Saturday, November 20, 1999

Expert: Children’s
health care is isles’
Achilles heel

The law professor says too
many people, especially kids,
still lack coverage here

Giving doctors the final say
to have 'tremendous impact'

By Helen Altonn


A noted mainland researcher and author on health-care issues who came here to write about Hawaii as "a poster child for health-care financing reform" says the situation isn't as good as she expected.

"The more I'm here, the more I see problems," Sylvia Law of New York University said in an interview. She is a professor in NYU's School of Law and co-director of the Arthur Garfield Hays Civil Liberties Program.

"No. 1, not as many people are covered by insurance as state or federal surveyors suggest," she said. "There are a lot of loopholes. And No. 2, the thing that really gets me angry is Hawaii is worse than many other states in terms of child health care."


Bullet Who: Sylvia Law
Bullet What: Mainland researcher and author on health-care issues.
Bullet Background: Professor in New York University's School of Law, co-director of the Arthur Garfield Hays Civil Liberties Program and author of books including "Law and the American Health Care System," "American Health Law," and "Patient's Rights."
Bullet Quote: "Hawaii is worse than many other states in terms of child health care."

Law said she came here on sabbatical leave as a University of Hawaii visiting law professor because Hawaii has the highest rate of insurance coverage of any state. She said she wanted to write an article primarily for mainland audiences about Hawaii has done it and how other states could follow its lead.

Hawaii has a unique exemption from the federal Employers Retirement Security Act that prevents states from adopting employer mandates for health care, Law noted.

"I think it is so evil. I have been fighting ERISA almost 30 years, since it was adopted," she said.

Hawaii was exempt because it had employer mandates for health coverage in the 1970s before the federal law was adopted, she said. "I think the leadership of labor unions here was more progressive than labor leadership in any other state."

She said labor leaders in most states don't want mandated health insurance coverage because then they can go to workers and encourage them to unionize to get health benefits.

"So big labor, along with big business, supported the federal law that says states can't require coverage. But in Hawaii, the labor leadership was more visionary."

Hawaii also has had "wonderful, effective, democratic representation in Washington," Law added, pointing out that when Congress adopted ERISA, "your representatives got Congress to say Hawaii can have an exemption but no one else should ever ask."

But in the six weeks that she's been here, Law said she's found "child health is the real Achilles' heel ... Hawaii does not do well on child health. I frankly do not yet understand why."

Congress has offered states grants to participate in the federal Children's Health Insurance Program (CHIP), established to provide health insurance coverage to children of low-income families, Law noted.

The state has estimated about 5,304 children may be eligible for the program. Human Services Director Susan Chandler has said it will expand eligibility for children for Medicaid based on 200 percent of the poverty level. The poverty line for Medicaid and state QUEST health benefits is 100 percent.

The state has joined the program and pledged to enroll 440 children and spend $250,000 over the next year, Law said. But she said, "There's $9 million (Hawaii's CHIP allocation) in Washington waiting for Hawaii to ask for it. It's outrageous."

States must provide 45 percent matching money to collect their share of the block grants, which Hawaii hasn't done yet. State funding is to come from Hawaii's share of the tobacco settlement next year.

"I appreciate that the state is in financial crisis," Law said. "But hey, Alabama is not in such great fiscal shape. Hawaii does worse than states with greater fiscal problems. I really don't understand why.

"I know a lot of advocates and providers are upset about it, but I'm also somewhat critical that there hasn't been more of a fuss about it."

Overall, she said, with no solution likely from Congress, the states must address the problems presented by a growing population without health insurance.

"The question of health care has to be answered in a particular political concept -- a deep tradition of providing benefits, health insurance and pensions through work. We have to build on that tradition."

With the failure to find a national solution to health care, she said, "I think most states will follow Hawaii's model and build on employment-based insurance."

Giving doctors
the final say to have
‘tremendous impact’

By Helen Altonn


The recent move by the nation's second-largest insurer to give doctors final say on medical treatment is "a bombshell," says Sylvia Law, a noted mainland researcher and author on health-care issues.

She said it's been clear to her, from studying the issues a long time, that micromanagement of doctors' decisions isn't cost beneficial. So, the UnitedHealth Care Group saying, " 'The emperor has no clothes' is, I think, going to have tremendous impact," Law said.

The fear is what the insurer will substitute for micromanagement, such as "creating schemes where doctors' income turns on how many tests they order, how many referrals they make," Law said. "The insurance company doesn't say you can't order a test or referral or keep a patient in the hospital an extra day, only if you do those things you'll make less money."

That's already being done in a lot of plans, she said, with financial incentives provided not to order tests.

"On the other hand," Law added, "there is no doubt the old system where doctors could order whatever they wanted and get paid by ordering more created excesses and tremendous injury to patients who had unnecessary surgery, who had unnecessary tests.

"So the old system, just saying whatever the doctor says goes, and the doctor gets paid, is not a good system" either.

Law said Dr. John Wennberg began doing research about 20 years on medical care and found that the chance of having an appendectomy, tonsillectomy or other procedures was greater in some geographical areas than in others. He identified the problem as "physician practice style," Law said.

"Doctors, like all of us, learn from our peers, from our mentors. Sometimes we learn things that aren't that beneficial."

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