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2006-0885-F
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:
1982
OA/ED Number:
FolderlD:
Folder Title:
[Political Power Structures Affecting Any National Health Care Reform Plan: Health care reform
concepts versus Social and Economic Values] [binder] [3]
Stack:
Row:
Section:
Shelf:
Position:
S
56
2
3
1
�•liver
Alabaster,
opposition
i s that
potentially
•r.
50
the
suFFered
i s " i r r e s p o n s i b l e and
oF A m e r i c a n s . '
t h e AMAs a s s e r t i o n i s a s t o n i s h i n g
t h e o l d Food
oF t h e h e a r t
cancers
t h e AMA's r e a s o n F o r
t o t h e h e a l t h and w e l F a r e
states that
Following
percent
disclosed that
therevision
dangerous
Alabaster
because
M.D.,
group
disease
regimen
and s t r o k e s
has caused
about
a n d 35 p e r c e n t
oF
6 7 - 1
i nthis
nation.
i
The
e s t a b l i s h e d Four
Department
oF A g r i c u l t u r e
industries!
The p r o p o s e d
Food
groups
t o promote
Four
diet
nutrients
groups
meat a n d l o w - F a t
by u s i n g
condiments
to
r a t h e r than
high-Fiber/low-Fat
iiFe-threatening
which
meal
diseases
provides
have
and d a i r y
on a
a l l t h e Fundamental
products
Countries
a Far lower
t o which
by t h s
a r e based
dairy
Focuses.
diets
designed
t h e meat
Food
high-Fiber/Iow-Fat
were
Americans
merely
which
adhere
incident
are
as
oF t h e
prone.
0 7 5
PHYSICIANS.
In
nation
$105.1
national
than
1983, spending
billion
education
Who C a r e
o r g a n i z a t i o n which
The d i F F e r e n c e
AMA i s t h a t
Pelieves
Only
only
hospital
those
services cost
t o $211.8
i s a 3,000-member
began
between
t h e AMA r e p r e s e n t s
i n preserving
represents
oF $ 5 3 9 . 9 b i l l i o n F o r
s e r v i c e s , mounting
Physicians
Texas.
o u t oF a t o t a l
h e a l t h spending.
physicians'
For p h y s i c i a n s e r v i c e s cost t h e
private
t
billion. '
grass
7
roots
i n 1 9 8 5 i n San A n t o n i o ,
Physicians
every
Who C a r e
and t h e
physician, while
practice,
i nprivate
more
PWC
and t h e r e F o r e
practice.
As a c o n s e q u e n c e
- 13 1 -
i
�of
that
belief,
PWC
does n o t
Ppos , e t c . , b e c a u s e
quality
are
care
firm
choose
t o be
own
It
health
advanced
system
technology
motive
of
hospitals. '
s i e g e " because
continue
and
t o overwhelm
they
patients
to
7 8
organization's viewpoint that
i s "under
HMOs,
Additionally,
6
p h y s i c i a n s and
care,
the p r o f i t
of p r e s e r v i n g the r i g h t
is this
care
perceive
managed
mutually r e s t r i c t i v e .
advocates
their
they
support
"the
any
the
American
costs
of
short-term
6 73
savings
states
that
from
that
every
managing
the
PWC
person
a high-quality,
Unless
will
the American
that
8
system
p r e d i c a t e d on
h i s or her
public
fair
American
is willing
Dr.
the
share
Health
t o pay
Bronow
assumption
to
guarantee
care
system...
for quality,
they
0
"Future
private
"...is
pay
lose
i t . "
I n h i s comments a t
Society's
He
Plan
Nevertheless,
high-technology
6
will
care."
the
St.
of Health
practice
Louis
Care
i s the
M e t r o p o l i t a n Medical
F o r u m , " Dr.
quality
core
and
that
technology
makes A m e r i c a n
advised
that
Canada,
1991,
in
Funded
oF
Bronow
the
health
medicine
merely
stated
50
care
unique.
percent
oF
68 1
its
type
top
medical
researchers
s y s t e m would
not
beneFit
To
remedy
the problems
system,
Bronow
advocates
with
some r e v i s i o n s
without
unduly
accomplish
1.
insurance
this
which
burdening
feat,
and,
by
imposed
by
our
preserving this
would
any
there
a
Canadian
Americans.
one
assure
current
very
- 1 92-
albeit
access
of s o c i e t y .
i s a f i v e - e l e m e n t PWC
high deductibles ( i . e . ,
crippled
system,
universal
segment
Universal employer-provided,
with
implication,
6 8 2
Plan.
community-rated
$1,000)
should
be
To
�required
to d i s c o u r a g e
pervaded
the nation
facilities.
High
the c r e d i t - c a r d
and r e s u l t e d
would
preventive
be r e s e r v e d f o r m a j o r
coverage
i n overuse
d e d u c t i b l e s would
more r e s p o n s i b l e a b o u t
t r i g g e r e d when
mentality
which has
of medical
care
i n c e n t p a t i e n t s t o become
behavior.
illnesses,
out-of-pocket
Insurance
coverage
with c a t a s t r o p h i c
expenses
exceed
a
G33
pre-determined
percentage
of a d j u s t e d g r o s s
income.
GS4
pre-existing
2.
with
Individual
pretax
annually.
health
the
Med-Save
dollars,
with
T h i s would
individuals,
dollars
c o n d i t i o n s would
care
services.
Long-range
accomplished
.vhich
a form
direct
strong
should
of s e l f
coverage.
be
established
private
by s t a t u t o r i l y
insurance for
c o n t r o l of t h e i r
incentives
insurance
funding
health care
f o r prudent
The Med-Save a c c o u n t s
of a d d i t i o n a l
685
expenses.
3.
to
c o n t r i b u t i o n s o f $ 3 0 0 t o $5DC
purchase
medical
accounts
provide
g i v i n g them
and p r o m o t i n g
be i r r e l e v a n t
could
or f o r p a y i n g
of Medicare
requiring
buying
be u s e d f o r
uninsured
could
the purchase
of
be
o f an IRA
would p a r t i a l l y f u n d Medicare For t h e f u t u r e .
An IRA t h a t c o s t $ 1 2 5 a n d e a r n e d ... a n n u a \
i n t e r e s t w o u l d a c c u m u 1 a t e . . . by M e d i c a r e a g e .
T h i s money c o u l d t h e n be u s e d t o o b t a i n
p r i v a t e h e a l t h care insurance t o supplement-•r replace--gavernment (Medicare) f u n d s .
6 8 5
This
every
one-time
child
subsidized
•ver
i n the f i r s t
would
year
be a r e q u i r e d
oF l i f e ,
by t h e F e d e r a l g o v e r n m e n t
and i s e x p e c t e d
For t h o s e
budget
to continue
recommends b a s i n g M e d i c a r e
p u r c h a s e For
partially
the past t e n years, Medicare's
Cy $ 5 0 b i l l i o n
Bronow
cayment
premiums
or completely
at poverty
has d i m i n i s h e d
on t h a t
on
level
trend.
recipient's
Dr.
�incomes
rather
than
diminishing
t h e program
Further or r a i s i n g
taxes.686a
4.
oF
Long-term
Medicaid
number
care
separated
eligibility
oF M e d i c a i d
From M e d i c a i d
i s essential.
recipients
During
and
expansion
t h e 198Ds, t h e
i n c r e a s e d by 9 p e r c e n t a n d
687
expenditures
Medicaid
Funding
percent
this
increaeed
has i n c r e a s e d
oF b u d g e t
Fact,
123 p e r c e n t .
over
t o 14 p e r c e n t
Bronow
States'
that
same
oF b u d g e t
explains, "state
shareooF
p e r i o d From
i n 1990.
governments
and
9
Because
oF
hospitals
R Pi P
have
become a d v e r s a r i e s . "
initiated
a suit
Servicees
alleging
Forced
against the C a l i F o r n i a Department
that
and
has r e s t r i c t e d
and
d i a g n o s t i c medical
Bronow
Medicaid
Medicaid
everyone
employment,
eligibi
5.
and
rehabilitative
treatment,
care.
care
poverty
the primary
reason
that
i t dedicates
almost
h a 1F oF
The PWC
i s that
long-term
and Family
690
departments,
would
plan
and a l s o change
level
structure
would
would
i t s
seoarate
eligibility
be i n c l u d e d .
so
Age,
be i r r e l e v a n t t o
lity.
ScientiFic
physicians
Follow
explained that
below
Health
examinations.
to long-term
From
care,
oF
From M e d i c a r e s e r v i c e s h a s
c e n t e r s and emergency
neonatal
is in crisis
payments
that
underpayment
c l o s u r e oF t r a u m a
Dr.
H o s p i t a l s i n C a l i F o r n i a have
medical
and n o t i n s u r a n c e
i n providing
care
care
guidelines,
companies,
For every
e s t a b l i s h e d by
For t h e procedures
possible medical
to
condition
t r e a tment.
Accomplishing
t h e above
objectives
would
be p r e F e r a b l e t o
�installing
has
a C a n a d i a n - t y p e system because
removed
the medical
decision-making
purview
of the physician
and
resides
i n the government
the Canadian
process from
the patient.
and,
as
That
a result,
system
the
decision-making
"(p]atients'
needs
69 1
take
a backseat t o budget c o n s t r a i n t s . "
American
system
because
patients'
in
the system,
described
as
having
It
Medical
into
t h e autonomy
For
Association
between
oF
high
physicians
president
low.
not perFect,
with
restrictions
states
PWC
who
it.
on
another
away.
and
In
the
strange
lack
oF
practice physicians
i n the
in
United
a r e i n c r e a s i n g l y F r u s t r a t e d by
oF i n d i v i d u a l
693
t o note
p a t i e n t s by
government
t h e c o u n t e r p o s i t i o n oF
states: "...although
i t s users,
m e m b e r s oF
On
has
and
companies."
citizen
satisFied
restricts
technology
states "...the
private
Canadian
deFiciencies
physicians
692
all-time
comment, Bronow
is illuminating
Canadian
Bronow
physicians
t h e p u r c h a s e oF
r e a c h e d an
to this
American
insurance
go
Ontario
micromanagement
those
blames
restrains
to the
c o n t r o l s on p r o v i d e r s ,
i s i n stark contrast to the s i t u a t i o n
States.
is
and
The
counterpoint
Canada
to care,
Fee
the strained r e l a t i o n s
government
intrusion
a r e g e n e r a l l y apposed
i t imposes
access
equipment.
the
physicians
The
t h e Canadian
primary
the medical
the level
oF
"The
issue
the Canadian
public,
opponents
oF
are
system
very
the system
establishment
who
Fees
can
oF
oppose
694
are
charge.
they
c o n c e r n t o t h e community
that
a
any
physicians,
Dr.
of Doctor Greed i s n o t g o i n g t o
- 1 55a d v o c a t e s d e v o t i n g one day p e r m o n t h F o r h e a l t h
�care
For t h e poor.
Forms,
just
He a d v i s e d
provide
care.
physicians
"Government
not t o F i l l out
and i n s u r e r s
have
S95
nothing
t o do w i t h
•r.
Greed
Bronow's c o n c e r n
i s appropriate.
health
reForm
sabotaging
Future
cost
the-board
already
costs,
eFForts
services,
imposing
their
established
by e i t h e r t h e AMA
used
receive
to<lfcermine
From
and c o m m e r c i a l h e a l t h
637
more common
a doctor
perFormed
supposed
abuses,
bills
separately
annual
claim
Fee
5 9 6
Forbidden
procedure."
replacement
For example,
averages
the rules.
code,
the provider
Cross,
Blue
" I n o n e oF t h e
by F e d e r a l
rules,
that are
and t h a t a r e
comprehensive
t h e charge
as
limits;
F o r t w o o r more s e r v i c e s
as a s i n g l e
system
Government.
on t h e same p a t i e n t a t t h e same t i m e
t o be r e p o r t e d
69S
I t is
Forms and a r e t h e
Blue
insurers.
across-
billing
oF p a y m e n t
Medicaid,
clearly
oF
payment
or t h e Federal
t h e amount
Medicare,
and h o s p i t a l s
t o circumvent
on i n s u r a n c e
concerning
Fee l i m i t s .
has a n u m e r i c a l
own
oF w h a t
activities
t h e Medicare
as F o l l o w s ,
service
codes a r e entered
criteria
view
their
the extent
to the imposition
governmenta11y-set
eFForts,
providers are
physicians
annual
Doctor
i s considering
and p o s s i b l y
Given
are i l l e g a l
that providers
Each m e d i c a l
Shield
oF r i s i n g
themselves
our time."
t h e r e p u t a t i o n oF
the nation
governmental 1y-set
apparent
will
While
report
For Medicare
be e x p o s i n g
hence,
about
containment
auditors
payments
could
because
t o donate
c o n t r o l oF Fee s e t t i n g .
Federal
The
our decision
For a t o t a l
$5,889.
But i F t h e p h y s i c i a n
- 196-
knee
�'unbundles'
bills
t h e medical
services
provided,
he
Cillegally)
For:
..replacing
upper
p a r t oF k n e e
joint
$3,012
..replacing
lower
part
joint
2,844
..relining
oF k n e e
kneecap
2,677
5
$8,533
It
added
care
i s estimated
that
5 to 6 billion
costs.
Medicare
Twenty
claims
such
dollars
percent
For s u r g e r y
illegitimate
a year
9
p r a c t i c e s have
to the nation's
oF t h e 8,000 d o c t o r s
unbundled
9
health
who
Filed
the services
700
provided.
oF
O r . James S.
t h e AMA
deFended
"The
purely
and s i m p l y
Medicare
charges
Follows
Fee s c h e d u l e
s p e c i a l i s t s who
702
president
codes:
codes i s
t o g e t adequate
physicians
do...it
is a
that
and t h e A m e r i c a n
has been
oF
vice
when r e i m b u r s e m e n t g o e s
701
manipulation will
increase."
Todd's comment
Government
gaming
oF p r o c e d u r e
a method
For what
oF e c o n o m i c s
down, s u c h
Dr.
the i l l e g a l
manipulation
reimbursement
law
Todd, e x e c u t i v e
"...a b i t t e r
Medical
battle
between t h e
Association
over
F o r d o c t o r s . . .The u n b u n d l i n g
observed
tended
most
oFten
i n claims
t o be t h e h a r s h e s t
oF
Filed
critics
t h e new
by
oF t h e Fee
schedule."
A physicians'
accidentally
consultant
Fraudulent
said
because
that
they
-197-
many d o c t o r s a r e
do n o t know
how
to bill
�For
their
a number
services.
Another
consultant said
oF c o n s u l t a n t s r u n n i n g
physicians
around
how t o game t h e s y s t e m ,
that
"There are
the country
how t o j a c k up
teaching
their
703
reimbursement
through
A diFFiculty
here.
ments
From
their
i n interpretation
providers.
a detailed
Replacement"
thres-step
amounts
invest
costs,
centers.
reFerral
testing,
practice
more
expensive-
c a r e , and
the recent
are necessarily
on t h e i r
this
goal
investments.
i s t o reFer
and t r e a t m e n t s
i s called
7C 4
a
"physician
their
t o these
very
selF
arrangement."
relates
Medicare
have
entities
ventures
t o accomplish
McDowell
bill
i n these
For care,
This
Knee
and t e c h n o l o g i c a l e q u i p m e n t .
i n increasing the return
patients
to question
oF p h y s i c i a n i n v e s t m e n t s i n
interested
own
"Total
a r e d e r i v e d From
who
e a s i e s t method
lists
open
be p r o v i d e d .
Physicians
The
leave
oF u n n e c e s s a r y
unnecessary
Facilities
be a t w o r k
t h e more d e t a i 1 e d - - a n d
Fast-increasing practice
care
may
merely
explanation should
corresponding
may a l s o
t o o b t a i n "det.3ilfe.ol " s t a t e -
This
statement
or whether
Considerable
health
practices."
Consumers a r e e n c o u r a g e d
whether
and
abusive
t o which
nationally,
that
ownership
they
at least
"twelve
or investment
make p a t i e n t
25 p e r c e n t
laboratories,
27 p e r c e n t
laboratories,
and S p e r c e n t
percent
oF p h y s i c i a n s who
interests in
r e F e r r a 1s. . . ( w h i 1 e )
oF i n d e p e n d e n t
oF i n d e p e n d e n t
oF d u r a b l e
suppliers
clinical
physiological
medical
equipment
a r e owned i n w h o l e o r i n p a r t by r e F e r r i n g
705
physicians."
C l i n i c a l l a b o r a t o r i e s and d i a g n o s t i c
_ I a Q _
�imaging
other
centers
appear
investments
laboritories,
homes,
being
the
Favored
d i r e c t e d toward
home h e a l t h a g e n c i e s ,
ambulatory
investments
t o be
may
surgical
take
the
centers
Form
70
corporations,
oF
investment,
psychological
hospitals,
and
HMOs.
joint
which
enable
the
nursing
7 0 5
The
ventures,
7
p a r t n e r s h i p s ' ' '- - es p e c i a 1 1 y
partnerships
with
physicians
limited
to acquire
an
7 08
equity
and
interest
simple
It
the
and
competitive
that
beneFits
g u i d e l i n e s which
behavior
procedures.
eFFective
belieF
r e g u l a t i o n s should
structural
reFerral
liability
709
agreements.
contractual
i s McDowell's
balance
abuse,
w i t h minimal
1
eFFective
w i t h the
provide
F o c u s on
remedy
potential
must
For
"...extensive
the
physician's
method
limit
restrictions
on
investment
Disclosure
0
and
an
requirements
may
be
an
overuti1ization
oF
For
monitoring
an
7 11
investment
Facility
because
"...selF reFerral
a r r a n g e m e n t s . . .have t h e
potential
to produce
oF
undermine
the
medical
services
proFessional
documented
that
judgment
evidence
oF
drivers
i s the
physician
oF
extensive
unnecessary
selF-reFerraJ
and
may
Without
In other
o F the
deFensive
- 193-
well
believes
unnecessarily
deFensive
care.
symptom
7 1 2
abuse, McDowell
s e . l F - r s F e r r a l and
conspicuous
"independent
practitioners."
legislative prohibition
71
competition.
Physician
care
oF
rigid
healthy
two
and
overuti1ization
medicine
words,
stiFle
are
unnecessary
ma J a d i e s k n o w n
care.
the
as
�S . 1 2 2 7 i s an
symptom
instead
acutely
of t h e cause
actual
causes,
however,
merely
t h e symptom
constituents,
sounds
political bill
who
are
reasonable.
of t h e malady.
would
aFFects
not
which
provoke
addresses
Addressing
t h e AMA,
A summary
t o oppose
oF
that
apathetic
legislation
section
the
while addressing
only disorganized, mostly
likely
the
oF
which
the b i l l
states
U n n e c e s s a r y c a r e w i l l be r e d u c e d by [ 1 ] a
p r o g r a m oF o u t c o m e s r e s e a r c h t o d e t e r m i n e w h i c h
care i s necessary or unnecessary,
(2) developm e n t oF p r a c t i c e g u i d e l i n e s t o a s s i s t p h y s i c i a n s
i n p r o v i d i n g o n l y n e c e s s a r y c a r e and a s s i s t
i n s u r e r s i n d e c i d i n g w h a t c a r e s h o u l d be
r e i m b u r s e d , and [ 3 ) an e n h a n c e d p r o g r a m
oF
t e c h n o l o g y assessment t o help determine the
u s e F u l n e s s oF e x p e n s i v e m e d i c a l t e c h n i q u e s .
In
a d d i t i o n , the program w i l l help develop p r i v a t e
a n d p u b l i c managed c a r e p r o g r a m s , w h i c h
will
e n c o u r a g e p a t i e n t s t o u s e p r o v i d e r s who
practice
e F F i c i e n t , h i g h q u a l i t y medicine.' '''^
7
It
should
provisions
be
concerning
care—provisions
privacy
recalled
and
the
that
S.1227 h a s
u t i l i z a t i o n review
which
deeply
aFFect
conFidentiality
oF
very
stringent
to c u r t a i l
a patient's
the
unnecessary
right
to
physician/patient
7 15
relationship.
oF
rising
Physician se1F-reFerraI
costs
which
the Senators
usurping a patient's
beFore
health
right
t o seek
governmental
care
is yet
and
insurance
AMERICAN HOSPITAL
The
United
nursing
States
Hospital
and
medical
control
care w i t h o u t
interFerence.
and
and
A s s o c i a t i o n r e p r e s e n t s more
other patient
Canada,
s c h o o l s , over
organizations
should
cause
ASSOCIATION.
American
7,000 h o s p i t a l s
industry
another
SO
and
Blue
agencies,
care
institutions
than
i n the
a p p r o x i m a t e l y 300
hospital
Cross
35 0 o t h e r
and
-200-
has
p l a n s , over
more
than
19,000
�7 16
members.
From
ing
The
hospital
to
Since
the
'prestige'
the
oF
teaching
the
the
Administrators
paid
which
pay
higher
hospitals
generally
oF
dues
i t s Financial
are
dues,
p o l i c i e s estab1ished.by
institution,
complexity
most o f
7 17
a particular hospital's
hospitals
over
Large
derives
membership
size
larger
inFluence
AHA
oF
the
considered
to
quality
care
Facilities
large
administrators,
are
oF
and
assessed
accord-
expenditures.
they
the
have g r e a t e r
7 1a
AHA.
most p r e s t i g i o u s ,
emanate
From
provided,
the
and
with
size
oF
the
services
provided.
hospitals
teaching
are
support
are
considered
to
be
the
most
leaders
highly
i n the
Field,
7 19
and
drivers
oF
legislative
activity
at
state
and
Federal
levels.
Legislative activity generally
concerns:
1.
i n c r e a s i n g t h e demand For h o s p i t a l c a r e t o i n c r e a s e
t h e r e v e n u e s oF t h e h o s p i t a l ;
2.
i n s u r i n g t h a t t h e m e t h o d oF r e i m b u r s e m e n t t o h o s p i t a l s
w i l l a l l o w h o s p i t a l s t o make a s h o r t - t e r m p r o F i t , t h e r e b y
enabling
t h e m t o i n v e s t i n t h e F a c i l i t i e s and s e r v i c e s
preFerred
by b o t h t h e a d m i n i s t r a t i o n a n d m e d i c a l s t a F F ;
3.
[ s e c u r i n g ] government subsidies
(For)...manpower,
capital,
( e t c . ) thereby i n h i b i t i n g the r i s e i n h o s p i t a l
costs;
4.
decrease
l i m i t i n g s u b s t i t u t e s For h o s p i t a l
t h e demand F o r
hospitals;
aare
so
as
not
5.
r e s t r i c t i n g a d d i t i o n a i . h o s p i t a l s From e n t e r i n g
where t h e r e are e x i s t i n g h o s p i t a l s , t h e r e b y t h r e a t e n i n g
m a r k e t p o w e r o F t h e AHA's c u r r e n t m e m b e r s h i j ; . 7
Feldstein
oriented
makes
though
the
diFFerences
hospitals.
decisions
prestige
hospitals
they
the
non-proFit
i t s investment
increase
these
and
notes
enjoy
constitute
oF
the
many
a
in goals
A
based
on
Factors
organization.
Facilities
duplication
-20 1 -
and
oF
areas
the
0
between
non-proFit
to
proFit
hospital
which
Physicians
services,
Facilities
will
at
even
and
services
�provided
nearby
hospitals
services
or w i t h i n
tend
t h e same c o m m u n i t y .
t o compete
with physicians
7 2 1
For-profit
i n providing
a n d do n o t g e n e r a l l y d u p l i c a t e s e r v i c e s
which
already
722
exist
within
In
the
1 9 3 2 , t h e AHA
hospitalization
instability
Blue
demand
be
not
For h o s p i t a l
i twould
as B l u e
reinvested
be
that
imposes
were
t o a decrease i n
required that
had i t been
7 2 4
Cross
interested i n
which
Additionally,
was
as
any p r o F i t s w o u l d
be
oF t h e o r g a n i z a t i o n , a n d c o u l d n o t
Increasing t h e growth
which
Medical
set according
oF t h e
would
care.
Association,
beneFited
on a c o m m u n i t y
Blue
""
t h e AHA
Cross
Blue
rating,
t o the cost
7^~
community.
t h e same p r e m i u m
Blue
t o miniir, i z e c o s t s ,
the h o s p i t a l s beneFited.
to the entire
care
w e r e n o t c o v e r e d by
increasing enrollment,
premiums
the Financial
to hospital
non-proFit,
because Medicare
charged
coverage
remained
prepayment
during the
lead
oF t h e h o s p i t a l s .
For h o s p i t a l
by e x t e n s i o n ,
rates
The AHA
because,
t h e American
Medicare
always
care.
have
t o shareholders.
meant
demand
Unlike
and,
would
For t h e growth
organization
pro
that
Cross
to counteract
alternatives
have e n d e a v o r e d
Cross
distributed
increase
cost
agency
i n the interest
long
system
p r a c t i c e oF p h y s i c i a n s )
because
a non-proFit
proFit
insurance
~ Lower
private
Cross
e s t a b l i s h e d t h e Blue
h o s p i t a l s were e x p e r i e n c i n g
•7 p n
Depression.
(i.e.,
community.
was
interestc
Cross had
which
meant
oF p r o v i d i n g
Community
r a t e s on e v e r y b o d y ,
-202-
rating
whether
they
�are
Frequent
users
the
(those
oF
medical
under
30
years
l o w - r i s k people
rates.
With
1940s and
its
users
the
rapid
1950s, Blue
at
commercial
lower
premiums
oF
costs
the
the
oF
elderly
were
From
elderly,
have
Blue
the
people's
premium
insurers in
diFFiculty
obtain the
experience
Cross
because
and
the
were t o
had
the
to
C r o s s by
retaining
same
-rated
increase
would
paying
For
the
lose i t s
subsidy
demand
inFrequent
rating,
commercial
to
or
community
high-risk
able
would
rescued
With
experienced
IF Blue
they
Medicare
oF
who
insurers.
insureds,
reduced.
Cross
(elderly),
age).
the
growth
premiums
low-risk
oF
subsidize
l o w - r i s k people
coverage
care
the
have
the
hospital
been
hospital
services
increased.
With
the
advent
hospital
costs.
care
being
was
being
oF
Medicare
I t became n e c e s s a r y
provided,
overuti1ized.
capable
and
monitoring
quality
"collegial
atmosphere
that
lack
oF
criticize
ProFessional
AHA
i n c e n t i v e s on
each
opposed
that
Hospitals
oF
the
came r a p i d
exists
the
a major
Review
within
part
oF
the
increased
not
were
care,
but
hospital,
the
and
physicians
to
establishment
oF
imperative
(PSROs).
which
'
The
established
Q
screening.
When h o s p i t a l s u n d e r s t o o d
advocating
the
Organizations
legislative
preadmission
the
quality
was
they
q u a n t i t y oF
-7 P
PSROs a n d
that
in
that
hospitalization
other" necessitated
Standard
to ensure
insisted
and
inFlation
that
u t i l i z a t i o n as
-203-
they
could
a means oF
not
continue
increasing
�their
p r e s t i g e , they
incorporation
changed
so t h a t
t h e AHA's a r t i c l e s o f
"hospital
care"
was a m e n d e d
to "health
7 29
care
services.
hearing,
Providing
an AHA
testimony
at a
Congressional
representative stated:
"No l o n g e r c a n a h o s p i t a l ' s s e r v i c e p r o g r a m
be d e F i n e d i n t e r m s oF i n - p a t i e n t c a r e a l o n e .
The
h o s p i t a l m u s t assume i t s p r o p e r r e s p o n s i b i l i t y t o
e n s u r e a c o n t i n u u m oF p r e v e n t i v e , a c u t e , r e h a b i l i t a t i v e a n d . l o n g t e r m c a r e t o t h e p a t i e n t w h e r e v e r he
may be . ' . . . The n e e d F o r o u t - p a t i e n t c l i n i c s , d a y
c a r e p r o g r a m s , c o o r d i n a t e d home c a r e , c h r o n i c
i l l n e s s u n i t s , and l o n g term n u r s i n g care u n i t s
i s g r e a t , a n d we b e l i e v e t h e s e a r e b e s t p r o v i d e d
e i t h e r d i r e c t l y u n d e r t h e a u s p i c e s oF, o r i n
^
closer a F F i l i a t i o n w i t h , a general
hospital."
