Health Law and Policy Commons^™

Shifting The Conversation: Disability, Disparities And Health Care Reform, Elizabeth Pendo

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This piece is an invitation to consider health care reform as a political shift in our thinking about the barriers and inequalities experienced by people with disabilities in our health care system. Traditionally, when these issues have been addressed, the predominant approach has been through a civil rights framework, specifically the Rehabilitation Act of 1973 and the American with Disabilities Act of 1990 (ADA). Now, the Patient Protection and Affordable Care Act of 2010 (PPACA) offers a new approach. This essay will outline the barriers to health and health care experienced by people with disabilities, drawing upon my ongoing research …

The Affordable Care Act And Competition: Antidote Or Placebo?, Thomas L. Greaney

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In the run-up to its enactment, the Patient Protection and Affordable Care Act (ACA) elicited howls of protest from opponents who claimed the federal government was, “taking over,” the American healthcare system, “micromanaging,” medicine, and generally exposing the nation to the bête noire of, “socialized medicine.” Hyperbole, misrepresentation and chauvinism aside, these sound bites suffer from a deeper flaw: They mischaracterize the fundamental thrust of the new law. Though the law establishes significant new regulatory authority, this is neither a new development (indeed it can be faulted for preserving pre-existing regulatory regimes) nor does it impair market competition. To the …

Regulating To Promote Competition In Designing Health Insurance Exchanges, Thomas L. Greaney

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Many of the most contentious issues in the debate over health reform concerned the performance and competitiveness of private health insurance including abusive and unfair practices such as denying coverage to individuals with pre-existing conditions; the impact of dominant insurers serving individual and small group markets; and purportedly excessive profits of the insurance industry and lavish salaries of their executives. A key component of the Affordable Care Act for implementing and overseeing reforms directed at these problems is the establishment of market-making entities, health insurance exchanges. These state-run entities will certify insurers’ compliance with regulations, monitor their performance, and take …

Racial Inequities In Mortality And Access To Health Care: The Untold Peril Of Rationing Health Care In The United States, Ruqaiijah A. Yearby

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On February 25, 2007, a 12-year-old African American boy named Deamonte Driver died of a toothache because he did not receive a routine $80 tooth extraction that may have saved him, which was covered by his insurer: Medicaid. Unable to afford $80 or find a dentist that took Medicaid, Deamonte wound up in the emergency room, underwent two brain surgeries, and was in the hospital for six weeks of treatment, which cost approximately $250,000. In the end, Deamonte still died from a brain infection caused by the spread of the bacteria from the abscess in his mouth.

While Deamonte did …

From Almshouses To Nursing Homes And Community Care: Lessons From Medicaid's History, Sidney D. Watson

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Home and community-based services are support and long-term care services that offer an alternative to institutional care for those who need assistance with life's daily activities. For Lois Curtis of Atlanta, one of the plaintiffs in the Olmstead v. L.C.¹ who spent most of her life in mental institutions, it means a live-in companion who helps her with the day-to-day activities of living in her own home, like managing finances, cooking meals, and keeping track of medications.² For Larry McAfee, another Georgian who was quadriplegic, community-based services involved round-the-clock personal care, wheelchair accessible bathrooms and kitchens, a specialized …

Litigation, Integration, And Transformation: Using Medcaid To Address Racial Inequities In Health Care, Ruqaiijah A. Yearby

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Instances of racial discrimination in health care continue despite the enactment of civil rights laws, such as Title VI of the Civil Rights Act of 1964 *329 (Title VI). Title VI prohibited racial discrimination by health care entities receiving government funding such as Medicaid payments. The federal government focused its initial efforts on hospitals. Because hospitals relied on federal funding, the federal government was able to force hospitals to integrate without much resistance from the hospital industry. However, since this accomplishment the government has relied too heavily on assurances of compliance from other health care entities, such as nursing homes, …

African Americans Can't Win, Break Even, Or Get Out Of The System: The Persistence Of “Unequal Treatment ” In Nursing Home Care, Ruqaiijah A. Yearby

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Empirical data show that racial disparities in the quality of care provided by nursing homes are a common occurrence, not isolated to Illinois. Nine years after the publication of the groundbreaking Institute of Medicine Study (“IOM study”) Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, which acknowledged continued racial disparities in health care and provided suggestions for the elimination of these disparities, racial disparities still remain. One chief example of the continuation of racial disparities in health care is in the provision of nursing home care.

