Health Law and Policy Commons^™

Pro-Choice Plans, Brendan S. Maher

Faculty Scholarship

After Dobbs v. Jackson Women’s Health Organization, the United States Constitution may no longer protect abortion, but a surprising federal statute does. That statute is called the Employee Retirement Income Security Act of 1974 (“ERISA”), and it has long been one of the most powerful preemptive statutes in the entire United States Code. ERISA regulates “employee benefit plans,” which are the vehicle by which approximately 155 million people receive their health insurance. Plans are thus a major private payer for health benefits—and therefore abortions. While many post-Dobbs anti-abortion laws directly bar abortion by making either the receipt or provision of …

A Case For Brandeisian Federalism: The Erisa Preemption Clause And State Health Care Reform, Jordan May

DePaul Journal of Health Care Law

The United States spends more for health care per capita than any other country in the world. Despite spending more, the United States has weaker health care outcomes than other similarly developed countries. This fact alone makes health care an important subject for policy reform. Given the current partisan gridlock in Congress, it is difficult to foresee any significant legislation in the area of health care reform at the federal level in the near future. As a result, Congress has allocated major health care reform efforts to the states. However, ERISA stands as a huge obstacle to state health care …

Dentistry And The Law: How Does An ‘Assignment Of Benefits’ Work?, Dan Schulte Jd

The Journal of the Michigan Dental Association

The use of an assignment of benefits form in dental practice is explored in this article, with a focus on its potential benefits and limitations. This form allows patients to assign their dental plan benefits to the provider, enabling direct payment for services. However, its acceptance by dental plans varies and is often subject to state and federal regulations. While assignment of benefits offers a pathway to independent fee setting and potential billing for any balance exceeding benefits, legal and regulatory considerations must be addressed to fully implement this approach.

Federalism, Erisa, And State Single-Payer Health Care, Erin C. Fuse Brown, Elizabeth Mccuskey

Faculty Scholarship

While federal health reform sputters, states have begun to pursue their own transformative strategies for achieving universal coverage, the most ambitious of which are state-based single-payer plans. Since the passage of the Affordable Care Act in 2010, legislators in twenty-one states have proposed sixty-six unique bills to establish single-payer health care systems. This paper systematically surveys those state legislative efforts and exposes the federalism trap that threatens to derail them: ERISA's preemption of state regulation relating to employer-sponsored health insurance. ERISA's expansive preemption provision creates a narrow, risky path for state regulation to capture the employer health care expenditures crucial …

10th Annual Pegalis Law Group Health Law Colloquium, New York Law School

Health Law Society Publications

Federalism, ERISA, and State Single-Payer Health Care. How to Make Sense of Future Legislation and the Impact on Population Health

(CLE Presentation on Oct. 24th 2019)

Moderator:

Adam S. Herbst, Esq., Senior Vice President, Chief Legal and Strategic Planning Officer of Blythedale’s Children Hospital; Adjunct Professor at New York Law School teaching Health Law and Policy; Co-director of the NYLS Health Law and Patient Safety Project; Lecturer, Mailman School of Public Health at Columbia University

Panelists:

Honorable Richard N. Gottfried, New York State Assembly (District 75) & Chairman of the Assembly's Committee on Health and Sponsor of …

For Whom The Bell (Equitably) Tolls: Erisa Compliance And Denial Of Benefits Notices Circuit Split, Sarah Smith

Akron Law Review

The circuit courts are split as to how a plan administrator of an ERISA-governed employee benefit plan must notify a claimant of a time limitation placed on a claimant’s ability to seek judicial review of an adverse benefit decision. Some courts indicate that inclusion of this time limitation in the Summary Plan Description is sufficient to notify a claimant. Other courts have held that the time period must specifically be included in adverse determination notices, which are documents notifying claimants of the denial of their claim and the right to judicial review. Much of the debate among courts concerns the …

Step Therapy: Legal And Ethical Implications Of A Cost-Cutting Measure, Sharona Hoffman

Faculty Publications

The very high and ever-increasing costs of medical care in the United States are well-recognized and much discussed. Health insurers have employed a variety of strategies in an effort to control their expenditures, including one that is common but has received relatively little attention: step therapy. Step therapy programs require patients to try less expensive treatments and find them to be ineffective or otherwise problematic before the insurer will approve a more high-priced option. This Article is the first law journal piece dedicated to analyzing this important cost control measure.

