The HSA does provide some resources for essential community
providers to become competitive participants against corporate
Furthermore, it attempts to eliminate the problem of providers
who do not want to serve ethnic American communities because of a
disparity in reimbursement rates(134)
The HSA does so by creating a 'blended rate.(135)
To the extent that this 'blended rate' will encourage plans and
providers not to make distinctions based on reimbursement rates,
it is critical to assuring equity in the system.
Nevertheless, regardless of the merit of these provisions,
they are inadequate. They attempt to induce health plans by
monetary incentive to focus on the provision of services to
ethnic Americans, rather than requiring such behavior.
Furthermore, there is no language specifying ethnic American
inclusion, participation or set-asides in the grants, contracts
or loans(136) Without such
language, it is likely that those best able to serve their
communities will be included in only a minimal capacity. With the
temporary and waivable protections for essential community
providers and the lack of specific affirmative action contracting
goals, the Act gives only a superficial effort to protecting the
pool of health care providers that traditionally serve ethnic
The Act appears to be structured around the provisions of
services in existing facilities. Although there are some
provisions for the development of infrastructure outside of the
discretionary grants by HHS, the HSA does not appear to
contemplate the building of additional hospitals or clinics. This
is unfortunate since prior hospital closure decisions have been
made by a 'patently imperfect market' and have affected ethnic
American and poor communities disproportionately(152)
Rather, the Act contemplates extending health care by requiring
academic health centers to extend their programs in primary care
to inner city and rural areas(153)
No doubt, these provisions could improve access to health care in
ethnic American communities. But they will do so only if
provisions are made for meaningful transportation and provider
hours for inner city and rural residents. Furthermore, these
linkages will prove beneficial only if the advisory and
policymaking levels within the academic health centers are
reflective of rural and ethnic American communities, and only if
the academic health centers are required to provide culturally
Unfortunately, while the HSA provides incentives for academic
health centers to establish outreach into ethnic American
communities, they are under no requirement to provide culturally
competent care or community participation. Furthermore, the
financial incentives to the academic health centers produces the
same stigma of making the provision of services to ethnic
American communities outside the 'normal' expectation of academic
health centers. The Act should mandate that academic health
centers include community-based goals that center on health,
community participation and education. Furthermore, academic
health centers must be forced to have ethnic Americans
represented at advisory and policymaking levels within the
academic health centers. Finally, academic health centers must be
required to provide culturally competent care.
The HSA establishes the National Council on Graduate Medical
Education to control nationally the number of individuals who can
enroll in medical programs(154)
Even though the Act contemplates training participants who are
members of racial or ethnic minority(155)
it does nothing to assure the viability of the primary source of
black health care professionals- historically black schools.
Historically black medical schools provide an irreplaceable means
of providing access to culturally appropriate care to African
Americans(156) Even though these
institutions are financially and structurally threatened, the HSA
makes no specific provision for sustaining or strengthening their
roles(157) Without sufficient
measures to assure the development of an adequate infrastructure,
ethnic American and poor communities face the disconcerting
prospect of depending on private, competitive for-profit health
providers for culturally competent health care. Access to health
care requires actual services provided by physicians and
hospitals. But, many physicians and hospitals are reluctant to
serve ethnic Americans(158)
Within a professional culture that is reluctant to serve ethnic
Americans and poor communities, universal coverage, by itself,
will not 'appreciably redistribute the physician supply' in a way
that would significantly improve access(159)
In sum, infrastructure barriers, separate and distinct from the
issue of financing, are not adequately addressed, and the promise
of universal coverage is not a promise of equality of care(160)
The plan maintains a fragmented system by excluding large
segments of the population, keeping them outside of the main
system. Specifically, undocumented aliens(161)
Medicare recipients(162) prison
populations(163) employees of
eligible corporate alliance sponsors(164)
military personnel and families(165)
veteran(166) and Indian(167)
are all either excluded or kept outside of the main system.
These exclusions are problematic for several reasons. First,
the exclusion of a large number of individuals threatens the
financial integrity of the main health system by producing
inefficiencies and duplications(168)
Second, the exclusion of some individuals inevitably causes
discrimination, because someone must determine who is not
covered. Consequently, providers and facilities may use skin
color or language as a de facto method of determining eligibility
for citizens who do not have health security cards(169)
Finally, a significant portion of ethnic American males will not
be in the system since prison populations are specifically
excluded and military personnel and veterans may opt out. This is
particularly troubling because the HSA does not assure that
individuals in alternative systems will receive at least the same
|122. FN122. Byrd & Clayton, supra
note 69, at 21-22.
