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FOIA
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:
OA/ID Number:
1982
FolderlD:
Folder Title:
[Political Power Structures Affecting Any National Health Care Reform Plan: Health care reform
concepts versus Social and Economic Values] [binder] [2]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
1
�According
to Missouri
employers
would
i n Missouri.
health
benefits
twice
" I n today's
closing
like
would
would
i n Missouri
t a x on
f o r employers t o
insurance market,
Chrysler
plants
t h e 75$ p e r h o u r
incentives
f o r 75 c e n t s a n h o u r
Companies
about
Action,
have p r o v i d e d
locate
century.
Citizen
employee
be t h e d e a l
of a
almost c e r t a i n l y
i fthey
could
think
cut their
291
health
insurance costs
totals
t o over
to
be t o o g r e a t
2.
Individuals
deductibles
currently
instead
With
like
$1,500 a n n u a l l y
a burden
would
on t h e i r
allocated
additional
left
health
on s m a l l
basic
However,
per employee.
no l o n g e r
business
that
That
75(t/hour
is likely
employers.
pay p r e m i u m s , c o p a y m e n t s , o r
health
insurance.
Part
o f t h e money
f o r premiums, copayments or d e d u c t i b l e s
be r e c h a n n e l l e d
t h e money
that."
into
over,
a progressive
individuals
income t a x s u r c h a r g e .
would
insurance f o r coverage
would
be f r e e
t o purchase
beyond what t h e b a s i c
293
plan
would
would
cover.
The g r a d u a t e d i n c o m e t a x s u r c h a r g e
have p r o v i d e d
$500 m i l l i o n .
b e e n as f o l l o w s :
F o r t h o s e w i t h i n c o m e s up t o
$
The a l l o c a t i o n
would
t h e surcharge would
$
15,000
beer
75.DO
25,000
125.00
35,000
225.00
45,000
325.00
55,000
612.50
65,000
687.50
75,000
The
have
have
812.50
maximum
surcharge would
have been $4,000 f o r t h o s e
294
earning
3.
to
over
$200,000 per y e a r .
F e d e r a l Me.d i c a r e - a n d M e d i c a i d F u n d s .
States are permitted
a p p l y t o t h e F e d e r a l g o v e r n m e n t F o r w a i v e r s oF M e d i c a r e
_
_
or
�Medicaid
Funds w h i c h
Funds
their
to
Missouri
then
program.
w i t h $2.2
Assurance
4.
own
would
billion
enable
the
state to
Such a w a i v e r
annually
apply
would
their
toward
have
the
provided
Health
Plan.
The S t a t e
would
have
c o n t r i b u t e d to the
Fund
the
$130
295
million
that
i t already
Within
insurers
health
the
and
s t a t e oF
eligibility
costs,
spend
23
spends
budget.
13
percent
oF
their
percent
19
oF
Missouri
enabled
them
cost
enjoyed
by
expected
that
to maintain
the
would
have
local
private
government
claims
process,
Insurers,
on
i n c o m e on a d m i n i s t r a t i o n
while
the
Canadian
budget
on
administration is 3
their
uniFied
plan
percent
would
3 percent a d m i n i s t r a t i v e
been a d m i n i s t e r e d
consumers
and
government.
other
institutional
oF
annual
and
providers
'global budget'
the
Facility
provide
the
institution's
board
will
which
adequate
resources,
amass h u g e
excess p r o F i t s at
but
the
-94-
would
will
be
have
on
designed
need
none w i l l
of
be
the
oF
labor,
negotiated
"Hospitals
the
to
i t and
Each h o s p i t a l
expense
a Board
business,
reimbursed
t o a l l who
ne.eds.
guaranteed
be
by
included
hospitals.
service
long-term
supplied)
have
The
Fees w i t h p h y s i c i a n s
(underlining
200
Medicare/Medicaid.
program
to
care.
over
out."
i t s h e a l t h care
whose m e m b e r s h i p w o u l d
;297
an
are
bureaucracy,
29E
percent,
Governors
annual
health
s t a t e and
Forms t o F i l l
Medicare/Medicaid
have
The
and
i t s own
For
there
Federal,
h o s p i t a l s spend
administration.
oF
Missouri,
"Each has
standards
U.S.
program
been p a y i n g
many d i F F e r e n t
programs.
average,
had
will
allowed
and
basis
allow
meet
be
to
community.
�As h o s p i t a l s w o u l d
individual
have
patient,
c u t back
Governors
there
would
played
a useful role
care.
2 9 9
i n such
i s a strong
A.
Plan--a
managed
warned
they
restrictive
support
the
of
to avoid
managed
best
method
physicians'
In
care
Nationwide
and i n s u r e r s '
providers
individuals,
agree
part of a
for
them
the
existence
patients'
'managed
to provide
those
o f 'managed
choice
At a
sponsored
organization--
i n t h e audience
legislation,
contends
costs,
that
they
that i f
should
managed
care i s
and t h e l e a s t
restrictive
providers contract with the
care
services
systems
services
care
a t lower
system,'
same s e r v i c e s
care
a t lower
cost.
i s advocated
and c u r r e n t p e n d i n g
to provide
have
interests.
system,
o f managed
also
health care.
care
organization t o provide
growth
many g r o u p s ,
Gephardt
care
would
(D-Mo.), House M a j o r i t y
physicians
forcontrolling
a managed
managed
become
care.
might
hospitals to
on June 2 1 , 1991 and
Congressman Gephardt
wanted
they
each
The B o a r d o f
f o r auditing
o f managed
B u s i n e s s Forum h e l d
t h e Group H e a l t h
on
monitoring.
Gephardt
advocate
based
that
days.
P a t i e n t advocates
Congressman R i c h a r d
by
the possibility
have been r e s p o n s i b l e
quality
HaalthWatch
was
on t h e n u m b e r o f i n p a t i e n t
assure
Leader,
n o t have been r e i m b u r s e d
then
by
legislation.
cost
when
I f
they
i ti s possible
a t lower
cost
o r g a n i z a t i o n s ' which
without
restrict
of p r o v i d e r s .
Oregon
John K i t z h a b e r ,
Oregon
Plan.
M.D.,
is
Or. K i t z h a b e r
the author
has been
o f Oregon's
a member o f t h e O r e g o n
300
State
Senate
since
1 9 8 0 , a n d was r e - e l e c t e d
-95-
acclaimed
i n 1989.
�Oregon
citizenry
to
Formulated
i t splan aFter c o n s u l t i n g
a t 47 c o m m u n i t y
determine
meetings.
and e s t a b l i s h
I n F o r m a t i o n on m e d i c a l
procedures
and t r e a t m e n t s were
insurance,
broadened
From
considered.
the concepts
eligibility
over
coverage.
the l i s t
to
oF d i F F e r e n t
The p u b l i c ' s
oF m a n d a t e d
managed c a r e , a n d s e r v i c e
is
care
eFFectiveness
used
value
t h e decisions."^ ''
utilizes
controversy
were
0
drove
Oregon
meetings
oF h e a l t h
prioritization
services.
sysstem
Those
with i t s
be b l a t a n t
For Medicaid
the elimination
The m o s t
oF s e r v i c e
priorities."^
but stirred
priorities,
However,
part
which
0 2
The p l a n
up much
oF many m e d i c a l
controversial
rationing.
emp1oyer-based
procedures
oF O r e g o n ' s
program
i s c o n s i d e r e d by many
a s Eddy
a n d many o t h e r s h a v e
pointed out:
(Medicaid already r a t i o n s by) w i t h h o l d i n g
c o v e r a g e oF a l l s e r v i c e s F o r a b o u t 40 p e r c e n t oF
p e o p l e under t h e F e d e r a l p o v e r t y l e v e l and a l l o w i n g
3 3 0 , 0 0 0 oF t h e n e a r - p o o r i n O r e g o n t o go w i t h o u t
insurance.
...
Oregon's p l a n a t t e m p t s t o s h i F t r e s o u r c e s
From l o w - p r i o r i t y s e r v i c e s F o r c u r r e n t 1 y - c o v e r e d
individuals to help provide h i g h - p r i o r i t y
services
F o r p e o p l e who c u r r e n t l y h a v e no c o v e r a g e .
That
i s r a t i o n i n g , b u t i t i s a m o r e j u s t i F i a b l e t y p e oF
r a t i o n i n g t h a n w h a t i s o c c u r r i n g now.- 30
Oregon's
plan
3
i s c o n s i d e r e d by some t o be v i o l a t i v e
oF t h e
304
Age
•iscrimination
those
with
less
rehabilitation
ments
are
which
because
than a year
statute"^
0 3
i t provides merely
to live;
because
and v i o l a t i v e
disabled
people
comFort t o
oF t h e
require
a r e n o t c o s t e F F e c t i v e , a n d some oF t h o s e
treat-
treatments
not provided.
The
list
Act
Oregon
i n February
H e a l t h S e r v i c e s Commission
1991
3 0 S
oF o v e r
-95-
established
700 c o n d i t i o n s
a
Final
and t r e a t m e n t s
�which
were c a t e g o r i z e d
Acute
Fatal
on
a scale
with treatment
"17"
was
of
1 to
preventing
recovery;
while
Condition
treatment
p r o v i d i n g minimal
or
no
17.
death
Fatal
or
" 1 " was
and
providing
NonFatal
improvement
Condition
Full
with
in quality
oF
11 Fe .
E a c h oF
17
o u t c o m e s and
condition's
ranking
are
This
by
the
From
plan
Emotions
run
has
are
oF
are
not
oF
w i t h one
established
main p r o b l e m
cut, the
The
plan,
the
and
not
media
oF
which
number
thereFore,
covered
the
the
with
in suFFicient
because
oF
700+ c o n d i t i o n s
nationwide
dying
at such
The
diminished
or
paired
pairing
1 t o 700.
subject
at r i s k
the
budget.
are
the
high
Oregon
oF
are
reduced
was
was
c o n d i t i o n s was
result
procedures
boy
700
when b u d g e t s
w i t h the
method
little
the
is that
which
over
ranking
covered
comply
on
the
concentrates
who
is
coverage
a denied
to
covered.
when
a
procedure.
times.
attempted
to
prioritize
and
oFFer
587
out
oF
the
303
709
considered
the
list
quality
were
oF
procedures.
those
liFe,
The
plan
that
and
primary
which
emerged,
with denial
i n the
For
birth
the
list
low
procedures
based
For
thereFore,
measures employed
oF
were
g r e a t e s t good
care,
extremely
The
oF
on
the
placed
increased
at
the
coverage
priority
For
oF
longevity,
g r e a t e s t n u m b e r , and
gave h i g h
top
to
equity.
preventive
extraordinary
last
m o n t h s oF l i F e a n d h e r o i c
eFForts
309
weight babies.
Procedures at the top
are
considered
For
example,
t o have
the
g r e a t e s t h e a l t h and
social
3 10
values.
p'r o v i d e d , " ^ ^
covered.^
oF
the
1 -
liFe
Anencephaly
brain.
hepatitus
while
but
Liver
not
For
surgery
support
i s the
For
For
a ruptured
anencephaly
congenital
transplants will
those
who a r e
-97-
be
spleen
will
absence
provided
alcoholics.
not
oF
For
3y
will
be
be
p a r t or a l l
those
these
with
rankings,
�Oregon
of
h a s made s o c i a l
Finite
Field
administrator
expressed
with
t h e warning
25 y e a r s
A diFFerent
oF e x p e r i e n c e i n
that:
" . . . r a t i o n i n g i s going t o
l i F e a n d I n F o r m a t i o n s h o u l d be
e d u c a t e t h e A m e r i c a n p u b l i c oF
s h o u l d be i n F o r m e d s o t h a t t h e y
Face t h e s i t u a t i o n i n t h e near
Heritage
and r a t i o n i n g
care.
A hospital
the
d e c i s i o n s on t r a n s p l a n t s
become a F a c t oF
c i r c u l a t e d now t o
that Fact.
They
can a d d r e s s and
Future."
v i e w p o i n t was a i r e d
by S t u a r t
Butler
oF t h e
Foundation:
" I t i s n o t inconceivable that our society
may d e c i d e t o s p e n d 20 p e r c e n t oF GNP o n m e d i c a l
care i n order t o avoid r a t i o n i n g .
As we become
a r i c h e r s o c i e t y , we s p e n d m o r e on h e a l t h c a r e .
O r d i n a r y p e o p l e s h o u l d be i n v i t e d t o d e c i d e how
much s h o u l d be s p e n t t o a v o i d r a t i o n i n g .
By
comparison,
i n t h e 1 3 6 0 s , we s a i d we c o u l d n o t
s p e n d s o much o n M e d i c a r e a n d M e d i c a i d , a n d y e t
now we d o . "
3 1 4
Currently,
Oregon
60 p e r c e n t
i s spent
The
eleven
oF t h e c o s t oF m e d i c a l
on l o n g - t e r m
Oregon D e p a r t m e n t
waivers
From
5
care."^
oF Human R e s o u r c e s
the requirements
security
Act.
Medicaid
program
Services
A c t and s t i l l
n _,•
M e d i c a i•
d
oF
people
also
a
oF
oF § 1 1 5 [ a ) oF t h e S o c i a l
p e r m i t Oregon
to coincide with
remain
t h e Oregon
eligible
to alter
Basic
their
Health
to receive
Federal
F u n _ s . 3 15
di
two most
eligible
reduce
Five-year
that
important waivers
For Medicaid
'demonstration'
not only
may w i s h
would
3 1 7
For Oregon,
t o determine
b u t as a m o d e l
or adapt
-98-
b u t would
Oregon has s u g g e s t e d
be i n i t i a t e d
t o adopt
i n c r e a s e t h e number
by 3 0 , 0 0 0 p e o p l e ,
the services provided.
t h e program
states
would
has r e q u e s t e d
T
The
The w a i v e r s
care i n
. .,
a similar
that
t h e succe:
For o t h e r
3 18
program.
�Eddy
considers that
O r e g o n ' s P I an s h o u l d be p r o v i d e d t h e
opportunity
t o demonstrate
emphasizing
that
the plan
i t s w o r t h For F i v e y e a r s ,
i s not ideal
but i s a
deFinite
319
improvements
For
over
considering
imagine
that
consider
risk
i s already
i t would
eliminating
line;
3.
citizen
be b e n e F i c i a l
coverage
200,000
list
people
For
and
inFurance
idea
one
then
to eradicate
For 330,000
developed
to
be n o t w o r t h t h e i r
It
i s an
interesting
greater
who
122 s e r v i c e s
surveys, medical
encourage
by s u g g e s t i n g t h a t
an a c t u a l i t y ,
a l l coverage
an a d d i t i o n a l
priority
presents a novel
i t by:
and t h e h i g h -
people;
120,000 p e o p l e
undar
the
and,
giving
Medicaid
He
t h e employer-based
p o o l by d i s c a r d i n g
poverty
the
the Plan
dismantling
2.
quo.
t h e w o r t h oF t h e P l a n
whether
1.
the status
currently
that
qualiFy
For
are a t the bottom
oF
through extensive public hearings,
specialists,
320
and
legislative
debate
costs.
and n o v e l methodology
s u p p o r t For t h e Plan
which
From
this
is likely
to
viewpoint.
Michigan
A problem
local
oFten
governments
reFuse
those
exists
governments
are t o provide services,
t o , or are unable
services.
when s t a t e
t o , appropriate
I n some s t a t e s
and
mandate
then
the states
the necessary
when a s e r v i c e
that
Funds
For
i s m a n d a t e d by
32 1
that
state,
local
When a s e r v i c e
cannot
always
entities
i s deemed
be r e l i e d
have g r e a t e r
optional,
upon.
assurance
Funding
ThereFore,
-99-
i s less
oF
Funding.
deFinite
i n designing a
and
program
�of
health
broad
mandate
In
local
with
i n the late
delivery
was o f t e n
i n local
obviously
prefer
limited optional
1960s,
of services
implementation
support
entities will
of services,
Michigan
mandated
for
care,
state
but placed
levels
not forthcoming
a
very
services.
3 2
"
l e g i s l a t i o n often
complete r e s p o n s i b i l i t y
o f government.
because
little
Financial
o r no
state
323
revenues
this
it
were
could
would
appropriated
be v e r y
appear
services,
and
the
to
many
health
services
monitor
This
lack
department
already
without
expand
In
with
departments
t h e program's
i n documenting
324
to provide
program
considerable
q u a l i t y , access,
i n turn,
needs
programs
state
services,
and t h e i n F o r m a t i o n
I n eFFect,
deFinitions
and
impeded
discretion in
they
the state
health
oF t h e d o l l a r s
occurred,
and i m p r o v e d
maintained
eFFectiveness.
and t h e i m p a c t
a dilemma
thus,
with
"locals
accountability
support,
and t h e s t a t e
reFusing to
additional
3 5
allocations." "
documentation
on t h e u s e oF
without
t h e 1970s,
however,
legislation stating
local
because
f i n a n c i a l l y competent t o
exercised
oF a c c o u n t a b i l i t y ,
additional
unwilling
had n o t been s t a n d a r d i z e d ;
delivered
t o expanded
officials
services.
( s t a t e - ) mandated
they
Politically,
elected
were e i t h e r
requirements
support
current
the
spent."
objecting
they
to local
o r were n o t s u f f i c i e n t l y
reporting
local
damaging
that
manage p r o v i d i n g
"For
f o r t h e programs.
unit
oF g o v e r n m e n t
Michigan
that
remedied
the state
to provide
"could
a new
this
situation
not require
a
service...unless
3 25
the
state
as
willing
t o bear
the Full
-10 0-
cost
of i t s
provision."
�After
federal
experiencing, throughout
deficit,
have t o bear
and
situations
h e a l t h care
such
health
reform
planned
with
s t a t e s are acknowledging
increasing financial
expanded
t h e 19803,
as t h i s
plan
or reform
Inadequate
planning of implementation
reality
or
i t may
t o any a t t e m p t
reform
merely
be
plan
at actual
be s u f f e r i n g
lead
carefully
and p r o c e d u r a l
to the belief
is fatally
from
once a
imp1ementaiton.
could
or system
I t is
flawed,
inadequate
when i n
p l a n n i n g and/
implementation.
Denver
and S a l t
Nine
Lake
City.
s t a t e s and c i t i e s
provide
health insurance
working
uninsured.
Tennessee,
supported
expected
to
measures.
appropriations, regulations,
prior
the entire
f o r a l l new
i t s implementation
guidelines
that
expect t o
make i t i m p e r a t i v e t h a t
i s chosen,
specific
they
responsibility
proposals
which
that
the increasing
Utah,
some b r o a d
coverage
Arizona,
Wood
which
fifteen
Florida,
and W i s c o n s i n
oF e a c h s t a t e
questions
about
plans
program
3 2
"
"will
t h e most
will
Maine,
Johnson F o u n d a t i o n .
the experiences
policy
through
Colorado,
Washington,
by t h e R o b e r t
that
have begun p r o j e c t s
f o r the
Michigan,
planning
7
I t
is
provide
eFFective
was
answers
ways t o
3^8
increase
the
plans
coverage
provide
For t h e w o r k i n g
basic
beneFits
The p l a n s
incorporate diFFerent
329
c o i n s u r a n c e , and copayments.
The D e n v e r
the
of
and S a l t
other projects
local
government
Lake
because
uninsured
through
population. "
managed
care
A l l
systems.
structures
For d e d u c t i b l e s ,
City Versions
are different
Denver's r e s u l t e d
i n conjunction with
- 101-
local
from
from
the efforts
private
�organizations,
solely
From
the
by
private
s t a t e or
existence
both
and
areas
the
Salt
Lake
City project
organizations.
Neither
Federal
government.
of
innovation
this
3 3 0
was
begun
r e c e i v e s any
The
reasoning
i s explained
by
Funding
behind
the
Fact
that
are:
" . . . p o l i t i c a l l y and F i s c a l l y c o n s e r v a t i v e , w i t h
a s t r o n g t r a d i t i o n oF i n d i v i d u a l i s m and
vo1unteerism.
T h e i r l e g i s l a t u r e s are g e n e r a l l y
a v e r s e t o g o v e r n m e n t r e g u l a t i o n and r e l u c t a n t
to i n c r e a s e tax r e v e n u e s For s o c i a l s e r v i c e
p r o g r a m s . . . t h e d e s i g n e r s oF t h e D e n v e r and U t a h
p r o j e c t s never sought s t a t e Funds; they
r e c o g n i z e d From t h e s t a r t t h a t t h e y w o u l d h a v e
t o F i n d a l t e r n a t i v e ways t o make t h e i r
insurance
p r o j e c t s a F F o r d a b l e to t h e i r t a r g e t m a r k e t s u n i n s u r e d s m a l l b u s i n e s s e m p l o y e e s and
their
Families.
I F these p r o j e c t s are s u c c e s s F u l ,
they w i l l h e l p to d e m o n s t r a t e t h a t a F F o r d a b l e
b e n e F i t p a c k a c e s c a n be d e v e l o p e d w i t h o u t s t a t e
subsidies."
3 3 1
The
imposed
two
cities
managed
providers.
utilizing
Dne
care
oF
the
First
deductible
tions
that
patients
merely
care
a return
a 50
percent
hospital
For
to the
From
to
1S50s-type
coinsurance
care,
admissions
high coinsurance.
become m o r e
services i n order
and
s t r a t e g i e s they
inpatient
hospital
providers
a l i m i t e d choice
innovative
$ 5 , 0 0 0 oF
will
with
most
require
in addition
primary
the
i s charged
discounts
arrangements
is actually
management--they
on
negotiated
interested
to avoid
The
are
health
payment
and
and
oF
a
$250
prescrip-
theory i s
in preventive
the p o s s i b i l i t y
and
oF
332
costly
hospital
Denver's
Program
with
pays
a $15
or
specialty
Shared
100
Cost
percent
copayment
For
cara.
Option
oF
the
visits
For
costs
to
- 102-
Private
oF
Employers
preventive
physicians
which
(SCOPE)
services,
are
not
�Far
preventive
catastrophic
per
person
care.
care,
a r e covered
project
male
businesses
employees
i s meant
t o provide
expenses above
$2,750
i n Full.
was a n n o u n c e d
1 9 9 0 , 41D s m a l l
healthy,
t h eplan
a l l out-oF-pdcket
per year
Denver's
June,
Because
on A u g u s t
2 2 , 1 9 8 9 . By
h a d e n r o l l e d 3,7B4
and t h e i r
dependents
young,
i n t h e program
334
because
the
will
oF t h e l o w c o s t
90,ODD u n i n s u r e d
then
total
A very
reaching
interesting
a SCOPE s u r v e y
target
to
eFFects
with
thereFore,
concerning
on h e a l t h
small
that
risk
others
arehigh
believing
oF i n s u r i n g
actual
authorship
small
be t h o r o u g h l y
special
growth
businesses.
Small
3 3 5
i s that
oF t h e
risk
I ti s surprising
Forty
and o n l y
Four
insurers
b i d on t h e
t h a t ' s m a l l employers
limit
and t h e i r
insurers' ability
groups.
The r a t i o n a l e
t o spread
For these
search
oF t h e p r o v i s i o n s t o s p e c i F i c a l l y
involved.
While
may h a v e
appeared
now d e t r i m e n t a l a n d , i n t h e i n t e r e s t
restrictions
reForm
t h eadverse
investigated, with that
interests
markets
t o have F a r -
t h ec h a r a c t e r i s t i c s
oF i n s u r e r s a n d t h e s p r e a d i n g
segmented
dependents,
risk.
should
the
insurance
SCOPE h a d c o n t a c t e d
Many s t a t e s c u r r e n t l y
the
may d e v e l o p
u n d e r w r i t i n g oF t h e P l a n ,
project--the
employees
which
that
i st o enroll
3 3 5
do n o t seem t o p r e s e n t
associated
learn,
Fact
The g o a l
who, w i t h t h e i r
persons.
disclosed
population
usually
employees
250,000
positive
oF p r e m i u m s .
should
restrictions
oF t h e i r
risk
beneFicial
oF c o s t
laws
t o include
determine
on t h e
across
a t one t i m e ,
i t
containment, t h e
be r e m o v e d .
businesses
which
are generally considered
- 103-
toogreat a
i s
�PROGRAM UPDATE
TABLE 1
? i a n Features
Alabama: Basic Care Pnvaie
Ootion—A
DEDUCTIBLE
SERVICE DELIVERY
NETWORK
INSURANCE
PROJECT
:
i
1
COINSURANCE CAP. 1 MAXIMUM BENEFIT !
PRE-EXISTING
AMOUNT
CONDITION CLAUSE'
OUT-OF-POCKET ;
i
i
MAXIMUM
StOO per maiviouai per j St 080 per person per
contact year. S300 per year—:eouct:Die pius
family
i coinsurance
S3.2AO per family
and private nosoitais anc pnvate
physicians
Unlimited (Limited
oenetit cacnagei
Same as aoove
; NetworK moce: HMO Ot DUDliC
Same as appve
Same as aoove
S-t 000 oe- oe-son per
year oaricioani's cpinS'j'ance
S250.00C per person per 12-12 'or inpatient
year
services ipregnancy:
normal cenvery not
covered 'pr "0 mon;ns
from enronmemi
t2-6t2
ODIIOD—3
NetMjrx moaei HMO ot ouoiiciy
supponeo nospaais ana county
pnmary care dimes
Arizona: ^.eaitn Care Grouo
Oction One
'JerAorn moaei HMO in 2 : : j n iies. IP In 1 cpunry
None
Arizona: Heaitn Care Grous
Ociion Two
Sane as apove
.'Jone
None
S250.000 per person oer Same as a:eve
year
Arizona: Heaitn Care GrouD
Oaiion T^ree
Same as aaove
None
None
S20.000 oe person per
year
Arizona: Heaitn Care GrouD
Ootion Four
Same as acove
Alabama: Basic Care PJDIIC
4
Denver: SCOPE
inpatient care-S250
per inaividuai oer caiencar
year. S500 per family
Outpatient prescnption
onjgs-S50 per year
EPO. co-payments 'A-aivea tor
low-income oe'sons using
puDiiciy-supponea nosoitais
Florida: Fionoa Heaitn Access
S'.anca'c Ootion
S2.000 per individual
per contract year
IPA .-nooe! HMO. inonproiili
None
Same as apove
r
S2.000 -axirn-jm outof-opc>e: oe person
per year
Same as aoove
S250.000 oer pe-son per i Same as aocve
year
-
!
i
S2.750 per person per Unlimited (Exceptipns.
year oecuctipie plus
mental neaitn. SUPcoinsurance. S5.500 per sance aouse. nospice
family
care, convalescent care,
person over 70)
St.500 per person per
caiencar year—total
c:oayme.~:s. $3,000 per
3-3-6 employee
3-3-12 dependent
Unlimited
None
Unlimited
None
family
None
:
Florida: F oriaa Heaitn Access i Same as asove
None
Maine: MameCare
IPA mocei HMO
Michigan: Blue Cross Blue
Siue Cross. B:ue Snieio artiiiatea , StOO per individual per
None
St.tOO ce: person per
Si.000.000 per
5-6 'or groups - or less
oenetit. an causes
270 davs trcm enronmemi no cause for
groups 5 or more
None
Mixed .Ttoos! HMO. start ana
Exists 90 davs after
enrollment, out does
not aopiy to pregnancy
Unlimited
coinsurance. SI.200 per
family
family
Michigan: Blue Care Neiworn
Oction
Same as aoove
Ncne
None
S500 per oe-son pe'
year or Sf250 oer tamily
maximum out-ot-oocnet
Ncne
Unnmitec isome
penetits umiteoi
networx components
I
Tennessee: MecTrust
:
HMO inducing :::nics ana pnysicians trom Tenn. P'imarv Care j
NetworK
j
5-3--2
Unlimited
i
Utah: Ccnmumty Heaitn Plan
\etworn nose: rMO inc:uomg
cpmrnumty nea::n centers ano
None
•.'c.-e
private oR-.-sicia.'.s
SI.000000 lifetime
!
oenetit maximum an
causes
Conc::ions 'Cr wnicn
meoica; acuce was
! receive: 2- mo. oetere
en.'oiiment. or treatment .
for 12 mo are covered
at SO : lor first 12 mo
3
Washington: Basic Heaitn
Plan
Vanety ot start, network ana IPA |
moaei HMO's
Srrvice OeYverv Hewon ieprMaiions
None
None
MMO — "fit'.' V.ainienaice Orcanijanon :PO - :«c:js:vt Prwicer O.'ca-i.-anrn
Unlimited
i?i - maiviouai Practice Assocui'On
6-12 •
�risk
by h e a l t h
shops,
exterminators
operations,
the
insurers are,
taxi
and crop
p o l i c e and F i r e
industry,
3
F o r example, barber
3
7
dusters,
workers,
mining
and beauty
and q u a r r y i n g
proFessional
h o t e l s and motels,
athletes,
medical
and d e n t a l
338
oFFices,
and p r o p e r t y
Fortunately,
management
United
States
project
and has i n c r e a s e d
intense
competition.
the
project
Exclusive
patients
the
because
Provider
preFerred
LiFe
accepted
i t s market
United
States
i t provided
the
Organization
u t i l i z e only
plan.
