6/15/94.
�Fact Sheet No. 4
DPC Health Can* Reform FACT SHEET
In an effort to keep debate focused on policy and set
the record straight, the DPC is examining charges
made about Democratic proposals and pro viding
factual information on the issues in question.
Monday, August 15,1994
CHARGE: Senator Cohen [bn an employer/employee share responsibility]: Employers
are not going to bear the cost of that insurance. Workers will, in the form of.
lower wages, lost benefits and lost jobs. And CBO's analysis confirms that.
FACT:
The real threat to worker wages and benefits are the skyrocketing health
care costs of the current system, which have forced employers fo cut benefits and hold, down wages. The percentage of families who received full
employer-paid medical coverage fell from 32 percent in 1988 to
.19 percent in 1992. {Hay/Huggins Benefits Report, 1992) And If health care
had been reformed in 1975, American workers would have more than $1,000
in extra wages each year. Without reform, by the year 2000, American workers will lose almost $600 in wages each year, just to keep the health benefits
they have today. (Commerce Department, Office of Management and Budget) As for the charge that an ^employer mandate would lead to a loss of
jobs, any number of independent studies — from the Employee Benefits
Research Institute to the Economic Policy Institute — have found that such a
requirement would have a negligible or slightly positive job impact. And the
CBO analysis itself states that "the loss of jobs from this mandate would
likely be very limited." (A Preliminary. Analysis of Senator Mitchell's Health
Proposal 8/9/94)
'
CHARGE: Senator Cohen: A national council on graduate medical education will set
quotas and will tell medical students what specialties they can
practice.
FACT:
There are no quotas in the Mitchell bill dictating the number of specialists,
surgeons, or ophthalmologists who would be trained. The only thing specified in the bill is the balance between generalists and specialists. Currently
more than 65 percent of the doctors practicing in the United States are specialists. No other country in the world has more than 50 percent. This imbalance contributes to the shortage of primary care doctors, particularly in rural
and urban areas, and helps drive up health care costs. The, American Medical Association, the'American College of Physicians, and the Association of
American Medical Colleges support bringing the existing balance between
primary care physicians and specialists more in line with the nation's needs.
And this is also why Senator Dole's own bill sets up an Advisory Commission
on Workforce to make recommendations on the appropriate composition the
nation's health care workforce and how to achieve it. (S. 2374, Title V,
sec. 501(C)(4)(i))
Democratic Policy Committee • United States Senate • Washington, D.C. 20510 • (202) 224-3232
�CHARGE: Senator Cohen: It's almost certain that the spending associated with
the new entitlements and the subsidies in the bill is going to exceed all expectation and will further fuel the deficit that threatens to cripple this economy
right now.
FACT:
Untrue. The CBO estimates that the Mitchell bill will save the Federal government $8.6 billion over ten years. The bill protects the Federal budget
through a fail-safe mechanism which guarantees that the cost of the bill will
never increase the Federal deficit. Under this fail-safe provision, if spending
. is higher than now anticipated, spending would be reduced to ensure deficit
neutrality.
CHARGE: Senator Coats: "Do we want a government run health care system? The
American people have said 'no.'" Senator Mack: "The choice is between a
government-controlled, government-dictated health care system with less
quality, less choice and less freedom, on the one hand. Or a market driven
health care system with high quality, more choice and freedom, on the other."
FACT:
Republican Senators may enjoy railing against the.straw man of a government-run health care system but it has nothing to do with the bill offered by
Senator Mitchell. As the Washington Post noted, the government role would
be kept to a minimum [under the Mitchell bill]." {Washington Post, 8/3/94).
His bill builds on the existing private sector system. And by eliminating the
i acute care portion of Medicaid and enrolling recipients into private he.alth
insurance "plans, it moves millions of Americans from government insurance
to private insurance.
CHARGE: Senator Bennett: "The Mitchell bill will fail to decrease the number of
uninsured."
FACT:
Not according to the Congressional Budget Office. Their analysis of
Senator Mitchell's bill concludes that, in their estimation, his proposal would
meet its target of 95 percent of the population covered by the year.2000.
CHARGE: Senator Mack: "The Dole bill encourages Americans to join Federal
Employee's Health Benefits plan (FEHBP). Unfortunately, the Clinton/Mitchell
plan takes a good program full of choices and obliterates it.
FACT:
That's just wrong. The Mitchell plan retains the FEHBP and makes it available to families and individuals working in businesses with fewer than
500 employees, the self-employed, and those between jobs. It provides the
same choice of high-quality health care plans that Federal employees enjoy
today.
;
�HMtth Care Reform
Iseue Sheet No. 4
August 17,1984
|
DPC Health Care Reform ISSUE SHEET:
The Mitchell Health Reform BillHealth Reform That Works for
Middle-class Families
A key force behind the drive for health care reform has been the support of working, middleclass Americans. A fundamental test of reform must be whether it works to solve the problems
of the middle class.
Risk of Financial Devastation. As medical costs have grown far beyond what families can
hope to pay on their own, not having or losing insurance has become tantamount to risking
complete financial devastation. This frightening sense of insecurity among the middle class
— not just a lack of insurance — has provided much of impetus behind reform.
For decades, insurance companies have run the show—charging customers what they choose;
dropping coverage when people become ill; refusing coverage; devising complex schemes to
exclude anyone who might get sick; and using indecipherable and unpredictable fine print to
stack the odds in their favor.
As a result, many insured middle-class families find themselves covered only for illnesses
they don't have — a result of pre-existing condition exclusions — and cut off from benefits
when they need them most — a result of lifetime limits. ,
The Mitchell Proposal
Works for Middle-class Americans. Senator Mitchell's proposal makes critical changes in
the structure of the health care system and the insurance market to protect middle class
families. As a condition of participation in the health insurance market, insurance companies
will have to adhere to certain rules. People that currently are insured or in danger of losing
their insurance will be guaranteed that their coverage will continue.
A Case History. Consider the hypothetical example of Sam, a middle-aged, middle-income
American:
Sam /s not poor or uninsured, yet he is still at the mercy of today's health insurance
companies. His health care coverage comes with a $2,500 deductible, yet his premium is still $3,600 a year—$300 a month. He must accept this deductible and this
price because there is only one insurance company willing to provide him coverage.
Sam is typical of many middle income Americans in today's system, who are insured, yet lack
health security., Nothing prevents his insurance company from dropping his coverage, raising
his rates, or cutting his benefits. If Sam's income goes down or he loses his job, nothing
stands in the way of him losing that coverage permanently. The Mitchell proposal dramatically
improves the coverage of people like Sam and provides a real guarantee that he will not iose
this insurance.
Democratic Policy Committee • United States Senate • Washington, D.C. 20510 • (202) 224-3232
�The Mitchell proposal will protect the financial and health security of middle-class
Americans like Sam in the following ways:
•
A Standardized Benefits Package. Sam will be guaranteed a standard package of benefits. He will have a choice of at least three plans and will be better able to compare plans
to decide which best meet his needs. Sam will not have to fear that fine print will deny him
coverage. He and every other American will know in advance what their benefits are.
•
Guaranteed Issue. Guaranteed issue means that insurers are prohibited, by law, from
denying Sam coverage — for any reason. Sam will be able to shop around for better
coverage, at a better price.
•
Guaranteed Renewal. Sam's insurer will not be able to drop him. Whether he is changing jobs, moving to another state, or retiring, Sam's insurer will not be able to drop him
from coverage. As long as Sam wants to buy this coverage, he will be able to retain it.
•
Elimination of Pre-existing Condition I>enials. No insurance company will be able to
charge Sam more for a pre-existing condition, deny him coverage, or permanently exclude
pre-existing conditions from coverage. To prevent people from buying coverage only after
they become sick, individuals who have not had coverage for an extended period of time
may still be subject to waiting periods.
•
Contains Costs. Purchasing cooperatives use market forces to keep health care costs
down and increase consumer buying power. In addition, insurers are discouraged from
the unreasonable rate increases prevalent in today's system through an assessment on
excessive growth in premiums. These provisions will keep Sam's premiums affordable.
•
Cuts the "Hidden Tax." Currently, Sam absorbs the cost of the uninsured in a "hidden
tax" in his health insurance premium. As the Mitchell proposal increases the number of
insured Americans, Sam's uncompensated care "hidden tax" will be reduced and ultimately
eliminated.
•
Reduces Bureaucracy and Cuts Red Tape. The bill will reduce paperwork for American
families by simplifying insurance forms. Many consumers will no longer have to submit
claims to their insurance companies.
•
Expands Choice. The proposal will expand choice of physicians and health plans for
millions of middle-class Americans. The bill requires every employer who offers health
insurance to his employees to offer a choice of at least three plans, including a fee-forservice plan.
•
Provides Long Term Care and Prescription Drug Coverage. The Mitchell bill provides
home and community, based long-term care to millions of disabled and elderly Americans.
This benefit will provide relief for millions of middle-class families who provide 80 percent
of the "infprmar care for their elderly parents and disabled children. In addition, a prescription drug benefit will help millions of Medicare beneficiaries afford prescription drugs.
Today, millions of elderly Americans must choose between filling drug prescriptions and
buying groceries.
,
�.J
Health Care Refonn
Issue Sheet No. 3
August 15,1994
DPC Health Care Reform ISSUE SHEET:
Hawaii: A Health Care System
That Works
Recently, the Governor of Hawaii, John Waihee, joined President Clinton at the White
House to discuss Hawaii's health care system. The President cited Hawaii as a model for
national health care reform and noted correctly that business is thriving in Hawaii.
Since then, the National Federation of Independent Business (NFIB) has issued misleading and inaccurate information about Hawaii's health care system. The NFIB charges that
Hawaii's employer mandate has not achieved 100 percent universal coverage; that
Hawaii has failed to contain health care costs; and, that Hawaii has a poor business
climate.
In fact, between 96 percent and 98 percent of Hawaiians have health insurance.
Employer-paid premiums in Hawaii are 30 percent lower than they are nationally. And
Hawaii has a healthier workforce, a lower unemployment rate, and a lower business failure rate than the national average. An MIT study (Entrepreneurial Hot Spots: The Best
Places in America to Start and Grow a Company, 1993) showed Hawaii to, be the "entrepreneurial hot spot" of the United States.
The trend in Hawaii is insurance coverage for more people, with more choice, at less cost.
Nationally, the trend is insurance coverage for fewer people, with less choice, at greater
cost, and no security.
Hawaii's Universal Coverage System
CHARGE:
FACT:
The NFIB charges that 90 percent of Hawaiians already were insured prior
to the 1974 enactment of Hawaii's health Care plan.
Wrong. Today, only two to four percent of hawaiians are uninsured. In fact,
, in 1971, over 17 percent of Hawaiians lacked health insurance coverage and
nearly 12 percent lacked hospital coverage; according to the Legislative Reference Bureau.
Democratic Policy Committee • United States Senate • Washington, D.C. 20510 • (202) 224-3232
�•J
I
CHARGE:
The NFIB says that fifteen years after passage, Hawaii's coverage rate is
91.9 percent.
FACT:
The numbers NFIB is using are outdated.and wrong. From 96 percent to
98 percent of Hawaiians have health insurance coverage — compared to
only 85 percent of all Americans. ,
:
.
i,
•
A sun/ey by the Hawaii Department of Health Survey, which included a larger
sample than the Current Population Survey (CPS), found that only
3.75 percent of residents lacked health insurance coverage. A 1992
National Governors' Association (NGA) study found that 98 percent of Ha:
waiians had health insurance.
•
CHARGE:
The NFIB charges that CPS data show that total "private insurance coverage" in Hawaii reached only 80.1 percent of the non-elderly population.
Private coverage levels are as high in other States which don't have a
mandate.
FACT:
This statement reflects the NFIB's continuing effort to misuse numbers to
present a distorted picture of the truth. The estimate reflects Hawaii's large
number of active and retired military personnel who are publicly insured. This
results in the appearance of a large "privately uninsiured" number.
Current Population Survey numbers do illustrate that coverage rates in
Hawaii are increasing among working families — contrary to the national
trend. Since 1988, Hawaii saw a 15 percent drop in working uninsured while
the number of working uninsured in America increased by 21 percent.
(CPS and Census data, 1988,1993)
Hawaii's Health Care System —
Lower Costs For Business
CHARGE:
Hawaii has failed at cost containment.
FACT:
Employer paid premiums in Hawaii are 30 percent lower than they are
nationally. (GAO, 2/94; Hawaii Department of Health, 11/92)
CHARGE:
The NFIB claims that by 1990, per capita health care costs were $2,469 in
Hawaii, vs. the national average of $2,318.
FACT:
This data is inaccurate. The NFIB information is taken from a questionable
Lewin ICF study done in 1991. In fact, the State of Hawaii itself reports that
Hawaii's health care costs are well below the national average. For example,
Medicaid expenditures per recipient, Medicare expenditures per recipient,
and small business costs are well below the national average.
