A Lesson for The Party of Hell No

In reading Jill Quadagno's One Nation Uninsured, Why the U. S. Has No National Health Insurance, I ran across an interesting discussion concerning the American Medical Association, that I expect has applicability to the Republican Party.

According to Quadagno's research, in 1945, 75 percent of Americans supported national health insurance; by 1949, only 21 percent favored President Truman's plan because of the outright opposition of the American Medical Association.  But the opposition came at great cost to the AMA according to Quadagno's book.  She quotes several sources for these paragraphs,

"During the campaign, the AMA drew heavily upon physicians' cultural authority as experts on health issues.  By the end of the decade, the abuse of this authority for such blatantly selfish ends made the public increasingly critical of the AMA, perceiving it as a negative organization that was against everything.  The AMA had opposed aid to medical schools on the grounds that federal aid would lead to federal control.  The AMA had also helped kill disability insurance and had blocked measures to provide school health programs and medical care to veteran's dependents. People were especially outraged when the AMA paid the Reverend Dan Gilbert $3,000 to mail Protestant clergymen a letter calling national health insurance 'this monster of anti-Christ.'

"A lot of us laymen are fed to the teeth with the AMA's methods.  With its persistently negative approach to everything.  With its unvarying misrepresentation of the efforts other countries are making to solve the problem.  With its "crusade" and its "battle" and its vilification of the government, the public, and its own members who speak out." 

If this can happen to the AMA, can it not happen to the Republican Party?  Clearly they have borrowed from this history in their distortion and misrepresentation of health reform with their references to non-existent death panels, charges of a government take-over of healthcare, and threats of Armageddon.  

They voted unanimously to oppose passage of the Patient Protection and Affordable Care Act, when even the American Medical Association had endorsed the legislation.  In addition, Republicans have worked to obstruct the extension of unemployment benefits for those most affected by the Great Recession, they have voted almost unanimously to oppose the fiscal stimulus bill that is helping to end the Great Recession, they oppose climate change legislation which can help us end our dependence on Middle Eastern oil, and they seem poised to oppose the financial regulatory reform that is required to reduce the chances of the Great Recession occurring again.

And is all this occurring because Republicans, who inherited budget surpluses in 2001, then passed trillions of dollars of unfunded tax cuts, an unfunded Medicare prescription drug benefit, two off-budget wars in Afghanistan and Iraq, and passed on a trillion dollar annual deficit in 2009,  have suddenly gotten fiscal discipline?  Or is it, as Jim DeMint (R-SC) said about Republican opposition to health reform, "If we are able to stop Obama on this, it will be his Waterloo.  It will break him."

At what point will the Party of No, or as they like to brag, the Party of Hell No, simply be seen for what it has become -- a persistently negative organization that is against everything for brazenly selfish ends?  Once in awhile, people vote against a candidate or a cause. More often, people want to vote for a candidate or cause.  Branding themselves as the Party of Hell No, and doing so for the primary purpose of regaining power, no matter the consequences to the country, does not seem like a winning political strategy to me.

Health Industry Supports Health Reform

A recently completed survey of healthcare opinion leaders undertaken by Commonwealth Fund and Modern Healthcare, which you can find here, shows broad support for key provisions of the Patient Protection and Affordable Care Act recently signed into law.  

Nearly nine of 10 leaders in health care and health care policy believe the comprehensive health reform legislation passed by Congress and signed into law by President Obama will successfully expand access to affordable health insurance coverage, the latest Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey finds. Virtually all of the key features of the health reform law—including income-related subsidies, new insurance market rules, and innovative payment methods—are supported by an overwhelming majority of opinion leaders.

Rescission Case #2

In this case, involving Blue Shield of California and Steven Hailey, a health insurance rescission was upheld by court review.  The case demonstrates the desperation of those who cannot find health coverage because of pre-existing health conditions, and the personal and societal impact that comes from allowing small group and individual health plans to exclude coverage for pre-existing conditions.  As I've written when asking "Should Health Insurance Be Sold For Profit?", the enforcement of pre-existing condition exclusions is mostly limited to the small group and individual health insurance market.  It doesn't happen in government run health plans like Medicare, Medicaid, CHAMPUS or the VA, nor does it happen in large group health plans.

In this case, Mr. Hailey, who had been covered through his wife's small group health insurance policy for nearly seven years, was badly injured in an auto accident.  While recovering at home, and facing medical and hospital bills of more than $450,000, of which Blue Shield had already paid $104,000, Blue Shield rescinded Mr. Hailey's coverage, because his wife had understated his weight on his application for insurance by some 45 pounds, and had omitted important parts of his medical history, dating to childhood, that would have been grounds for the insurer to decline coverage initially.