Decades of empirical research studies have shown that racial disparities in accessing quality …

Litigation, Integration, And Transformation: Using Medicaid To Address Racial Inequities In Health Care, Ruqaiijah Yearby

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Using a public health policy perspective, this article examines the persistence of racial inequities in nursing homes and prescribes a solution to address these inequities. I use empirical data to prove the persistence of racial inequities in health care, analyze the government policies that allow racial inequities to continue, and provide a solution of regulatory integration. Specifically, I propose that civil rights enforcement be integrated with the nursing home enforcement system, which has been aggressively enforced and monitored. There are many strategies that may lead to the adoption of this system. One such strategy is using the Medicaid Act to …

Accountable Care Organizations: A New New Thing With Some Old Problems, Thomas L. Greaney

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When pressed for evidence that the proposed health reform legislation will control costs, proponents invariably cite the numerous pilot programs and other innovations in Medicare payment policy contained in the bill. At first blush, the ACO model seems well designed to foster competition among providers. Not unlike health maintenance organizations and other integrated delivery forms, ACOs assume responsibility for coordinating care and thus have strong incentives to provide cost effective care and to do so in a manner that is transparent and hospitable to comparative shoppers. But at the same time, the path of ACO development could prove profoundly anti-competitive. …

Reducing Disparities Through Health Care Reform: Disability And Accessible Medical Equipment, Elizabeth Pendo

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People with disabilities face multiple barriers to adequate health care and report poorer health status than people without disabilities. Although health care institutions, offices, and programs are required to be accessible, people with disabilities are still receiving unequal and in many cases inadequate care. The 2009 report by the National Council on Disability, The Current State of Health Care for People with Disabilities, reaffirmed some of these findings, concluding that people with disabilities experience significant health disparities and barriers to health care; encounter a lack of coverage for necessary services, medications, equipment, and technologies; and are not included in the …

A Service Learning Project: Disability, Access And Health Care, Elizabeth Pendo

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Last summer, I was thinking about a public service project for my disability discrimination law course. I teach the course in fall, and try to incorporate a project each year. At the same time, I was working on a project looking at barriers to health care for people with disabilities. Some of the barriers are well known, such as lower average incomes, disproportionate poverty, and issues with insurance coverage, to name just a few. I was looking at barriers of a different type, however: those posed by physically inaccessible facilities and equipment. This was a new area for me. Like …

A Prisoner's Constitutional Right To Medical Information: Doctrinally Flawed And A Threat To State Informed Consent Law, Robert Gatter

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White v. Napoleon and its progeny recognize a substantive due process right to receive the disclosure of medical treatment information. While each case involves a prisoner receiving treatment while in custody, the constitutional right described in those cases is not limited to prisoners. Instead, the right is described as belonging to all individuals. Consequently, this line of cases is poised to interfere with the disclosure standards that operate in state informed consent law in the many instances where state action exists. This Article argues that the substantive due process right recognized in White should be overturned. The right is based …

Does Twenty-Five Years Make A Difference In “Unequal Treatment”?: The Persistence Of Racial Disparities In Health Care Then And Now, Ruqaiijah A. Yearby

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In 1985, the Secretary of the U.S. Department of Health and Services (HHS) issued a landmark report that exposed the persistence of racial disparities in the U.S. healthcare system. Unfortunately, twenty-five years later, racial disparities in healthcare continue to persist. For example, since 1985, more African-Americans have died from coronary disease, breast cancer, and diabetes than Caucasians, even though more Caucasians suffer from these diseases than African-Americans. Notwithstanding their increased mortality rates, African Americans “have a statistically significantly lower mean number of annual ambulatory [walk-in] visits and are less likely to have seen a physician in [any given] year.” Studies …

Race, Sex And Genes At Work: Uncovering The Lessons Of Norman-Bloodsaw, Elizabeth Pendo

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The Genetic Information Nondiscrimination Act of 2008 (“GINA”) is the first federal, uniform protection against the use of genetic information in both the workplace and health insurance. Signed into law on May 21, 2008, GINA prohibits an employer or health insurer from acquiring or using an individual’s genetic information, with some exceptions. One of the goals of GINA is to eradicate actual, or perceived, discrimination based on genetic information in the workplace and in health insurance. Although the threat of genetic discrimination is often discussed in universal terms - as something that could happen to any of us - the …