Firms.
share
LiFe
i n an a r e a
I t i s more r e s t r i c t i v e
means t o s t u d y a n
mandates
oF p r o v i d e r s
i nthat
provider organizations.
with
was i n t e r e s t e d i n
CEPO) w h i c h
the services
t h e SCOPE
that
l i s t e d by
respect
than
A t i n c e p t i o n oF t h e
SCOPE
339
Plan,
1,500 p h y s i c i a n s
The
Utah
nonproFit
itselF
Salt
was
Community
HMO d e v e l o p e d
a private,
Health
nonproFit
h e a l t h care
The R o b e r t
For planning
a t a cost
and development
oF a b o u t
private,
Health
Care
provider
which i s
system i n
Wood J o h n s o n
Foundation
oF UCHP
, and the
Plan
i nthe
S a l t Lake
City
businesses
40 p e r c e n t
enlisted.
(UCHP) i s a
by I n t e r m o u n t a i n
made a v a i l a b l e t o s m a l l
area
Plan
F u n d s From
Lake C i t y .
provided
a n d 12 h o s p i t a l s w e r e
less than
comparable
plans
340
in
the
area .
The
network
initial
oF p r i m a r y
secondary
and
care
hospitals.
system
plan
was " t o e s t a b l i s h
care
system
c 1 i n i c s . . .and
then
link
by n e g o t i a t i n g d i s c o u n t s
... I F UHCP d e m o n s t r a t e s
oF m a n a g e d c a r e
a private,
can c o n t r o l
- 104-
that
a
utilization
nonproFit
i t t oa
with
specialists
private1y-Funded
and keep t h e
�program
For
within
i t s budget,
p u b l i c Funds t o expand
uninsured
the
population.
able
the
to attract
plan
o
Private
Health
beneFits,
oF m i d - 1 9 9 0 ,
clinics,
the
attempted
which
would
primary
care
For
on
screens
care
i norder
coverage
were k e p t
have
cannot
solve
i t w o u l d be
t o sign
deductibles.
included
catastrophic
how t o m e e t h e i g h t
t o change
high-risk status
plan.
F o r example,
and weight
G hospitals,
physicians.
individuals
the
up F o r
l o w i n l i e u oF
increased
network
t o cover
t o shed
under
that
o u th i g h - r i s k i n d i v i d u a l s .
t o encourage
behavior
and ask
s e g m e n t s oF t h e
alone
oF e m p l o y e r s
oF c o v e r a g e
and two p r i m a r y
i t also
determined
number
UCHP i s n o t i n t e n d e d
and
t o other
initiatives
Care
a greater
i F t h e cost
increasing
t h e program
legislature
3 4 1
problem."
InterMountain
As
we c a n go t o t h e
criteria
illnesses,
They
their
have
health
a n d become
people
eligible
are counselled
a n d how t o c h a n g e
343
dietary
habits
to control
waiting
period,
covered
i nFull.
aFter
diabetes.
which
FiFty
time
percent
There
preexisting conditions are
oF c h a r g e s
are
paid For p r e e x i s t i n g c o n d i t i o n s during
. , 344
period.
UnFortunately,
the
wiFe
i sexperiencing
delivery!
not
that
3 6 7
a disease!
prenatal
startling
obvious
UCHP w i l l
n o tcover
At a time
i svery
t o discover
inFormation
For covered
that
an e n t i r e
that
Fact
when t h e e n t i r e
cost-eFFective
that
waiting
Family, i F
until
aFter
pregnancy i s
nation
i s recognizing
treatment,
i t is
this
plan
does n o t c o n s i d e r
and p r o v i d e
care
which
- 1 05-
services
one-year
a ' p r e e x i s t i n g pregnancy,'
I t i sa well-recognized
care
i s a twelve-month
such
i s so i m p o r t a n t t o
�an
infant's future health.
encourage
enrollees
services
before
And y e t ,
t o obtain
a medical
preventive
problem
to
"UCHP i s d e s i g n e d
and p r i m a r y
necessitates
care
expensive
hospitalization."358
UCHP d o e s c o v e r
laboratory
and x-ray
diagnostic
tests,
surgery
(except
nonsurgical,
services,
care
a l l o f t h e charges
services,
health
nonemergency
due t o a c c i d e n t a l
drugs,
immunizations,
services
outpatient
and m a t e r n i t y
and hospice
injuries.
care
minor
including
s e r v i c e s ) , and
ambulance
services,
There
for
services
outpatient services,
some home h e a l t h
prescription
p h y s i c i ans'
i n p a t i e n t care,
mental
for
and d e n t a l
i s a $5 c o p a y m e n t
and a $10 copayment f o r p r i m a r y
care
for
office
369
visits
which
include
well-baby
Premiums f o r a f a m i l y
per
of
month,
have been
through
lower
ten
premiums,
market
toward
independent
also
the
capable
would
percent
premium
higher
payment.
i f the
Plan
a t small
3 7 1
plan
an i n - h o u s e
monitoring
Also,
Premiums
h a d been
i t s plan
offered
t oprovide t h e
marketing
risk
businesses,
$176
t o c o n t r i b u t e a minimum
brokers.
used
exams.
be a p p r o x i m a t e l y
insurance
UCHP h a s p r o m o t e d
targeted
372
physical
arerequired
that
of closely
trends.
campaigns
of four
and employers
$50 p e r month
would
is
3 7 0
and a d u l t
staff
and d i r e c t l y
which
accessing
by d i r e c t - m a i l
with
few paid
advertisements.
The
April
and
Plan
1990,
had been
introduced
had e n r o l l e d
dependents.
December 1992,
3 7 3
with
150 s m a l l
The g o a l
businesses
i st o reach
a breakeven
6,000 a n d 7 , 0 0 0 m e m b e r s .
i n September
point
1989,
with
a n d by
800 employees
5,000 p e r s o n s by
estimated
T h e r e a r e 2D,000 s m a l l
-106-
t o be b e t w e e n
businesses i n
�374
the
area.
areas,
to
UCHP i s c o n s i d e r i n g
to S a l t
uninsured
State
Lake
County's
Medicaid
i n d i v i d u a l s , without
and l o c a l
governments
providing
health insurance
insurance
cost
similar
expanding
population,
to r u r a l
and
the involvement
directly
of e m p l o y e r s .
a r e a l s o r e s p o n s i b l e For
For government
For government
the plan
employees.
employees have
t o t h e n a t i o n as a w h o l e ,
so s t a t e
risen
Health
at a
agencies
rate
are well
35 4
aware
care
oF t h e e F F e c t s
costs
as a p e r c e n t
ments r o s e
cost
to
$2,836 For t h a t
the
by
5.1 p e r c e n t
per government
increased
oF h e a l t h c a r e
rose
same p e r i o d .
these
employer
employee.
That Figure
n e t p r o p - ^t s . 3 5 5
Fi
problems
must
which
proFessional
issues
continuing
Boards
than
oF M e d i c a l
medicine,
which
than
mirrors
those
Faced
$3,161 per
oF some
apparatus
Although
States
i s renewed
employers'
t o address
t h e AMA
require
upon
health
currently
registra-
evidence
oF
3 5 6
Examiners
p h y s i c i a n s who a r e a p p o i n t e d
an
administrative
with
beneFits
avoided...eFFective
regulations.
oF
body
are lower
26 p e r c e n t
being
education.
$1,200
oF P h y s i c i a n s .
a n n u a l l y ) which
medical
t h e average
oF h e a l t h
inFlation,
more e F F e c t i v e
are currently
govern-
approximately
The c o s t
represents
licenses to practice
(sometimes
and l o c a l
who, by 1 9 9 0 , was p a y i n g
establish
licensure
From
Figures
M o n i t o r i n g For L i c e n s u r e
States
oF s t a t e
Health
1982 t o 1989, w h i l e
employee
However,
the private
tion
From
a t a Far g r e a t e r r a t e
nation.
State
oF p a y r o l l
inFlation.
currently
are comprised
by t h e G o v e r n o r .
quasi-judicial
- 107-
mostly
The B o a r d i s
Functions,
subject
3 7 5
�to
court review,
state
and
governments.
i s under
3 5 7
The
the control
of branches
Board's Functions
establish
educational standards
standards
For
For
initial
c o n t i n u e d p r o F i c i e n c y and
are
of
to
licensure
and
proFessional
353
conduct.
the
Pursuant
Board
such
as
to standards
a d m i n i s t e r s peer
suspension,
states
permitted a
proFessional
tended
to
moral
3 6 0
1980s,
and
Although
this
corrected
area
not
the
oF
physicians
which
and
and
medical
a majority
(i.e.,
The
board
and
1.
education
2.
oF
oF
be
oF
connected
investigate
the
would
the basis
care
board
or
reForm.
be
a minority
physicians'
the
and
should
and
patient
during
oF
industrial
consumers
insurance
oF
boards
conduct
researched
should
only
a physician's
substandard
board
on
to the medical
monitor
to
1380,
broadened
knowledgeable
should
as
time, state
health
review
and
license
to criminal
scrutiny
part
care
late
to that
should
business
Additionally,
oF
as
a
challenged
quality
oF
law
health
p h y s i c i a n s which
renewal
Focus
as
oF
i n c l u d e s i n i t s membership
education
medicine.
For
to the
individuals
representatives
advocates).
t o be
conduct,
recommends a c t i o n s
that
activities
where necessary
established
and
Up
state
A state-Funded
complex,
license
359
policing
turpitude
care.
to note
incompetence!
limit
proFessional
r e v o c a t i o n or reFusal
practice medicine.
I t is extraordinary
15
review
oF
and
group
consumer
continuing
practice
establish
require,
as
prerequisites
completion
oF
valid
oF
regulations
to
licensure:
annual
prooF
oF
continuing
coursework;
diFFerent
Forms o r
g r a d a t i o n s oF
- 108-
licensure
For
medical
�diFFerent
l e v e l s of
3.
testing
The
American
voluntary
withdrawal.
it
For
the
From
is against
k n o w s he
to admit
also
a code
subject
oF
health
oF
their
a
Far
curable
then
health
oF
disease.
To
establishes
and
not
oFten
are
tested
For
disease
should
permitted
a double
have even
All
not
merely
on
no
For
ThereFore,
only
income
the
oF
selF-
For
liFe,
strength
oF
withdrawal.
knowledge
oF
their
about
IF
they
Fewer
AIDs,
but
the'
be
placed
withdrawal'
and
increase
i t i s so
would
a
exalted
For
a
deadly
unrealistic,
i s a mere c o n t i n u a t i o n
problem.
Not
dealing
malpractice
unlikely,
contract
qualms about
the
as
having
with
suits
oF,
the
stemming
providers
HIV
not
case,
i n the
is
is
i s also
in that
to p o l i c e themselves
standard,
will
than
not
voluntary
t o , the
t u b e r c u l o s i s , which
i s conducted
annua 1 1 y .
t
virus.
exceptional
to
damaging
makes a l l p a t i e n t s w o n d e r
workers
'request
that
HIV
p a t i e n t s w i t h no
testing
being
procedures
i s tantamount
oneselF
ostracism
recommending
invasive
proFessiona11y
deprive
Since
illness.
claim,
should
care
oF
recommends v o l u n t a r y
dangerous
eFFectively
this
to
skills;
physicians.
a solution
problem
From
own
disease.
position
to
leaves
workers
less
and
c a r r y i n g the
c o n d i t i o n , and
Social
only
oneselF
withdrawal
physician's
perFormance
p r e s t i g e , an
e t h i c s which
Voluntary
to
surgical
p r a c t i c e oF
is HIV-positive
human n a t u r e
esteem , p r o F e s s i o n a l
but
the
and
virus.
Association's
I t is personally
individual
experience,
AIDs
Medical
withdrawal
when a p h y s i c i a n
any
education,
virus,
so
then
themselves
they
tested
,
p a t i e n t s should
be
tested, a l l health
-103-
care
workers
�should
be t e s t e d .
testing
i s not r e l i a b l e ,
negatives
False
occurring
test
provide
tion
results
a l l health
care
positives
and
laboratory
False
Insurance
Some oF
an
the disease
s i x months
workers
False
aFter
does
t o be
tested
many
catch
not
i t s introduc-
the p o s s i b i l i t y
work, e l i m i n a t i n g
that
will
oF
result
the
in
False
negatives.
Commissions.
the Functions
to protect
and
that
Testing annually w i l l
i s even
oF
r e g u l a t e and s u p e r v i s e
order
excuse t o c o n t e n d
positives
since
until
There
more c a r e F u l
False
especially
t h e body.
requiring
..to
with
Frequently.
results,
positive
into
State
I t i s not a viable
a State
insurance
the i n t e r e s t s
..to
provide
..to
promulgate
..to
r e s o l v e or prosecute
..to
i s s u e , renew,
Insurance
oF
insurance
rate
insurance
laws,
the
transactions in
public;
structure;
rules,
violations
withhold,
industry
Commission a r e :
revoke,
and r e g u 1 a t i o n s ;
oF
insurance
or suspend
laws;
and,
the license
oF
36 1
a domestic
The
insurance
company.
t h e above
Functions
and e F F e c t i v e
rates
p u r p o s e oF
i s t o ensure e q u i t a b l e
insurance
c o v e r a g e For t h e i n s u r e d
policy362
holder
It
in return
For premium
i s i n the public
payments
interest
power
t
For t h e i n s u r a n c e
For each
state
company.
to retain
the
t o r e g u l a t e t h e k i n d a n d c h a r a c t e r oF i n s u r a n c e c o n t r a c t s
363
t h a t may be F o r m e d .
The l e g i s l a t u r e may r e q u i r e i n s u r e r s t o
use a s t a n d a r d i z e d p o l i c y o r r e q u i r e t h a t a p o l i c y must c o n t a i n
. .
.
. .
364
or m u s t e x c l u d e c e r t a i n p r o v i s i o n s .
In conFormity w i t h these powers, i t appears reasonable t o
- 1 10-
�consider
that
states
insurers
From
imposing
New
Federal
policies.
one
t o purchase
ability
to revoke
tion
bills
oF
payment
oF
renewal
dates
in
is
would
or
the
assistance to
industry,
pressures
on
any
laws
health
will
severely c u r t a i l
d e c l i n e renewal
The
only
this
oF
1991
oF
in the
oF
the
impact
and
new
Further Federal
on
on
oF
health
event
oF
non-
the r e t e n t i o n
oF
resulting
goals.
state
legislators
insurers'
reasons
a tradition,
Insurance
35
every-
permit cancella-
intent,
perpetuate
reForm
For
majority
in Fall
oF
insurance
require
Legislators,
N a t i o n a l A s s o c i a t i o n oF
insurance,
opposes
will
policy
health
i s comprised
insurance
group
and
N a t i o n a l ConFerence
Commissioners,
provide
merely
on
reForm
I n view
oF
with
dates
i n Congress
premiums.
aFFiliated
t h e power t o p r o h i b i t a l l
experiences.
insurance
a misstatement
The
health
policies
pending
a health
have
renewal
insurance,
high-cost/high-risk
reForm
would
which
Insurance
groups
which
work
subjects concerning
constituents,
trends
i n the
regulation
oF
the
consumer
industry.
the
to
The
insurance
industry.
Insurers
insurance
insurers
commission
over
considering
be
about
Health
h a v e b e e n r e g u l a t e d by
those
individual
commissions
are
the consumers
they
are
expected
the p o s s i b i l i t y
that
the
Federal
to take
Insurance
responded
and
each
hold
oF
the reins,
A s s o c i a t i o n oF
the
America,
vice
known
state's
to
Favor
t o champion.
government
may
p r e s i d e n t oF
Linda
5.
Kenckes,
with:
"We
h o p e t h e i n t r o d u c t i o n oF
encourage s t a t e s t o a c t next year
For F e d e r a l
legislation"
- 1 11-
these b i l l s
will
t o n e g a t e t h e need
In
now
the
�and
noted also
that
300
commercial
insurers--wauld
the
type of standards proposed
to
companion
25,
1991,
bills
by
the group—which
introduced
Senator
Lloyd
represents
prefer
by
t o see
t h e two
jointly
Bentsen,
more
states
adopt
b i l l s , r e f e r r i n g
t o Congress
and
than
on
October
R e p r e s e n t a t i v e Dan
Rostenkowski .
Blue
result
Shield
of Federal l i m i t s
increase
"If
Cross-Blue
you
the cost
reduce
maintained that
on
variation
"the
i n premiums would
of insurance f o r healthy,
rates
people
go
Health
I n s u r a n c e as
for high-risk
inevitable
low-risk
people, rates
be
to
groups."
f o r healthy
up."
a State-Regulated Public
Utility.
"Public u t i l i t i e s are those
facilities
which are necessary f o r the maintenance of l i f e
and o c c u p a t i o n o f t h e r e s i d e n t s , t h e s e r v i c e s
o f w h i c h a r e a v a i l a b l e t o a l l , and w i t h r e s p e c t ^ ^ ^
t o w h i c h a l l h a v e t h e r i g h t t o demand s e r v i c e . "
If
into
health
public
heirarchy
delegate
local
health
would
power
government
and
would
The
public
would
use
compensation
insurers
have
state
regulate
Legislation
for
industry
set rates
would
corporation
a different
and
under
the authority
intrastate,
interstate
and
would
the fourteenth
are undoubtedly
involved
- 1 12-
to regulate
have
the
the
and
the
power
federal
commerce.
considered a taking
insurers
commissioner,
would
imposing u t i l i t y 'status
be
S t a t e s would
utility
legislature
reconfigured
authoritarian
behavior.
to the public health
locally.
regulate
utilities,
oversee
governments
utility
to
i n s u r a n c e c o m p a n i e s w e r e t o be
have
on
a
private
of p r i v a t e
t o Pe
amendment.
property
provided
just
Although
i n a business which
is
3 6 7
�inherently
impose
utility
insurers
status
reFuse
providing
ability
and
i n the public
that
public
are brought
public
service
whom s u c h
to
those
its
oF t h e p u b l i c .
and
i s to provide
health
utilities,
stockholders,
Courts
return'
7
0
yields
no m o r e
plant,
provide
assure
pay a f a i r
Courts
profit
have
a utility
held
rate
373
attractive
to
investors.
individuals
a public
impair,
properly."
do e a r n
would
yield
service
the public
a
their
IF health
oF
with
must
i t s e l F oF, o r
that
3 7 1
proFit
primary
insurers
were
n o t be t o t h e i r
utilities
To a c h i e v e
"a s y s t e m
i s Fairly
fund
that
earn
that
renders
'Fair
return,
that
t o maintain
expenses, t o
t h e payment
a rate
a
oF c h a r g e s
and o p e r a t i n g
for
Fair
requisite
t o t h e owners o f t h e
also
i f that
duty
oF t h e
interests
interests
service.
charges
sinking
the private
deprive
t o impose
t o pay F i x e d
consumers
policyholders.
investment.
a suitable
with
private
t h e i r primary
than
t o protect
and b o n d h o l d e r s ,
the public
income
has t h e
"When t h e i n t e r e s t s
corporations
t o stock-
are permitted
government
i n order
t o serve
service
generally
r e s p o n s i b i l i t y oF
Accordingly,
but to their
on t h e i r
utilities
for
such
by c o n t r a c t
public
are responsive
duty
to
3
However, i F
o r oF p r i v a t e
power t o p e r f o r m i t s d u t y
Although
the
conFlict
deal,
work t o
interest.
corporations
cannot
then
t o note t h a t
into
companies
corporation
care,
For t h e p u b l i c
cannot
corporations.
industry
i s interesting
Fact
to the social
t o health
t o regulate
It
on s u c h
t o respond
access
provide
interest, that
o f d e b t s , and
3 7
property."' ^
of return
the u t i l i t y ' s
i ssufficient
securities
�The d i f f e r e n c e
insurance
"no
utility
would
constitutional
anticipated
those
who i n v e s t
providing
whether
That
they
insurance
but
spector
appealing
they
surely
i n t h e next
oppose
being
may make c u r r e n t l y
t o accept
considered
pending
prospect
t o i n s u r e r s from
that
to
a customer
which
i s liable
debate
such
a
service
Health
utility,
legislation
more
as t h e l e s s e r o f t w o e v i l s .
industry
utility
would
two y e a r s .
i s pro-insurance
A public
high
t h e business
to provide
S.1227, h o w e v e r ,
of evil
have
Indeed,
that
undertaken
to the public
adamantly
t o them
3 7 4
know a n d u n d e r s t a n d
policies,
may be d e c i d e d
would
would
as a r e r e a l i z e d o r
enterprises..."
companies have
have a d u t y
insurers
such
utility
of the t e r r i t o r y .
insurance
question
that
profitable
inutilities
i n s u r e r s and a h e a l t h
the public
to profits
are not part
Although
private
be t h a t
right
i n highly
divididends
of
between
so t h e r e
i s no
quarter.
has c o n t r a c t e d t o supply
f o r damages f o r b r e a c h
service
o f duty t o
375
perform
that
refusing
also
contract.
A h e a l t h insurance
t o p a y b e n e f i t s when
find
itselF
liable
utility
premiums have been
paid
would
i n damages.
INSURANCE COMPANIES
Brief
Hi s t o r y .
In
Boston
1847, t h e M a s s a c h u s e t t s
became
the f i r s t
Sy 1 8 5 0 , t h e f i r s t
in
Massachusetts,
insurer
insurance
Rhode
Health
Insurance
t o issue
'sickness'
supervisory boards
Island,
Company o f
New H a m p s h i r e ,
were
insurance.
initiated
and Vermont.
�Between
1890
oF
selected diseases
only
By
First
and
1910,
group
In
(which
health
health
the
and
ing
1938,
surgical
World
health
By
War
employee
3 7 6
i t s employees.
oF
Insurance
Commissioners
law
Insurance
which
attempted
to
was
assure
'operating conditions'
of
the
3 7 7
caused
expansion
oF
hospitals
insurance
and
the
coverage,
Cross
p l a n was
initiated
private
insurers
were
and
i n Sacramento,
oFFering
plans
which
expenses.
I I and
insurance
For
Blue
coverage
a l l diseases.
P r o v i s i o n s Law
the Depression
citywide
CaliFornia.
covered
For
model
i n the
t o demand
From
N a t i o n a l A s s o c i a t i o n oF
contract."
1930s,
public
First
policy
The
Fairness
For
grew
S Company, I n c . , e s t a b l i s h e d t h e
a Standard
most s t a t e s .
the
general
Ward
the
draFted
insurance
In
t o coverage
insurance
k n o w n as
Commissioners
''uniFormity
beneFits
the National Convention
i s now
by
disability
Montgomery
1912,
adopted
1900,
the r e s u l t a n t
"...an
wage F r e e z e s
i m p o r t a n t component
beneFits."
The
term
of
'wages'
made
group
collective
was
bargain-
determined
to
379
include
both
pensions
and
insurance
beneFits.
380
19G5
brought
Industry
Insurance
Medicare
Power
Insurers
only
those
are
and
beneFits
to the
nation.
laws
are p e r m i t t e d
Base.
organized
powers which
Medicaid
under
are
state
conFerred
and
e x p r e s s l y or
impliedly
38 1
by
the
legislature.
A state
regulate
insurers,
including
regulate
relations
between
ing
to the p u b l i c
has
a sovereign
t h e power
the
382
insurer
interest.
- I ' 5
1
duty
to establish
and
the
to
and
insured
accord-
�CLAIMS PAYMENTS BY TYPE OF INSURER: 1950-1988
YEAR
INSURANCE COMPANIES
BLUE CROSS-BLUE SHIELD
SELF-INSURED & HMO PLANS
Billions Of Dollars
TOTAL
1950
0.8
0.6
NA
1J
1955
1.8
1.4
NA
3.1
1960
3.0
2.6
NA
5.7
1965
5.2
4.5
NA
9.6
1970
9.1
8.1
NA
17.2
1975
16.5
16.9
NA
32.1
1980
37.0
25.5
16.2
76.3
1981
41.6
29.2
18.9
85.9
1982
49.2
32.2
21.6
97.1
1983
51.7
34.4
24.1
104.1
1984
56.0
35.7
26.1
107.5
1985
60.0
37.5
32.5
117.6
1986
64.3
40.6
36.8
128.5
1987
72.5
44.5
56.5
151.7
1988
83.0
48.2
62.8
171.1
souRcr- SOURCr: HOOK OF HEALTH INSUKANCL DATA, I ' m 1 KiAL II I INSURANCE ASSOCIATION Ol" AMERICA.
91-1
The Universal
nllhcare
Almanac
~ible 6.3
�HEALTH INSURANCE
KEY HEALTH INSURANCE STATISTICS:
1984
1985
1984-1988
1986
%CHANGE
1987-1988
1987
1988
240.5
208.7
181.1
146.7
31.8
243.1
211.6
188.4
153.3
31.5
1.1
1.4
4.0
4.2
-.01
MILUONS
PERSONS WITH AND WITHOUT HEALTH CARE COVERAGE
Total Population
233.4
Persons with Public and Private Coverage
202.1
Private Health Insurance
177.4
Employer Related
144.3
Persons without Coverage
31.3
235.5
204.2
180.1
147.1
31.3
238.2
204.7
180.1
145.8
33.5
BILLIONS
PRIVATE HEALTH INSURANCE CLAIMS PAYMENTS
Total
Insurance Companies
Blue Cross/Blue Shield
Other Plans'
5117.6
59.9
37.5
32.5
S128.5
64.3
40.6
36.8
5151.7
72.5
44.5
56.5
5171.1
83.0
48.2
62.8
12.8
14.5
8.3
11.2
PRIVATE HEALTH INSURANCE PAYMENT BY CATEGORY OF SERVICE
Total
S12I.6
S 133.2
Hospital Care
56.9
59.3
Physicians' Servires
30.4
33.7
Dentists' Services
8.5
9.1
Other Professional Services
46
5.2
Drugs and Medical Nondurables
4.7
5.2
Vision Products and Other Medical Durables
U<.
0.7
Nursing Home Care
03
0.3
Program Administration and Cost of Private Insurance
17.4
20.0
5142.6
63.5
38.3
9.9
6.8
6.0
0.8
0.3
17.7
5155.8
69.3
43.9
S174.6
75.0
50.0
12.4
8.3
7.7
1.0
0.5
19.7
12.1
8.2
139
12.7
18.6
11.6
11.1
25.0
20.1
$107.5
55.9
35.7
26.0
2
n.o
7.0
6.9
0.9
04
16.4
'Olher plan* include i«lf insured plans, leK adminiMrred plum, pl.ins cmplnyiiig Ihird p.my .idminiMriiinrs .ind hciilih in.nniin.imL- organiulions.
Oihcr prolcuion.il services include lees lor chiropraciors, podialnsis. lAythnlognls, ihcrnpiM*, audmlogiMs, npiomcinsis, ponnhlc < r;iv suppliers, ambulance service suppliers, and KSKI) Luihiu-v
SOURCE: HEALTH INSURANCE ASSOCIATION OK AMI-RICA
9
r
'
_
.
Reprinted:
...