�Small.businesses in Hawaii can purchase insurance at rates well below those
facing a small business virtually anywhere else in the Nation. A Harris study
found the 1993 insurance costs for Hawaii's small businesses were more
than $250 less than average U.S. small: business insurance payments in
1991. Tracked over time, a typical Hawaii business was paying about the
same as its California counterpart in 1974. Now it pays 60 percent .of a
California business for comparable coverage.
Hawaii's Business Climate
CHARGE:
NFIB charges that Hawaii's employer mandate has brought about an adverse business climate.
FACT:
The fact is that since Hawaii began asking all employers to provide insurance in 1974: the unemployment rate has dropped to one of the lowest in the
nation; small business creation has remained high; and the rate of business
failures was less than half the national rate [Hawaii Department of Labor
and Industrial Relations; Dun and Bradstreet, Monthly New Business Incorporation Rate; Journal pf the American Medical Association, 5/19/93)
;
CHARGE:
FACT:
The NFIB claims that in 1992, the number of business failures in that State
increased by 290 percent. It is significant that Hawaii led the Nation in job
loss in 1993.
NFIB's selective statistics reflect the devastating impact on small businesses
of .the recession in both the U.S. and Japan, and of Hurricane Iniki. Hurricane Iniki was the largest natural disaster in Hawaii's history. It severely
affected small businesses in 1992, which already were suffering from the
, Nation-wide recession. Iniki's effects were felt well through 1993. Private
insurance claims exceeded $1,674 billion. Despite this, there has been a
steady growth of business from fewer than 18,000 employers in 1970 to 27,000
in 1993. Hawaii's business failures in 1993 are sf/7/ below the national
average.
Hawaii — The Entrepreneurial Hot Spot
CHARGE:
The NFIB claims that Hawaiian health plan has had serious negative consequences for business.
FACT:
In fact, Hawaii has a lower unemployment, rate than the national average, a
lower business failure rate than the national average, and a healthier
workforce. An MIT study shows Hawaii to;be ^©"entrepreneurial hot spot"
of the United States.
�Background and Interest of the NFIB
The NFIB has an annual budget of more than $60 million. It has 30 Washington lobbyists,
and it runs a PAC that spent $785,000 on campaign contributions and political "education"
during the 1991-92 election cycle. According to the Wall Street Journal (1/5/94), "the
group has turned into a big business." In fact, their grassroots lobbying effort in opposition
to health care reform is funded by huge corporations including K mart, J.C. Penney, General Mills, McDonald's, Pespsico, and Marriott. (Politics of Health Care Reform, 8/10/94)
There are other groups representing small business. The Small Business Coalition
For Health Care Reform, formed on May 3, 1994, is composed of 29 national organizations which represent more than 626,000 small businesses employ more than 5.6 million
people. The Coalition's numbers continue to grow.
Health care reform through employee/employer shared responsibility enjoys wide
support — 72 percent of Americans support shared responsibility for full-time workers.
(Washington Post/ABC Poll, Washington Post, 6/28/94) In June, 1300 leading organizations and businesses endorsed shared responsibility. These groups represent over
93 million Americans — 155 times the membership of the NFIB.
What the NFIB Won't Tell You:
What Small Business Owners Believe
The Small Business Coalition For Health Care Reformj reports that according to a 1992
study conducted by Professor Charles P. Hall of Temple University for NFIB:
•
92.4 percent of small business owners agree that the cost of health insurance is a
serious business problem;
•
90.3 percent of small business owners believe that!health care is becoming prohibitively expensive;
•
69 percent of small business owners agree or agree strongly that every
American has a right to basic health insurance;,
•
64 percent agree or strongly agree that all Americans should receive a minimum level
of health care regardless of their ability to pay;
,
•
64 percent said that they would like to provide better or some health insurance for their
workers; and,
•
60 percent of responding small business owners who provide coverage said they do
so because their employees needed it. On the other hand, Hall found that almost twothirds of those who don't cover their employees cite high premiums as the reason why.
�Health Care Reform
Issue, Sheet No. 1
August 12,1994
,
DPC Health Care Reform ISSUE SHEET:
Republican Attack on "New Taxes"
Charge:
The Republicans charge that the Mitchell proposal includes 17 newjtaxes.
Response:
This is a game that Republicans play to avoid talking about the real and.serious issue of health care reform.
Their charge is not true and they know it. It is an attempt to politicize the issue rather than debate substance.
It is demeaning to the health care debate and an insult to the public.
There are not-17 tax increases in the Mitchell bill. In fact, the Mitchell proposal contains more tax cuts than
provisions to increase revenue.
1
"Mitchell's bill is hardly tax heavy,"says the Washington Posts Dana Priest in an article about the loss of bipartisanship in the health caire debate. [ Washington Post, 8/8/94], The subsidies in the Mitchell bill are
financed almost entirely by spending cuts.
Most of the items on the GOP list are compliance rules or clarifications of law. One of them is just a direction
to Treasury to submit a legislative proposal in the future. Other items on the list, like reduced subsidies for
high-income Medicare beneficiaries, do generate savings. Since the provision reduces subsidies based on
income, it is collected through the tax system. However, it really accomplishes a reduction in spending. This
particular idea was originally proposed by the Bush Administration.
;
'
•
"
I
'
,
Examples of So-called "Taxes" on GOP List
1.
Retiree health benefit funding. This anti-abuse provision prevents corporations from bunching their
deductions for the cost of retiree health.
2. Tax treatment of tax-exempt health care organizations. This includes numerous provisions overhauling in a revenue-neutral way the treatment and standards that apply to nonprofit health care organizations. According to the Joint Committee on Taxation, this has a negligible revenue effect; i.e., basically no measurable effect.
3. Disclosure of taxpayer return information. Safeguards are established with respect to the sharing of
Federal tax information with States in the administration of subsidies.
4.
Risk adjustment. The bill establishes a mechanism whereby experience-rated plans would share in
the cost of somei of the higher risk populations in the community pool. This is a transfer between
insurance pools, not money that goes to the government. Without this provision, companies in the
community-rated market would be asked to bear a disproportionate cost-shifting. This is not a tax, no
money goes to the government, and it saves money for small business.
5.
Limitation of prepayment of medical insurance premiums.' This is an anti-abuse rule to prevent
bunching of deductions to take advantage of the 7.5% of Adjusted Gross Income (AGI) rule to deduct
the cost of health care. The revenue gain is negligible, according to Joint Committee on Taxation.
'There are only eight provisions that raise revenue. There are more provisions -p nine — which cut taxes. Increasing the tax on
hollow point, exploding bullets actually results in a reduction of revenues since the tax is so high these bullets will no longer be sold,
denying the government the modest excise tax now collected.
Democratic Policy Committee • United States Senate • Washington, D.C. 20510 • (202) 224-3232
�6.
Penalty for failure to file correct information returns, with respect to non-employees. This provision encourages compliance with the law by increasing the penalty from $50 per employee to the greater
of $50 or 5% of the amount required to be reported. Revenue gain is negligible, less than $1 million a
year.
7.
Definition of employee. Treasury is directed to submit a legislative proposal with respect to the classification of workers. This is a legislative proposal.
8. Equal Contribution Rule. This provision originated in the bipartisan rump group. It provides that
employers may not deduct the cost of health benefits that are not offered equally to all employees.
Tax Cuts In Mitchell Bill
1.
Change the definition of salary income for partnerships with inventory income to reduce Medicare
Hospital Insurance (HI) taxes.
2.
Provide self-employed with a health insurance deduction.
3. Treat long-term health insurance as accident and health insurance, with respect to tax treatment of
employer-provided benefits, and with respect to tax treatment of long-term care benefits provided through
an employer plan.and an individually purchased plan.
4.
Provide insurance companies with more favorable reserve treatment for long-term care insurance.
5.
Permit accelerated death benefits paid to terminally ill to be treated as life insurance benefits paid to a
deceased's estate.
6. Tax credit for physicians ($1,000 a month) and other medical personnel ($500 a month) serving
underserved areas.
7.
Increase expensing for medical equipment in undersen/ed areas.
8. Tax credit for personal assistance services required by disabled working individuals.
9.
Removal of the $150 million per institution cap on the amount of bonds which may be issued by 501 (c)(3)
organizations.
Items With Revenue Implications
1.
Increased tax on tobacco products.
2.
Funding for Medical Research. 1.75% tax on insurance premiums to pay for academic health
centers, graduate medical education, and biomedical research.
3. Cost containment assessment. To encourage cost containment, insurers increasing premiums at
unreasonable rates will be assessed on these increases.
4.
Medicare Part B Income Related Premium. This is actually a reduction in the subsidy for Medicare
Part B benefits that are received by high-income elderly households, although it is collected through the
tax system for ease of administration. This proposa^has been in several deficit reduction and health
care reform bills proposed by Republicans over the last few years.
5. Service related income of Subchapter S owners. This provision treats owners of Subchapter S
corporations, who receive salary income, like partners for purposes of the 1.45% Medicare tax..
6. Extension of Medicare HI tax to State and local workers. This provision, to extend Medicare coverage to State and local government workers hired before April, 1986, has been included in several budgets proposed by Presidents Bush and Reagan.
7.
Health benefits may no longer be provided in a cafeteria plan.
8.
Limitation on health insurance exclusion beginning in 2004.
�{•
Fact Sheet No. 3
DPG Health Care Reform'FACT SHEET
,-
i
i
In an effort to keep debate focused on policy and set
the record straight, the DPC is examining charges
made about Democratic proposals and providing
factual information on the issues, in question.
Saturday, August 13,1994
Mitchell Proposal Provides Long Term Care
CHARGE: Senator Simpson: "It promises long-term care benefit that will be
there when they need it most. It won't be. It will be yanked away."
FACT:
The Mitchell proposal will provide millions of America's senior citizens
home and community-based long-term care. This benefit is one of
the reasons the American Association of Retired Persons (AARP) has
endorsed the bill calling it "an historic opportunity to provide each of
us with affordable high quality health care and long-term care." The
long-term care benefit is a capped entitlement to the States.
On the other hand, the Republican plan,sponsored by Senator Bob
Dole contains no long-term care program at all. It cuts billions of
dollars from the Medicare program, yet provides no additional benefits for senior citizens. No long-term care. No prescription drugs.
Mitchell Bill Protects Consumers Against Fraud
CHARGE: Senator Lott: "The bill contains extremeicriminal penalties for harmless behavior. Under section 5324, if you tip your doctor to get extra
services, you could go to prison."
FACT:
Senator Lett's statement is a clear example of a real scare tactic. The
Mitchell bill contains important consumer protections against fraud.
The provision mentioned by Senator Lott protects consumers from
"bribery and graft." Those who try to cheat the system and profit at the
expense of American families are subject to penalties.
Democratic Policy Committee • United States Senate •Washington, D.C. .20510'» (202) 224-3232
�•A
Mitchell Bill Protects Middle Income Families
CHARGE: Senator Lott: "Middle-income families will pay more for less health
care."
FACT:
In today's system, even insured middle class Americans are at the
mercy of insurance companies. Senator Mitchell's plan gives insured Americans the peace of mind that comes from insurance
that is there when it's needed. The Mitchell proposal guarantees
that middle-income families won't losei their health insurance and
protects them from insurance companies who cut their benefits or
raise rates excessively.
Partial reform proposals exemplified by the Dole bill, do not .guarantee middle-income families that they will always be covered. Proposals like Senator Dole's "increase premiums^for middle-class
people and cou/d increase the number of uninsured." (Winners
and Losers, Newsweek, 7/25/94)
L
CHARGE: Senator Hutchison: [Regarding the people the President met during town hall meetings who have had; problems with the current
health care system.] "Most people would be covered under the Dole
'
plan."
FACT:
Not true. Senator Dole's bill offers little help for people like Daniel
Lumley, who lost his insurance when he lost his job. The Dole
proposal contains no financial protection for Daniel Lumley to af. ford insurance until he gets a new job. Each day of Republican
delay, hurts Daniel Lumley and millions more like him.
�Fact Sheet No. 7
DPC Health Care Reform FACT SHEET
In an effort to keep debate focused on policy and set
the record straight, the DPC is examining'charges
made about Democratic proposals and providing
factual information on the issues in question.
Friday, August 19, 1994
FACT OF THE DAY: The Federal Employees Health Benefits Program (FEHBP) enrolls 10 million people in
50 states and contracts with hundreds of private health insurance:plans. Yet, the entire program-is administered by 164 people and has very low administrative costs. {Office of Personnel Management, March
1994) Enrollees may choose from an array of,private health insurance plans — i 4 different fee-for-service
and point-of-service plans and more than 200 health-maintenance organizations, which are included in a
total of 320 possible options. ("Health Care Reform: FEHBP," CRS Report 94-392 EPW, 5/5/94)
FEHBP is community-rated so that young, old, healthy, and sick participants pay the same price for the
same health care insurance. The FEHBP plans may not charge participants more for a history of illness or
a pre-existing condition.