A Defense Of Embryonic Stem Cell Research, Gregory Dolin

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On November 21, 2007, sensational scientific developments were reported by major newspapers, both in the United States and abroad. The media reported a new breakthrough in the area of stem cell research. According to two articles published in Science and Cell (both highly respected scientific journals), two teams of scientists were able to “reprogram” adult stem cells into embryonic stem cells, without actually having to experiment on embryos. The discovery was immediately hailed by the White House and other opponents of embryonic stem cell research. The New York Times gushed that the “stem cell wars” may be at an end. …

Changing Expectations For Board Oversight Of Healthcare Quality: The Emerging Paradigm, Valerie Gutmann Koch

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Within healthcare institutions, leadership is an essential driver of expectations, performance, and culture. Yet boards of directors traditionally played a limited role in overseeing healthcare quality, providing final approval of credentialing decisions but deferring to the medical staff to set standards for the institution. Case law and standards provide little guidance for board performance in verseeing quality of care. Recent developments — the availability of comparative quality data, public reporting, and financial incentives for higher quality — have transformed expectations for board oversight. Enforcement of fraud and abuse laws based on poor quality of care, as well as federal standards …

Conflicts Of Interest In Clinical Trial Recruitment & Enrollment: A Call For Increased Oversight, Valerie Gutmann Koch

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This White Paper makes several policy recommendations to eliminate or manage the conflicts of interest that arise pursuant to the compensation arrangements between investigators and their institutions with drug and medical device manufacturers as they affect the recruitment and enrollment of human research subjects in clinical trials. The paper seeks to accomplish overall financial neutrality as between treatment and research, so that physicians' decisions regarding inclusion of patients in clinical trials is unaffected by their own financial interests.

Competition Policy And Organizational Fragmentation In Health Care, Thomas L. Greaney

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A central challenge for all health care reform proposals currently being discussed is finding the means to effectively channel market forces given many deeply embedded features of our system and the peculiar economics of health care delivery and financing. This essay traces the path of competition law in health care and explains its chicken-and-egg relationship with provider organizational arrangements. It explores a central puzzle for future health care policy: why have market forces failed to counteract organizational fragmentation? Answering this question requires an understanding of why competition policy is inexorably linked to the organizational structures of health care providers and …

Medical Hope, Legal Pitfalls: Potential Legal Issues In The Emerging Field Of Oncofertility, Gregory Dolin, Dorothy E. Roberts, Lina M. Rodriguez, Teresa K. Woodruff

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The article will begin its discussion by identifying the values at stake in the field of oncofertility. These values include the constitutional protection of the rights of women and minors to bear children and to use reproduction-assisting technologies, as well as the feminist critique of gendered expectations that may pressure women to use these technologies.

Part III will focus on the medical options of oncofertility. It will also discuss some conditions that may lead otherwise fertile and young patients to lose their ability to bear children as a side-effect of necessary medical treatment. The article will then proceed to discuss …

Working Sick: Lessons Of Chronic Illness For Health Care Reform, Elizabeth Pendo

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Although chronic illness is generally associated with the elderly or disabled, chronic conditions are widespread among working-age adults and pose significant challenges for employer-based health care plans. Indeed, a recent study found that the number of working-age adults with a major chronic condition has grown by 25 percent over the past 10 years, to a total of nearly 58 million in 2006. Chronic illness imposes significant costs on workers, employers, and the overall economy. This population accounts for three-quarters of all personal medical spending in the United States, and a Milken Institute study recently estimated that lost workdays and lower …

Regulating Physician Behavior: Taking Doctors’ 'Bad Law' Claims Seriously, Sandra H. Johnson

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Physician behavior is a key target of government regulation intended to improve the efficiency, quality, and accessibility of health care. Yet according to physicians’ "bad law" claims, the legal effort to promote patient health and well-being has actually caused significant harm. These "bad law" claims - that malpractice litigation prompts defensive medicine, that patients’ rights policies prompt doctors to provide futile care, that controlled substance laws cause physicians to undertreat patients in pain - have diminished in significance due to the deconstruction of professionalism. Claims are often discarded as the cries of "bad apple" doctors or in the interest of …

Public-Private Partnerships And Insurance Regulation, Alexander A. Boni-Saenz

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A public-private partnership (PPP) is an institutional arrangement that embodies a collaborative approach to policy and regulation; it is a joint venture between the government and one or more private sector entities. Joint financing partnerships link public financing and private insurance to pay for certain social goods. Where the financing for social goods is fragmented and overlapping, as it is for health and social care, joint financing PPPs may help organize existing financing streams. This piece argues that partnerships of this type also present an opportunity for consumer-protective regulation of the insurance industry if certain conditions are met. Private insurers …

