Regulating Managed Care: Theory, Practice, and Future Options

By Stuart H. Altman; Uwe E. Reinhardt et al. | Go to book overview

in quality or will more individuals end up uninsured because of increased costs? It is clear that additional mandates and regulations on health plans will increase costs, but it is not known by how much. 20 Therefore, it is impossible to predict the extent to which employers and unions would stop providing benefits if faced with more regulations.

The central question is this: Can the present marketplace force a higher quality of health care, or will regulation better serve consumers? And if regulation is chosen, will many potentially innovative ways to finance health care be lost, as employers assert, because strict regulations limit experimentation?


Notes
1
The term group health plan is used in ERISA to describe “an employee welfare benefit plan providing medical care (as defined in section 213[d] of Title 26) to participants or beneficiaries directly or through insurance, reimbursement, or otherwise.”
2
For example, in the early 1960s, when the Studebaker automobile company collapsed, thousands of vested workers too young to retire were left with substantially reduced pension benefits.
3
Recent court rulings appear to have placed a limit on the states' ability to regulate completely the design of an insured plan. For instance, some states' any willing provider laws have been ruled to be preempted by ERISA. For example, in Texas Pharmacy Association v. Prudential Insurance Company, the Fifth Circuit Court of Appeals ruled that any willing provider law was preempted by ERISA.
4
States are able to regulate the solvency and other basic insurance aspects of stop-loss insurers but cannot mandate health benefits for stop-loss insurance plans.
5
An attachment point is the maximum amount a self-funded plan must pay on a total cost or per employee per benefit year basis before the stop-loss insurer assumes liability.
6
For example, see Brown v. Granatelli (1990).
7
Shaw v. Delta Air Lines (1983).
8
Debuono v. NYSA-ILA Medical Services Fund (1997), California Division of Labor Standards Enforcement v. Dillingham Construction, N.A., Inc. (1997), and Boggs v. Boggs (1997).
9
The test contained the following three parts: the activity must spread risk, the relationship between insured and insurer must be an integral

-200-

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