. ,
FEHBP is the'program through which the President, Cabinet Secretaries, and members of Congress get
their health care coverage. It is a system of shared responsibility. Government employees pay a portion
(28 percent) of their premium and their employer, the government', pays the rest (72 percent).
The Mitchell Proposal Expands FEHBP to Working Families
CHARGE:
Senator Stevens (R-AK): "The FEHB Program has been successful in holding down costs —
over the last 12 years, the program's average premium cost per person rose approximately
3.5 percent less than private sector premiums for large businesses. The system holds down
growth in costs by forcing insurers to compete for customers by providing the best service at
the lowest premiums."
"The program provides flexibility through its annual open enrollment season, which allows
individuals and families to change their policy to adjust to changing circumstances. And the
FEHB Program gives its participants the abilility to choose the health care plan which is offered
that is best for them...
;
"For example, FEHBP includes the ability, with copayment or deductibles, to choose one's own
physician; it basically insures everyone, regardless of pre-existing condition; and there is no
cancellation of FEHBP insurance for catastrophic illness...." (Congressional Record, p. S12027)
"... The Mitchell bill would open up the FEHB program to...employers with fevyer than 500
employees, the self-employed, and the unemployed."
Surprisingly, Senator Stevens is opposing allowingAmerican taxpayers, who pay for this
"government-run program," to enroll in it. He said:
"Under this system, [the Mitchell.proposal]...it is not that the American public will have
what we have now, we will have what they have..." (Congressional Record, p. S12030)
FACT:
Senator Stevens is correct that FEHBP — for those lucky enough to have this option — offers
good benefits, a fair price, a choice of doctors, and a choice of private insurance plans.
The Mitchell proposal-will expand the same quality, prjvate insurance to all Americans —
the same choice enjoyed by members of Congress and other Federal employees. In fact,
Americans will have the option of enrolling in the same plans as Members of Congress.
Democratic Policy Committee • United States Senate • Washington, D.C. 20510 • (202) 224-3232
i
�!
The Price of Delay
i
During the time the Senate has been considering the "Children First"
amendment-- children have continued to suffer.
~
In the four days the Senate has considered the pending amendment:
* 5,479 babies were, born to women who had no health insurance
(March of Dimes);
•
* 2,544 babies were born to mothers who received late or no pre-natal
health care (National Center for Health Statistics);
* 3,648 babies were born to mothers with private insurance that does not
cover maternity care'(March of Dimes);
* 3,204 babies were born at low birthweight (National Center for Health
Statistics)
,
;
* 224 babies died before they were one month old (National Center for
Health Statistics); and
* 440 babies died before they were one year old
(National Center for Health Statistics).
1
Prevention Pays Off.
Delay Costs.
$1
spent on prenatal care saves....
. $3.38
on the care of low-birthweight infants (Institute of Medicine)
Every time a low-birthweight delivery is prevented, it saves
between $20,000 and $50,000 (Instituteiof Medicine).
Every time a very low-birthweight delivery is prevented,
it saves approximately $150,000 or more on.neonatal intensive care
costs (National Commission on Children).
Routine preventive checkups can avoid hospitalizations that cost
$600 a day (Children's Defense Fund).
�1
Tomorrow,
tomorrow,
tomorrow.
And while we wait another day —
i
••
* 1,370 babies will be born to women who have no health insurance
(March of Dimes);
i
* 636 babies will be born to mothers who receive late or no pre-natal health
care-(March pf Dimes);
'
.
* 912 babies will be born to mothers with private insurance that does not
cover maternity care March of Dimes);
* 801 babies will be bom at low birthweight (Children's Defense Fund)
* 56 babies will die before they are one month old
(Children's Defense Fund); and
;
* 110 babies will die before they are one year bid
(Children's Defense Fund).
And this will be true -- not just tomorrow -- but everyday
until we ensure that all pregnant women and children in America
receive the preventive health services which we know will save
both money and lives.
�Tomorrow, tomorrow, tomorrow.
Each hour we wait
"
* 57 babies will be born to women who have no health insurance
(March of Dimes) - nearly 1 every minute
* 27 babies will be born to mothers who receive late or no pre-natal health
care (National Center for Health Statistics) - nearly 1 every 2 minutes;
* 38 babies will be born to mothers with private insurance that does not
cover maternity care (March of Dimes) -- nearly 1 every 2 minutes;
* 33 babies will be born at low birthweight (National Center for Health
Statistics)--nearly 1 every 2 minutes;
* 2 babies will die before they are one month old
(National Center for Health Statistics) - 1 every 30 minutes; and
r
* 5 babies will die before they are one year old;
(National Center for Health Statistics) --1 every 12 minutes.
This will be true every hour until we ensure that aH pregnant
women and children in America receive the preventive health
services which we know will save both money and lives.
�'
UPDATED: August 16, 1994 10:50 a.m.
LIST OF HEALTH CARE MATERIALS
MITCHELL
General
Information
DPC Health Care Reform Briefing Book (including section on Cost Containment)
8/8/94
Changes from August 9 Mitchell Health Proposal
8/9/94
'
Statement of Senate Majority Leader George J. Mitchell
Regarding Introduction of Health Care Reform Legislation (Floor)
8/2/94
Statement of Senate Majority Leader George J,, Mitchell
Regarding Health Care Reform Legislation (Press Conference)
8/2/94
8/2/94
8/2/94
8/2/94
8/2/94
Mitchell Health Care Legislation Executive Summary
Summary of Mitchell Health Care Legislation
Mitchell Chart Packet
.
.
.
Sources of Mitchell Health Care Reform Bill
.
i
Statement of Senate Majority Leader George J. Mitchell Regarding
Health Care Reform Legislation (Opening Floor Statemeht)
Preliminary CBO Charts
. '
'
A Preliminary Analysis of Senator Mitchell's Health Proposal
' List of Sections Affected -- Technical Changes to Legislation
Statement of Senate Majority Leader George J. Mitchell, Regarding Endorsement
of Health Care Plan By American Association of Retired Persons
CBO Validates The Mitchell Bill
8/9/94
8/9/94
8/9/94
8/9/94
8/10/94
�Talking Points on Mitchell
The Mitchell Proposal: Health Reform that Works
for Middle Class Families
.
'
The Mitchell "You're Covered" Plan
8/11/94
The Mitchell Bill Provides Strengthened Protection
and New Benefits for Older Americans
Problems with Reducing the Threshold for Community Rating
Letter of Support from the
American Occupational Therapy Association, Inc.
8/11/94
Talking Points on Comparison of Mitchell vs. Dole
Setting the Record Straight
Fact Sheet: Republican Attack on "New Taxes"
-
8/12/94
Fact Sheet: Response to Republican Attack on Community Rating
Fact Sheet: The Republicans Bogus Charge of Bureaucracy
Fact Sheet: The Mitchell Proposal: A Private Health Care System
. 8/12/94
DPC Health Care Reform Fact Sheet #1
•
8/11/94
-Payroll Tax, 18 New Taxes, Community Rating, Mental Illness, Cost Shifting
DPC Health Care Reform Fact Sheet #2
8/12/94
-The Mitchell Bill: Protects good Benefits, Discourages Skyrocketing Premium Increases,
Expands Private Insurance,. Makes Insurance Portability Real,
Uses Market Forces to Control Costs, Eliminates Pre-existing Condition Exclusions,
Streamlines Private System, Eliminates Bureaucracy, Phases-ln Voluntary System
DPC Health Care Reform Fact Sheet #3
-The Mitchell Bill: Provides Long Term Care, Protects Consumers Against Fraud,
Protects Middle Income Families
CHILDREN
.8/13/94
ISSUES
"The Price of Delay" Statistics - Talking Points
Children and Health Care: The Problem Today - Talking Points
Rebuttal To Republican Arguments - Argument/Response Sheet
.
8/15/94
�AMENDMENTS
Children's Amendment Information Packet
8/12/94.
Disability Amendment Information Packet
8/12/94
REPUBLICANS
Summary of Dole/Packwood Health Reform Proposal (long summary)
The Dole Proposal (short summary)
,
Bob Dole Plan: "You're Out of Luck" Talking Points
Letters Opposing Dole Plan
Republicans Have Favored Mandates in the Past
Republicans on Delay - Talking Points
8/4/94
Republicans Remarks on Mitchell Plan
Labor Committee packet on the Dole-Packwood Bill
HISTORICAL
PERSPECTIVES
Republican Opposition to Medicare
DPC Special Report- Dire Predictions on Health Care Reform
DPC Special Report- A History of Health Care Reform:
Six Decades of Debate
8/8/94
11/3/93
STATES
DPC Talking Points: Health Care Reform Benefits to the States
10/27/93
DPC Special Report: States of Emergency: Costs and Savings
of Health Care in the 50 States
5/26/94.
DPC Special Report: Health Across America, Part II, Spring 1993
2/01/93
EMPLOYERS
DPC Special Report: Health Care Through Shared Responsibility
DPC Background Brief: Small Business Talks to Clinton About Health Security Act
3/25/9.4
5/2/94
�MISCELLANEOUS
DPC Special Report: Health Care Questions Most Often Asked
DPC Special Report: Straight Talk About Health Care Reform
DPC Background Brief: Workers' Compensation and the Health Security Act
DPC Talking Points: Recent Medical Journal Articles Underscore Need for Reform
11/20/93
.2/2^/94
5/3/94
5/26/94
DPC Talking Points: AMA Journal Praises Health Security Act
Common Myths and Realities about the Heaith Security Act (Clinton)
CURRENT
SYSTEM
DPC Special Report: Believe It or Not: Incredible Facts
About'Am'erica's Health Care Crisis
People with Disabilities: The Current System >
Rural Communities and Health Care: The Problem Today
5/20/93
�August 16; 1994
Publication: SR-40-Health
dpc
special
report
The State of America's
Health Care System
& Health Care Crisis:
A Reference Guide
The Facts and Nothing But the Facts
DPC Staff Contact: Dave Corbin (202-224-3232)
DPC Media Contacts: Debra Silimeo (202-224-3232); Diane Dewhirst (202-224-2939)
E
Democratic Policy Committee
United States Senate
Washington, D.C. 20510
George J. Mitchell, Chairman
Thomas A. Daschle, Co-Chairman
�Contents
Introduction
1
Americans Without Health Insurance
2
Growing Number of Uninsured
2
Uninsured by Age
Number and Percent of Uninsured Americans Under Age 65 (1988-1992)
Percent of Uninsured Americans by Age (1991)
3
3
The Uninsured: Families Who Work
Percent Distribution of the Insured, 1992
Uninsured Worker by Firm Size, 1991
4
4
National Costs of Health Care
5
National Health Expenditures: Aggregate Amounts for Selected Years
(1960-1993)
Health Expenditures as Percent of GDP (CBO Projections for 1993-2000)
National Health Care Spending
National Health Spending (CBO Projections)
Per Capita Spending
CBO Estimated Insurance Premium by Type of Policy
Health Care as A Source of Growth in Federal Spending, FY 1981 -1993
Total Health Spending Financed by the Government
Health Programs as a Percent of the Federal Domestic Budget
Health Expenditures Growing as a Share of Federal Outlays
Family Expenditures on Health Care
Health Care Payments Per Family
Family Spending on Health Care
Health Payments as A Percent of Family Income (Pre-tax)
5
6
6
7
7
7
8
8
8
9
10
10
10
- 10
Prescription Drug Costs
11
The Health Care Bureaucracy
12
Employers
14
Health Insurance Premiums as a Percent of Payroll
The Cost of Non-Insuring Firms
14
15
Total Business Payments for Health Care
Increasing Costs of Employer-Sponsored Health Benefits
(Health Coverage Costs Per Employee)
How Businesses Pay for Health Care
Business Taxes for Health Care
-1 -
15
16
16
16
�Small Business
18
Reductions in Health Care Benefits
20
Workers
21
Job Lock
23
Relationship Between Health Care Costs and Average Wages, 1965-1992
Relationship Between Health Care Costs and Wages; 1995-2020
(projections based on trends during 1980-1992)
International Comparisons on Health Care Spending
Annual Rate of Real Per Capita Health Care Spending in the 1980s
Per Capita Health Care Spending (1991)
Average Change in Per Capita Health Care Spending (1985-1991)
Percent of GDP spent on Health Care, 1991 ..:
International Health Care Spending
Medicaid
24
24
25
25
25
26
26
27
28
Medicaid Outlays
Medicaid Beneficiaries by Assistance Status (FY 1991)
Medicare
<
Medicare Outlays
29
29
30
31
Mortality Rates
32
Leading Causes of Death in U.S., 1990
Mortality for Selected Cancers, 1990
Estimated Annual Economic Costs of Disease in U.S
Infant Mortality Deaths/First Year of Life per 1,000 Births, 1990
32
32
33
33
Percent of Uninsured Persons by State (1992)
34
Number of Firms, Establishments, Employment, and
Annual Payroll by Legal Form of Organization and
Firm Size for 1991
35
- ii -
�The State of America's Health
Care System & Health Care Crisis:
A Reference Guide
The Facts and Nothing but the Facts
As the health care debate continues, you may need to find facts about our
health care system quickly. This report provides facts and reference data on
many facets of the American health care system. It includes data on the
number and different groups of people who are insured or uninsured — with
a State-by-State table; costs; the health care bureaucracy; how businesses
pay for health care; benefits; and, international comparisons.