The Article explores the strengths and weaknesses of step therapy …

Consumer Financial Protection In Health Care, Erin C. Fuse Brown

Erin C. Fuse Brown

There are inadequate consumer protections from harmful medical billing practices that result in unavoidable, unexpected, and often financially devastating medical bills. The problem stems from the increasing costs shifting to patients in American health care and the inordinate complexity that makes health care transactions nearly impossible for consumers to navigate. A particularly outrageous example is the phenomenon of surprise medical bills, which refers to unanticipated and involuntary out-of-network bills in emergencies or from out-of- network providers at in-network facilities. Other damaging medical billing practices include the opaque and à la carte nature of medical bills, epitomized by added “facility fees,” …

Erisa And Graham-Cassidy: A Disaster In Waiting For Employee Health Benefits And For Dependents Under 26 On Their Parents’ Plans, Leslie Francis

Utah Law Faculty Scholarship

Graham Cassidy § 105 would repeal the ACA “employer mandate”. Although its sponsors claim that the bill will give states a great deal of flexibility, it will do nothing to help states ensure that employers provide their employees with decent health insurance; quite the reverse. It will also give employers the freedom to ignore the popular ACA requirement that allows children up to age 26 to receive coverage through their parent’ plans, at least when their parents get health insurance from their employers. Here’s why.

Managed Care, Utilization Review, And Financial Risk Shifting: Compensating Patients For Health Care Cost Containment Injuries, Vernellia R. Randall

Vernellia R. Randall

This Article examines current tort remedies for personal injury claims and explores the problems that arise when these remedies are applied to physicians' actions that are directed by third-party payers. Part II of this Article explores the organization and historical development of managed health care products. Part III considers the past and present uses of the utilization review process and financial risk shifting. Part IV explores the applicability of traditional theories of tort liability to third-party payers, including direct liability of third-party payers who market managed care products. Part V considers the barriers that ERISA presents to compensating patients for …

Dinner For Two: Employer Mandate, Meet Erisa; How Dave & Buster’S Response To The Affordable Care Act’S Employer Mandate May Open The Door For Employees To Seek Erisa Relief, Kendall Victoria Dacey

Pepperdine Law Review

When the Affordable Care Act (ACA) became law in late March, 2010, Dave & Buster’s (D&B) had a choice: it could either comply and offer its full-time employees the minimum health insurance coverage required by the new “employer mandate” or it could ignore the new requirements and incur a penalty. Dissatisfied with either option, D&B made the drastic decision to circumvent the ACA entirely, and reduced its full-time staff below the ACA’s employee threshold so as to avoid triggering any penalty or having to pay increased health care costs. However, by dodging the employer mandate, D&B may have come in …

Some Thoughts On "Healthism" And Employee Benefits In The Age Of Trump

Marquette Benefits and Social Welfare Law Review

None

From The Technical To The Personal: Teaching And Learning Health Insurance Regulation And Reform, Allison K. Hoffman, Whitney A. Brown, Lindsay Cutler

All Faculty Scholarship

In the Fall of 2016, I taught Health Law and Policy for the fourth consecutive semester. Over time, one thing has become increasingly clear: the aspect of this course that I work with most closely as a scholar—the regulation of health care financing and insurance, including the Patient Protection and Affordable Care Act (ACA)—is also the material that I find the most challenging to teach. Every time I reflect on teaching this material, and hear from students about how they learn this material, the thing that stands out is how critical it is that my students understand the profound impact …

Surviving The Storm 2016: Employee Benefit Compliance & Employment Law Update, George Thompson, Brooks R. Magratten, Mark A. Pogue, Kelli Viera, Cecily Banks, Roger Williams University School Of Law

School of Law Conferences, Lectures & Events

No abstract provided.

Regulating Employment-Based Anything, Brendan S. Maher

Faculty Scholarship

Benefit regulation has been called “the most consequential subject to which no one pays enough attention.” It exhausts judges, intimidates legislators, and scares off theorists. That need not be so. Reality is less complicated than advertised.

