Citizens’ Council on Health Care
CCHC HEALTH eNEWS
Friday, November 16, 2001


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Providing news and commentary on health care policy,
health insurance issues, and medical confidentiality.
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* CCHC REPORT: NEW HEALTH CARE RATIONING STRATEGY PROPOSED

 STATES BEGIN TO RATION IN MEDICAID PROGRAM

* NO RATIONING HERE - HIV PATIENT CAN GET NEW TAXPAYER-FUNDED LIVER

* UNINSURED WITH ACCESS TO EMPLOYER INSURANCE ARE LESS HEALTHY

* SENATORS FRIST AND KENNEDY INTRODUCE BIOTERRORISM BILL

* FORCEFUL VACCINATION AND QUARANTINE PROPOSED

* STUDY: SPECIALIST REFERRAL PROCESS MAY BE UNNECESSARY


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* CCHC Commentary included
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NEW HEALTH CARE RATIONING STRATEGY PROPOSED

”Accountability for Reasonability” is a new plan to implement
limit-setting in health care according to Norman Daniels, Ph.D.,
a Goldthwaite Professor of Philosophy and Professor of Medical
Ethics at Tufts University.

Daniels, who spoke at the University of Minnesota for its Health
Services Research Seminar Series, was speaking about his proposal
that will be rolled out this Spring with the publication of his
new book called “Setting Limits Fairly.”

There is, he said, “intense moral disagreement” over the issue of
setting limits, or rationing health care services. Some of the
unsolved problems include Priorities (sick people vs. well),
Aggregation (the extensive amount of services used by only a few
people) and Fair Chances/Best Outcomes (providing the possibility
of benefit for a few vs. using those resources to provide health
care to the many)

To build public acceptance of managed care organizations as the
”legitimate locus for making limit-setting decisions” and to solve
the “legitimacy problem” of health care rationing, he suggested:

* public disclosure of decisions and rationale for decisions,
something that health plans have avoided due to fear of
litigation;
* constraint on reasons (according to those who are “disposed
to finding mutually justifiable terms of cooperation and
according to value for money in meeting population needs)
* an appeals and due process mechanism
* voluntary or imposed regulation

Public disclosure and explicit rationing would be beneficial, he
said, to build “case law” (precedent) for future decisions, to hold
people and organizations accountable and to move the public to a
sense of “fairness” about, and acceptability of, the process.

Daniels is a a member of the Institute of Medicine, a Fellow of
the Hastings Center, a member of the International Society for
Equity in Health, and a consultant for the UN and the World Health
Organization. He was a member of the ethics working group of the
Clinton Health Care Task Force.

Source: Presentation attendee, Twila Brase, President of CCHC,
November 16, 2001.

CCHC COMMENTARY: CCHC President, Twila Brase, commented during
the Q&A that his proposal was premised on a concept of public
sharing and central planning for health care resources that many
members of the public do not accept, and that medical savings account
and personal cost-benefit decisions made in a consumer-driven,
and consumer-negotiated system will address many of the cost
concerns that drive his proposal.

-Citizens’ Council on Health Care
-November 16, 2001


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RISING MEDICAID COSTS, FALLING STATE REVENUES

During the booming 1990s, many states added benefits to their
Medicaid programs to care for low-income families. Now, because
of the wobbly economy, tax revenues are down and states are
considering rationing of medical care in attempts to balance
their budgets.

o State health-care costs are growing at their fastest rate
in a decade—nine percent a year.

o At the same time, states are struggling with budget
shortfalls totaling an estimated $15 billion.

o The Urban Institute warns that if the nation’s
unemployment rate rises to, say, 6.5 percent—only about
a point above what it is now—states may have to absorb
nearly two million more people into Medicaid.

o Some states are beginning to reduce benefits—for
example, Oregon recently proposed reducing benefits for
90,000 low-income people by adding cost-sharing co-
payments in order to extend coverage to 40,000 others, and
Utah wants to cut benefits by about 3 percent.

Under current Medicaid rules, states can add or cut optional
benefits, such as prescription drugs, and populations, such as
poor adults without children. But they must offer the same
benefits to all in the program. So, they can’t, for example, cut
prescription-drug benefits for poor adults without children,
while offering them to families.

States are seeking greater flexibility to make trade-offs in
benefits and coverage.

Source: Robert Gavin, “States Look to Ration Health Care,” Wall
Street Journal, November 14, 2001.