"The
Univr
( P h o e n i x:
., _
,
,
^1 H e a l t h c a r e
Almanac"
i l v e r S Cherner, L t d . , 1991)
TaWe 6 9
�An
(is)
i n s u r e r ' s c h a r t e r i s "merely
not r e s t r i c t i v e
However,
a c h a r t e r may
permitting
which
of a general
engagement
liait
enabling
power t o e f f e c t
t h e c o r p o r a t i o n by
in a particular
i s not reasonably
i n c h a r a c t e r and
incidental
contracts..."
not expressly
transaction
or
t o the purposes
business
f o r which i t
was i n c o r p o r a t e d .
There
and
are three types
mixed.
holders
I n a stock
may
earnings
invest
insurance
3
by t h e b o a r d
of d i r e c t o r s . " ^
stock
o f an i n s u r a n c e
payment
of a l l the debts
not a trust
c o r p o r a t i o n i n which
mutual
stock-
distribution
of
as b e t w e e n s t o c k h o l d e r s a n d p o l i c y h o l d e r s i s
capital
and
companies--stock,
i n the corporation, "...the
or p r o f i t s
determined
of insurance
fund
and
simply
4
However,
company...is a t r u s t
legal
liabilities
or even p r i m a r i l y
(T)he
fund
of the
f o r the
company,
f o r t h e payment
385
of
obligations
growing
out of contracts of
Although
p o l i c y h o l d e r s may
in
insurer's profits,
their
shareholders
share--according
they
to their
are not considered
385
policies-t o be
i n the corporation.
Premiums
unexpired
insurance."
a r e r e c e i v e d and r e t a i n e d
risks
and
occur
are accounted
risks
are barred
losses which
387
for.
from
by t h e i n s u r e r
are reasonably
Sums e q u i v a l e n t t o
inclusion
as p r o f i t s
until a l l
expected
to
unexpired
for distribution
dividends to shareholders.
"Upon no i m a g i n a b l e h y p o t h e s i s
i s i t p r o p e r t o t r e a t t h e w h o l e amount o f t h e premiums
o b t a i n e d f r o m r i s k s t h a t a r e s t i l l p e n d i n g as p r o f i t s f o r
388
distribution
to stockholders."
Insurers'
insureds
recent
i s an a t t e m p t
p r o p e n s i t y t o termirvte
t o rescue
funds
- - 151
from
high-risk
the unexpired
as
�risk
account
for
distribution
would
not
there
would
of
care
with
be
parties,
equitable
is
the
no
insurance
receive
the
or
route
and
which
of
be
dividends,
to
found
the
must
than
problem
be
of
investment,
Nevertheless,
risks
past.
which
less
adequate
investors
Without
become
health
benefit a l l
With
had
must
With
will
consumer/insured.
the
Without
uninsurable
only
achieve
s o l u t i o n to
form
companies.
belonging
m e t h o d s must
dividends.
companies.
non-renewals,
including
will
i n the
in insurance
a past,
reform,
party
profits
invest
terminations,
words
d i s t r i b u t i o n as
reform,
been
each
hoped,
uninsureds
and
but
an
uninsurables
followed.
"The c o n t r a c t o f i n s u r a n c e w i t h a m u t u a l
company i s a p e c u l i a r c o n t r a c t , f o r a l t h o u g h i n
t e r m s a c o n t r a c t w i t h t h e company, i t i s i n
s u b s t a n c e a c o n t r a c t b e t w e e n t h e i n s u r e d and a l l
o t h e r members of t h e company.
Members o f m u t u a l
i n s u r a n c e companies s u s t a i n a dual r e l a t i o n s h i p
i n t e r s e , and t h e i r i n t e r e s t s a r e t w o f o l d :
they
a r e b o t h i n s u r e r s and i n s u r e d , who c o n t r i b u t e t o
t h e p a y m e n t of l o s s e s , a r e e n t i t l e d t o h a v e
p a y m e n t made i n c a s e o f l o s s o r d e a t h , and a r e
e n t i t l e d p r o p o r t i o n a l l y t o t h e p r o f i t s made by
t h e company.
E a c h p e r s o n i n s u r e d i n s u c h a company
t h u s becomes s u b j e c t t o t h e same o b l i g a t i o n s t o w a r d
t h e o t h e r members t h a t t h e y b e a r t o w a r d h i m . "
3 8 9
The
of
above-quoted
a mutual
relative
insurance
to health
insurance
mutual
insurance
cost
may
contractual
company
care
might
i s appealing
reform.
be
control.
of
The
unnecessary
unnecessary
claims.
health
The
The
to
structure
dual
of
care
and
liability
companies
is joint
and
eliminate
o f members
- 1 1 7-
several.
the
to
health
insurer/insured
f o r insureds
390
insurance
of
benefit
nature
members
contemplate
significant
provide a greater incentive
seeking
r e l a t i o n s h i p between
to refrain
those
of
mutual
from
�Most
to
an
or
even
people
unknown
resist
quantity.
old
i s retained
new
concept
majority
from
and
expanding
life
about
minor
incorporated i n with
never
i n v o l v e d i n and
the concept
been
to different
Insurance
Companies'
1988,
Financial
the l a t e s t
year
quo
process
changes, t h e r e i s
i f some o f t h e
accepted
affected
o f t h e mutual
interest
any
t h e new.
i n s u r e r s t o h e a l t h i n s u r e r s may
palatable
In
the status
o f s u c c e s s f u l change
has h i s t o r i c a l l y
of those
preferring
In attempting to reform
i n attempting to bring
a greater possibility
Thus,
change,
by
An
entirely
by t h e
those
changes.
insurance
render
company
the idea
more
groups.
Considerations.
f o r which
data
i s available:
391
.. h e a l t h i n s u r e r s e a r n e d
.. $ 8 7 . 6
billion
premiums,
which
of that
$98.2
amount
i s 89 p e r c e n t
.. 52
percent
o f t h e $87.6
group
arrangements;
billion
was
i n premiums;
derived from
o f t h e premiums
billion
was
group
policy
collected;
d e r i v e d from
self-insured
and,
393
.. $ 1 0 . 6
The
expenditures
disposable
.7 p e r c e n t
individual
disclosed
over
$2,124.
family
f o r both
This
after
policy
figure
taxes,
premiums.
private
and
represents
and
i s an
public
6
percent
increase
employers
o f $119
Insurance
paid
A s s o c i a t i o n of America
an a v e r a g e m o n t h l y
for individual,
and $268
premium
payment
f o r family
395
coverage.
Organization
of
1987.
by t h e H e a l t h
that
employee
was
and
f o r 1988
p e r s o n a l income
394
A survey
per
from
p e r capita e x p e n d i t u r e s
health
of
billion
Dr. R o n a l d
Bronow,
of Physicians
President
Who C a r e
- 1 18-
of the National
disputes
those
figures,
�contending
that
some e m p l o y e r s
pay $600 p e r month p e r
.
396
employee.
Also
paid
during
1988, p r i v a t e
and c o m m e r c i a l
health
insurers
a total of:
397
.. $ 1 7 1 . 1 b i l l i o n
.. h o s p i t a l ,
For medical
surgical,
care
physician,
and d i s a b i l i t y
and m a j o r
claims;
medical
insurance
398
claims
accounted
.. B l u e
For $63.3
Cross-Blue
Shield
billion
paid
oF t h a t
amount;
$48.2 b i l l i o n
i n claims;
and,
399
.. s e l F - i n s u r e d
Another
was
the
Health
conducted
insurers.
group
o u t $62.8 b i l l i o n
Association
1 9 3 9 oF t w e n t y
insurers
health
individual
The
Insurance
i n July
These
total
total
a n d HMOs p a i d
receive
insurance
health
health
55 p e r c e n t
p r e m i u m s a n d 35 p e r c e n t
insurance
premiums
a commercial
oF 4.5 p e r c e n t
For group
insurance,
experienced
survey
commercial
approximately
disclosed
loss
oF A m e r i c a
leading
study
writing
i n claims.
paid.
insurer
4
0
health
oF t h e
0
underwriting
a n d an 8.4 p e r c e n t
For i n d i v i d u a l
oF
loss
under-
insurance
policy
40 1
claims.
L o s s e s s u s t a i n e d i n 1988 by 6 4 6 c o m m e r c i a l i n s u r e r s
402
t o t a l e d $3,780.9 m i l l i o n .
H o w e v e r , F o r t h a t same y e a r , 43
B l u e C r o s s - B l u e S h i e l d o r g a n i z a t i o n s e x p e r i e n c e d a g a i n oF
403
$1,086.7 m i l l i o n .
warrants
study
concessions)
That
disparity
b e F o r e any c o n c e s s i o n s
are accorded
t o those
i n Financial
(especially
commercial
success
legislative
insurers
claiming
hardship.
0
404
National
The
Health
health
For
care
a total
health
expenditures
Care F i n a n c i n g
spending
rose
i n 1988 w e r e $ 5 3 9 . 9
Administration
estimates
t o 12.2 p e r c e n t
oF $ 6 6 6 . 2 b i l l i o n .
Per c a p i t a
- 1 1 9-
oF GNP
health
that
during
billion.
total
1990
expenditures
�were
$2,566.
Insurers
loss
state
that
they
o f 4.6 p e r c e n t
From
group
percent
underwriting
a r e e x p e r i e n c i n g an
l o s s From
health
underwriting
i n s u r a n c e , a n d an 3.4
individual
health
insurance
405
policies.
provides
1.
and
thus
The H e a l t h
three primary
increases
Insurance
reasons
i n coverage
greater increases
A s s o c i a t i o n oF
America
For t h e l o s s e s .
raised
levels
oF e x p e c t a t i o n ,
i n demand;
2.
i n c e n t i v e s For p r o v i d e r s and consumers have:
. . e n c o u r a g e d h i g h l e v e l s oF u t i l i z a t i o n ;
..discouraged cost
consciousness;
. . c r e a t e d t o l e r a n c e For i n e F F i c i e n c y and p r o v i s i o n
oF m a r g i n a l l y u s e F u l c a r e .
3.
new
improvements
treating
t e c h n o l o g i e s have
along
insurance
increases
companies r a i s e d
h i g h e r d e d u c t i b l e s over
nevertheless,
i n quality
i n t h e c o s t oF
percent
that
i t suFFered
Metropolitan
premiums w i t h
rise
i n premium
income
an u n d e r w r i t i n g
LiFe,
however,
a proFit
top ten liFe
Prudential
r a t e s and
l o s s oF o v e r
$140
and h e a l t h
experienced
i n 1988 a t t h e same
experienced
oF o v e r
premium
t h e 1988-1330 p e r i o d and a r e ,
experiencing losses.
22.5
The
substantial
resulted
illness.
Many h e a l t h
imposed
with
usually
$190
rise i n
million.
companies
nation are:
P r u d e n t i a l I n s u r a n c e Company oF A m e r i c a
M e t r o p o l i t a n L i F e I n s u r a n c e Company
American Family LiFe
M u t u a l oF Omaha I n s u r a n c e Company
Connecticut General LiFe Insurance
H e a l t h Care S e r v i c e C o r p p r a t i o n
A e t n a L i F e I n s u r a n c e Company
P r i n c i p a l Mutual LiFe
T r a v e l e r s I n s u r a n c e Company
C o n t i n e n t a l Assurance Company. ^
4 0
- 120-
time
million.
a 19.3 p e r c e n t
407
insurance
a
i nt h e
�In
and
efforts
t o maintain
nation's
own
up
top
t o slow
their
health
health
following
been
share
o f the
market,
stable
cost
several
increases
of the
t o introduce
necessary
smaller
resources
t o achieve
care
have a t t e m p t e d
prohibit
Even t h e
suffficient
of health
Economies o f s c a l e
networks
suit.
rate
insurers
HMOs a n d PPOs.
these
the
for
health
o f Aetna
sources
their
setting
insurers
from
a n d CIGNA h a v e n o t
of profit
from
their
409
HMO a n d PPO n e t w o r k s .
Health Maintenance
Organizations.
Health
in
the
Organizations
Maintenance
Organizations
1930s a n d d i d n o t
1 9 7 0 s when h e a l t h
4 1 0
increase.
ability
care
Their
and P r e f e r r e d
experience
costs
success
t o manage c a r e
Provider
(HMOs] w e r e
first
a rapid growth
across
the
appears
nation
t o derive
f o r economies
formed
until the
started a rapid
mainly
of service,
from
their
and p r o v i d e
411
reduced
hospital rates.
HMOs a r e o r g a n i z e d
either
employees o f the
services
through
physicians
either
with
Medicaid
by
the
By
1989,
the
encouraged
late
were
their
Physicians
their
with
Some
the
o n e HMO.
so s u c c e s s f u l
Provider
or with
and e n r o l l m e n t
4 12
people.
t o two m i l l i o n
13 p e r c e n t o f
48 s t a t e s .
Organizations
- 12 1-
contract
t h a t Medicare and
beneficiaries to join
covering
HMO.
HMOs w i l l
of physicians,
close
may b e
o r may p r o v i d e
BOO HMOs h a d e n r o l l e d m o r e t h a n
population
Preferred
than
group
19B0s h a d r e a c h e d
nearly
American
negotiated
more
an e s t a b l i s h e d
individual
physicians.
HMOs' c o s t e f f o r t s
ways.
organization,
contracts
contract
with
i nvarious
(PPOs) w e r e
a
later
�development,
between
appearing
i n t h e 1980s.
HMOs a n d PPOs i s t h a t
incursion
The m o s t
the latter
oF a p e n a l t y - - g r e a t e r
patient
notable
diFFerence
p e r m i t s«-- a 1 be i t w i t h t h e
Freedom
i n the selection
413
oF
a personal
physician.
I n Missouri,
does e x i s t and i s s t r o n g l y
Gephardt,
his
Full
" I t i s unFair
Freedom
physician,
pharmacist,
an
oF a n y d u l y
chiropractor,
414
care
Richard
insured
licensed
dentist,
or p o d i a t r i s t . "
M o s t PPOs a r e o r g a n i z e d
caregivers
by i t s U.S. S e n a t o r
i n theselection
optometrist,
pharmacy
managed
d i s c r i m i n a t i o n t o not permit
oF c h o i c e
surgeon,
advocated
where
t o provide
by i n s u r e r s
service
who c o n t r a c t
with
according
t o a negotiated
Fee
r
4 1-
schedule.
It
Providers
i s conceivable
a r e chosen
that
based
on d e m o n s t r a t e d
t h e d e F i n i t i o n oF ' e F F i c i e n c y '
eFFiciency.
could
work
t o t h e d e t r i m e n t oF a p a t i e n t b e c a u s e i t r e F e r s t o c o s t e F F i c i e n c y
p r i m a r i l y For t h e o r g a n i z a t i o n , and s e c o n d a r i l y t o t h e p a t i e n t .
The p r i m e e x a m p l e oF s u c h d e t r i m e n t a l e F F i c i e n c y i s t h e o u t c o m e
ex p e r i e n c e d b y t h e p l a i n t i F F i n W i. c k 1 i n e v . S t a t e 41B
Antitrust
Exemption.
4 17
The
McCarran-Ferguson
limited
exemption
Fixing,
agreements
agreements.
protection
4 1 8
From F e d e r a l
on t e r m s
Protection
uniForm
setting.
the
the insurance
'business
antitrust
o f coverage,
i s evidence
boycotting.
regulate
grants
The A c t d o e s n o t p r o v i d e
i F there
rate
Act
oF
laws
states
industry,
insurance.
- 122-
such
and o t h e r
insurers
oF c o e r c i o n ,
was a c c o r d e d
Because
insurance
insurers
companies
as p r i c e
horizontal
with
i n t i m i d a t i o n , or
to Facilitate
r e t a i n t h e power t o
Federal
laws
do n o t a p p l y t o
�The
McCarran-Ferguson
(a)
therein
which
The
business
shall
relate
(b)
be
oF
No A c t
oF C o n g r e s s
supersede
purpose
oF
regulating
Sherman
any
Nothing
Act
or
the
taxation
be
business
contained
every
oF
person
by
oF
oF
any
t o any
States
such
business.
to
invalidate,
State
For
the
i n s u r a n c e u n l e s s
to the business
in this
engaged
several
construed
enacted
relates
inapplicable
and
laws
shall
law
the
speciFically
(c)
insurance
to the r e g u l a t i o n
or
Act
provides:
subject to the
impair,
such
Act
Act
shall
agreement
oF
insurance..."
render
the...
to b o y c o t t , coerce,
or
422
intimidate,
or
Insurers
From
a c t oF
b o y c o t t , c o e r c i o n , or
must meet t h r e e r e q u i r e m e n t s
the
McCarran-Ferguson
1.
Their challenged
boundaries
oF
insurance.'
what would
The
cooperative
(a)
eFForts
that
would
risks
beneFit
oF
Cb]
insured
includes
The
primary
to
oF
and
(policy]
oF
the
the
'business
oF
i s considered
concern
From
the
to include
policy
and
be
the
cooperative
antitrust
i t would
inFormed
the
in enacting
insure that
relationship
core
type
interpretation,
contractual
insurance
intra-industry
i s the
the
considered
oF
immunity,
i n an
within
beneFit
exemption:
be
was
exempt
w i t h o u t such
underwrite
the
be
Act
to
eFForts.
Congress'
McCarran-Ferguson
i n order
a c t i o n s must F a l l
business
ratemaking
intimidation."
laws.
too
ratemaking
They b e l i e v e d
diFFicult
r e s p o n s i b l e way
423
to
without
cooperation.
between
business
oF
the
insurer
insurance,
which i s issued,
424
enForcement.
the
which
i t s reliability,
ThereFore,
agreement i s d e F i n i t e l y
- 123-
and
although
within
the
the
�definition
of the business
ments
c o r p o r a t i o n s other than
to
with
l i e within
that
of
t h e realm
business
i s collateral
a
agree-
are not considered
of insurance
and concerns
merely
because
t h e 'business
,425
companies.'
(c)
the
insurers
of t h e business
.
insurance
of insurance, contractual
One o f t h e i n d i s p e n s a b l e c h a r a c t e r i s t i c s o f
business
of insurance
policy-holder's
i s the spreading
and u n d e r w r i t i n g o f
risk.
2.
Those
same a c t i o n s m u s t be r e g u l a t e d b y s t a t e l a w ;
3.
Those
same a c t i o n s c a n n o t
coercion,
or
be c o n s i d e r e d
boycotting,
intimidation.
Efforts
by i n s u r e r s
t o c o n t a i n or reduce
costs arenot
425
protected
by M c C a r r a n - F e r g u s o n
"...(E)ven
business
though
an a l l e g e d
from
antitrust
restraint
falls
scrutiny.
within the
t h e exemption w i l l apply only i f t h e
•427
state regulates the a c t i v i t y . "
T h e r e a r e some who c o n s i d e r
t h e M c C a r r a n e x e m p t i o n t o be "a s t a t e - a c t i o n e x e m p t i o n f o r a
428
p a r t i c u l a r l y favored state-regulated industry."
In
Act
of insurance,
March
antitrust
Aetna
and June
actions against Hartford,
Insurance
Companies
collusion
t o boycot
insurance
coverage
legal
o f 1988, e i g h t e e n s t a t e s
specific
affected
f e e s , and l o n g - t a i l
during
'states
which
c l a i m s may
Massachusetts,
New
York,
Ohio,
types
Allstate,
reinsurers
(i.e.,
be made a f t e r
Colorado,
Michigan,
Pennsylvania,
- 124-
CIGNA, a n d
coverage.
charges,
the length
an i n j u r y ) .
California,
Minnesota,
Sherman
alleging
of insurance
was f o r p o l l u t i o n
claims
were Alabama, A l a s k a ,
Maryland,
Jersey,
and t h e i r
brought
4
high
of time
2
9
The
Connecticut,
Montana,
Washington,
The
West
New
�430
Virginia,
and W i s c o n s i n .
liability
and n o t h e a l t h
the
expansiveness
industry
care
of a c t i o n s taken
i n the health
boycotting
coverage
of high-risk
(was c a u s e d
involved
against t h e insurance
field;
which
are also
i.e., refusing/
individuals
" t h e breakdown
by) j u d i c i a l
commercial
i t i s a reflection of
of practices
insurance
professor theorizes that
markets
this; suit
insurers,
and i s an i n d i c a t i o n
occurring
law
While
expansion
and groups.
One
i n insurance
of l i a b i l i t y
fand
431
therefore)
The
certain
argument
'special'
on
under
i n Arizona
Supreme
Court
public
that
and s h o u l d
industries
Court
types
of insurance
the health
be t r e a t e d
the antitrust
v. M a r i c o p a
intimated
that
s e r v i c e or e t h i c a l
care
c o v e r a g e ... u n r a v e l ( l e d ) . "
industry
differently
laws
County
i s somehow
from
was r e j e c t e d
Medical
professional
norms m i g h t
other
by t h e S u p r e m e
432
Society.
restraints
escape
The
premised
automatic
433
condemnation
Studies
had
adversely
a n d be e n t i t l e d
d u r i n g t h e 1980s
affected
t o more s y m p a t h e t i c
indicate
that
scrutiny.
antitrust
competition i n the f i e l d
and
immunity
antitrust
r e f o r m i s now a d v o c a t e d b y t h e F e d e r a l T r a d e C o m m i s s i o n ,
b u s i n e s s e s , s t a t e a t t o r n e y s g e n e r a l , t h e A m e r i c a n Bar
434
Association,
Chief
on
Counsel
Antitrust,
and consumer
and S t a f f
groups.
Director
Monopolies
be d i f f i c u l t
Mr. C o r r e i a ,
o f t h e Senate
and Business
t o withdraw
former
Subcommittee
Rights, states
antitrust
small
that
i t will
from
i n s u r e r s because:
"The i n s u r a n c e i n d u s t r y i s p o l i t i c a l l y
p o w e r f u l , i n p a r t because i t i s e c o n o m i c a l l y
s i g n i f i c a n t i n e v e r y s t a t e and i n p a r t because
it i s politically active.
The i n d u s t r y i s made
o f a number o f i n d i v i d u a l ' s u b i n d u s t r i e s , ' each
of which i s s u b s t a n t i a l i n s i z e - - l i f e i n s u r a n c e ,
- 1 25-
however
immunity
�h e a l t h i n s u r a n c e , a n d p r o p e r t y and c a s u a l t y
insurance.
I n a d d i t i o n , a g e n t s , b r o k e r s , and
r e i n s u r e r s , whose p r o F i t s a r e t i e d t o t h e s u c c e s s
oF t h e p r i m a r y c a r r i e r s , a r e g e n e r a l l y a l l i g n e d
w i t h them i n t h e p o l i t i c a l c o n t r o v e r s y o v e r
McCarran-Ferguson.
T r a d i t i o n a l l y , the major
c o m p o n e n t s oF t h e i n s u r a n c e i n d u s t r y h a v e b e e n
w e l l r e p r e s e n t e d by l o b b y i s t s i n W a s h i n g t o n and
in state c a p i t a l s , p o l i t i c a l action committees,
and F i n a n c i a l s u p p o r t For
candidates.'"^
3 5
The
Federal
deceptive
supplies
acts
Trade
or
Commission p r o h i b i t s
practices,
immunity
to
and
unFair
and
the McCarron-Ferguson
i n s u r e r s From t h a t
consumer
Act
protection
435
law.
to
P r i c e - F i x i n g immunity
property
laws
and
are oF g r e a t e r
In
rate
low
casualty
19S1,
oF
return
interest
"successFul1y
an
the
FTC
to other
unpleasant
legislate
Health
care
owes t o
on
the
to yield
one
which
to
achieve
to that
and
power
4 3 8
that
so
they
one
willingly
agency's
the
Function.
consumer
F a c e oF
to uphold
with
eFFectively
they
a Congress t h a t
than
the
insurance
be
that
a Federal
i n the
that
I t leaves
can
group
beneFit
protection
a provision prohibit-
Congress
oF
concern
extraordinarily
study
t o adopt
that
would
hand,
was
a
4 3 7
Found
LiFe
t h e FTC
insurance."
disempowerment
reForm
such
will
be
bald
use
Finds i t
the
loyalty i t
i t s constituency.
Divesting
antitrust
imposed
by
e special interest
diFFicult
power
easier
by
the
massively
oF
realization
Commission
investments.
incensed
studying
insurers.
insurance
l o b b i e d Congress
From
manipulated
liFe
oF
w h i l e consumer
to health
Trade
From w h o l e
c o m p a n i e s became so
ing
insurers,
the Federal
when c o m p a r e d
i s g e n e r a l l y more
by
the
immunity
the
insurance
industry
oF
involves conFronting
insurers,
but
also the
- 125-
the
not
comForts
only
"...dilemma
the
oF
obstacles
(oF)
how
to
�reconcile
with
the
the
every
Federal
e x t e n s i v e system
The
permit
the
oF
For
not
now
i n place
in
i n t e n t oF
to the
intervention.
oF
providing
government
state
action
articulated policy
Federal
to
over
determine
doctrine,
t o which
to
occupy
i n order
whether
For
to regulate
There
are
a state
i t adheres
that
antitrust policy.
a n t i t r u s t laws.
4 4 0
I t
the
4
4
1
have
and
state
policy
Each s t a t e
itselF
two
must
or
submit
components
to
has
take
the
to
to the
state
doctrine:
1.
the
challenged
aFFirmative1y
2.
the
supervised
r e s t r a i n t m u s t be
expressed
by
the
state
are
reluctant
antitrust
immunity
about
possibility
the
From s t a t e
the
eliminate
oF
the
oF
and,
conduct
m u s t be
actively
current
4
4
2
to relinquish
but
they
losing
There
level.
articulated
policy;
are
just
as
between
current
concerned
they
discussions
insurance
Achieving
conFlict
their
the p r o t e c t i o n
have been
transFerring
Federal
clearly
state
itselF.
status,
regulation.
possibility
to
as
anticompetitive
Insurers
state
Federal
the purpose
desire
Federal
the
precedence
action
without
For
the
antitrust scrutiny."
implements
Federal
From
without
conscientiously
power
evolved
a n t i t r u s t issues.
a clearly
the
regulation
competition
insurers
extended
to operate
According
and
state
to Function
was
license
not
Field
immunity
states
immunity
"broad
was
oF
Favoring
state."
Antitrust
to
a n t i t r u s t policy
enjoy
concerning
regulation
that
state
reForm
From
the
would
policies
and
443
Federal
a n t i t r u s t laws.
However,
- 127-
as
Correia
aptly
points
�out:
"The l o n g
and
difficulty
political
the
regulators
Bills
laws
of transFerring
oF r e t a i n i n g
oF
regulation,
currently
responsibility,
to provide
harbor'
4 4 5
immunity
From
F o r " d e v e l o p m e n t oF c 1 a s s i F i c a t i o n
collection
a n d d i s s e m i n a t i o n oF h i s t o r i c a l
the
use
of voluntary,
the
competitive beneFits
standardized
oF t h e s e
various
antitrust
The b i l l s
violations
and
a l lpoint i n
between F e d e r a l
oF i n s u r e r s .
'saFe
change,
i n Congress advocate
the conFlict
regulation
and t h e
4 4 4
pending
oF r e c o n c i l i n g
the complexity
t h e s t a t e s as t h e p r i n c i p a l
insurance."
and s t a t e
continue
of state
o p p o s i t i o n t o such a wholesale
direction
methods
tradition
antitrust
standards,
l o s s oF
policy
would
inFormation,
Forms...(because)
p r a c t i c e s outweigh
the
44B
competitive
risks..."
Correia
regulation
concludes
that
do n o t c o n F l i c t
incompatibility
i s even
Federal
and t h a t
weaker
when
antitrust
"(t)he
laws
argument
and
state
oF
i t comes t o c o n s u m e r
447
protection."
Additionally:
" . . . ( T j h e r e i s no p r i n c i p l e d a r g u m e n t t h a t
t h e F e d e r a l b a r o n d e c e p t i v e p r a c t i c e s i s somehow i n a p p r o p r i a t e b e c a u s e oF u n i q u e c h a r a c t e r i s t i c s oF t h e i n s u r a n c e b u s i n e s s .