Governments often consider intervention if markets fail to make some socially desirable Good X — such as education, health care, home mortgages, or pensions, for example — sufficiently available. One obvious fix is for the government to provide the good itself. A less obvious intervention is for the government to regulate employment-based (EB) arrangements that provide Good X as a benefit to employees and …

The Effect Of Pegram V. Herdrich On Hmo Liability, Dawn Marie Kelly

Touro Law Review

No abstract provided.

The Collective Fiduciary, Lauren R. Roth

Scholarly Works

Can fiduciaries be made to serve public goals? The movement under the Patient Protection and Affordable Care Act (“ACA”) towards universal access to health insurance requires us to focus on the fiduciary relationships between large organizations providing access to healthcare and the populations they serve. These relationships have become a collective undertaking instead of a direct, personal relationship.

In this Article, I introduce the concept of the collective fiduciary in response to the shift towards uniform, national goals in the realm of health insurance and healthcare. Only through a collective approach can we hold fiduciaries accountable for the welfare of …

Self-Insurance For Small Employers Under The Affordable Care Act: Federal And State Regulatory Options, Timothy Stoltzfus Jost, Mark A. Hall

Timothy S. Jost

As implementation of the Affordable Care Act reshapes the US health insurance market, state and federal policy makers should be prepared to revisit regulation of stop-loss coverage — a form of reinsurance — for small businesses. Aspects of the reform law could motivate small businesses to self-insure, rather than participate in state-regulated markets either inside or outside the new health insurance exchanges. If younger or healthier groups self-insure, premiums for insured plans will rise, perhaps to an extent that could seriously impair the regulated market. State or federal lawmakers can influence small businesses to participate in the regulated market by …

Are We Protected From Hmo Negligence?: An Examination Of Ohio Law, Erisa Preemption, And Legislative Initiatives, Amy K. Fehn

Akron Law Review

This comment discusses the various theories of HMO liability that are emerging in other jurisdictions as well as the extent to which current Ohio law bars several of these theories. In addition, this comment also discusses ERISA's preemption of state laws related to HMO liability. Finally, this comment analyzes legislative initiatives and other forms of regulation aimed at protecting consumers from HMO abuses .

Managed Care Organizations Manage To Escape Liability: Why Issues Of Quantity Vs. Quality Lead To Erisa's Inequitable Preemption Of Claims, Patricia Mullen Ochmann

Akron Law Review

In evaluating patients’ potential legal remedies, this Comment explores 1) the emergence of managed care organizations in the United States; 2) the creation of the Employee Retirement Income Security Act of 1974 (“ERISA”) and how it impacts patients’ claims against their MCOs; 3) the question of “quantity” versus “quality” in evaluating whether ERISA preemption exists; 4) three theories (direct liability, breach of fiduciary duty, and vicarious liability) used to hold MCOs liable for injuries resulting from malpractice or the wrongful denial of benefits; 5) state legislative attempts to circumvent ERISA’s inequitable preemption of claims; and 6) why, given ERISA’s failure …

Scaling Cost-Sharing To Wages: How Employers Can Reduce Health Spending And Provide Greater Economic Security, Christopher Robertson

Faculty Scholarship

In the employer-sponsored insurance market that covers most Americans many workers are “underinsured.” The evidence shows onerous out-of-pocket payments causing them to forgo needed care, miss work, and fall into bankruptcies and foreclosures. Nonetheless, many higher-paid workers are “overinsured”: the evidence shows that in this domain, surplus insurance stimulates spending and price inflation without improving health. Employers can solve these problems together by scaling cost-sharing to wages. This reform would make insurance better protect against risk and guarantee access to care, while maintaining or even reducing insurance premiums.

Yet, there are legal obstacles to scaled cost-sharing. The group-based nature of …

Overvaluing Employer-Sponsored Health Insurance, Lauren R. Roth

Scholarly Works

Although positive and negative assessments of tying health insurance to employment abound, most scholars and policymakers have acknowledged that our long history in this area predicts our future. What they have largely ignored, however, is the extent to which individual attachment to employment-based insurance is at the root of our inability to make broader health reforms. The attachment (1) harms exchange-based insurance and (2) denies employers the ability to use Health Reimbursement Arrangements (“HRAs”) to subsidize the purchase of insurance by their employees on the exchanges.

