Mandate Update

To hear some of the presidential candidates, you'd think that health-insurance companies are the driving force behind the growing cost of health insurance. The more likely culprits are our politicians and the laws they pass. Since the early 1990s, the Council for Affordable Health Insurance (CAHI) has tracked state health-insurance mandate legislation in all 50 states, and our actuarial team estimates the impact of those mandated benefits on the cost of a policy.

A health-insurance "mandate" is a legislative requirement that an insurance company or health plan cover (or offer coverage for) common -- but sometimes not so common -- health- care providers, benefits and patient populations. They include:

- Providers such as chiropractors (mandated in 46 states) and podiatrists (35 states), but also massage therapists (four states) and naturopaths (four states);

- Benefits such as mammograms (50 states) and drug abuse treatment (34 states), but also morbid obesity treatment (four states) and wigs for cancer patients (10 states);

- Populations such as dependent students (30 states), but also grandchildren (four states).

Although there were only a handful of state mandates in the 1960s, CAHI's just released "Health Insurance Mandates in the States, 2008" has identified 1,961 nationwide -- up from 1,901 a year ago.

For almost every health-care product or service, there are at least two groups that want insurance to cover it: those who sell the products and services so they can get more business, and those who use the products and services to lower their out-of-pocket costs. Both of these highly motivated groups push state legislators -- and increasingly members of Congress -- to require insurance to cover the care. As a result, government interference in and control of the health-care system is steadily increasing -- and so is the cost of health insurance.

Mandate proponents often claim that covering a particular medical product or service actually lowers health-care costs, because either the proposed coverage costs less than the standard of care (for example, a chiropractor or podiatrist usually charges less than a medical doctor), or the service will reduce or avoid future medical costs.

To be sure, some health-care services such as vaccines and mammograms can be very cost effective, especially when targeting certain at-risk groups and individuals. And many of the mandates we identify would normally be included in a comprehensive health-insurance policy. But the fact is that mandates almost always raise the cost of health insurance. That's because mandates require insurers to pay for care that consumers previously funded out of their own pockets, if they purchased it at all.

Although most mandates will have a relatively small impact when taken individually, it's the cumulative effect that drives up the cost of coverage. It's like telling people they must have a "Cadillac plan" loaded with options. Cadillacs are nice, but not everyone can afford one. And when people can't afford coverage, they join the ranks of the uninsured. Mandates also limit choices. Why should an older couple nearing retirement pay for maternity coverage, or a teetotaler pay for drug and alcohol abuse counseling?

One of the things you notice when tracking mandates over time is that some mandate legislation catches on. For example, over the past several years we have seen a steady increase in the cervical cancer/human papillomavirus (HPV) vaccine mandate. In the last state legislative session, at least 41 states introduced legislation to mandate coverage for this vaccine, and 24 states introduced legislation to mandate the HPV vaccine as part of the school entrance vaccine list.

Another trend is the "eligibility" mandates. Health insurance typically allows dependents to stay on a policy during their college years. But some states are increasing dependent eligibility up to age 30, regardless of student status. As a result, some commonly refer to this mandate as the "slacker mandate." In addition, we are seeing new eligibility categories emerging, such as "domestic partner," "legal alien," "elderly parent," "grandchild" and "U.S. armed services personnel." All of these are attempts to force insurers to cover people under someone else's existing policy.

Such micromanaging of benefits is unique to health insurance. State legislators aren't nearly as aggressive in controlling life, property and casualty, and even auto insurance. As a result, those insurance markets function better and provide consumers with more choices.

Fortunately, a few states are recognizing that mandates make health insurance more expensive. At least 10 states now permit mandate-lite policies, which allow individuals to purchase a policy with fewer mandates and so are more tailored to their needs and financial situation. And there are now at least 30 states that require a mandate's cost to be assessed before it is implemented.

Mandates aren't the only things driving up the cost of health insurance. States that require insurers to accept any individual who applies, regardless of their health status, are imposing costly burdens on health insurance. And those costs get passed on to consumers -- if they decide to keep their coverage.

Before politicians jump on the anti-health-insurance bandwagon, they should look at the role they are playing in driving up costs. Making health insurance more affordable would be a lot easier if they would stop legislating what it has to cover.

