Health Care Future Shock
Submitted by early-bird on May 15, 2008 - 4:45pm.
Health Care Crisis

Healthcare future shock: It’s closer than you think CROSSKOS:Thu May 15, 2008
By Donna Smith, American SiCKO, Communications Specialist for the California Nurses Association/National Nurses Organizing Committee
CHICAGO—We used to get annoyed when the admission desk at the hospital would hold us up from getting care with the co-pay collection effort, but now the world of medical finance and consumerism is about to take a giant leap forward. Co-pay collections of the early 21st century will seem mild and meek, and we patients will more formally and openly be viewed as earnings units and revenue streams... unless we act forcefully and quickly to alter the coming reality.
Shocked as we might pretend to be, we have been a party to the transition as we have stood by and watched as so many of our fellow citizens went without access to care at all – 47 million fellow citizens uninsured. Fifty million more under-insured. And the rest of us annoyed with the process but silently and slightly smug about our own insured status – else we would have been marching in the streets, screaming for change and fighting for one another and the human right that is our healthcare.
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- donnasicko's diary :: ::
Oh, wait, some of us have been doing that. But we must get louder and more clear and we must do so in larger numbers.
We haven’t fought enough – yet. The financial gurus have wined and dined with the healthcare bosses and the corporate/government policy wonks in Washington. And then the computer folks who brought us internet banking and online loan applications and adjustable rate, re-finance mortgages stepped in. The invitation list grew and now the stockholders were growing nearly rabid with glee and anticipation.
This summer, as the U.S. Presidential race drones on and the races for Congress heat up, the team working on our healthcare system’s update will keep marching steadily forward.
Medical institutions have already signed up to start using patients’ medical credit ratings to predict how patients will pay their portions of medical debt. Each of us has already secured our scores over the years – as we paid or didn’t pay medical bills, as insurance companies delayed payment and bills were turned over to collection agencies, as we incurred out-of-network bills we didn’t even know we had – we each began building our medical credit scores. And the piper must be paid.
Oh, hospital corporations say they’ll only use those scores to step up and "help" patients who may be in need of supportive programs and measures. Sure. OK. We believe that.
Here’s the more likely scenario. Here’s the more likely result of the push for even more corporatization that has the Republicans and even some Democrats salivating as the gross domestic product dedicated to healthcare and all the industries it touches in this nation swells toward the 20 percent mark.
Future shock, U.S. healthcare style:
- Mandate that every American carry private health insurance or buy into public programs (which are now largely moving to private administration), even when policies have huge deductibles and co-pays and include monthly premiums;
- Encourage Americans to save in medical savings accounts by making sure they understand the payroll tax breaks for doing so;
- Coordinate technologies to allow insurance companies and financial institutions to share consumer records with hospitals and clinics and other providers (the electronic medical records business is already moving rapidly forward, just ask retired Congressman Dennis Hastert who now lends his "expertise" to one of the medical technology firms);
- Complete development of financial products that integrate with insurance and health savings to provide "gap financing" on the spot in accordance with the patients’ medical credit rating, insurance coverage and health savings balance.
Anyone naïve enough to think that we aren’t well along in this process need only think back to the days not so long ago when we all thought it absurd that personal computer would be commonplace in every home let alone in every 10-year-old’s backpack.
So, that clerk in the hospital admissions office? Oh, he or she will perform an even more essential function shortly. Check-in for health care in this brave new world will mean providing one’s Social Security card (still our most efficient national identifier) for a multi-step, all inclusive financial transaction: a credit check, an insurance benefits check, a healthcare savings account balance and finally a rapid-response consumer loan transaction to make sure we have the financing in place to be treated for whatever ails us. Don’t make the grade? Well, I’m sorry.
Don’t like that future? Don’t want that sterile, inhuman transaction? Well, then get off your rear-ends now and start fighting with us for the other healthcare vision that is still possible, though chances will grow dimmer if the current power players squeeze us out.
Presumptive (don’t-cha love it) Presidential Candidates Obama and McCain don’t tell us exactly what they envision in the future for healthcare. Candidate Clinton is a bit more clear. Take a look and take a listen and read the plans – which future do you see for patients in this nation?
Let’s make sure we create a little pre-election noise and change those visions now. The healthcare industrial complex is not standing still and waiting for November or for January 2009. We must not either.
Join us in San Francisco on Thursday, June 19th, at noon in San Francisco, at 4th and Howard. We’ll be gathering to protest the 38,000 (yes, 38 thousand) insurance industry executives and groupies gathered for the annual AHIP, American Health insurance Plans, conference. And in other cities around the nation, citizens will gather to protest – watch for details – join in and make noise.
We will be heard. We will not succumb to the forces that would turn a caring and compassionate and strong nation into a corporate playground – and most certainly not in our healthcare system.
We have seen the future and it must be ours...

Agencies "Ruling" Out Tort Lawsuits - The Preemption Doctrine Explained Sun May 18, 2008
This is the third in a series on the usurpation of power that has taken place in the federal administration agencies. They are taking away the right to sue pharmaceutical companies for serious injuries caused by dangerous drugs, among other things. The first part described the basic problem.
To remind readers: This is huge
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The follow ups explain legal issues that, I hope, will help everyone understand just how bad this is in terms of having no basis in law as it was known in the US pre- the Bush administration.
The second part explained the operation of the Administrative Procedure Act and why, I would argue, these decisions violate the APA and the unconstitutional delegation doctrine.
In a third post I explained a bit about torts.
In this post, I will try to explain the third key doctrine the federal agencies and the courts are using to take away the right to sue for tortious injuries - preemption. This doctrine is so important to these cases that in Colacicco v. Apotex, Inc., No.06-5148 (3d Cir. Apr. 8, 2008) - the case I discussed in explaining the APA in the second part- the majority begins its decision by saying:
Clear?