For WSJ text
http://interactive.wsj.com/articles/SB1005686520537207320.htm

For more on Medicaid http://www.ncpa.org/iss/hea/

Source: taken directly from the Daily Policy Digest, National
Center for Policy Analysis, http://www.ncpa.org, 11/16/01


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NO RATIONING HERE - HIV PATIENT CAN GET NEW TAXPAYER-FUNDED LIVER

In possibly the “first ruling of its kind” in the nation, a
Massachusetts Medicaid appeals board on Nov. 14 ruled that an
insurer that covers Medicaid beneficiaries must pay for a liver
transplant for a man with HIV and end-stage liver disease, the
Boston Globe reports.

The decision comes just months after a separate state agency ruled
that the same insurer, Neighborhood Health Plan, did not have to
cover a liver transplant for an HIV-positive woman who was
insured privately, not through Medicaid (Arnold, Boston Globe,
11/15). The Division of Medical Assistance Board of Appeals ruled
yesterday that despite some scientific uncertainty about whether HIV
reduces a transplant’s recipient chances of survival, the procedure
is “medically necessary” and not “experimental” (AP/Boston Herald,
11/14).

The board’s decision cited 14 successful liver transplants conducted
since 1997 in which HIV-positive people were cured of their liver
problems and saw “no worsening of their HIV status”; two of these
individuals died for “reasons unrelated to HIV” (Boston Globe,
11/15).

Under the ruling, the unidentified 41-year-old man, who also has
hepatitis C, can now be referred to the University of Pittsburgh’s
transplant program, where he will go on a waiting list (AP/Boston
Herald, 11/14). Should the center deem the man medically eligible
for the transplant, Neighborhood Health will have to pay for the
procedure (Pope, AP/Newsday, 11/14). The procedure can cost
$300,000 or more (Boston Globe, 11/15)....

Source: Taken directly from “Massachusetts Board Orders Medicaid
HMO to Cover Liver Transplant for HIV-Positive Man,” KAISER DAILY
HEALTH POLICY REPORT, Thursday, November 15, 2001


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UNINSURED WITH ACCESS TO EMPLOYER INSURANCE ARE LESS HEALTHY

People who turn down employer-sponsored coverage are
generally in worse health than those who participate in employer
plans, according to a study in the latest issue of Health Affairs.
In an effort to gain a broader understanding of “uninsured decliners”
and their health status, Linda Blumberg, a senior research associate
at the Urban Institute, and Len Nichols, formerly a principal
research associate at the institute and now the vice president of the
Center for Studying Health System Change, analyzed data from the 1997
National Health Interview Survey, which includes responses from
39,832 households.

Some of the results from the study, which featured responses from
7,831 decliners of employer-sponsored insurance, 22,346 with employer-
based coverage, or “takers,” and 13,628 uninsured people who were not
offered employer coverage, or”uninsured not offered,” are provided below:

*Thirty-five percent of uninsured decliners said their health status
was excellent, compared to 39.8% of takers and 32.1% of uninsured not
offered. For the most part, the health status of decliners was
statistically insignificant from the uninsured not offered.

*Uninsured decliners were more likely than takers to have spent more
than seven days in bed in the past 12 months and to have stayed home
from work more frequently, a combination that “impl[ies] that
uninsured decliners were more likely to be sick than takers were, and
they may be more likely to be seriously ill when sick.”

*Decliners were more likely to go longer periods of time without
seeing a health care provider.

*The “most startling” difference between the two groups was found in
mental health conditions, as 13.7% of decliners and 13.8% of
uninsured not offered said they were depressed in the past 30 days,
compared to 7.6% of takers.

*The study found that a similar percentage from all three groups --
around 18% -- said that their health status was better compared to a
year ago. But a greater percentage of decliners and uninsured not
offered said they were worse off than takers. Further, more people
in the latter two groups also said they couldn’t afford drugs, mental
health services and dental care in the past year.

A ‘Fundamental’ Decision

Blumberg and Nichols write that the results of the study “are
somewhat surprising, for we expected workers voluntarily declining
coverage to be healthier than those enrolling.” They conclude that
the lesser health status of decliners “does not change the
fundamental calculus: To these workers, the marginal value of
insurance is lower than the out-of-pocket cost they would face if
they were to become insured.”....(Blumberg/Nichols, “The Health
Status of Workers Who Decline Employer-Sponsored Insurance,”
November/December 2001).

Source: Taken directly from “Study Finds that Those Who Decline
Employer-Sponsored Coverage Are In Worse Health Than Employees
Who Take Up Coverage,” KAISER DAILY HEALTH POLICY REPORT, Thursday,
November 15, 2001


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SENATORS FRIST ® AND KENNEDY (D) INTRODUCE BIOTERRORISM BILL

Sens. Bill Frist (R-Tenn.), Edward Kennedy (D-Mass.) and Judd
Gregg (R-N.H.) on Nov. 15 intend to introduce a $3.2 billion
bioterrorism bill that would increase the nation’s stockpile of
vaccines and medicines, boost CDC funding, increase food inspections
and help state and local governments prepare for biological or
chemical attacks, the AP/Minneapolis Star Tribune reports.