There is also a section on Medicare.
We hope this will be a useful reference source.
DPC Special Report — The State of America's Health Care System
p. 1
�Americans Without
Health Insurance
•
37.5 million Americans (15 percent) are without any form of
health insurance coverage (1992).
1
2
•
2,248,000 Americans lose their health insurance each month.
•
46 Americans lose their health insurance every minute.
•
58 million (or 17 percent of the population) were uninsured for
at least some part of the year.
3
4
•
60 percent of the uninsured adults said they could not afford
coverage.
5
6
Growing Number of Uninsured
1992
1991
1990
1989...
1988
37.5
36.6
36.0
34.7
33.9
million
million
million
million
million
1
Congressional Research Service (CRS), Health Insurance, IB-91093, March 14, 1993. (EBRI
uses 38.5 million.)
2
Families USA, "How Americans Lose Health Insurance," April, 1994.
3
The Health Security Act of 1993: Peace of Mind for America's Families; Families USA, Special
Report, Summer, 1993.
4
Joint Economic Committee (JEC), The 1994 Joint Economic Report, May 1994.
5
Kaiser Foundation, cited in JEC 1994 Annual Report.
6
Employee Benefits Research Institute (EBRI); Democratic Study Group (DSG) Special Report,
"A Health Care Plan We Cannot Afford: The Status Quo," No. 103-16, September 20, 1993.
/
DPC Special Report—The
State.of America's Health Care System
p. 2
�Uninsured By Age
Almost all Americans aged 65 and over are covered under Medicare.
Therefore, nearly all the uninsured are under 65.
1
Number and Percent of Uninsured
Americans Under Age 65 (1988-92)'
1992
1991
1990
1989....
1988
1987
37.0
35.2
34.4
33.0
32.4
30.7
million
million
million.
million
million
million
16.6%
15.9%
15.7%
15.3%
15.1%
14.4%
s
Percent of Uninsured Americans by Age (1991)
Under 18.....
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 and over
Total
22.1%
18.8%
23.4%
16.7%
10.7%
7.3%
0.9%
100.0%
A full 22 percent of the uninsured (8.34 million) are children.™
7
CRS, Health Insurance, IB91093, March 14, 1993.
8
House Committee on Ways and Means, Green Book, 1994, p. 951.
9
ibid., p. 944.
10
U.S. Dept. of Health and Human Services.
DPC Special Report — The State of America's Health Care System
p. 3
�The Uninsured: Families who Work
The vast majority of uninsured Americans — 72 percent — have incomes
above poverty. Nearly one in three uninsured Americans is a member of a
family making more than $30,000 a year.
11
12
•
84 percent of uninsured Americans are in working families.
•
47.7 percent of all uninsured workers are either self-employed
or working in firm with fewer than 25 employees (1991).
13
Percent Distribution of Uninsured, 1992"
Full year/full time
Part year/full time
Full year/part time
Part year/part time
Nonworker
46.4%
22.0%
7.2%
8.3%
16.1%
15
Uninsured Worker by Firm Size, 1991
Fewer than 25 employees
25-99 employees
100-499 employees
500 or more employees
47.7%
16.1%'o
11.4%
24.9%
11
U.S. Department of Treasury, 1994.
12
EBRI Data, 1992: CRS, Health Insurance, IB91093, March 14, 1993.
13
Facts From EBRI: Sources of Health Insurance and Characteristics of the Uninsured, January
1993.
,
u
House Committee on Ways and Means Green Book, 1994, p. 947.
15
EBRI; cited in DSG Special Report, "A Health Care Plan We Cannot Afford: The Status Quo,"
No. 103-16, September 20, 1993, p. 16.
DPC Special Report — The State of America's Health Care System
p. 4
�National Costs
of Health Care
Health care consumes (1993):
•
14.3 percent of GDP; and,
•
one dollar out of every seven.
16
National Health Expenditures:
Aggregate Amounts for Selected
Calendar Years (1960-1993)
17
1960
1965
1970
1975
1980
. 1985
1990.......
1991
1993
....$27.1 billion
$41.6 billion
$74.4 billion
$132.9 billion
$250.1 billion
$422.6 billion
$675.0 billion
$751.8 billion
$898.0 billion
16
JEC, The 1994 Joint Economic Report, May 1994: 1994 Economic Report of the President.
17
Health Care Finance Administration (HCFA); Office of the Actuary; cited in 1994 Green Book.
DPC Special Report — The State of America's Health Care System
p. 5
�Health Expenditures as a Percent of GDP
18
(CBO Projections for 1993-2000)
1989...!
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999..
2000
11.5%
12.2%
13.2%
14.0%
14.6%
15.1%
15.7%
16.3%
16.9%
17.5%
18.2%
18.9%
National Health Care Spending
19
Now (1993): 14 percent of GDP
Year 2000: 18 percent of GDP (CBO projection)
Year 2003: 20 percent of GDP (CBO projection)
18
JEC, The 1994 Joint Economic Report, May 1994.
19
Congressional Budget Office (CBO) Memorandum, Projections of National Health Expenditures:
1993 Update, October 1993.
DPC Special Report — The State of America's Health Care System
p. 6
�In less than 10 years, one dollar out of every five dollars earned by people
living in the U.S. will go to cover the cost of health care.
20
National Health Spending (CBO Projections)
1992
1993
1994
1995
1996
1997 ......
1998
. 1999
2000
2002
2003.....
$823 billion
$900 billion
$982 billion
$1069 billion
$1163biilion
$1263 billion
$1372 billion
$1488 billion
$1.6 trillion
$1.75 trillion
$2 trillion
Per Capita Spending
Now (1993)....
Year 2003
21
22
$3,358
$7,000
CBO Estimated Insurance Premium by Type of Policy
Single person
Married couple
Single-parent family
Two-parent family...
23
$2,100
$4,200
$4,095
$5,565
20
U.S. Department of Commerce, Industrial Outlook, January 1994.
21
CBO Memorandum, Projections of National Health Expenditures: 1993 Update, October 1993.
22
ibid.
23
CBO, An Ana/ys/s of the Administration's Health Proposal, 1994.
DPC Special Report — The State of America's Health Care System
p. 7
�Health Care as a Source of Growth
in Federal Spending, FY 1981-1993"
Medicare and Medicaid
Net Interest
Social security (& other retirement)
Other entitlement
(aid/poor, farm supports, etc.)
Defense
Domestic discretionary
International affairs
% Increase
113.0%
57.5%
6.5%
3.6%
1.9%
-7.0%
-15.3%
Twenty-one percent of Federal government revenues are devoted to health
care.
25
Total Health Spending Financed by the Government
Now (1993)
Year 2003.
26
46%
50%
CBO projects that the escalating costs of health care will be the dominant
force in driving the deficit by the end of the decade.
27
Health Programs as a Percent
of the Federal Domestic Budget
FY 1998
FY 1993
FY 1980
28
35%
27%
16%
" DSG Special Report, "A Health Care Plan We Cannot Afford: The Status Quo," No. 103-16,
September 20, 1993, p. 13!
25
1994 Economic Report of the President.
26
CBO Memorandum, Projections of National Health Expenditures: 1993 Update, October 1993.
27
1994 Economic Report of the President.
26
CBO data; DSG calculations, cited in DSG Special Report, "A Health Care Plan We Cannot Afford:
The Status Quo," No. 103-16, September 20, 1993 p. 14.
DPC Special Report — The State of America's Health Care System
p. 8
�Health Expenditures Growing
as a Share of Federal Outlays
29
(outlays in billions of dollars)
Fiscal Year
1970
, $95
Health Care
$14
Social Security
$30
Other Domestic
$51
Defense
$82
International Affairs
$4
Net Interest.....
$14
Total Federal Budget
$196
Health Care aS a %
of Domestic Budget
14.6%
Health Care as a %
of Total Federal Budget ....7.1%
1980
1990
1993
1998
$392.....;. $755
$944 ... $1,237
..$62
$168
$254
$434
$119
$249....... $305
$388
$211
$339
$385
$415
$134
$299. $293
$291
..$13
$14
$18
$20
..$53 ..$184
$198
$292
15.8%
22.2%
26.9% .... 35.1%
10.5%
13.4%
17.5% .... 23.6%
If health care costs had been kept under control—that is, if health care costs
had increased at the rate of growth in overall economy for the last 12 years:
• the Federal government would have saved $79 billion in 1992
alone — enough to cut this year's Federal deficit by 27 percent.
Over the last 12 years, the Federal government would have:
•
saved $391.2 billion — enough to fully fund all Federal grant
programs to States and localities at 1982 levels, with an
additional $160 billion left over for reducing the Federal debt
and investing in education and training.
30
29
CBO data cited in DSG Special Report, "A Health Care Plan We Cannot Afford: The Status
Quo," No. 103-16, September 20, 1993, p. 60.
30
Service Employees International Union (SEIU), "Out of Control, Into Decline: The Devastating
12-year Impact of Health Care Costs on Workers Wages, Corporate Profits and Government
Budgets," Data provided by Lewin-ICF, October 1992.
DPC Special Report — The State of America's Health Care System
p. 9
�Family Expenditures
on Health Care
31
Health Care Payments Per Family
Average payments per family, 1993
Average payments per family, 2000*
% increase, 1980-1993
% increase, 1993-2000*
Payments as a % family income, 1993
$7,739
$14,517
199% ($2,590 to $7,739)
88% ($7,739 to $14,517)
13.1%
Family Spending on Health Care
1993
2000
33
$5,190 (three times the amount they paid in 1980)
$9,993 (projected, without reform)
According to the Commerce Department, without reform, the annual cost of
health care for a family could reach as high as $14,000 by the end of the
decade.
32
34
Health Payments as a Percent of Family Income (Pre-tax)
1980.
.;
1993
2000 (projected, without reform)
9.0%
..13.1%
18.4%
Last year, total household spending of $196 billion was 26 percent of national
health spending.
35
31
Democratic Policy Committee (DPC) Special Report, Sfafes of Emergency: Costs and Savings
of Health Care in the 50 States, May 26,1994.
32
Families USA, "Skyrocketing Health Inflation, 1980-1993-2000," November 1993.
33
U.S. Department of Commerce, Industrial Outlook, January 1994.
34
Families USA, "Skyrocketing Health Inflation, 1980-1993-2000," November 1993.
35
1994 Economic Report of the President.
DPC Special Report — The State of America's Health Care System
p. 10
�Prescription Drug Costs
More than five million Americans over the age of 55 say they have to choose
between buying food and paying for medication.
36
Prescription drugs are the largest cost of dialy living for 45 percent of all
people over age 65.
37
On the average, Americans pay 54 percent more than Europeans pay for
25 prescribed drugs.
38
Since 1987:
• the drug Premarin (estrogen) increased 101 percent; and,
• the drug Zantac (used for ulcers) increased almost 50 percent.
39
36
American Association of Retired Persons (AARP) cited in President's Report on Health Security.
37
ibid.
38
"Why Drugs Cost More in the U.S.," New York Times, May 24, 1991.
39
DPC Special Report, Health Care Questions Most Often Asked, SR-26-Health, November 20,
1993.
,•
DPC Special Report — The State of America's Health Care System
p. 11
�The Health Care Bureaucracy
There are more than 1,500 health insurers in the U.S.
40
Each insurance company (all 1,500 of them) has its own forms that physicians
are required to fill out when they provide care for patients.
41
Hospitals have to fill out 15 or more forms for one patient's hospital stay.42
Lack of standardization in forms results in high administrative costs. In 1991,
over six percent of all health care expenditures went towards administrative
expenses — this exceeds total spending on all public health service programs.
43
The number of health administrators and bureaucrats has increased by 300
percent during the past decade. At the same time, the number of physicians
grew by only 18 percent.
44
Massachusetts Blue Cross employs more bureaucrats to insure 2.7 million
subscribers than Canada employs to insure 25 million people.
45
Private insurance carriers and insurance agents employ more than 2.4 million
(1990)—this is almost as many people employed in all the legislative .judicial,
and nondefense executive agencies of the American Federal government,
including postal workers.
46
40
Health Secunty: The President's Report to the American People, p. 50.
4,
ibid.
42
ibid.
43
1994 Economic Report of the President.
44
Health Security: The President's Report to the American People, p.' 50.
45
"Wasted Health Care Dollars," Consumer Reports, June 1992.
46
DPC Special Report, Health Care Questions Most Often Asked, SR-26-Health, November 20,
1993; Office of Personnel Management (OPM); JEC.