Virtually
every
i n d u s t r y i n t h e U n i t e d S t a t e s must c o m p l y w i t h
b o t h F e d e r a l and s t a t e consumer p r o t e c t i o n
s t a n d a r d s . ... I F a n y t h i n g , t h e i m p o r t a n c e oF
i n s u r a n c e t o c o n s u m e r s , a n d t h e e x t e n s i v e u s e oF
n a t i o n a l m a r k e t i n g p r a c t i c e s , makes a m o r e p o w e r Ful
case For a p p l y i n g F e d e r a l s t a n d a r d s t h a n For
most i n d u s t r i e s .
Thus, t h e anomalous
exemption
F o r t h e i n s u r a n c e i n d u s t r y From t h e c o n s u m e r
p r o t e c t i o n s t a n d a r d s oF t h e F e d e r a l T r a d e
C o m m i s s i o n A c t s h o u l d be r e p e a l e d a l o n g w i t h a n y
legislation dealing with the antitrust
exemption.
One l e s s o n oF t h e M c C a r r a n - F e r g u s o n e x p e r i e n c e
i s t h a t Congress s h o u l d speak c l e a r l y i F i t i s a t
all possible.
A n o t h e r l e s s o n i s t h a t an e x e m p t i o n ,
once g r a n t e d , i s d i F F i c u l t t o t a k e away.
Not only
-128-
�does t h e i n d u s t r y spend enormous p o l i t i c a l
eFFort
t o p r o t e c t i t s i m m u n i t y , t h e u n c e r t a i n r e s u l t s oF
e l i m i n a t i n g i t becomes an a r g u m e n t F o r t h e s t a t u s
quo.
Another l e s s o n , however, i s t h a t t h e i n d u s t r y
d e s e r v e s some c l a r i t y a b o u t t h e s t a n d a r d s oF
conduct i t i s expected t o Follow...IF s t a t e
r e g u l a t i o n h a s n o t w o r k e d w e l l i n some r e s p e c t s ,
a n d i F t h e F e d e r a l g o a l oF c o m p e t i t i o n i s deemed
more i m p o r t a n t t h a n c e r t a i n s t a t e r e g u l a t o r y
p r a c t i c e s , Congress s h o u l d say s o . "
4 4 8
Representative
to
a b o l i s h most
possess.
had
H.R.
been
Jack
oF t h e a n t i t r u s t
9 was i n t r o d u c e d
introduced
Committee
Brooks
but,
last
year
(D-Tex) has i n t r o d u c e d
exemptions
i n June
due t o i n s u r a n c e
bill
i n s u r e r s now
1991.
and approved
a
The same
bill
by t h e J u d i c i a r y
industry lobbying,
i t never
449
reached
a Floor
vote.
As a r e s u l t
public
criticism
insurer
May
that
Council
actuarial
standardized
pooling
research
the
"give
are intent
now b e g i n s
to avoid
property
stated:
Federal
mitigation
on r e t a i n i n g
halF
when p u b l i c c r i t i c i s m
i F some
oF some
a century."
l o t . "
4
antitrust
ability to
developing
u n d e r w r i t i n g and
oF an
the beginning
insurance
oF a new e r a
Driscoll
' saFe h a r b o r s '
oF t h e s e c u r i t y
452
a
and t h e American
by j o i n t
and s t a t e r e g u l a t i o n . "
"Even
giving
their
The v i c e p r e s i d e n t
the unraveling
For n e a r l y
risk
"We're s e e i n g
by s t a t i n g :
and
and c a s u a l t y
and b u i 1 d i n g - i n s p e c t i o n d a t a ,
4 5 1
vecal
policies,
Association--
proposed
Forms, and s p r e a d i n g
Firm
events
a little
Insurance
and more
industry i s beginning t o
representing
Insurance
arrangements.
combined
enjoyed
i t must
They
r a t e s , canceled
the insurance
American
oF L i F e
exemptions.
in
high
1991, t h e lobby
insurers--the
share
over
bankruptcies,
understand
In
oF i n c r e a s i n g l y s t r o n g e r
blanket
Congress
becomes s u F F i c i e n t l y v o c a l .
- 1 29-
simpliFies
survive,
i n s u r e r s have
does
respond
5
0
�Termination,
Health
Non-renewal,
insurance
former-insureds
which
Cancellation,
companies
Uninsurabi1ity.
are expressing
who a r e s u b m i t t i n g
have e i t h e r been
and
terminated
claims
concern
under
about
group p o l i c i e s
or modified.
Insurers
453
contend
t h a t coverage
Insurers
are
"already
termination
no l o n g e r
explain
exists.
t h a t many o r m o s t o f t h e s e
seriously
i l l ,
i n j u r e d or disabled
o r m o d i f i c a t i o n " and a r e t h e r e f o r e
new, s u b s t i t u t e h e a l t h
insurance
coverage.
former-insureds
"argue
that
for
t h a t commenced o r i n j u r y
any i l l n e s s
policy
that
pay
was i n f o r c e
" i fthis
benefits
or before
argument
without
a t t h e time
unable
have a v e s t e d
they
former-insureds
For t h i s
that
i s successful,
receiving
to obtain
reason, the
right
to benefits
occurred
i t was m o d i f i e d . "
Levy
i t requires
of
while the
explains
the insurer to
any p r e m i u m s w h a t s o e v e r
even i f
454
the
p o l i c y has teen
The
s o l u t i o n , of course,
premiums
which
and c o n t i n u e
i s at present
insurance
no
It
tan
Under
any f u r t h e r h a r m
the c i v i l i t y
receives
in distress.
i s obliged
to the injured
insurers
rule
our s o c i e t y
no p a y m e n t
f o r a moment
of health
B u t once
that role i s
to continue
aidto
party.
Samaritans.
a legal
adheres
has a t t a i n e d .
he r e c e i v e s by a i d i n g
- 1 30-
a concept
one i s u n d e r
i s n o t merely
f o r his troubles.
t o accept
Rule,
a r e n o t Good
our c u l t u r e generally
which
satisfaction
Consider
t h e Good S a m a r i t a n
t h e Good S a m a r i t a n
a r u l e t o which
innate
that
be f o r t h e i n s u r e r s
t o any c o n s i d e r a t i o n
t h e Good S a m a r i t a n
i s granted
However,
of
foreign
o b l i g a t i o n t o a i d another
minimize
would
coverage.
coverage.
undertaken,
but
terminated."
premise
as an
expression
The g o o d
Samari-
His reward
another.
i sthe
�It
not
been
since
to
that
a i d has a l r e a d y
with
commenced.
the injured
i t so c h o o s e s .
I tretains
condoned
that
such
behavior
by t h e e n t i r e
will
acknowledge
obliterated
In
really
rule
oF
the insurer
a strange
and d i s a b l e d
i n i t s journey
and u n i q u e
i s p e r m i t t e d and
I t s power
i s oppressive
the existence
has
Insurers are permitted
a t any p o i n t
nation.
e n d s F o r i t s own b e n e F i t
payment
a i d t o t h e weakened
up a n d d r o p
society
none
even
obliged to continue
such
pick
that
in
i s a paradox
position
thereFore
t o accomplish
these
and y e t e t h e r e a l because
oF t h a t
power
over
an
civilization.
t h e F a c e oF r a p i d l y
i n c r e a s i n g h e a l t h care
costs
which
began
to spiral
i n 1980, i n s u r e r s have
Found i t
economically
necessary
t o increase
Group h e a l t h
insurance
Forced
plans
have been p a r t i c u l a r l y
insurance
-- r a i s e
premiums.
problematical
and have
companies t o :
premium
rates;
-- m o d i F y e x i s t i n g p o l i c y p l a n s t o make t h e m
a F F o r d a b l e as p o s s i b l e t o e m p l o y e r s ;
-- t e r m i n a t e e x i s t i n g
as
policies;
455
-- w i t h d r a w
Margaret
From
Levy,
t h e group
health insurance
who p r i m a r i l y
deFends
business.
insurance
companies
455
in
'bad F a i t h '
litigation,
or
modification
of group
explains that
health insurance
oFten " t e r m i n a t i o n
policies
can c r e a t e
457
more p r o b l e m s
than
former
insureds
should
be e x p l a i n e d
accepted
Health
by
i t solves."
have
vested
that
by t h e c o u r t s
insurance
the c o u r t system
rights
in their
the vested
i n cases
benefits
When c o n s i d e r i n g
have
right
involving
whether
beneFits, i t
concept
i s generally
accident
insurance.
n o t been c o n s i s t e n t l y
to maintain that
- 1 21 -
vested
quality.
considered
458
�Generally,
the courts
will
strictly
construe
in
oF t h e i n s u r e r .
Favor
study
the policy contract
i t s p r o v i s i o n s , which
However,
will
and
generally
i n the event
oF
will
then
be
contract
45 9
ambiguity,
also
the insured
consider
reasonable
public policy
t h e same
That
insurance
tions
and
to prevail.
"provides
principle,
coverage.
will
insured's
continue
i n Force
4 5 0
policy contracts
the Foundation
are oFten
contracts
oF
For t h e r e a s o n a b 1 e - e x p e c t a -
unconscionabi1ity
reliance provides
Courts
i n t e r e s t s and t h e
reliance that a policy will
providing
adhesion
is likely
supplies
the rudiments
the motivation,
oF a s t a n d a r d
For
measurement."
Insurance
policies
employee's choice
the
oF c a r r i e r .
policy negotiated
insurance
policies
individual
contract
oF a d h e s i o n
any i n p u t
between
a t what
insurer
the reasonable
the extent
insurance
policy, there
among
the courts
i n determining
doctrine
that
the policy provide
believed
by
the
oF r e a s o n a b l e
imposing
coverage
and i n s u r e r .
cost.
and
t h a t an i n s u r e d
which
The r e s u l t
is a
insured.
expectations
oF an
a v a i l a b l e under a
diFFiculty
t h e d e F i n i t i o n oF a n d e x t e n t
Another
that
accept
as t h e
has been c o n s i d e r a b l e
t h e coverage
the requirement
an
ThereFore,
[as well
concerning
expectations.
had been p u r c h a s e d .
preclude
employee must
oF c o v e r a g e
health
the
employers
by e m p l o y e e s
are covered
When c o n s i d e r i n g
concerning
employer
to
consumer) p r e c l u d e
services
through
The i n s u r e d
between
agreed
provider
insured
obtained
One
view
requires
that the insured
view
modiFies
the insurance
would reasonably
- 1 32-
oF
the First
policy
expect
reasonably
provide
t o be
�covered
after
reasonable
For
eFFort
individuals
There
take
into
Favor
versus
are generally
consideration
oF c o v e r a g e
1.
recovery
known
commercial
three
or the insured
a reasonable
coverage."
and
that
may
have
coverage
"The e x t e n t
c o u l d have
have
3
t o hold i n
over t h e
actually
which
understood
expected
precludes
the limits
4 6 6
IF the insured
clariFied
or should
i n t h e i n s u r e d ' s shoes
i s an o b j e c t i v e
or a c t i v i t y
oF
have
would
inquiry
which
oF t h e i n s u r e r o r
c r e a t e d an o b j e c t i v e l y
467
reasonable
exists.
t o which
gained
knew
the insured
through a reasonable
an u n d e r s t a n d i n g oF t h e
could read
and u n d e r s t a n d
h a d s u F F i c i e n t t i m e t o do s o , b u t F a i l e d
would
6
policy.
the insurer
This
which
policy).
a
4
the courts
i n a dispute
inquiry
clearly
person
its
eFFort
parties.
which
an i n s u r e d
t o which
words, c o n d u c t ,
3.
under
t o which
considers
impression
insured
464
i n Force.
expected
agent
on t h e r e a d i n g oF t h e p o l i c y
Factors
i s a subjective
"The e x t e n t
that
d i F F e r e n t s t a n d a r d oF
i n d e t e r m i n i n g whether
by an i n s u r e d who
465
policy
2.
This
be a p p l i e d
available
"The e x t e n t
coverage."
have
would
oF t h e i n s u r e r
extent
the
reading the p o l i c y . A
the situation,
(contract/
the policy
t o take steps
that
the insured's claim i s
weaker."
"When members oF t h e p u b l i c p u r c h a s e p o l i c i e s oF i n s u r a n c e
t h e y a r e e n t i t l e d t o t h e b r o a d m e a s u r e oF p r o t e c t i o n n e c e s s a r y
469
to
Fulfill
that
their
coverage
reasonable
and e x c l u s i o n
expectations."
provisions
exist
p o 1 i c y . . .does n o t p r e c l u d e a r e a s o n a b l e
- 132-
Also,
"Knowledge
i n an i n s u r a n c e
expectation
that the
�exclusion
does n o t n u l l i f y
transaction.
reasonably,
t h e dominant
... The 1 aw ... p r o t e c t s
as c o n s o n a n t
with
purpose
of the
expectations
t h e purpose
objectively
of the standard
,,470
contract..."
While
of
the insurance
i t s burdensome
the
termination
industry
p o l i c i e s , and consumers have
of their
a precautionary
has been r e l i e v i n g
measure
insurers
to explicitly
coverage
will
above s p e c i f i c m o n e t a r y
their
why
catastrophic
i s necessary
which
of pre-existing
The
industry
they
expect
Insurers
health
care
appears
t o dwell
illness'
within
Without
coverage
experiencing
f o r mental
i n the lack
-- a d e f i n i t i o n
the four
corners
any e x p l i c i t
determinants,
.mental
illness
being
person
a t the time
illnesses.
which
i s most
of the health
the term
ofttimes
"understood
the
This i s
of
coverage.
reform
plan
o f 1992.
difficulty
'mental
not
insurance
deny
concerning
of
often
the courts
definition
half
The
of a d e f i n i t i o n
guidelines,
and t h e i r
i t s own h e a l t h
difficulty
their
coverage o f
f o rfuture
i n the f i r s t
included
policy.
are usually the
comes down t o
by a
reasonable
47 1
the contract
was
made."
Insurance
from
companies are f a c i n g
hospitals
because o f t h e f o l l o w i n g event.
- 133-
as
increasing
coverage.
require
conditions
public
be
and t h e e x c l u s i o n
i s developing
t o make
are also
will
illness,
consideration
which
their
will
that
terms
By r e d u c i n g
o f consumers, they
and l o n g - t e r m
insurance
be r e f o r m u l a t i n g
limits.
t o c o n t i n u a l l y reduce
legislation
challenging
and i n c l e a r l y u n d e r s t a n d a b l e
expectations
ability
been
p o l i c i e s , i t i s t o be e x p e c t e d
policies
reasonnable
itself
increasing c o s t - s h i f t i n g
Hospital
care
�is
the
Fact,
highest
health
physicians
patients
on
an
cost
have
For
expenditure.
years
outpatient
Because
been t r y i n g
basis.
The
to
result
of
this
care
has
For
been
a
their
decline
472
in
occupancy
hospital
rates
stays
at h o s p i t a l s .
declined
From
"[T)he
8.3
days
in
average
19S7,
to
length
7.2
oF
days
in
473
1987."
Rather
declines,
provided
state that
account For
From a l m o s t
1987
(the
the
latest
oF
by
the
monetary
cost
Health
oF
l o s s From
outpatient
Insurance
"community h o s p i t a l
these
services.
Association
occupancy
rates
oF
(which
more t h a n 80 p e r c e n t oF a l l h o s p i t a l s ) plummeted
80 p e r c e n t i n 1973 t o j u s t u n d e r 65 p e r c e n t i n
Insurers
because
suFFer
h o s p i t a l s r a i s e d the
Statistics
America
than
statistics
have been
other
available).
Faced
Factors
as
with
well,
s e r v i c e s and
increasing
some oF
costs
oF
claims
which
costs
are:
1.
increased
outpatient
services;
2.
i n c r e a s e d number oF d i a g n o s t i c t e s t s and p r o c e d u r e s
b e c a u s e oF p h y s i c i a n s ' F e a r s oF m a l p r a c t i c e
suits;
3.
' a n t i - s e 1 e c t i o n ' process wherein h e a l t h i e r
people
j o i n HMOs a n d PPOs a n d t h e i n s u r e r s r e t a i n h i g h - r i s k
high-cost clients.
Most i n s u r e r s b e l i e v e t h a t s m a l l
b u s i n e s s e s pose h i g h e r h e a l t h r i s k s t h a n l a r g e
corporations;
4.
AIDS-related
The
problem
474
insurmountable.
extended
on
to
i s the
From
the
costs
However,
clients
provision
of
pharmaceutical
direct
route
can
oF
drugs
because
the
the
the
i t s AIDS c l i e n t s
a l l i t s other
that
oF
claims.
save
as
oF
incurred
John Alden
the
with
AIDS p a t i e n t s
Insurance
same b e n e F i t
catastrophic
a l l necessary
manuFacturer
much as
the
by
which
elimination
oF
has
i t bestows
i11nesses...and
patient.
200-300 p e r c e n t
- 124-
Company
pharmaceuticals
to the
seems
directly
This
oF t h e p r i c e
475
markup!
When
�the
drug
costs
$30,000 per
passing
the
to
by
comprise
These
end
raise
coverage
4 7 6
10
1990s.
high
OFFice has
reach
percent
billion
as
as
$20,ODD t o
10
oF
during the
numbers have caused
high-risk
as
485,000
claims
are
a l l health
percent
oF
oF
expected
insurance
claims
span
each
projected that
high
AIDS-related
This
premiums For
as
is
this
expected
one
decade.
insurers to attempt
to
i n d i v i d u a 1 s , o r reFuse
altogether.
Having
insurers,
considered
the
m u s t a l s o be
solved
could
1991.
i n s u r e r s $35
run
Accounting
approximately
incredible
either
oF
can
becomes more i m p o r t a n t w i t h
AIDS c a s e s
during the
cost
step
General
oF
the
AIDS p a t i e n t s
this
The
incidence
claims
to
year,
day.
persons
For
by
other side
h e a l t h care
oF
insurers'
oF
considered.
pre-existing
policies
some F a c t o r s
the
are
substituted
problems
[1] insuring
(2) e l i m i n a t i n g
high-cost patients,
judgments
increase
health insurance
Three major
reForm
conditions;
which
and
the
costs
problem
which
those
the
must
cancellation
treating
be
with
(3) e l i m i n a t i o n
over
For
oF
oF
physician's
d e c i s i ons.
Patients
with
pre-existing
mercy
oF
insurance
wrote
oF
her
experience
expenses
For
a condition
husband
had
poignantly
honest
worked
wrote
Americans
companies.
For
with
Mary
an
which
being
had
Bush
held
E v a n s oF
insurer
a diFFerent
to President
are
c o n d i t i o n s are
that
existed
hostage
Columbus,
reFused
when M r s .
employer.
that
presently at
Mrs.
"Millions
by
the
Ohio,
to
cover
Evans'
Evans
oF
insurance
hardworking,
companies.
478
I am
one
oF
them."
The
reFusal
- 1 35-
to
issue
a policy
to
cover
�Mrs.
Evans*
savings
health
account
Under p r e s e n t
able
to
ever.
Education
is
legal
Uwe
health
staFF
For
liFe-saving
i s going
cover
Disability
the
will
some t i m e ,
CaliFornia,
i s any
cost
James M a d i s o n
at Princeton
University
insurance
by
treatment
evidence
insurer
be
iF
Rights
states " I t
that
Ca
money,
they
you."
Reinhardt,
contract
quite
the
For
there
to
cancer
For
in Berkeley,
IF
their
i t i s u n l i k e l y she
insurance
attorney
DeFense Fund
to
deregulated
social
any
Kilb,
and
have
pay
i n a n n i h i l a t i o n of
statutory conditions,
condition)
economy
to
discrimination.
medical
don't
resulted
i n order
purchase
Linda
costs
industry
proFessor
oF
proclaims:
has
political
"The
partially
been b r e a c h i n g
p r i c i n g insurance
to reward
the
the
healthy
473
and
by
maneuvering
should
that
and
be
mentioned
opposed
President
the
wall
are
and
children
aroused
similar
insurers
to
that
overcome
people
of
this
to
i s the
Roosevelt's
are
starting
to
supporting
expansion
to
themselves
the
oF
Uncertainty
To
that
coverage
the
social
protect
the
purchase
will
Canadian
impose
see
oF
i l l . "
I t
same i n s u r a n c e
security
Johnson's Medicaid/Medicare
nation
out
deny
President
Insurers
an
to
handwriting
to
From t h e
a national
system...which
program
programs.
the
aid
industry
elderly
on
people
possibility
health
that
program
could
put
health
Factor
For
most
Future
may
bring,
business.
i s the
biggest
uncertainties
insurance.
stress
that
The
i n s u r i n g , assumes a n o t h e r ' s
-136-
the
insurance
risk
industry,
in return
For
people.
i n the
payment.
act
�Purchasing,
should
be
and
remain
t h e r a f o r a assuming
liable
For
the
p e r m i t t e d t o t e r m i n a t e an
a situation
been
has
turned
originally
insurers
nation.
which
not
and,
by
not
the
risk
insurer
and
should
not
c o n t r a c t merely
because
advantageous
had
as
to
may
i s a two-way
Insureds
impose
extension,
In return,
a policy
that
insurance
one
however,
responsibility.
responsibility
oF
risk,
as
expected.
Insurability,
personal
into
cost
that
unnecessary
to
oF
have a moral
a l l the
i n s u r e r s must n o t
be
street
costs
other
seek
social
and
on
and
social
their
insureds
loopholes
in
the
through
repudiated.
" M o s t h e a l t h i n s u r a n c e p l a n s a r e oF t h e
Fee-For-service type.
Under t h e t y p i c a l
insurance
plan, the i n s u r e r agrees w i t h the insured to
r e i m b u r s e t h e i n s u r e d F o r ' u s u a l , c u s t o m a r y , and
reasonable' medical charges.
The
third-party
i n s u r e r . . . b e a r s the economic r i s k t h a t the i n s u r e d
w i l l r e q u i r e medical
treatment."
4 a D
However,
climb,
the
'usual,
customery,
exceeded
not,
on
not
and
high
want
limit
the
that
oF
t o be
the
those
individual
costs
medical
policy
i s then
an
has
have
suFFicient
(1) whether
For
and,
been r e a c h e d
1990
and
the
costs;
to
exceeded
charges
non-renewable
asked:
begin
or
is cancelled.
medical
and,
(2)
i s treatment
banned, r a t h e r than
p l a c i n g the
which
costs
reduced
providers
to reduce
issue
are
For
reasonable'
policy
need
why
whether
insurers
and
p e r m i t t e d are
then
The
and
the
questions
charges
costs
i n s u r e r contends
thereFore,
Two
when m e d i c a l
the
can
those
i s too
be
even
though
iF
ban
may
costs.
oFten
i n s u r e r may
debated
whether
terminate
discovering various
- 12 7 -
other
the
costs
policy.
methods
are
excessive
Thus,
oF t e r m i n a t i n g
�policies.
One
o f these
short-term
coverage
methods
i s the practice of
imposing
•
f o rpolicies;
renewable
every
insurance
c o n t r a c t s i s p e r m i t t e d by s t a t e s t a t u t e s .
utilizing
this
protect
level
from
Health
Security
(for health
election
of the e l i g i b l e
contract
i s terminated
cause'
refers
merely
misrepresentation,
costs
to
N e g o t i a t i n g new
method,
c o n t r a c t s which
has been p r o p o s e d
contract
the
12 m o n t h s .
By
i n s u r e r s can
show
a
suddenly-increasing
of costs.
American
"The
or every
statutorally-protected
themselves
A remedy
The
6 months
i . e . , the p o l i c i e s are
provide
Durenberger
(R-Mn).
A c t o f 1991 ( 3 . 7 0 0 ) r e q u i r e s
insurance)
m u s t be r e n e w e d
sma11-business employer
4
f o rcause." ^
t o nonpayment
1
The t e r m
o f premiums
and n o t t o t h e p o s s i b i l i t y
i n c u r r e d by e m p l o y e e s .
sma11-business
by S e n a t o r
Although
employer,
i t
this
i s a step
p r o t e c t i o n t o consumers
a t the
unless the
'terminated f o r
or f r a u d or
of high
bill
medical
only
covers
i n the right
as o p p o s e d
that
direction
to protection f o r
i nsurers.
The
-or
salient
may no l o n g e r
self-employed
status
many
points
2.
t o issue
no l o n g e r
health
u n i 1 a 1 1 e r a 11y , l e a v i n g g r o u p s
3.
coverage
may
no l o n g e r
under
t o small
as p o o r
Insurers
high-risk
insurance
groups
health
consider
operations.
contracts
unprotected.
exclude
an e m p l o y e r ' s
such
occupation.
t o be i n h e r e n t l y
cancel
insurers:
policies
f o r reasons
i n a high-risk
businesses
may
refuse
individuals
or working
small
o f S.700 a r e t h a t
individual
group
- 12a -
plan
employees
just
from
because t h e
�employee had poor h e a l t h ,
o r had a dependent
child
i n poor
health.
4.
may
periods
no l o n g e r
For coverage
establish excessively
oF e m p l o y e e s who
long
waiting
have p r e - e x i s t i n g
medical
problems.
Additionally,
regulation
1.
health
oF i n s u r a n c e
nationally
insurance
employed
2.
lating
S.700 a d d r e s s e s
the t r a d i t i o n a l s t a t e
c o m p a n i e s by
uniForm
products
requiring:
consumer
sold
protection
t o small
standards
businesses
For
and s e l F -
people.
states are to r e t a i n
the insurance
accomplish
market
t h e same d e g r e e
their
traditional
as l o n g as t h e y
role
enact
oF c o n s u m e r p r o t e c t i o n
oF
laws
reguthat
a s S.700
prov i des.
3.
insurance
which
Failed
abide
by F e d e r a l
companies
t o enact
37 m i l l i o n
p r o t e c t i o n s would
t o remedy
Americans
determined
coverage
make
age
this
that
For these
i n order
people,
i t more e c o n o m i c a l l y
than
i t would
objective
t h e Fact
Ctwo-thirds
who do n o t h a v e h e a l t h i n s u r a n c e
has
products
i n any
state
be r e q u i r e d t o
rules.
S.700 i s i n t e n d e d
than
such
selling
coverage.
Senator
Durenberger
t o incent insurers to provide
attractive
by i m p o s i n g
t h e r e a r e more
oF whom a r e e m p l o y e d )
legislation
be t o d e n y
that
i s needed
For them
coverage.
an e x c i s e
which
will
to provide
The b i l l
will
t a x on i n s u r a n c e
cover-
accomplish
companies
483
iF,
due t o ' w i l F u l
policy
products
neglect'
which
they
a r i called
t o oFFer two s p e c i F i c
484
MedPlans.
Any i n s u r a n c e
- 139-
Fail
�company
which
be F a c e d
v i o l a t e s these
with
a Federal
gross
accident
Force
during
product
excise
and h e a l t h
requirements
tax penalty
premiums
o f S.700
oF 2 0 p e r c e n t
For small
group
would
oF
contracts i n
4S5
that taxable
Senator
to
Durenberger
an i n s u r e r
and
year.
explains
t o deny o r c a n c e l
that " I t i s highly
coverage
i n d i v i d u a l s because t h e i n s u r e r
claims
such
e x p e n s e s down s i m p l y
groups
or i n d i v i d u a l s .
oF h i g h e r - r i s k g r o u p s
i s (then)
by a v o i d i n g
proFitable
able
the risk
Consequently,
t o keep
oF
enrolling
the level
oF S . 7 0 0 ' s
48E
tax
penalty
The
under
be h i g h
enough
which
insurers
beneFits
t h e MedPlan
MedPlan
are
must
policies
and t h e S t a n d a r d
will
t o deter
will
these
be r e q u i r e d
be d i v i d e d
MedPlan.
practices."
to
provide
b e t w e e n t h e Core
The C o r e M e d P l a n
beneFits
to include:
Inpatient
and o u t p a t i e n t :
Diagnostic
and s c r e e n i n g
Prenatal
hospital services
surgical services
physicians'
services
services
care
Ambulance s e r v i c e s
4B7
Durable medical equipment.
