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FOIA Number:
2006-0885-F
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MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Tarmey
Subseries:
1981
OA/ID Number:
FolderlD:
Folder Title:
[Carol Pollack Dworkowitz] [loose]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
2
3
�Withdrawal/Redaction Sheet
Clinton Library
DOCUMENT NO.
AND TYPE
DATE
SUBJECT/TITLE
RESTRICTION
001. letter
Carol P. Dworkowitz to Hillary Clinton [partial] (1 page)
2/1/1993
P6/b(6)
002. statement
Description of paper from Carol P. Dworkowitz [partial] (1 page)
n.d.
P6/b(6)
003. essay
"Health Care - America's Shame" by Carol P. Dworkowitz [partial]
(1 page)
7/1991
P6/b(6)
004. form
Carol P. Dworkowitz' Insurance Information (1 page)
9/30/1988
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA|
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PKA|
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information [(a)(4) of the PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
001. letter
SUBJECT/TITLE
DATE
Carol P. Dworkowitz to Hillary Clinton [partial] (1 page)
2/1/1993
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act -144 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the F01A|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute [(b)(3) of the FOIA|
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA|
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of Ihe FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOI.A|
b(8) Release would disclose information concerning the regulation of
financial institutions |(b)(8) of the FOIA)
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA)
National Security Classified Information 1(a)(1) of the PRA|
Relating to the appointment to Federal office 1(a)(2) of the PRA)
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA]
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors [a)(S) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�February
1, 1 993
Carol P o l l a c k Dworkowitz
O
O
Mrs. H i l l a r y C l i n t o n
C/O The White House
1600 Pennsylvania Ave.
Washington, D.C.
Dear Mrs.
Clinton,
I hope t h a t you w i l l take the time t o peruse the contents
this mailing.
There i s much t h a t I would l i k e t o t e l l you about the h e a l t h
care system as I see i t , but my student o b l i g a t i o n s preclude
me from doing so. However, t h e r e i s some v a l u a b l e i n f o r m a t i o n
i n my essay although since my daughter's i l l n e s s I have learned
much more.
Unquestionably, reform must begin by c o n t r o l l i n g p r i c e s .
I n a d d i t i o n , the a t t i t u d e of those i n d i v i d u a l s whose business
i t i s t o d e l i v e r Health Care t o the p u b l i c must change. L i k e
a c h i l d who has never known r u l e s or l i m i t s , i t w i l l not be
easy t o now c o n t r o l an e n t i r e i n d u s t r y t h a t has run w i l d f o r
over a decade -- e s p e c i a l l y one t h a t sees i t s e l f as omnipotent
and has mastered the economic concept o f i n e l a s t i c demand.
I n my o p i n i o n , many o l d e r members o f Congress, those whose
war-chests have been l i n e d by l o b b y i s t s r e p r e s e n t i n g the Health
Care I n d u s t r y , w i l l be r e s i s t a n t t o change as w e l l — even our
esteemed democrats. B e l i e v e or n o t , I see George M i t c h e l l as
your worst enemy. P e r s o n a l l y , I hate the man.
of
Feel f r e e t o c o n t a c t me i t 1 ma'y h6ip i n any
Regards,
way.
�9
Victim of the health care quagmire in America
By CAROL POLLACK
M
ANY SOUTH Floridians holding
individual health insurance policies are
hoping that The Herald, or someone, will
help them. Someone needs to question the
legitimacy of recent rate-hike
approvals sanctioned by
Insurance Commissioner Tom
Gallagher's ofFice.
Last year my premium
| jumped to $790 a month from
$520 — a 52 percent increase.
To get the earlier premium
down to $520,1 had already
raised my deductible and
co-payment limit. Now this
year my new premium is going
up to $948 — a total increase
of 82 percent. Although high,
health care costs have not
Carol Pollack
risen 82 percent.
My initial reaction is therefore to ask: If the
insurance commissioner's office was doing its job,
how could such exorbitant back-to-back rate
increases have been approved?
The insurance commissioner's staff informed
me that insurance companies must submit
x
proposed rate increases for individual policies to
his office for approval. Yet Mutual of Omaha, my
insurance carrier, tells me that, even though they
must submit proposed rate hikes, the state does not
have to approve them. Who is telling the truth?
Health insurance rates in Dade County rank
among the four highest in the United States.
Because Florida permits health insurers to
Balkanize people with pre-existing conditions into
smaller risk groups with higher premiums, many
are forced to drain their savings to pay these
unconscionable premiums. Many have already
exhausted their savings and now live in fear.
While insurance rates have climbed in other
parts of the state, rates for the same policy in Dade
and Broward are often twice as high as in other
Florida counties. Someone living in South Florida
with a pre-existing condition thus bears a double
financial burden.
Recently The Herald has printed several
editorials advocating a major overhaul of the
nation's health care system. However, until
Washington grants all Americans equal access to
quality health care, residents of Dade and Broward
counties who have pre-existing conditions and
don't get health benefits through their employer
must turn to the state for help. Becausee these
individuals are only solitary whispers, they need a
strong voice to speak for them.
It has become apparent that our state
government listens only to the insurance lobby and my last two years at the University of Central
is no longer responsive to constituents. Individuals Florida.
On May 5, 1991,1 graduated from Miami-Dade
or families dealing with an illness are already
with honors and a straight-A average. On May 12,
victims. Must Florida enforce a system that seeks
1991,1 sold my house. But the following week my
to punish them twice?
I am a widow. When my husband died, I decided daughter was diagnosed with a platelet disorder.
that I would try my best to make life normal for my She did not respond to the usual medication, and
young daughter and avoid day care at all costs. Our other treatments would have to be tried. Since we
had no family or friends in Satellite Beach, I
support systems were very limited. I worked part
couldn't muster the courage to go it alone. Luckily,
time for several years until she began junior high
I was able to get out of the sale of my house.
school. Searching for a full-time position, I found
, In five weeks I will be a senior at Florida
that many things had changed since I had last
International University. With my health
sought permanent employment in New Jersey 16
insurance premiums so high, I am not sure that my
years ago.
financial situation will allow me to finish. Now, at
I already had a pre-existing medical condition.
the age of 46,1 am angry that I too may become a
Small firms would hire me, but not offer me
medical benefits. Large companies offered me only victim of the health care quagmire in America — a
system that rations health care by wealth.
clerical positions at a low salary and low growth
potential. I was refused many interviews because I
Last year I went to see if Medicaid would help
was not a college graduate.
me absorb my deductible. I was declined because I
Although quite unsure of myself, I decided to try had health insurance, but I was shocked when the
college. After my first year at Miami-Dade
gentleman who interviewed me said: " I wouldn't
Community College, I realized that the cost of
pay those premiums. I f l were you, I would drop my
health insurance might be the one obstacle in my
health insurance and let the state help you." I
way. I searched for a town in Central Florida where replied, " I am not a gambler."
health insurance rates were half what I am now
After doing extensive research during the last
paying — a town that had both a superior high
five years and writing several papers on the issue of
school and a four year college. My daughter and I
health care, plus dealing with it first hand, I am
decided that the year she finished junior high we
firmly convinced that if this issue is not resolved
would move to Satellite Beach, where I could finish soon, it will strangle America.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
002. statement
SUBJECT/TITLE
DATE
Description of paper from Carol P. Dworkowitz [partial] (1 page)
n.d.
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act - (44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI National Security Classified Information 1(a)(1) of the PRA]
P2 Relating to the appointment to Federal office 1(a)(2) of the PRA]
P3 Release would violate a Federal statute 1(a)(3) of the PRA]
P4 Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA)
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA]
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA]
b(l) National security classified information 1(b)(1) of the FOIA]
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOIA]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA]
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�I mailed a copy o f t h i s essay, along w i t h a b r i e f cover
l e t t e r , t o many prominent democrats i n congress, and o u t o f
approximately 10 m a i l i n g s , t h e o n l y i n d i v i d u a l t o answer w i t h o u t
a form l e t t e r was Dante F a s c e l l . The r e s t responded w i t h t h e
usual a p o l o g e t i c r h e t o r i c . Sen. Graham's o f f i c e t o l d me t h a t
any major h e a l t h care reform was a t l e a s t t e n years
away.
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
003. essay
SUBJECT/TITLE
DATE
"Health Care - America's Shame" by Carol P. Dworkowitz [partial]
(1 page)
7/1991
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number: 1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act - |44 U.S.C. 2204(a)|
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information 1(b)(1) of the FOIA|
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA]
b(3) Release would violate a Federal statute 1(b)(3) of the FOI A]
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy ((b)(6) of the FOIA)
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA|
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA|
b(9) Release would disclose geological or geophysical information
concerning wells 1(b)(9) of the FOIA)
National Security Classified Information |(a)(l) of the PRA)
Relating to the appointment to Federal office 1(a)(2) of the PRA)
Release would violate a Federal statute 1(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA|
P5 Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA|
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA|
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�^7
r o A c ^ t ^
Health Care —
/
n hi
America's Shame
Equal access t o medical care should be every c i t i z e n ' s
u n a l i e n a b l e r i g h t , r e g a r d l e s s o f t h e i r age o r income, f o r w i t h o u t
adequate h e a l t h c a r e , l i f e , l i b e r t y , and t h e p u r s u i t o f happiness
are t h r e a t e n e d and o f t e n an i m p o s s i b i l i t y . However, w h i l e every
developed country except South A f r i c a agrees w i t h t h i s concept,
the U.S. government e l e c t s tc^ u n f a i r l y burden t h e middle c l a s s
and t h e small business person w i t h s k y r o c k e t i n g medical costs
r a t h e r than adopt a program t h a t would serve i n t h e best i n t e r e s t
of " a l l " Americans.
The middle c l a s s , some o f whom are unemployed and cannot
a f f o r d p r i v a t e insurance, o r are u n i n s u r a b l e due t o a p r e e x i s t i n g c o n d i t i o n , l i v e i n f e a r o f l o s i n g t h e i r homes and l i f e
savings. S t i l l o t h e r s i n t h i s category who were f o r t u n a t e enough
to have had p r i v a t e insurance before they became i l l , can only
watch as t h e i r premiums soar and t h e i r savings dwindle.
C e r t a i n l y , t h e impact o f d e a l i n g w i t h an i l l n e s s i s i n i t s e l f
d e v a s t a t i n g ; t h e r e f o r e , i t should n o t be c o r r e l a t e d w i t h
f i n a n c i a l concerns.
Conservatives i n t h i s country s t i l l subscribe t o t h e t h e o r y
t h a t o n l y t h e "have-nots" are w i t h o u t medical insurance; however,
a segment o f t h e middle c l a s s has now j o i n e d t h e ranks o f t h e
uninsured. As p r o o f , medical costs are now t h e l e a d i n g cause
of " p e r s o n a l " bankruptcy i n t h i s c o u n t r y . Americans should
not be f o r c e d t o choose between h e a l t h care costs and t h e basic
n e c e s s i t i e s o f l i f e , nor should government expect those f a m i l i e s
who have achieved t h e dream o f owning a home t o f o r f e i t i t i n
order t o pay f o r medical t r e a t m e n t .
While l a r g e f i r m s are able t o s e l f - i n s u r e , small businesses
are dependent upon insurance companies f o r h e a l t h b e n e f i t s .
The small businessman i s o f t e n a v i c t i m o f "Medical Red-Lining"
and f r a u d . At present t h e r e a r e no s t a t e o r f e d e r a l r e g u l a t i o n s
t h a t p r o t e c t them from these unscrupulous p r a c t i c e s . A d d i t i o n a l l y , many small businesses are v i c t i m i z e d by insurance companies
t h a t do n o t meet r e s e r v e requirements; consequently, as claims
come i n , these companies c l o s e t h e i r doors l e a v i n g p o l i c y holders
stranded.
In t h e l a s t decade h o r r o r s t o r i e s have increased i n number,
and y e t government has n o t responded t o t h e needs o f the people.
In t h i s c o u n t r y s i c k people a r e punished t w i c e , once by
u n f o r t u n a t e l u c k , and second by a governing body t h a t responds
to i t s "own needs" r a t h e r than those o f i t s e l e c t o r a t e .
Many U.S. c i t i z e n s f e e l shame t h a t a l l t o o f t e n fund r a i s e r s
are h e l d t o pay medical c o s t s f o r a f a m i l y member, f r i e n d , o r
co-worker. Why does our government approve monetary a i d f o r
the needy people o f o t h e r n a t i o n s , b u t looks t h e o t h e r way when
Americans c r y o u t f o r help?