7 3 0
Medical
corporations attempt
market
by c o m b i n i n g
health
insurance
hospital
t o corner
ownership
the health
care
w i t h PPOs, HMOs, a n d
7 32
control.
I F t h e c o r p o r a t i o n owns t h e h o s p i t a l s , t h e y
get a u t o m a t i c c o o p e r a t i o n and...unFi11ed bed
s p a c e a t c o s t . ...When t h e y own ( o r Form j o i n t
ventures w i t h )
insurance companies, they
can p u t t o g e t h e r a t t r a c t i v e l y d i s c o u n t e d
rate
p a c k a g e s F o r . . . e m p 1 o y e r s a n d b u s i n e s s e s who a r e
the b i g customers For group plans.
They c a n
d i s c o u n t a v a r i e t y oF r a t e s m o r e e a s i l y b e c a u s e
t h e y have g r e a t e r n e g o t i a t i n g power w i t h t h e
p h y s i c i a n s whowork i n t h e i r
hospitals.
7
3
3
7 3 4
American
oF
America.
Medical
International,
Humana, M a x i c a r e ,
the Hospital
and N a t i o n a l
Corporation
Medical
Enterprises
735
are
They
the largest
have
Found
Voluntary
Hospital
The
joint
corporations
ventures
Corporation
oF A m e r i c a
Humana H o s p i t a l
United
joined
-204-
with
based
and t h e
Equitable.
itselF
7 3 5
in Louisville,
For-proFit hospital
I t has p l a c e d
States.
t o ownership.
with Aetna,
joined
Corporation
i s o n e oF t h e l e a d i n g
States.
i n the United
preFerable
H o s p i t a l s oF A m e r i c a
Kentucky,
the
hospital
chains i n
in a position
t o be
�of
interest
to Representative
House E n e r g y
began,
being
The
a n d Commerce C o m m i t t e e ' s
on O c t o b e r
practiced
problem
which
John D i n g e l l ,
D-Mich.,
o v e r s i g h t panel
17, 1 9 9 1 , t o e x a m i n e
the pricing
by a l l 77 oF t h e Humana-owned
Humana
are provided
i s Facing
concerns
to i t s patients.
I tern
pricing
oF
arm pads
Rubber
tips
Saline
For c r u t c h e s
'
7
P a t i e n t ' s Cost
$
103.65
.90
23.75
.71
15.95
.81
44.90
5.74
118.00
For c r u t c h e s
pad
Esophagus
7 5
A Few e x a m p l e s a r e :
solution
Heating
policy
products
$ 8.35
Rubber
which
hospitals.
Humana's C o s t
Crutches
and t h e
tube
151.98
1,205.50
Tylenol
tablets
N/A
9.00
Nursing
bras
N/A
455.00
Markups
on s u p p l i e s a v e r a g e d
733
127 p e r c e n t
oF a c t u a l
cost.
M o s t c u s t o m e r s do n o t p a y i n F l a t e d p r i c e s s i n c e
t h e i r h e a l t h i n s u r e r s - - w h e t h e r t h e y a r e c o v e r e d by
Medicare or a p r i v a t e plan--are able t o n e g o t i a t e
healthy discounts with hospitals.
To make up t h e
d i F F e r e n c e — and t o c o v e r t h e c a r e oF i n d i g e n t
p a t i e n t s a n d o t h e r s who p a y l i t t l e , i F a n y t h i n g —
h o s p i t a l s r o u t i n e l y s h i F t c o s t s t o c u s t o m e r s who
pay F u l l r a t e s .
Moreover, markups a l s o i n c l u d e
a l l o c a t e d overhead c o s t s .
I n a n y e v e n t , Humana i s
merely F o l l o w i n g standard h o s p i t a l
practice. 7
3 9
S u p p l y c o s t s s h o u l d n o t be v i e w e d i n
i s o l a t i o n because they a r e a d j u s t e d t o r e F l e c t t h e
t o t a l c o s t oF p a t i e n t c a r e a t a h o s p i t a l .
S u p p l i e s c a r r y n o t j u s t t h e i r own p u r c h a s e p r i c e
b u t t h e c o s t oF r u n n i n g t h e h o s p i t a l . . . . S u p p l i e s
make up F o r i t e m s c h a r g e d b e l o w t h e i r c o s t . ' !
7
4
0
7 4
The
Federal
established
analyze,
Expenditure
by S.1227 w o u l d
and d i s s e m i n a t e
evaluating
providers
Health
J7 4
the eFFiciency
-
have
data
Board
the authority
that
will
and q u a l i t y
Humana's e a r n i n g s
which
have
_ -v n _
.
would
be
to "collect,
a s s i s t . . .consumers i n
oF h e a l t h
grown
care
steadily
a t 18
�percent
annually
since
1987, and
they
enjoy
a 20
percent
743
average
return
Daniel
on
Fox
equity.
i s president
Former
proFessor
Health
Services
a t , and
oF M i l b a n k
director
at the State
oF,
Memorial
Fund
the Center
University
oF New
and a
For
York
Assessing
a t Stony
744
brook.
ern
Daniel
University
C.
SchaFFer
School
position
that
an
practice
patient
oF
Fox
and SchaFFer
take
Northwestthe
has p e r m i t t e d
hospitals
to
dumping.
ruling
hospitals
to
For a F e d e r a l
provide
Free
The
tax exemption
or below-cost
thereFore
hospitals
Law.
at
I.R.S. r u l i n g
qualiFy
I.R.S.
i s a law p r o F e s s o r
sanctions
even t h o u g h
c a r e to t h o s e
the reFusal
to t r e a t uninsured
analyze
allows
persons.
the r e s u l t
unable
they
t o pay.
by v o l u n t a r y
7 4 5
do n o t
7 45
The
nonproFit
SpeciFically,
and
SchaFFer
as s t e m m i n g From
the
Fox
a change i n
d e F i n i t i o n oF ' n o n p r o F i t '
hospitals.
The r u l i n g d e F i n e d t h e c h a r i t y p r o v i d e d by
n o n p r o F i t h o s p i t a l s as t h e p r o v i s i o n oF b e n e F i t s
t o t h e c o - m u n i t y as a w h o l e , s u p e r s e d i n g a 1956
r u l i n g w h i c h h e l d t h a t a h o s p i t a l was c h a r i t a b l e
o n l y i F i t was " o p e r a t e d t o t h e e x t e n t oF i t s
F i n a n c i a l a b i l i t y F o r t h o s e n o t a b l e t o pay F o r
t h e s e r v i c e s r e n d e r e d and n o t e x c 1 u s i v e 1 f o r
t h o s e who a r e a b l e arid e x p e c t e d t o p a y . "
7 4 7
They
assert
determining
and
which
According
junior
and
the d e F i n i t i o n ,
are very
concerned
do n o t a c k n o w l e d g e t h a t
indicates
t o Fox
member oF
t h e change
and SchaFFer,
i t sstaFF
contemporary
healthy
the
industry
hospital
by c h a n g i n g
health policy
tax attorneys
evidence
that,
policy
t h e IRS
Fact
t h e IRS h a d
assigned
the law, h i s t o r y
i trelated
For a change
-205-
that
i n t h e Face oF
748
in hospital
behavior.
to research
as
t h e IRS i s
to a request
i n the deFinition
a
and
From
oF
�'charitable
hospital.'
The
tion
term
junior
oF
the
employees
In
on
to
d i d not
1SS3,
question
the
legislation
the
industry provided
employee,
the
validity
H o u s e Ways and
which
would
and
oF
i t s own
senior
the
I.R.S.
deFinition.
Means C o m m i t t e e
have p r o v i d e d
deFini-
held
hearings
hospitals with
relieF
74°
From
The
the
1356
American
advocating
been
standard
Hospital
passage
considering
Congress
the
pending
ineligible
received
matters
the
a ruling
was
under
and
requests
iF p o s s i b l e
by
the
For
tax
testiFied
and
to
the
From
deny
at
the
hearing,
the
I.R.S.
bill
those
care
Medicare.
exemptions.
that
stated
similar
would
Medicaid
relieve
bill
pressure
legislation
For
eligibility
Association
oF
"Frequent
law...to
oF
since;
who
to
7 5 1
As
From members oF
oF
the
who
Congress
oF
that
the
to
under
necessity
7 5 0
were
a result,
administrative decision
Congress
1967.
asserted
those
had
IRS
resolve
existing
new
legisla-
752
tion."
and
Hence,
SchaFFer
reFlect
should
our
pay
system'
reForm
was
the
with
warn
the
that
nation's
For
health
e x i s t s today
meant
to
challenged
adoption
"the
care."
and
Supreme C o u r t
7 -
"
197Cs
deciding
1969
3
The
I.R.S. r u l i n g .
treatment
to reach
does n o t
the
the
special
inability
beneFit
i n the
oF
oF
'working
bode w e l l
For
consumer/patient.
i n diFFerent
hospitals
a consensus
same
Fox
on
oF
how
we
the
health
The
may
care
156 9
ruling
jurisdictions,
with
that
t h e r u l i n g "had n o t h i n g t o
754
e i t h e r tax or h e a l t h p o l i c y . "
The
1959 I . R . S . r u l i n g s t i l l h a s e F F e c t d e s p i t e t h e
7S-
do
r
Consolidated
requires
room
care
Omnibus B u d g e t
R e c o n c i l i a t i o n Act
hospitals participating
to p a t i e n t s unable
in Medicare
t o pay.
-207-
to
oF
15 85
provide
~~
which
emergency
�A
paradox
has
developed
care.
There
oF
similar actions.
two
should
be
around
the
a similarity
The
two
of
dumping
by
hospitals;
..patient
dumping
by
insurance
reFerred
utilization
review
Patient
by
to
society,
and
hospital
staFF,
dumping
i s being
•n
the
the
patient
by
and
other
stop
such
other
that
dumping
outside
people
takes
a reFusal
reFuge
Utilization
rationing
and
insures
actually
behind
review
care
will
i s an
and
not
by
honestly
much o f
support
the
advocate
patient
dumping
does n o t
Because
A
iF the
and
to
the
aFFected
on
voice
the
phone
voice
which
a
reFusal
is
is occurring.
label
problem
groups
the
challenged.
h y p o c r i t i c a l denial
accurately
the
insurer
From
services,
have
beFore
Politicians
what
will
the
that
is
have
to
issue
be
will
ever
addressed.
Congressional
insurers
ThereFore,
consumer
For
dumping
nor
patients,
when
divorced
Fight.
insidious
admit
to
politically
has.
and
policy
patient
immoral
attempt
to
actually visible
reimburse
company
occurring.
addressed
be
oF
to
i n an
was
patient
i s more d i F F i c u l t t o
pronounces
i t i s not
oF
treatment.
oF
premises,
is
label
labelled
employees
dumping
provider's
and
been
i t i s obvious
oF
insurer
hospital
occurs
companies--which
legislation
reFusal
hand,
and,
has
hospital
practiced,
are:
been passed
Because
occurrence
care.
hospitals
has
health
the
po1itica11y-correct
unnecessary
activity.
visibility
the
legislation
that
to
oF
dumping
prohibit
necessary
with
of
r e s u l t From
actions
..patient
commonly
provision
pending
legislation
utilization
pending
review.
legislation
-20B-
i s the
(S.1227
While
and
the
reduction
others)
stated
oF
the
and
intent
oF
�inflationary
spiral
be
a n d t e r m i n a t i on oP c a p e .
rationing
drastically
the
last
a custom
physician
physicians
future
will
altered
Lois
Wickline's
patient to suffer
becoming
her
of health care,
as a m a l p r a c t i c e
may n o t f a r e
increase
t h e number
Consolidated
rite
While
which
i s fast
d i dnot include
likely
that
of utilization
of malpractice
Omnibus Budget
n o t be
i n t h elawsuit, other
I tappears
i l l effects
will
peview
and s h e w i l l
Wickline
defendent
as w e l l .
of the bills
Utilization
life
this
by i n s u r e r s .
lawsuits concerning
The
from
the effect
review
suits.
Reconciliation Act of
75B
1385
[COBRA]
funding
care
and r e f u s e s
may be h e l d
emergency
room
provides
that
treatment
liable
a hospital
accepts
t o p a t i e n t s unable
f o r harm
medicare
t o pay f o r
t o a p a t i e n t who i s i n an
condition or i n labor.
medical
which
COBRA a l s o
requires
emergency
t o d e t e r m i n e w h e t h e r an emergency
757
condition actually exists.
S e c t i o n S 1 2 1 o f COBRA i s an i m p o r t a n t
m e a s u r e b e c a u s e i t c r e a t e s a f e d e r a l med i ca 1
^
ma 1 p r a c t i c e c a u s e o f a c t i o n i n t h e c a s e o f
p r e m a t u r e t r a n s f e r o r dumping o f emergency
w a r d p a t i e n t s ... t h i s s e c t i o n o f COBRA [ i s ] a
'litigation
t i m e bomb w a i t i n g t o e x p l o d e
comparable t o RICO.'...in t h eabsence o f f e d e r a l
or s t a t e f u n d i n g programs t o cover t h ec o s t s o f
uncompensated h e a l t h care, t h e shunning or
t r a n s f e r o f p a t i e n t s f r o m emergency rooms f o r
f i n a n c i a l reasons w i l l continue.
At present,
monetary p e n a l t i e s and c i v i l l i a b i l i t y measures
( i . e . , malpractice s u i t s ) represent t h e best
s h o r t term ansver t o t h edilemma o f premature
t r a n s f e r o f t h e poor and u n i n s u r e d from p r i v a t e
75 8
hospitals."
Smith
in
relates
that
1985, t h e p r o b l e m s
acute."
and
screening
Human
Part
"Despite
associated
o f t h eproblem
Services
has been
-209-
t h epassage
w i t h p a t i e n t dumping
i sthat
less
of this
than
t h e"Department
vigorous
measure
remain
of Health
i nseeking
civil
�i LI i—i—rcrr
Cost Per State and Local
Government Employee, 1984-89
Current Year $
$3500
$2836
$3000
$243/
$2500
$2000
$1589
$1755
$1906
$2071
i
01
V
$1500
Between 1984 and 1989,
Health Plan Costs Increased 50 Percent
Even After Adjusting for Inflation
$1000
$500
$o
1983
1984
1985
1986
1987
1988
1990
1989
Source: Foster Higgins annual
H e a l t h Care B e n e f i t s Surveys
Source:
"Trends
i n Employna
Hnnlth
Bnnnfit
C u ^
i n -,-
,
i'
1980s" (Chart
1 ^
i nnn
r)
�Average Annual Cost of Health
Premiums in State Government, 1980 -89
CHART
3
Indemnity Plans
Current Year $
$3500
$2500
$3,080
Family P k a n s ^ ^
-
$2000
o
i
$1500
$1,343
-
$976
Individual
V\zxx%^^^'
$1000
$500 _
$437__——"
I
1
1
l
1
1
1
L
.
$0
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
S o u r c e : M a r t i n E. Segal,
Annual Surveys of State
Employee H e a l t h B e n e f i t Plans
a our c n :
•TVends
in
Employee
Health
Onnefit;
Costs
i,-.
S t n t e
and
Loc.-il
G o v n n unf? ri (:
in
the
IROOn"
fChant
^1)
�CHART
Percent Increase in State
Government Employee Health Benefit Costs
Compared to Inflation (CPI), 1980-89
25\
20%
15% -
10%
r
Inflation (CPI)
5% r
0%
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
Indemnity Plans
Sourct:
M a r t i n E. S#g»l Company
Note: Martin E. Segal Company d i d not conduct surveys i n 1981,
1982, and 1984. T h e r e f o r e , i n t h i s c h a r t , the annual percent
change for the 1980-83 was period was c a l c u l a t e d by d i v i d i n g the
premium c o s t i n c r e a s e from 1980 to 1983 by t h r e e to get an
average annual percent i n c r e a s e .
L i k e w i s e , the annual percent
change f o r the 1983-85 p e r i o d was c a l c u l a t e d by d i v i d i n g the
i n c r e a s e from 1983 t o 1985 by two to get an average annual
percent i n c r e a s e .
D
cur ze:
"Trends i n Employee H e a l t h B e n e f i t Costs i n S t a t e and Lzzs
Government i n t h e 1980s" (Chart 3 ) .
P r e s e n t e d t o t n e S t a t e and Local G o v s r n m s r t Lacor-Managemar
C o m m i t t e e . J u n e 15. 1990
-25 1 -
�penalties
maximum
(against
the offending
recoverable
penalty
h o s p i t a l s ] because t h e
i s $25,000 and i s l e s s
than the
759
cost
of prosecution."
a recognized
deterrent
the
answer
Why
was t h e p e n a l t y
Association
with
Many
s e t a t such
members w e r e
state
must
m u s t be v e r y
regulations
emergency
hospitals
also
that
impose
common
statutes
t o end p a t i e n t
way
that
hospitals
will
get reimbursement
American
with
Tha
with
t h e dumping
sibility
tion
few
will
needing
care
on h o s p i t a l
which
insurers
care.
utilization
of malpractice
review
which
Requiring
will
otherwise
have
should
stated
every
be
t h e same
f o rpatients
based
begin
-2 10 -
duty
7 5 2
insurers
years.
no
i n d i v i d u a l who
or t o provide
correlated
The
moral
as
would
on h a r m
respon-
access
eliminate the
caused
surfacing
same
hospitals
to provide
review/dumping
claims
regulations
i s t o guarantee
are p e r p e t r a t i n g .
t o care
indigent
Waxman
f o r every
dumping
be d r a w n - - i n s u r e r s
imposing
class
care
cr v e r a g e . "
t o p r o v i . de a c c e s s
to provide
without
new
health
information
conclusion
have
facility
t o pay."
imposed
dumping
sure
built
t o a l l who
760
and
Judith
"The o n l y
comes t o t h e i r
care
to treat
1
that
Hospital
amount?
of a b i l i t y
law w h i c h
a l l patients. ^
which
a l l "hospitals
a duty
7
to treat
at that
emergency
A l l these
t o overcome
i.e.,
by t h e A m e r i c a n
regardless
patients.
were p r o m u l g a t e d
obvious:
w r i s t slap
provide
t h e community
is
hospitals,
a low r a t e ?
H i l l - B u r t o n Act requires
penalty
of v i o l a t i v e
influenced
t o set the token
within
and/or
on
t o punishment
H i l l - B u r t o n funds
reside
the insignificant
to the f o l l o w i n g question
Congressional
The
Since
by
utiliza-
w i t h i n the next
�Legislators
tion
review
refuses
and
process
complaint
The
a prime
that
paradox
visibly
life
hospital
that
man
occurs
turning
because
termination
away
actions
and
the
the
hospital
could
Society,
condemnation
which
of
the
from
the
i s , therefore,
easier
corporate
economic
summed
i n one
up
hospitals
by
i s refused
insurers
malpractice,
soon
become
and
justify
on
PROFITS!
the
hopefully
on
sees
Fact.
- 2 VI -
I t
unethical
voiced
its
dumping
the
by
that
patient
insurers-action
in
governmental
but
of
medical
action.
is
question
and
e n t i r e s i t u a t i o n can
care
be
i. n
termination
f i n a n c i a l grounds.
of
the
suit.
Termination
insurer
cause
is
because
e t h i c a l grounds,
i s condoned
a recognized
The
of
a
hospital
that
action
in a c i v i l
location
to
one
In
Everyone
services,
interests.
word:
to
first
i t is
unethical.
action--patient
geographic
tongue."
recognizes
the
is
Indian
condemns t h e
sufficiently
e f f e c t i v e l y terminates
removed
care
second
merely
'reasoning'
forked
witness
that
not
but
utiliza-
American
i n need.
liable
however,has
the
services--bQcause
are
acknowledged
be
old
with
staffer
commonly
and
That
therefore
then
that
care,
society
of
a patient
and
the
speaks
threatening
insist
care.
of
s e t t i n g , many p e o p l e
staffer's
It
for
will
terminate
example
"white
action—hospital
is
does n o t
reimbursement
doublespeak,
staffer
insurers
of
I t is
malpractice
still
will
�MALPRACTICE.
The
in
First
England
i n t h e year
many p e o p l e
(including
Associations]
awards,
m a l p r a c t i c e case
13 7 5 ;
i s b e l i e v e d t o have
7 53
i
n
t h e American
the late
Medica
are attempting t o place
shorten
statutes
20th
occurred
century,
and H o s p i t a l
c a p s on m a l p r a c t i c e
oF l i m i t a t i o n ,
place
limits
on
754
discovery
rules,
But
eFForts
those
problem
do
are not viable
they
solutions
Fees.
to the malpractice
on t h e r e s u l t s
oF m a l p r a c t i c e a n d
n o t F o c u s on t h e c a u s e s
oF m a l p r a c t i c e
suits--neg1igence
l a c k oF s u F F i c i e n t k n o w l e d g e
ordinarily
litigious
Malpractice
l a w s u i t s have
cost
eFFects
oF ma 1 p r a c t i c e - - t h e
deFensive
health
care
oF t h e h e a l t h c a r e
medicine—are
costs.
or s k i l l s
and t h e e x t r a -
American p o p u l a t i o n .
overall
as
on a t t o r n e y c o n t i n g e n c y
Focus
and/or
because
and l i m i t s
n o t s i g n i F i c a n t 1y
raised the
p r o v i d e r system.
repercussions
causing
And d e F e n s i v e
commonly
worrisome
medicine,
The s e c o n d a r y
reFerred t o
increases
i n turn,
to total
i s causing
r a t i o n i n g oF m e d i c a l c a r e .
The c o n t i n u u m i s a s F o l l o w s :
I n s u F F i c i e n t knowledge and/or s k i l l
levels
leads to
N e g l i g e n t p r a c t i c e oF m e d i c i n e , w h i c h
leads to
Malpractice
l a w s u i t s , i m p o s e d by an o v e r l y l i t i g i o u s s o c i e t y
lead to
The p r a c t i c e oF d e F e n s i v e m e d i c i n e ,
which
leads t o
Higher h e a l t h c a r e c o s t s , which
lead to
I n s u r e r s r e F u s i n g t o pay F o r c a r e and c a n c e l l i n g p o l i c i e s , w h i :
leads t o
U t i l i z a t i o n review,
which
leads t o
R a t i o n i n g oF h e a l t h c a r e .
The
ability
American
to monitor
Medical
Association insists
i t s own m e m b e r s h i p ' s
- 2 'I 2 -
on m a i n t a i n i n g i t s
capabilities,
b u t i t has
�amply
demonstrated
quality
level
practicing
the
AMA
even
in
proFessional
has been
juries
and m a i n t a i n t h e
The AMA
irresponsibility.
pushing
that
arbitration,
Richard
to p o l i c e
oF i t s own m e m b e r s h i p .
advocating
avoid
i t s reFusal
A t t h e same
F o r c a p s on m a l p r a c t i c e
a l l malpractice
r a t h e r than
sympathetic
has been
a c t i o n s be
time,
a w a r d s and
determined
i n a c o u r t oF l a w i n o r d e r t o
to injured
patients.
G e p h a r d t (•-MD.) h a s s t a t e d t h a t
Congressman
malpractice
s u i t s are
765
necessary
and Former
that
a c a p on m a l p r a c t i c e
putting
Surgeon General
C. E v e r e t t
awards
Koop
is deFinitely
warned
succombing
766
to
the pressures
Inept
position
the
is
oF t h e AMA.
physicians
be m o r e
oF p r o v i d i n g h e a l t h
d i m i n u t i o n oF s o m e o n e ' s
a matter
patient's
and
oF b a l a n c i n g
ability
the nation's
rationing
gainFully
capacity.
poor
continue
path
the doctor's
can F u r t h e r
harm
i n the medical
physicians
liFe,
are leading to
patients.
Terminating
enable
but i n a
may g a i n
will
unacceptable
enhance
h i m t o be
diFFerent
bask
5
-2 1 2 -
politician,
to a society
the elimination of
i n t h e aura
Act.' '
For a
t h e p r e s t i g e oF t h o s e
a new s e c t i o n e n t i t l e d
Service
points
Additionally,
t o p r a c t i . ce who w i l l
Health
which
still
Field,
and e c o n o m i c a l l y
physicians
the Public
against the
i n t h e c u r r e n t mode oF p r o t e c t i n g
health care.
S.1227 a d d s
but this
h e a l t h a n d , i n some c a s e s ,
which
trained
quality
liFestyle
costs
To c o n t i n u e
t o advocate
and l i F e s t y l e ,
h e a l t h care
employed
quality
career
rising
i ti s morally
seeking
I t i s unpleasant
l i c e n s e t o p r a c t i c e may
inadequately
but
q u i c k l y e l i m i n a t e d From t h e
care.
to maintain
oF c a r e
a physician's
to
must
oF
excellence.
Malpractice
Section
who
ReForm
3 0 6 oF t h e A c t
�provides
that grants
covering
medical
be
awarded
malpractice
receive
such
eFForts
to develop
disputes
may
grants,
they
reForm.
will
be
alternative
that Fairly
to
protect
States
However,
required
methods
the
For
to
programs
iF states
do
"...include
to resolve
i n t e r e s t s oF
liability
a l l parties
i n v o l v e d . . ."
This
provision
Association's
number
oF
desires
medical
courtroom
with
resolution
would
by
an
The
with
recourse
the
require
some F a c t i o n s
to
the
their
Providers
medicine
become
have
a major
this
country.
1980
were
are
saFer
way
an
perFormed
For
the
For
Juries
and
economic
juries
extent
the
number
oFten
dispute
parties,
a
retired
necessary
by
lawsuits
The
health
time,
care
in drastic
services.
practice
deFensive
unnecessary
1S.5
percent
oF
section.
Less r i s k
-£ 1A-
most
sometimes-excessive
provide
to
oF
providers.
costs
with
in a
p a r t i e s , oFten
deemed
rising
caesarean
inFant,
on
have r e s u l t e d
t h a t such
example,
by
are
the
e F F e c t s on
the
i t necessary
heard
Alternate
are
other
and
the
appeal.
that caregivers
an
are
between
binding
Medical
possible
which
jury.
excessive
d r i v e r i n the
As
much as
lawsuits
careers,
Found
to such
be
the
and
t o p l a i n t i F F s by
i n the
a
American
a d m i n i s t r a t o r , oFten
physicians
providers
changes
oF
to
oF
eFFects
awards
the
lawsuits
courts
methods
psychological
and
as
arbitration
would
because
against
with
p1 a i n t i F F / p a t i e n t .
decision
Alternative
levelled
in Front
independent
judge.
no
to reduce
malpractice
setting,
sympathetic
reFereed
i s i n accord
oF
care
health
care
in
a l l births
in
Caesarean
oF
has
serious
sections
�complications.
malpractice,
on
23.8
By
perFormed
oF
For
as
that
brought
This
4 percent
year.
the
a deFensive .response
perForming
a l l births.
comprised
caesareans
mostly
p h y s i c i a n s were
percent
operations
19S9,
oF
This
caesarean
total
increase
average
cost
sections
l a r g e number
the
oF
oF
surgical
surgical
i n the
that
to
procedures
number
oF
procedure
to
7B9
$7,186
whereas a normal
amount.
Estimates
For
delivery
the
medicine
depending
deFensive
on who t h e e s t i m a t o r i s and
•
m e_ • c • n e . 770
di i
to
only
way
a t t e n d to the
1.
Reduce
to respond
root
the
risk
oF
tion
From
requirements
$21
incidents
and
oF
actual
i n c r e a s i n g the
experience
oF
annually,
is included
as
increases
types
oF
care.
should
be
e s t a b l i s h e d which
w i t h o u t economic
m a l p r a c t i c e and
continued
levels
certain
is
medical
physicians
as
practicing
oF
For
and
Completely
new
state-sponsored
have
to the
educa-
oF
licensing
ties
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as
i t s members
providing
sector
oF
review
only
the
establishment.
2.