The
Standard
The
MedPlan
beneFits
beneFits
are to include:
i n t h e Core
MedPlan,
I n p a t i e n t or o u t p a t i e n t treatment
c h e m i c a l dependency d i s o r d e r ^ Q B
There
i s t o be no d e d u c t i b l e
$500 d e d u c t i b l e
per
c os t
Family.
oF t h e s e r v i c e ,
will
For mental
For p r e n a t a l
per i n d i v i d u a l
Copayments
plus:
care,
disorder or
a n d a maximum
a n d $ 1 , 0 0 0 maximum
deductible
be e i t h e r 20 o r 5 0 p e r c e n t
depending
on t h e t y p e
oF
oF t h e
service
489
involved.
national
Copayments
eFFort
t o reduce
a r e an i m p o r t a n t
the overall
- 140-
component
costs
i nthe
oF h e a l t h
care.
�Copayments
incent
treatment
behavior
and
health
also
to avoid
Under
care
consumers
to practice
potential
S.700, i n s u r e r s
t o Forego
preventive
and
unnecessary
cautionary
illnesses.
will
n o t be p e r m i t t e d t o :
--
e x c l u d e any e m p l o y e e who w o r k s more t h a n 30 h o u r s
p e r week, n o r t h e e m p l o y e e ' s spouse o r c h i l d r e n
--
e x c l u d e any p e r s o n F r o m c o v e r a g e F o r l o n g e r t h a n s i x
m o n t h s F o r any p r e - e x i s t i n g c o n d i t i o n .
Pre-existing
conditions
during
is
are only
those
the three-month
First
--
"cause
covered
by
terminate
period
the
an
conditions
which
preceding the date
themselves
an
insured
contract.
insurance contract
to terminate."
maniFest
An
unless there i s
insurance contract
cannot
be
490
terminated
At
Senator
that
For
F o r any r e a s o n
least
Durenberger's
the b i l l
providing
also
37 m i l l i o n
has
remain
articles
and
to
within
have
and
tax
been
t h e y have
detriment
oF
unemployment,
immediate
I t is interesting
For becoming
may
be
i n need
oF
passage
to consider
the precedent
could
provisions.
also
be
written
regulated
about
percentage
recently
their
oF
i t s guaranteed
by S.70D a n d a r e
49 1
t h e " a c c e p t a b l e premium
paying a larger
which
S.700.
characteristics.
t h o s e same b e n e F i t s t o a l l A m e r i c a n s who
Premiums w i l l
to
to risk
A m e r i c a n s need
the p o t e n t i a l
b e n e F i t From
eligibility
related
oF
begun
employees.
a return
requiring
Many
employers
t h e premium
to
payments
practices
greater
on e m p l o y m e n t .
bill
comes t o t h e s m a 1 1 - b u s i n e s s e m p l o y e r s '
- 14 1-
to the
increasing
is likely
even
return
From
to release themselves,
I n t h e s e t i m e s oF
to those
negative impact
range."
required
t o have
Senator
rescue
an
Durenberger'
and
wisely
�turns
t h e issue
First
by
around
bill
requires
speciFied
rate
insurers,
the b i l l
those
insurance
oF i n c r e a s e .
will
t o both
premiums
available
price
a
larger
is
also
sales
a t a reasonable
the price
would
be i F t h a t
company
required
be
addressed
same
so t h a t
opportunity
on
t o themselves
a s an
and t h e n
maintain
level.
a t which
insurers
employers
contract
t o be made
contract
than
available to
oF b u s i n e s s .
t h e same l e v e l
The
insurer
oF m a r k e t i n g a n d
owner as i t does t o t h e
t h e sma11-business
to learn
make a
m u s t n o t be g r e a t e r
were
t o t h e sma11-business
corporations
t o look
oF p r e m i u m s
within a
requirement
or c o l l e c t i v e l y
w i t h i n t h e same c l a s s
t o extend
this
insurers
t h e cost
t o sma11-business
eFForts
larger
will
premiums r e m a i n
By i m p o s i n g
require
reduce
Additionally,
the
that
as i n d i v i d u a l c o r p o r a t i o n s
industry
the
t h e problem
insurers.
The
either
so t h a t
about
owner
the availability
will
have
oF t h e
492
health
insurance
Insurer
Cost
The
Kennedy,
coverage.
and R e s p o n s i b i l i t y
Health
America
Riegle
ShiFting.
and R o c k e F e l l e r
prohibiting
health
contract
limitations
conditions.
Act introduced
also
by S e n a t o r s M i t c h e l l ,
addresses
on i n s u r a b i l i t y
t h e problem
oF
due t o p r e e x i s t i n g
SpeciFically:
"A h e a l t h b e n e F i t p l a n s h a l l n o t e x c l u d e o r
o t h e r w i s e l i m i t a n y i n d i v i d u a l From c o v e r a g e u n d e r
t h e p l a n on t h e b a s i s t h a t t h e i n d i v i d u a l h a s
( o r a t any t i m e has h a d ) any d i s e a s e , d i s o r d e r ,
or c o n d i t i o n . "
4 9 3
However,
another
drawback
t o S.1227 i s e n c o u n t e r e d
- 1 42-
i n the
�very
next
s e c t i o n of
the
bill.
SpeciFically:
I n t h e c a s e oF a l e s s . - t h a n - F u l 1 - t i m e o r
p a r t - t i m e e m p l o y e e who i s s u b j e c t t o , a n d i s •
c h a r g e d , an i n c r e a s e d p r e m i u r n . . . t h e e m p l o y e e
may , n o t w i t h s t a n d i n g any o t h e r p r o v i s i o n oF
t h i s p a r t , waive e n r o l l m e n t . ..(and) such
•w a i v e r . . . s h a l 1 t e r m i n a t e on t h e d a t e t h e
e m p l o y e e i s no l o n g e r b e i n g s u b j e c t t o , a n d
c h a r g e d , s u c h an i n c r e a s e d p r e m i u m .
4 9 4
I n t h e case ( s t a t e d a b o v e ) , t h e e m p l o y e r
s h a 1 1 . . . m a k e a p a y m e n t u n d e r T i t l e V oF t h e
H e a l t h A m e r i c a A c t e q u a l t o t h e minimum amount
t h e e m p l o y e r w o u l d h a v e made t o w a r d t h e
a c t u a r i a l c o s t oF c o v e r a g e oF t h e e m p l o y e e i F
t h e e m p l o y e e had n o t w a i v e d s u c h e n r o l l m e n t .
4 9 5
In
other
amount t h a t
words,
the
iF the
employee
employee
may
waive
does n o t
pay
a premium
oF
paying
the
plan.
t o be
That
taxes.
an
The
occurs
The
this
insurer.
share
oF
under
legislatively
and
the
oF
insurance
the
the
§ 2 7 2 3 ( d ) oF
interpretation
oF
§ 2 7 2 3 ( c ) by
any
From
the
health
paid
For
Further
This
relieF
oF
r u l e s oF
i n biased
stating:
to
aFFairs
risk
From
has
the
should
Fair
play.
selection
conduct.
to bolster t h i s
- 1 43-
be
itselF
s t a t e oF
is abetting that
S.1227 a p p e a r s
For
to
insurer's responsibility
i n a n y b o d y ' s book
legislation
and
premium
will
individual.
That
i n d u s t r y i s engaging
the
plan,
in order
oF
an
emp 1 o y e r - - i n s t e a d
health plan
( v i a S.1227) s h i F t e d
'Foul'
i n the
government-sponsored
high-risk
because
premium,
employee's
relieved
s t a t e governments.
a cry
pending
this
the
The
t o AmeriCare
insurer is. thus
responsibility
elicit
the
amount
t o pay
to enrollment
government-sponsored
For
Federal
to
covered
responsibility
been
i s unable
his right
employer's
insurer--pays
employee
by
the
i n s u r e r r a i s e s premiums t o such
writer's
and
�I F an e m p l o y e e ' s c o v e r a g e o r c o v e r a g e F o r
t h e F a m i l y members oF a n e m p l o y e e w o u l d n o r m a l l y
t e r m i n a t e d u r i n g a p e r i o d oF h o s p i t a l i z a t i o n ,
such coverage s h a l l c o n t i n u e u n t i l t h e employee
o r F a m i l y member i s d i s c h a r g e d From t h e h o s p i t a l .
Health
insurance
nonpayment
coverage
oF p r e m i u m s !
consumer/patients
a consumer
Most
passible
by r e d u c i n g
dollar
However,
health
w h a t a p p e a r s t o be a
concerning
are estimated
logical
p r o v i d e r s have
For years,
For each p a t i e n t
insurer's
Form
and s u b m i t t e d
is--iF
administrative
why
change
is legislation
center
are
on t h e i d e a
legislators
Form.
that
a u n i v e r s a l Form F o r
a
Filled-out
c a n be a t t a c h e d
For payment
physicians
quietly
which
which
astonishing heights.
each p h y s i c i a n has i s s u e d
Form
then
savings
t o reach
been u s i n g
beneFit.
industry-wide claim
t o remind
universal
question
the cost
a d m i n i s t r a t i v e costs
i t seems o n l y
For
§2723(c) o r ( d ) , b u t r a t h e r i s d e F l e c t i n g
oF a u n i f o r m / s t a n d a r d
savings
care
years!
by w i t h
discussions
n o t be t e r m i n a b l e e x c e p t
S.1227 i s p r o v i d i n g no a i d t o
o u t c r y by s t a t i n g
oF u t i l i z a t i o n
The
should
i n that
were a b l e
manner.
to institute
a n d a l l by t h e m s e l v e s
now r e q u i r e d t o make
to the
The
this
years
ago,
i n s u r e r s do t h e same
thing?
Additionally,
state-regulated
comprised
the
insurance
oF s m a l l
t h e number
deal.
This
claims
will
i s advocating
consortia.
insurance
p u r p o s e oF p a y i n g
reduce
in
S.1227
oF
The c o n s o r t i a w o u l d
be
c o m p a n i e s who a r e t o " c o m b i n e F o r
providers
oF p a y m e n t
the establishment
( i n order
entities
to)
with
make p o s s i b l e s i g n i F i c a n t
processing,
Facilitate
electronic
dramatically
which
e c o n o m i e s oF
claims
496
and
reduce
administrative costs
oF p r o v i d e r s . "
- 144-
providers
must
scale
processing,
�S. 1227 a l s o
states:
"...a
h e a l t h b e n e f i t p l a n s h a l l p l a c e no
497
l i m i t s on t h e a m o u n t , s c o p e , o r d u r a t i o n o f b e n e F i t s . "
That
number
oF
clause
i s commendable,
oF c o n s u m e r s who
t h e c o s oF
especially considering the
are dropped
illnesses
which
by t h e i r
extend
beyond
considers
t o be a " r e a s o n a b l e "
amount
the
section
by t h e v e r y
above
is curtailed
insurers
what
the insurer
or d u r a t i o n .
next
because
However,
s e c t i o n oF t h e
bill:
"A h e a l t h b e n e F i t p l a n may l i m i t t h e a m o u n t ,
s c o p e , a n d d u r a t i o n oF p r e v e n t i v e s e r v i c e s . . .
p u r s u a n t t o r e g u l a t i o n s oF t h e S e c r e t a r y
speciFying
t h e a m o u n t , s c o p e , a n d d u r a t i o n oF s u c h c a r e .
The
S e c r e t a r y s h a l l d e v e l o p such r e q u l a t i o n s a F t e r
498
c o n s u l t a t i o n w i t h a p p r o p r i a t e medical
experts.
The
questions
1.
What
services
2.
the
bill
Why
be a s k e d a r e :
preventive
s e r v i c e s , and
which
limited?
will
the regulations state?
the l e g i s l a t i o n ,
no
oF c o u r s e ,
were r e g u l a t o r y g u i d e l i n e s n o t i n c o r p o r a t e d
What
have
must,
are the allowable
a r e t o be
bill?
within
which
idea
what
legislators
i t i s they
3.
Who
are the "appropriate
4.
How
connected
are those
who
Without
vote
into
guidelines
For or a g a i n s t t h e
a r e v o t i n g For o r a g a i n s t .
medical
medical
experts?"
experts
to the
insurance
industry?
Section
able
to place
legislators.
reducing
2722(d]
i s t o o easy
a way
limits
on c o v e r a g e
by a p p l y i n g
This
health
Preventive
care
Long-term
costly
provision
insurance
illnesses
is a built-in
plan
i s important
o u t F o r i n s u r e r s t o be
pressure
legal
on
loophole
beneFits
For p r e v e n t i v e
as a m e t h o d
For r e d u c i n g
and s h o u l d
- 145-
n o t be
For
care.
Futi
curtailed.
�S.1227
individuals
and
lose
does n o t h i n g
who
their
t o ease t h e burden
change employment
health
of those
o r move f r o m
i n s u r a n c e as a
state
to state
result.
" N o t h i n g i n t h i s p a r a g r a p h s h a l l be c o n s t r u e d
as r e q u i r i n g a h e a l t h b e n e f i t p l a n i s s u e d t o a
s m a l l e m p l o y e r by a c a r r i e r t o make c o v e r a g e
a v a i l a b l e t o an i n d i v i d u a l who no l o n g e r h a s an
employment r e1 a t i o n s h i p . .. w i t h r e s p e c t t o t h i s
p l a n . "499
A national
health
insurance plan
ment t h a t
insurance follows
or
The f a c t
live.
irrelevant
included
reform
struggling.
Much
with
care
which
And so S.1227
o f S.1227 n e g a t e s
health
to
t h e problems
reform policy.
feature
which
t h e people
i s once
the entire
again
principle
of a
no one w i l l
Provision
must
be made f o r i n s u r a n c e c o v e r a g e
citizen
system
of the United States.
does
quo.
Reform
little
f o r t h e consumer
5.12 27 i s a p o l i t i c i a n ' s
society
adheres,
the nation.
5.1227
nation are
of reform i s
t o be
ongoing,
of every
i s i n t e n d e d t o impose a
currently
which
will
not reform
Laws r e f l e c t
i s not: 2 f f 2 c t i v a
hodge
improve
t o s e t s t a n d a r d s o f decency
and t h o s e
merely
insurance.
or replacement
bill,
n o t be
national
f o r the lifespan
imposes a d d i t i o n a l
L a w s a r e made
of
health
i n place of t h e c o n g l o m e r a t i o n which
S.1227 m e r e l y
and
interruption
m u s t be
a disappointment.
that
without
will
will
The p r i m a r y c o n c e p t
be w i t h o u t
work
i snot
of this
ensure
continuing
s/he may
the result
situation
the require-
o f employment
I f this
of a l l plans,
include
wherever
or lack
t o insurance coverage.
b u t a m i n i m a 11y-a 1 1 e r e d
prolong
now
t h e person
of employment
f o r a l l facets
must
exists.
podge
the status
legislation.
to which
t h e mora),
stature
i n a d v a n c i n g •.:•
:-:
�oeliefs
needs
oF
of
consumers
Fraction
oF
insurers
i t s policyholders
stockholders.
tive
that
Senator
oF
the
the
are
i n Favor
oF
Durenberger's
length
oF
disregarding
proFits
bill,
S.1227 b u t
insurance
industry,
assurance
programs
and
more
For
its
S.700,
i s Far
the
is a
less
protect-
i n agreement
with
consumers.
Quality
oF
hospital
to
protect
care,
but
and
patients
also
unnecessary
physicians
oF
their
physician
to
derive
and
services
and,
There
are
already
whether
IF
the
any
wil
insurer
to
event,
insurers
amounts
in
order
the
only
health
about
rarely
charged
to
types
takes
For
believes
problem
encouraged
and
pay
cover
consideration
The
two
been p r o v i d e d .
they
determine
thereFore,
costs
place
At
the
the
which
1
is
aFter
charges
amount
are
has
been
and
utilization
review
is
review.
medical
services
insurers
oF
the
provided
oF
determine
care
excessive,
a c e r t a i n percentage
care
From
reasonable-cost
that point,
Full
result
consumer
utilization
only
hospital
Hospitals
From
review
i s not
and
utilization
oF
utilization
purpose
hospitalization.
beneFit
oF
surgical
excessive
utilization
reimbursement
study
The
unnecessary
Financial
Retrospective
have
services.
eliminate
surgery
necessary.
based
From
include
they
the
prior
provided.
may
cost.
to
In
any
payment.
with
retrospective
denied
claims,
nor
by
health
care
the
providers
maximize
to
utilization
sought
to
providers.
overtreat, overtest,
proFits
For
themselves.
- 14 7-
review
pay
is
less
than
These
and
that
the
circumstance;
overhospitalize
Eventually,
�consumers
began
services.
This
for
t o demand
state
providers
review
While
a remedy
utilization
takes
place
pr ior
t h eintention
economically
difficult
i nprospective
i i s that
throws
the cost
n o table
utiliza-
of that
payment,
receive
the
the
care.
permanent
health
care
physicians
readily
oFten
actual effect
onto
coi. n c i d e
pressured
i s to
of that
type o f
t o pay f o r
patient.
a portion
the
of that
patient
does n o t
death.
Health
the
time
and q u a l i t y
this
5 0 0
review.
Maintenance
Organizations
quality
goal.
order
The b a s i c
oF a n d access.i. bi. l i t y t o
t o each
patient,
ProFessional
oF p r i o r i t i e s .
sanctions
imposes
HMOs r e q u i r e member
allocated
oF c a r e .
by e c o n o m i c
can lead
utilization
with
care
I f a patient
and even
goal,
with
review
w i t h h o l d i n g o f care
services a secondary
t o reduce
the
i sthat
prospective
primary
access
utilization
care.
effective
of for-profit
as t h e
care
result
disability
proFit
the
for
prospective
p r o v i s i o n of medical
t o pay f o r even
This
HMOs p r a c t i c e
structure
theincentive
a d e c i s i o n by t h e i n s u r e r n o t
to afford
refused
t o the
cost,
removes
p a t i e n t s because
of prospective
unnecessary
review
reducing
review
to overtreat their
sliminate
to
sought
proved
care
review.
Prospective
is
of affairs
i n s u r e r s who t h e n
tion
i n c r e a s i n g amounts o f h e a l t h
thereby
e t h i c s do n o t
Physicians are
and r e p r i s a l s
to limit
time
501
.vhiie
simultaneously
Profit
determining
and h e a l t h care
a method
arediFFicult
or t r e a t m e n t .
t o blend
F o r tine p a t i e n t ' s
beneFit. .
All.
position
potential
oF r i s k
patients,
thereFore,
oF h e a l t h a n d e v e n
- 1 43-
liFe
areplaced
whenever
ina greater
their
insurer
�or
provider
instead
It
opts
f o r using
of t h e l e s s - r i s k y
i s clear, then,
that
counter-productive,
patient
prospective
may
they
has been c h o s e n
which
own
Medicare
determine
plan.
with
related
payment
power
regarding
case
payment
uses almost
5 0 0 DRGs t o
procedures.
could
example
not
already
for
both
The W i c k l i n e
on
diagnostic
would
not
warrant
can happen
tragic
t o make
decisions
h a s become
case.
This
t o happen w i t h
Wickline
when
i s permitted to
t h e power t o
provision of health
i s going
country.
care.
case
i s the
increasing
i s becoming,
become, t h e s t a n d a r d
i f i t has
of
behavior
a n d p r i v a t e i n s u r e r s , h o s p i t a l s , HMOs a n d PPOs.
case
i s many
malpractice
a defendent
The p o w e r
the
surreptitiously
public
be r e i n s t a t e d
o f what
review
ultimately
another
o f what
in this
utilization
f o r care
i s not just
care
i s an e x a m p l e
carriers.
regarding
i sthe
by i n s u r e r s .
5 0 2
of prospective
make d e c i s i o n s
medical
This
specific
Canada a n d G e r m a n y , a n d
r e t r o s p e c t i v e review
to providers
i n insurance
frequency
A
(DRG).
and t h e r e f o r e e x c e s s i v e
The W i c k l i n e
prime
by b o t h
of providers
f o r each
a d i f f e r e n c e - - t h a t p a y m e n t be b a s e d
groups
Wickline
group
Medicare
payment f o r P a r t
Alternatively,
reside
i s n o t merely
the greed
are to receive
remedy
the
review.
interference i n the doctor/
diagnostic related
full
review
l i e i n containing
procedure.or
but
review
retrospective utilization
but i s also
r e g u l a t i n g t h e fees
our
utilization
relationship.
The r e m e d y
by
prospective
case
things.
I t i s most
obviously
a
(although
Wickline's
physician
was n o t
i n t h e case) b u t i t i s also
economica 11y-imposed
�substituted
care
of
judgment,
and h e a l t h care
health
health
receiving
most
containment
program
judgment
f o r harm
5
0
3
that
Lois
Court
private
behind
those
five
years,
impression.
has l e g a l
The
responsibility
t o a p a t i e n t when
ofthe treating
i s alleged to
physician's
t o discharge
payer
a cost
the patient
i s Medi-Cal,
program.
I ti s this
which
fact--
i s a p u b l i c e n t i t y - - w h i c h may be t h e
that
reversed
Medi-Cal
t h e Los Angeles
was n o t l i a b l e
County
f o r the
decision.
Wickline
was a m a r r i e d
who was b e i n g
s u f f e r e d from
artery
ventrical
t o have
i n a manner w h i c h
o f Appeal
and h e l d
the terminal aorta
parts
payor
when
resulted in
the next
of f i r s t
assistance
payer
t h e Court
her f o r t i e s ,
Wickline
which
of rationing.
The t h i r d - p a r t y
medical
was t h e v i c t i m
immediately
caused
i s applied
the third-party
discharge
main
party
in' d e t e r m i n i n g
the h o s p i t a l .
Superior
of
was a c a s e
a third
case
some f o r m
of health
the current benefits of
Within
affected the implementation
reason
in
v. S t a t e
California's
that
enjoying
and M e d i c a i d .
was w h e t h e r
medical
Wickline
judgment
are i n line
experience
a malpractice
from
But those
Medicare
Wickline
have
substituted
insurance
o f us w i l l
issue
Lois
rationing
b e c a u s e s h e was n o t f o r t u n a t e e n o u g h
insurance.
private
is
facilities.
economica11y-imposed
rationing
in
economica11y-imposed
o f t h e body.'"'
04
with a limited
t r e a t e d by h e r g e n e r a l
an o b s t r u c t i o n ( c a u s e d
i n her r i g h t
o f t h e body
of the heart
woman
which
from
i n a l l organs
Her p h y s i c i a n
- 15D-
blood
obtained
practitioner
arteriosclerosis
l e g . The a o r t a
carries
to arteries
by
education,
i s the
the l e f t
and t o a l l
the services
�oF
a specialist
E.
Po1onsky--because
treatment.
Far
in peripheral
Dr.
advanced
Wickline's
According
Daniels,
For
G,
clot
had
in
her
Later
problems
Formed
surgery
that
groin,
removal
pain
with
hallucinatory
lumbar
a chain
oF
she
From
the
attempt
practitioner,
authorization
and
which
vessels
a
ten-day
the
vessels.
causing
had
expected
and
such
Dr.
oF
on
experienced
that
to undergo
the
a
additional
incision
restitching.
severe
For
spasmodic
Daniels
had
to
is a severing
and
removal
the
spinal
i n the
3 0 5
"The
lower
open p o s i t i o n
spasms w h i c h
blood
cord.
patient's
Spasms s t o p
the
Wickline
Wickline
i n a wide
to r e l i e v e
Mrs.
Polonsky
that
blood
vessels
on
clot,
l i e along
i n those
the
so
graFt.
For
reopening
which
t o become p a r a l y z e d
blood
the
episodes
extremity
experiencing
the
sympathectomy
nerves
surgery
experienced
causes
i n an
oF
surgery
Wickline
oF
procedure
done
the
l e g and
necessitating
thereaFter,
oF
a part
general
aFternoon,
graFt.
days
a
the
that
Five
perForm
was
a TeFlon
the
other
disease
to Medi-Cal
approved
in that
i n the
day,
right
a request
perFormed
1977.
circulatory
i t with
the
to
Gerald
period.
Polonsky
January
t o remove
procedure,
Medi-Cal
hospitalization
responded
that
replace
submitted
not
necessary
to normal
treatment.
Dr.
and
had
surgery--Dr.
concluded
i t was
artery
•r.
Wickline
Polonsky
that
vascular
and
was
Wickline
the
t o back
was
outFlow
up
oF
into
the
506
graFt.
Failure
While
was
assisted
Dr.
by
to r e l i e v e
such
spasms can
cause
Polonsky
perFormed
a l l three
a board
certiFied
specialist
- ' ~z 1 -
clotting."
surgeries,
i n general
he
surgery
�(Or.
Kovner),
and Dr. D a n i e l s
observed
the First
and
third
o p e r a t i ons.
By
January
condition
made
hospitalized
15, a l l t h r e e
i t medically
the appropriate
requesting
the eight-day
surgeon
denied
a
employed
a 4-day
telephoned
registered
extension.
until
he s i g n e d
As
additional
in
days,
discharging
third
her
pain
by M e d i - C a l
l a t e r .
5
oF t h e M e d i - C a l
a l l three
obtained
was t h e p e r s o n
0
who
He w o u l d
only
h i s decision not
o u t Form,
b u t merely
t o h i m by a M e d i - C a l
s e e t h e Form
decision to allow
the hospital
physicians
on J a n u a r y
pain
only
Four
concurred
21st.""^^
By h e r
was s o e x c r u c i a t i n g
From D r . K o v n e r
practitioner
adverse
2Sth,
i n h i s oFFice.
substantial
Wickline's
hospital,
change
discharge
However,
Wickline
From
by J a n u a r y
where
every
was e x a m i n e d
His records
the hospital
30th,
eFFort
by h e r g e n e r a l
do n o t i n d i c a t e any
i n the condition
oF t h e l e g s i n c e
one week
Wickline
7
earlier. ''"
was b a c k
was made t o s a v e
that
t o increase the
medication.
On J a n u a r y
on
7
oF W i c k l i n e ' s
permission
general
d i dnot actually
d a y a t home, M r s . W i c k l i n e ' s
husband
extension.
Dr. Classman based
Dr. Glassman
h e r From
t o Medi-Cal
extension.
Filled
Wickline's
As p e r r e q u i r e d
certiFied
For d e c i s i o n p l a c e d
i t days
a result
a board
and c o r r e c t l y
nurse.
days.
that
she r e m a i n
was s u b m i t t e d
F o r an e i g h t - d a y
request
that
hospitalization
a t t h e time
the completely
eight
Form
S. C l a s s m a n ,
the request
approve
on
William
concurred
necessary
F o r an a d d i t i o n a l
procedure,
Dr.
doctors
in
the
the heavily
�infected
leg.
wound had
broken
of
infection
on
to
the
Because
The
open,
t o the
stage
of
the
do
i n Dr.
the
death
After
knee
clot
from
on
of
cooler
changed
than
groin,
Dr.
To
B.
from
Death
the
other
leg.
Polonsky
have
heat
then
5
1
0
was
attempted
have r e s u l t e d
throughout
the
to
in
body,
in repetitive
through
clotting
and
5
blood
Polonsky
the
and
poisoning. ''''
attempting to treat
Dr.
that
marble
the
o p i n i o n , would
septicemia,
February
infected
blue-gray
resulting
condition,
so
l e g had
infection
system,
was
surgically.
unsuccessfully
deteriorated
the
the
graft's
circulatory
possible
the
i n the
Polonsky's
the
area
appearance
infection
t o remove
spreading
and
of becoming
unable
so,
incision
the
amputated
badlyleg
below
have o c c u r r e d
would
the
had
he
not
5 12
sacriFiced
ended
here.
Failed
to
another
the
the
leg.
However,
improve
i t does n o t .
on
the
l e g on
" I n Dr.
certainty,
Polonsky's
had
her
Wickline
other
treating doctors,
5 14
her l e g . "
Dr.
chieF
Kovner,
surgeon
certiFied
Dr.
he
though
at the
specialist
Polonsky
d i d not
hospital
days,
was.