_
DPC Special Report — The State of America's Health Care System
p. 12
�Children's Hospital in Washington, D.C. reports that it spends more than
$2 million a year filling out forms that have nothing to do with the treatment of
patients.
• 47
The number of hospital administrators is growing at four times the rate that the
number of doctors is growing.
48
Insurance overhead accounts for nearly 25 percent of total spending.
By contrast, administrative costs in other industrialized countries total
11 percent or less.
49
4
DPC Special Report, Heatf/7 Care Questions Most Often Asked, SR-26-Health, November 20,
1993.
48
President's Report on Health Security.
49
U.S. Dept of Commerce, Industrial Outlook, January 1994.
DPC Special Report — The State of America's Health Care System
p. 13
�Employers
The average cost of providing health coverage to employees increased more
than 100 percent between 1984 and 1992. The average cost per employee
was $3,968 in 1992 compared with $1,645 in 1984.
S0
Between 1987 and 1992, average premium for health benefits for a single
employee rose 108 percent — about 16 percent a year.
51
The cost of coverage per employee has more than doubled since 1987, to
$3,968 in 1992.
52
Health Insurance Premiums
as a Percent of Payroll
53
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
10.7%
11.5%
12.4%
13.5%
14.8%
.16.1%
17.7%
19.3%
21.0%
22.9%
50
Facts from ERBI: Employers Spending on Health Care and Initiatives to Reduce Health Care
Costs, August 1993
51
CRS, Health Insurance, IB91093, March 14, 1993.
52
JEC, The 1994 Joint Economic Report, May 1994.
53
ibid.
DPC Special Report — The State of America's Health Care System
p. .14
�The Cost of Non-Insuring Firms
Employers who provide health insurance spent $26.4 billion covering dependents who are employed by non-insuring firms.
54
Employers providing health insurance pay an additional $10.8 billion (1991)
in premiums to cover uncompensated hospital care — nearly half of which
was provided to workers in firms that do not provide coverage and to .the
dependents of those workers.
55
If health care costs had been kept under control—that is, if health care costs
had increased at the rate of growth in overall economy, for the last 12 years:
•
employers would be paying an average $1,015 less per employee per year for health insurance coverage. ($1,015 of the
$3,054 spent per employee per year, on average, is attributable
to excess health care cost growth).
56
Businesses are responsible for one-third (33 percent) of all health care
payments.
Total Business Payments for Health Care
57
1980.... $75 billion
1993.... $279 billion (3.7 times higher)
2000.... $512 billion (nearly double the amount
they paid in 1993 and 6.8 times greater
than in 1980)
M
National Association of Manufacturers (NAM), Employer Cost-shifting Expenditures, prepared by
Lewin/CF, December, 1991.
ss ibid.
56
57
SEIU, Out of Control, Into Decline: The Devastating 12-year Impact of Health Care Costs on
Workers Wages, Corporate Profits and Government Budgets, Data provided by Lewin-ICF,
October 1992.
Families USA, "Skyrocketing Health Inflation, 1980-1993-2000," November 1993.
DPC Special Report — The State of America's Health Care System
p. 15
�Increasing Costs of Employer-Sponsored Health Benefits
Health Coverage Costs Per Employee
58
1992
1991
1990
1989
1988
1987
1986
1985
$3,968
$3,605
$3,217
$2,748
$2,354
$1,985
$1,857
$1,724
How Businesses Pay for Health Care
$279 billion, 1993
Insurance premiums
General Taxes
Medicare Payroll Taxes
Other
59
57%
23%
13%
8%
Business Taxes for Health Care
1993 ....$63 billion in general taxes to support public health
programs. (This is 4.6 times the amount paid in 1980.)
$35 billion in Medicare payroll taxes. (This is 3.4 times
the amount paid in 1980.)
2000 ....$142 billion in general taxes to support public health
programs. (Projected, without reform.)
$55 billion in Medicare payroll taxes. (Projected, without reform)
60
58
Foster Higgins Annual Health Benefits Survey, cited in DSG, Special Report, No. 103-16,
September 20, 1993, p. 9.
59
Families USA, "Skyrocketing Health Inflation, 1980-1993-2000," November 1993.
60
ibid.
DPC Special Report — The State of America's Health Care System
p. 16
�Health care costs add more than $1,000 to the price of every car manufactured in the United States. Japan spends half this amount.
61
In 1990, General Motors spent $3.2 billion in medical coverage for its
1.9 million employees and retirees. That is more than the company spent on
steel.
62
61
U.S. Department of Commerce, Industrial Outlook, January 1994.
62
ibid.
DPC Special Report — The State, of America's Health Care System
p. 17
�Small Business
If health care costs had been kept under control — that is, health care costs
had increased at the rate of growth in overall economy, for the last 12 years:
•
small businesses would be paying an average $1,283 less per
employee per year for health coverage.
63
Small businesses premiums have risen as much as 50 percent a year.
64
The Small Business Coalition for Health Care Reform was formed to give a
unified voice to smaller employers across the country — and to insure that
health care reform will include thecritical elements needed to meet the special
requirements of small businesses. According to its research:
•
more than. 90 percent of small business owners agree that
health care is becoming prohibitively expensive and is a serious
business problem;
•
70 percent of small businesses insure their employees;
•
nearly 70 percent of small business owners want to offer their
employees better health care benefits and agree that all Americans have a right to basic health insurance;
•
small businesses now pay 35 to 50 percent more than large
firms for the same insurance. Large corporations can offer
more benefits at a lower cost, thus putting smaller firms at a
great disadvantage;
63
SEIU, Out of Control, Into Decline: The Devastating 12-year Impact of Health Care Costs on
Workers Wages, Corporate Profits and Government Budgets, Data provided by Lewin-ICF,
October 1992;
64
U.S. Department of Commerce, Industrial Outlook, January 1994.
DPC Special Report — The State of America's Health Care System
p. 18
�•
paperwork and administrative burden on small businesses that
offer employee coverage bosts small firms as much as 40 cents
out of every health care dollar while large firms average only a
nickel;
•
small businesses can pay up to 40 percent more than large
businesses for the same coverage;
•
by the year 2000, without reform, health care costs may eat up
60 percent of businesses' pre-tax profits; and,
•
an NFIB poll found that 64 percent of small business owners
would like to provide some or better health insurance to their
workers.
DPC Special Report — The State of America's Health Care System
p. 19
�Reductions in
Health Care Benefits
In 1988, neariy nine out of ten employers offered health care plans that let
employees choose any doctor in their community. By 1993, only six out of ten
employers offered this option.
65
More and more businesses are eliminating or reducing benefits. A survey of
larger corporations found:
•
12 percent of companies have eliminated or plan to eliminate all
retiree health benefits ; and,
66
•
56 percent have reduced, or plan to reduce, health benefits
covered.
67
Percent of full-time employees in medium and large establishments received
employer-sponsored health insurance as an employee benefit:
1980
1991
65
99 percent
92 percent
68
White House Fact Sheet, "America's Health Care Crisis: The Facts."
Survey excerpted in Families USA, "Skyrocketing Health Inflation, 1980-1993-2000," November
1993.
67 ;
ibid.
68
Facts from ERBI: Employer Spending on Health Care and Initiatives to Reduce Health Care
Costs, August 1993.
DPC Special Report — The State of America's Health Care System
p. 20
�Workers
Over the past 20 years, the wages of American workers have fallen in real
terms while health care costs have climbed 10 to 15 percent each year.
69
Between 80 and 100 percent of business insurance spending ultimately is
paid for by workers through reduced wages, or slower wage growth.
70
If business spending on health insurance were the same share of total
compensation today as in 1975, average wages per employer could be as
much as $1,000 higher than they are now.
71
Because of the increase in health care costs, American workers took the
equivalent of a 5.3 percent pay cut (take-home) in 1992.
Workers now earning the average wage must work 5.4 weeks a year to pay
household health costs compared to 4.8 weeks two years ago.
72
If health care costs had been kept under control — increased at the rate of
growth in overall economy, for the last 12 years:
•
personal wages would not have declined; and,
• the average working family could have saved $12,000.
73
69
U.S. Department of Commerce, U.S. Industrial Outlook, January 1994.
70
JEC, The 1994 Joint Economic Report, May 1994: 1994 Economic Report of the President.
71
1994 Economic Report of the President: JEC, The 1994 Joint Economic Report, May 1994.
72
DSG Special Report, A Health Care Plan We Cannot Afford: The Status Quo, No. 103-16,
September 20, 1993, p. 1.
73
SEIU, Out of Control, Into Decline: The Devastating 12-year Impact of Health Care Costs on
Workers Wages, Corporate Profits and Government Budgets, Data provided by Lewin-ICF,
October 1992.
DPC Special Report — The State of America's Health Care System
p. 21
�If health inflation continues as projected, workers will lose another $600 per
year in real wages by the year 2000.
74
Average employee contribution for family insurance coverage doubled in
three years:
1988.... $48 per month
24% of average total premium. '
1
1991 .... $98 per month
28% of average total premium.
75
74
Commerce Department and Office of Management and Budget (OMB) data, White House
Domestic Policy Council, Health Security: The President's Report to the American People ;
Families USA, "Skyrocketing Health Inflation, 1980-1993-2000," November 1993.
75
Families USA, "Skyrocketing Health Inflation, 1980-1993-2000," November 1993.
DPC Special Report — The State of America's Health Care System
p. 22
�Job Lock
Three out of every 10 workers say that they are staying in jobs they wanted
to leave only because of a need to keep their company health coverage.
76
Health coverage reduces job mobility by as much as 25 percent. 77
76
77
1991 New York Times/CBS News poll, cited in JEC, The 1994 Joint Economic Report, May 1994.
1994 Economic Report of the President.
DPC Special Report — The State of America's Health Care System
p. 23
�Relationship Between
Health Care Costs and Average Wages, 1965-1992
78
($ amounts in constant 1990 dollars)
Year
Health costs
as % of
earnings
Weeks of work
needed to pay
heaith costs
1965,
1970
1975,
1980.,
1985
1990,
1992,
6.6%.
,6.6%.
,6.9%.
6.6%.
,8.2%.
9.5%.
10.8%
,3.3
.3.3
,3.4
,3.3
.4.1
.4.8
5.4
Relationship Between
Health Care Costs and Average Wages, 1995-2020
79
(Projections based on trends during 1980-1992)
78
Year
Health costs
as % of
earnings
1995
2000
2005
2010
2015
2020
12.5%
16.1%
20.8%
27.0%
35.5%
46.6%...,
Weeks of work
needed to pay
health costs
6.3
.8.0
10.4
.......13.5
17.7
23.3
DSG.Special Report, A Health Care Plan We Cannot Afford: The Status Quo, No. 103-16,
September 20, 1993, p. 57.
"ibid.
DPC Special Report — The State of America's Health Care System
p. 24
�International Comparisons
on Health Care Spending
Anyway you measure it, health care spending in the U.S. far exceeds that of
other nations.
The U.S. spends 14.3 percent of its GDP on health care compared to less
than nine percent of GDP among other industrialized nations (1993).
80
The U.S. spends twice as much on health care as the average for the
24 industrialized countries in Europe and North America.
81
Annual Rate of Real Per Capita
Health Care Spending in the 1980s
•
82
4.4 percent for U.S. (Thiswasthree
times greater than GDP growth per
capita.)
3.2 percent (average) for Canada,
France, Germany, Japan, and U.K.
83
Per Capita Health Care Spending (1991)
U.S
Canada
Australia
Germany
Japan
U.K
$2,867
$1,407
....$1,035
$1,659
$1,267
........$1,035
0
' JEC, The 1994 Joint Economic Report, May 1994.
81
8J
83
U.S. Department of Commerce, U.S. Industrial Outlook, January 1994.
1994 Economic Report of the President.
CRS, Health Care Fact Sheet: International Health Spending, November 15, 1993.
DPC Special Report — The State of America's Health Care System
p. 25
�Average Change in Per Capita
Health Care Spending (1985-1991 J
U.S
Canada.
Australia
Germany
Japan
U.K
84
5.0%
3.6%
2.1%
2.1%
4.2%
3.3%
Percent of GDP spent on Health Care, 199185
U.S
Canada
Germany
Australia
Japan
U.K
M
65
!
13.2%
10.0%
8.6%
8.5%
6.8%
6.6%
CRS, Heallh Care Fact Sheet: International Health Spending, November 15, 1993.
ibid.
DPC Special Report — The State of America's Health Care System
p. 26
�86
International Health Care Spending
Country
Mozambique
Bangladesh
Egypt
India
Bolivia
Poland
Mexico
Brazil
South Africa
South Korea
U.K
France
Canada
Sweden
US
Income
Spending % GDP
per capita* per capita** (1990)
$80
$220.