Eight years after the auto accident and rescission decision by Blue Shield, Orange County Superior Court Judge Peter J. Polos ruled in favor of Blue Shield on every issue, finding that the Hailey's willfully omitted and willfully mis-represented information on their application for insurance, and that Blue Shield's rescission investigation was timely and its investigation procedures were reasonable.  Mr. Hailey had many "health issues," as reported here.  These included heart problems, shortness of breath, acid reflux, obesity, swallowing difficulties and he took several prescription drugs for these problems, which would have caused Blue Shield to decline coverage for Mr. Hailey had these conditions been disclosed.  

What of the societal impact?  Mr. Hailey's problems will be covered with no questions asked by Medicare if he lives to age 65.  If the Hailey's were poor enough to quality for Medicaid, his problems would be covered.  If Mr. or Mrs. Hailey worked for a large employer, his problems would be covered.  It is only because Mr. Hailey is self-employed, and Mrs. Hailey works for a small business that underwriting of Mr. Hailey's health occurs, and an intrusive health insurance application must be completed to obtain health insurance coverage.  To its credit, Blue Shield is reported here, to have offered an alternative policy, with a different premium (likely a higher premium for less coverage) that would have provided coverage from the beginning.  There is no word as to whether Hailey purchased such coverage.  If he did not, or could not afford such coverage, or if he did buy the coverage, but it left him with large deductible, co-pay and coinsurance obligations, it is not unreasonable to expect that his medical debts will be discharged through bankruptcy, and these costs will be spread among those of us who have health insurance.  

What of the personal impact?  Blue Shield garnished the wages of Mrs. Hailey to recover the $104,000 that it had paid out, and the Hailey's were left with half a million dollars worth of health expenses.  Because of the rescission, Mr. Hailey's health was adversely affected.  Because he waited so long for surgery to repair an injured urethra, his bladder stopped working, and he had to depend on an implanted catheter to drain urine into a bag strapped to his body.

Blue Shield of California's news release, issued on May 28, 2009, concludes:

While we are very pleased with today's victory, we acknowledge that the healthcare system needs to be reformed. We will continue our longstanding advocacy of universal health coverage regardless of pre-existing conditions because we believe everyone has a right to quality health care.

Once the Patient Protection and Affordable Care Act has become fully effective, we will see the end of tragic stories like this one involving the Haileys and Blue Shield.

Tear Down This Sign

A Florida urologist comes very close to breaking his Hippocratic Oath and to abandoning his patients who supported President Obama over Senator McCain, in 2008. 

The modern Hippocratic Oath requires a physician to respect his patient's privacy.  Since how a patient voted two years ago is unrelated to the patient's need for health care, asking a patient for information that is not needed in their treatment seems, to me, to violate this obligation.  The Hippocratic Oath also obligates the physician to prevent disease, since prevention is preferable to cure.  Since the Patient Protection and Affordable Care Act requires coverage for preventive services, it is not unreasonable to assume that it may provide benefits to this physician's patients -- preventive care benefits that have long been recognized as important by physicians who have taken the Hippocratic Oath.

"I'm not turning anybody away — that would be unethical," Dr. Jack Cassell, 56, a Mount Dora urologist and a registered Republican opposed to the health plan, told the Orlando Sentinel on Thursday. "But if they read the sign and turn the other way, so be it."

Patient “abandonment” is a legal term developed primarily in medical malpractice litigation. According to the case of Lee v Dewbre, abandonment is defined as “the unilateral severance of the professional relationship between [the physician] and the patient without reasonable notice at a time when there is still the necessity of continuing medical attention.”

If I saw this sign on the office door of a physician who was providing care to me, I would feel as if my professional relationship with that physician had been unilaterally severed, with no notice.   As attorney James W. Saxton writes here:

Patient discharge has serious implications. If done incorrectly, the patient can make a claim of abandonment. An abandonment claim means leaving a patient without appropriate care or guidance while the physician-patient relationship exists. An abandonment claim has serious implications since there could further be a claim of unprofessional conduct and the Bureau of Professional and Occupational Affairs could become involved. Further, a lawsuit could be instituted. The claim of abandonment could lead to a claim for punitive damages not insured in the Commonwealth of Pennsylvania. When a discharge occurs patients can also be bitter and consider other possible bases for a professional liability claim.

I strongly advise:  Dr. Cassell, tear down this sign! 

