Academic journal article Health and Social Work

Managed Care: Satisfaction Guaranteed ... Not!

Academic journal article Health and Social Work

Managed Care: Satisfaction Guaranteed ... Not!

Article excerpt

"There's got to be a better way."

- Harry and Louise [TV commercial], 1993

Three original articles in this issue of Health & Social Work highlight social work s growing involvement in the institutionalization of managed health care, providing us with an opportunity to appraise the remarkable transformative effects of this uniquely U.S. hybrid market form of privately administered health care delivery. August 1999 - only 14 months from the next national election - is an opportune time to reconsider whether social work's values and interests are being served by this new industry.

The first article by Rocha and England Kabalka examines the experiences of low-income people with the now-notorious TennCare Medicaid managed care, in which Tennessee, like many other states, attempted in the mid-1990s to bring under a managed care umbrella people previously uninsured (approximately 30 percent of the state's population) and uninsurable (those whose Medicaid benefits had run out). Comparing the satisfaction of people who had Medicaid previously with those who had no insurance, the authors discovered early in the Tennessee "experiment" the vulnerabilities of health care reform through 50 unique state Medicaid programs. A frenzy of newly generated business interests soon riddled the program with accountability problems. Then, with TennCare's credibility low, Tennessee was unable to raise the required matching funds to sustain benefits and entitlements.

Various states have tried different approaches with managed care organizations (MCOs) under the Health Care Financing Administration-(HCFA-) approved 1,115 waivers. In mental health and substance abuse services, carve-in and carve-out models have been tested. Recently, the limited state tax bases (for example, no sales tax) apparently have redefined TennCare's original aspirations. Poor coordination of care, inadequate coverage, insufficient knowledge of special populations, and the excessive demands of a profit-oriented industry have combined to cause other MCOs to fail in other parts of the country. The cycle of inflated hopes dashed under Medicaid managed care has been repeated in Oregon, Florida, and dozens of other well-intentioned states. Even so, managed care has become the new "scientific" paradigm for business to counteract allegedly "profligate" doctors and "bleeding-heart" social workers. Caught between jargon and data, consumers and providers are now earnestly searching for assurance that managed care can work for them.

In 1997 the number of uninsured Americans reached a new high of 43.4 million - 16.1 percent of the population - the highest proportion in five years. People of color and other oppressed groups often were hardest hit. The proportion of working-age people (ages 19 to 64) without health insurance grew from 15.1 percent in 1979 to 23.3 percent in 1995 (Kronick & Gilmer, 1999). In our capitalist society, where employers call the shots on so much about health care expenditures, only 61.4 percent of employed people are insured by their employers. If one adds to these numbers the marginalized populations who pay out of pocket, are underinsured, or go without any health care, it becomes clear that our nation's health plans, managed or otherwise, are not meeting the needs of the people.

About 40 percent of health care spending is from public sources, and accountability for public sector funds is especially murky, with buck passing among the administration, Congress, the states, the courts, and lobbyists. Realistically, neither market forces, special interest groups, government response, nor public opinion seems likely to interrupt the power of managed care.

"Market demand for benefit diversity disadvantages plans that remain attached to a uniform benefit design" (Robinson, 1999, p. 15). Although MCOs are positioned to maintain control over private and public health care dollars in the future, they could also mutate into another kind of service if consumers demand change. …

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