Reduce
attorneys
possible
include
that
t o a l l Forms
billion
what
halF
causes .
m a l p r a c t i c e by
medical
about
to malpractice cost
t o renewed
those
due
t o $130
prerequisites
boards
cost
incurred
deFensive
The
range
costs
would
the
to alter
liability
a moral,
the
as
path
well
oF
actually
n e g l i g e n t or
oF
oF
claim.
evidence
Accidents
the
number
case
m a l p r a c t i c e l a w s u i t s by
they
Follow
Attorney
as
legal,
to determine
merely
circumstance
do
an
not
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oF
by
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requiring
oF
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lawsuits.
IF a
suit
�is
warranted,
only
i n cases
physicians
the
root
to
cause
reduce
or
been
the
public
current high
p l a i n t i F F s to
instituting
which
data
which
would
inFormatio
1.
be
be
set
nor
removing
From
a
legislated
provided
For
and
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that
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would
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to beneFit
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employed
The
interest
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S.1227 r e q u i r e s
analyze
them
should
not
potential
For
in malpractice
have
be
incurred i s minimal.
malpractice
inhibit
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malpractice
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where
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The
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enable
ineFFective
or
collect
a r e p o r t t o be
additional
collected will
entity
malpractice
relate
unnecessary
and
made t o
reForms.
7 7
Congress
^
The
to:
medical
testing
and
p r a c t i ces;
2.
the
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(including
oF
number
oF
claims
the
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oF
existing
disciplining
4.
and
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and
Filed
malpractice
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awards
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Findings
n e g 1 i gen c e ) ;
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and
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oF
the
reasonableness
rate-setting
5.
any
procedures
practices;
other
issues
medical
p r a c t i c e s , oF
medical
malpractice,
medical
practices.
772
health
in preventing
oF
malpractice
relevant
the
provider
licensing
malpractice;
insurance
premiums
and,
oompensation
and
care
impact
to
For
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oF
current
resulting
liability
on
From
�S.1227 r e q u i r e s
ment B o a r d
maintain
out
whose p u r p o s e
and
improve
the S t a t e .
which
each
will
7 7 3
State to establish
will
be
t o r e v i e w and
the q u a l i t y
The
board
acknowledge
of health
will
a health
a Quality
conduct
Improve-
continue to
care
provided through-
a certification
care provider
as
being
process
an
774
outstanding
practitioners.
advisability
reconsider
insurance
zation
an
the c e r t i f i c a t i o n
company
incentive
performed
coverage
or s t a t e
benefit
certification
plan
may
o r o r d e r e d by
may
n o t be
7 7 7
a problem,
substandard
While
such
The
board
payment
and
would
on
grounds
that
often
methods
authori-
time.
7 7
"
'
As
Specifically,
i s medically
to deal
positively
for dealing
the subjects
1
service
the service
commendable
must
'outstanding,'
f o r any
pro v i der .
not mention
are
as
the
plan,
have
a t any
77£:
certified
i t i s always
who
periodically
t o become c e r t i f i e d
S.1227 d o e s
physicians
re-examine
of a provider
n o t deny
denied
will
upon r e q u e s t o f a h e a l t h
agency.
f o r physicians
unnecessary.
with
board
of continued c e r t i f i c a t i o n
t o suspend
a health
The
of
with
malpractice
litigation.
A method
different
change
f o r r e d u c i n g the problem
state
when t h e home s t a t e
to a national
licensing
investigate
physicians
the
licensing
federal
and
bureau
would
i f the physician
he
would
n o t be
licenses
same F e d e r a l
are
i n good
would
able to
emanate
bureau,
standing
and
were
regarding
notified
practice
the single
could
state: s
benefit
would preFer
-2 17-
i s to
licensure,
about
licensure
medicine
federal
state,
since
bureau.
those physicians
t o move
to a
would
t o move t o a n o t h e r
legally
from
however,
be
moving
his license
While
make d e c i s i o n s
Thus,
all
revokes
bureau.
statuS.
still
of physicians
to another
That
who
state.
�Since
Free
their
to
l i c e n s e would
p r a c t i c e anywhere
be
valid
they
i n any
state,
they
would
be
chose.
LABOR UNIONS.
Health care i s the major issue i n the vast
m a j o r i t y oF c o l l e c t i v e b a r g a i n i n g n e g o t i a t i o n s .
The l a b o r m o v e m e n t i s u n i t e d i n i t s d e t e r m i n a t i o n
to achieve u n i v e r s a l access, s i g n i F i c a n t cost
containment,
q u a l i t y c a r e and
progressive
Financing.778
IF c u r r e n t t r e n d s c o n t i n u e a t t h e b a r g a i n i n g
t a b l e , by t h e end oF t h e d e c a d e o n e - t h i r d oF t o t a l
c o m p e n s a t i o n w i l l go t o pay F o r h e a l t h c a r e a t t h e
e x p e n s e oF wages a n d o t h e r b e n e F i t
improvements. 79
7
There
i s broad
union
government
does n o t
play
ing,
will
there
health
care,
be
and
consensus
a broader
that
role
increasing inequity
costs
may
increase
so
iF the
Federal
i n h e a l t h care
among t h o s e
rapidly
that
Financ-
seeking
the
nation's
hearings
in eight
780
ability
t o compete
During
the
cities
i n order
health
care
aFFiliated
globally
Fall
oF
to spur
reForm.
unions
may
1990,
Founder.
the
interest
They
present
expect
AFL-CIO h e l d
i n and
build
consensus
For
t o h a v e r e p r e s e n t a t i v e s oF
the
90
Federation's views to a p p r o p r i a t e
7 81
c o m m i t t e e s oF t h E House a n d S e n a t e .
They i n t e n d t o d e v e l o p a
" . . . n a t i o n w i d e g r a s s r o o t s c a m p a i g n by
m o b i l i z i n g t h e i r m e m b e r s i n an a l l - o u t l o b b y i n g
eFFort t o win n a t i o n a l reForm.
To s u c c e e d i n
t h i s e F F o r t , t h e F e d e r a t i o n w i l l Form c o a l i t i o n s
w i t h consumer g r o u p s , e m p l o y e r s , community-based
o r g a n i z a t i o n s and p r o v i d e r s t o c a l l on C o n g r e s s
F o r e x p e d i t i o u s e n a c t m e n t oF F e d e r a l
legislation
that w i l l :
...guarantee Americans the r i g h t to h e a l t h care;
...establish a social insurance n a t i o n a l health
care program;
. . . c r e a t e a n a t i o n a l c o m m i s s i o n oF c o n s u m e r s , l a b o r
m a n a g e m e n t , g o v e r n m e n t and p r o v i d e r s t o
e s t a b l i s h a n a t i o n a l cost containment
program
w h i c h i s t o i n c l u d e a cap on h e a l t h e x p e n d i t u r e s , a v o i d d u p l i c a t i o n oF
technology,
i m p r o v e a l l o c a t i o n oF r e s o u r c e s , a n d n e g o t i a t e
uniForm reimbursement r a t e s ;
_? I S -
�...guarantee a core package o f b e n e F i t s , w i t h
supplementary b e n e F i t packages a v a i l a b l e ;
. . . a s s u r e c o v e r a g e r e g a r d l e s s oF a g e , i n c o m e , e m p l o y ment s t a t u s o r p r i o r h e a l t h c a r e h i s t o r y ;
. . . d r o p M e d i c a r e e l i g i b i l i t y t o age BO i n o r d e r t o
c o i n c i d e w i t h average r e t i r e m e n t age.782
The
health
this
Federation
care
reForm
_,
decade
explains
health
care
entity
to negotiate
rates,
providers
providers
eFFectively.
deemed
and
could
that
save
their
recommendations For
t h e n a t i o n $165 b i l l i o n i n
a, o n e . 7 8 3
l
Sheinkman
regulation
contends
that
control
under
costs.
and e s t a b l i s h
would
Medicare
the present
be F o r c e d
provides
By r e q u i r i n g
nationwide
t h e precedent
Medicaid--is
because
Such
F o r 40 p e r c e n t
Federal
cost
For government
r e g u l a t i o n was
t h e government--through
responsible
a
reimbursement
t o practice•more
oF p r o v i d e r r e i m b u r s e m e n t s .
necessary
system
Medicare
oF t h e n a t i o n ' s
784
health
oF
care
expenditures.
Sheinkman
justiFies
cost
this
c o n t r o l by e x p l a i n i n g :
C r i t i c s claim t h a t Medicare's e x i s t i n g
reimbursement system simply s h i F t s h o s p i t a l
c o s t s From t h e g o v e r n m e n t t o p r i v a t e p a y o r s
l i k e e m p l o y e r and u n i o n p l a n s because h o s p i t a l s
charge those plans h i g h e r r a t e s t o compensate
For t h o s e t h a t pay l e s s .
But i F t h e p r o p o s e d c o s t c o n t r o l s y s t e m s
w e r e made l a w , t h e l o o p w o u l d be c l o s e d : c o s t
s h i F t i n g would s t o p and c o s t c o n t a i n m e n t
would
be a c h i e v ab 1 e .
...
A s k i n g i n d i v i d u a l s t o F i n a n c e t h e i r own
h e a l t h care v i o l a t e s t h e basic p r i n c i p l e s of
pooling risk i n insurance.
I talso v i o l a t e s
o u r s o c i e t y ' s s e n s e oF d e c e n c y .
Health
care
c o s t s s h o u l d n ' t be F o i s t e d o n t h e s i c k a n d t h e
disenFranchised.
T h e y s h o u l d be d i s t r i b u t e d
r a t i o n a l l y and F a i r l y .
...
(T)he p o l i t i c i a n s won't l e a d t h e Government
i n t o h e a l t h care F i n a n c i n g .
Real l e a d e r s h i p
78
m u s t come f r o m b u s i n e s s a n d l a b o r .
c
-2 19-
method
�EMPLOYERS.
The
cost
t o employers
health
insurance
1989.
This
net
reached
represents
proFits.
"the
insurance
Factors
costs
additional
illnesses
$3,161,
contributing
From
and i n c r e a s e d
employees'
oF $ 5 6 1 o v e r
(average)
oF 1,355 e m p l o y e r s
are medical
pressures
an i n c r e a s e
a 26 p e r c e n t
A survey
principle
i n 1990 F o r t h e i r
oF e m p l o y e r s '
revealed
that
to escalating health
price inFlation
large claims
u s e oF m e n t a l
generally, with
For c a t a s t r o p h i c
h e a l t h and substance
787
abuse
beneFits."
Other
about
sources
claim
that
$4,500 F o r each employee
employees c o n t r i b u t e about
a 400 p e r c e n t
that
the"typical
increase
on
States
t o expand
on
employers.
legislators
increase
1980 t o t a l s .
i n cost
minimum
services
7
8
These F i g u r e s a r e
8
Butler
package
warns
implies
was e p p a r e n t l y
pressure
requirements
i m p o s e d on
l o b b y i s t s (A.M.A. a n d A.M.A.) t o
and r e d u c e
copayments
by i n s u r e d s .
Having t h e government r e q u i r e people t o
buy i n s u r a n c e t h a t p a y s F o r t h e s e r v i c e y o u
p r o v i d e i s a n i c e way t o i n c r e a s e demand F o r
t h a t s e r v i c e whether i t s orthopedic surgery
or acupuncture t r e a t m e n t .
State lawmakers...
have . . . e n a c t ( e d ) more t h a n 800 l a w s d u r i n g
t h e p a s t 15 y e a r s r e q u i r i n g i n s u r e r s t o c o v e r
speciFic providers or services—even
when
t h e r e was l i t t l e c o n s u m e r demand.
Butler
while
may h a v e come From
beneFits
The p r e s s u r e
by p r o v i d e r
dependents,
$1,300 a n n u a l l y .
over
p a r t oF t h e i n c r e a s e
including
c o m p a n y " now p a y s
that:
When i n s u r a n c e c o s t s g e t h i g h e n o u g h ,
e q u a l i n g o r e x c e e d i n g t h e c o s t s oF p a y i n g
i n t o t h e f p r o p o s e d pay o r p l a y
insurance
Funds) government i n s u r a n c e Fund,
business
e x e c u t i v e s w i l l e i t h e r F i n d ways t o c u t c o s t s ,
-220-
�o r d r o p t h e company i n s u r a n c e a n d p a y t h e
government's non-insurance t a x ( o f7 t o 9
percent of p a y r o l l ) .
Thus p l a y o r pay i s a w e i g h s t a t i o n on
the
road t o a g i a n t M e d i c a i d program f o r a l l
A m e r i c a n s - - a phony a l t e r n a t i v e t h a t w i l l
become so u n a t t r a c t i v e o v e r t i m e t h a t
e v e n t u a l l y w e ' l l g e t t h o s e long l i n e s and
w a i t i n g l i s t s , s o common i n Canada a n d B r i t a i n ,
despite ourselves.790
The
is
National
comprised
special
Leadership
o f about
interest
sixty
groups.
Coalition
large
f o r H e a l t h Care
companies,
Some o f t h e s i x t y
Reform
u n i o n s , and
companies
a r e Xerox,
7 91
Lockheed,
Southwestern
corporations;
Burger
ing
--
coverage.
K o d a k , 3M, a n d
membership
i n the
t o be d i s a g r e e m e n t
participation
The C o a l i t i o n
p r o v i d e coverage
concerni n cost
rocommends:
t o a l l employees
public
health
plan v i a
taxes; and,
uniform
Employers
compensation
fees f o rphysician
also
cost
shifting
insurance.
Those
employers
are i n s t i t u t i n g
services i n
insured
t o uninsured
increases i n their
premiums went
i n 1990.
attempts t o reduce
and h o s p i t a l
fromthe
f a c e premium
1985 t o $ 6 7 b i l l i o n
In
Other
t h e r e f o r m which i s
t o a government-sponsored
order t o e l i m i n a t e
«
p a t i e n t-s . 7 9 2
in
Eastman
o f government
a l l employers
contribute
payroll
extent
Electric.
from
over
The p r o b l e m a p p e a r s
and b e n e f i t
that
withdrawn
of apprehension
the appropriate
-or
because
advocated.
control
and G e n e r a l
i . e . , ATST, D u P o n t , A r c o ,
K i n g , have r e c e n t l y
coalition
being
Bell,
workers'
f r o m $35
billion
7 9 3
the costs of workers'
safety
-22 1 -
programs,
compensation,
light-duty
programs
�Work-Related Injuries in the Private Sector
(1980-1988)
10
1980 1981 1982 1983 1984 1985 1986 1987 1988
SOURCE U.S. Department ol Labor
"The U n i v e r s a l H e a l t h c a r e Almanac"
(Phoenix:
S i l v e r S C h e r n e r , L t d . , 1991), p . 89
Repr i n t e d :
Work-Related Illnesses in the Private Sector
(1980-1988)
350
300
1980 1981 1982 1983 1984 1985 1986 1987 1988
SOURCE. U.S. Department ot labor
pointed:
- i r l f l v ^ r S n e ? : " ^ ! ' ;
1901), P . 8 B
�for
injured
screening
ing
employees r e t u r n i n g t o work,
of prospective
process
record
includes
checks
has
filed
the
record
injury,
checks
checke
known
unions
as b e i n g
records,
because
however,
filing.
groups
claims
Also,
is filing
f o r t h e same
workers'
object
t o the record
of privacy
and "an a t t e m p t
to certain
classes
a r e n o t used
Thirty-eight
employer.
filing.
jobs
a potential
employee
any e m p l o y e e
insurance
screen-
but also
the prospective
whether
and consumer
t o deny
examinations
w i t h any o t h e r
and h e a l t h
an i n v a s i o n
of prior
reconsider
whether
reveal
as d o u b l e
some c o m p a n i e s
The
will
The p r e - e m p l o y m e n t
physical
comp c l a i m s
comp c l a i m s
Labor
not only
t o determine
workers'
workers'
workers.
and pre-employment
t o deny
comp c l a i m s ,
employee
states
of
workers."
employment
merely
b u t c a n be u s e d t o
who h a s p r a c t i c e d
provide
by
this
data
double
t o employers
734
upon
request.
In
stood
a discussion
that
However,
t h e employer
'employer'
companies
involved
equipment,
also
includes
of physicians,
cost-control
measures."
the
yrew
number
7.7
of Americans
pert: e n t ,
e t c . These
growth
t o support
I n the one-year
employed
t o 3.4 m i l l i o n .
-222-
those
medical
homes, and p r o f e s s i o n a l
the continued
and a r e u n l i k e l y
of
manufacture,
dentists,
expenditures
under-
retailer, etc.
consideration
i n pharmaceutical
" . . . b e n e f i t from
i t i s generally
i s a manufacturer,
h o s p i t a l s and n u r s i n g
corporations
all
of 'Employers,'
employers
of health
aggressive
period
i n the health
care
new
1389 t o 1 9 9 0 ,
care
Dr. Blumenthal.
industry
considers
�this
trend
t o be
a signal
that
the health
become a m o r e
Formidable
opposition
programs,
and
"political
consensus
tion
become more d i F F i c u l t
is
will
"...no c o n s e n s u s
among
achieve
the c r i t i c a l
support
regulation
[these
goal
or
oF
t h e as
care
to Federal
industry
cost-control
concerning Federal
to a c h i e v e . "
businesses)
controlling
7 9 5
To
about
costs:
y e t unproved
will
legisla-
date,
how
there
to
whether
strategy
to
oF
79G
camper, i t i o n . "
The
From
C o n g r e s s i o n a l Budget
the Subcommittee
Committee
on
on
H e a l t h oF
Energy
on
and
H e a l t h and
Commerce
the Committee
diFFerent
methods For
Expansion
oF
OFFice,
on
i n response
the Environment
and
From
Ways a n d
the
coverage
oF
the
Subcommittee
Means, s t u d i e d
r e d u c i n g t h e n u m b e r oF
employment-based
to requests
two
uninsureds.
or M e d i c a i d
were
the
797
options
covered.
From
the standpoint
emp1oyment-based
would
be
would
eFFectively
rolls
oF
coverage
p r o v i d e d For
Medicare,
an
remove
oF
the Federal budget,
expansion
i s p r e F e r a b l e because
additional
a number
Medicaid,
and
oF
17.3
coverage
million
those people
the Veterans
790
beneFits.
However, t h e r e i s a s t r o n g
oF e m p 1 o y m e n t - b a s e d c o v e r a g e .
oF
people,
From
and
the
Administration
downside
to
expansion
The p r i n c i p a l a d v a n t a g e oF t h e e m p l o y e r m a n d a t e
i s i t s m i n i m a l e F F e c t on t h e F e d e r a l b u d g e t d e F i c i t - r o u g h l y $1.8 b i l l i o n c o m p a r e d w i t h $15.4 b i l l i o n
For
the
Medicaid expansion.
The emp J o y e r m a n d a t e ' s m a j o r
.
d i s a d v a n t a g e i s i t s p o t e n t i a l e F F e c t on e m p l o y m e n t ,
b e c a u s e m a n d a t i n g c o v e r a g e w o u l d r a i s e l a b o r c o s t s For
a F F e c t e d F i r m s and w o r k e r s .
Some e m p l o y e r s m i g h t l a y
oFF w o r k e r s o r r e d u c e t h e h o u r s oF t h o s e who remai. n e d
employed t o below t h e mandated t h r u s h o l d For c o v e r a g e .
A F F e c t e d t h e m o s t w o u l d be s m a l l F i r m s , w h i c h e m p l o y
233-
�over h a l f of a l l uninsured workers.
Exemptions For
s m a l l Firms would p r o t e c t them, b u t would a l s o reduce
t h e e F F e c t i v e n e s s oF t h i s a p p r o a c h i n e x p a n d i n g c o v e r age.
S u b s i d i e s For s m a l l b u s i n e s s e s would
mitigate
t h i s problem, b u t they would i n c r e a s e t h e Federal
deFicit.
I n a d d i t i o n , e n F o r c i n g t h e employer mandate
w o u l d be a d m i n i s t r a t i v e l y d i F F i c u l t , e s p e c i a l l y F o r
i n d u s t r i e s where w o r k e r s changed j o b s F r e q u e n t l y o r
h a d F r e q u e n t s p e l l s oF u n e m p l o y m e n t .
F i n a l l y , an
e m p l o y e r m a n d a t e w o u l d l i m i t t h e c h o i c e s oF F i r m s a n d
workers.799
The p r i n c i p a l a d v a n t a g e oF e x p a n d i n g M e d i c a i d
w o u l d be t h a t a l l a d d i t i o n a l F e d e r a l a n d s t a t e s p e n d i n g
w o u l d be c o n c e n t r a d e d on i n d i v i d u a l s who a r e l e a s t a b l e
t o aFFord p r i v a t e c o v e r a g e - - t h o s e w i t h F a m i l y incomes
b e l o w 2 0 0 p e r c e n t oF p o v e r t y . 8 0 0
Hie Relationship of Wages to Providing Health Benefits
Otter health benelits
Percent ot emoloyees earning
Less than
$10,000
Size ol firm
Fewer
'0-24
25-99
100 or
Do not otter health benelits
Percent ot employees earning
man 10 employees
emoloyees
emoloyees
more emoloyees
$10,000$30,000
More than
$30,000
Less than
$10,000
$10,000$30,000
More than
$30,000
11
16
11
13
50
62
69
65
28
22
20
22
30
J7
J2
52
53
^1
•13
33
18
12
• • r s o r o e n i -.amD.*!
SOURCE, -eaun insurance Avsoaairfyi ol America
Dollar Outlay by Employers for
Employee Insurance Coverage (1988)
(from total compensation)
Group Life Insurance
S10
Worker s
Compensation
S31
Supplemental
Insurance
S4.6
Group
Health Insurance
S133
J. 5. Ceo.nnmem ol Commerce Bureau ol Economic Analysis. Survey ot C^rreM Business
Senate
Bill
700 h e l p s t h e s m a l l
employer's
p l i g h t but
30 1
doesn't
oF
go q u i t e
S.700 w i t h
Durenberger
Far enough.
Combining
the Cleveland Plan
objectives.
-224-
would
the
advantages
meet a l l t h e F u t u r e
�Small
Business
In
the
1973,
Council
insurance
Coalitions.
Cleveland,
of Smaller
Ohio's
Chamber o f Commerce
Formed
E n t e r p r i s e s (COSE) t o p u r c h a s e
F o r 8,000 s m a 1 1 - b u s i n e s s e m p l o y e r s
with
health
145,000
802
employees
was
oF
and d e p e n d e n t s .
increased
had
and a d m i n i s t r a t i v e
thecoalition.
2,000 s m a l l
been
insurance
health
The c o s t
employers
unable
membership
i n , COSE.
t o provide
will
encourage
decreased
by
t o t h eFormation
just
between
34 p e r c e n t ,
power
Formation
approximately
health insurance
rates increased
Nancy
purchasing
enabled
As a c o n t r a s t ,
rates increased
insurance
costs
savings
t o do s o p r i o r
Representative
which
The e m p l o y e r s '
when
they
oF, and t h e i r
1984 a n d 1990,
while
COSE
commercial
803
by 154 p e r c e n t .
Johnson
(R-Ct.)
t h e Formation
introduced a
oF s m a l l - e m p l o y e r
bill
purchasing
g r o u p s b a s e d on t h e C l e v e l a n d m o d e l b y :
.. e x e m p t i n g t h e c o v e r a g e From s t a t e - m a n d a t e d
health
beneFits;
.. e x e m p t i n g e m p l o y e r s From s t a t e t a x e s o n h e a l t h
i n s u r a n c e premiums; and,
..
e x e m p t i n g t h e p l a n c o v e r a g e From s t a t e
p r o h i b i t c e r t a i n t y p e s oF m a n a g e d c a r e
Individuals
who a r e s e l F - e m p l o y e d
small-employer
deductions
purchasing
groups
For h e a l t h i n s u r a n c e
will
l a w s t h a t QQQ
activities.
be e n c o u r a g e d
to join the
by i n c r e a s i n g t h e i r t a x
p r e m i u m s From
25 p e r c e n t
t o 100
805
percent.
John
explains
Polk,
that
t h eCleveland
under
Council's
executive
director
currentlaw:
C o r p o r a t i o n s c a n w r i t e oFF t h e e n t i r e c o s t
oF e m p l o y e e h e a l t h b e n e F i t s , w h i l e s o l e p r o p r i e t o r s
and p a r t n e r s h i p s c a n n o t .
Large companies t h a t
s e l F - i n s u r e a r e e x e m p t From a h o s t oF c o s t l y s t a t e
�r e q u i r e m e n t s , while small Firms are not. A l l
e m p l o y e r h e a l t h c a r e p l a n s s h o u l d be t r e a t e d
t h e same.
I n s u r e r s a r e b e h a v i n g t h e way t h e e n v i r o n m e n t
p e r m i t s them t o behave.
U n l e s s we c a n i n t e r j e c t
i n t o t h e m a r k e t p l a c e an o r g a n i z a t i o n l i k e o u r s
w h i c h s e r v e s as an a g g r e s s i v e a d v o c a t e F o r o u r
m e m b e r s , i n s u r e r s do n o t h a v e any g r e a t i n c e n t i v e
t o c l e a n up t h e i r
act."
3
A company
•"j.-
••' • •
^ r.-F- by
employers
t o Fund
their
Companies
with
Few
t h e y had
as
companies
costs
is
that
In
early
data
Maryland,
t o 30
would
oF
antitrust
be
valuable
. .
decisions.
the
with
premiums
Each
e m p l o y ees
was
Formed
plan
in
each
unions,
i n the
hospitals,
insurance c a r r i e r s
in coalescing
whether
was
lengths
changes
to
oF
in
and
share
stay,
and
health
beneFicial.
Justice
enable
pooled
r e i n s u r a n c e i s pirovided.
diagnoses,
had
oF
liability.
would
been
inFormally
queried
Forming
coalitions
without
The
DOJ
concurred that
dissemination
to a l l concerned
i n making
oF
the
purpose
i n F o r m a t i o n which
inFormed
health
would
care
803
A southwest
by
oF
small
plans.
insurers.
employers,
health
the p e r m i s s i b i l i t y
the group
p e r c e n t oF
and
purpose
be
are
poolinj
enables
beneFit
t o t h e t y p e oF
utilization,
Department
oF
charged
up
processed,
Their
packages
r e g a r d : , ng
oF
save
i n order to understand
The
care
that
F i F t e e n employees
third-party
hospital
beneFits
Fear
health
consisted
regulators.
charges
as
a service
a state-wide coalition
13SDs w h i c h
on
own
to respond
c l a i m s aare
physicians,
state
selling
smal1-employer
been p a y i n g t o t r a d i t i o n a l
custom-designed
company,
5
in Minneapolis assists
'
other
0
area
Michigan
hospitals
coalition's
For
g o a l was
to publish
rates
the t w e n t y - F i v e most F r e q u e n t l y - u s e d
-22B-
�hospital
services
so
costs.
The
procedure
compilation
antitrust
free
had
t o change
each
a competing
The
Stark
hospital
area
care
beneFit plans.
would
t o be
a i d them
be
subject
continue
to
to
be
being
provided
organization
which
was
made
not
intention
The
was
comprised
to compile
was
and
Department
plan, especially
8 11
inForma-
d e s i g n oF
to also
of
health
disseminate
oF
since
Justice
the
inForma-
public.
i n thousands
l o w e r e d and
was
i n the purchase
Their
These a r e m e r e l y
possible
the
were
whose g o a l
the procompetitive
was
would
Care C o a l i t i o n
inFormation to the p u b l i c .
tion
that
n o t be
the rates
t o an
Health
employers
which
lauded
would
compare
810
County
tion
can
and
able to
hospital.
twenty-Five
the
and
be
replied
a l l hospitals
prices,
,
Department
purpose
because
their
by
consumers would
Justice
a public
scrutiny
voluntarily
that
a Few
oF
money
examples
oF
localities
saved
the selF-help
around
that
the nation.
but c r e a t i v e
is
Costs
leadership
is
necessary.