Of the $3.2 billion, about $1.1 billion would be allocated to the
antibiotics stockpile and for doses of a smallpox vaccine and another
$1 billion would go toward helping state and local officials prepare
for bioterrorism. In comparison, President Bush’s $1.5 billion
proposal would give $643 million to increase the vaccine/antibiotic
stockpile and $509 million for 300 million doses of the smallpox
vaccine. A “small fraction” of the Bush bill would help state and
local officials prepare for bioterrorism attacks, the AP/Star Tribune
reports.

House Democrats last month introduced a $7 billion bioterrorism bill
(Zuckerford, AP/Minneapolis Star Tribune, 11/15). Rep. Billy Tauzin
(R-La.) was expected to introduce another House bioterrorism bill
yesterday that would provide funds for the CDC, the vaccine/
antibiotics stockpile, physician and nurse training and volunteer
certification. Tauzin said House Republican leaders wanted to have
a bill available for floor consideration should the Senate reach a
consensus on its bioterrorism bill (CongressDaily, 11/14)...

Source: Taken directly from “Senators To Introduce Bioterrorism
Bill Today,” KAISER DAILY HEALTH POLICY REPORT, Thursday,
November 15, 2001


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FORCEFUL VACCINATION AND QUARANTINE PROPOSED

In the event of a smallpox attack on the U.S., the nation’s
publichealth agencies must be allowed to forcefully vaccinate
the entirepopulation, with the help of the military if necessary,
said Dr.Stephen D. prior, the research director at the National
Security Health Policy Center

”There has to be compulsion” he said. Every state has different
law. Because there is no federal law, the federal government does
not have the authority to use the stockpile of 300 million smallpox
vaccine doses they intend to soon have available.

Since smallpox vaccinations were discontinued in 1972, about 40%
of the US population “has never been vaccinated and lacks immunity
to the disease, which is fatal in about one third of cases,”
according to Reuters Health. While federal law gives the US Surgeon
General power to vaccinate and quarantine, there is no means of
enforcing it.

A spokesman for Senate Health, Education, Labor, and Pensions
Committee Chair Edward Kennedy (D-MA) denies that federal authority
for mass vaccination is in the bioterrorism bill he plans to introduce.

Causes for concerns over enforced vaccinations and rounding up non-
compliant citizens include the growth of anti-government sentiment
and the possibility of death from an adverse reaction to the vaccine.
Historically, smallpox vaccine has caused 4 deaths per 1 million
vaccinated.

Source: “Expert: Federal law needed on smallpox vaccination,” Todd
Zwillich, Reuters Health, November 5, 2001

-Citizens’ Council on Health Care
-November 16, 2001


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STUDY: SPECIALIST REFERRAL PROCESS MAY BE UNNECESSARY

The elimination of the physician referral process for access to
specialists was found to add no additional costs or unnecessary
care, according to a study by Dr. Steven D. Pearson of Harvard
medical School in Massachusetts, and reported in the November 1^st
issue of The New England Journal of Medicine.

Pearson studied the Boston, Massachusetts-based Harvard Vanguard
Medical Associates HMO which ended their 25-year old gatekeeping
referral system in April 1998.

Overall, there was only a minor increase in visits to primary care
doctors and specialists, however, more patients visited occupational
and physical therapists. Only specialists dealing with back pain saw
a significant jump in services. The authors note however that the
lack of increase in visits to most specialists may be because the
specialists are salaried and have little reason to encourage an
increase. In addition, the study was done two years after the change
and patients habits may now have adjusted.

He cautioned that the results of one HMO may not be reflective of
other HMOs and care systems.

Source: “Physician Referral Process May Not Cut Costs—Study,”
Charnicia E. Huggins Reuters Health, October 31 5:24 PM ET

-Citizens’ Council on Health Care
-November 16, 2001


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NOTE: These news items have been taken directly
from email received by CCHC or from Internet
newspaper publications. Titles in ALL CAPS are
CCHC creations except for those heading articles
from the National Center for Policy Analysis,
the Health Law Pulse, PrivacySecurityNetwork,
and LIST.HEALTHPLAN. Credit to the sending
organization or news service is listed at the
end of each article.
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CITIZENS’ COUNCIL ON HEALTH CARE
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