As a l i f e t i m e r e g i s t e r e d democrat, I f a i l t o understand
why my chosen p a r t y has been s i l e n t on an issue t h a t n e g a t i v e l y
a f f e c t s t h e e m o t i o n a l , f i s c a l , and p h y s i c a l w e l l being o f people
across t h i s l a n d . Of course, t h e wealthy a r e n ' t a f f e c t e d because
they can a f f o r d insurance p o l i c i e s t h a t o f f e r t h e best protection .
r(_ 2.
00
�-2Since I have done e x t e n s i v e r e s e a r c h on t h e h e a l t h insurance
i s s u e s f a c i n g Americans, please read my comments and suggestions
r e g a r d i n g t h e proposed i n s u r a n c e p l a n by Senator R o c k e f e l l e r .
Although i t i s n o t a permanent s o l u t i o n , i t would o f f e r many
Americans a temporary compromise. My comments a r e based on
an enclosed a r t i c l e .
COVERAGE: I t i s n o t f a i r t o p u t t h e burden on employers.
F i r s t o f a l l , s m a l l businesses a l l over t h e c o u n t r y are c l o s i n g ,
and o t h e r s have stopped o f f e r i n g employee h e a l t h b e n e f i t s because
o f t h e c o s t . A d d i t i o n a l l y , even w i t h Managed H e a l t h Care Plans
(HMO's and PPO's), l a r g e c o r p o r a t i o n s have n o t been a b l e t o
stem t h e t i d e o f r i s i n g c o s t s .
I n c r e a s i n g l y , more and more
companies and l a b o r unions a r e c a l l i n g f o r some type o f n a t i o n a l
health plan.
"The amount o f c o r p o r a t e p r o f i t s consumed by h e a l t h c o s t s
are now a s t a g g e r i n g 49%," and " h e a l t h care c o s t s c o n t i n u e t o
r i s e a t almost t w i c e t h e r a t e o f i n f l a t i o n " ( C r o n k i t e ) . I f U.S.
f i r m s a r e t o be f o r m i d a b l e c o m p e t i t o r s i n t h e new g l o b a l market,
h e a l t h care c o s t s must be c o n t r o l l e d . To compensate f o r h e a l t h
e x p e n d i t u r e s , companies have r a i s e d r e t a i l p r i c e s , y e t employees
are n o t p r o f i t i n g s i n c e r e a l wages have n o t kept up w i t h
i n f l a t i o n . As more and more i n d i v i d u a l s see t h e i r d i s p o s a b l e
income s h r i n k i n g , l e s s money i s a v a i l a b l e t o spend o r save.
In a d d i t i o n , "3/4 o f a l l l a b o r s t r i k e s i n 1990 were over h e a l t h
b e n e f i t s " ( C r o n k i t e ) . While Republicans endorse c u t t i n g t h e
c a p i t a l g a i n s t a x , c i t i n g t h e supply s i d e t h e o r y as a way t o
s t i m u l a t e t h e economy, why haven't t h e democrats e x p l o i t e d t h e
adverse economic e f f e c t s h e a l t h care c o s t s have produced?
O f f e r i n g h e a l t h b e n e f i t s t h r o u g h employers promotes
d i s c r i m i n a t i o n . As h e a l t h c o s t s have soared, employers have
begun q u e s t i o n i n g j o b a p p l i c a n t s about p r e - e x i s t i n g c o n d i t i o n s ,
as w e l l as t h e h e a l t h o f any dependent who might be e n r o l l e d
i n t h e program. While some a p p l i c a n t s have d i s c r e e t l y been
t u r n e d down, o t h e r s have been o f f e r e d j o b s , b u t have had h e a l t h
benefits withheld.
I have enclosed p r o o f o f t h e l a t t e r , and
i t s h o u l d be noted t h a t t h i s was permanent.
Since p a r t - t i m e j o b s c a r r y no b e n e f i t s , many b u s i n e s s e s ,
e s p e c i a l l y r e t a i l , have t u r n e d f u l l - t i m e p o s i t i o n s i n t o p a r t time as a means o f l o w e r i n g c o s t s .
Some people work two o r
t h r e e j o b s and a r e s t i l l n o t a f f o r d e d b e n e f i t s .
BENEFITS: U n t i l a u n i f o r m b e n e f i t package e x i s t s , b e n e f i t s
f o r a l l c i t i z e n s o f t h i s c o u n t r y w i l l s t i l l n o t be e q u a l . I s
government prepared t o p o l i c e businesses t o ensure t h a t w h i t e
and b l u e c o l l a r workers o f t h e same c o r p o r a t i o n a r e o f f e r e d
the same coverage?
W a i t i n g p e r i o d s o f 30 days as proposed a r e f i n e p r o v i d e d
i n d i v i d u a l s would be covered under t h e proposed Americare d u r i n g
t h a t t i m e . E l i m i n a t i n g t h e w a i t i n g p e r i o d on p r e - e x i s t i n g
c o n d i t i o n s i s d e f i n i t e l y an i m p o r t a n t p a r t o f t h i s proposed
p l a n , and s h o u l d be passed as law i m m e d i a t e l y . F i r s t , i t would
�-3g i v e a sense o f s e c u r i t y t o those people w i t h p r e - e x i s t i n g
c o n d i t i o n s who u n t i l now have been a f r a i d o f changing j o b s .
Second, i t would a l s o p r o t e c t those i n d i v i d u a l s w i t h i l l n e s s e s
who are p r i v a t e l y i n s u r e d from p a y i n g "double" premiums d u r i n g
the usual one year w a i t i n g p e r i o d when b e g i n n i n g a new j o b .
However, i n an e f f o r t t o a v o i d f u r t h e r d i s c r i m i n a t i o n a g a i n s t
those i n d i v i d u a l s w i t h p r e - e x i s t i n g c o n d i t i o n s , c o n s i d e r a t i o n
should be g i v e n t o passing a law t h a t would make i t i l l e g a l
t o ask t h e h e a l t h o f a p r o s p e c t i v e worker and/or dependents.
AMERICARE: 80% o f d o c t o r s w i l l not accept i t . Drawbacks
t o Medicaid are the myriad o f b u r e a u c r a t i c paperwork and fee
schedule t h a t accompany i t . A l s o , w o r k i n g women w i t h young
c h i l d r e n who do not have b e n e f i t s , complain o f l o s i n g t o o much
time from work w a i t i n g t o be seen i n overburdened c l i n i c s .
How would t h i s p l a n c o r r e c t these shortcomings?
Would t h i s
p l a n cover f u l l t i m e c o l l e g e s t u d e n t s and s i n g l e p a r e n t s who
are not employed?
SMALL BUSINESSES: Along w i t h i n d i v i d u a l p o l i c y h o l d e r s ,
they are a t the mercy o f i n s u r a n c e companies. I n c r e a s i n g l y ,
s m a l l businesses, once t h e backbone o f t h e American economy,
have c l o s e d due t o t h e c o s t o f h e a l t h c a r e ; moreover, o t h e r s
have been f o r c e d t o withdraw b e n e f i t s i n o r d e r t o s u r v i v e / a d d i n g
more t o the number o f u n i n s u r e d . A l s o , businesses l o c a t e d i n
m e t r o p o l i t a n areas are a t a d i s t i n c t disadvantage s i n c e they
pay c o n s i d e r a b l y h i g h e r r a t e s (sometimes between 50-60% h i g h e r )
than do those s i t u a t e d i n l e s s densely p o p u l a t e d l o c a t i o n s .
As mentioned e a r l i e r , would government r e g u l a t e t h e i n s u r a n c e
i n d u s t r y more c a r e f u l l y so s m a l l businesses would n o t become
v i c t i m s o f " r e d - l i n i n g " and f r a u d ?
Although t h i s proposed N a t i o n a l i n s u r a n c e p l a n i s c e r t a i n l y
b e t t e r than what p r e s e n t l y e x i s t s , i t has t h r e e main f l a w s :
^
1.
H e a l t h care c o s t s w i l l never be s t a b i l i z e d or c o n t a i n e d
as l o n g as i n d i v i d u a l s and c o r p o r a t i o n s must r e l y on i n s u r a n c e
companies. Insurance companies do not operate on a s o c i a l l y
o p t i m a l p r o f i t margin, they o p e r a t e s o l e l y w i t h two t h i n g s i n
mind — p r o f i t and s t o c k h o l d e r s . As a p o i n t o f i n t e r e s t , many
have accused t h e i n s u r a n c e i n d u s t r y o f j a c k i n g up insurance
r a t e s t o compensate f o r a l l t h e l o s s e s i n c u r r e d as a r e s u l t
of t h e drop i n r e a l e s t a t e v a l u e s and t h e j u n k bond market d u r i n g
the l a t t e r p a r t o f t h e 80's.
There i s no mention o f p r o t e c t i n g i n d i v i d u a l p o l i c y
holders
from t h e p r a c t i c e o f r i s k p o o l s . I n t h e s t a t e o f F l o r i d a , and
I b e l i e v e i n o t h e r s t a t e s as w e l l , i n s u r a n c e companies f i l e
f o r r a t e i n c r e a s e s based on t h e i r c l a i m l o s s e x p e r i e n c e .
Every
few years i n s u r a n c e companies i n t r o d u c e brand-new p o l i c i e s .
Agents w i l l then t r a n s f e r i n d i v i d u a l s who are a b l e t o meet t h e
medical u n d e r - w r i t i n g c r i t e r i a i n t o the new p o l i c y . Those
i n d i v i d u a l s who have subsequently developed a " p r e - e x i s t i n g
�-4c o n d i t i o n " s t a y w i t h t h e o r i g i n a l p o l i c y ; t h e r e f o r e , the l o s s
experience i s g r e a t e r s i n c e e i t h e r one or more p a r t i c i p a n t s
of the p o l i c y now have a medical problem. i n essence, the o l d e r .
p o l i c y h o l d e r s are t e c h n i c a l l y i n an "assigned r i s k p o o l " o n l y
no one l a b e l s i t as such. Once a g a i n , s i c k people are punished
t w i c e . Since i t i s obvious t h a t t h e people who need coverage
t h e most may be p r i c e d out of t h e market, awarding the insurance
companies r a t e i n c r e a s e s u s i n g these g u i d e l i n e s i s not o n l y
u n f a i r -- i t i s c r i m i n a l . Indeed, i t g i v e s credence t o the
t h e o r y t h a t i n s u r a n c e companies no longer wish t o take any r i s k
w i t h o u t undue compensation. I t i s i m p o r t a n t t o note t h a t f o r
r e s i d e n t s o f m e t r o p o l i t a n areas, where r a t e s are c o n s i d e r a b l y
h i g h e r , t h e burden i s even g r e a t e r .
2. The p l a n does a b s o l u t e l y n o t h i n g t o e l i m i n a t e t h e
enormous amounts o f b u r e a u c r a t i c paper work. F u l l y 25<P o f every
d o l l a r spent on h e a l t h care pays f o r an i n d i v i d u a l t o process
t h e myriad o f paperwork i n v o l v e d i n c l a i m p r o c e s s i n g and b i l l i n g .
"A t y p i c a l Canadian h o s p i t a l may employ fewer than a dozen
b i l l i n g c l e r k s , w h i l e a comparable U.S. h o s p i t a l may employ
over 3 0 0 " ( C r o n k i t e ) .
3. The p l a n would c r e a t e g u i d e l i n e s r e g a r d i n g procedures
and p r i c e s f o r b o t h d o c t o r s and h o s p i t a l s ; however, when speaking
about d o c t o r s ' f e e s , i t i s v e r y hard t o c o r r a l a runaway b u l l .
I f any p o s i t i v e changes are t o be made i n the c o s t o f h e a l t h
care i n t h i s c o u n t r y , i t must begin w i t h p h y s i c i a n s . As a
n a t i o n , we need t o q u e s t i o n why "American d o c t o r s earn 50% more
than t h e i r Canadian p e e r s " ( C r o n k i t e ) .
My e x t e n s i v e r e s e a r c h enables me t o make these a d d i t i o n a l
c o n s t r u c t i v e comments about h e a l t h care i n t h i s c o u n t r y :
1. Most h o s p i t a l s pad t h e i r b i l l s .
As an a l e r t consumer,
I have had them c o r r e c t e d , b u t how many people, e s p e c i a l l y t h e
e l d e r l y , examine t h e i r b i l l s .
2. Everyone t a l k s about t h e c o s t of m a l p r a c t i c e i n s u r a n c e ;
however, no one suggests a means by which incompetent d o c t o r s
may be r e p o r t e d . Kenneth S. Abramowitz, a h e a l t h care a n a l y s t
a t Sanford C. B e r n s t e i n & Co., s t a t e s , "The p r o b l e m . . . i s t h a t
no one knows who t h e good d o c t o r s and bad d o c t o r s a r e . Only
d o c t o r s know and they are not t e l l i n g " ( D e G e o r g e 118).