$610
$330
$650
$1,790
$3,030
$2,940
$2,560
$6,340
$16,550
$20,380
$20,440
$25,110
$22,240
$5
$7
$18
$21
$25
$83
$89
$132
$158
$377
$1,039
$1,869
$1,945
$2,343
$2,763
5.9%
3.7%
2;6%
6.0%
4.0%
5.1%
3.2%
4.2%
5.6%
6.6%
6.1%
8.9%
9.2%
8.8%
12.6%
* Gross Domestic Product Per Capita, 1991
** Health Care Expenditures per capita, 1990.
Internationally, health care spending amounted to an estimated $1,700 in
1990, eight percent of the world's income. The U.S. accounted for approximately 40 percent of global spending on health care.
87
86
World Bank, World Development Report, 1993, in U.S. Department of Commerce, U.S. Industrial
Outlook, i 994, January 1994.
87
U.S. Department of Commerce, U.S. Industrial Outlook, January 1994.
DPC Special Report — The State of America's Health Care System
p. 27
�Medicaid
Medicaid serves 31.4 million persons (FY 1992).
88
Medicaid has the combined cost to Federal, State, and local governments of
$118.8 billion (FY 1992).
89
Medicaid is estimated to have constituted about 15 percent of total national
health Spending (FY 1992).
90
The Federal share of Medicaid spending is about $67.8 billion (about
57 percent of the total). State and local governments pay the remainder.
91
Medicaid is available to persons with very low incomes. However, the
program covers less than one-half (47 percent) of the non-institutionalized
population with incomes below the Federal poverty line.
92
Medicaid has become one of the fastest growing components of both Federal
and State budgets:
•
between FY 1989 and FY 1992, spending on Medicaid nearly
doubled; and,
•
by FY 1997, spending on Medicaid is projected to double
again.
93
86
CRS,Health Care Fact Sheet: Medicaid, 92-371, March 31, 1993.
89
ibid.
90
ibid.
91
CRS, Medicaid: An Overview, 93-144, January 22, 1993.
92
CRS, Health Care Fact Sheet: Medicaid, 92-371, March 31, 1993.
93
ibid.
•
,
DPC Special Report — The State of America's Health Care System
p. 28
�Medicaid Outlays
94
(dollars in billions)
FY
1980
1985
1989
1990
1992
1993
1995
1997
Federal
spending
$14.6
$22.7
$34.6
$41.1
$67.8
$80.3
$105.0
$131.0
Total
spending
$25.8
$0.9
$61.2
$72.5
$118.8
$140.7*
$183.8*
.....$229.4*
* Based on CBO projections
Medicaid Beneficiaries
by Assistance Status (FY 1991 )
AFDC
:
SSI.:
Non-AFDC Families,
Pregnant Women, Children
Non-SSI Aged, Blind, Disabled
Medically Needy
Other/Unknown
94
CRS, Health Care Fact Sheet: Medicaid, 92-371, March 31, 1993.
95
CRS, Medicaid: An Overview, 93-144, January 22, 1993.
95
45%
16%
18%
7%
12%
2%
DPC Special Report — The Sfafe of America's Health Care System
p. 29
�Medicare
Medicare is the Nation's largest health care program.
96
Medicare is the Nation's second largest entitlement program in the Federal
budget after Social Security.
97
Medicare covered 35 million people in FY 1993.
98
Medicare outlays amounted in the top 9.3 percent of the Federal budget in
F Y I 993."
i
Total Medicare outlays were estimated at $149.2 billion in FY 1993. Net
Medicare outlays (after deduction of $15.1 billion in beneficiary premiums)
are estimated at $134.1 billion.
100
Total Medicare outlays increased from $32 billion in 1980 to $131 billion in
1993, an average annual rate of growth of 11.5 percent.
101
More than 95 percent of the aged population was enrolled in Medicare in
1991.
102
96
CRS, Health Care Fact Sheet: Medicare, 93-344, March 25, 1993.
97
CRS, Medicare: President's FY 1995 Budget Proposal, 94-223, February 25, 1994.
96
CRS, Health Care Fact Sheet: Medicare, 93-344, March 25, 1993.
99
CRS, Medicare: President's FY 1995 Budget Proposal, 94-223, February 25, 1994.
,00
CRS, Health Care Fact Sheet: Medicare, 93-344, March 25, 1993.
101
CRS, Medicare: President's FY 1995 Budget Proposal, 94-223, February 25, 1994.
102
House Ways and Means Committee, 1993 Green Book. p. 238.
DPC Special Report — The State of America's Health Care System
p. 30
�More than three-quarters of the Medicare enrollees had some form of
supplemental coverage.
103
Medicare spending constitutes 53 percent of total Federal outlays for health
in FY 1992.
Medicare expenditures constitutes 16 percent of total national health expenditures.
104
Medicare Outlays
105
(in millions of dollars)
FY
1971
1975
1980
1985
1990
1991
1992
Total
Outlays
Percent Increase/
Prior Year
$7,875.......
,......$14,782
.....$35,025...
:
$71,384
,....$109,709
,......$116,657
$132,256
10.2%
30.3%
20.1%
14.3%
13.6%
6.3%
13.4%
CBO projections
1993
1994
1,995
1996
1997
1998
$149,494
$169,692
$191,481
$213,776
..$237,130
$262,038
103
House Ways and Means Committee, 1993 Green Book. p. 238.
104
CRS, Health Gare Fact Sheet: Medicare, 93-344, March 25,1993.
105
House Ways and Means Committee, 1993 Green Book, p. 192.
13.0%
13.5%
12.8%
11.6%
10.9%
10.5%
DPC Special Report — The State of America's Health Care System
p. 31
�Mortality Rates
Leading Causes of Death in U.S., 1990
106
Cause of Death
Number/Deaths
Heart Disease
720,058 .
Cancer
505,322
Stroke
144,088
Accidents
91,983
Chronic Obstructive Pulmonary Disease
86,679
Pneumonia and influenza
79,513
Diabetes
47,664
Suicides
30,906
Chronic Liver Disease
25,815
AIDS
25,188
Homicide
24,932
Kidney Disease
20,764
All Causes
.2,148,463
Mortality for Selected Cancers, 1990
Lung, Bronchus, Trachea
Colon, Rectum, Anus
Breast
Prostrate
Pancreas
Non-Hodgkin's Lymphoma
Leukemia
Ovary
Bladder
Mouth, Lip, throat
Skin:
Uterus
Cervix
All types of cancer
107
141,285
56,525
43,663
32,378
25,082
18,601
...18,574
12,566
10,341
8,405
6,420
6,028
4,627
505,322
106
CRS, "Leading Causes of Mortality in the United States and Their Associated Economic Costs,"
93-653, July 15, 1993.
10?
ibid.
DPC Special Report — The State of America's Health Care System
p. 32
�Estimated Annual Economic Costs of Disease in U.S.
Cause of Disease
108
Medical Cost*
Cardiovascular Disease (heart disease and stroke)
Cancer
Chronic Obstructive Pulmonary Disease*
Emphysema
Chronic Bronchitis
Asthma
Influenza
Pneumonia
Diabetes
Chronic Liver Disease
AIDS
Kidney Disease
1
$99.8 billion
$35.0 billion
$0.6 billion
$2.5 billion
$3.6 billion
$0.9 billion
$1.2 billion
$20.4 billion
$16.0 billion
$10.3 billion
$6.0 billion
Direct Medical Costs includes treatment, hospital and nursing home care,
physician and other professional; services, and prescription drugs.
Infant Mortality Deaths/First Year of Life
per 1,000 Births, 1990
109
Japan
Sweden
Canada
Germany
France
U.K,
Australia
Italy
U.S.
Average
4.6
6.0
6.8
7.1
7.2
7.9
8.2
8.2
9.2
7.5
,08
CRS, "Leading Causes of Mortality in the United States and Their Associated Economic Costs,"
93-653, July 15, 1993.
, M
OECD Health Data Bank, cited in DSG Special Report, "A Health Care Plan We Cannot Aflord:
The Status Quo," No/103-16, September 20, ,1993, p. 28, 66.
DPC Special Report — The State of America's Health Care System
p. 33
�Percent of Uninsured Persons by State (1992),110
U.S
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
1,0
14.4%
16.6%
16.1%
14.9%
19.8%
19.3%
12.4%
•8.1%
10.3%
...19.5%
19.0%
6.0%
16.3%
12.9%
10.9%
10.1%
.,10.8%
.14.6%
..22.1%
11.1%
11.2%
10.4%
9.9%
8.1%
19.2%
14.3%
Montana
Nebraska
Nevada..
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota.....
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin..
Wyoming
9.3%
9.3%
22,7%
12.6%
13.0%
19.3%
13.5%
13.8%
8.3%
11.0%
21.6%
13.2%
8.5%
9.3%
17.0%
15.0%
13.6%
22.4%
11.7%
9.4%
14.5%
:.. 10.2%
15.4%
9.0%
11.8%
U.S. Department of Commerce; Bureau of the Census, 1992.
DPC Special Report — The State of America's Health Care System
p. 34
�Number of Firms, Establishments,
Employment, and Annual Payroll by Legal Form
of Organization and Firm Size for 1991
Employment Size of Firms
Iota!
Firm
Establishments
Employees
Payroll
(in thousands)
100-249
53,468.
164,150
8,027,967
25-49
50-74
75-99
4,642,171 .
4,734,562
21,184,366
$431 million
223,104
282,762
7,606,640
$155 million
70,3113
113,238
4,229,557
$87 million
33,122
66,204
2,838,660
$59 million
250-499
500-999
1.000-2.499
2.500-4.999
5.000-t-
14,870
96,445
5,115,423
6,842
81,740
4,715,151
$107,065,336
4,362
110,405
6,701,359
$161,582,065
5,051,025
6,200,859
92,307,559
$2.1 billion
$169,420,799 $110,016,099
111
£t24
1,407
1,366
469,029
82,319
27,179,042
4,709,396
$120,210,33 $743,143,809
U.S. Department of Commerce, Urban Institute Tabulations of Current Population Survey.
DPC Special Report — The State of America's Health Care System
p. 35
�.4
•6'
August 22, 1994
Publication: LB-85B-Health
n
bulletin
SUPPLEMENT B to
Legislative Bulletin, Part i
«
Mitchell Substitute to S. 2351,
Health Care Reform Bill
POSSIBLE AMENDMENTS
DPC Staff Contact: Rindy O'Brien (202-224-3232)
Democratic Policy Committee
United States Senate
Washington, D.C. 20510
George J. Mitchell, Chairman
Thomas A. Daschle, Co-Chairman
n
�1
}
Amendments
1. Strike Ammunition Excise Tax (Baucus): amendment to strike the
10,000 percent excise tax on hollow point ammunition. Cosponsors: Baucus,
Hatch, Shelby, Breaux, Craig, Murkowski, Wallop, Stevens, BoVen,
Simpson, Heflin, and Johnston. (Nick Giordano, 4-2651.)
i
2. Critical Rural Access Hospitals (Baucus): designates 30 percent of
the 1.5 percent aissessment on insurance premiums toward strengthening
critical rural access hospitals (this'amount is less than 15 percent of the
funds for teaching hospitals). (Maureen Testoni, 4-2651)
3. Enhanced State Waiver/State Opt-out (Graham): provides for enhanced State waiver authority to allow State universal health care coverage
and cost-containment demonstration projects. (John Lovejoy, 4-3041)
4. Repeal Section 1512 on Licensure (Graham): strikes provisions
relating to the override of restrictive State practice laws. (John Lovejoy,
4-3041)
5. Repeal Section 1511 on Medical Waivers (Graham): strikes provisions
relating to pre-emption of certain State laws relating to health plans. (John
Lovejoy, 4-3041)
6. Research Funding. (Graham): includes funding for prevention and
primary care research. (John Lovejoy, 4-3041)
;
7. Lifestyle Incentives (Graham): allows health plans to provide incentives (discounts or rebates) for its members to join health, clubs. (John
Lovejoy, 4-3041)
8. High Medicare Hospitals/Report (Graham): requires a report on high
Medicare hospitals by the Prospective Payment Advisory Committee (ProPAC).