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Inquest jury blames NHS hospital for unlawful killing of mother

The "chaotic" storage of drugs at a hospital led to a woman who was in labour being given a powerful epidural anaesthetic in her arm instead of a saline drip. An hour after giving birth to a son, Mayra Cabrera complained of feeling dizzy and soon afterwards she suffered a fatal heart attack. Her husband was in the room as doctors fought in vain to save her life. More than a year after her death, the Great Western Hospital in Swindon, Wiltshire, admitted that there had been a mix-up with bags of intravenous saline solution and Bupivacaine. The painkiller should have been administered direct to her spine.

An inquest jury found the Swindon and Marlborough NHS Trust responsible yesterday for unlawful killing. It is believed to be the first such finding against an NHS trust, rather than a named person. Senior staff at the hospital face a possible prosecution after Wiltshire police said that they would reopen the investigation into her death.

After the verdict Arnel Cabrera, Mrs Cabrera's widower, called for a prosecution against the midwife who made the fatal error. In a statement he said: "Mayra was my love and my life. However, our life together was ripped apart by the action of a midwife who failed to check the fluid she gave to my wife. "The midwife's failure to accept responsibility or show any remorse for her actions has made me very bitter and angry. I cannot forgive her and now hope that the police and Crown Prosecution Service will prosecute her for manslaughter."

The NHS trust apologised unreservedly for the mistake and said that it had learnt its lesson. It supported a call by the coroner for improvements to the labelling and storage of drugs and for other measures to prevent a recurrence.

Mrs Cabrera, 30, was a Filipina midwife at the Great Western Hospital, where she gave birth to Zachary in May 2004. The handling and storage of drugs there was described as chaotic. David Masters, the Wiltshire Coroner, said that he would be writing to the Health Secretary recommending stricter controls on the handling and administration of drugs.

After 17 hours' deliberation at the end of the four-week inquest in Trowbridge the jury returned a majority verdict. It stated: "Mayra Cabrera was killed unlawfully - gross negligence/manslaughter - storage and administration."

The midwife accused of the mistake, Marie To, repeatedly denied having made the fatal blunder and said that she was unable to explain how the Bupivacaine had been connected to Mrs Cabrera's drip. Gerwyn Samuel, for Mr Cabrera, told her: "It is because you are blocking from your mind the blindingly obvious - that you put up that bag and that it was Bupivacaine."

Mr Masters said that he would be writing to the Health Minister, the Midwifery Council, relevant royal colleges and the General Medical Council to recommend that staff training and the storage and administration of drugs should be overhauled. He also wants the connectors for epidural drugs to be changed so that a mix-up would be unlikely to recur. He said: "The nettle needs to be firmly grasped. It is quite clear that what is needed is a firm and radical approach to tackle the problems raised. "Firstly we need equipment which can be only used for epidural use - giving sets, syringes, and infusion bags which can only be attached for epidural use. Because we are in a global market place the manufacturers have to look to Europe and not just UK requirements. This is something the Minister for Health should tackle."

Detective Inspector Ian Saunders, of Wiltshire Police, who led the original investigation, said that the evidence presented to the inquest would be reviewed. "The CPS will carefully review what has been said in these proceedings to see if any new evidence has come to light."

Lyn Hill-Tout, chief executive of Swindon and Marlborough NHS Trust, apologised for the blunder that killed Mrs Cabrera. She promised that the trust had learnt its lesson. "I want to reiterate our sincere and unreserved apologies to Mr Cabrera and Zac. The trust admitted liability for Mrs Cabrera's death as soon as possible. We sincerely hope that other hospitals will be able to learn from the bitter lessons that we have learnt. This tragic case should not have happened and one death is one too many.

"We wholeheartedly support the coroner in his call for better labelling of drugs by the manufacturers and most importantly the introduction of new special fittings which do not allow for drugs to be connected to the wrong route. "We can never bring Mayra back but we can do all in our power to ensure that there are no similar tragedies. We have been criticised for a number of failures, failures which we accept, deeply regret and from which we have learnt important lessons."

Mr Cabrera, whose work permit expires at the end of this month, is to ask the Home Office for permission to stay in Britain on compassionate grounds. His request was backed by the coroner, who criticised the way in which his case had been dealt with up to now.

Mr Masters said: "I find it quite extraordinary that this man has not had the benefit of knowing that he can stay in this country for the foreseeable future. I would wholeheartedly support his right to stay, had I any say in the matter. It seems to me that the red tape should be cut and thrown away and that should done quickly, sooner rather than later."

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