C o n f i d e n t i a l r e v i e w boards must be e s t a b l i s h e d i n an e f f o r t
to c o r r e c t t h i s s i t u a t i o n .
I n a d d i t i o n , m a l p r a c t i c e s u i t s should not be heard i n f r o n t
of uninformed j u r i e s who, as a way o f g e t t i n g back a t i n s u r a n c e
companies f o r t h e i r h i g h r a t e s , o f f e r huge s e t t l e m e n t s even
i f the evidence does not support t h e award.
was
3. The Cobra Law i s b e n e f i c i a l o n l y i f t h e i n d i v i d u a l
employed i n a group o f 20 or more, remains h e a l t h y , can
�-5a f f o r d t h e premiums w h i l e unemployed, o r f i n d s another j o b w i t h
b e n e f i t s i n t h e time a l l o t t e d . To use an o l d c l i c h e , i t has
more h o l e s than swiss cheese.
4. The excesses o f t h e e i g h t i e s a l l o w e d p h a r m a c e u t i c a l
and medical supply companies t o f u r t h e r expand t h e i r p r o f i t
margins.
I n a d d i t i o n , b o t h charge t h e i r customers i n t h e medical
p r o f e s s i o n more than they charge t h e r e s t o f t h e p r i v a t e s e c t o r ,
a p r a c t i c e t h a t i s known as t h e "Pentagon E f f e c t . " What w i l l
be done t o curb t h e "greed" t h a t e x i s t s i n t h i s s e c t o r o f t h e
economy?
5. We must s t o p spending m i l l i o n s o f d o l l a r s i n an e f f o r t
t o p r o l o n g t h e l i v e s o f t e r m i n a l l y i l l p a t i e n t s f o r whom t h e r e
i s no hope and no q u a l i t y o f l i f e .
6. With an e s t i m a t e d 37 m i l l i o n people u n i n s u r e d , h o s p i t a l s
are r e c o u p i n g some o f t h e c o s t s they i n c u r t r e a t i n g t h e
u n i n s u r e d , by i n f l a t i n g everyone e l s e ' s b i l l — hence " c o s t
s h i f t i n g . " H e w i t t A s s o c i a t e s , i n Chicago, a b e n e f i t s c o n s u l t i n g
f i r m , " e s t i m a t e s t h a t 'cost s h i f t i n g ' i s r e s p o n s i b l e f o r one
t h i r d o f t h e y e a r l y i n c r e a s e i n some companies' medical b i l l s "
(Bradburn 4 8 ) .
7. The burden o f d e a l i n g w i t h t h e u n i n s u r e d and Medicaid
i s u n f a i r l y g e n e r a t i n g f i n a n c i a l h a r d s h i p s t o many c i t i e s and
s t a t e s — e s p e c i a l l y those communities d e a l i n g w i t h u n r e s t r i c t e d
immigration.
8. E f f o r t s s h o u l d be made t o f i n a n c i a l l y h e l p s t u d e n t s
who i n c u r s u b s t a n t i a l debt d u r i n g t h e i r years i n medical s c h o o l .
S t a r t i n g a p r a c t i c e w i t h a s i g n i f i c a n t debt might tempt even
the most honorable person t o perform unnecessary t e s t s i n an
e f f o r t t o earn more, thus p a y i n g o f f t h e debt more q u i c k l y .
9. I n d i v i d u a l s a r e w o r r i e d about s u r v i v i n g b o t h p h y s i c a l l y
and f i n a n c i a l l y w i t h America's d y s f u n c t i o n a l system o f h e a l t h
c a r e . "When p o l l s t e r s asked U.S. c i t i z e n s i f t h e y ' d p r e f e r
Canadian h e a l t h care over t h e i r own, 72% s a i d ' y e s ' " ( S c h m i t z ) .
10.
Many s t a t e Blue Cross and Blue S h i e l d p l a n s a r e i n
financial trouble.
11.
S i n g l e p a r e n t f a m i l i e s , those where a spouse i s e i t h e r
deceased o r n o t i n t h e p i c t u r e , a r e a t a d i s t i n c t disadvantage
s i n c e t h e r e i s o n l y one a d u l t t o shoulder t h e burden o f p r o v i d i n g
h e a l t h b e n e f i t s and f u l l - t i m e care should a c h i l d develop a
s e r i o u s m e d i c a l problem.
S t a t i s t i c a l l y , t h e m a j o r i t y o f these
f a m i l i e s a r e headed by women l a c k i n g t h e s k i l l s o r e d u c a t i o n
necessary t o secure a good j o b t h a t o f f e r s b e n e f i t s .
Kate Cagney, a w r i t e r and h e a l t h care advocate
from Chicago,
�-6summarizes t h e i s s u e s u c c i n c t l y when she says "No c o u n t r y i n
the i n d u s t r i a l w o r l d devotes a l a r g e r p o r t i o n o f i t s resources
t o medical c a r e ; y e t no i n d u s t r i a l i z e d c o u n t r y has denied a
l a r g e r p o r t i o n o f i t s p o p u l a t i o n access t o such c a r e " ( 3 0 1 ) .
The t i m e has come f o r America t o meet t h e needs o f i t s
c o n s t i t u e n c y and a b o l i s h i t s system o f r a t i o n i n g h e a l t h care
by " w e a l t h . " When i t comes t o p r e - n a t a l care and i m m u n i z a t i o n s ,
the U.S. i s g u i l t y o f spending zero up f r o n t and m i l l i o n s l a t e r .
U n q u e s t i o n a b l y , g r e a t e r access t o h e a l t h care i n t h e U.S. c o u l d
save b o t h l i v e s and money w i t h e a r l y d i a g n o s i s and prompt
t r e a t m e n t o f many i l l n e s s e s .
For y e a r s , e l e c t e d o f f i c i a l s and i n s u r a n c e i n d u s t r y spokespeople have p e r p e t r a t e d t h e "myth" t h a t s o c i a l i z e d medicine
doesn't work i n o t h e r c o u n t r i e s and w i l l n o t work h e r e . I n
a d d i t i o n , t h e y c l a i m Americans w i l l never accept i t . M a n i f e s t l y ,
Congress i s n ' t l i s t e n i n g t o what Americans a r e s a y i n g .
F a c t u a l l y , Canada expands 9% o f i t s G.N.P. on h e a l t h care
and i n s u r e s a l l o f i t s c i t i z e n s ; c o n v e r s e l y , t h e U.S. spends
almost 12% o f i t s G.N.P. on h e a l t h care b u t s t i l l has 37 m i l l i o n
people u n i n s u r e d and m i l l i o n s more u n d e r - i n s u r e d .
Unquestiona b l y , i f t h e American system o f d e l i v e r i n g h e a l t h care were
an i n v e s t m e n t , i t would y i e l d zero r e t u r n .
Americans are no longer willing to accept the propaganda
surrounding the issue of socialized medicine. As more individuals file for unemployment, more families will find themselves
facing the health insurance quagmire. Congress must act quickly
to find an equitable solution that protects "all" Americans
-- if not, the people may decide to hold their elected officials, /
accountable the next time they enter the voting booth, -j- •f/^cti^f [
�Works C i t e d
Bradburn, E l i z a b e t h , e t a l .
"Can You A f f o r d t o Get S i c k . "
Newsweek 30 Jan. 1989: 45-51.
Cagney, Kate.
"Health K i c k . "
Cronkite, Walter.
The N a t i o n 25 Sept. 1989: 301.
" B o r d e r l i n e Medicine."
PBS S p e c i a l 20 Mar,
1 991
DeGeorge, G a i l , e t a l .
"Ouch!"
Business Week 20 Nov. 1989:
110-118.
Schmitz, Anthony.
39-47.
"Health Assurance." I n H e a l t h Jan. 1991:
�Withdrawal/Redaction Marker
Clinton Library
DOCUMENT NO.
AND TYPE
004. form
SUBJECT/TITLE
DATE
Carol P. Dworkowitz' Insurance Information (1 page)
9/30/1988
RESTRICTION
P6/b(6)
COLLECTION:
Clinton Presidential Records
Health Care Task Force
Tarmey
OA/Box Number:
1981
FOLDER TITLE:
[Carol Pollack Dwarkowitz] [loose]
2006-0885-F
wr839
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act -15 U.S.C. 552(b)|
PI
P2
P3
P4
b(l) National security classified information [(b)(1) of the FOIA)
b(2) Release would disclose internal personnel rules and practices of
an agency 1(b)(2) of the FOIA)
b(3) Release would violate a Federal statute |(b)(3) of the FOIA)
b(4) Release would disclose trade secrets or confidential or financial
information 1(b)(4) of the FOIA]
b(6) Release would constitute a clearly unwarranted invasion of
personal privacy 1(b)(6) of the FOIA|
b(7) Release would disclose information compiled for law enforcement
purposes 1(b)(7) of the FOIA)
b(8) Release would disclose information concerning the regulation of
financial institutions 1(b)(8) of the FOIA]
b(9) Release would disclose geological or geophysical information
concerning wells |(b)(9) of the FOIA|
National Security Classified Information [(a)(1) of the PRA)
Relating to the appointment to Federal office 1(a)(2) of the PRA]
Release would violate a Federal statute [(a)(3) of the PRA|
Release would disclose trade secrets or confidential commercial or
financial information 1(a)(4) of the PRA)
PS Release would disclose confidential advice between the President
and his advisors, or between such advisors |a)(5) of the PRA)
P6 Release would constitute a clearly unwarranted invasion of
personal privacy 1(a)(6) of the PRA)
C. Closed in accordance with restrictions contained in donor's deed
of gift.
PRM. Personal record misfile defined in accordance with 44 U.S.C.
2201(3).
RR. Document will be reviewed upon request.
�\
/
N T N L NW
AI A E S
O
PS
THURSDAY. JUNE 6,1991 1 C «
THE MIAMI HERALD l O A ?
insurance plan unveiled
HIGHLIGHTS O DEMOCRATS' H A T P A
F
E LH L N
• Covaragt: A
O
Americans vmukf b*
covered, either
through their jobs or a
new program that
wouldreplaceMedicaid
Emptoyers that choose not to
offer coverage would face a new
6 to 8 percent payroll tax.
• Benefits: All
health plans would
have to meet or
exceed a standard
periods could not exceed _
SOURCE: HwMtWMMq]
days; Btnlts on coverage of
pre-existing conditions would be
^minated
• AmeriCare:
Medfeaid would be
replaced by a new
federal-st^e
program called
AmeriCare, with an initial cost
of $6 billion. The program
would cover the poor and those
not insured through work. It
would pay doctors, hospitals
more than Medicaid now does.
Medicaid would continue paying
for nursing home care.
-O^i
:
_
• Costa: Savings
of $78 bSHon projected
over five years, mainly
by eliminating unneeded procedures.
New federal agency would set
spending targets, negotiate rates
between providers, consumers.
m Small
businesses:
Would have up to
five years to
provide coverage. To
encourage them to buy insurance,
businesses with fewer than 60
employes would get tax credits. —
�You m i g h t f i n d these two a r t i c l e s i n f o r m a t i v e .
Although
you have p r o b a b l y read t h e one on f r a u d , t h e o t h e r one i s from
a r e l a t i v e l y obscure magazine.
�IN CANADA, A LITTLE PLASTIC CARD GETS YOU FREE CARE ANYWHERE. WHAT'S THE CATCH?'
I
HE LAST SNOW HAD MELTED JUST DAYS BEFORE, though
the mountains .towering
over Vancouver were still blanketed. In the city flowers bloomed—crocuses,
daffodils. A fresh breeze swept in from the Pacific, through the open windows of the
heart ward at Vancouver General.
Six days after open heart surgery, Tom Berrie lay naked on his bed. A nurse bent
over him, tugging at the glinting metal staples that held the sixty-three-year-old
retiree together.
"I'll be done here in a minute," he said in a Scotsman's brogue that was surprisingly hale, considering the circumstances.
Berrie had every reason to be pleased. He'd gotten the operation he needed. He'd
lived to tell about it. And thanks to Canada's health care system, he hadn't paid a cent. Still,
there was one substantial hitch. Berrie had waited to get his surgery for the better part of a
year. During those long months he wondered if this were a bargain that would kill him.
When the nursefinished,he rose and wrapped himself in a hospital gown. With his full
head of hair and trim dark mustache, Berrie lookedfit—solong as he stood still. When he
moved it was with the caution of a man who feared he might fly apart.
A Scot by birth, Berrie left Glasgow for Canada with his wife and two children in the
19.50s. "1 came here because it was far away from Britain," he said. "Too far to turn back.
Once I got here I had to make a go of it." In Burnaby, a Vancouver suburb, Berrie returned
to law enforcement, the occupation he'd left behind in Scotland. He'd been retired for just
ten months in January of 1989 when he suffered a heart attack while reading the morning
, ::.(#•- ' • • , .