Tales From The Crypt: Scientific, Ethical, And Legal Considerations For Biohistorical Analysis Of Deceased Historical Figures, Lori B. Andrews, Jordan K. Paradise

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Biohistorical analysis involves using historic specimens of human remains or human material extracted or derived from historical artifacts to gather evidence about specimens that are identifiable or at least attributed to a historic figure at the time of the research. Biohistorical studies are being undertaken for myriad reasons, such as identification and authentication of remains, investigation into alleged criminal behavior, investigation into medical or psychological conditions, and even for purposes of commercialization. This article analyzes federal statutes, case law, and codes and guidelines from twenty-six professional organizations and societies informative to the field of biohistory. We surveyed the field, identified …

Review Of Jonathan Baron, Against Bioethics, Chad Flanders

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This is a short review of a recent book by Jonathan Baron, entitled "Against Bioethics."

Brave New Babies, Lori B. Andrews

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No abstract provided.

Newsgathering In Light Of Hipaa, Alexander A. Boni-Saenz

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This short piece examines the interaction between the Health Insurance Portability and Accountability Act (HIPAA), a federal law designed to protect the privacy of individuals’ health information, and state Freedom of Information (FOI) laws, which are designed to ensure public access to government documents. It describes three recent cases from different states that addressed difficult issues about where and how to draw the line between the public’s right to know and individuals’ rights to keep their medical information secret. It concludes that questions about the interaction of state FOI laws and HIPAA should be guided by the framework suggested in …

Striving For Equality, But Settling For The Status Quo In Health Care: Is Title Vi More Illusory Than Real?, Ruqaiijah A. Yearby

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Prior to 1964, racial segregation and discrimination in health care was government funded under the Hospital Survey and Construction Act, better known as the Hill-Burton Act. Specifically, section 622(f) of the Hill- Burton Act proscribed federal funding for “separate but equal” health care services. The United States tried to put an end to racial discrimination in the health care system by intervening in a private action that challenged the constitutionality of the Hill-Burton Act and with the enactment of Title VI of the Civil Rights Act of 1964, which banned racial discrimination in health care for institutions receiving federal funding. …

Polluting Medical Judgment? False Assumptions In The Pursuit Of False Claims Regarding Off-Label Prescribing, Sandra H. Johnson

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Over half of the FDA-approved prescription medications taken by patients are prescribed for a different purpose, in a higher or lower dose, for a discrete population, or over a longer period of time than that for which the drug was approved. Safety and efficacy concerns attract the most attention; but critical benefits in fostering innovation and providing patients with medications that may be uniquely effective for them are often overlooked.

The current dominant public policy response to off-label prescribing addresses this practice as a particular breed of financial conflicts of interest in which pharmaceutical firms pollute medical judgment by appealing …

The Road From Massachusetts To Missouri: What Will It Take For Other States To Replicate Massachusetts Health Reform?, Sidney D. Watson, Timothy Mcbride, Heather Bednarek, Muhammad Islam

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In April 2006, the Massachusetts Legislature passed Chapter 58 of the Acts of 2006, An Act Providing Access to Affordable, Quality, Accountable Health Care, sweeping health reform legislation designed to achieve nearly universal health insurance coverage.¹ While Massachusetts is not the first state in recent years to enact legislation intended to achieve near-universal coverage, its efforts have attracted the most national attention and the most notice from other states interested in duplicating the Massachusetts Model.

Fortuitous political and budgetary circumstances converged in Massachusetts to move reform forward. First, stakeholders and elected officials worked together over a number of years …

Striving For Equality, But Settling For The Status Quo: Is Title Vi More Illusory Than Real?, Ruqaiijah Yearby

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A plethora of empirical studies, such as the Institute of Medicine’s Unequal Treatment report, have shown that racial inequities in health care continue at the same level as in the Jim Crow Era. Innumerable reasons have been offered to explain the continuation of these health inequities, including racial discrimination. Congress enacted Title VI of the Civil Rights Act of 1964 to put an end to racial discrimination in health care, but it still persists. Given the regulation and enforcement mechanisms established under Title VI explicitly aimed at remedying racial discrimination such as that directed at elderly African-Americans it is unbelievable …