Can the federal government apply an individual mandate like the one in Massachusetts across the country?
And how would the government enforce such a rule in very large states like California, with a population of 37 million, where 34% of non-Medicare age residents lack health coverage? How much would the feds charge uninsured Americans when they get sick? And how should the government collect fines for not getting insurance?
What about in Texas, population 24 million, where 42% of low-income residents under age 65 are now uninsured, and a state where many don't appreciate government intervention?
Massachusetts managed to reduce its percentage of uninsured to 2.6% (a drop from 10% to 12%) in just a few years by setting thresholds for people to purchase health insurance, either through their employers or from an array of state-approved plans. So far, state officials say, it's been a success.
With all filings for the 2007 tax year complete—the first year that fines were assessed—only 70,000 who earned enough money to be required to have coverage didn't file the required 1099 HC form with their tax filings to prove they had it, officials say.
And those who didn't get their required 2007 health policies by Dec. 31, 2007–through their employer, private insurance, or the Massachusetts system–paid a $219 fine, which was kept low during the first year of enforcement. There were 7,277 taxpayers who indicated on their 2007 tax returns that they wished to appeal the individual mandate penalty. Of that number, 2,478 actually followed up. Within that group, 1,813 appeals were approved.
It's too soon to say what has happened in the 2008 tax year, when the maximum fine, depending on age and income, was $912 for the year, because tax forms have not all been filed and reviewed, although state officials say they expect to find even better compliance this year.
Can the individual mandate work elsewhere?
Could other states get similar cooperation from its residents, and see such dramatic reductions in their rates of uninsured as Massachusetts has enjoyed?
Yes, most definitely, says Linda Blumberg, health policy analyst for the Urban Institute, who has written extensively on health reform and the commonwealth effort. What are needed are sufficient subsidies for lower-income populations, exemptions for the truly poor, and grants to help social services agencies get people enrolled, she says.
Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector, which runs the Massachusetts program, concurs with that assessment. "Remember, there's going to be subsidies for people who can't afford it, and exemptions for people who are too poor to have access to the subsidies or because the (program) costs too much. The feds are talking about allowing that."
But Ian Duncan, a member of the 10-person Connector Authority Board, is extremely doubtful a Massachusetts-like plan could play well throughout the country, suggesting that it would be a "nightmare" to execute in most if not all other states.
Getting compliance in Massachusetts was relatively painless because the percentage of uninsured was already low and the state is relatively wealthy, he says. "There were really no implications for 90% of the population.
"But there's several things that will make this an absolute nightmare to administer at the federal level. It would be a bureaucratic nightmare," he says.
For starters, Duncan lists the difficulty for a larger state or federal government to determine what Massachusetts calls "minimum credible coverage." That coverage must include certain drugs and how that would be determined across the country would be problematic at best, he says.
Additionally, many employer plans that would otherwise qualify don't offer drug coverage, "even though everything else about the plan is gold-plated," he says.
"Go to a place like California, where 25% of people don't have health insurance, and you can imagine what this would be like." In other states, he says, "You'd have lobbying from people saying, ‘You can't cover birth control and abortions.' "
In many states, the number of legal immigrants, or documented workers, is an enormous issue as well, much more so than in Massachusetts, which made a decision to drop some 30,000 residents from the program last month for budgetary reasons. Covering undocumented residents would be politically charged as well.
And Duncan says there's the issue of deciding who should merit a hardship waiver, or what should copays be for certain types of care. "I think it's something quite beyond the scope of government bureaucrats to regulate. And because it's government money, the government would have to regulate every single detail."
Enforcement
Another problem is how to apply a requirement that one show proof of health insurance with a tax filing. "Do you really want the IRS to insert itself in people's lives to figure out whether people have credible coverage?" he asks.
And there is more confusion that would be compounded nationally with hundreds of thousands of employers asking that the policies they provide their employees, who may not meet Massachusetts' standards, qualify as credible coverage.
Duncan predicts endless regulations and bureaucracy that would lead to "a whole army of people enforcing it."
"Having the government try to do this would be like putting the Department of Motor Vehicles in charge of healthcare. Can you imagine that? It seems to me to be an impending nightmare."