Illustrations
by
RAFAL 0 L B I N S K I ~ T 0 M E K
OLBINSKI
JANUARY/FEBKUARY 19!* 1 I N H L A L T H
39
�paper. His daughter rushed him to a local hospital.
ON OUR SIDE OF THE BORDER, as Tom Berrie obAnywhere in the United States, an intake clerk
served, we cover neither everything nor everybody.
would have grilled Berrie about how he planned to
The number of U.S. citizens with no health insurpay his bills. In British Columbia, Berrie simply
ance at all—37 million—exceeds Canada's total
handed over his bright plastic "Care Card," which
population. Ask Americans whether they believe
guarantees him free treatment anywhere in Canaour health care system needs wholesale reform (as
da. A $55 monthly premium, paid through Berrie's
several polls have), and nine out of ten say yes.
pension plan, covers him and his wife. "The emerMost say they'd rather have care like Canada's.
gency ward was packed," Berrie recalled, "but 1
This is not an opinion shared by the American
was on a table, snap, with a cardiologist looking
health industry. Every few months, organizations
after me."
such as the American Medical Association or the
Health Insurance Association of America deliver a
This, however, was the last aspect of his care that
gloomy report on Canada's health scheme, pormoved with any speed. After two weeks, Berrie was
traying it as a rotten edifice on its way to ruin, a
released with a May referral to a specialist for an
system only fools would emulate.
angiogram, a procedure to reveal blockages in the
vessels that supply the heart musTo make this argument requires
cles with blood. The specialist rethat one skip lightly over a few nigferred him to Vancouver heart " I W O U L D N O T LIKE T O LIVE UNDER YOUR SYSTEM. gling points._Qinadians, for insurgeon Lawrence Burr, and from
stancejj^enOT^n medicine for
Burr, Berrie learned that he needed
every liOjwe spend. They live longIF I TRIED T O GET INSURANCE D O W N THERE
a six-vessel bypass. On June 2,
er than we do. Fewer of their babies
1989, the surgeon entered Berrie on
N O W , T H E Y D COVER EVERYTHING BUT M E
die. Everyone has full health coverVancouver General's waiting list.
age. No one is denied insurance beHe joined no fewer than 720 other
cause of an expensive illness. No
HEART. IF 1 NEEDED CARE FOR M Y HEART AGAIN
^patignts waiting in a nerve-racking
one pays a deductible for a doctor's
aueujpfor beds in British Columcare. People pick their own doctors.
I ' D FINISH M Y DAYS O N T H E STREET."
bia's three heart surgery wards.
Their family doctors see them
quickly, either in the office or, when
Berrie waited through summer,
necessary, at home.
fall, then most of winter. He lived in
Canada has accomplished all this with a system
slow motion, fearful of another heart attack. Simof sweeping controls. Private insurance that comple jobs like washing the car took three times as
petes with the provinces' medical plans is illegal.
long. He relied on his sons-in-law for help around
Health ministry officials keep a lid on doctors' fees.
the house. During his many idle hours he fumed at
Almost all hospitals are publicly owned. The govthe government. "They're more interested in giving
ernment caretully limits the number of hospital
away things people can see," he reckoned. "A new
beds and the purchase of expensive new equipbridge, a new ferry. A guy waiting for a heart
ment. In the process, it drastically trims costly
operation, he's all but invisible."
.paper-shuffling in doctors' offices and wipes out
Finally in late February of 1990 he got a call from
insurance company overhead and profit.
Burr. Another surgeon was leaving on a week's
vacation, so Burr had appropriated his two surgery
uur health industry charges that Canada runs a
slots. He could operate on March 5. Berrie was
bargain-basement operation that Americans would
simultaneously grateful and bitter.
never tolerate. The AMA claims that Canada jeopar"I'd get angry, but then I couldn't afford to get
dizes the public health by scrimping on items such
angry," he said. " I wasn't supposed to have any
as magnetic resonance imaging, radiation therapy,
stress. I was supposed to take everything nice and
and open heart surgery. The Health Insurance Ascalm." At this Berrie assumed a tone of mock transociation argues that Canadian bureaucrats' fear of
quility. "'Oh,' I said, 'I'll get my operation evenspending stifles creative programs such as those
tually. They may do it with me in a wooden box,
that send surgery patients home that day. Doctors
but I'll get it.'
complain that Canadian fees are so low that brilliant surgeons and innovators flee to the United
"Ah, but it was a worry. I worried when I went to
States, where their talents are rewarded.
bed at night, 'Am I going to be here in the morning?'
Then I got here and, poof, the weight came off my
But the objection most consistently raised
shoulders."
against Canadian health care is that patients wait in
line for major operations. The AMA, for instance,
As Berrie's eyesflutteredshut, 1 asked him one
recently paid for ads depicting a winsome girl belast question. "Do you think you'd have gotten
neath the headline, "In Some Countries She Could
better care in the States?"
Wait Months for Her Surgery."
He sighed. " I would not like to live under your
system. If I tried to get insurance down there now,
It's the queues for heart operations that attract
they'd tell me I had a heart problem. They'd cover
the greatest attention—and most sharply illuminate
everything but me heart. If I needed care for my
the distinctions between care in Canada and the
heart again I'dfinishmy days on the street.
United States. The Canadian newsweekly Mac"Canada," he said slowly, "covers everything."
Lean's defined the issues with the case of a particu40
IN HEALTH
JANUARY/FEBRUARY
1991
�larly hapless Toronto patient named Charles Coleman. The 63-year-old diamond setter's operation
was postponed 11 times to make room for more,
seriously ill heart patients. Eight days after Coleman finally got his bypass, he died. Before his case
could fade into obscurity, the issue flared again in
British Columbia. Provincial health officials, beset
by criticism of the long queue in which Tom Berrie
and 720 others languished, announced a plan to
send patients to the United States for their heart
surgery.
Surely, if waiting for treatment routinely harms
Canadian heart patients, the proof could be found
in Vancouver. Or so I thought.
f
TAKING COVER I N OHIO, NEW YORK, AND OREGON
: .vy^v
WHEN LOUIS SULLIVAN, the top health official in the United States, unveiled
his strategy for the 1990s recently, he suggested smoking less, eating right,
and using seat belts. But as for extending health insurance to the 37 million
Americans who have. none, he had nothing to say.
The message from Washington to the states was clear: If you want all
your citizens to receive decent health care, do it yourselves. And many have
been trying. Hawaii, for instance, has beefed up its state-run health plan
while maintaining the requirement that employers offer health plans, so
all its citizens are covered. But several states are attempting the more
.,. ^ y •<
aggressive reforms they believe their citizens want and need. .'
V : ^frV--.:.!;,;';-^
companies and from Medicare and
OHiOi IYIINO CANADA Sometimes
Medicaid. Doctors benefit from a simthe burden of reform falls on unlikely
pler, cheaper payment system, while . •
AFTER i LEFT T O M BERRIE 1 called on his surgeon,
) shoulders. "I'mV locomotive engi- 'v.
the state gains an advantage: As New
Lawrence Burr, to find out why Berrie had waited
neer," says Ohio legislator Bobby
York medicine's sole paying customer,
so long. We met in Burr's office, a modest room on a
. Hagan. "What the hell do l.know .,
it can demand lower rates and more
side street. Bamboo stood outside the window.
about health?" Yet shortly after he
efficient service. With the state's budget
Geese pecked at the courtyard grass. Perched on the
took office in 1987, Hagan{'dove into
corner of Burr's desk was a plastic model of a
currently squeezed tight, however, the ^
^
the debate on health insurahce. He
human heart.
represents the Ypungstownlarea,
proposal is on hold.
C
where steel mill shutdowns have left . ^ ^OMOONsWriONINOCAU H o p i n g - t j ? ; , ^ ^ ^
An American surgeon, considering Burr's lot,
might call this a hardship post. When Burr does a
thousands with neither paycheck nor . get all.its residents covered, Oreigoni^
routine four-vessel bypass, the British Columbia
mcuranro
• - ••>. .• • x \ i - r recently passed legislation that will|^;.fj
insurance.
government pays him $1,700. He'd earn $6,575 for
...soon qualify 116,000 uninsured.proplje-f
"1 felt compelled to do something
the same piece of work at a teaching hospital in
for Medicaid, benefits they can t get#,'.C;v.t,:;
to help protect those people,"'sayS'.
Minneapolis. There, he'd get as much operating
Hagan. He introduced a bill proposing now because they aren t poor enpughi; • JSPVT
time as he wanted, because the heart unit runs at
that everyone in Ohio be covered un- . The state will then rank all m e d i c a j ^ ^ , ,
about half capacity. In Vancouver, he's allowed to
procedures, weighing their cosB*^**^'.
der a Canadian-style health scheme
operate 12 times a month, eight times fewer than
against their known health benefits?^'/
_
financed by taxes. Hagan's bill bars'
he'd prefer. Because Burr has far more patients than
Expensive, ineffective treatmentsj^^k ^
private insurers from competing with
surgery slots, most wait months.
will be lopped off the list. By t h i s - ' ^
the state's basic coverage plan. The
kind of rationing the state intends^ \ ^ ^
"1 promised Tom Berrie he wouldn't wait more
measure was quickly condemned by
to save enough money to coverall ' . ^ j f ^ j - ^
than a year," Burr said quickly, with the supremely
the state's medical association and by
confident manner of a person who holds a beating
insurance industry representatives, but • - the neyv;people e n r o l l e d ; ; % . S § ^ &
But a moral fog bank has now.rolled;^*^!
heart in his hands several times a week. " I had other
embraced by labor, church, and senior
in. Thefirst attempt to create sucha U s t f e ^
patients who were worse, who had more chest
groups representing 3 million of ; !
ended in disaster, with care for thumbr
pain. But they'd only been waiting two months. 1
Ohio's 11 million residents. Hagan's
' sucking-related jaw problems ranked l ) {
decided come hell or high water I was going to keep
bill—considered a long shot by local
. higher than some AIDS treatments..'
this promise."
observers—is slowly making its way
Oregon's number-crunchers are back
through the legislature. ''Y.4? .'«..• • >:.
•
Berrie was one of 75 patients on a waiting list
at their computers, aiming at a new
NIW YORKi MYINO THI •ILLS ITMLF
that Burr keeps in a small black book. The surgeon
deadline in early 1991. Even if they conAs a state where 2.5 million people
, decided that Berrie was an urgent case, one of many
lack health insurance, New York has ': '• coct an acceptable list, Oregon will
in the broad range between emergency and elective
seen its share of proposals! A provoca-' ' have to ask Congress to let it rob Peter
surgery. Burr can take an emergency case into the
to pay Paul—trim the roster of treatfive new one calls for all employers to
operating room almost immediateiy by trading anments now available to Medicaid pacover their workers or pay afine.The
other surgeon for operating time. Urgent cases wait
tients so it can offer the same reduced
state itself will insure the unemployed
until Burr fits them into one of his three weekly
care to a larger group. The state.should
and low-income part-time workers,
operating slots.
with a sliding fee scale for.the 1
"Every week I have to decide," Burr said. "Is the
• instead be raising t^xes, critics say, and-ysl;
more affluent.
"
guy who's been waiting ten months worse than the
looking for ways to'cut waste so.eyery- V^, '
guy who's been waiting five months? But even if he
one can be given decent care. V But this plan has an especially bold
isn't, the guy waiting ten months has got to have
"It's harder to do something than to
provision. Right now, doctors and hossome pride of place. After all, he's been waiting
build up an ideal that no one could
pitals send bill after bill to patients, to
twice as long."
their insurance companies, and to the .. ever actually pay for," says John GoThe long lists don't have to exist, Burr explained.
federal government—a bureaucratic ..: j.lenski, a bioethicist who helpeddesign.
If British Columbia's 15 heart surgeons took on a
Oregon's plan? Among the states this is 5 ^
nightmare that wastes millions. New
full, combined work load of 60 to 75 operations a
York proposes instead that dortors and • an increasingly common refrain: If we
^
week, the waiting list could be whittled down in less
hospitals send all their bills straight to
can't afford everything medicine has
than a year. As it is, in a good week they operate 50
the state. The state sends out checks,
to offer, then how and where do we
t
times. They're limited by the number of hospitals
then collects in bulk from insurance
draw the line?