Employers'
beneFits
at reasonable cost
sabotaged
lobby
eFForts to provide
by
groups
employers
state
and
must
beneFit
Dr.
is
partially
that
b e n e F i t s impose
contracts
annually
From
believes
responsible
For
who
diFFiculty
with
lebor
insurance
i s oFten
"bow
expands
statB-mandatod
that
health
employees
Federal l e g i s l a t o r s
legislation
8 12
provide."
s i g n i F i c a n t 1y
Bronow
to their
enact
State-mandated
must n e g o t i a t e
and
adequate
to
the
on
powerFul
coverage
employers
unions.
The
unions
beneFits.
state-mandated health
increases in health
-227-
care
care
who
costs.
�Mandated
care
includes drug
chiropractic
care,
and
counseling.
pastoral
raised
insurance
invitro
and a l c o h o l abuse
Fertilization,
Because t h e s e
r a t e s b y 20 p e r c e n t ,
treatment,
acupunture ,
m a n d a t e s may
many
large
wigs,
have
employers
813
have
decided
to selF-insure their
SelF-insured
Retirement
state
to
on m a n d a t e d
premiums.
employers
employees,
who a r e t h e n
t h e employer
prove
better
than
beneFits
translate
subjected
chooses
that
t h e Employee
able
and s t a t e
into
on
which
accrue
b e n e F i t s For
t o h e a l t h care
This
coverage
coverage
by a r e g u l a t e d
be s u b s t a n d a r d
t o avoid
taxes
the beneFits
to provide.
provided
b u t i t a l s o may
under
and a r e t h u s
UnFortunately,
do n o t a l w a y s
which
carrier,
operate
Q 14
Income S e c u r i t y A c t
regulation
insurance
employers
employees.
may
insurance
coverage.
As D r .
Bronow
states:
There are n e i t h e r standards t o ensure
a d e q u a c y oF h e a l t h c a r e c o v e r a g e n o r s a F e g u a r d s
t o g u a r a n t e e t h a t e m p l o y e r s w i l l be a b l e t o p a y
claims i F they close t h e i r business or t e r m i n a t e
the
h e a l t h p l a n . . . t h e r e m u s t be r e g u l a t o r y
s a F e g u a r d s F o r e m p l o y e e s oF t h e s e 1 F - i n s u r e d .
Another
companies
average
For
care
Who
Care.
mandated
process
i s that
Fewer c l a i m s
t h e community
which
oF t h e c o m m u n i t y
numbers
would
File
made by D r . B r o n o w
o p t For se1F-insurance.
selection'
the rest
higher
point
whose e m p l o y e e s
will
'adverse
interesting
oF c l a i m s
eliminate
However,
would
which
Filers.
That
than
would
cause
would
Eliminating
mandated
o r g a n i z a t i o n advocates
- P ^ a—
~>
oF
health
to the Physirian'
i n s t e a d oF t h e c u r r e n t s y s t e m
this
i n an
rates to rise
be c o m p r i s e d
se1F-insurers , eccordinq
h e a l t h care,
result
oF
mandator-/
�employer-provided
E.R.I.S.A. and
The
State
tion
who
oF
Se1F-Insurance
preemption
laws
oF
c o v e r a g e . 816
insurance
that
clause
relate
employee
selF-insure
to
pension
are
not
E R I S A , many s t a t e s
oF
ERISA
the
Funding,
beneFit
not
and
and
administra-
Because
to adhere
require
any
vesting
plans.
required
do
supersedes
to
employers
the
employers
a l l
imperatives
to
oFFer
health
817
insurance.
through
ERISA p r e e m p t s
the
surgical,
oF
purchase
or
accident,
beneFits,
states
insurance
h o s p i t a l care
sickness,
vacation
oF
the
or
or
otherwise--medica 1,
beneFits,
disability,
apprenticeship
From r e g u l a t i n g - -
or
death
or
beneFits
or
other
i n the
unemployment,
training
event
or
programs,
or
818
day
caree
centers,
S.1227 w o u l d
who
do
not
scholarship
levy
an
provide
government-imposed
or
prepaid
e s p e c i a l l y heavy
insurance
813
legislation.
Not
pending
Funds,
penalty
coverage
penalty
on
i n compliance
only
would
15
percent
oF
legal
employers
oF
employers
with
be
total
services.
the
liable
to
wages p a i d
a
For
820
the
year,
but
they
would
also
be
liable
For
a l l health
care
82 1
costs
This
ing
incurred
type
on
your
extended
and
oF
by
the
penalty
point
only
oF
token
politially
employee
may
appear
view.
and
on
his
Family,
commendable or
However,
penalties
powerFul
and/or
the
generous
damages.
excessive,
authors
insurance
plus
oF
the
companies — a
industry--For
dependbill
cohesive
digressions
on
82 2
its
part.
plans
1
t' )
which
are
instructions
( 2 ) pay
is
An
a modest
insurance
not
carrier
i n conformance
to cease
and
providing
with
desist
health
5.1227
From
such
care
is subject
violations;
beneFit
only
to
and,
c i v i l p e n a l t y ; and ( 3 ) o t h e r c o r r e c t i v e a c t i o n as
323
appropriate."
The p e n a l 2 3 - m e n t i o n e d i n ( 2 ] i s d e s c r i b e d
-2t y
as
�Follows:
" . . . a n y c i v i l money p e n a l t y i m p o s e d . . . s h a l l
n o t exceed $ 2 5 , 0 0 0 For each c a r r i e r w i t h r e s p e c t
t o w h i c h a v i o l a t i o n o c c u r s . "824
["underlining
supplied)
The
minimal
penalty
i s not
even
compared
to the
harsh
employers
the
For
noncompliance.
disparity
organized
imposed
"per
penalty
One
imposed
on
and
is
small
i s moved t o p o i n t
in penalties is in direct
political
violation"
out
that
proportion to
power.
CONSUMERS.
"This country i s a very i n d i v i d u a l i s t i c
s o c i e t y -- w i t h o u t s o c i a l c o n s c i o u s n e s s . " 8 2 5
to
"It
care
i s t o each p e r s o n ' s i n d i v i d u a l b e n e F i t
For h i s / h e r h e a l t h i n a r e s p o n s i b l e manner."
During
placed
been
all
the
on
who
That
President
January
1965
Medicare.
poor,
not
a i d , on
many
Lyndon
anyone's
government
oF
which
the
introduction
i t ' snot
have
oF
uneducated;
oF
become
conceived
Union
anyone's F a u l t
are
has
take: c a r e
t o have been
State
the
iF they
g r e a t e r emphasis
assistance
Johnson's
that
Fault
having
appears
proclaimed
stated
years,
F o r m s oF
phenomenon
which
He
twenty-Five
public
r e q u i r e the
available.
during
past
Message
Medicaid
oF
and
iF they
are
rather,
i t is
still
helping
82 7
government's
job to a i d those
While
many
many
truly
needy
values
aid.
person
has
There
good
people,
occurred
has
programs
been
an
i n need.
have
helped
unFortunate
and
change
are
in
traditional
nationwide
concurrently with
expansions
a decided
diminution in the
value
responsibility.
The
ISBOs and
-220-
1970s b r o u g h t
in
oF
with
them
an
�intensification
•n
into
to
of interest
t h e everyday
There
t h e 90s, the B i l l
person
i s nothing
themselves.
understand
rights,
that
with
increased
comes g r e a t e r
another.
The p a t h
their
We
sadly,
have,
nation
and
become
who
the surrounding
more e a s i l y
are also
recognized
concepts of
when
Rights
on t h e r i g h t s
of
f a r has been t o
others'
rights
o f 'me
The
of benefits.
first'
'me
instead
first'
i t i s viewed
attempt
i n order t o
interested in their
community.
important
few p e o p l e
and a c c u m u l a t i o n
a nation
more
as w e l l .
thus
or subjogate
own f r e e d o m s
of people
very
impinge
liberties,
d e v e l o p m e n t s by
and broadened
of Americans
downplay,
increase
often
and
part of t h e C o n s t i t u t i o n .
responsibility
by o n e w i l l
ignore,
any o t h e r
i s that
rights
h a s become
w i t h any o f t h e s e
i s wrong
exercised
to
of Rights
than
wrong
What
i n individual
of a
neighbors
syndrome i s
i n i t s inherent
form--greed.
The
in
generation-old
t h e demand
retribution
f o r excessive
i n t h e form
most p e o p l e - - i n
despite
by
leaps
despite
the deadliness
and bounds.
heartwarming
by
the people
own a c t s
impose
such
on f e t u s e s
nation
on o t h e r s ,
which
abuse
the refusal
i s now
spreading
are t h r i v i n g ,
and,
The
1990s h a s
by f u t u r i s t s .
I t would
t o see g r e a t e r
For t h e consequences
-23 1 -
by
f o r AIDS
on f a m i l i e s
and newborns.
whether
itself
t h e demand f o r
suits,
abuse wreaks
o f decency
manifests
be t e s t e d
and drug
and sou 1 - s a t i s f y i n g
of t h i s
care,
of l i f e - - t o
Alcohol
t h e decade
be
medical
system
of the disease
the devastation
labeled
value
of malpractice
a l l walks
most h e a r t r e n d i n g ,
been
skewed
those
others
be
concern
that
their
Family
�members
The
must
or neighbors
1990s,
First
o r unknown
i n order
reinvigorate
Fellow
Americans.
t o become t h e d e c a d e
the traditional
value
responsibility
For t h e consequences
responsibility
F o r t h e h e a l t h oF o n e s e l F
oF
decency,
oF
personal
oF i n d i v i d u a l
a c t s , and
and one's
Family.
"...(W)e a r e aFForded numerous o p p o r t u n i t i e s F o r p r o m o t i n g h e a l t h and p r e v e n t i n g
disease.
With these o p p o r t u n i t i e s ,
though,
c o m e s r e s p o n s i b i l i t y , a n d t h e F i r s t r o l e we m u s t
a l l u n d e r t a k e i s r e s p o n s i b i l i t y F o r o u r own
personal health habits.
Improving personal h e a l t h
b e h a v i o r c a n c o u n t among t h e m o s t p o t e n t means t o
p r e v e n t d i s e a s e and p r o m o t e h e a l t h .
Measurable
d e c r e a s e s i n r i s k s t o h e a l t h c a n r e s u l t From
changes i n d i e t , e x e r c i s e , tobacco use, a l c o h o l
and o t h e r d r u g u s e , i n j u r y p r e v e n t i o n b e h a v i o r ,
a n d s e x u a l h a b i t s , b u t e a c h oF u s m u s t c h o o s e t o
make t h e s e c h a n g e s a p e r s o n a l p r i o r i t y . " 8 2 8
" . . . ( W ) e c a n no l o n g e r a F F o r d n o t t o i n v e s t
in prevention.
F r o m t h e p e r s p e c t i v e oF a v o i d i n g
human s u F F e r i n g a s w e l l as s a v i n g w a s t e F u l
costs
For t r e a t i n g d i s e a s e s and i n j u r i e s t h a t c o u l d have
b e e n p r e v e n t e d , t h e 1 9 9 0 s s h o u l d be t h e d e c a d e oF
prevention i n the United
States."829
Studies
have shown t h a t
m o r e money
they
holds
across
true
points
out that
will
spend
t h e m o r e money
on h e a l t h c a r e .
national
people
That
have, t h e
relationship
and c u l t u r a l
Wesbury
to patient
"responding
boundaries.
expectations
i s one oF
330
the
costliest
example
required
in
t h e Fact
that
1
oF o u r system.' '
i n Great
t o w a i t one y e a r
t h e U.S.,
unacceptable,
Veterans
beneFits
not only
Britain
cite:
a patient
may
For a c a t a r a c t o p e r a t i o n .
would
most A m e r i c a n s
b u t i F i t happened
A d m i n i s t r a t i o n system,
331
investigation.
The U n i t e d S t a t e s
He
has a l s o
Find
to a patient
t h e r e would
been
that
as an
be
Here
wait
i nthe
be a c o n g r e s s i o n a l
ineFFective
i n dealing
�with
ethical
such
credence
"This
issues.
that
ambivalence
system.
W i t h no
Both
sides
ethicists
of every
dumps e t h i c a l
clear
are
to reach
are unable
issue
a
i s s u e s back
legislative
on
direction,
given
conclusion.
the health
the
care
only
832
solution
Far
i s t o spend
more d e c i s i v e .
terminal
to
patients
those w i t h i n
more money."
The
and
scarcity
understand
how
countries
are
Netherlands provides euthanasia to
Great
speciFic
understand
European
Britain
age
and
how
t o demand
limits
833
groups.
People
t o cope w i t h
more
and
certain
it.
procedures
in
Europe
Americans
then reFuse
t o cope
only
with
less.
ATTORNEYS.
In
annual
the
August
meeting
problem
October
to
1991,
23,
at which
oF
1991, P r e s i d e n t
with
encourage
The
Filed
Vice
the American
t a k e eFFect
agencies
the American
i n January
oF
every
year
and
Bush
m u s t be
established.
achieve
consensus
less
The
between
issued
which
oF
alternate
a
Dan
over-1itigious
1991
Federal government
Association
President
the development
t h e use
Bar
costly
administrative
policy
to
resolution.
i n about
50,000
dispute
i s to t r y every
with
On
an E x e c u t i v e O r d e r ,
means oF
parties,
addressed
society.
regulatory
i s a party
goal
Quayle
charges
dispute
held i t s
court
cases
resolution
method
being a
to
last
834
resort
For
and
every
dispute
a high
not the F i r s t .
agency
plan
to "designate a senior
resolution
enough
The
level
specialist.
The
i n t h e agency
-223-
ADR
to achieve t h i s
oFFicial
is
as i t s
specialist
t o promote
goal
m u s t be
at
ADR--bureaucratic
�A35
inertia
and
Frank
gladiatorial
instincts
Freedman,
chieF
H.
Massachusetts,
shake
hands"
the
lamented
and
Attorneys
now
"People
Americans
have p l a y e d
malpractice
milieu
oF
malpractice
suit
system
For
and
should
which
not
cases.
Neither
should
tion
caps
jury
oF
gross
on
negigence.
Filed
by
levied.
when no
The
sue
remedy
be
because
e x t r a o r d i n a r y procedures
be
a backlash
American
groups
their
path
detriment
Focus
attorneys
by
will
American
oF
v i a caps
turn
to
malpractice
the
Bush
cases.
to
our
They
might
the
tort
in a l l
by
imposi-
the
was
caused
suits
are
F a u l t can
have
be
occurred
physician
reForm
away
already
At
There
the
their
that
point,
power
contingency
the
will
the
oF
Fees
backing
oF
E x e c u t i v e Order.
837
t h e . N a t i o n a l Law J o u r n a l
states that
and t h e i r a l l i e s i n g o v e r n m e n t
o n l y t o o w i l l i n g t o see
lawyers
t h e i r woes.
But t h i s s t r i d e n t
- 334-
by
to
earning
have
no
establishment
turns
earnings.
an
employed.
Association,
medical
by
and
justiFiable..
other
evidenced
remedy
a p a t i e n t experienced
and
legislate
The
that
no
d i m i n i s h i n g the
A d m i n i s t r a t i o n , as
editorial in
"...doctors
and a c a d e m i a a r e
as t h e s o u r c e oF
on
the
physicians
and
Medical
and
and
t o ADR
curtailed
which
h e a l t h care
attempting
For
An
the
Hospital Association
iF the
Financial
outcome
i s understandable
From
oF
reduced
occurred
Filed
an
in
nation.
against
matter
Fear
the
role
i n cases where harm
attorneys
in
easily."
i t i s common k n o w l e d g e
are
judge
t h i n g s out
836
essential part
outcome,
Physicians'
to talk
too
unFortunate
what
district
legislatively
negligence
suits
used
gripped
awards
over-zealous
hospitals
has
the
But
U.S.
a consequential
i s an
be
notwithstanding."
�a n d by-now t r a d i t i o n a l r i f t b e t w e e n t w o l e a r n e d
p r o f e s s i o n s serves n e i t h e r the p u b l i c ' s nor the
professions'
interest.
What i s n e e d e d i s a c o n s t r u c t i v e d i a l o g u e .
E v e r y t h i n g s h o u l d be up f o r d i s c u s s i o n , s u c h as
whether t h e fees of both groups remotely r e f l e c t
r e a l i t y , t h e r o l e o f i n s u r e r s and a l t e r n a t i v e
systems of f i n a n c i n g care.
I n s t e a d o f s q u a b b l i n g , l a w y e r s and p e r h a p s
even d o c t o r s c o u l d c o n t r i b u t e toward t h e c r e a t i o n
o f a j u s t and e q u i t a b l e h e a l t h c a r e s v s t e m t h a t
r e f l e c t s the greatness of the n a t i o n .
8 3 8
Consider
5.1227 w h i c h
establishes a Federal
Health
S39
Expenditure
health
to gather
services,
as
access,
products,
842
oF s p i r a l l i n g
conjunction with
data,
below.
Consider
note
durable
The new
laboratory
equipment,
h a s become
c o s t s , some oF w h i c h
necessary
were caused
the detail
oF t h o s e
to gather
by
as t h e p a t i e n t - - i n
Federal
government
to speciFically
monitor
quality
achieve
the aForementioned
c o s t and
requirements,
The
rates--to
medical
Board
on h e a l t h
expenditure
t h e r a m i F i c a t i o n s For t h e r i g h t
requirements.
able
separate
the requirement
t h e p h y s i c i a n as w e l l
data
data
i s also
attorneys.
quality
For
national
The B o a r d
and q u a l i t y
with
other health services.
In
8 4 0
For
services, physician services,
pharmaceutical
a result
goals
and q u a l i t y .
and p u b l i s h c o s t
84 1
For h o s p i t a l
over-zealous
be
i s t o develop
p r o v i d e r s and p u r c h a s e r s
breakdowns
and
which
expenditures,
required
care
Board
goal
quoted
to privacy--
relation
would
oF c a r e
as
to the
n o t , however,
and p r o v i d e r
oF c o s t
control--
w i t h o u t u s e oF t h e F o l l o w i n g i n F o r m a t i o n .
"Sec.
2 7 7 1 . UniForm B i l l i n g and M a n d a t o r y R e p o r t i n g .
Ca)
I n General.
The ( F e d e r a l H e a l t h E x p e n d i t u r e ) B o a r d
s h a l l e s t a b l i s h a s y s t e m oF u n i F o r m b i l l i n g a n d r e p o r t i n g . . .
t h a t w i l l e n a b l e t h e B o a r d t o d e t e r m i n e t h e p r o g r e s s made i n
m e e t i n g t h e g o a l s e s t a b 1 i s h e d ... a n d t o r e d u c e a d m i n i s t r a t i v e
costs of the h e a l t h care system.
-235-
�(bj
...The B o a r d s h a l l - ...
(3)
a u d i t i n F o r m a t i o n p r o v i d e d by h e a l t h c a r e p r o v i d e r s
on a s a m p l e b a s i s o r i n s i t u a t i o n s w h e r e t h e r e e x i s t s r e a s o n a b l e
c a u s e F o r s u c h an a u d i t ;
and,
(4)
i s s u e p u b l i c r e p o r t s c o n c e r n i n g h e a l t h c a r e c o s t s and
t h e e F F e c t i v e n e s s oF t h e h e a l t h c a r e p r o v i d e d by h e a l t h c a r e
prov i ders.
(c)
Data C o l l e c t i o n .
(1)
Data sources s h a l l submit t o the B o a r d . . . a l l data
required. . .
(2)
D a t a s h a l l be c o l l e c t e d by t h e B o a r d t h r o u g h t h e u s e
oF one o r m o r e F e d e r a l U n i F o r m C l a i m s and B i l l i n g F o r m s d e v e l o p e d
by t h e B o a r d a n d u t i l i z e d by p r o v i d e r s and p u r c h a s e r s oF h e a l t h
c a r e t h a t s h a l l , a t a minimum, i n c l u d e - (A)
a uniForm p a t i e n t i d e n t i F i e r ;
(B)
t h e d a t e oF b i r t h oF t h e p a t i e n t ;
(C)
t h e g e n d e r oF t h e p a t i e n t ;
(•)
t h e z i p c o d e oF t h e p a t i e n t ;
(E)
t h e d a t e oF a d m i s s i o n oF t h e p a t i e n t F o r
inpatient hospital services;
(F)
t h e d a t e oF d i s c h a r g e oF t h e p a t i e n t r e F e r r e d
to i n subparagraph
CE);
CG)
t h e p r i n c i p a l a n d s e c o n d a r y d i a g n o s e s oF t h e
pati ent;
(H)
t h e p r i n c i p a l a n d s e c o n d a r y p r o c e d u r e s t o be
Followed i n t r e a t i n g the p a t i e n t ;
Ci)
a uniForm h e a l t h care F a c i l i t y
identiFier;
(J)
u n i F o r m i d e n t i F i e r s oF p h y s i c i a n s t r e a t i n g t h e
patient;
(K)
F o r s e r v i c e s p r o v i d e d i n an i n p a t i e n t s e t t i n g ,
t h e t o t a l c h a r g e s oF t h e h e a l t h c a r e F a c i l i t y
treating
the p a t i e n t , segregated i n t o major c a t e g o r i e s determined
a p p r o p r i a t e b y the Board;
(L)
t h e a m o u n t s oF a c t u a l p a y m e n t s made t o t h e t r e a t i n g
h e a l t h care F a c i l i t y ;
(M)
t h e a m o u n t s oF t h e c h a r g e s oF e a c h p h y s i c i a n o r
proFessional rendering s e r v i c e to the p a t i e n t ;
(N)
t h e s e r v i c e s p r o v i d e d i n an i n p a t i e n t s e t t i n g ;
CO)
t h e a m o u n t s oF a c t u a l p a y m e n t s made t o e a c h
p h y s i c i a n or p r o F e s s i o n a l r e n d e r i n g s e r v i c e t o the p a t i e n t ;
CP)
a u n i F o r m i d e n t i F i e r oF t h e p r i m a r y p a y o r ;
CQ)
t h e z i p c o d e oF t h e F a c i l i t y w h e r e s e r v i c e i s
rendered to the p a t i e n t ;
(R)
the p a t i e n t discharge status;
and,
CS)
s u c h o t h e r m a t e r i a l as t h e B o a r d d e t e r m i n e s
n e c e s s a r y o r u s e F u l t o c a r r y o u t t h e d u t i e s oF t h e B o a r d
o r t o p r o v i d e a d e q u a t a e i n F o r m a t i o n t o p u r c h a s e r s oF
h e a l t h care t o a s s i s t such purchasers i n a p p r o p r i a t e l y
p a y i n g For s e r v i c e s .
While
numbers
provides
are
the
the
speciFicity
not
within
the
means t o t h a t
oF
names, a d d r e s s e s ,
required
and
phone
inFormation, subsection
inFormation.
Additionally,
(S)
patients
�with
unusual
could
be
illnesses
readily
The
legal
living
proFession,
been
a prime
its
role
in malpractice
an
mover
Far-reaching
considered
entire
actions
as
being
nation's
could
not
many s i n g l e a c t s
similar
actions
results
are
caused
and
by
a speciFic
zip
code
identiFiab1e.
has
have had
within
with
i n opening
suit
oF
have been
Foreseen,
countless
to occur.
The
the
over
never
But
oF
when
decades,
the
oF
their
consequences
t o mend
e s t a b l i s h i n g and
of
oF
actions
Financial health
to predict.
times
because
probably
result
since
I t i s time
by
Box
were
the
system.
culture,
Attorney's
which
aFFecting
impossible
taken
a t t o r n e y greed
more d e t a i l e d
Pandora's
acceleration.
h e a l t h care
i s oFten
bound
this
eFFects--eFFects
capable
are
i t s w i n - a t - a 11 - c o s t s
adverse
wound
adhering
to
stricter
attorney practice guidelines.
ADDITIONAL SPECIAL INTEREST GF10UPS AND
ORGANIZATIONS.
" E a c h one p l a y s t h e game oF h i s own
Faction,
i g n o r i n g t h e i n t e r e s t s e n d t h e a c h i e v e m e n t s oF a
collective
strategy."343
And
;
n
and
For
the
Instead
oF
common g o o d ,
to steadFastly
this
seeking
Country,
conciliation
i t appears
adhere
and
t o be
to t h e i r
own
w i t h human
on
common
more n a t u r a l
concepts,
beings
ground
For
interests,
pursuits.
An
o r g a n i z a t i o n ' s advantage
is
derived
oF
the
[3)
i t is throughout
general.
people
and
so
the
From
group,
(2) the
strategic
political
the
ease
economy."
oF
dominance
position
The
oF
in wielding political
o r g a n i z a t i o n and
oF
the
an
economic
group
-227-
maintenance
incentive,
i n s o c i e t y and
more d o m i n a n t
the
pressure
economic
in
and
the
incentive,
�the
easier
A group
t h e group
will
break
may
organize
apart
and m a i n t a i n
gradually
i f o r when
i t s membership.
8 4 5
i tloses i t s
center .
Health
Insurance
Association
o f America
National
Association
of ManuFacturers
National
Association
oF C h i l d r e n ' s
and
Related
Children's
Institutions
DeFense Fund
American
Medical
Association
American
Academy
oF P e d i a t r i c s
American
Dental
American
Hospital
Blue
Association
Cross-Blue
United
States
above
organizations
Chamber
For t h e purpose
oF
which
would
Association
oF
Commerce
organizations
Formed
expressly
a bill
Association
Shield
What do a l l t h e a b o v e
The
Hospitals
have
the Children's
i n common?
Medicaid
Coalition
oF
lobbying
Congress
t o assure
expand
Medicaid
t o cover
a l l poor
passage
children
S47
through
t h e a g e oF 18.
The
Carl
oF
Children's
J . Schramm,
America.
instigated
persistence
clamor
president
Coalition
the coalition
oF
partly
l a r g e numbers
Libassi,
health
senior
was t h e b r a i n c h i l d
oF t h e H e a l t h
The HIAA r e p r e s e n t s
For n a t i o n a l
F. P e t e r
Medicaid
Insurance
commercial
insurance.
vice
Association
i n s u r e r s and
o u t oF c o n c e r n
oF u n i n s u r e d
that the
people
might
Elaborating
president
oF
lead
to a
on t h e t h o u g h t ,
oF t h e T r a v e l e r s
Health
Insurance
Corporation
explained:
" . . . I F we d o n ' t F i n d a way t o p r o v i d e c o v e r a g e
F o r t h e n a t i o n ' s 31 m i l l i o n u n i n s u r e d , t h e F e d e r a l
G o v e r n m e n t may move t o a d o p t some F o o l i s h , i l l - a d v i s e d ,
i11-conceived national h e a l t h insurance
strategy."848
Robert
Pear
wrote
that
"The s u c c e s s
oF t h a t
campaign
is a
�lesson
...
i n t h e value
T h e i r success
achieved
from
as p a r t
of p o l i t i c a l
i s a l l t h e more r e m a r k a b l e
of a deficit-reduction
t h e nation's governors
for
expansion
tion
coalition-building
oF M e d i c a i d
at this
coverage.'
An A d m i n i s t r a t i o n
over o b j e c t i o n s
mandate
The B u s h A d m i n i s t r a -
expansion
oFFicial
i t was
any F e d e r a l
time.
a l s o o b j e c t e d t o 'the mandatory
because
bill
who o p p o s e d
i n Washington
oF
described
Medicaid
the coalition
849
as
an ' u n b e a t a b l e
A group
is
political
which
seeks
Common C a u s e , h e a d e d
that
over
medical
industry
by F r e d
contributed
i n oFFice.
industry
t o guard
t h e welFare
Wertheimer,
t h e 1980 t o 1 9 9 0 p e r i o d ,
Representatives--For
still
combination."
Health
Congressional
contributed
members.
over
t o S e n a t o r s and
companies
$14 m i l l i o n
and i n s u r a n c e
to current
The p h a r m a c e u t i c a l
$5 m i l l i o n ;
i n the
$ 8 0 , 0 0 0 p e r member--who a r e
insurance
associations provided
who d i s c l o s e s
v a r i o u s groups
$43 m i l l i o n
an a v e r a g e o F
oF c o n s u m e r s
industry
and t h e American
PACs
Medical
Associa350
tion
PAC
While
i s r e p o r t e d t o have
$1.7 m i l l i o n
incumbents
oF t h a t
who c o u l d h e l p
4102,000 went
health
care
44.8
oF
t h e PACs
t o pass
industry.
