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Medical Care
Section Newsletter
Fall 2010

Should Public Health Departments be Diverted to Monitor Private Insurance Companies? A Losing Case for the Medical Loss Ratio

Should Public Health Departments be Diverted to Monitor Private Insurance Companies? A Losing Case for the Medical Loss Ratio


by Ellen Shaffer


On Aug. 17 the National Association of Insurance Commissioners adopted proposed rules for measuring the Medical Loss Ratio (MLR), a key instrument for controlling health insurance premiums.  The MLR is the 80-85 percent of premiums that new law requires insurance companies to spend on medical care, or improvements to the quality of care (80 percent for small companies, 85 percent for large ones).  Companies that fail to meet that test must give subscribers a rebate. The usually out-gunned consumer representatives to the NAIC supported the state insurance commissioners’ vote to adopt the proposed rules unanimously, claiming a victory against insurance industry lobbyists.


But the EQUAL Health Network found a key provision that slipped through and that threatens both the effectiveness of the MLR, and the integrity of public health departments. A late amendment would allow insurance companies to count their collaborations with public health departments as quality improvements, making it easier for them to reach 80 or 85 percent without actually spending enough money on subscribers’ health care. The U.S. Department of Health and Human Services (HHS), which is now tasked with "certifying" the NAIC's proposal, is backing this proposal to date.


What this means:  Partnerships between private, for-profit health insurance companies and cash-strapped public health departments would be counted as part of the legitimate expenditures of enrollees’ premium dollars to improve their health. 


The key questions are:


1. Should insurance companies be able to get off the hook for paying rebates to customers, who may believe their company is unfairly denying them specific medical care in order to save money, by virtue of engaging in health promotion campaigns aimed at non-members of the plan?  Many such programs are thinly veiled marketing exercises.


Further, these programs can backfire directly on subscribers. "Wellness" programs give insurance companies privileged information about the health habits of current or prospective enrollees. Until 2014, they can use this info to cherry-pick enrollees; after that they can still charge more to enrollees who use tobacco.


 2. And should scarce public health resources be diverted to ascertaining whether or not these interventions are both legitimate and effective? Incentivizing insurance company partnerships to sponsor "wellness" and "community benefit" programs not only skews the purpose of the MLR, it can disadvantage genuine public health programs. It threatens to divert time, resources and credibility away from public health departments - who are expert and publicly accountable for improving the public's health, but not historically tasked with policing the insurance industry to ascertain that any insurance company-public health department alliance is bona fide, meets Community Guide standards, and does in fact improve the quality of medical care


This is a classic mismatch of policy priorities. Concerns about the proposal merit an open public airing. See EQUAL's analysis and the public health sign-on statement at:

Meet the Candidate: Maggie Huff-Rousselle


APHA Executive Board Candidate: Dr. Maggie Huff-Rousselle 

Dr. Huff-Rousselle was kind enough to share with us her vision for APHA, as well as the strengths she brings to leadership.

Experience in Policy-Formulation and Consensus-Building on Executive Bodies: Dr. Maggie Huff-Rousselle has worked on policy- and decision-making bodies in the health sector for decades, e.g. seven years on the Health Ministers’ Policy Board in the Eastern Caribbean (seven countries), the Global Fund Technical Review Panel, the APHA Governing Council, etc. Her varied roles in international health have made Dr. Huff-Rousselle well-attuned to stakeholder needs, and very pragmatic in ensuring that multiple stakeholders are engaged in a process and that their perspectives are taken into consideration. Dr. Huff-Rousselle’s background is very multi-disciplinary, and her long-term program experience includes: 1) health sector reform insurance; 2) reproductive and sexual health; 3) pharmaceutical financing, management and policy; 4) maternal and child health; and 5) HIV/AIDS.