Feel
caused
Van
or
enough
February
17,
opinion, to
remained
would
not
this
a
i n the
Kovner
Wickline's
have
c o n t r i b u t e d to the
_ i - ~> -
by
discharge
and
board
as
trial
From
her
and
the
surgeon
a
the
For
him
suFFered
surgery
l o s s oF
above
hospital
not
stated at
early
time
requested
N u y s H o s p i t a l , was
perForm
reasonable
a board-certiFied general
Dr.
iF i t
were r e q u i r e d t o
originally
she
bad
i n peripheral vascular
Yet,
that
as
be
Wickline's condition
physicians
eight additional
oF
would
the
the
loss
saga
and
amputation
5 13
knee.
medical
The
that
the
leg.
This
�testimony
i s i n c o n s i s t e n t w i t h h i s concurrence
Polonsky's
eight
original
request
days h o s p i t a l i z a t i o n
All
the
that
the
d e c i s i o n was
medical
in
his
the
medical
conForm
permitted
without
First
discussing
•r.
"Dr.
agreed
in
that
testiFied
that
consultant's rejection
acute
a Four-day
care
and
extension
He
the
patient,
d i d not
would
care
oF
not
c
in
be
a patient
reviewing
patient's condition with
oF
his
stated that,
a physician
regarding
the
trial
standards
standards.
seeing
^
Polonsky
oF
additional
subsequent
medical
standards,
the
5 1
an
Dr.
the p a t i e n t ' s
the
treating
. .
p h y s i c i a n s . ,,517
or
Glassman
w i t h help
treatments
the
the
extension
medical
w i t h those
at
Medi-Cal
t o make d e c i s i o n s
.
.
p h y.s i c i a n
walk
usual
For
Wickline.
yet,
a u t h o r i z a t i o n oF
either
or
And
eight-day
to the
accordance
chart
within
opinion, the
requested
substituted
For
witnesses
community.
medical
t o Medi-Cal
with
assumed
and
that
that
because
day,
that
she
because W i c k l i n e
was
Four
scheduled
additional
was
For
days
able
to
whirlpool
would
be
5 1S
adequate.
He
peripheral
vascular
However,
and
be
not
this
any
complete
d i d not
surgery
neglect
Failing
consult
on
may
the
understanding
a Medi-Cal
prior
be
a problem
part
by
t o making
one
of
Dr.
who
specialist
in
his decision."'
w i t h Medi-Cal's
Glassman.
does n o t
There
have
1 5
procedure
cannot
comparable
expertise.
The
State
not
negligent
the
B-day
oF
CaliFornia
(Medi-Cal) contended
i n a u t h o r i z i n g the
extension.
Medi-Cal's
Four-day
view
- 1 34 -
that
extension
is that
the
i t
rather
three
was
than
�physicians
made t h e d e c i s i o n
Cal's
decision
only
hospitalization.
citing
was t o r e F u s e
the patient.
payment For Four
A d d i t i o n a l l y , Medi-Cal
the "doctrine
CaliFornia
t o discharge
deFends
Code
days'
itselF
oF d i s c r e t i o n a r y i m m u n i t y "
Government
Medi-
by
provided
§820 a n d §818.4 w h i c h
by
"provide(s)
520
the
state
The
with
absolute
court
insurer--bore
immunity"
had t o d e c i d e
responsibility
in this
which
matter.
party--the
For d i s c h a r g i n g
physician
or t h e
t h e p a t i e n t From
the h o s p i t a l .
The C a l i F o r n i a A d m i n i s t r a t i v e Code s t a t e s t h a t
"The
d e t e r m i n a t i o n oF n e e d F o r a c u t e c a r e s h a l l be made i n
accordance
with
t h e usual
standards
oF m e d i c a l
practice in
..521
the
cnmmunity.
Medi-Cal
submitted
by
t o them
the phsycian
physicians
on
procedures
she
required
have
submitted
d a y oF d i s c h a r g e
Further
oF
sought,
h o s p i t a l care
physicians
that
no o p p o r t u n i t y
t o do s o .
discharge
decision
The
also
without
protest
such
with
Wickline's
additional
iF, i n their
medical
request
opinion,
A d d i t i o n a l l y , "while
against
522
the nature
was oF p a r a m o u n t
t h e medical
a t t h e time
oF a c t i o n
court
just
that
For t h e Funds t o pay For t h e
t o be p r o v i d e d
treating
cause
contend
and i t s i n p u t r e g a r d i n g
d i d not override
viable
necessary
hospitalization.
Medi-Cal
given
t o be
deemed m e d i c a l l y
They
M e d i - C a l .. .was t h e r e s o u r c e
treatment
a d d i t i o n a l requests
For t r e a t m e n t s
i n charge.
should
t h e planned
permit
judgment
importance,
oF
oF h e r d i s c h a r g e .
ThereFore,
and l e n g t h
Wickline's
I t was
there
c a n be no
i t For t h e consequences of
"
stated:
"The p h y s i c i a n
the limitations
imposed
who
complies
by a
third-party
�payer,
avoid
when h i s m e d i c a l
his ultimate
cannot
goat
point
judgment
dictates
responsibility
to his health
care
For h i s p a t i e n t ' s
payer
go s o u r . . . M e d i - C a 1 was
decision
to discharge Wickline)
to
i n t h e harm
share
made."
Following
1.
How
not a party
i F such
scape-
medical
t o ( t h e medical
and t h e r e F o r e c a n n o t
q u e s t i o n s may
many t i m e s ,
a protest
decision
be
was
held
negligently
how
court
For a p h y s i c i a n
The
court
s h o u l d have
interFerence,
2.
and w i t h
the protest
be
himselF
considered that
would
conversation
requirements
oFten,
t o remove
Mr^ . W i c k l i n e
What Form
telephone
n e e d t o be
posed:
how
much
vehemence
be made i n o r d e r t o be c o n s i d e r e d a d e q u a t e
the
Would
determinative
He
5 2 3
The
must
resulting
care.
as t h e l i a b i l i t y
when t h e c o n s e q u e n c e s oF h i s own
decisions
o t h e r w i s e , cannot
would
have
suFFicient?
h a v e t o be
satisFied
Followed
liability?
b u t For t h e
n o t have been
the protest
be
From
up
iF a registered
insurer's
discharged
to take?
Would
i t be
Would
early.
a
recorded?
in writing?
nurse
by
Would
executed the
Form?
3.
How
A.
to
to
many
per
t o pay
B.
what
would
oF
tney
these p r o t e s t s
the protest
a malpractice
would
consume?
a physician
be
expected
be c o n s i d e r e d
suit,
and
suFFicient
(b) persuade
third-party
For t h e c a r e .
Should
cost?
these protests
day?
When w o u l d
(a) avoid
payers
At
How
Field
5.
much t i m e w o u l d
proFessional medical
Who
need?
would
train
them?
care p r o t e s t e r s
What k i n d
of
be
hired?
training
�The
above
questions
have
ridiculous,
in a ridiculous
prospective
utilization
by
physicians,
price.
There
reached
the point of
situation.
review,
and r e q u i r i n g
a r e as b a d as u s e d - c a r
i s something
Associate
else
J u s t i c e Rowen
Insurers
being
imposing
numerous
protests
dealers n e g o t i a t i n g
going
on h e r e
concluded
by
besides
price!
stating:
T h i s c o u r t a p p r e c i a t e s t h a t what i s a t
issue here i s t h e e f f e c t of cost containment
programs
upon t h e p r o f e s s i o n a l judgment o f p h y s i c i a n s t o
prescribe hospital treatment f o r patients requiring
t h e same.
W h i l e we r e c o g n i z e , r e a l i s t i c a l l y ,
that
c o s t c o n s c i o u s n e s s h a s become a p e r m a n e n t f e a t u r e o f
the h e a l t h care system, i ti s e s s e n t i a l t h a t cost
l i m i t a t i o n p r o g r a m s n o t be p e r m i t t e d t o c o r r u p t
medical judgment.
We h a v e c o n c l u d e d ,
from t h e f a c t s
i n i s s u e here, t h a t i n t h i s case i t d i d n o t . For t h e
reasons expressed h e r e i n , t h i s court Finds
that
( M e d i - C a l ] i s n o t l i a b l e F o r ( W i c k l i n e ' s ) i n j u r i e s as
a m a t t e r oF
law."
5 2 4
Prospective
economically
thus
review
victimizes patients
a n d p s y c h o l o g i c a l l y when t h e y
From p h y s i c a l
and
utilization
inFirmities.
Wickline
encourages p r i v a t e
sets
are already
an u n F o r t u n a t e
insurers to treat
same m a n n e r a s t h e g o v e r n m e n t a l
suFFering
example
patients i nthe
bureaucracies,
and t h e c o u r t
system.
It
is
i s not reasonable
not being
procedure
•ue
iF
re-examined,
which
to that
i s being
result,
diagnoses,
Insurers
should
position
they
that
denied,
the cost
For t h e r e s u l t
incorrectly
decision
oF t h e
i s t h e same,
suFFer
just
as s u r e l y as
made.
IF a physician
t h e p a t i e n t sues For m a l p r a c t i c e .
be no l e s s
have
the physician's
i ti s merely
the patient will
t h e d e c i s i o n had been
incorrectly
t o say t h a t
liable
than
usurped.
- 1z 7 -
the physician
whose
�S.1227, t h e b i l l
Riegle
aND
which
introduced
RockeFeller,
has been
states
that
review
does n o t h i n g
illustrated
each
oF s u c h
by S e n a t o r s
denial
to resolve
by t h e W i c k l i n e
oF a c l a i m
M i t c h e l l , Kennedy,
will
t h e problem
case.
The
be a c c o r d e d
bill
a
timely
525
denial.
However:
In cases i n which t h e F a i l u r e t o p r o v i d e
h e a l t h c a r e p r o m p t l y w o u l d be 1 i F e - t h r e a t e n i n g o r
r e s u l t i n a r i s k oF p e r m a n e n t d i s a b i l i t y , t h e
b e n e F i c i a r y . . . s h a 1 1 be e n t i t l e d t o a d e c i s i o n . . .
n o t l a t e r t h a n 1 day a F t e r s u p p l y i n g t h e i n s u r e r
with a l l requested inFormation.
I n t h e e v e n t oF
a d e n i a l oF c o v e r a g e F o r s u c h c a r e , t h e b e n e F i c i a r y
s h a l l be e n t i t l e d t o an e x p e d i t e d r e v i e w oF an
a p p e a l oF s u c h d e n i a l w i t h i n 5 d a y s . 3
Although
processing
Five
d a y s may
and d e c i s i o n
making,
interval
F o r one t o s u F F e r
position
oF r i s k
Senators
o r an i n s u r e r
but
merely
the
nation
with
our health
merely
prolongs
C.
dilemma
oF p e r m a n e n t
Everett
i s Far t o o long
disability.
t h e care
oF l a c k
oF t h e p r e s e n t
care
5 days
to state
i s interested
For i n F o r m a t i o n
i n a 1iFe-threatening
the p o s s i b i l i t y
a continuation
be n e e d e d
3
Koop, Former
would
problem--and
reimbursement
or i n a
For e i t h e r t h e
n o t be
oF r e i m b u r s e m e n t ,
i n establishing
the problem
mode
an
withheld,
i s merely
o n e oF t h e r e a s o n s
health
system.
care
reForm--
Once a g a i n ,
S.1227
a n d o F F e r s no s o l u t i o n .
Surgeon
General,
summarized t h e
succinctly:
3?7
making."
M
"Cost
control
should
n o t mean r e m o t e
control
decision
32 3
In
Williams
her
primary
her
to a specialist.
Failure
the
care
v. H e a l t h A m e r i c a ,
physician
to deliver
right
because
The c l a i m
they
against
quality health
t o be r e f e r r e d
a patient
sued
had d e l a y e d
t h e HMO
beneFits
to a specialist.
t h e HMO
i n reFerring
was b a s e d
as p r o m i s e d ;
The c o u r t
and
on
i.e.,
restated
�the
cause
of action against
the
HMO a s a t o r t
claim
For breach
529
oF
the
The
oF
duty
court
the
described
points
the
out
(managed
provide
rights
that
care
it,
in
claims
or
oF t h e
injury
the
Although
involving
analysis
causal
3
3
Function
i st o Finance
physician t o
0
Chittendon
oF m o s t MCOs
health
oF F i d u c i a r y
duty
care,
would
not to
seem t o
m a n a g e m e n t oF h e a l t h
with
greater
care
provides
Frequency,
includes
quality
care.
"negligent
oF c o s t - c o n t r o l m e c h a n i s m s may a F F e c t t h e
judgment
whether
primary
beneFiciary
the
as p a t i e n t s . "
b u t a t t h e same t i m e
physician
t o the
For economic
medical
the
required
Faith.
5 3 1
Financial
judgment
physical
which
For breach
as i s o c c u r r i n g
implementation
medical
contract
organizations)
containment,
However,
i n good
p a t i e n t as a " t h i r d - p a r t y
"(b]ecause
deFensible."
cost
p l a i n t i F F ' s claim
oF e n r o l l e e s
claims
EFFective
the
the
HMO-physician
promote
be
t o handle
and e m o t i o n a l
injuries"
was a c o n t r i b u t i n g F a c t o r
there
have
judgment
been
insurers' reFusal
i sthat there
was n o t
t o provide
the
whether
533
the
provider's
i nplaintiFF's
532
i n issue."
beneFits,
t o Wickline
Chittendon's
malpractice
The i n h e r e n t
a
and t h e
diFFicultyi s
a p t l y d e s c r i b e d by t h e C a l i F o r n i a M e d i c a l A s s o c i a t i o n i n
amicus c u r i a e b r i e F which s u p p o r t e d
including third-party
5 34
p a y e r s as m a l p r a c t i c e d e F e n d a n t s :
The C a l i F o r n i a M e d i c a l A s s o c i a t i o n h a s a n
o b l i g a t i o n t o describe p a t i e n t r i s k s with badlyconstructed or maintained
systems present.
CMA
i s a l s o c o n c e r n e d t h a t p h y s i c i a n s n o t be o l a c e d
1 - Q _
injury
diFFiculty " i n proving
physician's
MCOs c o s t - c o n t r o l m e c h a n i s m ' . '
resulting
may r e s u l t i n
Few c a s e s s i m i l a r
i s an i n h e r e n t
between
provider,
patient...(which)
provider's
connection
or other
its
�b e t w e e n t h e p r o v e r b i a l r o c k and h a r d p l a c e .
The
p a t i e n t who i s i n j u r e d when c a r e w h i c h s h o u l d
h a v e been p r o v i d e d i s n o t p r o v i d e d w i l l
recover
f r o m someone.
I f the t h i r d - p a r t y payer imposing
t h e s e c o n t r o l s i s p e r m i t t e d t o a v o i d l i a b i l i t y by
m a i n t a i n i n g t h e f i c t i o n t h a t the mechanisms have
o n l y f i s c a l c o n s e q u e n c e s , so t h a t p a t i e n t c a r e i s
s o l e l y the p h y s i c i a n ' s r e s p o n s i b i l i t y , the
p h y s i c i a n becomes t h e i n s u r e r .
I f rationing
m a l f u n c t i o n s , t h e p h y s i c i a n who c o m p l i e s w i t h t h e
program i s l i a b l e to t h e p a t i e n t .
I f the p h y s i c i a n
does n o t comply, t h e p h y s i c i a n i s p u n i s h e d or f a c e s _
r e s o o n s i b i l i t y for incurring (un)authorized
costs." '
(underlining
supplied)
-
Interestingly,
held
i n Wilson
refusal
primary
the p a t i e n t ' s
under
The
v. B l u e
theories
insurer's
1.
successful
of t o r t i o u s
defensive
decided
of S o u t h e r n
suicide
breach
physician's
Wickline
California
stay
with
attempt.
of c o n t r a c t
i n conduct
by t h e
causative
Plaintiff
and
factor"
claimed
negligence.
i s nondelegable;
or u t i l i z a t i o n
considerations warrant
utilization
that the
included:
decision
the c a r r i e r
5 3 6
recommended
was a " s u b s t a n t i a l
reasoning
public policy
engaged
that
r e s p o n s i b i l i t y f o r damages r e s u l t i n g from
be s h a r e d
2.
court
for a hospital
physician
a treating
therefore,
cannot
Cross
to pay b e n e f i t s
patient's
in
t h e same
3
review
the d e c i s i o n
review
protecting
activities
firm;""
the p u b l i c
i n order t o
the
withhold
It
p h y s i c i a n had n o t a p p e a l e d
costs.
the decision to
beneFits.
is interesting
companies
and
i n t e r e s t i n c o n t r o l l i n g medical
contend
that
y e t i n s u r e r s usurpe
also
t o note
physicians
that,
first,
decisions
the physician's
duty
are
insurance
nondelegable,
t o make
decisions.
Second,
insurers proclaim
a public
controlling
medical
costs,
the stronger
but ignore
- I GO-
7
insurers
:; 3 s
uphold
0
those
interest in
public
�interest
in receiving
individual
patient's
'decision'
which
an
appeal.
appears
Allowing
and
increase
While
considerations
there
their
would
but
i t
t o diagnose
any
Further
usurpation.
public
because
policy
i t involved
i td i s t i n g u i s h e d
For a s i m i 1 a r
a
of course.
prerogative
had Found
plan,
was no s u p p o r t
subject,
preclude
to the
not require
as a m a t t e r
to the insurer
health
should
due t o i n s u r e r ' s
i n Wickline
Favorable
Third,
rendered
appeals
litigation
a state-administered
because
expect
own p a t i e n t s
the court
attuned
a litigious
to retain
i n medical
care
status.
health
is this
insurers
their
medical
i s responsibly
physicians
treat
personal
Not only
that
competent
public
Wilson
policy in
539
the
prrivate
insurer
context.
540
Hughes
the
v. B l u e
same d e n i a l
care
physician
was b a s e d
Fair
a standard
oF N o r t h e r n
oF h o s p i t a l
as o c c u r r e d
on b r e a c h
dealing
Cross
oF
because
which
stay
CaliFornia
prescribed
i n Wickline.
implied
care
was n o t i n a g r e e m e n t
by t h e
The c a u s e
covenant
t h e managed
involved
oF g o o d
oF
action
Faith
organization
with
primary
and
had
employed
t h e community
54 1
standard.
MCO
must
Those
the
The c o u r t
be c o n s i s t e n t
concerned
potential
communities
which
their
Currently,
negligence
with
that
own
insurers
view
breach
oF h e a l t h
when
that
oF c o m m u n i t y
standards.
care
should
oF m e d i c a l
care
by t h e
542
consider
care
ina l l
i s d i c t a t e d by
organizations, a l l
standards.
breach
or implementation
-1G1-
utilized
standard
a n d managed
oF c o n t r a c t ,
in the design
medical
i. n t h e standard
is possible
oF
the standard
community
the Future
alteration
a proJ. i . F e r a t i o n
espousing
about
held
oF
oF
warranty,
quality
assurance
�and
cost-containment
tortious
are
interFerence
a l ltheories
upon
stemming
From
so
to their
vital
which
was
cost
i n.s u r e r s
physician
with
sclerosis
victims
oF t r u s t ,
relationship
may Face
liability
review
goals.
and
that
appears
I t i s a problem
solution.
sclerosis
unsuccessFul
breach
utilization
containment
in su r a r rarused
multiple
Fraud,
the doctor/patient
the prospective
n o t and w o u l d
were
with
which
demands p r o m p t
One
with
mechanisms,
coverage
based
on t h e F a c t
n o t improve
in their
accepted
For t r e a t m e n t
From
that
oF a
h i s condition
the treatment.
attempts
t o impress
Physicians
the insurer:'^
medical
knowledge
improve
don't
patient
that
multiple
but the treatment
i s necessary
543
to
assure
that
Medical
~: am1ne
<
the condition
underwriting
appl icants
does n o t d e t e r i o r a t e .
i s t h e process
and d e t e r m i n e
u t- o n e - h a I F m i l l i o n a n n u a l
receive a risk
being excluded
coverage
v/hethsr
applicants
by
h1 • i
:
'• ur ri
o r not. t _ i - - s • >
For h e a l t h
insurance
c1 a s s i F i c a t i o n w h i c h condemns them t o e i t h e r
From a n y i n s u r a n c e c o v e r a g e o r a c c e p t e d F o r
544
but with
exorbitant
premiums.
S p e n d i n g F o r p r e v e n t j . ve m e d i c i n e , i n c l u d i n g g e n e t i c
GENETIC ENGINEERING.
t e s t i n g , w i l l provide inescapable long-term beneFits.
Genetic
research
and t e s t i n g
preventable
•ue
already
and
must
conditions
be e n c o u r a g e d
i s essenti. a l t o Future
to the discrimination
e x h i b i t i n g when
tendencies,
genetic
because
they
which
obtain
inFormation
- 152-
health.
insurance
knowledge
m u s t be
k n o w l e d g e oF
companies are
oF g e n e t i c
legislatively
traits
�excluded
From r e v i e w
respond
negatively
the
inFormation
For
high
costs,
by F u n d i n g
ScientiFic
objections
is
From
everyone
Genetic
into
research
t o achieve
the greatest
aspects
Genetic
best
deFective
genetic
productive
n o t be a b l e
Future
insurance
during
health
Genetic
good
health
when
testing
reveals
be t r e a t e d p r i o r
genetic
and wide
race.
engineer-
publicity
which
oF t h e
i s a problem
care
which
must
reForm.
to the beneFits
through
i t may
i s the
oF
retaining
be
Genetic
and t e s t i n g
be p o s s i b l e
preconditions
t o the onset
- 1 S3-
carriers
although
many
counter-
oF p r e d i c t i v e m e d i c i n e
oF t h e p o s s i b i l i t y
genetic
oF
addressed
I t i s d i s c r i m i n a t o r y and
engineering
because
i s using the
i n t h e F a c e oF k n o w l e d g e
advantage
achievable
cost.
on t h e human
that
i t
will
a t lower
c o n t r a c t i n g a disease,
access
t o take
Yet,
which
The d i F F i c u l t i e s
health
become i l l .
t o deny
support
medicine.
oF e v e n t u a l l y
never
and l i F e
care.
has r a i s e d
groups.
i s p r e d i c t i v e medicine
material
Formed
preventive
and e n g i n e e r i n g
God b e s t o w e d
potential
inFormation
engineering
religious
oF
breakthroughs.
engineering
genetic
at risk
carriers
and
oF a l l
and h e a l t h
policies
are
diligent
a i d to preventive
employment
the
expensive
a healthier liFe
giFt
view
For h a r b o r i n g
i s n o t ' p l a y i n g God,' i t
projects receive
beneFicial
can
t h e Far l e s s
chosen t o
and n a r r o w
oF u t i l i z i n g
i s e s s e n t i a l t o human h e a l t h
ing
by
persons
many c o n s e r v a t i v e
engineering
human m i n d ,
I n s u r e r s have
a short-term
instead
research
precisely genetic
enable
It
and w i t h
by c o n d e m n i n g
medical
positively
by i n s u r e r s .
oF
improved
engineering.
actually
aid in
t o avoid
oF s e r i o u s
oF d i s e a s e .
serious
diseases
promoting
illness
which
IF the p o l i t i c a l
�power
of
testing
It
insurance
would
i s only
be
companies
a huge p o s i t i v e
the
power
of
a specter
into
t o be
avoided.
employers
to reFuse
deFects.
In that
acknowledge
corrective
the
could
negative
action
discounted,
i n the
i n s u r e r s which
to hire
very
be
who
sense,
genetic
to assure
are
positive
as
health
the
even
care.
testing
influencing
carriers
insurers'
Findings
of
i s making
I n s u r e r s are
those
real
Future
genetic
oF
genetic
reFusal
to
o p p o r t u n i t i e s For
Future
h e a l t h borders
on
pathogenic.
There
should
employment
Found
and
t o be
progressed
would
be
logical
genetic
and
with
employees
oF
insurance
oF
p o i n t to which
oF
the
insurance
the
From
i t has
coverage
or
would
not
economic
necessity
workForces
reduce
long-term
--
reduce
h e a l t h and
--
reduce
workers'
--
reduce
potential
are
had
not
be
and
thereFore
secure.
now
when
Future
eliminating
i n order
I t i s not
i t is
health.
g e n e r a l l y agree.
oF
there
They
high
are
risk
to:
absenteeism;
--
who
arrived,
gene
alter
those
science
IF
insurance
continued
oF
now
would
however,
reduce
coverage
deFective
employment
their
permitting
disease.
possible to beneFicially
Employers,
Faced
question
carriers
knowledge
to reFuse
becoming
no
continued
to the
no
employment
be
More c o m p a n i e s
health
disability
compensation
liability
are
pre-employment
genetic
that
are
the
tests
problems;
oFten
costs;
payments;
For
becoming
and
insurance
occupational
interested
in
enzyme s c r e e n i n g
inaccurate.
- 1 E4-
The
accidents.
instituting
despite
the
Fact
current targeted
�conditions
kidney
are atherosclerosis;
and l u n g
disease;
high
diabetes; hypertension;
cholesterol;
urinary
liver,
tract
546
infections;
and p e r i o d o n t a l
Approximately
disease.
4 , ••• d i f f e r e n t
diseases
have
been
identified
547
which
of
a r e each
these
caused
single-gene
by a s i n g l e
diseases
defective
gene.
c a n be d e t e c t e d
Seventy
through
548
diagnostic
occur
testing.
as a r e s u l t
Most
diseases
of i n t e r a c t i o n
between
genetic
to
are " m u l t i f a c t o r i a l "
make up ( p r e d i s p o s i t i o n ]
, ^
54S
external
factors.
with
an
and
individual's
the addition
of exposure
The i n f l u e n c e o f t h e e n v i r o n m e n t ,
however,
r e m a i n s t h e w i l d c a r d i n most c a s e s , because
possess ion o f t h e g e n e t i c p r e d i s p o s i t i o n alone
may be i n s u f f i c i e n t t o c a u s e d i s e a s e .
I t is
l i k e l y t h a t f o r some t i m e m o d e r n s c i e n c e w i l l be
more s u c c e s s f u l i n i d e n t i f y i n g t h e genes and t h e
markers than i n i d e n t i f y i n g t h e environmental
a g e n t ( s ] necessary f o r a c t i v a t i o n of t h e
p r e d i s p o s i n g g e n e s . ... O f t e n , p r e d i s p o s i t i o n
o n l y m a n i f e s t s i n d i s e a s e when t h e r e i s
a c c o m p a n y i n g e n v i r o n m e n t a l i n s u l t , e.g. t o x i c
substances, viruses, or other disease. ^
5 5 1
(underlining
supplied)
"Conceivably
everybody
carries
genes t h a t
are associated
55 1
with
it
some p r e d i s p o s i t i o n
i s imperative that
to certain
h e a l t h care
from t e r m i n a t i n g p o l i c i e s
p a r t i c u l a r di. s e a s e s .
of those
Many o b j e c t t o g e n e t i c
paternalistic
heritable
involved.
testing
and d i s c r i m i n a t o r y ,
c o n d i t i o n s a r e beyond
Others
ing
benefits
the
worker
both
with
diseases."
reform
prohibit
insurers
who a r e p r e d i s p o s e d
on t h e b a s i s
and p a t e n t l y
the control
counter
that
workers
and i n d u s t r y
valuable
laws
Therefore,
argument
that
i ti s
unfair
because
of the individual
by s t a t i n g
because
i n f o r m a t i o n which
to
may
that
test-
i t provides
be u s e d
�preventively
endangered
sick
and,
by
days
or
thereFore,
illness,
nor
disabiliity
the
employee's
i s the
job
employer
payments
or
is
not
inconvenienced
worker
by
replacement
555
concerns.
lower
Additionally,
rate,
the
levels,
lower
claims,
and
employer
insurance
medical
would
enjoy
premiums
Fewer p o t e n t i a l
bills
could
higher
and
at a
productivity
workers'
lawsuits.
remain
compensation
Insurance
companies
c o u l d e n c o u r a g e and p r o v i d e c o v e r a g e For p r e v e n t i v e c a r e
which
c o u l d k e e p p r e m i u m s and b e n e F i t s a t l o w e r l e v e l s .
Those
p 5 3
are
beneFits
made oF
use
oF
which
genetic
knowledge
could
accrue
inFormation
which
t o s o c i e t y j_F p o s i t i v e
r a t h e r than
i n s u r e r s are
the
more
use
likely
were
negative
employing.