Ways a n d Means C o m m i t t e e
million,
amount Found
t o 19 c h a l l e n g e r s .
members a r e now s e e k i n g
the
contributed
and t h e Senate
3
5
1
million,
causes,
T h o s e same
legislation
membership
million.
i t s way t o 3 5 9 H o u s e
legislative
Wertheimer
Finance
n e a r l y $8
which
only
Congressional
will
reForm
singles
o u t t h e House
as h a v i n g
r e c e i v e d $6.3
Committee
as h a v i n g
received
w h i c h i s an a v e r a g e oF $ 2 5 0 , 0 0 0 F o r e a c h member
352
t h e Committee.
I n response t o t h e above i n f o r m a t i o n , W e r t h e i m e r posed
- 229-
�the
to
Following
questions
to
readers:
1.
Why d i d t h e m e d i c a l i n d u s t r y w a n t t o g i v e
m e m b e r s oF C o n g r e s s d u r i n g t h e l a s t 10 y e a r s ?
2.
What a r e t h e c e r t a i n t h i n g s
t h e medical industry?
For
members w i l l
$43
million
have
t o do
3.
And how much w i l l i t c o s t y o u a n d me a n d e v e r y o t h e r
A m e r i c a n when t h e t i m e comes F o r members oF C o n g r e s s t o make
d e c i s i o n s a b o u t m a j o r r e F o r m oF o u r h e a l t h c a r e s y s t e m ? 3 5 3
Mark
Fred
with
Shields,
a syndicated
Wertheimer
columnist,
apparently
agrees
and has s t a t e d :
854
"PACs a r e l e g a l
Because
social
tion
conditions,
behind
clauses.
In
se1F-interest
encouraging
reForm
groups,
those
ultimate
The
issues
areas
oF s o c i e t y
which
user
oF r e F o r m
benefitting
will
have
eFFects
also
truly
beneFit
will
which
the large
have
motiva-
health
care.
particular
oF t h a t
on s p e c i a l
beneFit
From
accept
interest
those
For passage
the consumer/patient--the
oF any F u t u r e
deserve
the
questionable
t o reForm
i s t o s o r t o u t and o n l y
and b e n F i c i a r y
which
may
members t o p a s s
have b e n e F i c i a l
The t a s k
bills
which
i ti s i n e v i t a b l e t h a t p o r t i o n s
will
makeup a n d
t o consider
i s needed
Congressional
b u t most
reForms.
oF t h e human
prudent
legislation
legislation
measures,
legisllation
i s part
i ti s only
pending
Major
extortion."
system,
good
t h e most s c r u t i n y w i l l
an a d v e r s e
corporations
eFFect
or bad.
be
those
on c o n s u m e r s
and o r g a n i z a t i o n s
while
and
assoc i a t i ons.
Recalling
author
on
may
health
urge
care
words
oF w i s d o m
and w a r n i n g
a few more c o n s u m e r s
reform
to their
- 540-
by a f i n e
t o express
elected
their
American
opinions
representatives:
�" I t h i n k I can s a y , and say w i t h p r i d e , t h a t
we h a v e some l e g i s l a t u r e s t h a t b r i n g h i g h e r p r i c e s
t h a n any i n t h e w o r l d . "
Samuel
(Mark
The
AMA
could
more p h y s i c i a n s
its
New
would
membership.
casts
votes,
York.
individual
have
less
vote
At p r e s e n t ,
with this
Merely
inFluence
only
i t now w i e l d s i f
which
25 p e r c e n t
dwindling
a common
From
3 5 5
than
issues
percentage
sharing
physicians
Twain)
o n AMA
[1873)
L. C l e m e n s
vastly
oF t h e m e m b e r s h i p
t o 10 p e r c e n t i n
interest
holding
are submitted to
does
not preclude
opposing
viewpoints
857
From
the majority.
vote,
Were a g r e a t e r
t h e outcomes might
reForm
beneFicial
diFFer
sense
oF p o w e r 1 e s s n e s s
participation,
able
while
to participate
Presently,
votes
not
tends
are inextricably
t o produce
the existence
about
count.
They
overshadowed
special
It
cannot
interest
that
oF d o l l a r s
their
than
encourages
858
those
population
s i n g l e vote
vote
counts
does
when i t i s
c o n t r i b u t e d by p o w e r F u l
climate
take
that
their
r e o r 2 z ^ .. t - t i v s s by l i t t e r
-
are regarding
Washington.
the time
h e a l t h care
will
around
rather
oF t h e A m e r i c a n
Few A m e r i c a n s
positions
a
groups.
i s in this
elected
linked:
t o do s o . "
believe their
by t h o u s a n d s
apathy
oF p o w e r
50 p e r c e n t
i n e l e c t i o n s a n d many F e e l
o p p o r t u n i t y For
result.
i n i t s exercise
only
oF p h y s i c i a n s t o
and a g r e a t e r
t o p a t i e n t s may
"Power and p a r t i c i p a t i o n
number
o r make t h e e F F o r t
t h e many r e F o r m
Some w i l l
-24 1-
reForm
merely
or phone
bills
vote
must
evolve.
t o inForm
what
their
now F l o a t i n g
on e l e c t i o n
day and
�consider
that
steps
members o f
of
An
effort
Diego
on
the
s u b j e c t of
and
Selling
sufficient
to guide
the
political
Congress.
interesting
San
t o be
speech
February
was
delivered
15,
and
"Money
1991.
the P o l i t i c s
to the
G e o r g e S.
City
Club
Mitrovich
of Betrayal
of
addressed
--
the
Buying
859
in
the
of P o l i t i c a l
1990
races
were
a number
were
able
In
oF
For
the
U.S.
incumbents
to raise
CaliFornia
A c c e s s and
alone,
Four
House oF
who
more t h a n
Favors."
opponents
million
unopposed
revealed
that
Representatives there
F a c e d no
$28
He
For
and
still
campaign
incumbents
Funds.
received
$1.4
850
million.
care
who
Senator
reForm--raised
raised
Texas
Banking,
and
won
$1.7
Senator
oF
the
bank;
and
Phil
amounts
oF
the
lost
million
active
in
health
a g a i n s t an
is the
action
p a r t iplays ,
t t e e ed
comm
the American
stated
i s on
38
more t h a n
a g a i n s t an
percent
the
opponent
oF
the
and
that
spent
political
these
8 5 4
who
862
raised
$4
"At
million
a deeply
But
i h e t h e - r a i s i n g P oFC s . " s e
tn
so called
A the
million
the
in
"...extraordinary
reFlects
scene.
$15
votes.
Gramm h a d m o r e t h a n
863
$1,581.38."
concern
Appropriations,
opponent
Senator
monies r a i s e d
oF
(R)--who
votes
with
expresses
aspect
has
Gramm
h i s opponent,
oF
$3.B
Committees--raised
the campaign
Mitrovich
Dole
more t h a n
Budget
percent
million
end
RockeFe11er--very
$2 1 , 3 4 1 .
and
52
Jay
disturbing
more ominous
yet
F u n d s e n a t opro l i t i c a l
As S by
Robert
"When t h e PACs g i v e money, t h e y
expect
something
,,865
in
return
In
other than
1990,
$147.8 m i l l i o n
good
H o u s e and
from
government.
Senate
PACs, w h i c h
-242-
c a n d i d a t e s r e c e i v e d more
amounts
t o 33
percent
than
of a l l
�monies
contributed
by
Congress r e c e i v e d
PACs.
50
More t h a n
percent
or
half
more o f
the
their
members
of
campaign
contribu-
866
tions
From
PACs.
Federal
the
limits
requirement
insuFFicient
that
the
on
that
to
both
those
control
Federal
personal
a m o u n t s be
inFluence
Election
and
PAC
contributions,
reported,
peddling.
Commission
has
have
been
Mitrovich
exhibited
and
contends
"appalling
867
incompetence."
He
a regulatory
agency
Republicans,
with
views
which
r e c o m m e n d s "A
the
to
establish
congressional
races,
new
with
From
t h e most s e v e r e
.
868
oFFice.
Failure
to
criminal
Democrats
too
Few
Election
campaign
r e s u l t i n g From
and
members.
Commission
Financing
observe
(with)
For
these
all
limits
penalties
or
disqua1iFication
system
campaign
Jrr
The
is
on
as
between
p o w e r s and
Federal
limits
exacting
incompetence
is divided
insuFFicient
Mitrovich
power
this
the
true
cost
reduced
oF
the
current
conFidence
which
accountability
oF
oFFicials.
representative
government,
replace
the
elected
current
system
the
public
oF
oF
American
To
has
reestablish
Financing
special
voter
oF
Financing
in
a
truly
campaigns
interest
the
must
group
869
Financing.
The
with
those
American
elected
dollars
or
oFFicials
communications
congressional
From
consumer
the
From
arrive
encouraged
letters
and
powerFul
will
have
that,
i n t e r e s t groups,
voter.
to
phone
in suFFicient
members u n d e r s t a n d
registered
Senator
via
m u s t be
To
-243-
the
communicate
calls.
numbers
although
they
r e t a i n the
consider
to
Only
will
they
derive
job,
that
constituents'
when
may
their
derive
jobs
Representativ(
viewpoints.
�In
this
plus
way,
one
occasional
vote
will
'votes'
count...one
i n the
Form
oF
vote
on
election
opinions
on
day,
important
i ssues.
Americans
process
as
shopping
minimal
From
The
they
and
are
For
care
reForm
that
consumer
Because
r .
r
Financial
change
toward
diFFiculty
Each
the
and
the
by
that
and
cost
oF
take
part
health
lives
Health
aFFect
car.
ways
legislation
d e c i s i o n and
and
anywhere
same
health insurance
insured beneFits.
should
them
a new
passage
h e a l t h care
the
insurance
Comparison
w a l l e t s i n the
Yet,
Fact
individual
a beneFicial
will
i m p o r t a n t - - t h e h e a l t h and
removed
(
Policymaking
and
oF
legislative
considered
t o 30,000 For
aFFect
will.
employer-provided
coverage.
t o $10-
will
purchases
more
i s oFten
a d e c i s i o n which
legislation
the
home a p p l i a n c e s .
health insurance,
something
members.
Familiar with
Consumer R e p o r t s
a microwave
oF
as
at purchasing
perusing
purchase
•"'• i\'.i
become
p r e p a r a t i o n For
$100-t-
aFFect
should
the
of
will
Family
i s pro-,
protected
reForm
From
may
extent
~
oF
in guiding
the
process
cutccme.
i s oFten
370
stalemate.
Brown
a F F l i c t e d by
chronic
deadlock
states:
Perhaps the d i s c o n n e c t i o n between problems
and p o l i t i c s r e F l e c t s a d e e p e r d i s j u n c t i o n
b e t w e e n s o c i a l e n d s a n d p o l i c y means.
A society
t h a t i n p r i n c i p l e wants t o r e s p o n d t o t h e needs
oF t h e d i s a d v a n t a g e d
m i g h t n o t a g r e e e i t h e r on
j u s t w h a t i t w a n t s t o t e l l g o v e r n m e n t t o do o r
t h a t g o v e r n m e n t s n o u l d be e n c o u r a g e d t o e x e r c i s e
i n t h i s s p h e r e t h e d i s c r e t i o n i t has u s e d
on^^
o t h e r occasions t o advance o t h e r causes..."
He
states also
and
be
yet
lack
that
u n c e r t a i n about
conFidence
although
Fashioning
that
the
p u b l i c may
means t o e n d s ,
government
will
deliver
want
they
change
may
i t wisely
�and
Fairly
-- w h i c h
may
i n d i c a t e a proFound
F a i l u r e oF
S72
political
nation
trust.
would
a national
reject
health
"re1uctance...to
sphere
the u n i v e r s a l entitlements
insurance
quote
program.
incorporate
oF c i t i z e n s h i p
To
so
I t was B r o w n ' s b e l i e F i n 1990 t h a t t h e
Joseph
The
inherent i n
reasoning:
policy entitlements
87 3
within the
rights..."
CaliFano,
because
only
h i s w o r d s c a n be
basic
and s u c c i n c t :
"So what c a n we do t o a r r e s t t o w e r i n g
health
c a r e c o s t s and p r e s e r v e and e n h a n c e o u r m i r a c u l o u s
medical
system?
Plenty.
We c a n s h a p e t h i s i n c i p i e n t r e v o l u t i o n i n t o
a Fundamental t r a n s F o r m a t i o n
oF t h e p e r s o n a l
m o t i v a t i o n s , F i n a n c i a l i n c e n t i v e s , and i n s t i t u t i o n a l
r o l e s and r e l a t i o n s h i p s oF d o c t o r s , h o s p i t a l s ,
p a t i e n t s , and p u r c h a s e r s oF h e a l t h c a r e .
To do s o , we've g o t t o s t o p b l a m i n g t h e
other guy--the p a t i e n t , doctor, h o s p i t a l a d m i n i s t r a t o r , h e a l t h i n s u r e r , m e d i c a l equipment m a n u F a c t u r e r ,
d r u g company, m a l p r a c t i c e l a w y e r , u n i o n ,
corporate
employer, government b u r e a u c r a t .
A l l oF u s must
l o o k t o o u r s e l v e s , t o what we c a n do d i F F e r e n t l y . Q
We must c h a n g e t h e way we t h i n k a b o u t h e a l t h c a r e .
7 4
CONCLUSION.
The
oF
health
personal
maniFested
and
It
health
overzealous
does
c a u s e s oF h e a l t h
health
care
consumer
responsibility
oF a
which i s
demand, p h y s i c i a n
attorneys,
n o t seek
care
lack
incompetence
and o p p ) o r t u n i s t i c
ways
to correct the
cost problems
will
not provide
and
individual
reForm
oF t h e
rsForm.
i s imperative that
care
i s a consequence
consumer
Any p l a n w h i c h
social
spiral
and c o r p o r a t e moral
selF-reFerral,
eFFective
cost
i n excessive
insurers.
root
care
every
understand
- 2 '-I 2 -
interest
that
group
eFFective
�American
health
care
industry
tion,
or other
Those
who a r e b e n e f i t t i n g
be
called
organization,
upon
spent
were
complete
care.
mOst.
The p a s t
forty
number
of visits
will
with
have
insurance
sacrifices.
that
to give
they
f o r (2 v e r y
stays
were
o f each
a
and
dollar
to physicians
a rarity for
has seen a s i g n i f i c a n t r i s e
of health
will
up e x p e c t i n g
ago, v i s i t s
to caregivers, but without
has improved,
corpora-
reform.
coverage
and h o s p i t a l
years
i n the state
person,
now may f i n d
One g e n e r a t i o n
few and f a r between
health
t h e most
medical
each
t o make some e c o n o m i c
and f a m i l i e s
on h e a l t h
increase
require
t o s a c r i f i c e t h e most
Individuals
demanding
will
i n the
corresponding
individual.
b u t n o t a t t h e same r a t e
that
To be
costs
sure,
have
increased.
Employers,
insurable
premiums
especially
groups
which
larger
Physicians,
to
lower
required
so t h a t
they
groups
can b e n e f i t
will
from
have
t o form
t h e lower
are able
t o enjoy.
providers
on e c o n o m i c p r o s p e r i t y .
an e n t i r e
more-than-camfartab1e
employers,
and o t h e r
hospitals,
their sights
that
small
national
standard
population
of living
will
be
required
I ti s not
subsidize
an
f o r one segment
already
of
i t s
p o p u l a t i on.
Insurance
addition
carriers
to the legal
are
written,
there
not
t o abandon
will
obligations
i s also
now u n d e r s t a n d
drawing
f o r decades
he I p f u t u r e
t o understand
they
a moral
incur
that in
when
and s o c i a l
policies
responsibility
patients.
Unions
been
have
emp I o y e e s ,
that
the well
has almost
union
from
run dry.
demands w i l l
have
which
they
have
I n order to
t o be
i n Line
�with
the requests
tottering
health
Federal,
stand
t h a t everyone e l s e w i l l
care
be making on a
industry.
s t a t e and l o c a l l e g i s l a t o r s w i l l
t h a t they
No l o n g e r w i l l
are dealing with
submission
a more s o p h i s t i c a t e d
In
order
F o r any o f t h e reForm p l a n s
economically
and s o c i a l l y - - a l m a s t
will
be a d v e r s e l y
a F F e c t e d by some a s p e c t
We w i l l
each e x p e r i e n c e
to
n o t be i n s u r m o u n t a b l e ,
but w i l l
a s s u r e t h a t t h e chosen p l a n w i l l
Health
c a r e reForm w i l l
power s t r u c t u r e
disinclination
t o be
every
eFFective--
p e r s o n i n t h e U.S.
o f t h e p l a n t o some
some Form o f d i s s a t i s F a c t i o n
w h i c h we a r e n o t now e x p e r i e n c i n g .
will
results in
of society.
both
extent.
consumer.
t o p o w e r F u l i n t e r e s t g r o u p s by
l e g i s l a t o r s be t o l e r a t e d when such s u b m i s s i o n
detriment t o the health
have t o u n d e r -
require
However, t h e d i s s a t i s F a c t i o n
be r e a s o n a b l e
and n e c e s s a r y
remain economically
Feasible,
t h a t t h e most p o w e r F u l
oF a l l has t o be o v e r c o m e . . . t h e b a s i c human
t o change.
u»
un • un
-247-
�CHART
Health Care Costs as a
Percent of Payroll for
State and Local Governments
10.3%
5.2%
i
C
O
OJ
i
1982
989
S o u r c e s : 1982: C e n s u s Bureau, 1982
Census of G o v e r n m e n t s ; 1989: Foster
Higgins H e a l t h Care B e n e f i t s Survey
Source:
"Trends i n Employee H e a l t h B e n o F i t Costs i n S t a t e and L o c a l Government i n t h e 1980s" ( C h a r t
P r e s e n t e d t o t h e S t a t e a n d L o c a l n o v e r n m e n t L a b o r - M n n a c j e m e n t C o m m i t t e e , J u n e 12, 1990
1)
�CHART
average Annual Health Plan
Cost Per State and Local
Government Employee, 1984-89
2
C u r r e n t Year $
$3500
$2836
$3000
$243j
$2500
$2000
$1906
$1755
$1589
$207t
01
nj
i
$1500
Between 1984 and 1989,
Health Plan Costs Increased 50 Percent
Even After Adjusting for Inflation
$1000
$500
$0
1984
1983
1985
1986
1987
1988
1989
1990
S o u r c e : Foster Higgins annual
H e a l t h Care B e n e f i t s Surveys
Source:
"Trraridc
in
P r e s e n t -.^,1
Emp
to
t h n
S f ^ t n
^n-
n r
,H
,
,
Locnl
n
n
n
r
G o v P r,,
m
„,,,
•
L
l
t
n
„,,
t
"
0
n
^
_
M
n
n
'
,
^
L
r
o
,„
n
m
1
^
Govemmer.t
„ „ ,.
,
. „
r
n
m
r
i
l
M
in
t h /
1980G"
1 ^
1 C| n p
( C h a r t
nl
�CHART
Average Annual Cost of Health
Premiums in State Government, 1980-89
3
Indemnity Plans
Current Year $
$3500
$3,080
$3000
Family Plans
$2500
i
$2000
$1500
$1,343
$976
Individual Plans
$1000
$437
$500
$0
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
Source.- M a r t i n E. Segal,
Annual Surveys of State
Employee H e a l t h Benefit Plans
Sourcn:
"Trendp,
in Employee
^
„
P r m e r i !; r? i
(
t
U
Health
1
D
R
L
r
n
r
a
F
U
0
l
:
n
t
a
R
n
r
l
,
c
n
I
i
t
Costs
in
Government
State
anrl
Local
L n b n r - M a n n r . i o m e r , I;
Government
Comm i t h e e ,
in
the
June
1S80s"
12
1930
(Chart
4
�CHART
Percent Increase in State
Government Employee Health Benefit Costs
Compared to Inflation (CPI), 1980-89
25%
20*
-
Health Benefits
^S%r
10% h
Inflation (CPI)
5% r
0%
1980
1981
1982
1983
1S84
1985
1988
1987
1988
1989
1990
Indemnity Plans
Sourct: Martin E. S«g»l Cotnpmny
Note: Martin E. Segal Company d i d not conduct surveys i n 1981,
1982, and 1984. T h e r e f o r e , i n t h i s c h a r t , the annual percent
change for the 1980-83 « s p e r i o d was c a l c u l a t e d by d i v i d i n g the
premium c o s t i n c r e a s e from 1980 to 1983 by t h r e e to get an
average annual percent i n c r e a s e .
Likewise, the annual percent
change for the 1983-85 p e r i o d was c a l c u l a t e d by d i v i d i n g the
i n c r e a s e from 1983 t o 1985 by two to get an average annual
percent i n c r e a s e .
S our ~e :
" T r a n d s i n Employee H e a l t h B e n e F i t C o s t s i n S t a t s and L o c a l
Government i n t h e 198Qs" ( C h a r t 3 ) .
P n e s e r . t s d t o t n e S t a t e a n d L o c a l G o v e r n m e n t L a o o r - M a r . age." er.
C o m m i t t e e . J u n e 1 2 . 19 S C
-25 1 -
4
�APPENDIX
Insurer
Substituted
THE
Judgment
NEW YORK TIMES,
F e b r u a r y 26, 1991
Letters
The Bane of Medical Second-Guessing
To the Editor:
In "Medical Second-Guessing — In Advance," Feb. 24, Glenn Kramon makes the point that medical necessity reviews protect patients from unnecessary procedures while cutting costs to insurance companies. My personal experience is that case review is an
open invitation to insurers to deny or indefinitely delay treatment
where (costly) medical intervention ts legitimately requried.
I suffer from a genetic disorder — Gaucher's disease. Unable to
produce an essential enzyme, my body allows a fatty material to accumulate uncontrollably in various places. My liver, bones and
bone marrow are most severely affected and I continue to deteriorate at a frighteningly rapid pace. I am essentially homebound except for infrequent forays on my motorized scooter.
Last year, a miracle occured. The Genzyme Corporation of Boston developed Ceredase, the enzyme replacement necessary to
treat Gaucher's disease. Initial studies have shown remarkable results and in June 1990, the F.D.A. decided to expand access to this
promising new treatment in cases like mine where a patient is seriously ill. Ceredase is the only treatment for Gaucher's disease and
my only hope for survival.
In September, my physician and a representative from Genzyme sent exensive information about my case and the Ceredase
treatment to my insurer. For six months now I've been waiting for
the insurer to fulfill its end of our contract and agree to pay for my
treatment The insurer maintains that it will decide on my claim
only after studying treatment results on several other Gaucher's
sufferers to determine the efficacy of enzymerela cement therapy.
Since Gaucher's is an uncommon disorder with a wide range of diversity among cases, garnering sufficient data for its review may
take my insurer years. It is likely that by the time the insurer is finished second-guessing I will be either completely debilitated or, the
ultimate In cost-effectiveness, deceased.
LINDA SHAFARMAN
New York, N.Y., Feb. 20
�NOTES
1.
D o n a l d G. M c N e i l , J r . , " W a s h i n g t o n T r i e s t o S o r t
H e a l t h I n s u r a n c e P r o p o s a l s , " The New Y o r k T i m e s ,
1 9 3 1 , p. E2.
1 and
Out
Nov.
17,
2.
I d . cols.
2.
3.
I d . c o l . 2.
4 .
Id .
5 .
Id. , cols.
6.
P. A. P a u l - S h a h e e n , " O v e r l o o k e d C o n n e c t i o n s : P o l i c y
D e v e l o p m e n t and I m p l e m e n t a t i o n i n S t a t e - L o c a l R e l a t i o n s , "
15 J o u r n a l o f H e a l t h P o l i t i c s , P o l i c y a n d Law 8 3 3 , W i n t e r
1990.
(Hereinafter,
Paul-Shaheen)
7.
Id . at
836 .
8.
Id . at
334 .
9.
Id . at
855 .
10 .
Id . at
835 .
11 .
Id .
12 .
Id .
13 .
Id . at
14 .
Id .
15 .
Id .
16 .
Id .
17.
R a s h i I- e i n , 'The H e a l t h S e c u r i t y P a r t n e r s h i p , " J o u r n a l oF
t h e A m e r i c a n M e d i c a l A s s o c i a t i o n , May 15, 1 9 9 1 , a t 2 5 5 5 .
18.
Id.
19.
F a i t h P o p c o r n , "The P o p c o r n R e p o r t , " (New Y o r k : D o u b l e d a y ,
1 9 9 1 ) a t 7.
F a i t h P o p c o r n i s a m a r k e t i n g c o n s u l t a n t and
F u t u r i s t , a t r e n d F o r e c a s t e r F o r b l u e - c h i p compEsnies s u c h
as E a s t m a n K o d a k , N i s s a n , a n d IBM.
She p r e d i c t e d t h e
F a i l u r e oF New C o k e , a n d t h e demand F o r F r e s h F o o d s a n d
Four-wheel d r i v e .
She h a s c o i n e d d e s c r i p a t i v e p h r a s e s s u c h
as C o c o o n i n g ( t h e s t a y - a t - h o m e s y n d r o m e ) a n d the. D e c e n c y
• ecade (1 330s) .
2 and
3.
83S .
-25S-
�20.
Exception:
See W i c k l i n e v. S t a t e , 192 C a l . A p p . 3 d
239 C a l . R p t r . 810 ( 1 9 8 6 ) , i n f r a p.
149.
21.
David WilsFord, "Doctors
U n i v e r s i t y Press, 1991).
22.
R e g i n a E. H e r z l i n g e r ,
M o n t h l y , August 1991,
23.
Robert
The
New
and t h e S t a t e , " (Durhcam: Duke
(Hereinafter, WilsFord)
" H e a l t h y C o m p e t i t i o n , " The
p. 69 a t 7 8 .
Potts,
"Who
Asked
York
Times,
Nov.
1630,
a F a v o r ? Who
21,
1991,
Wrote
Dp-Ed p.
the
A19,
Atlantic
Law?"
cols.
2,
3,
24.
I d . c o l . 2.
25.
Id.
25.
J o s e p h A. C a l i F a n o , J r . , " A m e r i c a ' s H e a l t h C a r e R e v o l u t i o n ;
Who L i v e s ? Who D i e s ? Who P a y s ? " (New Y o r k : Random H o u s e ,
1986).
(HereinaFter, CaliFano)
27.
WilsFord,
23.
Id.
29.
I d . at
30.
M a l c o l m G. T a y l o r , " I n s u r i n g N a t i o n a l H e a l t h C a r e ;
C a n a d i a n E x p e r i e n c e , " ( C h a p e l H i l l : The U n i v e r s i t y
C a r o l i n a P r e s s , 1 9 9 0 ) , a t 16.
31.
Id.
32.
I d . at
33.
Id.
34.
I d . at
18,
19.
35.
I d . at
19,
20.
36.
I d . at
20.
37.
Id.
38.
I d . at 2 1 .
39.
Id.
40.
I d . at
• 1.
a
42 .
supra
note
21,
at
2.
26.
17.
22.
Id. at 23.
I d . at
137.
- 257-
the
oF N o r t h
�43.
I d . a t 1 8 7 , 188.
44.
I d . a t 187.
45.
I d . a t 29.
46.
I d . a t 1 8 8 , 189.
47.
I d . a t 189.
48,
S t u d i e s by Woods G o r d o n
a t 194 e t s e q .
49.
I d . a t 197.
50.
I d . a t 198.
51.
I d . a t 199, 200.
52.
I d . a t 198.
53.
I d . a t 202.
54.
a t 192 e t s e q . , a n d J o h n
Horne
Id.
55 .
I d . a t 2 1 .0.
56
I s a a c E h r l i c h , e d i t o r , " N a t i o n a l H e a l t h P o l i c y ; What
Role For Government?" ( S t a n f o r d : Hoover I n s t i t u t i o n
P r e s s , 1 9 8 0 ) , a t 38.
(HereinaFter, Ehrlich)
57.