.—
ASK^J
:
:
•f
1
%
�"HE SAYS FIFTEEN DIED on the waiting list?" said
quipped for open heart surgery—three for a popuRobin Hutchinson with an odd touch of glee.
ition of 3 million, or about a third the number
As senior medical consultant to the health minisou'd find in the United States—and by the amount
try's heart program, Hutchinson helps decide how
> operating room time these hospitals parcel out.
f
many people ought to get heart surgery each year in
The Ministry of Health limits the number of
British Columbia. His office is in the capital city of
ieart surgery wards, claiming operations are done
Victoria, separated from Vancouver by about 30
heaper and better at hospitals that handle at least
miles of water. Not that the distance brings
iOO heart patients a year. It then gives these hospiHutchinson much peace. He dashed into our meetals enough money to perform about 2,100 heart
ing late, just off a helicopter from a meeting on the
>perations annually, a number set by ministry offimainland. His desk was piled high with papers, his
ials working with a panel of cardiologists and
phone rang incessantly, his hair was a mess.
ieart surgeons. The Canadian rate of heart surgery
"That's right," I said. "Fifteen."
s less than half ours.
"Well,'now," said Hutchinson. "We know the
"In the States," Burr said, "too many cases are
mortality rate on the operating table is between
lone. People have a bit of angina, they come i n t o " ^ ^
two and three percent. So if they
he hospital, get an angiogram
operated on the whole waiting list
done, and bang, they're referred to
last year we'd expect them to kill off
surgery without a good trial of
" W H A T ' s t B E L O N ^ S T YOU
'AIT I N L I N E
twenty-two! You don't hear about
medications. The bed is empty, the
the guys who never get off the table.
riospital wants to make money. 1
YAr&QYfD?
AT A BANK BEFORE GETTING
They only talk about the guys who
don't think that's an indication for
die on the waiting list and some of
surgery, but that's not a view that's
FIVE MINUTES?
them would die no matter what.
always shared by my colleagues in
the States. You're overeager to use
"Look, it's hard for me to sit here
WHAT IF YOU NEEDED A HEART ( ' E R A T I Q ^ ^
the technology that's available. In
and say there is a huge amount of
Canada, on the other hand, we've
medical necessity to take care of
HOW LONG WOULD YOU WAIT THEN^"
been excessively conservative."
every case on our waiting list.
That's a little harsh because many
By carefully pinching the supply
people feel they need surgery. But
of heart surgery slots, British Cosome medical necessity is iatrogenic—which is to
lumbia has created a sensible but high-strung syssay the docs themselves create it. So many surgeons
tem. Disruptions at any of the surgery units—the
portray coronary bypass as a lifesaving operation.
recent nurses' strike, for instance, or the chronic
But then you look at the outcome studies and they
shortage of operating room technicians, or the brief
show it isn't."
walkout of workers who sterilize instruments—all
lead to maddening backups.
Research to date generally reveals that except for
patients with certain types of heart trouble, such as
Meanwhile the demand for heart surgery keeps
obstructions of the left main coronary artery or
growing. "Our population has increased," said
three-vessel disease, those with bypasses don't live
Burr, "but even so the growth in demand is out of
longer than people who take heart medicine and
proportion to population growth alone. We've got
watch their diet. In fact, the patients most likely to
better diagnosis, better treatment. We can operate
benefit from a bypass are also those most likely to
on people now that we wouldn't have touched ten
die from one.
years ago. We've got a better product."
"So what do the surgeons say ro this?" HutchinI asked Burr whether waiting for an operation
son asked. "They say, 'Yeah, well, but a bypass
harmed patients such as Berrie.
relieves chest pain when medicine won't.' To which
He tapped on the armrest of his chair. His fingers
I say, 'Of course. But you bastards, you haven't
were surprisingly pale, the nails well-trimmed.
been going to the press saying Mr. So-and-So has
"People decline while they wait," Burr said.
anginal pain and we think he'd feel better if he had
"They're less active. They gain fat, they lose muscle.
an operation. You're saying this guy has a time
They can have a heart attack that makes surgery
bomb in his chest that only you can defuse, and the
more risky. Some people have become depressed.
government is preventing you from laying your
They withdraw to their family.
God-guided hands inside this guy's chest and mak"The only positive thing about waiting is that
ing him better.'"
people have time to think about what's happening
Nonetheless, 720 people waited for surgery they
in their life. They can ask, 'Who am I? Where am I
thought would help them. Taking up the American
going?' All the questions we never have time to ask.
Medical Association's line, I proposed to HutchinOften they say, 'Okay, I've smoked too much or
son that his government was rationing medicine,
eaten too much. I can change these things.' They
promising everyone health care, then withholding
can start changing their life around."
it to save money.
But there's one other possibility. "They can die,"
"We ration according to the severity of the disBurr said. By his count, 15 British Columbia pagase," Hutchinson replied. "For us, those who need
tients did just that last year while waiting for their
care most get it first, regardless of economic status.
heart surgery.
3
JANUARY/FEBRUARY 1 9 9 1
I N HEALTH
43
�That's a fundamental philosophical difference be"As of now," Hutchinson said, "we've had nine
tween Canada and the States. Both sides ration.
people sign up. The opposition party, the press,
You've got thirty-seven million people who don't
everybody's making a big stink about our waiting
have diddley-squat for an insurance plan. They're
lists. And we've got nine people signed up! The
rationed, too.
surgeons ask their patients and they say, 'I'd rather
wait.' We thought we could get maybe two hun"Second, it's not a conscious decision by the bean
dred and fifty done down in Seattle and get our own
counters here that there should be this many heart
list down to four hundred and some. Which sounds
operations done and the rest can just line up and the
a little grisly but isn't really so bad. Ideally we'd
ones that survive get it and theothers, good, wedon't
have a four- to six-week waiting list to make the
have to pay for it. It's not a case of someone deciding
system flow smoothly. But if nobody wants to go to
we're not going to do these things because it costs
Seattle, we're stuck."
too much. But we have a hard time grappling with
this waiting list. We don't know who's waitingor for
Did the people offered the Seattle operations
how long. We don't know how severe their case is.
actually need bypass surgery?
We do know that all the real emergencies are get"If I can be convinced that this is a medical
ting done, but we're left struggling
necessity I'll go to bat," Hutchinson
with this nebulous class of elective
said. "But there are a thousand
operations."
other things all clamoring for attenWHEN POLLSTERS ASKED U.S. CITIZENS
tion and resources. I have to be very
The rewards of promptly operatconfident in believing these heart
ing on everyone are anything but
IF THEY'D PREFER CANADIAN HEALTH CARE OVER
operations are a real need. Right
certain. Research shows that far
now we just don't know what hapfewer than half the people who get
THEIR OWN, 72 PERCENT SAID YES.
pens to these people. Besides just
bypasses later pronounce themliving or dying, what are they doing
selves free of chest pain. Follow-up
AS FOR THE NUMBER OF CANADIANS WHO'D
five years later? Are they back at
studies of bypass patients show
work? What's their quality of life?
they're only 25 to 40 percent more
CHOOSE T H E U . S . SYSTEM! 3 PERCENT.
We're trying to get some kind of
likely to be relieved of pain than
handle on what the public is buying
people who stay on heart medicine.
with its money."
But the provincial ministry decidIn the States, the social cost of a dubious operaed it couldn't afford to stand on statistics. As the
tion, paid for by an insurance company, is at best
waiting list grew, the British Columbia Medical
obscure. In British Columbia the tradeoff is obAssociation hammered the government with radio
vious. Medicine is a staggering line item in the
ads that asked, "What's the longest you'd wait in
provincial budget—a third of all expenditures, for a
line at a bank before getting really annoyed? Five
total of $3.65 billion last year. Money spent on
minutes? Ten minutes? What if you needed a heart
medicine can't be spent on roads, schools, or job
operation to save your life? How long would you
programs. That the money might be wasted on
wait then?" The association aimed to pressure the
operations that profit only surgeons is more than a
provincial government into spending more tax
nagging thought.
money on hospitals, medical hardware, and not
coincidentally doctors' fees. Local newspaper editors, of course, heard news knocking every time a
TOM BERRIE'S ANGUISHED WAIT for his surgery
waiting patient fell dead.
lingered in my mind as I drove from place to place
"Because of the public outcry over these poor
in Vancouver. Yet as I talked to Canadians about
souls walking around with their hearts about to
their health care, the stories 1 heard were typically
pinch off and drop like flies all over the province,"
mundane. A reporter, a professor, a salesman, a
said Hutchinson wearily, "we did a deal with the
clerk in a store—all had the same prosaic experiUniversity of Washington in Seattle." The deal, he
ence. If they or their children got sick they picked
explained, called for the hospital there to take 50
up the phone and called the doctor of their choice.
bypass cases at $18,000 per head, a bargain comUsually they got in within a day. They didn't have
pared to the $40,000 to $75,000 a bypass typically
any complaints. Deductibles, copayments, preexcosts in the States. Still, for the government iarepreisting conditions—the routine curses of American
sented a loss on several fronts. The same operation
health care—seemed to horrify them more than
costs $15,300 in Vancouver. In addition, all the
their own waiting lists. "If our worst-case scenario
money was going out of the province. In theory the
happened to someone in the States," one labor
Seattle operations promised to take the heat off the
leader told me, "they'd still think they got lucky."
Ministry of Health until a fourth heart surgery unit
When pollsters asked Canadians if they'd prefer the
opened in the Vancouver suburb of New WestminAmerican system over their own, only 3 percent
ster. If the first batch of Seattle bypasses went
answered yes.
smoothly, Hutchinson said, then the government
"Here," said Morris Barer, an expert in health
planned to buy three or four more 50-head blocks.
policy at the University of British Columbia, "yOu
But four weeks after announcing the plan, health
don't have to think about how much a doctor's visit
administrators had to admit they were stumped.
is going to cost or whether you can afford to go at
44
IN HEALTH
JANUARY/FEBRUARY
1991
�i' Jjr-'T-w/
WOULD A CANADIAN UMBRELLA LEAK I N THE UNITED STATES?
In fact, however, most people in the
United States don't really have full coverage. Overall, American insurance now
covers just 74 percent of the costs of doctors' services, 39 percent of dentists' services, and 25 percent of prescription drug
charges. We pay the rest out of pocket.
"SOCIAUZED HEALTH AND MEDICAL SERVICES," said the politician, "are incompatible with
the rights and responsibilities inherent in a free and democratic society." The year was
1959, and the speaker was J. Donovan Ross, Alberta's Minister of Health. Remarkably,
Canada's citizens disagreed. By 1966 the government had declared itself the nation's only
health insurer, and by 1971 every Canadian had full, free coverage.
Now Americans are jealous. Anyone bold enough to endorse Canada as a suitable
model, however, can expect an argument. Here are eight objections and the rejoinders.
WOULDN'T FREE CARE ENCOURAGE PEOPLE T O ^ j ^ C
RUN TO THE DOCTOR FOR EVERY ACHE AND P A I N T ^ -' <,
WOULDN'T NATIONAL HIALTH INSURANCI
AMOUNT TO "SOCIALIXID MIDICINI," FULL Ot
•URIAUCRATS TILLING OUR DOCTORS HOW
TO TRIAT UST
THE THOUGHT of handing Washington
power over everyone's health is indeed a
little spooky. Who can forget the government's attempt to "simplify" our income
tax forms by adding a mass of befuddling
new instrurtions?
But look at U.S. health care now. Our
doctors already obey legions of intrusive
bureaucrats: Insurance officials regularly demand that your doctor call for permission to go ahead with treatment. Medicare
officials dictate precisely how long patients
can stay in the hospital. The number of U.S.
health care administrators has climbed 3.5
times faster than the number of doctors. In
Canada, there are no meddling insurers,
while the government's main power is in
raising money and paying bills, with minimal monitoring for outlandish practices.
"No one second-guesses me," says the
president of British Columbia's medical
association. "I've got clinical freedom."
DON'T WE ALREADY HAVE THE WORLD'S
BEST HEALTH CARET
IT'S CERTAINLY the most expensive. In
1987, we spent $2,050 per citizen on health
care. Canada spent an average of $1,480,
most European nations even less.
Unfortunately, spending the most hasn't
made us the healthiest. Canada, culturally
most like the United States, has an infant
mortality rate 25 percent lower. Their rate
of heart disease death is 20 percent lower.
Their average life span—77.1 years—is
almost two years longer.
paper-shuffling. (Even the picky Consumers Union recently came to that same conclusion and endorsed a Canadian-style
plan.) In Canada, according to the latest
study, citizens each spent $J£. a year for
"administrative costs," while each of us
spent $95—for a total of $20 billion more
than we would have with Canadian-style .
insurance. That's not allTOur doctors, hos-¥^
pitals, and nursing homes spend much
more—$62.1 billion by a 1983 estimatefilling out insurance forms, billing patients,
and collecting.
PEOPLE WHO GET free treatment do go to ^ V / ^
the doctor and hospital about a third mor6V t a /
often than those who have to pay a share^of^V^
their medical bills.