Rescission Case #1

Health reform is now the law of the land.  One of the most despised practices of the health insurance industry will no longer be legal as this law is implemented:  rescission.  Rescission is the insurance industry practice of cancelling coverage when a beneficiary files a significant claim, if the insurer can find an error or omission in the insured's application, even when it is unrelated to the problem for which the beneficiary needs health services.  Having health insurance to cover significant claims is why we pay for insurance coverage in the first place.

Every individual and small group health insurer has its underwriting department review applications for insurance before granting coverage.  They look for reasons to deny coverage.  Pre-existing conditions, like heart disease, diabetes or cancer are immediate red flags.  But, if an insurance policy is issued, rescission gives the insurer another chance to avoid paying a significant claim.  When a beneficiary presents a significant claim, or is diagnosed with a condition that will generate significant claims over time, many carriers ask their rescission departments to review applications to see if there were any errors or omissions, previously overlooked by underwriting, that could be the basis for rescinding the policy, and avoiding a large claim payout.  These departments will compare the application against medical records which applicant's are often required to provide as part of the insurance application process, looking for a lab result, a physician's note, test result or physical finding that differs from the application.

Health Net, Inc., one of our nation's largest health insurers, cancelled Patsy Bates' policy after she began treatment for breast cancer.

Bates, 51, said the first notice she had that something was awry with her coverage came while she was in the hospital preparing for lump-removal surgery. She said an administrator came to her room and told her the surgery, scheduled for early the next day, had been canceled because the hospital learned she had insurance problems. Health Net allowed the surgery to go forward only after Bates' daughter authorized the insurance company to charge three months of premiums in advance to her debit card, Bates alleged. Her coverage was canceled after she began post-surgical chemotherapy threatments.

The reason for the rescission?  Health Net alleged that her application for health insurance indicated her weight was 35 pounds less than it actually was, and that she had been screened for heart damage due to taking the diet drug combination known as fen-phen.  Nothing in the story indicates the fen-phen drug combination caused any heart damage, only that she was screened for it.  There is no allegation on the part of Health Net that either her weight or heart screening in any way contributed to or caused her breast cancer, although obesity is a known risk factor for breast cancer.

Her application for insurance was completed by the insurance agent who stopped by her beauty salon, and promised her he could saver her money on health insurance.  He asked her questions while she styled a customer's hair.  She is not certain that he asked her every question on the application, and given that the insurance agent earns a commission of as much as 10 percent of premium, it is in the agent's interest to complete applications in a way that will pass underwriting, so it's not impossible to believe that an unscrupulous agent would have shaved a few pounds off her stated weight, or decided that since her heart screening may have been negative, there was no need to report it.  Over my years of working with the health industry, the underwriting department is known by the sales and marketing staff as the "business prevention unit," because underwriting turns down applications the agent thought were solid.  When underwriting declines an application, the agent earns no commission. 

This case is made more egregious by the finding that Health Net set goals for the rescission unit for the number of policies they cancelled, and provided bonuses to underwriters who exceeded their goals.  The Los Angeles Times found this:

Woodland Hills-based Health Net Inc. avoided paying $35.5 million in medical expenses by rescinding about 1,600 policies between 2000 and 2006. During that period, it paid its senior analyst in charge of cancellations more than $20,000 in bonuses based in part on her meeting or exceeding annual targets for revoking policies, documents disclosed Thursday showed.

And what of the beneficiary/patient?  Ms. Bates chemotherapy was delayed for four months because Health Net had terminated her coverage.  Eventually a program for charity care covered her treatment -- a program which collected no insurance premiums from her.  Meanwhile, the company which had collected health premiums for at least six months, declined coverage when the patient desperately needed it.  Three years later, Ms. Bates was still uninsured, now with a pre-existing condition -- a breast cancer diagnosis -- far worse than being overweight. 

The Patient Protection and Affordable Care Act will help Americans like Patsy Bates.  It will also help the rest of us who know not when we would have been in a situation like that of Ms. Bates.

The rest of the story can be found here.  Health Net was ordered by a private arbitration judge to pay Ms. Bates $9 million.

Calling Health Net's actions "egregious," Judge Sam Cianchetti, a retired Los Angeles County Superior Court judge, ruled that the company broke state laws and acted in bad faith.

"Health Net was primarily concerned with and considered its own financial interests and gave little, if any, consideration and concern for the interests of the insured," Cianchetti wrote in a 21-page ruling.

Sadly, Health Net will undoubtedly pass the cost of this judgement, less any reimbursement they may have received from their own errors and omissions insurance policy, along to policy holders in the form of higher health insurance premiums. Policyholders will pay for the outrageous behavior of their health insurer.