Id.
58.
I d . a t 39.
39.
I d . at 41.
60.
I d . a t 54.
6 1.
I d . a t 54, 55.
62.
I d . a t 55.
S3.
I d . a t 57.
64.
Id.
65.
Id.
66.
Id.
67.
L i g h t a n d S c h u l l e r , e d i t o r s , " P o l i t i c a l V a l u e s oF H e a l t h
C a r e : The German E x p e r i e n c e , " ( C a m b r i d g e : M . I . T . P r e s s ,
1 9 3 6 ) a t 103, 125.
-2!
�58 .
Id . at
254 .
59.
Id . at
28
70 .
Id . at
28 .
7 1 .
Id . at
35 .
72 .
I d . a t 45 .
73 .
Id . at
46 .
74 .
Id . at
49 .
75 .
Id . at
55 .
75 .
Id . at
63 .
77 .
Id .
78 .
Id . at
79 .
B r a d f o r d L. K i r k m a n
I m p l e m e n t a t i o n i n t h e N e t h e r l a n d s and t h e F e d e r a l R e p u b l i c
o f G e r m a n y , " 265 J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n
1 4 9 6 , May 15, 1 9 9 1 .
80.
Id.
81.
Senator
82.
Id.
83.
I d . at
5.
84.
I d . at
4.
85.
I d . at
5.
86.
Id.
37.
Id.
38.
I d . at
89.
Id.
90.
Id.
91.
S e n a t o r Bob K e r r e y , H e a l t h USA A c t o f
Cost Containment P r o v i s i o n s , J u l y 11,
92.
Id.
and
fn
3.
64 .
Bob
K e r r e y , News R e l e a s e ,
July
11,
1991,
at
4.
6.
-259-
1991,
1991,
Over-view o f
p.1 and n . 1 .
�•3.
I d . a t 2.
94.
I d . a t 3.
95.
96.
97.
Id.
Senator
Bob
Kerrey,
News R e l e a s e ,
July
1 1 , 1 9 9 1 , a t 5.
Id.
98.
I d . a t 7.
99.
CaliFano,
supra
n . 26, a t
179.
100.
I d . a t 184..
101.
Tom W i c k e r , " I n t h e N a t i o n : A C o s t l y 10 P e r c e n t , " The New
Y o r k T i m e s , J u l y 2 1 , 1 9 9 1 , a t 17E, q u o t i n g J o h n B u r r y , J r .
102.
I d . ,paraphrasing
103.
John B u r r y , J r .
Id.
104.
C l a r k C. H a v i g h u r s t , " H e a l t h C a r e Law a n d P o l i c y , "
[ W e s t b u r y : The F o u n d a t i o n P r e s s , 1 9 8 8 ) a t 1 1 6 3 .
(HereinaFter
Hav i g h u r s t )
105.
Health
Health
106.
I d . a t 37.
107.
I d . a t 36.
108.
I d . a t 33.
109.
A s s o c i a t i o n oF A m e r i c a ,
D a t a 1990" a t 35.
" S o u r c e Book
oF
Id.
110.
Insurance
Insurance
Id.
111.
P e p p e r C o m m i s s i o n H e a l t h C a r e A c c e s s and ReForm
S.1177, a t §421.(HereinaFter, S.1177)
112.
I d . at
113.
A c t oF
1991,
§2101(a).
Id.
114.
I d . at
§2108(d).
115.
I d . at
§2105(c).
116.
The H e a l t h A m e r i c a :
A F F o r d a b l e H e a l t h Care For a l l A m e r i c a n s
A c t , S . 1 2 2 7 , was i n t r o d u c e d by S e n a t o r s M i t c h e l l ,
Kennedy,
Riegle,
and R o c k e F e l l e r
on J u n e
-250-
5,
1991.
�117.
S . 1 177 a t
§2106(b).
118.
I d . a t §2102Ca)CA).
119.
I d . a t §2102(a)C B) .
120.
I d . a t §2204(3) and
121 .
I d . a t §2204(d).
122 .
I d . a t §2224(a).
123.
I d . a t §2312(b)(2) (A) .
124.
I d . a t §2254(a) and
125.
I d . a t §2303(a)(2)(A) .
125 .
S . 1 177 , T i t l e X X I I , c o v e r s Acc
Basic H e a l t h Through a P u b l i c H e a l t h
(d)(2)(B).
(b)(1).
Insurance
Plan.
127.
S.1177, §2251(b)(2).
128.
I d . a t §2261 ( c ) .
129.
I d . a t §2263(b). P r o v i s i o n t o t a k e eFFect
y e a r s a F t e r t h e e n a c t m e n t oF 3 . 1 1 7 7 .
130.
I d . a t §306.
131.
I d . a t §305.
132.
Foster
133.
Summary oF S . 1 2 2 7 , p r o v i d e d by S e n a t o r s M i t c h e l l , K e n n e d y ,
R i e g l e , a n d R o c k e F e l l e r , J u n e 5, 1 9 9 1 , a t 3.
(HereinaFter,
Summary)
134.
I d . a t 2.
135.
Higgins
i s an e m p l o y e e
beneFit
Id.
135.
Summary,
supra
137.
S. 1 2 2 7 , §270 1 ( a ) ( 1 ) .
133.
I d . a t §2701 ( a ) ( 2 ) .
139.
Summary,
140.
S.1227, §2722(b).
14 1.
I d . a t §2722(a).
supra
n . 1 3 3 , a t 5.
n . 1 3 3 , a t 6.
-26 1 -
January
consulting
1, s i x
Firm.
�142.
Id.
at
§27E2(aH6)
143.
Id.
at
§27220).
144.
Summary, s u p r a
145.
Additional discussion
in included infra.
of the actual
146.
Summary, s u p r a
a t 3.
147.
I d . a t 5.
148.
I d . a t 7.
149.
I d . a t 6.
150.
I d . a t 7.
151.
I d . a t 5.
152.
See
infra,
p.212 f o r f u r t h e r
153.
See
infra,
p p . 5 7 a n d 198 f o r f u r t h e r
154.
See
infra,
p.230 f o r f u r t h e r
155.
Summary, s u p r a
156.
Id.
157.
158.
159.
160.
161 .
n . 1 3 3 , a t 7.
n.133,
n.133,
sections
discussion
of the b i l l
of malpractice.
discussion
discussion
of technology
o f consumers.
a t 5.
Id.
Pamela J. B l a c k , " T u r n i n g O f f Renegade T C e l l s , "
Week, Nov. 18, 1 9 9 1 , a t 6 9 .
Business
Id.
Business
Week, Nov.
18, 1 9 9 1 , R e a d e r s R e p o r t ,
a t 14.
Id.
Califano,
163.
Summary,
:
§ 272 1 ( b ) ( 3 ) .
a t 6 .
162.
154.
and
supra
supra
n . 2 5 , a t 102.
n . 1 3 3 , a t 6.
Id.
165 .
S.700
i s covered
166.
Senator
157.
H.R.
1S3.
infra,
I d . at 1 .
Gurenberger,
3205,
Summary,
p. 140.
Press
August
release,
2,
- 2E2-
p.2. n o t d a t e d .
1 9 9 1 , a t 4.
�169.
I d . at
2.
170.
I d . at
4.
171.
I d . at
5.
172.
I d . at
7.
173.
I d . at
8.
174.
M a r k T h o r n t o n , " A l c o h o l P r o h i b i t i o n Was a F a i l u r e , "
I n s t i t u t e P o l i c y A n a l y s i s N o . 1 5 7 , J u l y 17, 1 9 9 1 , p.
(HereinaFter, Thornton)
175.
Id.
175.
Id.
CATD
14.
177.
I d . at
2.
178.
I d . at
13.
179.
I d . at
9.
189.
I d . a t 6, q u o t i n g L a w r e n c e W. R e e d , " W o u l d L e g a l i z a t i o n
I n c r e a s e Drug Use?"
F r e e M a r k e t , Feb.
1990.
181.
Thornton, at
182.
Id.
183.
L u d w i g v o n M i s e s , "Human A c t i o n , "
Henry R e g n e r y , 1 9 5 6 ) , a t 733.
184.
Id.
185.
R i c h a r d H a r r i s , "A S a c r e d T r u s t , " ( B a l t i m o r e :
1 9 6 9 ) , a t 35.
(HereinaFter Harris)
185.
Id.
187.
Supra,
183.
J . H o l a h a n , S. Z e d l e w s k i , " I n s u r i n g L o w - I n c o m e A m e r i c a n s :
I s M e d i c a i d t h e Answer?"
(The Urban I n s t i t u t e , W o r k i n g
P a p e r , J u l y 1 9 9 0 . ( H e r e i n a F t e r , Ho 1 a h a n / Z e d 1 e w s k i )
189.
I d . at
190.
6.
n o t e 56,
2.
Id.
191 .
I d . at
3.
192.
I d . at
3.
at
3d r e v i s e d
ed.,
(Chicago:
Penguin
Books,
416-417.
�193.
I d . a t 19.
194.
I d . a t 10.
195.
I d . at
196.
I d . a t 1.
197.
19.
Id.
198.
I d . a t 2.
199.
K r i z a y a n d W i l s o n , "The
L e x i n g t o n Books, 1974),
200.
Id.
201.
Ho 1 a h a n / Z e d 1 e w s k i , s u p r a
202.
I d . at
203.
P a t i e n t As
a t 80.
n.188,
Consumer,"
(Lexington:
a t 2.
14.
Id.
204.
I d . a t 20.
205.
I d . at 21.
206.
207.
Id.
I d . a t 22.
208.
Id.
209.
D a v i d B l u m e n t h a l , "The T i m i n g a n d C o u r s e o f H e a l t h
ReForm,§ The New E n g l a n d J o u r n a l oF M e d i c i n e , J u l y
a t 138.
(HereinaFter,
Blumenthal)
210.
Id.
211.
Id.
212.
Id.
Care
18, 1 9 9 1 ,
213.
W i l l i a m Roper,
W h i t e House,"
2 14.
Id.
215.
I d . at
2 16.
Id.
217.
Lynn Etheredge, " N e g o t i a t i n g N a t i o n a l H e a l t h
Insurance,"
16 J o u r n a l oF H e a l t h P o l i t i c s , P o l i c y a n d Law 127,
Spring
" F i n a n c i n g H e a l t h C a r e : A V i e w From t h e
H e a l t h A F F a i r s , W i n t e r 1989, pp. 97, 99.
100.
1991.
-254-
�218.
I d . a t 158.
2 13.
I d .
220.
I d .
221.
I d . a t 160.
222.
S t u a r t M. B u t l e r , "A T a x ReForm S t r a t e g y t o D e a l W i t h t h e
Uninsured,"
J o u r n a l oF t h e A m e r i c a n M e d i c a l
Association,
May 1 5 , 1 9 3 1 , a t 2 5 4 1 . ( H e r e i n a F t e r , B u t l e r )
223.
I d .
224.
I d .
225.
225.
I d . a t 2542.
I d .
227.
I d . a t 2543.
228.
S.84 § 2 5 A ( a ) ( 2 ) ( A ) , w h i c h w i l l a F F e c t
Code C h a p t e r 1 ( a ) ( I V ) ( A ) (§ 25A) .
229.
S .84,
230 .
.
I . R . S Code
231 .
s .84,
§25A(2)(B)(b)(2)(A).
232 .
s .34,
§25A(2)(B) ( b ) ( 2 ) ( B ) .
233 .
s .85,
§40a(1)(a)(7)(A).
234 .
s. 35 , § 4 3 2 ( a ) .
235 .
s .85,
§433(b)(2)(A).
235 .
s .37,
§25A(a).
237 .
I . R . 5 Code
.
238 .
A l a i n E n t h o v e n and R i c h a r d
H e a l t h P l a n F o r t h e 1 9 9 0 s , " 3 2 0 New E n g l a n d
M e d i c i n e 2 9 , J a n u a r y 5, 1 9 8 9 . ( H e r e i n a F t e r ,
the Internal
Revenue
§ 2 5 A ( 2 ) (B) (b) (1 ) .
§213(F).
§25A(c ) ( 1 ) .
J o u r n a l oF
JAMA 1 / 5 / 3 9 ) .
239.
A l a i n Enthoven and R i c h a r d K r o n i c k , " U n i v e r s a l
Health
I n s u r a n c e T h r o u g h I n c e n t i v e s R e F o r m , " 2S5 J o u r n a l oF
t h e A m e r i c a n M e d i c a l A s s o c i a t i o n 2 5 3 2 , May 1 5 , 1 9 9 1 .
( H e r e i n a F t e r , JAMA 5 / 1 5 / 9 1 ) .
240.
Missouri
p.4.
Citizen Action
(HereinaFter,
Report,
QEA)
-255-
Question
and Answer
section,
�241.
J.A.M.A. 5 / 1 5 / 9 1 ,
supra
n. 2 3 9 , a t 2532.
242. I d .
243.
I d . a t 2533.
244.
I d . a t 2534.
245.
I d . a t 2533-2534.
245.
I d . a t 2534.
247.
A m e r i C a r e i s t h e p r o g r a m e s t a b l i s h e d by t h e H e a l t h A m e r i c a
A F F o r d a b l e H e a l t h Care F o r A l l A m e r i c a n s A c t , S.1227,
i n t r o d u c e d J u n e 5, 1 9 9 1 .
243.
T h e H e a l t h I n s u r a n c e C o v e r a g e a n d C o s t C o n t a i n m e n t A c t oF
1 9 9 1 , H.R. 3 2 0 5 , was i n t r o d u c e d by R e p r e s e n t a t i v e Dan
R o s t e n k o w s k i ( C - I l l . ) o n A u g u s t 2, 1 9 9 1 .
249.
J.A.M.A., 5 / 1 5 / 9 1 ,
supra,
note
250. I d .
251 . I d .
252. I d .
253. I d .
254.
I d . a t 2535.
255. I d .
255.
I d . a t 2536.
257.
4 2 C.F.R. § 4 3 3 . 1 0 ( a ] ( b ] .
258.
42 C.F.R. § 4 3 3 . 1 4 ( b ) ( 6 ) ( i ) .
259.
4 2 C.F.R. § 4 3 3 . 3 3 ( b ) .
250.
4 2 C.F.R. § 4 3 3 . 3 3 ( c ) ( 2 ) .
251 .
4 2 . U.S.C. §2102(g) .
252.
5.1227
§ 2742(a) ( 1) (A) .
263.
S.1227
§2742(b ) ( 1 ) ( 3 ) ( 1 ) .
254.
S.1227
§2742(b ) ( 1 ) ( 3 ) ( i i ) .
265.
3.1227
§2742(c)(1).
-2E5-
239, a t 2534.
�2SS.
S.1227
§2781(a).
2G7.
S.1227
§2781(b)(2).
268.
6.1227
§2781(d).
269.
6.1227
§2781(F).
270.
S.1227
§2781(g).
271.
J o n e s v . R a t h P a c k i n g Company, 4 2 0 U.S. 5 9 1 ( 1 9 7 7 ) , as
s t a t e d i n M a n d e l k e r , N e t s c h , S a l s i c h , Wegner , " S t a t e
and L o c a l G o v e r n m e n t i n a F e d e r a l S y s t e m , " ( C h a r l o t t e s v i l l e :
The M i c h i e Company, 1 9 8 3 ) , p . 5 1 9 .
(HereinaFter, Mandelker)
^
272.
S i l l ^ w o o d v . K e r r - M c G e a C o r p o r a t i o n , 4 6 4 U.S.
s t a t e d i n M a n d e l k e r , s u p r a , n. 2 7 1 , a t 5 1 9 .
273.
F i d e l i t y F e d e r a l S a v i n g s S L o a n A s s o c i a t i o n v . De La C u e s t a ,
458 U.S. 1 4 1 , 153 ( 1 9 8 2 ) , as s t a t e d i n M a n d e l k e r , s u p r a n o t e
27 1 , a t 5 19.
275.
M a r y l a n d v . L o u i s i a n a , 4 5 1 U.S. 7 2 5 , 746 ( 1 9 8 1 ) ,
i n M a n d e l k e r , s u p r a n. 2 7 1 , a t 520.
274.
P a c i f i c Gas S E l e c t r i c Company v . E n e r g y R e s o u r c e s
C o n s e r v a t i o n S D e v e l o p m e n t C o m m i s s i o n , 4 6 1 U.S. 1 9 0 , 204
( 1 9 8 2 ) , as s t a t e d i n M a n d e l k e r , s u p r a n o t e 2 7 1 , a t 5 1 9 .
275.
S.1227 §471 oF t h e H e a l t h A m e r i c a A c t w h i c h w i l l a F F e c t
§§2791 a n d 2 7 9 3 oF t h e P u b l i c H e a l t h S e r v i c e A c t .
277.
InFra,
273.
Missouri
279.
See W i c k l i n e
230.
The D u r e n b e r g e r
23 1.
p. 1 4 9 .
Rev. S t a t u t e
375 . 935( 1 1 ) ( b ) .
v. S t a t e ,
Report,
inFra
p. 1 4 9 .
April
1 9 9 1 , a t 2, c o l . 2.
Id.
233.
S.700,
234.
Julie
March
§5000(d).
235.
I d . a t 7C3, c o l . 1.
285.
I d . a t c o l . 2.
2 3 7.
I d . a t 7 0 9,
K o s t e r l i t z , "Seeking
24, 1990, a t 708.
t h e Cure," N a t i o n a l
c o l . 1.
-2S7-
as
as s t a t e d
Id.
232.
238 ( 1 9 8 4 ) ,
Journal,
�238.
283.
Paul-Shaheen, supra
note
S a t 834.
I d .
290.
M i s s o u r i C i t i z e n A c t i o n R e p o r t on t h e M i s s o u r i U n i v e r s a l
H e a l t h A s s u r a n c e P l a n ( H . B . 1 1 2 7 ) , i n t r o d u c e d by S t a t e
R e p r e s e n t a t i v e G a i l L. C h a t F i e l d ( 6 9 t h D i s t r i c t ) i n 1 9 9 0 .
( H e r e i n a F t e r , MCA R e p o r t )
291.
QSA, s u p r a
292.
MCA R e p o r t , a t j .
293.
QSA , s u p r a
294.
QSA a t
295.
note
note
240,
240,
a t 2.
a t 2.
1.
I d .
296.
MCA R e p o r t ,
supra
note
290,
a t 2.
297.
QSA, a t 3.
298.
MCA R e p o r t ,
299.
QSA a t 4.
300.
"The H e a l t h
G r a y , 1991)
301.
Thomas W. G r a n n e m a n n , " P r i o r i t y S e t t i n g : A S e n s i b l e
A p p r o a c h t o M e d i c a i d P o l i c y ? " 28 I n q u i r y 3 0 0 , 3 0 1 , F a l l
1991 ( H e r e i n a F t e r , G r a n n e m a n n )
302.
D a v i d M. E d d y , " O r e g o n ' s P l a n , S h o u l d I t Be A p p r o v e d ? "
26 J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n 2 4 3 9 , 2 4 4 3 ,
Nov. 6. 1 9 9 1 . ( H e r e i n a F t e r , E d d y )
a t 2.
Care 500,"
a t 159.
(Washington,
D.C:
F a u l k n e r and
303. I d .
304.
305.
R e h a b i l i t a t i o n A c t oF 1 9 7 3 ,
306.
C h a r l e s J. D o u g h e r t y , " S e t t i n g H e a l t h Care P r i o r i t i e s ,
O r e g o n ' s N e x t S t e p s , " 2 1 H a s t i n g s C e n t e r R e p o r t 1 , 6,
May-June 1991 ConFerence R e p o r t .
307.
f
Age D i s c r i m i n a t i o n A c t , 4 2 U.S.C. § 6 1 0 , a n d Age D i s c r i m i n a t i o n i n E m p l o y m e n t A c t 2 9 U.S.C. § 6 2 1 .
Grannemann,
supra
308.
Eddy,
note
supra
note
302,
301,
42 U.S.C.
a t 302.
a t 2442.
-268-
§6000.
�309.
B u s i n e s s Week, S e p t e m b e r 3 0 , 1 9 9 1 , "The 1 9 9 1 B u s i n e s s
WeeK S y m p o s i u m o f H e a l t h C a r e CEOs," a t 1 2 5 .
310.
Eddy,
supra
note
302, a t 2442.
3 11. I d .
312.
I d .a t 2444.
313.
S t . L o u i s M e t r o p o l i t a n M e d i c a l S o c i e t y s p o n s o r e d a Forum
on N o v e m b e r 2 0 , 1 9 9 1 , i n F r o n t e n a c , M i s s o u r i , o n t h e F u t u r e
oF H e a l t h C a r e .
The s p e a k e r was an a t t e n d e e , s p e a k i n g From
t h e a u d i e n c e . ( H e r e i n a f t e r , S t . L o u i s Med. S o c i e t y F o r u m )
314.
S t u a r t M. B u t l e r , D i r e c t o r o f D o m e s t i c P o l i c y S t u d i e s a t
t h e H e r i t a g e F o u n d a t i o n , W a s h i n g t o n , D.C., was a s p e a k e r a t
t h e S t . L o u i s M e t r o p o l i t a n M e d i c a l S o c i e t y Forum.
315.
R o n a l d B r o n o w , M.D., s p o k e s p e r s o n f o r t h e N a t i o n a l O r g a n i z a t i o n o f P h y s i c i a n s Who C a r e a t t h e S t . L o u i s M e d i c a l
S o c i e t y ' s Forum, o f f e r e d t h i s comment.
31S.
Eddy,
317.
I d . a t 2440.
318.
319.
320.
321.
322.
supra
note
302, a t 2439.
I d .
I d . a t 2445.
I d .
Paul-Shaheen,
supra
note
6, a t 3 4 7 .
I d .
323.
I d .
a t 837.
324.
Id.
a t 838.
325.
I d .
32S.
Id.
a t 8 3 8 , n . 5.
327.
" H e a l t h Care f o r t h e U n i n s u r e d Program
D.C.: The A l p h a C e n t e r , J a n u a r y 1 9 9 0 ) ,
Alpha ) .
Update,"
(Washington,
a t 1.
(Hereinafter
The R o b e r t Wood J o h n s o n F o u n d a t i o n was e s t a b l i s h e d i n 1935
i n P r i n c e t o n , New J e r s e y , a n d e x i s t s t o i m p r o v e h e a l t h
s e r v i c e s i n t h e U.S. w i t h e m p h a s i s on i m p r o v i n g a c c e s s t o
h e a l t h care f o runderserved groups.
#
328.
Alpha,
supra
note
3 2 7 , a t 1.
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�329.
I d . at
7.
330.
Id.
331.
Id.
332.
Id.
333.
I d . at
334
J u d i t h G l a n z e r , SCOPE P r o j e c t D i r e c t o r , as s t a t e d
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W i e n e r , J u n e 13, 1 9 9 0 , a t 4.
335 .
Alpha,
336 .
Id .
337 .
Id . at
4.
338 .
Id . at
6.
339 .
Id . at
3.
340 .
Id . at
6.
341 .
Id . at
5.
342 .
Id .
343 .
Id . at
344 .
Id .
345 .
Id .
346 .
Id .
347 .
Id .
348 .
Id .
349 .
Id . at
350 .
Id .
351 .
Id . at
3.
352 .
Id . at
a.
353 .
Id .
2.
SL
7.
8.
-270-
in
Ochs
�354.
" T r e n d s i n Employee H e a l t h B e n e F i t C o s t s i n S t a t e and
L o c a l Government i n t h e 1980s," p r e s e n t e d t o t h e S t a t e
and L o c a l Government Labor-Management C o m m i t t e e ,
J u n e 12, 1 9 9 0 .
355.
David Warner, "Costs Rise For Medical P l a n s , "
B u s i n e s s , A p r i l 1 9 9 1 , a t 3 2 . See a l s o i n F r a ,
and A p p e n d i x , pp. 2 4 8 - 2 5 1 .
355.
A r e e n , K i n g , G o l d b e r g , a n d C a p r o n , "Law, S c i e n c e a n d
M e d i c i n e , " f W e s t b u r y : The F o u n d a t i o n P r e s s , 1 9 8 4 ) , a t 3 0 1 .
357.
I d . a t 300.
358.
W a d l i n g t o n , W a l t z , a n d D w o r k i n , "Law a n d M e d i c i n e , "
( W e s t b u r y : The F o u n d a t i o n P r e s s , 1 9 8 0 ) , a t 8 0 .
359.
Id.
360.
Nation's
p. 2 2 0 ,
Id.
361.
43 A m . J u r . 2 d ,
362.
P u b l i c S e r v i c e M u t u a l I n s u r a n c e Company v . L e v y ,
87 M i s c . 2 d 9 2 4 , 387 NYS3d 9 6 2 , a s r e p o r t e d i n 43 Am . J u r . 2 d
I n s u r a n c e §22.
353.
I d . a t §26, p . 1 0 2 .
354.
I d . a t 103.
365.
E n c y c l o p e d i a oF A s s o c i a t i o n s , ( D e t r o i t :
Company, 1 9 9 1 ) .
356.
R o b e r t P e a r , "2 B i l l s Seek A F F o r d a b l e H e a l t h I n s u r a n c e , "
The N e w Y o r k T i m e s , O c t . 2 5 , 1 9 9 1 , p. A 1 0 , c o l . 5.
367.
I d . at cols.
368.
Insurance
§22.
Gale
Publishing
3 a n d 4.
Id.
369.
G i n s b e r g v . D e n v e r , 164 C o l . 5 7 2 , 4 3 6 P.2d
i n 43 A m . J u r . 2 d I n s u r a n c e § 2 2 .
3 7 0.
C e n t r a l T r a n s p o r t a t i o n Company v . P u l l m a n ' s P a l a c e Car
Company , 139 U.S. 2 4 , 35 L.Ed. 5 5 , 11 S . C t . 4 7 3 ;
U n i o n T r u s t S S a v i n g s Sank v. K i n l o c k L o n g D i s t a n c e
T e l e p h o n e Company, 2 5 8 1 1 1 . 2 0 2 , 101 N.E. a 5 3 5 ; as r e p o r t e d
i n 34 A m . J u r . 2 d P u b l i c U t i l i t i e s §26.
3 7 1.
Id.
-27 1 -
6 8 5 , as
reported
�372.
373.
U n i t e d Gas P i p e L i n e Company v. L o u i s i a n a P u b l i c S e r v i c e
Company, 241 La. 687, 130 S.2d 652, as r e p o r t e d i n
64 Am.Jur.2d §192.
374.
B l u e F i e l d W a t e r w o r k s S I m p r o v . Co. v. P u b l i c S e r v i c e
C o m m i s s i o n , 262 U.S. 6 7 9 , 67 L.Ed. 1176, 43 S.Ct. 675, as
r e p o r t e d i n 64 Am.Jur.2d §192.
375.
64 Am.Jur.2d §28.
376.
" S o u r c e Book o f H e a l t h I n s u r a n c e Data 1990" [ W a s h i n g t o n ,
D.C.: H e a l t h I n s u r a n c e A s s o c i a t i o n o f A m e r i c a , 1 9 9 0 ) , a t
103.
C H e r e i n a f t e r , S o u r c e Book)
377.
Id . at
103- 104.
378 .
Id . at
104 .
379 .
Id . at
105 .
380.
Id .
381 .
43 Am . J u r . 2 d ,
382 .
Id . at
§ 1 8 , p. 9 1 .
383.
Id . at
§57, p p .
1 4 2 , 143
384 .
Id . at
§60, p p .
1 4 5 , 146
385 .
Id . at
§61 , p.
146.
386 .
Id . at
§63, p.
147.
387 .
Id . at
§ 6 4 , p.
148.
388 .
I d . a t §64, p. 148, c i t i
I n s u r a n c e Company v . Pag
389 .
Id . at
§73, p.
154.
3,90 .
Id . at
§77,
157.
391 .
Source
Book ,- s u p r a
392 .
f
P e n n s y l v a n i a R a i l Company v. P h i l a d e l p h i a C o u n t y ,
220 Pa. 100, 68 A. 676, as r e p o r t e d i n 64 Am.Jur.2d §190.
Id . at
16 .
393.