^"C^'*^<*
Still, Canadians—who pay nothing atithe'^e ^
doctor's—have a lower per-person healtli^- ^ . " ^
bill than we do. That's because, among ^L*** S
other things, they've given their govern- JgjJSo
ment power to bargain with doctors and ^
hospitals over fees. An office visit that's
$52 in Seattle is $18 in Vancouver.
THERE'S NO WAY THE GOVERNMENT CAN PAY
FOR EVERY AMERICAN'S CARE WITHOUT RAISING
TAXIS THROUGH THE ROOF.
MORE NEEDLESS TREATMENTS AND TESTST
THE FEDERAL GOVERNMENT ivould have to
come up with billions of dollars more than
the $115 billion it now spends on its health
programs for the poor and aged. Some
could come from income taxes, some from
luxury taxes on cigarettes or cosmetic surgery. In Canada, several provinces charge
a small monthly premium.
But before you reflexively holler "No
new taxes," consider what you're already
paying. That grand total of $2,050 we
spend per citizen doesn't come out of thin
air. It comes in dribs and drabs out of your
own earnings—in existing state and federal
taxes, insurance premiums, payroll deductions, deferred wages, deductibles, copayments, and ordinary cash transactions with
doctors and hospitals. Canadians pay theirs
once in taxes but get more care—for $600
less out of each citizen's earnings. Last year
our country spent $640 billion on health
care. With a Canadian-style system, at
Canadian rates, we could cover everyone
for $365 billion.
SYSTEM SO IT REACHES ALL THE PEOPLE WHO
WOULDN'T NATIONAL HEALTH INSURANCE
AREN'T NOW COVEREDT
MEAN THAT AMERICANS WHO ARE NOW FULLY
MANY PROPOSALS for full U.S. health coverage would require all businesses (except
the smallest) to insure the health of their
workers, with the government looking out
for everyone else.
Suchfine-tuningcan improve our system
but won't reallyfixits biggest problem: the
billions of dollars we waste every year on
IN CANADA, provincial insurance covers all
health costs except dental care, eyeglasses,
prescription drugs, ambulance service,
and private hospital rooms—so many
Canadians do end up buying some private
insurance. A policy to cover all of these
things runs about $30 to $40 a month.
IN HEALTH
JANUARY/FEBRUARY
1991
DOISNT LETTING DOCTORS SEND PATIENTS'
BILLS STRAIGHT TO THE GOVERNMENT LEAD TO
WHY NOT JUST FINE-TUNE OUR EXISTING
46
1
INSURED MIGHT HAVE TO SETTLE FOR LBSST
!'
WHEN PATIENTS get free care and doctors .
can charge no more than a set amount per >
treatment, the tide does tend to run toward
more and more treatments. Studies in Canada have shown jumps in the number of
doctors' billings—and in their incomesafter the government froze their fees.
But the same thing's now going on in this
country—except here federal regulators
and private insurers have been trying, witlv
even less success, to keep a lid on physi- ,
cians' incomes. Last decade American
doaors increased their cut of the national
^ _ income by 40 percent while "Canadian
doctors captured only another 10 percent.}
ISN'T THE PRIVATE HIALTH INSURANCI INDUS* .
TRY JUST TOO BIG AND POWERFUL TO KILLT
DISMANTLING the health segment of our
insurance industry would be "politically
thorny," in the quiet words of one advocate
for a national plan. Some 1,200 firms now
sell more than $192 billion in health insurance. They'd put up a hard fight. Not only
has the industry grown eightfold since
Canada shut down its own health insurers,
but our government leaves politicians
more open to lobbyists than does Can- '
ada's parliamentary system.
Still, there's no legal barrier to making
health insurance an American public
service. The states have broad powers to
legislate business affairs and to promote citizens' health. Likewise, the federal government can use its control of tax revenues—
as it does'with highway funds—to set standards for the states. .
��tion study showed 44 percent of all U.S. bypasses
all." Barer, for example, with a wife and two chilwere performed for dubious or inappropriate readren, pays a $51 monthly premium. Around 20
percent of his income tax is set aside for health care.
sons. (For instance, some patients with one clogged
Above that, the only bills he'll ever see are for
heart vessel got bypass surgery though no evidence
prescription drugs, ambulance service, or a private
indicated it would do any good.) At one hospital
hospital room. He's never had trouble finding a
the rate of unwarranted surgery was more than six
likable family doctor with an office nearby. In Canin ten. If a waiting list withholds operations from
ada, as in the United States, there are about 490
patients who'd be better off without, then some
people per physician. In both countries, in fact, the
American hospitals could use one.
number of practicing doctors keeps going up.
"You've got to remember that you've got a waitBarer's one experience with the trumpeted shorting list as well," Anderson said when I asked for his
coming of Canadian care began when he realized
view. "Your waiting list is based onfinances,just
his daughter had a problem with her feet. He took
like ours, but it's not as obvious. If you're poor and
her to the doctor and was told there'd be a six"you don't have insurance, you don't go to a surmonth wait to see an orthopedic surgeon. Instead
geon. In the States you ration by ability to pay."
of waiting, said the doctor, she
could see an occupational therapist
A SHORT WHILE" LATER I headed
next week. The therapist recomYOU'VE GOT TO REMEMBER, YOU'VE GOT
back to the United States, a trip that
mended shoe inserts; but when
for Canadians evokes a sense of
Barer's daughter finally did get in to A WAITING LIST AS WELL, BUT I T S N O T AS OBVIOUS
dread. What if they get sick or have
see a surgeon, he declared there was
an accident? Their health plan pays
nothing wrong with her. And that
U.S. doctors the going rate in CanaIF YOU'RE POOR AND YOU DON'T HAVE
was it: Case closed.
da—$277 for an emergency appendectomy, for instance, less than half
Had she needed surgery, Barer's
INSURANCE, YOU DON'T GO TO A SURGEON.
the typical surgeon's bill across the
daughter would have gone on a
border. Prudent Canadians buy
waiting list, just as Tom Berrie had.
I N THE STATES YOU RATION BY ABILITY TO PAY."
special traveler's insurance before
In some Vancouver area hospitals,
they leave.
queues for elective surgery are
13,000 patients long. Similar situaStill, they fear the worst that
tions abound across Canada. People in Saskatoon
American medicine can do. They believe that
can expect to wait almost five months for a hip
Americans routinely die from lack of insurance
replacement. In Winnipeg, patients who need
right in the hospital foyer. They're appalled by the
emergency surgery routinely wait an extra day.
unfairness of American care as well as by its bloated
That's the landscape in Canada, though it's
costs—$2,000 a year for each citizen, compared to
changing continuously and not necessarily for the
Canada's $1,400. People with no particular reason
worse. The lists regularly shrink or even vanish
to know, such as a retired cigarette salesman I enwhen new medical centers open, or when citizens
countered, can cite with reasonable accuracy the
and doctors pressure the government into spending
cost of both paper slippers and major heart surgery
more on health care. And no citizen who needs
in a U.S. hospital.
surgery—or any other form of treatment—ever
At the Vancouver airport, a customs agent took
goes without it, except by choice. Emergencies, of
it upon himself to give me one last lecture. He asked
course, get top priority. It's rationing by medical
the usual questions: occupation, nature of visit. His
need, as Hutchinson said, but Barer and most other
ears pricked up when I said I was reporting on
Canadians accept it the way we'd accept waiting
Canada's health care system.
for someone in a wheelchair to board an airplane.
"And what's your conclusion?" he asked me
Even Tom Berrie preferred his own long delay to a
suspiciously.
roll of the dice with American health care.
"Some people wait for surgery." I shrugged. It
I couldn't help but wonder, though: Was Berrie's
didn't seem like the place for a symposium.
surgeon wrong when he claimed that heart patients
" I just want to make sure you understand," he
decline while waiting for surgery? Wouldn't pasaid in that commanding tone of a man with a
tients in the United States fare better?
badge. "When my kids need to see a doctor, I call in
"Right now, no one knows whether being on the
the morning, they get in that afternoon. When I
waiting list is any more harmful to you than being
hurt my shoulder I got sent to the top joint man in
operated on earlier," Barer said. "Studies that would
the province." He was getting worked up, waving
show that haven't been done. Meanwhile, no one in
my passport to make his point. "It doesn't matter
the States has demonstrated that your heart surgery
how much money you have. This is a great system."
rate is optimal or anything close to it."
A line backed up behind me. I nodded earnestly.
Just the opposite seems to be true. A study re"Okay," he said. Then, noticing that he still held
cently completed by Geoffrey Anderson, a univermy passport, he stamped it with a flourish and sent
sity colleague of Barer's, revealed that American
me on my way.
•
Medicare patients get bypass operations at double
the rate of Canadians. Yet a 1988 Rand CorporaAnthony Schmitz is a contributing editor.
JANUARY/FEBRUARY 1 9 9 1
I N HEALTH
47
�mm
C VR SO Y
OE T R
HEALTH CARE
Up to $80 billion is stolen each yearfrom
taxpayers and insurers. Bolder scams arise
all the time, and little is done to stop them
W
hite-collar "wilding," one regulator calls it — an orgy of economic crime. As America's
health-cure bill spirals to an estimated
$817 billion this year, it is attracting an
ever more impudent and wily army of
scam professionals. Experts now estimate that fraud and abuse in the healthcare field cost somewhere between $50
billion ancl $80 billion each year-a figure that dwarfs the estimated $5 billion
lost through criminal fraud in the entire
savings and loan debacle. And of course,
consumers and businesses arc paying for
these heallh-carc rip-offs in higher taxes
and skyrocketing insurance premiums.
The thing that spooks insurers and
federal regulators these days is that the
scums are growing dramatically bigger,
bolder and more sophisticated. "Previously, the usual situation was single-subject fraud, involving one doctor or supplier," said Assistant Attorney General
Stuart Gerson. "Now we are encountering more cartel-type frauds." Florida,
with its huge elderly population, is a hotbed ol health fraud, especially around
Miami. The Philadelphia region has also
been host to a variety of unsavory
schemes, as have New York, Texas, Arizona. California and Michigan.
Investigators stress that the overwhelming majority of physicians and other health-care providers arc dedicated
and honest. But it doesn't take many to
steal a lot, argues Richard Kusserow, inspector general for the Departmenl of
Health ancl Human Services. " A welfare
citieen would have to work mighty hard to
steal $100,000. Somebody in the [medical] practitioner or provider community
can burp ancl steal $100,000."
Authorities worry, too, that shifts in
health care are opening the door wider
for fraud. A burgeoning movement to
electronic claims filing is eliminating the
paper trail that provided investigators
with many of their best leads. And as
more health care moves away from the
hospital ancl into outpatient settings ancl
homes, keeping an eye on it gets tougher.
Finally, each new advance in medical
technology presents a new forum for
fraud. The result is an endless game of
cat and mouse. "For every loophole in
the system we close," says IZclward Kuriansky, New York's special Medicaidfraucl prosecutor, "the voracious provider seems to find another." What follows
is a look at some of the more ingenious
and far-reaching new kinds of fraud.
ROLLING LABS
One of the hottest schemes involves socalled rolling labs that conduct unnecessary ancl sometimes fake tests on unsuspecting patients, while billing insurance
companies or the government for the
cost. Federal authorities allege that the
biggest such operation took place in
Southern California, masterminded by
two Russian immigrant brothers, M i chael and David Snuishkevich. Investigators claim the Smushkeviches and 10 cohorts filed $1 billion in false claims, of
which some $50 million was paid by government and private insurers. At its peak
between 1986 and 1988, the operation
involved 1,000 separate companies and
400 bank accounts worldwide, according
to insurance-firm estimates.
Indictments allege that patients were
solicited through "boiler room" telemarketing operations. Phone sales represenU.S.NiavSA WOKI.I) KKmKT. I-'KIIKUAKY
m>
�talives olTerccI comprehensive physical
In order lo work, the alleged scheme
exams, including siate-ol'-lhe-arl diag- had to circumvent imporlant health-innostic testing, at little or no lee to the surance basics: Most policies provide litpatient. The tests were conducted at tle or no coverage for preventive tests.
health clubs, retirement homes, mobile- They cover only testing that is medically
home parks or shopping malls serviced necessary for a specific, current illness.
by the rolling labs, and later at free- And most require patients to pay a porstanding clinics. To Constance Otero of tion of the fee —usually 20 percent.
Irvine, Calif., and many like her, it all
Investigators say patients were resounded legitimate. The woman on the tiuircd to fill out medical-history forms
phone was "such a personable lady that that were used lo later justify the "medshe sounded like my best friend," Otero ical necessity" of the tests —though
recalls. Although Otero, then 65, wasn't many said they were not complaining
feeling ill, after many phone calls, "given about any symptoms. A battery of diagmy age, 1 thought, 'what the heck.' " The nostic tests would be performed, sometwo-hour exam at a Tuslin, Calif., clinic times before the patient had been exin 1988 resulted in $7,500 in billings.
amined. The defendants then doctored
U.S.NEWS a WoKi.n RKIORT. I-'KHKUAKY 2.1. mu
the medical records with false facts designed to result in payment by the insurance company or (he government,
according to the charges.