Experience in Management, Program Development and Resource Mobilization: Dr. Huff-Rousselle has a dual MBA (in Health Management and Public Management), and has founded or been instrumental in the establishment of five health sector organizations. Both her training and her practical experience have given Dr. Huff-Rousselle a very strong financial management and planning background, including controller functions in U.S.-based non-profits and management of health sector projects with budgets as large as $30 million. Her experience in financing – not limited to control functions – encompasses the incentives in pricing, and this experience will be useful in advising on membership dues, and the trade-offs (as viewed by members) of the benefits of membership. Dr. Huff-Rousselle also has a great deal of experience studying the way in which the health sector’s financing systems can “make everything tick” and create incentives.

Bringing a Global Perspective to the Executive Board and US-based Health Sector Reform: Dr. Huff-Rousselle has residency experience in both Canada (where she was born) and France.  She has managed health sector reform projects (with national health insurance as a key issue) in other countries where the models of Western health care systems were compared and contrasted. Dr. Huff-Rousselle has also lived in nine countries and worked short-term in approximately 50 different nations. She is able to situate the United States (both theoretically and practically) in an appropriate comparative international context to help inform the current health sector debate, and to bring a global perspective to this and other discussions on the Executive Board.


Letter from the Chair




Dear Colleagues,


Recently, I returned from a trip to the Baltic Sea that included visits to St. Petersberg, Copenhagen, and Stockholm.  All three cities presented opportunities to think about structural change and human health.  St. Petersberg, the city of the Russian czars, is a place where it is hard to avoid thinking about structural change.  People there experienced transitions from imperial monarchy, to communist revolution, to resistance to Hitler’s armies (600,000 died in a 3-year siege), to Soviet hegemony over Eastern Europe, to Glaznost/Perestroika, to dissolution of the Soviet Union, to emergence of a new hybrid economy run by the “oligarchs.”  Failure to plan an effective transition from a state run to a market economy left the country vulnerable to corrupt self-interested manipulators who stepped into the breach and snatched opportunity from a population that might have benefited from new opportunities.  Their experience suggests that change you can believe in requires meticulous attention to implementation.    


On the other end of the Baltic, in the City of Copenhagen, people live in a social democracy, i.e. a free market economic system that is married to a social welfare system.  Based on principles that come from both traditions, the Danes recently overhauled their health system.  Their new approach offers ideas that could help us move forward as we try to make our health system work in the 21st century.  For example, 70 percent of the contacts between patients and clinicians happen asynchronously.  Much medical care is delivered through communication only, so that clinicians have more time for the people who are most sick.  Planned and proactive management of chronic conditions such as asthma is reducing hospitalization rates.  Many Danish innovations are worth considering.    


As we enter the home stretch before the APHA Annual Meeting, we face a possible shift in the balance of political power.  Financial hardship and new legal structures such as health insurance mandates are frightening some people into hoping that new candidates will do better.  Manipulators are hard at work taking advantage of this.  Some are spreading bold lies and hate in an effort to change the balance of political power again.  If this occurs, we may be at another pivotal point in U.S. history having lost an opportunity to push adjust ahead with the limited structural changes that were achieved.  Many simple acts can contribute to a better outcome.  Canvassing, calls, and monetary collections are a few.  Since Pennsylvania is a swing state, the case for involvement here is compelling.  I encourage you to be involved and do whatever you can over the next two months.  I look forward to seeing you in Denver.    




Mona Sarfaty, MD, MPH

Chair, Medical Care Section                    

Arizona Fights Back Against Attack on Elimination of Racial and Gender Preferences

Arizona Fights Back Against Attack on Elimination of Racial and Gender Preferences

by Allison Hughes


Most of us know that in 2003 Ward Connerly succeeded in his effort to eliminate racial and gender preferences at the University of California.  Since that time, according to Jeffrey S. Lehman, an affiliate of the Woodrow Wilson International Center for Scholars and former president of Cornell University, African American enrollment on campuses such as Berkeley and UCLA is only 2-4 percent.

In 2006 the anti-affirmative action crusader succeeded again when  Michigan  voters passed the “Michigan Civil Rights Initiative.”