Occupational exposures to c e r t a i n substances
can a l t e r g e n e t i c makeup t h r o u g h s t r u c t u r a l
damage t o b o t h g e n e s a n d c h r o m o s o m e s .
Genetic
d a m a g e - - r e g a r d l e s s oF c a u s e - - a p p e a r s as
r e c e s s i v e and d o m i n a n t m u t a t i o n s , l a r g e r e a r r a n g e m e n t s oF ONA,
p o i n t m u t a t i o n s , a n d l o s s oF g e n e t i c
m a t e r i a l , l e a d i n g t o d i s t o r t i o n s oF e i t h e r t h e
e x p r e s s i o n o r b i o c h e m i c a l F u n c t i o n oF g e n e s .
B u t n o t a l l m u t a t i ons c a u s e d i s e a s e . 5 5 4
Reports
result
not
so
in heritable
clearly
the
that
most o c c u p a t i o n a l
damage.
understood
Former
There
and
suggest
between
b e l i e F may
diFFerence
do
the r e l a t i o n s h i p
mutations
e v e n t u a l l y be
is a signiFicant
genetic
However,
exposures
and
proven
between
health
not
is
eFFects""
erroneous.
genetic
screening
monitoring.
With screening, a one-time t e s t to d e t e c t a
s i n g l e t r a i t i n a w o r k e r or j o b a p p l i c a n t i s u s u a l l y
s u F F i c i e n t , w h i l e m o n i t o r i n g ( F o r chromosomal damage)
g e n e r a l l y i n v o l v e s m u l t i p l e t e s t s oF a w o r k e r o v e r
time (For s u s c e p t i b i l i t y to o c c u p a t i o n a l
illness).
M o s t i m p o r t a n t l y , g e n e t i c s c r e e n i n g F o c u s e s on t h e
p r e e x i s t i n g ( i n h e r i t e d t r a i t s which are u n r e l a t e d t o
the
w o r k o l a c e ) q e n e t i c makeup t h a t w o r k e r s o r j o b
_ 1E5-
3 -
�Biological Consequences of Exposure to
Mutagenic Agents
Components of Genetic Testing in the
Workplace
Exposure
Genetic monitoring
j
!
immediate
:— ettects ot
exposure
Genetic
damage
Occupationally related
exposure
! Cell oeain
Repan
Mutation
Womers
j
j
I
Delayed
adverse
heaitn
outcomes
Somatic cell
change
I Reproauctive
!
loss
I
Nonoccupationaliy
related disease
Woikers
Cancel
Heritable
disoraer
|
Genetic screening
Somatic cells
Germ cells
Occupationally relateC
disease
Job applicants
1
Occupationally related
disease
J
[ )
Occupationally relatec
susceptibility
SOURCE: Otlice ol Tecnnoiogy Asssssmem. aaaoiea trom J.B. Wara.
"Issues in Monilonng Population ELxposures." Cascmogens and
Mutagens in the Environment Volume II. The Worx&lace. Hans
F. Sticn iod.i (Boca Raton. R_: CRC Press. 1985).
p.3
Nonoccupationaliy
reiatea susceptiDili!>
SOURCE: CWioe ot Tecfinology Assessman'.. 199C.
p . 3?
Genetic Tests Available and Total
Americans Affected
Genetic condition
Total cases
Currently
available:
Adutt polycystic kidney disease
Fragile X Syndrome
SickJe cell anemia
Duchenne muscular dystrophy
Cystic
fibrosis
Huntington's disease
Hemophilia
Phenylketonuria
Retinoblastoma
500.000
100,000
65.000
32.000
30.000
25.000
20.000
16,000
10,000
Total
Potential future
Hypertension
Dyslexia
Atherosclerosis
798,000
tests:
58,000.000
15.000,000
6,700,000
Cancer
5,000.000
Manic-depressive illness
Schizophrenia
Type 1 diabetes
'imiliaJ Alzheimer's
jltiple sclerosis
.Myotonic muscula/ dystrophy
2,000.000
1,500.000
1,000.000
250,000
250,000
100.000
Totai
89.800.000
SOURCE: MedicaJ WondNews. p. 58, Apr. 11, 1988.
p.
15
Source :
U.S. C o n g r e s s , O F F i c e oF
Technology Assessment,
" G e n e t i c M o n i t o r i n g and
Screening i n t h e
Workplace"
OTA-BA-455
( W a s h i n g t o n , DC:
U.S.
Government P r i n t i n g OFFice,
October, 1930)
pp.
9, 15, 33
�applicants bring to the job.
This i s d i s t i n c t from
g e n e t i c m o n i t o r i n g w h i c h f o c u s e s on h a z a r d o u s w o r k p l a c e
exposures t h a t induce changes i n the g e n e t i c m a t e r i a l
i n an e x p o s e d p o p u l a t i o n as a w h o l e . o 5 B
Genetic
screening
For
occupationa 11y-re1 ated
nonoccupationa11y-re1 ated
1.
to
improve
compensation
traits
employee
costs
through
could
be
productivity
traits
and
For
perFormed:
and
lower
b e t t e r worker h e a l t h
workers'
[beneFits
the
employer) ;
2.
to
eFForts,
improve
employers'
e s p e c i a l l y For
health
health
through
exclusion
with
gene s t r u c t u r e b e c a u s e
health
to promote
and
the
genetic
also;
(This
i . e . , not
oF
the
could
hiring
potential
be
those
drain
on
insurance);
3.
cost-containment
insurance.
accomplished
altered
care
through
use
oF
4.
who
to
are
determined
diseases;
5.
ensure
(oF
to
to
and
to
health
interest
determine
lead
death
mation
are
to
employees
need
to
hazards;
_
to
worrkers'
suits.
which
Genetic
can
necessary,
be
both
lower
(oF
areas
5
precautions. ''
advocate
worksite
susceptible
i d e n t i F y work
Employers
can
be
general
counselling
appropriate
previously-unknown
B.
encourage
7
(oF
genetic
i n the
exposure
and
oF
employees
occupational
levels
to
need
and
employee);
unions)
interest
monitoring
to
to certain
testing
the
placements
and
which
awareness
(beneFits
interest
compensation
used
health
unions)
increased
to
oF
saFety
unions)
because
health
sometimes
screening
even
-167-
and
For
wrongful
provide
i n d i c a t e when p r e v e n t i v e
workplace
risks
employee
inFor-
actions
health
�558
care.
For
tested
would
could
the
him
physician
An
an
individual
know w h e t h e r
render
producing
he
susceptible
could
occupational
and
exist.
counsel
so
physician
a strict
A n d r e w s and
unauthorized
disclosure
oF
either
a p p l i c a n t or
job
possibility
and
oF
suit
violation
employee
bargaining
The
may
r u l e .
Fitness
at
5
6
are
3
will
There
an
the
this
knowledge,
in a
dust-
employee's
one's
could
treating
however,
be
inFormation
employee.
tortious
Occupational
held
liable
right
his union's
For
concerning
public disclosure
under
that
In addition to
constitutional
does
oF
to
the
private
privacy,
collective
or
Medical
Association
Code
oF
r e c o m m e n d s t h a t c o n F i d e n t i a l i t y be
maintained
inFormation to the employer r e g a r d i n g
552
For
the
subject
based
type
to
the
the
on
oF
work
intended.
doctor/patient
current status
are
genetic
test
Free
oF
conFidentiality
the
to reFuse
results
SpeciFic
which
employment
and/or
may
not
terminate
be
reliable.
present,
directly
With
point out,
medical
a claim
B e c a u s e oF
employment
At
oF
i s not
employers
d o c t r i n e , employers
accurate
which
agreement.
ethical.
conduct
by r e l a t i n g o n l y
diagnoses
For
File
American
medical
deFiciency
working
to avoid
Jaeger
and
an
a genetic
been g e n e t i c a l l y
physician/patient relationship
550
physicians
Facts
had
t o emphysema.
him
occupational
a
had
who
environment.
physician
not
example,
with
there
the
is a
subject
is considerable
case
very
oF
limited
genetic
body
oF
monitoring
law c o n c e r n i n g
- 1S8-
drug
law
or
and
dealing
screening.
alcohol
�testing,
This
and t h e body
o f law r e l a t e d
i s t h e law c u r r e n t l y
cases.
I t i s expected
concerning
genetic
medical
testing
being
that
issues
i si n c r e a s i n g .
applied t o genetic
changes
testing
t o AIDS
testing
i n t h e common l a w
o f workers
i n t h e near
generally will
future,
inFluence
a n d may h e l p
shape
565
legislation.
--
The m a j o r
privacy
issues
concerns
a t present a r e :
surrounding
unwanted
monitoring or
screening ;
--
conFidentiality
--
potential
--
Future
--
oF t h e i n F o r m a t i o n
discrimination
obtained;
i n employment
5 6 5
h e a l t h oF t h e t e s t e d w o r k e r s .
u s e , by h e a l t h and l i F e
inFormation
t o determine
Fortunately,
insurance
risk
some p r o t e c t i o n
opportunities;
and.
companies,
oF g e n e t i c
and coverage;
i s a f f o r d e d employees
by a d a p t i n g
567
federal
legislation
t o t h e issues.
^63
The
Occupational
to
an e m p l o y e e ' s
to
communicate
unions
to
Actual
medical
provided
and
with
5 6 9
because
authority
5 7 1
records,
with
Act"
and a l s o
regulates
requires
Under
o f each
employee, however,
OSHA r e q u i r e s , h o w e v e r , t h a t
medical
interest
t h e government
Federal
t o access
employers
OSHA
i n f o r m a t i o n on e m p l o y e e s '
access
rules,
exposures
and a n a l y s i s o f r a t e s o f exposure.
employees'
confidential
and H e a l t h
t o i t s employees.
records
governmental
benefits.
and
hazards
hazards,
confidential.
strong
medical
areprovided
potential
Safety
ity.''
i nensuring
provides
agencies
medical
5
7
records, ' ^
have
records
-
- 163-
g o v e r n m e n t be
based
safe
remain
on t h e
workplaces,
h e a l t h and d i s a b i l i t y
statutory
despite
grants of
claims
of privacy
�The
Employee R e t i r e m e n t
prohibits
already
Income S e c u r i t y
From d i s c r i m i n a t i n g a g a i n s t
employers
medically
h i g h - r i s k employees,
employees
who
The
must u n d e r g o
National
examinations
collective
protected
Labor
and
From
Act^
testing
be
subjects.
genetic
but
does n o t
pre-employment
Relations
medical
bargaining
574
7 5
but
(ERISA]
screening.
requires
that
physical
mandatory
employees
job
. ,
potential
protect
considered
Thus,
testing,
Act
could
applicants
and
be
non-union
575
employees would
Title
genetic
group'
civil
not
V I I oF
testing
which
the
the
against
by
could
578
Civil
by
Rights
oF
render
a
this
Act
oF
'disparate
testing
Civil
Rights
employers
Act
or
to
Act.
1364
impact
violative
L e g i s l a t i o n i s being
inFormation.
include
i n s u r e r s on
oF
5 7 7
on
an
considered
those
the
New
suspect
Jersey's
class.
The
s t a t u t e which
may
a
apply
to
protected
individual's
which
would
discriminated
basis
oF
These p o t e n t i a 1 1 y - h i g h - m e d i c a 1 - r i s k
become a p r o t e c t e d
resemble
protected
because
rights.
expand
be
Federal
prohibits
genetic
people
could
legislation
an
employer
From r e F u s i n g t o " h i r e o r e m p l o y . . . b a r
o r . . . d i s c r i m i m a t e " a g a i n s t a p e r s o n on
"...atypical
The
hereditary cellular
Americans With
discrimination
who
contract
assistance.
Disabilities
against
with
In
the
1994,
handicapped
Federal
this
businesses
which
employ
time
1994,
a cause
aFter
or
Act
prohibits
individuals
government
legislation
FiFteen
oF
or...discharge...
t h e b a s i s oF
any
579
blood
trait."
580
or
or
will
by
receive
aid
Federal
extend to a l l
58 1
more w o r k e r s .
a c t i o n may
- 1 70 -
employers
in
Some
determining
may
�whether
a genetic
mrker
or t r a i t
would
c o n s t i t u t e an
impairment.
Section
504 o f t h e R e h a b i l i t a t i o n A c t o f 1973 g u a r d s t h e
handicapped
that
this
person.
not
Act w i l l
discrimination, but i t i s not likely
protect the potentially
The A c t ' s d e f i n i t i o n
coincide
risk
and
against
with
by g e n e t i c
may n e v e r
State
harm
takes
decades
of a handicapped
that
a person
o r enzyme t e s t i n g
become
laws
incur
the fact
ill
provide
high
medical
person
deemed
i s not i l l ,
a high
risk
does
medical
n o t handicapped,
or handicapped.
n o - f a u l t compensation
of their
as a r e s u l t
t o w o r k e r s who
However,
f o r genetic
employment.
damage t o o c c u r b e c a u s e
i t often
ofthe
582
employment
North
environment.
Carolina
genetic
As o f 1 9 8 3 , F l o r i d a , L o u i s i a n a , a n d
limited
testiing
t h e u s e oF i n F o r m a t i o n
anemia
against
carriers.
Pennsylvania,
anemia.
Tay-Sachs c a r r i e r s
Arizona,
Rhode
cell
Montana,
New
From
Flatly
583
b a n n e d e m p l o y m e n t d i s c r i m i n a t i o n b a s e d on g e n e t i c t r a i t s .
C a l i F o r n i a a n d s e v e n o t h e r s t a t e s p r o h i b i t i n s u r e r s From
discriminating
For s i c k l e
gleaned
Jersey
or s i c k l e
New Y o r k ,
I s l a n d and Texas e i t h e r
cell
Oregon,
have
laws i n
584
place
or are currently
Given
grounded
t h e u n c e r t a i n t y oF o u t c o m e s
on e x i s t i n g
Representative
the
w o r k i n g t o pass
John
laws
federal
privacy
persons
are assured
From
court
decisions
but pertaining to genetic
Conyers
Human Genome P r i v a c y
them.
(D-Mich.)
recently
A c t (H.R.2045).
act to include
genetic
of t h e ' r i g h t
introduced
The a c t e x t e n d s t h e
i n f o r m a t i o n so
t o determine
- 1 71 -
testing,
that
the disclosure
�SELECTED VITAL STATISTICS AND
DEMOGRAPHICS
STATE HEALTH RANKINGS
RANK
39
50
39
39
22
10
5
25
44
34
4
33
34
20
7
10
38
45
12
23
7
25
1
47
25
18
5
47
3
16
DO-4
STATE
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW H A M P S H I R E
NEW JERSEY
LIFESTYLE'
ACCESS'
DISABILITY
42
23
34
40
31
12
16
29
50
38
5
8
40
29
12
17
39
41
2
6
45
4
46
6
34
26
3
4
49
6
48
32
40
12
22
1
16
29
29
5
46
36
23
16
7
38
45
19
7
3
24
6
47
28
41
14
34
2
19
4
21
42
46
11
34
17
The Universal
Healthcare
*
6
21
21
45
12
1
12
12
28
45
28
28
12
41
12
28
21
28
28
45
12
41
9
28
Almanac
3
DISEASE
19
44
47
30
39
4
25
42
45
30
19
13
26
14
10
9
28
27
19
43
30
14
3
19
37
7
4
MORTAL
45
45
21
34
21
13
9
40
27
48
2
34
30
29
3
9
40
44
14
30
6
34
3
49
i. I
16
g
48
12
41
40
X
19
Table '
�SELECTED VITAL STATISTICS AND DEMOGRAPHICS
STATE HEALTH RANKINGS - CONTINUED
RANK
45
34
32
12
19
25
43
20
17
39
23
34
30
1
12
15
30
49
7
25
LIFESTYLE'
STATE
NEW MEXICO
NEW Y O R K
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
R H O D E ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
31
4X
3K
2
26
23
26
22
23
44
9
44
31
1
12
20
12
34
9
20
ACCESS'
DISABILITY
3
i
50
12
25
44
20
25
36
11
HI
33
43
31
34
20
14
9
25
49
16
42
12
21
28
28
21
21
45
41
12
28
28
5
6
28
12
11
45
28
9
DISEASE
4
MORTAL
19
45
30
2
16
28
50
40
37
30
40
37
1
211
37
21
21
9
50
18
37
36
7
30
24
6
16
16
49
30
11
1
21
5
14
21
16
45
6
30
' L I F E S T Y L E F A C T O R i n c l u d a lha»e componenU (hat reflecl on Ihc way wc live and accounlj lor M)% of the overall ranking The componenu and respective percenugej arc: Prevalence o(
Srooking-10%, M o l o r Vehicle Deaitu 5%. Vtolenl Cnme Rate 5%, Risk (or Mean Disease 5%. and Percent ol High Scfu-ol f.raduaies 5%.
ACCESS F A C T O R meuures Ihe avaiUbtlily o( healih care lo the population o( the slate and accounts lor 2 0 ^ of the overall ranking. The componcnis and rapectrve percrnLages are
Unempteiyment R»te -5%, Kesuier Index (mejuure of accoa l o prenatal care) 5%, Health Manpower Shortage Areas 5%. and Resource I n d a (tneaiures l u t e ' s expenditures OA health care) 5%.
' D I S A B I L I T Y F A C T O R meuures Ihe impact of disability on a state s health and associated lost time, but because the data on a slate by sine level was poor, only 5% was assigned to this factor
The componenu and rapeciive percentages are: A c l m l i e s U m i l a l i o n Status 2.5% and Acute Illnesses 2 5 ^
*DISEASE F A C T O R measures Ihe burdens thai diseases and illnesses place on the overall health of the populaiion and accounts for 20% of the overall ranking The components and respenivr
percenlages are: Heart Disease 7.5%. Cancer Cases 7.5%, and Infectious Disease 5%.
M O R T A L I T Y F A C T O R consists of three oomponcnls measuring death rales and accounts (or 25% of Ihe overall ranking
Ihose componenls and respective percenlages arc: Total Mortality
Rate 10%, Inlanl Mortality Rale 7.5%, and Years of Potential U l e Lost 7 5%
SOURCE:
90-4
T H E N O R T H W E S T E R N N A T I O N A L L I F E I N S U R A N C E C O M P A N Y S T A I I I H f c A L T H R A N K I N G S . 1990 E D I T I O N
"The
Universal
Healthcare
Almanac,"
(Phoenix:
Silver
S Cherner,
Ltd.)
1991
l a t }
i
e 1 1
.g2
�585
of
their
own
testing
records.
attorney
for Representative
does n o t
address
the
privacy
privacy
it
of
genetic
of r e c o r d s
to
are
this
legislate
the
privacy
employers
and
occupational
reason,
even
by
13,
the
there
has
insurance
1 9 9 1 , and
587
present.
the
genetic
under
testing
the
by
real
industry.
intent
i s to
Americans
to
private
insurers.
were
support
this
held
Disabilities
For
bill
on
From
legislatively
With
October
those
expand
Act
to
include
not s p e c i F i c a l l y
588
provide protection against genetic d i s c r i m i n a t i o n .
The A m e r i c a n C o u n c i l oF L i F e I n s u r a n c e r e p r e s e n t s
BOO
c o m p a n i e s w h i c h w r i t e a b o u t 93 p e r c e n t oF t h e n a t i o n ' s l i F e
insurance
America
early
policies.
represents
Together,
in
they
1992,
availability
to
iF Forthcoming
by
As
records
f a r as
objection to
broad
assures
government.
so
and/or
Hearings
received
go
bill
maintaining
public
established
physicians
no
the
of
does n o t
records
the
H.R.2045 m e r e l y
privacy
bill
been
bill
Conyers'
protection
of
the
that
concerning
maintained
assure
staff
stated
information.
that
private records,
this
Conyers,
Sherille,
585
a l l p e r t i n e n t issues
i s much e a s i e r
than
Mr.
The
Formed
generate
of
genetic
establish their
Health
commercial
have
r e g u l a t i o n s do
the
Insurance
health
a special
insurers
task
Force
Insurers
to genetic
oF
nationwide.
which
industry's position
information.
"right"
Association
on
will,
the
will
information in
seek
order
589
to
a p p r o p r i a t e l y assess
oF
view,
however,
appropriate
risk,
i t may
risk.
appear
From
that
i n s u r e r s w i l l be
- 1 72-
an
insured's
rather
than
attempting
to
point
assessing
exclude
as
�much r i s k
as
is scientifically
Legislation
prime
importance
health
care
should
at
their
least
to the
interest
used
The
an
of
involved
in
activist-oriented
r e p r e s e n t a t i v e s of
l e a d p r o v i d e d by
and
By
the
of the
industry
not
of
on
i s making
and
able
and
becomes
tools
of
their
macro-data,
monitoring
privacy.
the
insurance
(be
contain i f
demographic
gaining control
genetic testing,
refusing
might
current
monitoring information
poses
i n the
of unobtrusive,
tables
i s already
effects
provided
in establishing
these
here
industry
will
range
becomes p a r t
becomes s t i g m a t i z i n g
society
are
of g e n e t i c screening
negative
insurance
what
and
associated with
care.
testing
be
knowledge of c o n s t i t u e n c y
pages w h i c h
invasive right
insurance
imposing
health
not
the
insurers
information
micro-data
represents
momentum
Without
the broad
by
Consider
to i n s u r e r s ,
the
The
are
follow
facing
genetic screening
industry.
(and)
two
data
criteria.
available
the
will
groups
Congressional
issue.
of d e m o n s t r a t i n g
non-personal
while
their
should
industry.
Refer
future
the
legislators
insurance
is
on
activist
C o n s u m e r s who
notify
position
genetic testing
t o consumer
reform.
positions,
risk
concerning
possible.
and
future
of
to those
sure
that
socially
that
and
control
American
with
defects,
"...genetic
handicapping...
to) benefit
from
new
590
approaches
to disease
is
unacceptable.
totally
industry
and
control
will
with
a
placed
have
legislative
prevention."
with
This
C o n t r o l m u s t be
the
indivual
consequences.
mandate
is imperative.
73-
wrested
control
from
himself--where
positive
- 1
negative
Individ ua1
the
that
control
�AMERICAN MEDICAL
ASSOCIATION.
"The
Medical
American
A s s o c i a t i o n i s perhaps
the
53 1
strangest
trade union
The
AMA
and
students,
ing
has
thus
throughout
i n the
t h e power
United States."
to r e s t r i c t
t h e number
the n a t i o n .
oF
By
t h e number
licensed
of
medical
physicians
restricting
entrance
practicinto
the
592
Field,
incomes
The
AMA
Hospitals
adhere.
he
oF
the proFession
e s t a b l i s h e d the
which
No
members oF
Council
sets standards
one
may
i s a graduate
obtain
oF
a
t o which
license
a medical
on
remain
Medical
medical
Education
schools
to practice
school
approved
elevated.
must
medicine
and
and
unless
a c c r e d i t e d by
593
the
Council.
In
care
the
U n i t e d S t a t e s , government
industry
regulatory
group
and
thereFore
oF
AMA
the
control
cally
been
weak
594
statements.
Control
and
has
insurance
the health
positioned
independence
care
AMA
i s an
care
the
such
industry
body
pressures
political
will
as
to
structural
gained
The
was
oF
by
stated
" t o promote
public
belieF
such
purpose
oF
the
AMA
the science
and
a r t oF
health."
that
the
a major
society
5 9 S
only
Over
way
time,
ambiguous
care
reForm
and
cohesive
Field.
must
the
place
strategi-
oF m a i n t a i n i n g
insurers.
probably
views
be
gained
and r e v i e w s
595
beneFits
change.
when
i t was
medicine
Founded
in
and
betterment
the
t h e AMA's p o s i t i o n
to achieve
- 1 74-
health
a s t r o n g and
t h e AMA
control
the
resides within
i s capable
merely' i n i n c r e m e n t a l stages
be
health
care
with
which
oF
with
currently
Health
oF
ideologically
i n the
industry
industry.
governing
From
UnFortunately,
The
Fragmented
a s t r o n g Force
the health
oF
and
control
their
stated
goal
1347
included
was
to
the
�assure
that
through
anything
private
having
t o do
means, w i t h o u t
w i t h medicine
any
semblence
was
of
accomplished
government
597
intrusion.
AMA
even
This
belieF
was
carried
t o such
extremes
that
the
opposed:
--President Roosevelt's
S o c i a l S e c u r i t y Program
- - P r e s i d e n t Truman's n a t i o n a l h e a l t h c a r e program
- - P r e s i d e n t J o h n s o n ' s M e d i c a i d and M e d i c a r e p r o g r a m s
-- c o m p u l s o r y v a c c i n a t i o n a g a i n s t
smallpox
- - m a n d a t o r y r e p o r t i n g oF t u b e r c u l o s i s c a s e s
- - e s t a b l i s h m e n t oF p u b l i c v e n e r e a 1 - d i s e a s e
clinics
- - e s t a b l i s h m e n t oF Red C r o s s b l o o d b a n k s
- - F e d e r a l g r a n t s For m e d i c a l s c h o o l c o n s t r u c t i o n
- - F e d e r a l g r a n t s For m e d i c a l s t u d e n t
loans
- - B l u e C r o s s and o t h e r p r i v a t e h e a l t h i n s u r a n c e p r o g r a m s
- - g o v e r n m e n t s u b s i d i e s t o r e d u c e m a t e r n a l and i n F a n t d e a t h s
- - F r e e c e n t e r s For c a n c e r d i a g n o s i s .
5
Richard
195Cs a n d
which
H a r r i s , a staFF
19BDs, was
occurred
writer
primarily
For
The
interested
p r e d i c t a b l y whenever
9
3
New
Yorker
in political
a major
issue
in
the
warFare
surFaced.
599
One
oF
oF
the
h i s books
American
Truman's
disclosed
Medical
proposed
Harris'
the
Association
national health
opening
massive
statements
and
successFul
i n opposing
insurance
describe
eFFort
President
program.
the
mission
oF
special
interest
groups:
Since the p o l i t i c i a n ' s F i r s t p r i n c i p l e i s to
a v o i d t a k i n g on any m o r e o r g a n i z e d o p p o s i t i o n t h a n
he h a s t o , t h e F i r s t p r i n c i p l e F o r t h o s e
who
want t o i n F l u e n c e p o l i t i c i a n s i s t o o r g a n i z e . . .
In a sense, the Washington r e p r e s e n t a t i v e s
oF s p e c i a 1 - i n t e r e s t g r o u p s c o n s t i t u t e a t h i r d
h o u s e oF C o n g r e s s , s i n c e h a l F oF a l l t h e
m e a s u r e s i n t r o d u c e d i n t h e S e n a t e and t h e
H o u s e oF R e p r e s e n t a t i v e s w e r e o r i g i n a l l y
written
in t h e i r oFFices."600
The
AMA
existence
One
a
oF
gathered
to
become
i t s earliest
proposal
to
study
s t r e n g t h over
a major
i t s First
national political
'accomplishments'
national health
was
the
insurance
90
years
Force
by
in
1925.
d e s t r u c t i o n oF
as
a o a r t oF
the
�Social
Security
campaign
of
program.
I t was
misinformation,
said
t h a t the
f a l s e rumors,
AMA
and
led
scurvy
a
attacks
,. .
S01
on p e r s o n a l i t i e s .
In
1935,
(Secretary
and
were b o t h
also
advocates
the
Borden
and
Millbank
by
on
the
committee
studying
physicians
boycott,
supported
t h a t he
0
insurance . S1935
announced
a busy
passage
that
i n s u r a n c e .'
The
AMA
of
national
a
underwriting
and
encouraged
to t u r n his
elim-
boycott
desirable
costs
6 0 2
care.
of
So
supported
national
the
While
on
a
many
patients
back
was
health
that a
have
n a t i o n a l medical
longer
Millbank
effectively
journals
was
forced
year
of
6 0 4
for
the
i t was
advocated
level.
Their
against
a l l Forms o f
that several
quarter
the
compulsory
motivations
years
of
AMA.
to
his
beliefs
health
Congress
social security b i l l ,
Nevertheless,
bravely
a
no
insurance.
i n f a n t s would
boycott,
was
Fund, r e s p e c t i v e l y ) ,
advocates
which
Millbank
3
was
considerin
for
of
the
that Millbank
announce
as
Fund,
costs
health
i n medical
milk
Millbank
A l b e r t G.