A major break in the case came in mid1987 when Dr. William Marr, who
worked for Pacific Mutual Insurance, got
a phone solicitation. Marr was promised
a complete physical and was told there
would be no charge to him. When he
reported for the exam, Marr told investigators, he filled out a routine healthhistory form, but was asked nothing specific about his current health. After some
tests, his insurance firm, Pacific Mutual,
was billed for more than $7,500. The diagnoses on the claims included high
III USIRATlON'j UY S C O n SWA! ES FOR USNAWR
35
�• C VR S O Y
OE T R
blood pressure, diabetes,
heart disease and cancer, but
Marr claimed he suffered
from none of these conditions. Eight months later, authorities, prompted by private
insurers with other claims
against the Smushkeviches,
raided their boiler rooms,
clinics and offices.
Some of their alleged victims were haunted by the
wild diagnoses. One was
Craig Keoshian, a Woodland
Hills, Calif., chiropractor.
An active athlete, Keoshian
was astounded when he
learned months after his
tests that a life-insurance application had been rejected.
"All of a sudden, this glaring
thing comes up on my record
stating that 1 have all these
diseases, including heart defects and obstructive pulmonary emphysema," says KeoFraud artists sell services like unneedshian. "According to their
ed lab tests or unnecessary medical
diagnoses, I was ready to
die." It took him two years
supplies through high-pressure phone sales operations run out of "boiler
to clear his medical record.
Most of the defendants
rooms." The pitch is aimed at getting unsuspecting patients, especially the
will be tried in May in U.S.
District Court in Los Angeelderly, to agree to undergo tests or buy high-profit medical equipment. Often,
les. They are charged with
175 counts of mail fraud,
the pitch deliberately confuses people into believing the caller represents the
money laundering, rackegovernment. Insurers or the government picks up the tab.
teering and other offenses.
Michael Smushkevich, the
alleged ringleader, has
pleaded not guilty. His lawyer, James selling overpriced and unneeded wares tion employing teenage girls operating
out of boiler rooms in Philadelphia-area
Barber, says the issues really should be to the elderly.
An ongoing case against a Philadel- shopping centers. The girls called local
handled in civil court, and focus on who
determines what tests were "medically phia supplier illustrates how authorities Medicare beneficiaries who had renecessary." David Smushkevich is in claim the operations work. In their civil sponded to newspaper advertisements
Amsterdam, fighting extradition. His at- suit, federal officials allege that Mark offering a "free Medicare covered packtorney, Howard Schecter, says David is Mickman, the former owner of a televi- age." The telemarketers would obtain
sion rental business, and his companies, the seniors' Medicare numbers and ask
"absolutely" not guilty.
Federal Home Care and Home them if they had any physical comHealth Care Products, filed plaints. If so, the caller said, their firm
EQUIPMENT SALES
al least 2,200 fraudulent could get equipment that would help.
i ^ ^ r T ^ ' , - ^ c l a i m s and bilked Medi- Though Medicare requires beneficiaries
Some of the slickest operators in the health-care field
i&ZsS-Jtii".. .Vv-^&V
care out of several mil- to pay 20 percent of the cost of any suphave set up what HHS Secion dollars in l%K and plies, the seniors were told that Mediretary Louis Sullivan
1989. The case will care would pay "100 percent for everycalls a "high-tech, moclnot go to trial thing," according to the complaint.
em medicine show"
until the spring, "Teenagers who had no medical trainthat is treating Medibut the govern- ing were making medical diagnoses
care like an open checkmenl did get an upon which sophisticated, expensive
book. Experts estimate that
injunction in Decem- equipment was being purchased for pacrooked marketers of items
be r 1989, at which time a tients that neither needed nor wanted
like seat lift chairs, oxygen
federal judge's opinion the equipment," said Judge Donald
concentrators, braces and
called Mickman's operation VanArtsdalen in a bench opinion.
home dialysis systems may be
an "out-and-out scam."
Authorities say the companies easily
ripping the government off for as
Mickman's plan relied short-circuited another "safeguard" in
much as $200 million yearly by
on a telemarketing opera- the system by filling out elaborate forms
T L M R EI G
EE A K T
N
pkooucT ntoios IJY mrmy M.TCMIUAN - USHAWH
US.NFAVS * WORLD Ri-mHT. KEHRUAKY M. VW
�m
C P Y E T W VR
OAMN AE
I
Unsuspecting patients often
agree to undergo tests or buy
medical equipment on the promise that they will not have to pay anything for
With doctors' signatures in
place, Mickman was entitled
to fill the orders and bill
Medicare, he says.
In many frauds, the equipment is not only nonessential
but also often outrageously
overpriced because suppliers
have cleverly manipulated
a variety of loosely drawn
Medicare rules. For instance,
a bed-size hunk of tlimsy pink
foam that cost a supplier $28
was charged to Medicare as a
"dry flotation mattress" to
prevent bedsores. Medicare
was billed $900. One highprol'il item is called a transcutaneous electronic nerve
stimulator, or TENS unit,
which generates electrical impulses that can help control
pain. It has legitimate therapeutic benefit for some, but
has been marketed as a virtual
magic elixir by high-pressure
pitchmen. The components
could be purchased at Radio
Shack for about $50, but
Medicare is often billed $500
for each one.
the service. Under most insurance or government regulations, the patient
Savvy equipment companies also take advantage of
regional variations in paythe provider offers to waive that copayment. The consumer sees the service as
ment rates. Medicare contracts with 35 private firms to
free and loses any incentive to keep an eye on what's being done.
oversee payments for equipment. Each of these "carriers" until recently had the unthat only required a doctor's signature was 72 and suffering from the early stages restricted right to establish its own
before the claim was filed. Medicare of Parkinson's disease, but he was still pricing schemes for the suppliers in its
will not pay lor such equipment unless bowling and jogging regularly. "My wife region. For instance, Medicare pays
lhe patient's doctor certifies it is neces- answered the call. They gave their name $41.93 for a wheelchair seat cushion in
sary. Surprisingly, many doctors do sign as Federal something. It was our impres- Tennessee, but pays $248.96 in Pennsylprccomplcted forms. Why? Sometimes sion the government was calling," recalls vania for the very same item. Not surbecause they are buried under exasper- McCarthy. Authorities charge that the prisingly, lots of suppliers have set up
ating paperwork and don't really exam- certificate of medical necessity prepared "branch offices" that are little more than
mail drops in high-priced states.
ine the form; sometimes because they by Federal said McCarthy was conMost shocking of all is that
figure the patient wouldn't have or- fined to his room on a floor withMedicare doesn't even
dered il if it weren't needed, and some- out bathroom facilities, neither
know who the supplitimes because patients apply pressure, of which was true. A few
ers are, or if they
threatening to find another doctor if weeks later, two large boxare legitimate.
es were delivered, conthey don't sign.
Suppliers must
taining among other
When the forms were completed,
be assigned
a
items a wheelchair, a
l ederal Home Care or Home Health
"provider numCare would bill Medicare and ship the commode chair and an
ber" by Medicare to
equipment, says the government com- electric heating pad. Medicare
gel paid, but getting
plaint. Seniors attempting to return the was billed $1,800 for the equip•i number requires virment. "1 didn't need anything
equipment —there were at least 50 such
tually no documentation.
calls to the companies a day-would be that was in the box," says
"It's like the government issuMcCarthy. Mickman's attorput on hold, cut off or told the responsiing a lifetime gold card with
ney, Neil Jokelson, said the
ble person was not available.
an unlimited balance and no
deeision to order the
John McCarthy was among those enannual service fee to these supsnared in the alleged scheme. When the equipment was based on
pliers without first running a
doclor-approvcd orders.
company called in June 19SJ, McCarthy
would have to pay a portion of the cost, usually 20 percent. But in this fraud,
l
U.S.NKWSX WOHI.I) Khll )KT, l-'KHKUAKY 2.1, HW
:i7
�al Care Inc. of Plainview, N.Y. Professional Care and its top two officers paid a
credit cheek," argues Sen. William Co- total of $5.2 million in restitution, fines
and interest for Medicaid overcharges.
hen of Maine.
In addition, PCI pleaded guilty to grand
larceny and falsifying business records,
INFLATED HOME-CARE BILLS
while the two officers pleaded guilty to
Like all tliieves, heallh-carc crooks fol- conspiracy. Working with an inside inforlow the money, and these days, the mant, Kuriansky charged that the commoney is increasingly in private homes. pany systematically overbilled the state
Patient preferences, new technologies over a four-year period for home health
and a Medicare-mandated trend toward services rendered by untrained and unshorter hospital slays have created a qualified workers, or in some cases, by no
booming $15 billion market in home- one at all. The state charged that home
health-care services. More than 12,500 health aides billed for many more hours
firms now provide some kind of home- of care than they actually provided.
care services, and the business is "atRight now, regulators are especially
Iracting the sharks," says Kuriansky, the worried about lhe growing number of
New York special prosecutor-in part companies providing intravenous drugs
because the market is relatively unregu- or nutrients at home. These so-called
lated. "From an investigative stand- home infusion services have proved espoint," says Kuriansky, "it's far harder pecially popular for AIDS treatment.
to get at, because you're talking about But a report by the New York City Definding out what's going on behind partment of Consumer Affairs charged
closed doors in hundreds of thousands that the home infusion market for
of individual homes, where there may AIDS patients was plagued by widebe no other witness than an incompe- spread price gouging. For instance, a
lent, vulnerable elderly person."
milritional supplement called TPN that
In August 1990 Kuriansky's office set- is often used by AIDS patients wholetled one of lhe largest medical-fraud sales for about $1,300 a month-but
cases in recent times, against Profession- home infusion billings for TPN ran as
• C VR S O Y
OE T R
D CO SG - F
O T R I NO F
Under federal guidelines, Medicare will pay
for equipment only after a physician signs forms certifying that it's
needed. Rip-off artists sometimes fake these signatures or pay off
corrupt doctors to sign the forms indiscriminately. Honest but
busy doctors occasionally sign without thoroughly examining the
forms, or sign under pressure from patients.
high as $10,000
monthly.
MENTAL
HEALTH
Similar storm clouds
are appearing over
the once growing field of
mental-health services.
Coverage for mental-health
and substance-abuse maladies
sprouted in the 1970s,
and the tendency among
insurance firms was to
reimburse for inpatient
stays rather than outpatient treatment. One result was massive growth
throughout the 1980s in forprofit psychiatric hospitals
hoping to take advantage of
these new streams of revenue. But problems began when the industry was overbuilt and insurance firms, alarmed by
exploding costs, began scrutinizing payments more carefully - a process that ultimately trimmed the average patient's
length of stay.
The result is that "private hospitals
that once made a great deal of money are
now desperate for patients," says Dr.
Alan Stone, former president of the
American Psychiatric Association. And
that desperation has opened the door for
fraud. Among the alleged abuses: Patienls abducted by "bounty hunters";
others hospitalized against theirwill until
their insurance runs out; diagnoses and
treatments tailored to maximize insurance reimbursement; kickbacks for recruiting patients; unnecessary treatments; gross overbilling.
The most infamous charges have
been leveled in Texas. Last April, two
security agents showed up at the Harrell family home in Live Oak to pick up
Jeremy Harrell, 14, and admit.him on
suspicion of drug abuse to Colonial
Hills Hospital, a private psychiatric facility in San Antonio that was owned by
the Psychiatric Institutes of America.
Family members believed the agents to
be law-enforcement officers. If Jeremy
didn't cooperate, the agents said, they
could obtain a warrant and have him
detained for 28 days. "They acted just
like the Gestapo," the boy's grandmother—and legal guardian —later told
a Texas State Senate committee.
According to that testimony, Jeremy
was denied any contact with his family
for six days and released only after a
state senator intervened. State officials
discovered that the boy had been ordered detained by a staff doctor after
his disturbed younger brother lied
U.S.NKWS & WORLD REIWT, KEBKUARY 24,1'JSH
�EKSESS
general is suing PIA
for an allegedly illeabout Jeremy's drug use. The guards gal patient-referwho brought him in worked for a pri- ral system. Texas
vate firm paid by Colonial Mills for each officials also suspatient delivered. And the doctor who pect some psychisigned the admission order had falsified atric hospitals are
recruiting crime vichis own credentials.
