Politics and Your Healthcare

The American public has always wanted quality, affordable healthcare and union families are no exception. Since 1980, a great majority of the healthcare delivery system in the United States has been managed by Health Maintenance Organizations (HMOs). While the type of enrollment varies from company sponsored plans to individual plans, union families are fortunate enough to have health insurance provided by their employers. As a consequence, most union families feel safe and protected in the area of medical needs. But are they really?

HMO Growth

While enrollment in HMO's has steadily grown since 1980, the overall quality of medical care provided under these plans has declined. One of the main reasons for the decline has been the HMO's are in business to make money. Some are publicly traded and accountable to shareholders and others are privately held. Both share the primary objective of revenue generation and bottom line growth. One of the easiest methods to achieve these goals is to reduce expenses, one of the largest of which is providing the very thing subscribers think they are paying for -- quality healthcare.

For the most part, HMO's have succeeded in generating cash, large quantities of which have gone directly into the pockets of company executives. According to Families USA, in 1996 the top 25 HMO executives averaged $6.2 million in compensation with an average of $13.5 million in unexcercised stock options.

HMO companies have been able to support these high salaries and beef up their bottom lines by denying people's access to quality care and other expense reducing tactics such as:

1. Elimination of specialists that the HMO companies think cost too much.
2. Replacement of family doctors with cheaper labor, usually non physicians.
3. Limited emergency room visits, hospital care, diagnostic testing and drugs.
4. Denied access for women to their gynecologists.
5. Denied bone marrow transplants as a breast cancer treatment.
6. Recommended "drive-through" mastectomies.

As services have been eliminated and horror stories regarding poor coverage, deaths and disabilities have grown, there is growing sentiment among Americans who want to hold HMO's accountable. Unfortunately, the HMO industry is protected by a Federal law called ERISA. Originally designed to protect pension plan looting by employers, ERISA has somehow been applied to the HMO industry and has protected it from lawsuits.

HMO Regulation

Politicians have heard public criticism and are trying to change the system. First, President Clinton introduced the 1993 Health Security Act which was beaten by a $50 million advertising campaign by insurance industry lobbies. Then California Senator Barbara Boxer courageously stepped forward and introduced the Patient's Bill of Rights in 1997. Included in her bill were the following provisions:

1. Health insurance plans shall maintain an adequate number of health care providers to give enrollees a choice of doctors. In addition, plans shall allow enrollees fair access to specialty care, provide for automatic referrals for chronic conditions and permit direct access to Obstetrician/Gynecologists for women enrollees.
2. A right to appeal denials of care to outside review panel.
3. A right to go to the emergency room if person experiences symptoms that "a prudent layperson" would conclude might result in death or serious injury.
4. Elimination of gag clauses that prohibited doctors to talk to patients about treatment options.
5. Elimination of discrimination on basis of race, gender, age, health status, sexual orientation, or anticipated need for services.
6. Requires proper information regarding healthcare rights and benefits be sent to patients.

This issue proved so popular that Republicans agreed with Boxer's bill and emphasized a review agency for complaints. All of this helps subscribers, but once again HMOs have the upper hand. Under capitation agreements, the HMO's pay doctors $10 per month per enrollee. Doctors then use this money for treatment and anything leftover is a bonus to the doctor. Thus, the system encourages undertreatment with patients typically left unaware and unable to complain to a review agency. An example of this is in California where a review panel has been in place for two years and has received only one complaint.

The Democratic leadership at all levels, including Senator Boxer, Lieutenant Governor Gray Davis, former Assembly leader Cruz Bustamante, former Senate Majority Leader Bill Lockyer and former State Democratic Chairman Phil Angelides feel that injured patients should have the right to file a lawsuit against an HMO.
As a physician, I have personally been held accountable and carried malpractice insurance my entire career. All healthcare professionals choose to do so. I agree with the Democratic leadership that HMO's should be held accountable and further that ERISA should not apply to HMO's.

The Republican position is quite different. Bolstered by $1 million per month in campaign contributions from HMO's during the early months of the 1998 election cycle, Republicans can justify their position that the HMO industry must be protected from lawsuits. Republicans further argue that healthcare premiums will rise if HMO's are held accountable. A study by the University of Berkeley indicates that this will not occur.

It's hard for me to believe that campaign contributions of this size don't play a significant role in the Republican decision to keep ERISA applicable to the HMO industry. As a strong consumer advocate, I feel healthcare is an important issue in the next election. Please study the candidates carefully and make a decision based on who will provide quality and affordable healthcare.