hopeful Bill Bradley has placed health care reform on the national agenda as
well it should be. However, the Bradley plan does not go far enough to resolve
real need and it protects the insurance industry – the very culprit which is
undermining access to quality health care in the nation.
"universal" health care reform plan would abolish Medicaid and use
Medicaid plus budget surplus funds to provide subsidies to 95% of the 43 million
uninsured Americans so they could join (with little or no premiums) the Federal
Government’s employee health insurance system or utilize tax credits to buy
private insurance. Bradley rationalizes his blueprint will "let the market
do what it does best and government do what it does best."
is a mystery to this writer what the market has done best. Health care in the
U.S. is a trillion dollar industry. It is obliviously driven by profit motives,
not social responsibility. Could this be more pronounced than in the
market-heightened HMO/giant health care conglomerate era of today? Columbia/HCA
executives, for instance, were recently convicted of intentionally defrauding
Medicare of millions of dollars after a run of soaring profits on Wall Street.
Humana Inc. and Aetna/US Healthcare face class action lawsuits alleging, amongst
other things, that they pay doctors for withholding costly treatments and offer
them other financial incentives to diminish the cost of the care the companies
I want to focus on how the private system does least by those who utilize health
care the most.
medical insurance game is played like this: the industry first studies data and
calculates rates that will assure profits. It then "cherry picks" by
denying insurance to bad risks. A 1996 study, for example, revealed that 47% of
those insurance applicants who had been screened for "defects" were
denied health insurance. Another way insurers turn risky subscribers away is by
limiting their obligations through underwriting practices. They may insert
pre-existing condition clauses which disallow treatment for periods of time.
They may limit coverage so that specific treatments, drugs, or medical equipment
are not included. They may cap benefits or they may charge exorbitant premiums
for those with a history of a disabling condition.
paraplegic’s premium, for example, was $750 per month. Others have reported
premiums as high as $1,100. Such rates are not affordable for most working
people and they discourage employers, who do not want to see insurers jack up
their premiums, from hiring or retaining disabled workers.)
nondisabled people, those diagnosed with conditions such as diabetes or asthma,
cannot go without treatment for six months or one year. Restrictions placed on
benefits coupled with high premiums mean that those who experience disablement
from birth or acquire one later in life may be forced to apply for health care
from a public program like Medicare and/or be reduced to penury to qualify for
market forces have shifted people needing ongoing health services onto the
public health care system by out pricing, undercovering, or denying essential
care for periods of time. Indeed the government stepped in to provide Medicare
and Medicaid to serve those segments of the population the private system
squeezes out: seniors and those under sixty five who are disabled from birth or
acquire a disability later in life.
systemic underwriting practices which leave many "uninsurables" out of
the private insurance loop are meant to shift the burden of cost onto
government. They assure that "non-profitable" people will not narrow
the profit margins of health corporations. In a display of such intent, the
business lobby fought for and won passage of a law, (USC 42 1395 y (b), which
allows private insurers (and employers) to rid themselves of their disabled
retirees by dumping them onto Medicare.
the Managed Care Era, "cherry picking" has taken a more insidious
form. Ever wonder why HMO advertising leaves out images of disabled people?
Advertising and promotions meant to attract Medicare beneficiaries mainly target
healthy senior citizens and leave out younger disabled people who are eligible
to join. This is because "cost containment," the managed care mantra,
has led to a payment paradigm shift. Hospitals and doctors no longer get paid
for individual services rendered (fee-for-service), they get paid a flat fee as
they would if medicine were socialized. However, unlike a socialization
scenario, there are financial incentives for physicians and hospitals to keep
costs low. As a consequence of market forces shifting the payment and delivery
system from fee-for-service to managed care, those needing the most health care
are no longer perceived as an asset (bringing more money in), they are seen as a
liability (draining the profits).
brief history of Medicare HMOs offers an example of how cherry picking and HMO
business structures result in a disastrous combination for those utilizing the
health care system the most. HMOs’ desire to sign up only those who would cost
them the least to care for clashed with federal Medicare contracts because the
government held the HMOs to enrolling ANY Medicare beneficiary wanting to
subscribe. But gatekeeper physicians and administrators found other ways to get
more costly subscribers out. Studies by the General Accounting Office(GAO), for
example, show that one out of every 5 Medicare HMOs had disenrollment rates
above 20%. Further, the GAO found "the rates of early disenrollment from
HMOs to fee for service were substantially higher among those with chronic
conditions." Why? The GAO (and other studies) found that most subscribers
left HMOs due to "problems receiving medical treatment." Medicare
beneficiaries found it necessary to revert to fee for service for vital care.
The upshot — subscribers most needing services were forced out of HMOs by
denial of care.
the end, several large HMOs abandoned the Medicare population and did renew
their Medicare contracts. They dumped 400,000 Medicare beneficiaries in 22
states off their plans.
managed care encroaches upon public health care, corporate bottom lines have
come to dominate the entire health care delivery system, both public and
private. In most states, fee-for-service Medicaid is being replaced with HMO
contracts. But government, so far, does not mandate enrollment of the disabled
population into Medicaid HMOs because studies reveal systemic problems with
disabled people getting the care they need. There are problems, for example,
with HMOs inability (or unwillingness) to provide high level individualized care
for "nonstandard" subscribers who are blind, deaf, developmentally
disabled, mobility impaired or require psychiatric support. Pwds may have
conditions which require treatment beyond gatekeeper physicians’ training, yet
often HMOs do not make access to specialists easy or possible at all, nor do all
HMOs retain the specialists some pwds require. In addition, pwds may not be
"curable" but still require modes of care in order to maintain optimal
functioning and quality of life which go against the HMO grain to save money by
rationing care. And, HMOs tend to trim rehabilitation services which often
routes pwds, unnecessarily, into nursing homes.
Bradley’s reformed system would wipe out Medicaid fee-for-service and throw the
disabled population onto the private HMO system that does not want them.
plan does not square off against the real problems the market juggernaut erects:
cherry picking, underwriting practices which restrict benefit packages, HMOs’
outright denial of care, restricted access to specialists and lack of personal
assistance services (now available through Medicaid in some states). Bradley’s
plan does not address the possibility that employers will dump coverage and that
premiums will rise left under the auspices of a private market.
to the World Institute on Disability, the vast majority, or 80% of the
population, will experience some form of disablement in their lifetimes- either
permanent or temporary. Genetic screening forebodes that in the future most, if
not all, will be subjected to health insurers’ scrutiny. It behooves us to
assure that all people get the care they require when they need it.
its ideological opposition to collectivism, the private health insurance
juggernaut has done its best to force government to subsidize (collectivize)
their risks. The budget surplus could be put to a more complete and satisfactory
use. Why not be sensible this go-round and jilt the unworkable market system? A
universal single payer system — if designed to be disability sensitive — could
go a long way to close gaps inherent to the private market place.
Marta Russell author Los Angeles, CA
Beyond Ramps: Disability at the
End of the Social Contract