Id .
394 .
Id . at
6.
p.
Insurance
note
�396.
397.
S o u r c e Book, s u p r a
393.
I d . at
15.
399.
I d . at
14.
400.
I d . at
15.
401.
Id.
402.
I d . a t 30,
403.
Id.
404.
I d . at
7.
405.
I d . at
15.
406.
I d . at
6.
407.
"Industry
S Poor's,
SSP]
408.
"1991 B u s i n e s s R a n k i n g s A n n u a l , ( D e t r o i t : Gale R e s e a r c h ,
Inc.,
1991), q u o t i n g Best's Review, L i F e / H e a l t h e d i t i o n ,
D e c e m b e r 1 9 8 9 , p. 3 1 5 .
409.
SSP,
410.
Source
Book, s u p r a
411.
I d . at
20.
412.
Id.
413.
Id.
414.
M i s s o u r i Rev.
415.
Source
416.
W i c k l i n e v.
417.
f
Dr. R o n a l d Bronow, s p e a k i n g a t t h e November 20,
S t . L o u i s M e t r o p o l i t a n M e d i c a l S o c i e t y F o r u m on
F u t u r e OF H e a l t h C a r e .
The M c C a r r a n - F e r g u s o n
( 1988) .
418.
E d w a r d 0. C o r r e i a , "The
Applying Federal Policy
A n t i t r u s t Laws a n d I n s u r a n c e :
to a State-Regulated
Industry,"
25 T o r t S I n s u r a n c e Law
(HereinaFter, Correia)
Journal
table
note
note
Book,
at
14.
2.14.
Surveys,
J u l y 12,
supra
376,
1991
the
I n s u r a n c e and I n v e s t m e n t , "
1 9 9 0 , S e c t i o n 2, p. 1-32.
407,
Stat.
at
note
88.
376,
§375.936
inFra note
Standard
(HereinaFter
376,
S t a t e , i n F r a p.
Act,
-273-
a t .19,
20.
(I1)(b).
at
20.
149.
59
Stat.
793,
33,
15
813;
U.S.C.
Summer
1011-1015
1991.
�419. I d .
420.
15 U.S.C. § 1 0 1 2 ( a ) .
421.
15 U.S.C. § 1 0 1 2 ( b ) .
422.
15 U.S.C.
423.
U n i o n L a b o r L i F e I n s u r a n c e Company v . P i r e n a , 4 5 3 U.S. 119
( 1 9 8 2 ) , as s t a t e d i n H a v i g h u r s t , s u p r a n o t e 104, a t 1 1 5 1 .
§1013(b).
424. I d .
425. I d .
42S.
I d .at
1158.
427. I d .
428.
I d .at
1159.
429.
American Bar F o u n d a t i o n Working Paper S e r i e s #8801,
" A e t n a , We're S o r r y We M e t W i t h Y a ? " by I a n A y r e s a n d
P e t e r S i e g e l m a n , 1 9 8 8 ( H e r e i n a F t e r , A y r e s / S i e g e 1 man)
430.
I d .at
431.
I d . a t 2.
432.
A r i z o n a v. Maricopa County
102 S . C t . 2 4 S 6 . ( 1 9 8 2 ) .
1.
Medical Society,
433. I d .
434.
Correia,
supra note418,
a t 814.
435. I d .
436.
I d . a t 8 1 5 , n.S.
437. I d .
438. I d .
439.
I d . a t 815.
440.
I d . a t 8 1 8 , n.20 .
44 1.
I d . a t 816.
442.
I d . a t 316,
443.
I d .at
n.13.
19.
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4 5 7 U.S. 3 3 2 ,
�444.
I d .
445.
I d .a t 821, notes
446.
I d .
at 821.
447.
I d .
a t 830.
448.
I d .at 831.
449.
L i s a D r i s c o l l , " I n s u r e r s Are Giving a L i t t l e t o Avoid
G i v i n g a L o t , " B u s i n e s s Week, J u n e 3, 1 9 9 1 , a t 2 7 .
(HereinaFter,
Driscoll)
450.
I d .
452.
34. 38.
Id.
451.
a t 20.
Id.
453.
454.
M a r g a r e t Levy, " C u r r e n t Coverage Issues i n H e a l t h
Insurance
Law:
I s T h e r e C o v e r a g e When T h e r e I s No C o v e r a g e ? " 26 T o r t
S Insurance
law J o u r n a l 621 (1991) ( H e r e i n a F t e r , Levy)
I d .
455.
Id.
456.
I d .at 621.
457.
Id.
458.
a t 622.
a t 622.
I d .
459.
Id.
a t 624.
450.
Id.
a t 622.
45 1.
R o b e r t H. J e r r y I I , " U n d e r s t a n d i n g I n s u r a n c e Law," (New
Y o r k : M a t t h e w B e n d e r , 1 9 8 7 ) , p. 109, n . 1 5 , q u o t i n g
ProFessor Rahdert's a r t i c l e , "Reasonable
Expectations
R e c o n s i d e r e d , " 18 C o n n . L .Rev.
3 2 3 , 344 ( 1 9 8 6 ) .
(HereinaFter,
Jerry).
462.
J e r r y , a t 107.
453.
Id.
a t 111.
454.
Id.
a t 110.
453.
Id.
465.
Id.
457.
I d . a t 111.
-275-
�468.
I d .
469.
I d . a t 106, n.6., q u o t i n g K i e v i t v. L o y a l P r o t e c t i o n
I n s u r a n c e Company, 170 A . 2 d a t 24 ( 1 9 6 1 ) .
470.
J e r r y , s u p r a n o t e 4 6 1 , a t 107, n.4., q u o t i n g E s t r i n
C o n s t r u c t i o n Company v . A e t n a C a s u a l t y S S u r . Co., 6 1 2 S.W.2d
413 (Mo.App. 1 9 8 1 ) .
471.
Levy, supra note 453, a t 628, r e F e r r i n g t o Kunin v . Senef i t
T r u s t L i F e I n s u r a n c e Company, 6 9 6 F.Supp. 1 3 4 2 ( C . O . C a l . 1 9 8 8 )
472.
SSP,
473.
note
4 0 7 , a t 1-33.
I d .
474.
supra
LiFe
Id.
475.
I d . a t 1-35.
476.
I d . a t 1-34.
477.
I d .
478.
C o t t o n , " P r e e x i s t i n g C o n d i t i o n s 'Hold Americans Hostage' t o
E m p l o y e r s anD I n s u r a n c e , " J o u r n a l oF t h e A m e r i c a n M e d i c a l
A s s o c i a t i o n 2 4 5 1, May 1 5 , 1 9 9 1 .
379.
B u s i n e s s Week, S e p t e m b e r 3 0 , 1 9 9 1 , "The 1 9 9 1 B u s i n e s s
S y m p o s i u m o F H e a l t h C a r e CEOs," a t 1 2 3 + .
480.
Havighurst,
481.
S.700
482.
The D u r e n b e r g e r
483.
S.700
§5000A(u)(3).
484.
S.700
§5000(B)(d).
485.
The D u r e n b e r g e r
486.
I d . a t 2.
487.
S.700 § 5 0 0 0 ( B ) ( D ) ( 1 ) a n d ( 3 ) .
483.
S.700 § 5 0 0 0 ( B ) ( d ) ( 2 ) a n d ( 4 ) .
489.
S.700
§5000(B)(d)(5).
490.
S.700
§5000(a)(1)(c)(ii)(II).
491.
S.700
§5000(C)(c).
supra
note
104, a t 1133, n.7.
§5000(b)(1)(C).
Report,
Report,
A p r i l 1991.
A p r i l 1991.
-276-
Week
�492.
S.70Q
§5000(3)(b)(2)(A).
493.
S.1227
§2723(b) a t p . 4 0 .
494.
S.1227
§2723(c)(1).
495.
S.1227
§2723(c)(2), a t p. 4 1 .
495.
S . 1 2 2 7 Summary
497.
S.1227
§2722(c), a t p. 3 4 .
493.
S.1227
§2722(d).
499.
S.1227
§2743(c)(1)(B).
500.
Havighurst,
501.
Bronow, B e l t r a n , Cohen, E l l i o t t , Goldman, and S p o t n i t z ,
"The P h y s i c i a n s Who C a r e P l a n , " 2 6 5 JAMA 2 5 1 1 , 2 5 1 4 ,
May 1 5 , 1 9 9 1 . ( H e r e i n a F t e r , B r o n o w / J A M A )
502.
Wickline
(1986).
503 .
Wickline,
504 .
Id .
at
812 .
505 .
Id .
at
813 .
506 .
Id .
507 .
Id .
at
814 .
508 .
Id .
at
815 .
509 .
Id .
at
817 .
510.
Id .
at
8 16 .
511.
Id .
5 12 .
Id .
5 13.
Id .
at
8 17.
5 14.
Id .
5 15.
Id .
a t 817,
5 15.
Id .
a t 3 16.
5 17.
Id .
a t 3 17.
a t 9.
supra
note
104, a t
1058.
v . S t a t e , 192 C a l . A p p . 3 d
(HereinaFter, Wickline)
2
-277-
1630, 239 C a l . R p t r .
810
�518.
Id . at
814.
5 13.
Id . at
815 .
520.
Id . at
817.
521 .
Id . at
819.
522 . I d . a t
819 ,
523.
S l i p o p i n i o n , W i c k l i n e v . S t a t e o f C a l i F o r n i a , No. B 0 1 0 1 5 S ,
( C a l . C t . App. 2d C i s t . , J u l y 3 0 , 1 9 8 B ] , a t 2 9 , 3 0 .
524.
W i c k l i n e , 239 C a l . R p t r . 810, a t 320.
525.
S.1227,
§2725(eHl)
52S.
S.1227
§2725(e)(3).
527.
C.
528.
W i l l i a m s v . H e a l t h A m e r i c a , 4 1 O h i o A p p . 3 d 2 4 5 , 5 3 5 N.E.2d 7 1 7
( 1 9 8 7 ) , as e x p l a i n e d by W i l l i a m A. C h i t t e n d e n I I I , " M a l p r a c t i c e
L i a b i l i t y a n d Managed H e a l t h C a r e : H i s t o r y a n d P r o g n o s i s , "
26 T o r t S I n s u r a n c e I I r n l . 4 5 1 , a t 4 7 4 , S p r i n g 1 9 9 1 .
(HereinaFter, Chittenden)
529.
W i l l i a m s v. H e a l t h A m e r i c a
530.
I d . a t 722.
531.
Chittenden,
532.
I d . a t 476.
533.
I d . a t 477.
534.
I d . a t 478.
535.
I d . a t 4 7 8 , n. 136.
536.
2 2 2 C a l . App. 3d 6 6 0 , 2 7 1 C a l . R p t r . 7 8 7 6
i n C h i t t e n d e n , supra n o t e 528, a t 478.
537.
I d . a t 479.
538.
supra
TV,
note
June 30, 1991.
a t 720.
528, a t 475.
(Cal.Ct.App.
1990),
Id.
539.
E v e r e t t K o o p , NBC
and ( 2 ) .
Id.
540.
2 6 3 C a l . R p t r . 850
n o t e 528, a t 480.
34 1 .
( C a 1 .Ct . App.
I d . a t 480.
-279-
1989),
Chittenden,
supra
�542.
I d .
543.
See a l s o A p p e n d i x , p . 2 5 2 , F o r a d d i t i o n a l a n e c d o t a l
c o n F i r m a t i o n oF t h e d e t r i m e n t a c c r u i n g t o p a t i e n t s
From i n s u r e r s ' s u b s t i t u t e d
judgments.
544.
U.S. C o n g r e s s , O F F i c e o f T e c h n o l o g y A s s e s s m e n t ,
" I n s u r i n g t h e U n i n s u r e d : O p t i o n s and A n a l y s i s , "
( W a s h i n g t o n , O.C:
Government P r i n t i n g OFFice, 1388).
545.
D e b o r a h S t o n e , " P r e d i c t i v e M e d i c i n e : I m p l i c a t i o n s and
E F F e c t s , " i n " D r i v i n g Down H e a l t h C a r e C o s t s , " e d . by
M a r t i N C e n s o r ( G r e e n v a l e , N.Y.: P a n e l P u b l i c a t i o n s , 1 3 8 3 )
a t 5-2.
( H e r e i n a F t e r , Stone)
546.
Stone,
547.
P a t r i c i a A. B a i r d , " G e n e t i c s S H e a l t h C a r e : C h a l l e n g e
a n d C h o i c e , " i n " D r i v i n g Down H e a l t h C a r e C o s t s , " e d . by
M a r t i n C e n s o r ( G r e e n v a l e , N.Y.: P a n e l Pub 1 i ceat i o n s , 1 3 8 3 )
a t 6-2.
(HereinaFter, Baird)
548.
Baird,
543.
I d . a t 6-2.
550 ,
U.S. C o n g r e s s , O F F i c e oF T e c h n o l o g y A s s e s s m e n t , " G e n e t i c
M o n i t o r i n g and S c r e e n i n g i n t h e W o r k p l a c e , "
(Washington,
D.C:
U.S. G o v t . P r i n t i n g O F F i c e , O c t o b e r , 1 9 3 0 ) p . 1 1 .
( H e r e i n a F t e r , OTA)
551.
J e a n E. McEwen, a s q u o t e d b y R o r i e S h e r m a n i n " E m p l o y e r
Use oF G e n e t i c T e s t s t o be R e s t r i c t e d ? " N a t i o n a l Law
J o u r n a l , Nov. 2 5 , 1 3 3 1 , a t 18, c o l . 1 . ( H e r e i n a F t e r ,
Sherman)
552.
OTA,
553.
I d . a t G.
554.
I d . at71.
555.
a t 505.
a t 6-4.
supra
note
5 5 0 , a t 5.
I d .
5 5 6.
I d .
a t 5.
Similar
quote
557.
Id.
a t 32.
558.
I d . a t 33.
559.
L. B. A n d r e w s a n d A. S. J a e g e r , " C o n F i d e n t i a l i t y oF
G e n e t i c I n F o r m a t i o n i n t h e W o r k p l a c e , " 27 A m e r i c a n
J o u r n a l oF Law £ M e d i c i n e 7 5 , 1 9 9 1 ( H e r e i n a F t e r , A J L S M ) .
560.
Id.
a t 32.
-220-
appears
a t p. 3 2 .
�5S1.
I d .
562.
I d . a t 83.
563.
I d . a t 82.
564.
OTA, s u p r a
555.
Id. at
566.
note
5 5 0 , a t 14.
12.
I d .
567.
Id.
558.
The O c c u p a t i o n a l
29 U.S.C. §650.
559.
AJLSM, s u p r a
570.
29 C.F.R. § 1 9 1 0 . 2 0 ( a ) ,
57 1.
AJLSM a t 9 8 .
572.
at
15.
SaFety
note
and H e a l t h
Act (Public
Law
91-595),
559, a t 96.
AJLSM
a t 98.
I d .
573.
E m p l o y e e R e t i r e m e n t I n c o m e S e c u r i t y A c t , 29 U.S.C. § 5 1 0 ,
as m e n t i o n e d i n S t o n e , s u p r a n o t e 5 4 5 , a t 5 - 6 .
574.
Stone,
575.
National
576.
OTA, s u p r a
577.
42 U.S.C.
573.
OTA, s u p r a
579.
Stone,
Annot.
580
Americans With D i s a b i l i t i e s
42 U.S.C. § 120 1 .
531.
OTA, s u p r a
532.
a t 5-6.
note
Relations
550, a t
A c t , 29 U.S.C. §151 e t s e q .
IS.
§2000e.
note
5 5 0 , a t 15.
s u p r a n o t e 5 4 5 , a t 5-7, q u o t i n g
§10:5-12a ( W e s t S u p p . 1 9 8 8 ) .
note
New J e r s e y
Act, Public
Id.
at
534.
Sherman,
5 5 0 , a t 16.
17.
supra
note
I d . a t 13, c o l .
55 1, a t 13, c o l s .
3.
-23 1 -
Stat.
Law 10 1-336,
I d .
533.
535
Labor
3, 4.
�586.
537.
538.
589.
Telephone
i n t e r v i e w , December
10, 1 9 9 1 .
Id.
Sherman,
supra
note
5 5 1 , a t 13, c o l . 1 .
Id.
590.
Baird,
supra
note
5 4 7 , a t 5-9.
591.
Areen,
supra
note
355, a t 295.
592.
Id.
393.
I d . a t 295.
594.
WilsFord,
595.
supra
note
2 1 , a t 25.
Id.
595.
R i c h a r d H a r r i s , "A S a c r e d T r u s t , "
B o o k s , I n c . , 1 9 S 9 ] , p. 1 .
59 7.
I d . a t 2.
598.
Id.
599.
Id.
500.
I d . at 1 .
501.
I d . a t 9.
502.
Id.
303
I d . a t 10.
504.
I d . a t 11.
505.
Id.
505.
I d . a t 13.
507.
I d . a t 14.
503.
I d . a t 15.
503.
I d . a t 16.
5 10.
Id.
5 11.
I d . a t 13, 17.
5 12.
I d . a t 17.
(Baltimore:
Penguin
�513.
Id.
at
18.
514.
Id.
at
32.
615.
Id.
at
33.
6 16.
Id.
at
34 .
617.
Id.
at
39.
618.
Id.
at
40.
619.
Id.
620.
Id.
at
50.
521 .
Id . at
51 .
622.
Id.
at
52.
623.
Id.
at
72,
624.
Id.
at
73.
625.
Id.
at
72.
625.
Id.
at
77.
527.
Id.
at
83.
528.
Id.
at
84.
529.
Id.
at
85.
630.
Id.
631 .
Id . at
109.
632.
Id.
at
113.
533.
Id.
at
134.
534.
Id.
at
125,
635.
Id.
at
14 1.
536.
Id.
at
79.
537.
Id.
at
SO.
538.
Id.
at
79.
539.
Id.
at
145.
73.
136
-23::-
�640.
I d . at
150.
541 .
I d . at
151 .
542.
I d . a t 153, 154,
Post column.
543.
I d . at
544.
Id.
545.
I d . at
545.
Id.
547.
I d . at
175.
548.
I d . at
180.
549.
I d . at
180.
550.
I d . at
181.
55 1.
I d . at
185.
552.
I d . at
187.
553.
I d . at
192.
654.
I d . at
209.
555.
I d . at
188.
656.
I d . a t 2 16.
657.
I d . at
553.
Id.
559.
J . 5. T o d d , S. V. S e e k i n s , J . A. K r i c h b a u m , L . K. H a r v e y ,
.
"HealthAccess
A m e r i c a - - 5 t r e n g t h e n i n g t h e U. 3. H e a l t h
CarE S y s t e m , "
J o u r n a l of the American Medical A s s o c i a t i o n
2 5 0 3 , May
15, 1 9 9 1 . ( H e r e i n a f t e r , T o d d )
560.
I d . at
55 1.
Id.
552.
D r . Thomas R e a r d o n , s p e a k i n g F o r t h e AMA
at the St.
M e t r o p o l i t a n M e d i c a l S o c i e t y F o r u m on t h e F u t u r e o f
H e a l t h C a r e , November 20,
1991.
553.
Todd,
quoting William
V.
Shannon's
New
York
170.
174.
217.
2504.
supra
note
659,
at
2503.
_p34-
Louis
�BS4.
B65.
Id.
I d . a t 2505.
BBS.
Id.
SB7.
Id.
SB8.
BBS.
P a u l J . F e l d s t e i n , " H e a l t h A s s o c i a t i o n s a n d t h e Demand
For L e g i s l a t i o n , " (Cambridge:
Ballinger Publishing
Company, 1 S 7 7 ) .
(HereinaFter, Feldstein)
B70.
I d . a t 4.
671 .
I d . a t 5.
B72.
I d . a t 9.
673.
I d . a t 10.
674.
t
5 . 1 2 2 7 Summary, a t B.
New Y o r k T i m e s , May 2 6 , 1 9 9 1 , L e t t e r t o t h e E d i t o r , by
O l i v e r A l a b a s t e r , M.D., D i r e c t o r o f t h e I n s t i t u t e f o r
Disease P r e v e n t i o n a t George Washington U n i v e r s i t y .
675.
Id.
676.
Id.
677.
Source
678.
T e l e p h o n e i n t e r v i e w w i t h K a t h y S u t t o n oF P h y s i c i a n s
C a r e , San A n t o n i o , T e x a s , D e c e m b e r 6, 1 9 9 1 .
579.
Bronow/JAMA, s u p r a
680.
I d . a t 25 13,
681.
S t . L o u i s M e t r o p o l i t a n M e d i c a l S o c i e t y F o r u m on t h e
F u t u r e oF h e a l t h C a r e , F r o n t e n a c , M i s s o u r i , N o v e m b e r
20 , 1 9 9 1 .
682.
Book, s u p r a
note
note
376, a t 47.
Who
501, a t 2511.
c o l . 2.
Id.
683.
684.
I d . a t 25 1 1 .
685.
t
Bronow/JAMA, s u p r a
I d . a t 2 5 1 3 , c o l . 2, a n d c o m m e n t s made a t t h e S t . L o u i s
M e t r o p o l i t a n M e d i c a l S o c i e t y Forum.
636.
note
5 0 1 , a t 2 5 1 2 , c o l . 3.
Id.
-235-
asss
�3
686a. I d .
587.
I d .
588.
I d . a t 2513,
683.
I d . a t 2 5 1 4 , c o l . 2.
690.
I d . a t 2 5 1 4 , c o l . 2.
691.
I d .
692.
2514.
I d .
693.
I d . a t c o l . 3.
594.
The New Y o r k T i m e s , N o v e m b e r 2 1 , 1 9 9 1 , L e t t e r t o t h e
E d i t o r by M i l o u
Erickson.
695.
S t a t e m e n t s made a t t h e S t . L o u i s M e t r o p o l i t a n M e d i c a l
S o c i e t y F o r u m on t h e F u t u r e o f H e a l t h C a r e , Nov. 2 0 , 1 9 9 1
696.
Robert Pear, "Federal A u d i t o r s
M e d i c a l B i l l i n g , " The New Y o r k
a t 018.
697.
I d . a t A 1 , c o l . 2.
698.
I d . a t C18, c o l . 1 .
699.
I d . a t C.18, c o l s .
700.
I d . a t C18, c o l . 1 .
70'1 .
I d . a t C18 , c o l s . 1 , 2 .
702.
I d . a t C18, c o l . 3.
703.
I d . a t C18, c o l . 4 .
704.
T h e o d o r e N. M c D o w e l l , J r . , " P h y s i c i a n S e l F
ReFerral
Arrangements: L e g i t i m a t e Business or Unethical
E n t r e p r e n e u r i a l i s m , " 15 A m e r i c a n J o u r n a l oF Law S
M e d i c i n e 6 1 , S p r i n g 1990.
705.
I d . a t 6 1 , n o t e 1 , q u o t i n g a r e p o r t From t h e O F F i c e oF
t h e I n s p e c t o r G e n e r a l , D e p a r t m e n t oF H e a l t h sand Human
S e r v i c e s , " F i n a n c i a l A r r a n g e m e n t s B e t w e e n Phy s i c i J:-. ..
.
_:,]-.' .'i_-oluii C u r e b u s i n e s s e s , " p p . i i i a n d 1 1 , May 1 9 8 9 .
706.
I d . a t 6 2 , n . 5.
5, 6.
-286-
HEHSS
R e p o r t R i s e i n Abuses i n
Times, December 2 0 , 1 9 9 1 ,
�707.
I d . at
B2, n. 7.
708.
I d . at
63 .
709 .
I d . at
62,
710 .
I d . at
61 .
711.
Id . at
107 .
712.
Id .
713 .
Id .
714.
S . 1 2 2 7 ,, Summary
715 .
Supra,
pp.
88 , 8
715.
Feldstein,
supra
717.
Id . at
133 .
718 .
I d . at
134.
719.
Id .
720 .
I d . at
721 .
Id .
722.
Id .
723 .
I d . at
136.
724 .
I d . at
137 .
725.
Exp
I d . a t 137.
i n s u r e r s , e s t a b l i s h e s p r e m i u m s b a s e d on t h e u t i l i z a t i o n
o f c a r e e x p e r i e n c e d by t h e p a r t i c u l a r g r o u p b e i n g i n s u r e d .
725.
I d . a t 138.
727.
I d . a t 139.
728.
n. 7.
135 .
Id.
729.
I d . a t 140.
730.
I d . a t 1 4 0 , r e g a r d i n g t h e U.S. C o n g r e G S , S e n a t e S p e c i a l
C o m m i t t e e on A g i n g , S u b c o m m i t t e e on H e a l t h oF t h e E l d e r l y ,
" B a r r i e r s t o H e a l t h C a r e F o r O l d e r A m e r i c a n s , P a r t 5,"
9 3 r d Cong., 1 s t s e s s . , J u l y 1 1 , 1973.
731.
Feldstein,
supra
note
6 6 9 , a t 140.
-237-
�732.
WilsFord,
supra
note
21,
a t 208,
209.
733.
I d . at
211.
734.
I d . at
209.
735.
Id.
735.
I d . at
737.
S t . L o u i s P o s t D i s p a t c h , "A H e a l t h y M a r k u p , " O c t o b e r
1 9 9 1 , a t 11D, F o l l o w i n g a L o s A n g e l e s T i m e s a r t i c l e .
738.
Id.
739.
Z a c h a r y S c h i l l e r , S u s a n G a r l a n d , and J u l i a S i l e r ,
Humana F l a p C o u l d Make A l l H o s p i t a l s F e e l
Sick,"
B u s i n e s s Week, Nov.
4, 1 9 9 1 , c o l s . 2, 3.
740.
Id.
741.
St.
742.
S.1227,
743.
D a n i e l M. Fox and D a n i e l C. S c h a F F e r , "Tax A d m i n i s t r a t i o n
as H e a l t h P o l i c y : H o s p i t a l s , t h e I n t e r n a l R e v e n u e S e r v i c e ,
a n d t h e C o u r t s , " 15 J o u r n a l oF H e a l t h , P o l i t i c s , P o l i c y S
Law 251 , Summer 1 9 9 1 .
744.
Id . at
745 .
I d . a t n . l . , r e g a r d i n g Rev. R u l . 5 9 - 5 4 5 , 1 9 6 9 - 2 C B .
117,
a l s o r e l e a s e d as t . I . R . 1022, d a t e d O c t o b e r 2 8 ,
1969.
745 .
Id . at
25 1 .
747 .
Id . at
251,
748 .
Id . at
252 .
749 .
I d . a t 2 6 1 , n. 2 0 , H e a r i n g s on Tax R e F o r m , 1969, P a r t I V ,
beF o r e t h e H o u s e C o m m i t t e e on Ways and M e a n s , 9 1 s t C o n g . ,
1 s t s e s s . 1425,
1438
(1969).
750 .
Id .
751 .
Id . at
164 .
752 .
Id . at
262,
753 .
Id . at
263 .
754 .
I d . a t 25 3 and
We 1 F a r e R i g h t s
211.
Louis
Post
§441,
Dispatch,
and
Summary
at
11D,
at
col.
20,
"The
3.
11.
437 .
252
n.3.,
Rev.
Rul.
56-185,
1956-1
CB.
202.
253.
n.S,
r e g a r d i ng S i m o n v. E a s t e r n K e n t u c k y
O r q a n i z a t i o n , 425 U.S.
26 ( 1 ^ 7 5 )
�755.
I d . a t 253 and n.7, r e g a r d i n g C o n s o l i d a t e d Omnibus B u d g e t
R e c o n c i l i a t i o n A c t of. 1 9 8 5 , P u b . L. 9 9 - 2 7 2 , 100 S t a t . 8 2 ,
164 ( 1 9 8 6 ) , 42 U.S.C. §1395dd.
755.
The C o n s o l i d a t e d Omnibus Budget R e c o n c i l i a t i o n A c t o f
1 9 8 5 , P u b . L. No. 9 9 - 2 7 2 § 9 1 2 1 , 100 S t a t . 164 ( 1 9 8 6 ) , a s
s t a t e d by D a v i d R a n d o l p h S m i t h , " M e d i c i n e a n d Law: A I D s ,
C o n s t i t u t i o n a l C h a l l e n g e s t o T o r t Reform and Medical
M a l p r a c t i c e , " 23 T o r t S I n s u r a n c e Law J o u r n a l 3 7 0 , 4 0 2 ,
n. 2 1 0 , W i n t e r 1 9 8 8 .