Kingsdale and Blumberg heatedly disagree with Duncan's stance. Blumberg says that requiring citizens to show proof they or their employers purchased appropriate health insurance policies with their annual tax returns, or give income data showing they were exempt, is the best way to apply such a plan across the nation.
"The first line of offense in implementing a mandate is to structure reform so that voluntary compliance is affordable and easy," Blumberg says. That means not implementing a mandate that people don't think is fair, that requires people to spend too much of their income, "and you have to have a subsidy program for the modest income population, and require coverage that is meaningful," and exemptions for those who are too poor.
Penalties
Should there be a penalty for not complying or for ignoring the individual mandate? "Yes, because otherwise it's not fair," she says. "But no, we don't put people in jail for not paying it. Will we get to 100% coverage? No. But we can get very close."
Blumberg says that if some of the suggested proposals now being discussed in health reform bills come to pass, there will be more uniformity of coverage. "It would bring all the states up to a uniform level, and a much bigger expansion of the number of people eligible for pubic subsidies."
With grants to hospitals and other healthcare providers to encourage enrollment, "safety net providers are enrolling people right and left, and that's so the hospitals don't lose out on their reimbursement," she says.
Kingsdale also agrees that a universal mandate could extend across the country.
"The process has worked very smoothly [in Massachusetts]," he says. "We have no security at our office, an open plaza, and no angry taxpayers with pitchforks have showed up.
"Would it be simple, and easy? Probably not. I wouldn't want to tell you that. But is it do-able? Yes."
Tulare Healthcare, which includes Tulare Local Healthcare District, Tulare District Healthcare System, and Tulare District Hospital, agreed to pay the government $2.4 million to settle allegations that the company violated the False Claims Act, anti-kickback statute, and the Stark Law, according to a Department of Justice release.
The case was filed last year by former Tulare Healthcare Chief Financial Officer Maria Lucy Reimche. Reimche alleged that Tulare Healthcare, based in Tulare, CA, was involved in illegal financial arrangements with physicians that referred patients to the facilities.
She alleged Tulare forgave physician debt, and allowed physicians to purchase and rent real estate priced below fair market value. The conduct allegedly went on from 2001 to 2007 and was designed to be remuneration to physicians who referred Medicare patients to Tulare Healthcare.
Such arrangements violate the federal anti-kickback statute, which prohibits anyone from offering, paying, soliciting, or receiving anything of value to generate referrals for items or services payable by any federal healthcare program. The agreements also reportedly violated the Stark law, which prohibits physicians from referring patients for specified services to a hospital or other entity with which the physician or an immediate family member has a financial relationship. Any services performed by the physicians with illegal relationships are considered false claims.
A New York City nurse slapped a lawsuit on her hospital after allegedly being forced to assist in a late-term abortion that defied her religious beliefs.
Catherina Cenzon-DeCarlo, a devout Catholic operating room nurse employed at Mount Sinai Hospital, claims she had to compromise her faith and perform the procedure on a 22-week pregnant patient or risk losing her job and her license. The hospital has known of the nurse's objections to participating in abortions since she interviewed for her position in 2004. But Cenzon-DeCarlo accuses supervisors of refusing to assign the procedure to another nurse when she begged out of the procedure.
Cenzon-DeCarlo says her involvement in the May 24 abortion has left her with nightmares that prevent her from sleeping, reports the New York Post.
The incident is alarming to some of the most seasoned nurses in the field.
"Ms. Cenzon-DeCarlo has experienced employer bullying at its finest," says Deanna Miller, RN, MSN, Ed, HCE, manager of critical care and staff development at University Hospitals Geneva (OH) Medical Center. "During my 22 years in healthcare, I have never witnessed or experienced this type of infringement on a clinician's rights. If Mount Sinai was aware of [her] beliefs, she should never have been put into such an emotionally taxing position."
The abortion was performed on a patient with preeclampsia—a condition characterized by high blood pressure that can result in seizures or death if left untreated. However, the suit filed last week alleges Mount Sinai supervisors embellished the patient's condition and told Cenzon-DeCarlo that the mother may die if she did not assist with the abortion. The nurse claims she later found out hospital records stated the abortion was a "Category II" procedure, which is not immediately life threatening.
