FW: een artikel over ziekteverzekeringen in VS

[Vital E.H. Moors]

----------
Van: "mihai martoiu ticu" <mart1119 at exact.nl>
Aan: <veh.moors at planet.nl>
Onderwerp: een artikel over ziekteverzekeringen in VS
Datum: din, 2 nov 1999 09:12


Ik dacht dat het onderwerp je interesseert. Als het artikel interessant
vindt zeg het maar en ik stuur ze ook in de toekomst op.

The Private Health Care Juggernaut Needs Jilting
by Marta Russell

Presidential 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.

Bradley's "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."

It 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 deliver.

Here I want to focus on how the private system does least by those who
utilize health care the most.

The 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.

(One 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.)

Unlike 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 Medicaid.

Essentially, 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.

These 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.

In 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).

A 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.

In 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.

As 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.

Yet, 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.

Bradley's 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.

According 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.
Despite 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
http://www.commoncouragepress.com/ramps.html