This Article advocates reducing or eliminating workers’ overvaluation of their health insurance and increasing …

The Affordable Care Act, Remedy, And Litigation Reform, Brendan S. Maher

Faculty Scholarship

The Patient Protection and Affordable Care Act of 2010 (“ACA”) rewrote the law of private health insurance. How the ACA rewrote the law of civil remedies, however, is — to date — a question largely unexamined by scholars. Courts everywhere, including the United States Supreme Court, will soon confront this important issue.

This Article offers a foundational treatment of the ACA on remedy. It predicts a series of flashpoints over which litigation reform battles will be fought. It identifies several themes that will animate those conflicts and trigger others. It explains how judicial construction of the statute’s functional predecessor, the …

The Compliance Case For Information Governance, Peter Sloan

Richmond Journal of Law & Technology

In an increasingly convoluted information environment, organizations strive to manage information-related risks and exposures, minimize information-related costs, and maximize information value. The inadequacy of traditional strategies for addressing information compliance, risk, and value is becoming clear, and so too is the need for a better, more holistic approach to governing the organization’s information.

It's A Mistake: Insurer Cost Cutting, Insurer Liability, And The Lack Of Erisa Preemption Within The Individual Exchanges, Christopher Smith

Cleveland State Law Review

In today’s society, most people receive their health insurance through their employers. If their employment-based insurer engages in cost cutting that leads to patient injury, Employee Retirement Income Security Act of 1974 (“ERISA”) preemption means that these people have no state tort-based recourse against their insurers. ERISA is a federal statute that regulates employee benefit plans, and the Supreme Court has interpreted the ERISA statute to preempt most beneficiary state tort claims against an employment-based insurer. In other words, even if the insurer, and not the doctor, caused the patient’s harm, the patient with employment-based insurance can only sue their …

A Restatement Of Health Care Law, David Orentlicher

Scholarly Works

No abstract provided.

The Pay Or Play Penalty Under The Affordable Care Act: Emerging Issues, Kathryn L. Moore

Law Faculty Scholarly Articles

The Affordable Care Act does not require that employers provide employees with health care coverage. It does, however, impose an excise tax on large employers that fail to offer their employees affordable employer-sponsored health care coverage. The excise tax, commonly referred to as a “pay-or-play penalty,” was scheduled to go into effect beginning in 2014. The United States Treasury Department (“Treasury”), however, has delayed enforcement of the penalty until 2015 for employers with 100 or more full-time employees, and until 2016 for employers with 50 to 99 employees.

Implementation of the pay-or-play penalty has given rise to a host of …

Managed Care Grievance Procedures: The Dilemma And The Cure , Joyce Krutick Craig

Journal of the National Association of Administrative Law Judiciary

No abstract provided.

Enough About The Constitution: How States Can Regulate Health Insurance Under The Aca, Brendan S. Maher, Radha A. Pathak

Faculty Scholarship

Last term, the United States Supreme Court upheld the constitutionality of the Affordable Care Act in a landmark decision. It is a forceful reminder that America’s oldest question — how power should be shared between federal and state sovereigns — retains powerful political salience. Critics have reflexively attacked the decision as an assault on states’ rights, while supporters have celebrated the result. Regrettably, insufficient attention has been paid to how, in actuality, health care regulatory authority has been and will be divided between federal and state governments. In this Article, we fill that gap. To do so, we apply “federalism-in-fact,” …

Equality Standards For Health Insurance Coverage: Will The Mental Health Parity And Addiction Equity Act End The Discrimination?, Ellen M. Weber

Faculty Scholarship

Congress enacted the Mental Health Parity and Addiction Equity Act in 2008 to end discriminatory health insurance coverage for persons with mental health and substance use disorders in large employer health plans. Adopting a comprehensive regulatory approach akin to other civil rights laws, the Parity Act requires “equity” in all plan features, including cost-sharing, durational limits and, most critically, the plan management practices that are used to deny many families medically necessary behavioral health care. Beginning in 2014, all health plans regulated by the Affordable Care Act must also comply with parity standards, effectively ending the second-class insurance status of …