For the 2008 elections, Connerly headed a campaign that he called "Super Tuesday for Equal Rights" that aimed to dismantle affirmative action programs in five different states via ballot measures. In three of the states, Connerly's measures failed to make it onto the ballot, and in Colorado voters rejected Amendment 46 (or the Colorado Civil Rights Initiative) by a very slim margin. Voters in Nebraska were the only ones to approve a new anti-affirmative action measure, called Initiative 424.

Connerly has again taken his crusade to Arizona.  (It failed the last time.) This comes on top of the House Bill 1070 debacle that has turned Arizona into the nation’s “boycott state.”  During the 2010 legislative session, conservative legislators passed House Concurrent Resolution 2019, signed by Gov. Jan Brewer, adding the issue of civil rights on the ballot for the November 2010 election.  The wording of the initiative is such that many voters will think that a “yes” vote support supports non-discrimination --

“This state shall not grant preferential treatment to or discriminate against any individual or group on the basis of race, sex, color, ethnicity or national origin in the operation of public employment, public education, or public contracting.”

Arizona women’s and people of color organizations are partnering to make sure the initiative fails during the fall election. If it passes, the initiative will eliminate state contracting policies that support minority and women-owned small businesses.  It will eliminate state-supported programs in schools, colleges and universities such as women’s studies, Mexican American/Latino studies, African American studies, Native American studies, and preparatory programs for underprivileged young people of color to enter colleges, etc.   It will eliminate state support for gender specific programs that support victims of domestic violence, teen parents, health centers, etc.  In short, if it passes, the initiative will be disastrous for the state, and potentially or other states that could follow suit.  I currently chair the Pima County/Tucson Women’s Commission, which this week voted to publicly act against the initiative.

Medical Care activists should keep alert for November’s election results.  This well-funded political trend may eventually come to your states if it has not already done so.  An ACLU’s lawsuit threat stopped the initiative in Missouri this past May.  Contact your state’s ACLU chapter for further information, and get involved.

APHA Annual Meeting -- Medical Care Section Highlights

  APHA Annual Meeting

Denver, Nov. 6-10, 2010


This year's Annual Meeting is jam-packed with fabulous programming. What follows is but a small sampling of the diverse and full Medical Care Section programming. To see the entire programming of the Medical Care Section, follow this link:

And don't forget our business meetings!

Saturday 11/6 5:30-7:00 p.m.

Sunday 11/7 5:30 – 7:00 p.m.

Monday 11/8 7:00 – 8:00 a.m.

Tuesday 11/9 7:00 – 8:00 a.m.

Wednesday 11/10 7:00 – 8:00 a.m.



224.0 10:00 – 11:30 a.m.  Student Mentoring Session

261.0 If I Can’t Dance I Don’t Want to be Part of Your Revolution: A Tribute to the Life and Work of Dr. Walter J. Lear



3052.0 8:30 – 10:00 a.m. Drug Policy and Pharmacy Services

3136.2 10:30 a.m. -12:00 p.m.  Health Economics: Care Costs and Evaluations of Interventions

3332.0 2:30 – 4:00 p.m. Women’s Health and Gender-based Research in Access, Utilization, and Quality of Care



4072.0 10:30 a.m. – 12:00 p.m. Prescription Drug Misuse: Predictors, Measuring, and Related Factors

4202.0 12:30 – 2:00 p.m. Avedis Donabedian Award in Quality

4369.0 4:30 – 6:00 p.m. Medical Care Section: Student Paper Award Session

4392.0 6:30 – 8:30 p.m.  Evening with Donna Smith and Presentation of the Viseltear Award to Susan Reverby



5064.0 8:30 – 10:00 a.m. Health Services Research: Insurance and Treatment Compliance

5121.0 10:30 a.m. – 12:00 p.m.  Health Services Research: Quality and Coordinated Care

5173.0 12:30 – 2:00 p.m. Social Sciences in Health: Cultural Sensitivity in Clinical Settings/Encounters