Company.
editorializing
evaporated
and
Millbank
national
the
Borden's
spend
of
of
Kingsbury
effect
AMA
Kingsbury
of
insurance
and
John
Chairman
Chairman
inated
of
Dr.
were
later
so
the
a million
Medical
insurance
completely
CMA
on
the
'sickness
Association
state
eradicated
deemed
d o l l a r s to
AMA
compulsory
California
health
the
was
by
i t necessary
defeat
its
the
to
own
505
program.
As
early
interests
apposed
to
such
as
the
19203,
attempts
establish prepaid
attempts
and
by
group
1934
had
- 1 75-
w e r e made by
health
various
plans.
adopted
a
5 0 5
private
The
statement
AMA
of
�principles
which
come b e t w e e n
relation."
health
declared
Harris points
insurance
out that
have a r g u e d
interFeres with
pocketbook ."
p a r t y must
t h e p a t i e n t and h i s p h y s i c i a n
6 0 7
necessarily
"no t h i r d
BOS
that
be p e r m i t t e d t o
i n any
"Advocates
t h e only
Richard
oF
government
relationship i t
i s t h e one b e t w e e n
Additionally,
medical
Carter
a p a t i e n t and h i s
609
exp1 a i n s . t h a t :
" . . . ( T ) h e AMA's o p p o s i t i o n t o a n y l a r g e s c a l e h e a l t h i n s u r a n c e p r o g r a m has been based
on t h e F e a r t h a t e c o n o m i c p l a n s oF t h a t s c o p e
w o u l d r e q u i r e p u b l i c s u p p o r t so e x t e n s i v e a s t o
necessitate public control.
The k n o w l e d g e
that p u b l i c control w i l l c u r t a i l the proFession's
Fee p r i v i l e g e s u n d e r l i e s o r g a n i z e d m e d i c i n e ' s
p o s i t i o n on h e a l t h i n s u r a n c e and on e v e r y
other
c o n t r o v e r s i a l issue i n t h e Field."610
During
Washington
who
cared
their
t h e Depression,
was F o r m e d .
t h e Group H e a l t h
This
was a g r o u p
F o r 2,500 l o w - i n c o m e
Families
who p a i d
A s s o c i a t i o n oF
oF s e v e n
physicians
government employees and
$2.20 p e r month
i n r e t u r n For
61 1
assured
medical
society
tried
abar-don
t h e group
persuaded
patients
Society
to
over
persuasion
a n d , when
physicians
persuaded
discovered
elderly
The D i s t r i c t
t o t h e group.
morphined
agreed
simple
other
t h e seven
patient
care.
area
oF C o l u m b i a
t o g e t t h e seven
that
d i d n ' t work,
n o t t o reFer
When
even
that
w i t h acute
t o withdraw
staFF
woman h a d b e e n
by a c a r a n d t h e n ,
privileges
One p a t i e n t h a d a l r e a d y
From
the operating
t h e Group H e a l t h
rushed
theater.
care
until
Association.
to a hospital
despite coercion
- ! 77-
been
when h e r d o c t o r
a p p e n d i c i t i s was d e n i e d
From
higher-paying
d i d n ' t work, t h e
i n p r e p a r a t i o n F o r an o p e r a t i o n
he was b a r r e d
doctors to
the Society
other
h o s p i t a l s t o reFuse
physicians.
Medical
after
A
he
An
being run
by t h e h o s p i t a l t o
�denounce
her
refused
association
treatment
with
when s h e
the
kept
Group H e a l t h
insisting
Plan,
that
her
she
own
was
group
G 12
doctor
treat
her.
Finally,
patients,
both
after
the
the
decided
of
the
above m i s t r e a t m e n t
J u s t i c e Department's A n t i t r u s t
AMA
violation
learning
and
the
oF
the
Sherman
i n the
District
oF
Columbia Medical
Antitrust
Supreme C o u r t ,
Division
Act.
The
case
of
indicted
Society
was
For
ultimately
when J u s t i c e Owen J . R o b e r t s
stated:
" . . . ( P r o F e s s i o n a l l i c e n s i n g does n o t )
justiFy
c o n c e r t e d c r i m i n a l a c t i o n to p r e v e n t the people
From d e v e l o p i n g new m e t h o d s oF s e r v i n g t h e i r n e e d s .
The p e o p l e g i v e t h e p r i v i l e g e oF
proFessional
monopoly and t h e p e o p l e may
take i t away."SlJ
The
AMA
do
had
no
above
placed
on
a great
their
deal
about
how
much v a l u e
oFt-repeated
ethical
standard,
end
War
the
"First,
Governor
harm."
Shortly
Warren
oF
bill.
The
pending
aFter
firm
CMA
Blue
plans.
By
advocating
them
an
Cross-Blue
The
the
PR
Shield
and
a plan,
v o l u n t a r y , versus
health
the
campaign
firm's
alternative
such
II,
Association hired
lead
legislation.
proposing
World
a compulsory
Medical
to help
propose
support
oF
supported
California
state
the
the
California
relations
that
says
a public
against
bill
commercial
CMA
insurance
the
recommendation
to the
the
Earl
which
would
health
would
government's
was
insurance
appear
to
be
required, health
6 14
insurance
The
the
plan.
public relations
California
$100,00 0
support
Medical
that year
From
on
firm,
by
assuring
A s s o c i a t i o n would
newspaper
1 D0 California
spend
advertising,
newspapers
- 1 73 -
newspapers
was
t o 432
that
approximately
able
For
the
to
increase
CMA.
�Governor
Warren's
When
to
t h e AMA
the defeat
profession,
That
firm
which
"The
6 1 6
to resign
has y e t t o seek
of medicine,
of
i t s physician
(to
wage)...the
which
with
Congressional
lobby
t h e AMA
rejected,
the explanation
the truth
that
on t h e e c o n o m i c a n d
first,
and t o
6 1 5
t o i m p o s e d u e s o f $ 2 5 on e a c h
members t o r a i s e
greatest
of t h e medical
to put the public
decided
reacted
public relations firm.
to i t s responsibilities."
1 9 4 9 , t h e AMA
public
distrustfu1ness
recommendations
the firm
become a d e q u a t e
a
with
a different
made s e v e r a l
aspects
defeated.
r e a l i z e d t h a t t h e American
i t engaged
Association
In
was
of the b i l l
prompted
social
bill
a $350 m i l l i o n
grass-roots
lobby
"war
chest
in history."
i n v e s t i g a t i n g committee
5 1
'
called the
5 13
fee
" b l a t a n t , undisguised
explained
could
that
t h e AMA
coercion."
One
physician
was n o t a p r i v a t e c l u b
from
w h i c h one
resign.
Membership i s almost i n d i s p e n s a b l e t o t h e
p r a c t i c i n g p h y s i c i a n , b e c a u s e many p r i v i l e g e s
and o p p o r t u n i t i e s s u c h a s h o s p i t a l a p p o i n t m e n t s
and a d m i s s i o n s t o e x a m i n a t i o n
by t h e s p e c i a l t y
b o a r d s a r e c o n t i n g e n t o n s u c h m e m b e r s h i p . 5 19
That
year,
t h e AMA
spent
$ 1 , 5 2 2 , 5 8 3 on
$ 5 5 0 , 0 0 0 on n e w s p a p e r
advertisements,
$250,000
advertisements. ^
firm
f o r magazine
developed
small
businesses
advertising
supportive
owner
reaped
o f t h e AMA
own.
who w e r e
position,
$19 m i l l i o n
with
included
space
- 1 73-
those
t o provide to
to afford
copy
much
which
was
f o r the cusiness
a t t h e bottom.
from
f o r r a d i o and
The p u b l i c r e l a t i o n s
unable
The l a y o u t s
t o a d d h i s name a n d l o g o
a bonanza
1
advertising layouts
nationwide
on t h e i r
$300,000
5
ready-made
l o b b y i n g . 620
The n e w s p a p e r s
prepared
layouts.
�In
1350,
t h e AMA
spent
$250
r e l a t i o n S j and t h e d e f e a t
and
four other
health
which
provided
on
lobbying,
Claude Pepper
members who
submitted
the b i l l
had
nursing
public
(D-Fla. )
supported
was
From
which
Social
would
also
$4,200
Security
have
hospital
major
national
have
t o $5,000,
taxes
a
were
care
recipients.
(D-RI),
5
1957.
5 2 4
The
including
been
imposed.
The
insurance
Means. Forand
paid
oF
The
increase
tax rate
plan
surgery,
between
t h e amount
10 p e r c e n t
health
Aime F o r a n d
diFFerence
i t would
provided
security
i n August
oF
that
own
on Ways a n d
The
home c a r e .
others
social
days
i t s
to Representative
i n Congress
For s i x t y
and
formulated
t h e House C o m m i t t e e
increasing,
to
t h e AFL-CIO
was
introduced
plan
o f Congressman
Congressional
1955,
a member oF
and
dollars
insurance.
In
plan
million
this
For
by
income
tax
on
increase
i n payments
For e m p l o y e r s
625
and
employees
The
would
because
had
increased
and
For s u r g e r y
medical
5
would
raised
from
2
6
The
impose
private
t h e 1950s
63
million
policies
AMA
From
Toward
percent.
also
had
socialized
this
medicine
AMA
decided
enlisting
this
to organize
the assistance
end, s h o r t l y
as
hospitalization
91 m i l l i o n
doubled
opposed
the plan
i n that
bill,
of doctors
b e f o r e t h e 1958
- 1 80-
t o 72
contending
The
lengthy
i t sfight
million,
General
time
nationwide.
and
being
policies
t o 121
t o 109 m i l l i o n .
by i n c r e a s i n g d i s c u s s i o n s
fi?7
1958.
The
by
.50
insurance
alive
during
bill
during
insurance
million.
kept
been
Eisenhower A d m i n i s t r a t i o n opposed
unnecessary
it
have
against
that
bill
was
hearings
the Forand
nationwide.
Congressional
elections,
�t h e AMA
every
developed
a q u e s t i o n n a i r e which
state
and c o u n t y
medical
questiions
illustrate
that
details
of persuasion
was d i s t r i b u t e d t o
society.
The w o r d i n g
t h e AMAs a b i l i t y
had reached
a peack
of the
to attend to the
of
efficiency.
1.
"Who i s t h e p e r s o n o r p e r s o n s i n e a c h w a r d o r c o u n t y
i n t h e C o n g r e s s i o n a l d i s t r i c t who i s m o s t i n f l u e n t i a l
with
Congress?
L i s t t h e names, a d d r e s s e s , and b u s i n e s s o r p r o f e s s i o n
of each."
each
2.
"Who i s t h e p h y s i c i a n who k n o w s a n d c a n w o r k
o f t h e above?"
with
3.
"Who a r e t h e f o u r o r f i v e men i n t h e C o n g r e s s m a n ' s
d i s t r i c t who r e a l l y i n f l u e n c e h i m ?
L i s t t h e i r names,
a d d r e s s e s , and b u s i n e s s o r p r o f e s s i o n . "
A.
"Who
are the p r i n c i p a l
contributors
5.
"Who i s t h e C o n g r e s s m a n ' s p e r s o n a l
home a n d i n W a s h i n g t o n ? "
t o h i s campaign?"
physician at
6.
"What a r e t h e C o n g r e s s m a n ' s h o b b i e s ,
c h a r i t i e s , boards or o r g a n i z a t i o n s , church?"
his
7.
last
"What n e w s p a p e r s i n t h e d i s t r i c t
campaign?
What i s t h e i r p r e s e n t
his favorite
s u p p o r t e d him i n
a t t i t u d e toward him?"
8.
"What c o n t a c t d o e s t h e m e d i c a l p r o f e s s i o n h a v e w i t h
any o r a l l o f t h e s e n e w s p a p e r s , e i t h e r d i r e c t l y w i t h t h e
-go
e d i t o r s or through other i n f l u e n t i a l c i t i z e n s or a d v e r t i s e r s ? "
Fortunately,
Congressional
public
more
when
members
not only
t h e q u e s t i o n n a i r e became
became
questioned
importantly,
elected
wary
oF t h e AMA,
the sincerity
an a d d i t i o n a l
public,
and t h e g e n e r a l
oF p h y s i c i a n s b u t ,
16 D e m o c r a t s
to the
629
Senate
a n d 48 t o t h e H o u s e .
The
AMA
encouraging
was t h e n
the growth
a "judicious,
this
they
Forced
tolerant,
t i m e , t h e AMA
to mildly
oF p r i v a t e
alter
health
i t s p Q S i t i o n by
insurance
and p r o g r e s s i v e a t t i t u d e . "
had opposed
plans
with
Prior to
any i n s u r a n c e p l a n s u n l e s s
6 30
h a d b e e n a d m i n i s t e r e d by p h y s i c i a n s .
D e s p i t e a l l t h e i n t e n s e a c t i v i t y on t h e F o r a n d
bill,
-1 81 -
�6
C o n g r e s s s t i 11 r e j e c t e d
i t i n 1960. '
j 1
I n response
defeat,
Senator
J o h n F. K e n n e d y
introduced
Senator
Clinton
Anderson
Mexico,
than
t h e Forand
coverage.
major
bill
The AMA
newspapers
o f New
by m a n d a t i n g
responded
which
with
to that
a bill,
which
along
went even
considerably
with
further
more i n s u r a n c e
Full-page advertisements i n
warned:
When g o v e r n m e n t s t a r t s t e l l i n g t h e d o c t o r
how t o p r a c t i c e m e d i c i n e , t e l l i n g t h e n u r s e s how
t o n u r s e , t e l l i n g t h e h o s p i t a l how t o h a n d l e i t s
p a t i e n t s - - t h e q u a l i t y oF m e d i c a l c a r e i s s u r e t o
decline."632
The
AMA
wanted
t o be a b l e t o c o n t r i b u t e
t o Congressional
c a m p a i g n s b u t , as a n o n - p r o F i t o r g a n i z a t i o n ,
lost
i t s tax-exempt
candidates.
Political
an
To a v o i d
Action
initial
status
i F i t p r o v i d e d Funds
the constriction,
Committee
contribution
i t would
oF $ 5 0 , 0 0 0 From
directly to
t h e American
(AMPAC) was F o r m e d
have
Medical
i n 1961, with
t h e AMA
For 'educational
633
purposes.'
Followed
all
Within
suit
t h e PACs
a y e a r , 46 s t a t e
and o r g a n i z e d t h e i r
was t o d e F e a t
One oF t h e AMAs m a i n
Medicare
are
i n poor
Financial
ment
was t h a t
"Surveys
medical
own l o c a l
any M e d i c a r e
arguments
show
hea1th . . .(and ) t h a t
circumstances than
that
those
other
PACs.
plan.
against
s o c i e t i e s had
6
3
4
t h e need For
relatively
over
The g o a l oF
Few oF t h e a g e d
55 a r e i n b e t t e r
age g r o u p s . "
was r e p e a t e d i n a d v e r t i s e m e n t s n a t i o n w i d e
6 3
-
J
This
state-
despite
s t a t i s t i c a l evidence t o t h e c o n t r a r y which i n d i c a t e d :
- - 8 0 % oF a l l p e o p l e w i t h i n d i v i d u a l h e a l t h i n s u r a n c e p o l i c i e s
had t h e i r i n s u r a n c e c a n c e l l e d a F t e r t h e f i r s t c l a i m ;
--10 m i l l i o n p e o p l e o v e r age 65 h a d a n n u a l i n c o m e s o f l e s s
t h a n $ 1 ,000; 6 3 6
- - I n t h e e n t i r e p o p u l a t i o n , t h a s e w i t h i n c o m e s oF $ 1 , 0 0 0
a n n u a l l y o r l e s s r e c e i v e d no m e d i c a l t r e a t m e n t ;
-iez-
�- - I n t h e e n t i r e p o p u l a t i o n , t h o s e w i t h incomes o f $5,000 or
more, 90% r e c e i v e d m e d i c a l t r e a t m e n t ; 5 3 7
--The e l d e r l y w i t h i n d i v i d u a l h e a l t h p o l i c i e s F a r e d w o r s e
t h a n e l d e r l y on g r o u p p l a n s ;
--19%
had
One
to
policies
point--which
the American
oF
would
The
Committee
doubts
your
about
oF
smoking.
tobacco
companies
actually
Thompson
paid
a health
(D-NJ),
which
Americans
have
exhiPit
"a
Forces
t h e AMA
legislative
oF
thirty
d o c t o r won't
I F you
as
your
which
days
decide.
have
any
doctor,
ask
announced
warnings
AMA
i m m e d i a t e l y , t h e AMA
For
their
mutual
$10
million
has
with
which
powerFul
made a d e a l w i t h
c o n s i d e r e d t o be
stated
placed
an
interest
oF
"an
to
the
Six
establish
tobacco
that
the
was
assault
on
the
appeared
like
1
o 4 C
in a
to
1
even
- P3-
Faith
t h e AMA
the study-For-a-promise
groups
against
doctors."
which
they would
tobacco
to vote
in their
editorial
i n t e g r i t y .
pollution
and
beneFit.
dollars
t o b a c c o - s t a t e Congressmen
more
about
A c c o r d i n g t o R e p r e s e n t a t i v e Frank
sidsd
little
moral
to
committees
i n excess
"Your
General
traditionally
journal
two
objected
I i m p l o r e you
hazard.
"The
he
physicians
medical
the
AMA
research i n s t i t u t e " t o study whether
Medicare"
The
brought
i s being considered i n
i t meets.
Almost
joined
i n d u s t r y . ..to get
Many
that
decide--when
t h e Surgeon
industry
"tobacco
warned
stay
Amis,
50.
S 3 9
tobacco
a
hospital
t o age
Square Garden i n
u t i l i z a t i o n review
these plans,
1964,
dangers
The
Annis
will
doctor."
In
the
Dr.
which
any
Dr.
a t Madison
a situation
hospital
scrutinize
duration.
at a r a l l y
legislation.
1991-1992 p e n d i n g
about
w e r e n o n c a n c e l l a b l e up
t h e AMA's s p o k e s p e r s o n ,
public
^ 362--has s h a d e s
provisions
which
aFFected
deal
elected
between
�legislators.
American
Medical
Program
Committee,
bill
lators
Mills,
medical
they
voted
For Medicaid,
elderly
that
by k e e p i n g
election,
they
bill
by t a k i n g
would
In
i F they
"mandate
usual
seven
o u t oF t e n R e p u b l i c a n
pro-AMA
seats,
seats
From
constituenciesiF
n o t want
5
i t .
Johnson
senior
Republican
states
i n theSenate.
5 4 6
AMA's $ 1 t o $2 m i l l i o n
Physicians
started
gained
This
voted
their
true
attended
t h e AMA's a n n u a l
courage
to state
y o u do i t .
the
United
change
And y o u ' r e
States
want
you t o . "
Mills
the b i l l ,
6 4 4
switched
t o Democratic,
Democratic.
6 4 5
lost
and
Three
their
i n t h e House, and 4
despite the
campaign.
t o t h e campaign
convention.
going
3
citizens
occurred
opinions
"The ( M e d i c a r e ]
4
achieved h i s
advertising
who h a d c o n t r i b u t e d
t o voice
how
44 s e a t s
nationwide
t o Face t h e
beFore t h e
members oF t h e Ways a n d Means C o m m i t t e e
as t h e D e m o c r a t s
legis-
n o t want t o
i n the F u t u r e .
President
pattern
any v o t e on
For d e l a y i n g
Two m i l l i o n
their
would
against
himselF
every
whether
o u t oF t r o u b l e
support
For Medicare."
voting
would
voted
t h e blame
t h e 1964 e l e c t i o n ,
they
industry
Friends
owe h i m t h e i r
t o delay
His reasoning:
and they
his
5 4 2
For d i s c u s s i o n
i n order
and i n s u r a n c e
or t h e unions
and t h e
oF t h e M e d i c a r e
Committee."
were For o r a g a i n s t M e d i c a i d ,
their
industry
oF t h e H o u s e Ways a n d Means
to election.
Face
knew
t h e deFeat
t o and s u b m i t t e d
oF t h e M e d i c a r e
prior
t h e tobacco
Ways a n d Means
Chairman
objected
provision
between
A s s o c i a t i o n caused
i n the-House
Wilbur
the
"The a l l i a n c e
aFter
Finally
theelction
as t h e y
One p h y s i c i a n h a d t h e
problem
i s n o t what
t o do b u t
t o do i t t h e way t h e p e o p l e
Another
- iea-
oF
p h y s i c i a n , who b e l i e v e d
�that
the
AMA
should
governmental
compromise
control,
care
For
proclaimed:
i n matters
oF
liFe
t h e aged
"We
and
do
death,
even
not,
nor
by
with
some
proFession,
with
honor
and
5 4 7
duty."
In
State
support
January
oF
the
19G5,
Union
immediately
aFter
message a d v o c a t i n g
President
the
quick
Johnson's
passage
oF
rr A Q
Medicare,
which
the
they
elderly
AMA
announced
contended
than
the
would
the
Eldercare
Plan.
had
Congressman
government
was
known
1965,
on
the
the
Ways a n d
5 4 9
the
an
along
Mills
astounded
oF
choosing
to
amend
with
that
anyone
plan
would
health
bill.
the
a l l oF
basic
industry
which
proposed
policies.
19B1
and
64 1
their
5
5
0
I t
February
witnesses
speak
and
Medicare
pending
bill
Eldercare
by
bills,
bill.
under
bills,
proposing
they
There
Congressman
that,
should
was,
considera-
instead
combine
then,
no
them
way
could
oppose t h e r e s u l t because each F a c t i o n ' s
652
enacted.
The m e a s u r e p a s s e d t h e House 313
be
to
C! /\
and
response
introduce
plan
heard
f —,
115.
two
1
Washington
Medicare
to
the
enlisted
They
insurance
Kerr-Mills
Byrnes
Program
to
insurance
Between
Medicare. ^
among t h e
the
the
Means C o m m i t t e e
expanded
tion,
later,
5
s u b j e c t oF
plan.
introduce their
Byrnes
Ways and
With
A day
Eldercare
greater beneFits
Means C o m m i t t e e
s u b s i d i e s For
as
provide
administration's
members oF
their
i t s Doctors'
the
was:
5enate
" I never
by
68
to 31.
thought
we'd
The
end
AMA's
up
lobbyist's
spending
several
655
million
dollars
President
the
presence
oF
in advertising
Johnson
Former
signed
t o expand
the
President
the
Medicare
Harry
S.
b i l l . "
bill
into
Truman,
in
law
in
Independence
�Missouri,
now
part
on J u l y
30, 1 9 5 5 .
Despite
of t h e law o f t h e l a n d ,
physicians
patients
decided
to b o y c o t t
not to s i g n
refused
to t r e a t
the Fact t h a t
90 p e r c e n t
t h e program
up f o r M e d i c a r e .
those
p a t i e n t s who
the plan
was
of t h e n a t i o n ' s
by u r g i n g
their
elderly
Many o f t h e d o c t o r s
did sign
up f o r t h e
556
program.
At
a special
Medicare
had b e e n
process,"
that
collaborators
political
AMA,
opposition
'expected
proclaimed
mockery
of t h e
that
by
labor bosses,
I n s t e a d of a d v o c a t i n g
the v i t a l ,
had a n o t h e r
power-hungry
t h e camp
the vulnerable s p o t s . "
and p o i n t e d
who
out t h a t
and women,
t o medicine
however,
of the
6 5 7
The
spoke i n
p h y s i c i a n s were
t h e p r e s s , and t h e C o n g r e s s
and m a t u r e men
i s as d e l e t e r i o u s
Democratic
boycotts,
member, D r . A p p e l ,
by t h e p u b l i c ,
that
"appeasers,
and
p h y s i c i a n s get " i n s i d e
to Dr. Annis
reasonable
by e v e r y
t h e enemy,
leaders."
(and) find
crisis
"passed
with
however,
m e e t i n g , Dr. Annis
p h y s i c i a n s had b e e n b e t r a y e d
he r e c o m m e n d e d
enemy
AMA
(and) that
no
to a c t as
political
as one b r o u g h t a b o u t by
,.658
its
members.
In
which
of
are
1 9 9 1 , t h e AMA
would
improve
six principles
similar
proposed
health
to health
and s i x t e e n
care plans.
improvements
2.
affordable
assured
access
a plan,
"HealthAccess
care.
key p o i n t s .
to generally-accepted
1.
7 .
.
developed
The p l a n
0 0 9
access
i n many
other
They a r e :
forall,
to health
consists
The s i x p r i n c i p l e s
goals included
should preserve strengths
coverage
America,"
regardless
care
of our current
of
income;
For t h e e l d e r l y :
system;
�4.
high
quality
5.
p a t i e n t autonomy r e g a r d i n g c h o i c e o f p r o v i d e r
in which h e a l t h care beneFits are d e l i v e r e d ;
S.
a l l p h y s i c i a n s s h o u l d be c o m m i t t e d t o t h e h i g h e s t
s t a n d a r d s i n t h e d e l i v e r y oF c a r e t o p a t i e n t s . S B O
Concerning
'3'
governments
care
For
health
above,
"...must
a l l persons
care
t h e AMA
ensure
with
Bacause
u n r e a 1 i s t i c a 11y
access,
Medicaid
Medicare
are
level."
a t 45
should
the
maintains that
access
provider
reimbursement
5
0
1
poverty
to
nation,
health
HealthAccess
i n s u r a n c e For
Employers
would
oF
would
and
t h e AMA
37
t a x b e n e F i t s t o ease
state
medical
level.
...
levels
reduce
increased to the
only
those
believes
who
Medicaid
level.
5 5
'
-
uninsured across
employers
employees
manner
ethical
For
poverty
million
the
and
the poverty
s h o u l d be
require
a l l Fulltime
receive
Funding
10 0 p e r c e n t oF
help solve the problem
Federal
Medicaid covers
level
costs:
and
reimbursement
levels
Presently,
p e r c e n t oF
t o and
incomes below
low
p r o v i d e coverage
To
provided at appropriate
to provide
and
their
their
Families.
financial
.
,
663
burden .
The
stated
is
HealthAccess
i n 5 . 1 3 2 7 and
for states
private,
help
plan
5.700.
to enact
t h a n 23
The
created
would
which
benefit
oF
the proposals
t h e AMA
would
advocates
establish
pools s p e c i f i c a l l y
small
to
businesses
with
employees.
i n every
state
risk
by
the medically
the
opportunity
the
premiums
group
health
which
t h e u n i n s u r e d , and
not-for-profit
cover
w i t h some
A variant
legislation
not-for-profit
the uninsurable,
fewer
coincides
to
join
state
a group
The
be
inBurance
legislation.
uninsurable,
f o r insurance.
insurance rates.
p o o l s would
plan,
those
and
would
who
those
Premiums would
state
The
pay
be
programs
risk
do
who
equal
pool
not
have
cannot
afford
to standard
t h e premiums
f o r those
�who a r e u n e m p l o y e d , n o t c o v e r e d
between
100 and 15D p e r c e n t
Funding
For the r i s k
1.
would
be r e q u i r e d
tand
assessments
state,
3.
with
would
able
level.
come From:
a percentage
oF t h e b e n e F i c i a r i e s
t o pay;
on i n s u r a n c e
a tax credit
general
e m p l o y m e n t , o r who a r e
of the poverty
t h e premiums w h i c h
2.
the
pool
through
carriers
to ease
doing
their
business in
burden;
tax revenues;
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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
An unambiguous reference to the resource within a given context
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
The type of object, such as painting, sculpture, paper, photo, and additional data
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
A name given to the resource
[Political Power Structures Affecting Any National Health Care Reform Plan: Health care reform concepts versus Social and Economic Values] [binder] [2]
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Health Care Task Force
Jason Solomon
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 3
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 38
<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
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Reproduction-Reference
Date Created
Date of creation of the resource.
3/16/2015
Source
A related resource from which the described resource is derived
42-t-12092971-20060885F-Seg3-038-001-2015
12092971