I know it sounds like a bunch of platitudes, but within the platitudes is the concept of preemption, one that has the power to take away the key to the courthouse door.
The Basics
The doctrine of preemption is grounded in the Supremacy Clause in Art. VI of the US Constitution:
In short, when there is federal law in conflict with a state law, the federal law trumps the state law. Put another way, it preempts the state law. The preemption doctrine was created by the Supreme Court, a history that is discussed in the Colacicco case on page 15, bu the majority.
http://www.ca3.uscourts.gov/...
Sounds simple, but it has its own complexities, and understanding those complexities is key to getting what is happening in these cases . . . and why it should not be happening. Why it is contrary to established preemption law.
Here are some of the concepts I will cover: what all can be a law, congressional intent, and types of preemption.
What can be a law
This will be brief. In our system, laws can take many forms. They can be federal and state statutes, federal and state judicial decisions, administrative regulations, among other things. All of these can come into play in connection with preemption.
But here we are concerned with just the preamble (that is, the introductory language) of a federal administrative regulation and whether it can preempt state statutes or judicial decisions.
Congressional intent
Preemption is not supposed to happen willy-nilly. It requires finding that Congress intended to preempt state laws in an area. Or at least that is what the norm has been until these agency preambles.
It would be nice if Congress would just say in every statute: "We intend to preempt state law in any area covered by this law." Or we do not intend to preempt state laws in this area. When Congress clearly states that something is preempted, this is called express preemption.
Sometimes Congress does state its intent in this way, and that is very helpful. But unfortunately, sometimes Congress is vague, so that leaves it to the courts to interpret whether preemption exists and the scope of it. If the courts find there is preemption, this is implied preemption. It is the court interpretation of what Congress' intent was as to preemption, when Congress was vague.
OSHA is a good example. Congress actually included preemption section, but it is so vague, we have yet to get a clear ruling from the Supreme Court as to what it means. The most recent decision, and it was awhile ago, had no majority for preemption or no preemption and for whether there was express or implied preemption.
Types of preemption
Now, add to this a new difficulty. There are several ways preemption can apply to affect state laws. And this can be the case whether or not preemption is express or implied.
So first, bear in mind, that in our country, we basically run two parallel legal systems - state and federal. When a federal law conflicts with a state law, the federal law trumps / preempts because it is the supreme law of the land. But also remember that whether and how much of a conflict or of preemption there is depends on Congress' intent.
But how do we know when there is a conflict?
This may sound like a silly question, but let me give you an example to illustrate the problem. Let's say that Congress passes a federal law that says anyone who violates this law will be subject to a fine of $100. And let's say that there is a state law that covers a similar area and that says anyone who violates the state law will be fined $200. Is there a conflict?
Or, let's say that Congress passes a federal law that says anyone who violates this law will be subject to a fine of $200. And let's say that there is a state law that covers a similar area and that says anyone who violates the state law will be fined $100. Is there a conflict?
In the first case, the state is topping up the federal law. It may be making the federal law more effective, you might say. But what if Congress meant that the perfect fine was where it set it. It is easier to think that in the second case, the state law might undermine Congress' intent.
This is conflict preemption, and this is just one problem that occurs in interpreting Congress' intent. In fact, this issue of conflict preemption was part of the dispute among the Justices when they failed to agree on the nature of OSHA preemption.
A second kind of preemption is field preemption. Field preemption exists when Congress has enacted legislation that occupies the whole area and to such an extent that no state legislation can exist without upsetting the delicate balance created by Contress. The best example is preemption under the National Labor Relations Act.
By the way, in the Colacicco decision, starting on p.15, the majority reviews these types of preemption.
I think now you can understand what the court majority meant when it began its decision by saying:
States have rights too
There is an important brake on preemption that recognizes that states have rights too, and federal law does not always trump. Among those rights are to make laws and decide cases in areas of traditional state regulation, for example, property law, criminal law, and tort law.
In the dissent, you will find on p.43 this quote:
So what sort of preemption do we have with these administrative preambles?
Great question.
First, we have NO statement of congressional intent to allow federal agencies to preempt state laws by using their preambles.
Second, since there is no congressional intent to preempt, the only source for such preemption seems to be action by the agencies themselves. But if this is the case, then we have an unconstitiutional delegation of power to the agencies, an issue that I discussed in the prior post on this subject.. As I discussed there, certain decisions by law must be made by Congress. The decision to preempt state law belongs to Congress. It is not supposed to be within the power of administrative agencies to make this sort of decision.
Until now under the Bush Administrative Procedure Act, which is not available for public view.
So back to the Colacicco case
Here are some excerpts from the decision dealing with preemption. I hope now you can follow the discussion going on between the majority and dissent.
The majority says that this is a case of conflict preemption. (p.18): "whether the plaintiffs’ state law claims conflict with the federal scheme."
Here is the core part of the majority decision discussing whether the agency preamble should preempt a state tort case based on harm caused by a drug.
pp.37-38
Here is another important excerpt:
p.40
This is all, really, nonsense, or at least serious overreaching. In my opinion, the dissent has the better analysis.
The dissent's decision begins:
The dissent argues that the majority "under-emphasizes congressional intent as the 'ultimate touchstone of pre-emption analysis.'" He also points out that the majority is relying on cases that involved express preemption as a basis for finding that the (at-best) implied preemption that exists in this case is sufficient to preempt state tort law.
There is much more in this 58 page opinion. I leave you to read the rest. It's actually a pretty exciting read, both for the impact and, I hope, for the debate about preemption. I hope that now you can appreciate the latter.
I will end with the dissent's conclusion, which, I think, you can now fully appreciate, even if you knew nothing about preemption before.
So should we all dissent!