(John Lovejoy, 4-3041)
9. Medical Specialties Providing Transition Services (Moseley-Braun):
requires the Secretary of Hesalth and Human Services (HHS) to identify any
non-primary care medical specialties that provide primary care services in
underserved areas "during the transition period. (Francesca Cook, 4-2854)
DPC Legislative Bulletin — S. 2357, Health Care Reform Bill
p. 1
�10. Standards for Essential Community Providers (Moseley-Braun):
ensures that health professionals have a long standing/established practice
in the target area in order to be designated as an essential community
provider. (Francesca Cook, 4-2854)
11. Disclosure of Federal Employee Health Benefits Program (FEHBP)
(Moseley-Braun): requires the Internal Revenue Service (IRS) and Office of
Personnel Management (OPM) to annually provide information on the range,
type, and cost of health plans available offered to members of Congress and
Federal employees through FEHBP. (Francesca Cook, 4-2854),
12. Traditionally Black Hospitals as Essential Community Providers
(Moseley-Braun): allows traditionally black hospitals to be included as
essential community providers. (Francesca Cook, 4-2854)
13. Supplemental Security Income (SSI) Children (Moseley-Braun): continues requirements that States pay disproportionate share payments for SSI
children. The Secretary of HHS would be required to develop recommendations for designation of hospitals serving disproportionate numbers of SSI
persons. (Francesca Cook, 4-2854)
14. Tax-Deductibility for Self-Employed (Harkin): provides for full tax
deductibility for the self-employed. (Anne Ford, 4-6265)
15. Out-of-Network Coverage (Harkin): would give individuals the opportunity to obtain coverage for out-of-network options and services. (Anne Ford,
4-6265)
16. Drug Donation Insert Card Act (Dorgan): requires the Secretary of the
Treasury to include organ donation information with individual income tax
refund payments. (Steve Kroll, 4-1185)
17. International Prescription Drug Pricing (Dorgan): requires the Secretary of Health and Human Services to examine prescription drug prices in
foreign countries and issue quarterly reports. (Steve Kroll, 4-1185)
18. International Prescription Drug Prices (Dorgan): if prices exceed a
certain index, manufacturers must show the cause of disparity at a public
hearing by the Secretary of Health and Human Services. (Steve Kroll,
4-1185)
'
-, .
DPC Legislative Bulletin — S. 2351, Health Care Reform Bill
p. 2
�19. Cost Containment (Bingaman): combines the National Health Benefits
Board and National Cost Containment and Coverage commission; and,
establishes checkpoints to ensure that the Commission and Congress are
accountable to the American People for decisions relating to costs of the
standard benefits package, the availability of subsidies, and overall health
care system cost containment. (Carrie Billy or Linda Scott, 4-5521)
20. Shared Responsibility (Bingaman): modifies the employer-employee
mandate provision for firms with 25 or more employees and the individual
mandate for employees of firms with fewer than 25 employees which is
triggered under the act if 95 percent coverage is not achieved by January
2000: (1) stipulates that before these mandates become effective, the
National Commission on Cost and Coverage would make recommendations
to be considered by the bongress to ensure that low-wage employees of
exempt firms would not be disproportionately burdened in terms of premium
costs vis-a-vis low-wage employees in non-exempt firms; (2) clarifies that the
"trigger" for universal coverage is 95 percent of the non-medicare eligible
resident population; (3) requires that before an employer contribution becomes effective for a part-time worker, a worker must be employed for at least
a month and requires the Secretary of Labor to submit a report to Congress
on the economic impact of the mandate on seasonal employees. (Carrie Billy
or Linda Scott, 4-5521)
21. Direct Billing (Bingaman): changes, in section 1128 (h), "clinical
laboratory services" to "ancillary health services, such as clinical laboratory
services, and other ancillary health services as defined by the Secretary."
(Carrie Billy or Linda Scott, 4-5521)
22. Tobacco Use Disincentive (Bingaman): permits health plans to offer
premium discounts to individuals who do not smoke or who enroll in smoking
cessation programs. (Carrie Billy or Linda Scott, 4-5521)
23. Uncompensated Care- Undocumented Workers (Bingaman): helps
ensure a stable funding source for hospitals providing significant amounts of
uncompensated care. (Carrie Billy or Linda Scott, 4-5521)
DPC Legislative Bulletin —S. 2351, Health Care-Reform Bill
p. 3
�24. School Health Education (Bingaman): increases funding for school
health education to a level more consistent with the amount authorized in
President Clinton's Heaith Security Act. {Carrie Billy or Linda Scott, 4-5521)
25. Workforce Development (Bingaman): amends the Advisory Board on
Health Care Workforce Development section to ensure that where appropriate, the Department of Education is involved in Federal workforce education
and training initiatives and program support; and, authorizes the National
Academy of Sciences to issue a report assessing the ability of the current
health care workforce to meet the Nation's needs (baseline) and making
projections on health care workforce need in the future. (Carrie Billy or Linda
Scott, 4-5521)
26. Cataract Centers of Excellence (Bingaman): strikes, in section 4303,
"cataract surgery" from the services which Medicare would cover through
competitive contracts with "centers of excellence," and requires that the
Secretary's discretion to add new services to such contracting procedures be
limited to "such other intensive in-patient services as the Secretary determines to be appropriate." (Carrie Billy or Linda Scott, 4-5521)
27. Preventive Care (Bingaman): improves clinical preventive health
services and encourages basic research on preventive health care. (Carrie
Billy or Linda Scott, 4-5521)
28. Outpatient Rehabilitation (Bingaman): adds outpatient neuro-psychology to the standard benefits plan (this is a clarifying change and would not
add to the cost of the benefits package). (Carrie Billy or Linda Scott, 4-5521)
29. Long-Term Care (Wofford): improves long-term care provisions. (Darrel
Jodrey, 4-6324)
30. Self-Employed Premium Deduction (Wofford): increases deduction
for heath insurance premiums for self-employed to 100 percent. (Darrel
Jodrey, 4-6324)
31. Annual Report Card (Wofford): requires annual report cards on trends
in health care coverage and costs and biannual recommendations by the
Coverage and Cost Commission. (Darrel Jodrey, 4-6324)
DPC Legislative Bulletin — S. 2357, Health Care Reform Bill
p. 4
�32. Affordability (Wellstone): ensures affordability of premiums and protection of cost-sharing subsidies for low- and middle-income Americans.
(Ellen Shaffer, 4-5641)
33. Small Business (Wellstone): ensures small business fair-share contributions. (Ellen Shaffer, 4-5641)
34. Small Business Employees (Wellstone): protects individuals in small
(less than'25) firms from exorbitant cost of "individual mandate." (Ellen
Shaffer, 4-5641)
35. Cost Control Trigger (Wellstone): cost-control trigger vs: cuts to
subsidies and coverage. (Alex Clyde, 4-5641)
36. Accelerated Trigger (Wellstone): accelerates dates for reports on
95 percent coverage to January 1, 1998, effective mandate date of
January 1, 1999, and other relevant dates. (Ellen Shaffer, 4-5641)
37. Declining Coverage (Wellstone): implements employer mandate in
any year in which coverage declines. (Ellen Shaffer, 4-5641)
38. Domestic Violence (Wellstone): implements domestic violence riskassessment measures. (Sherry Ettleson, 4-5641)
39. Guns and Violence (Wellstone): denies access to guns to people with
histories of domestic violence. (Ellen Shaffer, 4-5641)
40. Community Representation (Wellstone): provides for representation
of low-income Americans and other consumers on boards and commissions.
(Ellen Shaffer, 4-5641),.
41. Health Care As Good As Congress (Wellstone): provides for health
care as good as Congress receives. (Ellen'Shaffer, 4-5641)
42. Mental Health (Wellstone): (Ellen Weissman, 4-5641)
43. Consumer and Provider Protection (Wellstone):
4-5641)
DPC Legislative Bulletin — S. 2351, Health Care Reform Bill
(Ellen Shaffer,
p. 5
�44. Medicare Competitive Bidding For Laboratory Services (Reid): strikes
this provision. (Kim Bengtson, 4-3542)
45. Medicare Competitive Bidding For Radiology Services (Reid): strikes
this provision. (Kim Bengtson, 4-3542)
46. Medicare Copayments for Laboratory Services (Reid): amends
collection requirements for Medicare copayments for laboratory sen/ices.
(Kim Bengtson, 4-3542)
47. Federally Qualified Blood Centers As Essential Community Providers (Reid): (Kim Bengtson, 4-3542)
48. Employer contribution (Rockefeller): strengthens employer contribution requirement from 50 percent to 72 percent, the average Federal employer
contribution for employees of the Federal government, including Congress
and the President. (Mary Ella Payne or Tom Morgan, 4-6472)
49. Cost containment (Rockefeller): (Mary Ella Payne, 4-6472)
50. Special Needs Children Study (Rockefeller): provides for institute of
Medicine study on how managed care plans (HMOs) effectively treat special
needs children. (Howard Rabinowitz, 4-6472)
51. Primary Care Research (Rockefeller): establish a primary care research center at Agency for Health Care Policy and Research. (Howard
Rabinowitz, 4-6472)
52. Veterans (Rockefeller): (Diana Zuckerman or Kim Lipsky, 4-9126)
53. Increase Tobacco Tax (Simon): increase tobacco tax and earmark for
expansion of long-term care and prescription drugs for the elderly, or
increased subsidies, or reduction of low-income cost-sharing. (Judy Wagner,
4-2152)
i
54. Coverage Trigger (Simon): redefine the 95 percent trigger to exclude
individuals already guaranteed coverage under Federal programs such as
Medicare. (Judy Wagner, 4-2152)
DPC Legislative Bulletin — S. 2351, Health Care Reform Bill
p. 6
�55. Americans-Abroad (Simon): to permit private sector employees working abroad to purchase non-subsidized insurance policies through OPM-run
program. (Judy Wagner, 4-2152)
56. The Community Scholarship Program under the National Health
Service Corps program (Daschle): would be funded at $2 million annually
from FY 1996 to 2000. (Lucia Guidice, 4-2321)
57. Medicare Prescription Drug Benefits (Boxer): grandfathers in drugs
now covered under Medicare part B. (Rebecca Rozen, 4-8130).
58. Prior Authorization (Boxer): modifies the prior authorization provision
for prescription drug benefits. (Rebecca Rozen, 4-8130).
59. Tobacco Tax (Simon): increases tax to seventy-five cents, effective
immediately. Revenue goes to 100 percent deduction for self-employed,
beginning 1995. The remainder shall go to long-term care, implementing the
program in 1996 as funds become .available, for a total increase of
approximately $30 billion over ten years. (Cheryl Young, 4-2152)
60.
Standard Benefits Package for Indian People (Inouye): would
insure that Indian people have full access to the standard benefits package.
(Yvette Joseph-Fox or Pat Rogers, 4-2251).
DPC Legislative Bulletin — S. 2351, Health Care.Reform Bill
p. 7
�Senate Action on Amendments
Amendments Adopted
1. Prenatal and Infant Care (Dodd): requires health plan sponsors to
include prenatal and infant care and immunizations, without cost-sharing
requirements, before 1995. Approved, 55-42, August 16, 1994.
2. Employer Penalty (Nickles/Moynihan): would strike from the Mitchell
substitute amendment the $10,000 civil penalty per employee for employers
who do not offer the standard benefit package as defined in the Health reform
bill. Approved, 100-0, August 17, 1994.
3. Rural Health Amendments
1994.
•
•
•
•
•
•
•
•
•
•
•
(Daschle) Approved, 94-4, August 17,
Rural Based Managed Care Program
Office of the Assistant Secretary for Rural Health (OASRH)
Technical Amendments to Medical Assistance Facilities
(MAF)
Antitrust Safe Harbors for Rural Health Providers
Medicare Bonus Payments for Non-physician Practitioners
Amendment
Rural Representation on Advisory Committees and
Councils
National Health Sen/ice Corps
Allocation for Participation of Physicians Assistants in NHSC
Scholarsthip and Loan Program
Eligibility of RHC's to Receive Funds
Grants for Systems to Transport Rural Victims of Medical
Emergencies
Grants for telemedicine-funding of $15 million for FY 1996
- FY 2001
4. Federal Advisory Committee Act Compliance (Mack): requires actions of all boards and commissions created by Health Security Act to be
subject to provisions of Federal Advisory Committee Act. Approved, 100-0,
August 18, 1994.
DPC Legislative Bulletin — S. 2357, Health Care Reform Bill
p. 8
�•i •
5. Provisions Regarding Nonpayment of Premiums (Mitchell): states
that a health plan may terminate coverage for nonpayment of premiums by
an individual or individual's family members after proper notification and after
a period of not less than 60 days. Approved, by voice vote, August 18, 1994.
6. Strikes Surcharge Under Federally Operated System (Hutchinson):
strikes provision which allows Secretary of HHS to impose a 15 percent tax
on health plans in a state that is found not to be in compliance with new
Federal Health care regulations. Approved, by voice vote, August 19, 1994.
7. Flexible Services Option (Harkin): allows health plans the flexible
option of providing, with consent of the enrollee, items and services that are
not listed in the standard benefits package, but which the plan determines to
be the most cost-effective way to provide appropriate treatment to the
enrollee. Approved, by voice vote, August 19, 1994.
DPC Legislative Bulletin — S. 2351, Health Care Reform Bill •
p. 9
�DPC'f!
Friday, August 19,1994
From the DPC
Latest Schedule
Senate Convenes
at 9 AM
dpc-tv
channels
The Senate will convene today at
9 a.m.
A period of morning business will extend
until 9:30 a.m. with Senators permitted to
speak for up five minutes.