While late-term abortion is permissible in cases where the mother's life is at risk, the clinician's cultural and spiritual beliefs must also be taken into consideration, says Miller. "We emphasize cultural competency and diversity with those that we care for, but who is looking out for the provider?"
Still, religion, rights, and emotions aside, Cenzon-DeCarlo asserts the hospital had time—six hours—to find a replacement nurse for the abortion. Supervisors allegedly chose not to, and threatened she would be brought up on charges of insubordination and patient abandonment if she did not participate in the procedure, according Cenzon-DeCarlo.
This ethical dilemma could have been avoided simply by placing an alternate in Cenzon-DeCarlo's role, such as a peer, manager, or physician, according to Miller.
"Ms. Cenzon-DeCarlo should not have been even considered to take part on this case," she says. "If she were on call for the surgical team, an alternative should have been in place. What if [she was] ill during her call time? Who would have covered for her then?"
Cenzon-DeCarlo is still employed at the hospital but filed a complaint with her union after the incident. She says her on-call shifts have since been cut "solely because of her religious objection to assisting in abortion."
According to The Washington Times, hospital officials ordered Cenzon-DeCarlo to sign a form signifying she will participate in future abortions that Mount Sinai considers as emergencies occurring during her shift, but she refused.
Cenzon-DeCarlo requested a court order that Mount Sinai pay her unnamed damages, reinstate her overtime work shifts, and honor her opposition to assisting in abortions. The lawsuit also calls for Mount Sinai to give up federal funding it receives because of its failure to comply with an amendment that protects "the right of conscience of pro-life healthcare workers."
Senate negotiators are inching toward bipartisan agreement on a healthcare plan that seeks middle ground on some of the thorniest issues facing Congress. The emerging Finance Committee bill would shave about $100 billion off the projected trillion-dollar cost of the legislation over the next decade and eventually provide coverage to 94% of Americans, according to participants in the talks. It would expand Medicaid, crack down on insurers, abandon the government insurance option and, tax healthcare benefits under the most generous plans.
After a meeting among Senate Democrats to hone their message on revamping healthcare, some centrist lawmakers expressed confidence that they would be able to sign on to the legislation and sell it to their constituents back home. Some Democrats, anticipating raucous debate in their home states, expressed frustration that they were leaving for the summer recess without a consolidated proposal to rally behind.
As Congress examines ways to overhaul the nation's healthcare system, the United Agricultural Benefit Trust has found itself in the national spotlight as a model for a proposed co-op option consumers could consider along with private insurers. The Trust works like a commercial insurer, negotiating rates with a network of doctors and hospitals, but it is owned by its members. Many of them say co-ops offer better service and are cheaper because they don't have to turn a profit. But critics say co-ops, which are not as tightly regulated as other insurance providers, are susceptible to insolvency and would not work on a large scale.
Five Philadelphia-area hospitals had higher-than-expected death rates among patients undergoing open-heart surgery in 2007, according to a state report. But the quality of care statewide improved for patients who got heart bypass and valve operations even as the number of patients declined, the Pennsylvania Health Care Cost Containment Council's annual cardiac surgery report found. The most dramatic improvement came in surgery to treat diseased heart valves.
The new owners of Blue Island, IL-based MetroSouth Medical Center say the facility is growing thanks in part to capital investments that have helped to draw new physicians who, in turn, are expected to bring in more patients. A group led by Transition Health Care Co. last year bought MetroSouth Medical Center, formerly St. Francis Hospital & Health Center, from SSM Health Care. MetroSouth executives say a $30 million commitment from New York-based Falcon Investors is helping to finance new imaging equipment, an electronic medical records system, and a conversion to all private rooms for patients. The commitment to enhancements has helped the hospital recruit 11 primary-care physicians who are expected on staff by October and will be key to boosting admissions.
In a bid to get parents to take a more active role in keeping their hosptialized kids safe, the Joint Commission is launching a new pediatric effort as part of its long-running "Speak Up" campaign. The campaign encourages patients to say something if they see a potential error or problem with their care.
The California Nurses Association plans protested in San Francisco in the wake of a Sacramento nurse's swine flu death last month. The union wants hospitals to provide better masks, equipment, and protocol to protect nurses from further sickness. The union says nurses across the state are reporting difficulties getting the masks recommended by the Centers for Disease Control and Prevention, and having them properly fitted to be airtight.