757.
Id . at
4 0 3 , and
758 .
Id . at
404 .
759.
Id . at
403 .
760 .
Id . at
403 , n . 2 1 2 ,
761 .
Id . at
4D3 , n . 2 1 2 .
762 .
I d . a t 404 , n . 2 2 4 ,
Law Pr o g r a m
753.
Schmidt, Heckert, and Mercer, " F a c t o r s A s s o c i a t e d With
Medical M a l p r a c t i c e : Results from a P i l o t
Study,"
7 J o u r n a l o f C o n t e m p o r a r y H e a l t h Law a n d P o l i c y 1 5 7 ,
Spring
1991.
764.
I d . , q u o t i n g P. D a n s o n , " T h e F r e q u e n c y
Medical Malpractice Claims," 7 Journal
H e a l t h Law a n d P o l i c y 1 5 8 , n . 7.
765.
Comments made a t G r o u p H e a l t h I n s u r a n c e f o r u m
Care R e f o r m , June 1991, S t . L o u i s , M i s s o u r i .
765.
C. E v e r e t t K o o p , c o m m e n t s J u n e
on h e a l t h c a r e r e f o r m .
767.
S.1227 §906, 42 U.S.C. 2 9 9 e t s e q .
768.
S.1227,
769.
Source
770.
I d . a t 256.
771.
5.1227
772.
S.1227 " 4 4 2 ( a ) .
773.
S.1227 §451,
Service Act,
n .2 1 2 .
42
U . S C. §291 ( 1982 ) .
Judith
Waxman o f t h e N a t i o n a l
and S e v e r i t y o f
o f Contemporary
30, 1991,
on H e a l t h
NBC TV p r o g r a m
"90S(a).
Book, s u p r a
note
375,
a t 47.
§442(a)(b).
which
Title
w i l l be §2785(a) o f t h e P u b l i c
XXVII.
-289-
Health
�774.
S.1227
§27B5Co)(3)[•).
775.
S.1227
§2785(a)(4).
776.
S. 1227
777.
§2785(d) .
Id.
778.
S t a t e m e n t made by L a n e K i r k l a n d , AFL-CIO P r e s i d e n t ;
A F L - C I O D e p a r t m e n t o f I n F o r m a t i o n S t a t e m e n t on H e a l t h
C a r e ReForm, F e b r u a r y
19, 1 9 9 1 .
779.
AFL-CIO E x e c u t i v e C o u n c i l H e a l t h Care S u b s t i t u t e
R e s o l u t i o n No.2, Book Dne, p a g e 1 .
Undated, but
p r o b a b l y F e b . 19, 1 9 9 1 .
780.
J a c k S h e i n k m a n , "How t o S o l v e t h e H e a l t h C a r e C r i s i s , "
The New Y o r k T i m e s , J u l y 2 8 , 1 9 9 1 , Op-Ed c o l u m n .
Jack
S h e i n k m a n i s P r e s i d e n t oF t h e A m a l g a m a t e d C l o t h i n g a n d
T e x t i l e Workers Union.
[ H e r e i n a F t e r , Sheinkman)
781.
Id.
782.
A p a r t i a l l i s t i n g oF l e g i s l a t i v e g o a l s s o u g h t by t h e
A F L - C I O , a c c o r d i n g t o t h e S t a t e m e n t by t h e AFL-CIO
E x e c u t i v e C o u n c i l on N a t i o n a l H e a l t h C a r e R e F o r m ,
February
19, 1 9 9 1 , p . 2.
783.
AFL-CIO D e p a r t m e n t o f I n F o r m a t i o n
R e F o r m , F e b . '19, 1 9 9 1 .
784.
Sheinkman,
785.
supra
note
State
on H e a l t h
Care
780, a t
Id.
785.
David Warner, "Costs Rise For Medical P l a n s , "
Nation's
B u s i n e s s , A p r i l 1 9 9 1 , a t 32.
D a t a p r o v i d e d by A. F o s t e r
H i g g i n s S Company, a n d u t i l i z e d by D a v i d W a r n e r .
787.
Id.
788.
S t u a r t M. B u t l e r , " P l a y o r Pay H e a l t h C a r e P l a n i s
B o u n d t o be a L o s e r , " W a l l S t r e e t J o u r n a l , J a n . 3. 1 9 9 2 ,
a t A6, c o l . 3., r e F e r r i n g t o a H a y / H u g g i n s S Company
estimate.
Hay/Huggins i s a beneFits c o n s u l t i n g Firm.
(HereinaFter, Butler)
789.
Butler,
790.
791.
•
c o l . 5.
Id.
Susan
Isn't
B. G a r l a n d , "AL.-JM..:,, ^ : ^ • • i n - . r ' H e a l t h P l a n
F e e l i n g So H o t , " B u s i n e s s Week, Nov. 16, 1 9 9 1 , a t 43
-290-
�792.
793.
794.
I d .
David Warner, " T a c t i c s For C u t t i n g
B u s i n e s s , A p r i l 1 9 9 1 , p. 33.
Costs,"
Nation's
I d .
795.
I d . a t 200.
79B.
Blumenthal,
797.
C o n g r e s s i o n a l Budget OFFice, " S e l e c t e d O p t i o n s f o r
Expanding H e a l t h I n s u r a n c e Coverage," J u l y 1991, PreFace.
798.
I d . at xi i i.
799.
I d . a t xx.
800.
Id. at xxi .
801.
S.700, s u p r a a t
802.
R. A. Z a l d i v e r , " C l e v e l a n d S m a l l B u s i n e s s G r o u p F i n d s
T h e r e ' s S t r e n g t h a n d S a v i n g s i n N u m b e r s , " The J o u r n a l o f
C o m m e r c e , May 2 2 , 1 9 9 1 , a t 9A .
(Hereinafter, Zaldiver)
803.
N a n c y L. J o h n s o n
HeALth I n s u r a n c e
804.
note
2 0 9 , a t 198.
( R - C t . ) Summary o f t h e " S m a l l E m p l o y e r
I n c e n t i v e Act of 1991" (undated).
I d .
805.
supra
I d .
80G.
Zaldiver,
supra
note
807.
S h e l l e y Neumeier, "Companies
Nov. 4, 1 9 9 1 , a t 1 0 2 .
808.
A m e r i c a n B a r A s s o c i a t i o n s e c t i o n on A n t i t r u s t
" I n f o r m a l A n t i t r u s t E n f o r c e m e n t Agency A d v i c e
C a r e , " 1 9 9 1 . ( H e r e i n a f t e r ABA/AL).
809.
ABA/AL, D e p a r t m e n t o f J u s t i c e b u s i n e s s r e v i e w l e t t e r t o
t h e M a r y l a n d H e a l t h C a r e C o a l i t i o n , F e b r u a r y 19, 1982 a t 3 1
810.
ABA/AL, D e p a r t m e n t o f J u s t i c s b u s i n e s s r e v i e w l e t t e r t o
t h e S o u t h w e s t M i c h i g a n H e a l t h S y s t e m s , I n c . , M a r c h 3, 1 9 8 2 ,
p. 3 2 .
811.
ABA/AL, D e p a r t m e n t o f J u s t i c s b u s i n e s s r e v i e w l e t t e r t o t h e
S t a r k County H e a l t h Care C o a l i t i o n , August 30, 1985, p.38.
812.
Mary
F. C a l l a n a n d D a v i d
Care
Cost
Spiral,"
802, a t
C. Y e a g e r ,
(New Y o r k :
-291-
•KM&aes..
waSiiS*-
t o Watch," F o r t u n e
Magazine
Law,
on H e a l t h
"Containing the Health
McGraw-Hill,
1991),
p. 7.
�813,
Bronow/JAMA
814 ,
Employee R e t i r e m e n t
Income S e c u r i t y A c t (E.R.I.S.A.,
29 U.S.C. §1001-1451 ( 1 9 8 2 ) .
815 ,
Bronow/JAMA
81G ,
Id . a t cols.
817,
29 U.S.C. § 1 1 4 4 ( a ) , 1 9 7 5 , a n d Comment, " F e d e r a l
Preemption
oF S t a t e M a n d a t e d H e a l t h I n s u r a n c e P r o g r a m s U n d e r ERISA-t h e H a w a i i P r e p a i d H e a l t h Care A c t i n P e r s p e c t i v e , "
8 S t . L o u i s U n i v e r s i t y P u b l i c Law R e v i e w 3 3 9 ( 1 9 8 9 ) .
818 ,
Id.
819,
S.1227,
820,
§2732(a)(1).
821 ,
§2732(b).
822 ,
S.1227 §2741(b)(9).
The b i l l s t a t e s : "The amount o f any
c i v i l money p e n a l t y i m p o s e d . . . s h a l 1 n o t e x c e e d $ 2 5 , 0 0 0
For each c a r r i e r w i t h r e s p e c t t o w h i c h a v i o l a t i o n
occurs.
823 ,
S. 1227
824.
§2741(b)(9), p . 5 9 .
825 .
Thomas R e a r d o n , M.O., c o m m e n t i n g o n t h e AMA n a t i o n a l
h e a l t h r e F o r m p l a n a n d i t s p o s s i b i l i t y oF a c c e p t a n c e a s
t h e c h o s e n p l a n , a t a F o r u m on t h e F u t u r e oF H e a l t h C a r e
s p o n s o r e d by t h e S t . L o u i s M e t r o p o l i t a n M e d i c a l
Society,
Frontenac,
M i s s o u r i , Nov. 2 0 , 1 9 9 1 .
825
CaliFano,
827 ,
P r e s i d e n t L y n d o n B. J o h n s o n ' s
J a n u a r y 4, 1 9 5 5 .
828
" H e a l t h y P e o p l e 2 0 0 0 -- N a t i o n a l H e a l t h P r o m o t i o n a n d
D i s e a s e P r e v e n t i o n O b j e c t i v e s , " U.S. D e p a r t m e n t oF H e a l t h
a n d Human S e r v i c e s , P u b l i c H e a l t h S e r v i c e ( 1 9 9 0 ) , p . 8 5 .
( H e r e i n a F t e r , HHS)
829 ,
HHS , s t a t e m e n t
For H e a l t h .
830 ,
S t u a r t A. W e s b u r y , J r . , "Why O t h e r N a t i o n s '
W o r k , " The W a s h i n g t o n P o s t , M a r c h 18, 1 9 9 0 ,
831
Id .
a t 342,
supra
supra
note
note
501,
501,
a t 2511.
a t 2513,
c o l . 2.
1 , 2.
n. 19.
§2732(a) a n d ( b ) , p.
§2741 ( b ) ( 4 ) ,
supra
note
61.
p.57.
25,
at
State
oF t h e U n i o n
b y D r . James 0. M a s o n , A s s i s t a n t
-292-
Message,
Secretary
Rx Won't
a t B1, c o l . 3 .
�832. I d .
833. I d .
834.
Marshall
National
J . B r e g e r , " L a w y e r s M u s t L e a d t h e Way,"
Law J o u r n a l , N o v . 1 8 , 1 9 9 1 , p . 1 6 , c o l . 3.
835. I d .
836.
I d . , a t 1 6 , c o l . 2.
837.
National
Law J o u r n a l
Editorial,
August
1 2 , 1 9 9 1 , a t 16.
838. I d .
839.
S.1227 " 2 7 6 1 .
84D.
S.1227
§2762.
841.
S.1227
§2764.
842.
S.1227
§2763.
843.
W i l s F o r d , supra note 2 1 , a t 84, q u o t i n g Jacques Beaupere,
P r e s i d e n t , C o n f e d e r a t i o n des S y n d i c a t s Medicaux F r a n c a i s ,
L e C o n c o u r s M e d i c a l , 1 0 8 - 4 0 , Nov. 15, 1 9 8 6 , r e g a r d i n g t h e
d i s s e n s i o n between s p e c i a l t i e s i n t h e French medical
proFession.
844.
WilsFord,
845.
I d . a t 89.
846.
R o b e r t P e a r , " D e F i c i t o r No D e F i c i t , U n l i k e l y A l l i e s
B r i n g A b o u t E x p a n s i o n i n M e d i c a i d , " The New Y o r k T i m e s ,
Nov. 4, 1 9 9 0 , p . 1 .
a t 86.
847. I d .
848.
I d . a t 14, c o l . 1.
849. I d .
850.
Common C a u s e
'Circulation
Letter'
85t.
Common C a u s e M a g a z i n e ,
852.
Common C a u s e c i r c u l a t i o n
853.
I d . a t 3.
854.
M a r k S h i e l d s , c o m m e n t made on M c N e i l L e h r e r
T e l e v i s i o n , Oct. 25, 1991.
July/August
Oct. 22,
1991.
1991, a t 43, 44.
letter.
-293-
Report,
PBS
�855.
M a r k T w a i n [ S a m u e l L. C l e m e n s ) , " A F t e r D i n n e r S p e e c h , "
S k e t c h e s , New a n d O l d [ v o l . 19 o f t h e W r i t i n g s o f Mark
T w a i n ) , p.235 [ 1 8 7 5 ) , as s t a t e d i n " R e s p e c t F u l 1 y Q u o t e d , "
e d . , Suzy P i a t t , C o n g r e s s i o n a l R e f e r e n c e
Division
( W a s h i n g t o n , D.C: U.S. G o v t . P r i n t i n g O f f i c e , L i b r a r y o f
C o n g r e s s ) 1989.
856.
no
857.
Wilsford,
858.
G e r a l d E. F r u g , " T h e C i t y a s a L e g a l
Law R e v i e w 1 0 5 9 , 1 0 7 0 , A p r i l 1 9 8 0 .
Concept,"
859.
G e o r g e S. M i t r o v i c h , " P u b l i c F u n d i n g
and t h e P o l i t i c s o f B e t r a y a l , " V i t a l
May 1 , 1 9 9 1 , p . 4 3 5 , 4 3 6 .
o f E l e c t i o n s ; Money
S p e e c h e s o f t h e Day,
860.
supra
note
2 1 , a t 98.
93 H a r v a r d
I d .
861.
856...misnumbered.
I d .
862.
D o l l a r f i g u r e s f r o m p.436 o f M i t r o v i c h ' s speech;
f i g u r e s f r o m W o r l d A l m a n a c o f U.S. P o l i t i c s (New
S c r i p p s Howard, 1991).
863.
Mitrovich,
864.
supra
note
Percentage
York:
859, a t 436.
I d .
865.
I n n u m e r o u s TV i n t e r v i e w s
866.
Mitrovich,
867.
I d . a t 438.
868.
by M i t r o v i c h ,
p.
a t 436.
I d .
869.
and q u o t e d
I d .
870.
L a w r e n c e 0. B r o w n , " T h e D e c o n s t r u c t e d C e n t e r : Of P o l i c y
P l a g u e s c n P o l i t i c a l H o u s e s , " 15 J o u r n a l o f H e a l t h P o l i t i c s ,
P o l i c y a n d Law 4 2 7 , Summer 1 9 9 0 .
871.
I d .
872.
I d .
873.
L a w r e n c e D. B r o w n , " T h e M e d i c a l l y U n i n s u r e d :
P o l i c i e s , a n d P o 1 i t i c s , " 15 J o u r n a l oF H e a l t h
P o l i c y a n d Law 4 1 3 , 4 1 5 , Summer 1 9 9 0 .
874.
CaliFano,
supra
note
2 5 , a t 185.
-294-
Problems,'
Politics,
�POLITICAL POWER STRUCTURES AFFECTING
ANY
NATIONAL HEALTH CARE REFORM PLAN
HEALTH CARE REFORM CONCEPTS
versus
SOCIAL AND ECONOMIC VALUES
Synopsis
The
l a w a f f e c t s and i s a f f e c t e d by s o c i e t y
that society
thinks, believes
and e v e r y t h i n g
and a c c o m p l i s h e s .
T h i s r e s e a r c h paper c o n s i d e r s power s t r u c t u r e s t h a t
a f f e c t reForm o f o u r h e a l t h
project
i st o provide
a reform
First
care system.
a p a n o r a m i c view o f t h e p o s s i b i l i t i e s
Providers
needs o f p a t i e n t s , and t h e i r
of individuals.
structure
of the health
or m u t u a l
insurers
it
will
for
and i n s u r e r s e x i s t because o f t h e
profits
insurance industry
a f f e c t n o t only
plan
that health i s
i s t o transform
or public health
health reform
s h o u l d be s e c o n d a r y t o t h e
One way o f a s s u r i n g
v a l u e d ahead o f i n s u r e r p r o f i t s
Any
The p u r p o s e o f t h e
p r o g r a m w h i c h aims t o b e n e f i t t h e c o n s u m e r / p a t i e n t
and f o r e m o s t .
health
will
will
the organizational
into either non-profits
insurance u t i l i t y
be p o l i t i c a l l y
volatile
t h e b o t t o m l i n e F o r many
and
organizations,
but also
and
economic s e c u r i t y w i l l
their
companies.
because
corporations
spheres o f i n f l u e n c e .
n o t be e a s i l y r e l i n q u i s h e d .
Power
The p l a n
of c h o i c e w i l l
have t o b a l a n c e t h e i n t e r e s t s o f t h e s e
while
t h e primary goals o f providing s u f f i c i e n t q u a l i t y
health
assuring
c a r e f o r an e n t i r e p o p u l a t i o n
a t reasonable
factions
cost.
�-2-
Reconsideration
activity
i n p o l i c y Formulation.
the a F F e c t s
clearer
of the s t a t u s quo
will
spur major
U n d e r s t a n d i n g and
of the v a r i o u s power s t r u c t u r e s w i l l
view of the soundness and
Congressional
attempts at h e a l t h care reform.
p l a y e r s i n the p r o c e s s
will
Insurance
acknowledging
provide
a
of
The
primary
be:
F e d e r a l , S t a t e , and
the
justifiability
political
L o c a l Governments
industry
the American M e d i c a l
the American H o s p i t a l
the American Bar
Association
Association
Association
Labor Unions
E m p l o y e r s , both l a r g e and
small
Consumers, the r e c i p i e n t s of h e a l t h
Much has
been s a i d about the Canadian p l a n and
Play-or-Pay plans.
plan w i l l
more and
Few
people r e c o g n i z e
t h a t the
the
American
Play-or-Pay
become, by d e f a u l t , an A m e r i c a n i z e d C a n a d i a n p l a n when
more employers e l e c t to pay
t h e i r employees.
i n the h e a l t h and
system s h o u l d
the government to
E v e n t u a l l y , the government w i l l
major i n s u r e r i n the U n i t e d
to e x i s t
care.
S t a t e s , and
insurance
a l w a y s be encouraged.
industries.
to be r e q u i r e d ,
imperatives,
The
A Free
cease
market
However, i n c o n s i d e r i n g
insurance
individuals.
become the
a F r e e market w i l l
perFormance of the p a s t decade, the
through l e g i s l a t i v e
insure
i n d u s t r y may
u n u s u a l c o n c e p t of s t r u c t u r a l
the
have
to i n s u r e a l l
transFormation
�-3oF the h e a l t h i n s u r a n c e
Utility
Company
pervasive
and
into a Public Health
be the most v i a b l e s o l u t i o n to
Insurance
the
problems oF p o l i c y c a n c e l l a t i o n of h i g h - r i s k p a t i e n t s
exorbitant
restricted
may
industry
insurance
rates.
to s u b s i d i z a t i o n oF
Insurers•
established.
A two-tiered
The
governmental r o l e s h o u l d
insurance
health
premiums For the
insurance
I n s u r e r s would be r e q u i r e d
poor.
program s h o u l d
to p r o v i d e
be
be
the
l e g i s l a t i v e l y - e s t a b l i s h e d BASIC p l a n a t a community r a t e to
every
person applying
negotiated
Federal
annually
insurance
providers,
with
For c o v e r a g e .
by a F e d e r a l
administrator,
community r a t e would
insurance
The
r e p r e s e n t a t i v e s oF
second t i e r
i n s u r e r s and
of h e a l t h
majority
insurance
a d d i t i o n a l coverage, l a r g e l y unregulated,
and
p r i c e d a t p r e v a i l i n g market r a t e s .
E m p l o y e r s would no
c o v e r a g e , but
provide
would merely a d m i n i s t e r
Employers s h o u l d
business.
longer
not be r e q u i r e d
to be
A l t e r i n g t h i s long-standing
complete p o r t a b i l i t y oF h e a l t h
health
i n the
i n d i v i d u a l s to p u r c h a s e t h e i r own
oF
claims.
insurance
p r a c t i c e would
coverage so
i n d i v i d u a l s would be F r e e to move From one
w i t h o u t F e a r oF l o s s oF c o v e r a g e .
insurance
the F i l i n g
insurance
provide
that
employer to another
Additionally,
permitting
coverage would e l i m i n a t e
the
c u r r e n t e x i s t e n c e oF c o n t r a c t s oF a d h e s i o n to which a l l
employees a r e s u b j e c t .
Attorneys
must be h e l d to a h i g h e r
be
board, composed oF a
consumer r e p r e s e n t a t i v e s c o m p r i s i n g the
of the board membership.
would p r o v i d e
The
ethical
standard
where
�-4medical
m a l p r a c t i c e c l a i m s are concerned.
They must
discourage
l a w s u i t s F o r i n j u r i e s which o c c u r through mere h a p p e n s t a n c e ,
w i t h no
wrongdoing having
been committed by the p h y s i c i a n .
However, where p r o v i d e r wrongdoing has o c c u r r e d ,
caps s h o u l d
not
r e d u c e awards to l e s s than the amounts n e c e s s a r y
to c a r e For
the
plaintiFF
For h i s l i F e t i m e , i n a d d i t i o n to compensation For
of r e a s o n a b l e
p o t e n t i a l income.
P r o v i d e r s who
substandard
loss
a r e known w i t h i n the community to p r a c t i c e
m e d i c i n e must e x p e r i e n c e
the very r e a l p r o b a b i l i t y
oF temporary or permanent l i m i t a t i o n , s u s p e n s i o n ,
oF the l i c e n s e to p r a c t i c e m e d i c i n e .
A s s o c i a t i o n has h i s t o r i c a l l y
The
or r e v o c a t i o n
American
protected substandard
Medical
physicians.
By doing s o , i t has c o n t r i b u t e d to the m a l p r a c t i c e morass to
same e x t e n t as have greedy a t t o r n e y s .
The
A.M.A. has done a
g r e a t d i s s e r v i c e to t h a t m a j o r i t y oF i t s membership who
knowledgeable and
the
are
capable p r o f e s s i o n a l s .
Consumers/Patients.
An
a s p e c t oF reForm which has not
been
adequately
( i f ever] considered
i s t h a t the e n t i r e
population
be c o n s i d e r e d
i n s u r a b l e group For the BASIC
insurance coverage.
legislation
medical
as one
Because one
oF the c u r r e n t g o a l s oF pending
i s t h a t everyone w i l l
p l a n , each
component oF one
person
should
be
i n s u r e d under a BASIC
be c o n s i d e r e d
as an
individual
n a t i o n a l group, w i t h the burdens oF h i g h - r i s k
i n d i v i d u a l s borne by the e n t i r e n a t i o n a l group.
must be a v a i l a b l e For a l l .
i n d i v i d u a l s and
U.S.
The
poor and
F a m i l i e s would p u r c h a s e
lower-
Preventive
care
to middle-income
i n s u r a n c e For
preventive
�-5c a r a , w i t h government s u b s i d i e s a c c o r d i n g to
necessity.
I n d i v i d u a l s who
For t h e i r own
subsidies.
are F i n a n c i a l l y
h e a l t h care should
Financial
capable
oF
providing
not r e c e i v e government
Upper income i n d i v i d u a l s and
F a m i l i e s would
BASIC i n s u r a n c e For p r e v e n t i v e c a r e , but w i t h a h i g h
purchase
deductible
and/or copayment.
A n a t i o n a l health care plan w i l l
will
and
by
be d i F F i c u l t
to Formulate
be t e c h n i c a l l y
to a v o i d c o n F l i c t i n g
must be F i s c a l l y r e s p o n s i b l e .
Fiscal
complex,
criteria,
viability
can be
aided
l e g i s l a t i o n which would a l t e r some o r g a n i z a t i o n a l power
s t r u c t u r e s and
i n t e r n a l revenue r e g u l a t i o n s .
changes, s o c i e t a l
expectations concerning
e v o l v e to a broader
broader
understanding
understanding
may
Through t h e s e
h e a l t h c a r e may
oF the "whole p i c t u r e . "
provide
For a l l t h o s e
enable
responsibility will
oF our s o c i e t a l
t h e n a t i o n to p r o v i d e
i n and
v a l u e oF
Financial
health care
personal
reap p o s i t i v e change a c r o s s the e n t i r e g r a i n
Fabric.
Note the s i m p l i F i e d view
oF the c u r r e n t m e d i c a l
m a l p r a c t i c e problem and
of i t s domino e F F e c t .
Consider,
to t h i s s i t u a t i o n
(listed
the
i F a l l concerned
below)
consequences
then, the p l e a s a n t
alternative
would e x e r c i s e p e r s o n a l
r e s p o n s i b i l i t y For t h e i r a c t i o n s toward o t h e r s .
legislative
those
i n need.
I n c r e a s i n g the b e l i e F
v a l u e system,
This
i n d i v i d u a l s with a s u F F i c i e n t
enough background to encourage them to undertake
o b l i g a t i o n s which w i l l
also
Absent such a
the only v i a b l e a l t e r n a t i v e would be to i n c r e a s e
imperatives.
Consider
now
the F o l l o w i n g
continuum:
�-6-
P r a c t i o i n g medicine d e s p i t e
and/or s k i l l
i n s u f f i c i e n t m e d i c a l knowledge
l e v e l s i s e v i d e n c e of a l a c k of
personal
r e s p o n s i b i l i t y on the p a r t of the t r e a t i n g p h y s i c i a n
leads
and
to
N e g l i g e n t p r a c t i c e of m e d i c i n e , which
leads
to
Malpractice
society,
overly-litigious
which
leads
The
l a w s u i t s , i n c r e a s e d by an
to
p r a c t i c e of defensive medicine
by a l l p r o v i d e r s ,
which
leads t o
Higher h e a l t h care c o s t s , which
leads
to
I n s u r e r s and
H o s p i t a l s imposing U t i l i z a t i o n Review (a
p o l i t i c a l l y - c o r r e c t term f o r r a t i o n i n g of h e a l t h c a r e ) which
leads
to
I n s u r e r s r e f u s i n g to pay
f o r c a r e and,
possibly,
the
c a n c e l l a t i o n of a p o l i c y , which
leads
to
P a t i e n t s b e i n g r e q u i r e d t o pay
may
be e s s e n t i a l t o t h e i r
unable
t o pay
care.
The
lead
o u t - o f - p o c k e t f o r care
future health.
o u t - o f - p o c k e t , he may
I f the patient i s
not r e c e i v e the necessary
l a c k of adequate h e a l t h care
may
to
A d i m i n i s h i n g state of h e a l t h f o r the
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that
p r a c t i c e of u t i l i z a t i o n
nation!
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adversely
affecting patients.
the d e t r i m e n t a l
Thus, p a t i e n t s a r e
t h e i r own
bodily health care.
of the W i c k l i n e
(starting
on page 149
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experiencing
r i p p i n g away of t h e i r r i g h t to make autonomous
d e c i s i o n s concerning
provide
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i n s i g h t to t h i s now-pervasive
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activity.
I t r e m a i n s to be seen whether the N a t i o n ' s s o c i a l
system w i l l
d r i v e the economic c o n s i d e r a t i o n s of h e a l t h
r e f o r m , or v i c e v e r s a .
E l i s s a Ornato Delaney
14779 Chermoore D r i v e
C h e s t e r f i e l d , MO.
B3017
(314)
391-8488
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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] [3]
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
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
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-Seg3-038-002-2015
12092971