•
•
•
Floor Action
Bill Summaries
Amendments
Floor Action/Unanimous Consent Agreement
Senate to Vote on Conf. Rpt to Commerce, State, Justice;
Continue Debate on Health Care Reform
Today, at 9:30 a.m., the Senate will begin debate on the Conference Report to H.R. 4603,
the Commerce, State, Justice Appropriations, FY 1995. There will be one hour of debate
equally divided with a roll call vote on the Conference Report immediately following debate.
Following disposition of the Conference Report to H.R. 4603, the Senate will return to
consideration of the Mitchell Substitute to S. 2351, the Health Care Reform bill.
Recent Highlights
Senate Approves Daschle Rural Health Amendment
Yesterday, the Senate continued debate on the Mitchell Substitute to S. 2351, the Health
Care Reform bill. In related action the Senate approved, 94-4, a Daschle amendment
establishing a grants program for the development and operation of rural managed care
plans; and, approved, 100-0, a Mack amendment requiring actions of all boards and
commissions created by Health Security Act to be subject to provisions ot Fed Advisory
Committee Act.
On The Democratic Agenda...
Attention Democratic
Health Care Policy Staff:
•
Daily briefing oh current health care reform status. 9 a.m. in SD-608.
•
Please call Rindy O'Brien, DPC Health Policy Advisor, at 4-3232
with new Health Care Reform bill amendments.
�•4
What Others Are Saying Regarding...
THE HEALTH
CARE REFORM
LEGISLATION
Senator Tom Harkin:
"Perhaps nowhere else is the health care crisis more acute than in rural America. Rural
Americans are more often poor, more often uninsured, and more often without access to
healthcare.
'
"Now, the Mitchell bill provides funding to build up the health care infrastructure in rural
areas. It provides grant money and loans to help local communities develop health care
networks and plans...
"The grant program in the Mitchell bill would encourage the development of telemedicine
networks which can play a critical role in ensuring that people in rural areas have access
to high quality health care. Telemedicine puts technology to work to improve the delivery
of health care. It uses technology to link patients and their doctors in rural or remote
hospitals with highly trained medical specialists in state-of-the-art medical technology
located hundreds or even thousands of miles away. These linkages will allow more
patients to receive care in their community and will ease the burden oh specialists in
undersen/ed areas. By increasing the education and training opportunities for providers
in these areas, these links will also help underserved communities recruit and retain
physicians...
"Senator Mitchell's bill will expand access to care for rural Americans, access to the
Federal Employees Health Benefits plan, or another purchasing cooperative will help
keep the cost of coverage down for rural residents. Many people in the rural areas are
either self-employed or work in small businesses, and currently pay much more than big
businesses for the same benefits. And they face much higher administrative costs.
"The insurance reform provisions in the Mitchell bill are critical for rural residents,
particularly for our farmers. Farming is now the most dangerous occupation in America
with annual death rates at 52 per 100,000 workers, almost five times the national average.
Under the Mitchell bill, farmers will have access to a community rated plan. This means
that farmers in a given area will be charged the same premium for health insurance
regardless of their occupational risk. In addition, health plans will nbt be able to deny
coverage because of preexisting conditions...
"If any group of Americans need health care reform, it is the people who live in our small
towns in rural America. They are not getting access because they do not have the
providers. They do npt have the providers because the system is skewed against
providers being able to serve in underserved areas.
"The Mitchell bill addresses all of that. It does it in a very forthright manner.... [It] is most
critical to make sure that our people in rural areas have the kind of access and quality of
care that they not only need, but they deserve."
Idpc
1
Democratic Policy Committee
United States Senate
Washington, D.C. 205.10
George J. Mitchell, Chairman
Thomas A. Daschle, Co-Chairman
u.s.s.
Friday, August 19,1994
THE
DAILY
REPORT
�Monday, August 22,1994
Latest Schedule
Senate Convenes
at 10 AM
The Senate will convene today at
10 a.m.
From the DPC
Supplement to Health Care
Reform Bulletin Available
Today the DPC delivered, via inside mail,
Supplement B to Legislative Bulletin
Part I, on the Mitchell Substitute to
S. 2351, Health Care Reform bill. Extra
copies are available in SH-5i2 (4-1414).
The DPC contact is Rindy O'Brien
(4-3232).
Floor Action/Unanimous Consent Agreement
Senate Continues Debate on Health Care Reform
Today, at 10 a.m., the Senate will return to consideration of the Mitchell Substitute to
S. 2351, the Health Care Reform bill. A Moynihan/Packwood amendment on Work Force
Modification is expected. No votes will take place prior to 6 p.m.
Items possible for consideration during the upcoming week include:
•
•
•
conference report to accompany H.R. 3355, The Omnibus Crime bill;
any other available conference reports; as well as,
any Legislative or Executive calendar business by unanimous consent.
Recent Highlights
Senate Debates Health Care Reform;
Passes Commerce, Justice, State Conference Report
On Friday, the Senate continued debate on the Mitchell Substitute to S. 2351, the Health
Care Reform bill. In related action, the Senate, by voice vote, adopted a Hutchison
amendment to strike the surcharge under a federally operated system; and adopted a
Harkin amendment that allows health plans the flexible option of providing, with consent,
items and services which are not listed in a standard benefits package, but are costeffective.
In other action, the Senate passed, 88-12, the Conference Report to H.R. 4603,
Commerce, Justice, State, the Judiciary, and Related Agencies Appropriations, FY 1995.
emocratic
aybook
On The Democratic Agenda...
Attention Democratic
Health Care Policy Staff:
NOTE:
A Weekly Update was not delivered
this week. Any hearings scheduled
during this week will be announced in
the Daily Report.
Daily briefing on current health care
reform status. 9 a.m. in SD-608.
Please call Rindy O'Brien, DPC
Health Policy Advisor, at 4-3232
with new Health Care Reform bill
amendments.
�What Others Are Saying Regarding...
HEALTH
CARE REFORM
LEGISLATION
Senator Carl Levin:
"We hear over and over again, Govemment-run insurance, Govemment-run health
insurance. That is the attack on the Mitchell bill, despite the fact that the Democratic
leader has over and over again gotten up and said this is not Govemment-run insurance.
This is private insurance which, hopefully, will be made available to every American the
way private insurance is made available to Members of Congress, our families, and all
Federal employees.
"So I wanted to be sure that point is clear, that the so-called Government insurance that
is made available to us is not Govemment-run insurance. It is made available to us by
the Government — mostly at taxpayers' expense — but it is private insurance. All those
companies with all those plans that are offered to us on that menu are private
insurance...
"It is not just us, it is 9 million Federal employees and their families who have this
insurance. If it is good enough for us, why is it not good enough for the rest of the people
of America? Is it the best plan in America? No, there are some better. Yes, there are
some companies that offer even better plans than this. That is not the issue...
"There can be a lot of give and take as to what is good and what is bad. But one thing
is real clear, and that is this green booklet... In that book, on page 4, it says that we are
guaranteed 'protection that can't be canceled by the plan.' Listen to this one...: 'Coverage
without restrictions because of age, current health or.preexisting medical condition. No
Federal employee can be denied health care because of a preexisting medical
condition.'
"It is right here in the book. If we hire someone on our staff back in our home State or
here in Washington, that person could have diabetes, could have a heart condition,
could have skin cancer. That person is entitled tp health coverage.
"Some of us are trying to provide that kind of assurance to every American. We provide
it to ourselves and 9 million Federal employees and their families. Why is it not good
enough for every American family? The answer is: it is. They are paying our salaries.
They are paying three-quarters of our health care. They ought to have the same
opportunity as every Federal employee has...
"All Americans should have the same opportunity that we do for health care. That is what
some of us are trying to achieve. It is not right that we have access to health care which
is not available to all Americans, that we can obtain health insurance despite any
preexisting condition, but other Americans do not have that opportunity."
i
dpc
'
Democratic Policy Committee
United States Senate
Washington, D.C. 20510
George J. Mitchell, Chairman
Thomas A. Daschle, Co-Chairman
u.s.s.
Monday, August 22,1994
THE
DAILY
REPORT
�I
DPC Daily Report
Thursday, August 18,1994
Latest Schedule
From the DPC
Today's DPC Lunch:
Health Care
Senate Convenes
at 9:30 A.M.
The Senate will convene today at
9:30 a.m. for morning business during
which Senators may speak up to five
minutes each, with Senator Hatch recognized for 10 minutes.
dpc-tv
channel 6
•
•
•
•
Floor Action
Bill Summaries
Amendments
Alerts
At today's DPC lunch Democratic
Senators will discuss health care reform.
12:30 p.m. in S-211. (Senators only)
Supplement to Health Care
Reform Bulletin Available
Today the DPC delivered, via inside mail,
the revised Supplement A to Legislative
Bulletin Part I, on the Mitchell Substitute
to S. 2351, Health Care Reform bill. Extra
copies are available in SH-512 (4-1414).
The DPC contact is Rindy O'Brien
(4-3232).
Floor Action/Unanimous Consent Agreement
Senate Continues Debate on Health Care Reform Bill
Today, at 10 a.m., the Senate resumes consideration of the Mitchell Substitute to S. 2351,
Ihe Health Care Reform bill.
Recent Highlights
Senate Adopts Nickles/Moynihan Amendment
Yesterday, in continued discussion of the Mitchell Substitute to S. 2351, the Health Care
Reform bill, the Senate adopted, 100-0, a Nickles/Moynihan amendment that strikes the
$10,000 civil penalty per employee for employers who do not participate in the Federal
health care program.
emocratic
*0aybook
Hearings Today
Judiciary Cte.: nomination of Lois Jane
Schiffer, Washington, D.C, to be Assistant Attorney General. 9:30 a.m.,
SD-226.
Judiciary Cte.: nominations of Nancy
Gist to be director of the Bureau of
Justice Assistance; Laurie Robinson to
be Assistant Attorney General for the
Office of Justice Programs, Jan Chaiken
to be Director of the Bureau of Justice
Statistics, and Jeremy Travis to be Director of the National Institute of Justice.
10 a.m., SD-628.
On The Democratic Agenda...
Attention Democratic
Health Care Policy Staff:
Daily briefing on current health care
reform status. 9 a.m. in SD-608.
Please call Rindy O'Brien, DPC
Health Policy Advisor, at 4-3232
with new Health Care Reform bill
amendments.
�; What Others Are Saying Regarding...
Health Care Reform Legislation
Senator Barbara Boxer:
"In my State of California, 6 million people live without the security of health insurance —
6 million people. One in four Califomians under the age of 65 is uninsured; 59 percent of
those without health insurance are in families headed by someone who works. So these
are working families; 1.3 million are children.
"My State's uninsured rate is five points above the national average, making my State the
eighth worst among the 50 States and D.C. These statistics are chilling. In four years, the
number of uninsured in my State exploded by more than one million people...
"So let us put to bed this notion that we do not have a problem in America. You have to be,
frankly, completely insensitive and, frankly, out of touch to say that this is not a problem.
"It goes well beyond the uninsured, as I have pointed out, because those of us with
insurance are walking on a tightrope. It is like Russian roulette. What is going to happen?
Who is going to pull the trigger? Will my body get a disease that takes me out of the
insurance pool? We have to stop this. It is un-American...
"I like to think America is about more than just speaking out for things when you need it. I
hope we would be more of a community. I have already shown you by telling you the
problems that we face — those of us with insurance — that it really is our problem anyway.
Why do you think we pay five or ten dollars for aspirin in a hospital when we are insured.
Because there are so many uninsured Americans who are using the emergency room. It
is so expensive, they do not carry their weight and we, those of us who are insured, have
to carry their weight. So we need to insure as many Americans as possible. That is what
the Mitchell bill tries to do...
•
'*
v
"I close with this. Any American who is watching today, please listen for certain things.
Listen for the scare tactics. Listen to the facts. Make up your own mind and let your voice
be heard because we are still threatened by a filibuster, a filibuster that would mean we could
not move forward on this issue, and this whole issue of health reform will languish into the
next century... '•'
"I will be here as long as it takes, as late as it takes to do what I can to help bring this to fruition.
I think we will be proud when that moment comes that we send a bill to the President of the
United States and we can say, when we are old and very gray, to our children and our
grandchildren and our great grandchildren, we did something to help the people of
America."
/
^•iiifF-
dpc
-r'
„•>,
x
w
f
Democratic Policy Committee
United States Senate
Washington, D.C. 20510
George J. Mitchell, Chairman
Thomas A. Daschle, Co-Chairman
u.s.s.
Thursday, August 18,1994
THE
DAILY
REPORT
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
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William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
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Paper
Dublin Core
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Title
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[Democratic Policy Committee]
Creator
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Task Force on National Health Care
White House Health Care Task Force
Jason Solomon
Identifier
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2006-0885-F Segment 2
Is Part Of
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Box 37
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12093764" target="_blank">National Archives Catalog Description</a>
Provenance
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Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Preservation-Reproduction-Reference
Date Created
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2/6/2015
Source
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42-t-12093764-20060885F-Seg2-037-008-2015
12093764