Jo Ann De Hoyos, an attorney repre- tims for unnecessary treatsenting the Harrell family, claims the boy ment ancl billing the state's
was snatched because his family was fully Crime Victims Compcnsa- v
covered for extensive mental-health tion Fund up to $25,000 per
benefits under CHAMPUS, a military patient; as a precaution, the
insurance plan. Soon after the ordeal, the state recently froze all reimHarrells got a bill for Jeremy's six-clay bursements to such facilities.
stay: a stunning $11,000. CHAMPUS And last summer, a PIA-alTilipaid the tab but has asked the Depart- ated hospital in New Jersey paid
the state a $400,000 settlementment of Defense to investigate.
It was the Harrell case that led to though it admitted no criminal
those Texas Senate hearings, which in wrongdoing—after officials there alturn brought to light other allegations legeel fraudulent billings.
of fraud and abuse. They involved some
Other patients who voluntarily sought
of PIA's 12 other Texas facilities and help claim they were imprisoned.
at least three other national hospital Among them is Susan Aklcrson, who
chains. Similar charges have been made told the Senate committee how her docagainst hospitals in New Jersey, Florida, tor referred her lo Brookhavcn PsychiatAlabama ancl Louisiana; three federal ric Pavilion near Dallas, another PIA
agencies have opened investigations, hospital, after she had a psychotic reacand more lhan a dozen slates now have tion to pain medication. "1 thoughl I'd be
probes underway. Some have already there a day or two and released," she
taken legal action: The Texas attorney said, "bul lhal dav or (wo lasted three
• C VR S O Y
OE T R
KC B C S
I KA K
Health care provides many opportuni-
ties for kickbacks for steering business
to suppliers, pharmacies or laboratories. A medical-equipment
supplier might pay off a hospital to get a monopoly on its business,
or slip cash to a doctor in return for patient referrals; a pharmacy
may pay "incentives" for a nursing home to steer patients its way;
labs may reward doctors for a stream of patient referrals.
U.S.Nl-:U'S & WOKI.I ) Klil-OKT, l-'liMKUAKY M. IMK
-.••••r^.'-'.'r"'-.v-
months." After Icarn'ng the terms of her
insurance policy with
Aetna Life and Casually, she testified, the
hospital tried twice to
change her status from
"psychiatric" lo "medical,"
therebv increasing her coverage from'$50.()00 10"$! million.
She says she was heavily sedated, isolated from visitors and
warned by her doctor that
she'd "be in a mental hospital the rest of her life" if
she made waves. When her
ccwcragc was exhausted, and
a family member threatened to call
the police, Alderson was told to pack her
bags ancl leave, she claims. Once home,
she learned her insurance company had
paid a $48,864 bill.
In recent months, a number of doctors have gone public with stories portraying Ihcir former employers as
greedy, mielhical and corrupt. Quentin
Dinardo, director of clinical services at
Laurelwood Hospital in suburban
Houston before he ciuil in disgust, says
"every decision was based on dollars
ancl cents. If you're selling shoes that
might nol be so bad, but wc are talking
about human beings." A clinical psychologist with 20 years' experience, Dinardo claims the entire hospital staff
spent half its time promoting the P1Arun facility to prospective clients. He
also alleges lhal Laurelwood charged
unconscionable fees for deplorable care.
David Olson, a spokesman for National Medical Einterpriscs Inc., which
absorbed PIA last December, calls Dinarclo's charges "absurd." Hospital employees are never required to spend
half their time marketing, he says, although the company docs expect staff
to educate the public about services offered. "Wc don't regard that as unreasonable," he adds. Olson says Laurelwood offers "quality" care.
Dr. Duard Bok, who ran a chemicaldependency unit at the Psychiatric Institute of Fort Worth, makes similar
charges about abuse in a recent lawsuit
against that facility. The suit alleges
that the PIA hospital routinely gave financial support lo doctors, social workers and even local high-school guidance
counselors for referring patients, ancl
pressured doctors to change discharge
orders "so patients could be maintained
in the hospital for a longer period for
no therapeutic reason whatsoever."
Bok was fired last August, he says, after
criticizing the facility's practices. PIA
contends Bok was disabled by a personality disorder ancl that they suspended
41
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his contract only alter he failed to show
up for work for two months. The company has filed a countersuit.
Privacy rules prohibit hospital staff
from discussing patients' cases-like
Susan Alclcrson's — without their permission. Bul Olson disputes the general
charges leveled against PIA facilities,
calling allegations of abduction •'absolutely, utterly false." There is no evidence to support charges that professionals are paid kickbacks to refer
patients lo PIA hospitals, or to detain
them once they've been admitted, he
says. Olson maintains the staff would
never revise a diagnosis to maximize insurance coverage, though he adds that
"it's not unustial for a patient's diagnosis to change" during a stay. "We're not
perfect," Olson says, "but to draw the
conclusion that isolated patient complaints mean widespread problems is
extremely dangerous to people who
need care."
ENFORCEMENT PROBLEMS
Despite the sums at slake, there has been
no great call lo arms againsl health-care
fraud among governmenl regulators,
law-enforcement agencies and private
insurers. There has been a recent awakening in some ijuarters, but the effort
still too often falls victim to funding
crunches and conflicting priorities.
Since 1985, 27 insurance companies
have joined a special investigative consortium against fraud, and the number
of special anlifraud units at Blue Cross
and Blue Shield plans has grown from 28
to 41 in the past three years. Several
firms have developed sophisticated artificial-intelligence programs lo massage
computerized claims data and
spot suspicious anomalies.
Still, many believe lhal private
insurers have been sluggish in
confronting fraud. A survey two
years ago by the Health Insur
ance Association of America
found that only half the
companies queried had
organized anlifraud programs. "Health-insurance companies, with
some exceptions, are content to pass the cost associated with fraud along lo their customers in the form of higher
premiums," charges Louis
I'ai isi, director ol the New
Jersey insurance department's fraud division.
The governmenl record is
spotty as well. Much of the
HM C R Ri OFFrrrr
O E AE P
tect. It involves charging insurers for more services than patients
got, billing for more hours of care than were provided, falsifying
records and charging higher nurses' rates for care given by aides.
flak is directed at lhe Health Care Financing Administration, which runs the
$115 billion Medicare program and
oversees the 58 private firms that process and pay Medicare claims. Congress
and the HHS inspector general's office
complain bitterly that HCFA is lousy at
closing loopholes that invite fraud and
at correcting administrative laxity. Reports with recommendations on how to
fix the flaws "seem lo disappear into a
black hole," says Harvey Yampolsky,
former chief counsel lo the HHS inspector general. One such report,
written in March 1988,
spotlighted abuses of provider numbers by equipment suppliers, but
HCFA didn't announce
changes in the system until
last fall. Critics arc also exasperated by HCFA's delays
in implementing new laws to
fix (he system. A 1987 law
authorized HCFA to develop rules for physician
investments in medical facilities, bul those prescriptions
didn't come out until last July.
as "payment safeguards" —has fallen
from $358 million in 1989 to $333 million in 1992, despite the fact that each
dollar spent this way saves Medicare as
much as $11.
The congressional General Accounting Office also roasted one of the contractors' primary tools for sniffing out
fraud: toll-free hot lines for Medicare
beneficiaries. The GAO study said that
over half the calls from beneficiaries
complaining of possible fraud were not
properly referred for investigation. Part
of the problem, says the GAO, is inadequate oversight from HCFA. Many beneficiaries complain of poor treatment
when they do call. "Why do they give you
this runaround?" argued OttoTwitchell,
who tried to report an excessive bill. "1
was beginning to feel like I was the guilty
party." HCFA Administrator GaifWilensky counters that her agency is caught
in a philosophical and financial squeeze.
It is often difficult, she says, to balance
the conflicting priorities of getting the
money out quickly, reducing the hassles
for legitimate physicians and suppliers
and keeping an eye out for fraud. In
addition, she says, new laws require exWorst of all, HCFA is pro- tensive time for public comments before
viding the private contractors rulescan be implemented. And workload
with less money lo watch out increases have outpaced manpower.
for fraud. Funding for these Medicare claims rose from 217 million in
watchdog activities— known 1981 to 600 million in 1991, but HCFA's
U.S.NKWS & WOKU) Kl-lWr. Hl'HKUARY 2-1. W>
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Some for-profit mental-health facilities reportedly pay "bounty
hunters" to bring in patients, hospitalize patients against their
will, tailor treatments to maximize insurance payments, take
kickbacks for recruiting patients and overbill for services.
stall' has fallen to 4,027 from 4,972 a
(.leeatle ago. Meanwhile, HCFA has also
been overwhelmed by other duties, like
instituting a massive change in physician
payment rates. Wilcnsky notes that
HCFA did announce a major package of
reforms last November to clean up the
medical-ec]uipmcnt industry. HCFA
would love to hike spending to sniff out
fraud, Wilensky says, but is doing the best
it can vmder budget constraints.
The same goes for the HHS inspector
general's office, which shares responsibility with the Justice Department for
investigation of hcalth-care-fraud cases.
The IG's office has boosted prosecutions for 1 years, bul has only 270 in1
vestigators nationwide'-.who are also re-
SIMPLE PRECAUTIONS
sponsible for HHS's 300-odd other
programs. "A lot of cases can't be
opened because we just don't have the
resources," says James Cottos, the IG's
head sleuth in Atlanta. Cottos has just
13 investigators for the whole state of
Florida, which is home to 2.3 million
Medicare beneficiaries. Their overtime
pay was cut off last fall.
Until recently, there wasn't much
good news at the Justice Department
cither. The focus at the FBI and among
U.S. attorneys during the 1980s was on
violent crime, the drug crisis and the
savings and loan scandal. Health-care
cases were boring and difficult to prove.
Those problems still exist. But a sense
of alarm is slowly starting to yield more
resources for battling health-care fraud.
The FBI has tripled its commitment
over the past three years, to 95 agents,
and early this month Attorney General
William Barr announced that 50 more
agents would be transferred from counterintelligence duties to health-fraud
probes. The number of states with special Medicaid fraud control units has
grown from 31 in 1984 to 42 today.
Still, no one believes the good guys
are catching more than a small fraction
of the health-related crime. Many feel
the system is too big and too geared toward processing the claims. Cracking
down may ultimately depend on smarter, more vigilant consumers who are fed
up. After all, it's their money.
•
BY GORDON WITKIN WITH DORIAN
KKIKDMAN AND MONIKA GU'ITMAN
licensed by the state, certified
by Medicare (about 5,800 of ..
the nation's 12,500 agencies'/;
are) and accredited by either '
the Joint Commission for the'
• Watch your bills. You could Accreditation'of Healthcare
be paying for part of the scam Organizations (1,800 agencies
accredited) or the Comfnuni- ;
when you pay your'share of
your bill. Be sure to check out' ty Health Accreditation Program Inc. (375 agencies \ . '
billing discrepancies very
accredited).
thoroughly.
• Home-care safeguards. Get • Fraud fighters. They can be
found at all major insurance" " .
the advice of a doctor you
companies, Medicare and \
trust on the level of home
Medicaid, arid most states' at- •''
care.you need. Be wary if
someone tries to sell you ser- torney general's offices. Medicare beneficiaries can file susvices or equipment no one
else has suggested. It's best to picions with the government'
by calling a toll-free fraud hot
choose a home-care agency
that has been operating in the line (1-800-368-5779): \ , ";
community for five years or
longer and one that has been
B STEVEN KINDLAY
Y
How to thwart health-care fraud
I ere are some'ways to '
1 spot arid prevent fraud:
• Be wary. Phone solicita-'.
tions, especially those promising free checkups, testing or
equipment, should trigger
suspicion. Don't give out your
Social Security, insurance policy or Medicare numbers!
• Rolling labs and health fairs.;
Rip-offs usually involve a
battery of tests rather than,
say, a single test like one for a
cholesterol check or a mammogram. Don't provide a de-.
tailed medical history or sigri'
multiple insurance forms that
US.Ni'WS
assign reimbursements to a
provider.
• White lies;. Be skeptical if
someone tries to talk you into
a "free" treatment scheme/
brie scenario: The provider
says your insurance will probably cover only $500 of a treatment for which he usually
charges $1,000. He says he's '
going to submit fees of
$2,000 — expecting to get reiriibursed around $1,000 —and
waive your part of the bill. .
These lies could prevent you "
from getting life or health insurance down the road.
& WORLD RKI-OKT. I'TUKUARY 21 MM
:
1
1
:
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Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
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2006-0885-F
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
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[Carol Pollack Dworkowitz] [loose]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
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2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 35
<a href="http://clinton.presidentiallibraries.us/items/show/36148" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092971" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
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William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Reproduction-Reference
Date Created
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3/16/2015
Source
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42-t-12092971-20060885F-Seg3-035-004-2015
12092971