123. FN123. See infra part III.A.
124. FN124. See infra part III.B.
125. FN125. See generally Arnold S.
Relman, Controlling Costs by 'Managed Competition'-Would It
Work?, 328 New Eng. J. Med. 133 (1993).
126. FN126. See generally Randall, supra
note 79, at 146-60; Sidney D. Watson, Health Care in the Inner
City: Asking the Right Question, 71 N.C. L. Rev. 1647 (1993).
127. FN127. One-quarter of the U.S.
population, about 65 million persons, resides in rural areas.
Rural Americans face unique health needs which require access to
local health care. Charles Marwick, Educating Farmers, Physicians
Who Treat Them, About Rural Life's Potential Health Hazards, 261
JAMA 343 (1989); Ross M. Mullner et al., New Report Cites Rural
Health Problems, Needs, 107 Pub. Health Rep. 486 (1992); Ross M.
Mullner et al., Rural Community Hospitals and Factors Correlated
with Their Risk of Closing, 104 Pub. Health Rep. 315, 316 (1989)
(hereinafter Mullner et al., Rural Community Hospitals). However,
rural Americans do not have access to as many or as wide a range
of health care services as suburban Americans. The health care of
rural Americans is restricted both because of the lack of medical
providers and the lack of health care facilities. In 1986, rural
areas had 44% fewer physicians than cities. C. Neil Bull &
Share DeCroix Bane, Growing Old in Rural America: New Approach
Needed in Rural Health Care, 365 Aging 18, 20 (1993); cf. David
A. Kindig & H. Movassaghi, The Adequacy of Physician Supply
in Small Rural Communities, 8 Health Aff. 63-76 (1989); Joseph P.
Newhouse et al., Where Have All the Doctors Gone?, 247 JAMA 2392,
2393 (1982); William B. Schwartz et al., The Changing Geographic
Distribution of Board-Certified Physicians, 303 New Eng. J. Med.
1032 (1980). Very small rural counties had 112 fewer physicians
per county than the national average. Shawn Tully, America's
Painful Doctor Shortage, 126 Fortune 103 (1992). In fact, in
1992, the Department of Health and Human Services estimated that
more than 100 U.S. counties had no physicians. Id. The shortage
of providers is so severe that in some communities essentially
all medical practices are closed to new patients. Id. Many
communities have no training programs and find it extremely
difficult to recruit providers. Stephen J. Pearson, Health Care
for Uninsured and Underinsured Children: Letter to the Editor,
145 Am. J. Dis. Child 1085 (1991). In 1988, there were 2,549
rural community hospitals. David G. Whiteis, Hospital and
Community Characteristics in Closures of Urban Hospitals,
1980-1987, 107 Pub. Health Rep. 409 (1992) (citing American
Hospital Association, Hospital Statistics, 1989-90 (1990)).During
a seven year period, estimates of hospital closures ranged from
161 to 200. See Bull & Bane, supra, at 20 (reporting 190
rural hospital closing between 1981 and 1988); Tully, supra, at
103 (reporting over 200 hospitals closed between 1987 and 1992);
Mullner et al., Rural Community Hospitals, supra, at 318
(reporting 161 hospital closings between 1980 and 1987).
The reasons for rural closings are complex, and include the
disproportionate impact of Medicare's prospective payment system
on rural hospitals. However, the lack of available physicians is
another story. Many rural communities are unable to replace
physicians who retire or leave. 'You can have a physician without
a hospital, but you cannot have a hospital without a physician.'
Emily Friedman, Analysts Differ Over Implications of More
Hospital Closings Than Opening Since 1987, 264 JAMA 310, 313
(1990). Other health services are also in short supply, including
nursing homes, allied health care professionals, nurses, health
technology personnel, dentists, physical therapists, pharmacists
and opticians. In fact, inpatient psychiatric services are
'virtually nonexistent' in rural communities. Bull & Bane,
supra, at 21. Thus, a rural person's ability to obtain (e)qual(ity)
health care is severely impaired by the serious lack of
infrastructure for the delivery of care.
128. FN128. Ethnic Americans and poor
Americans who live in inner cities are similarly affected by the
lack of infrastructure. As in rural communities, many hospitals
and primary care clinics have been forced to close. Boger, supra
note 75, at 1330. Many hospitals have abandoned the inner city
and moved to more lucrative suburban areas. Between 1980 and
1989, of the 508 general acute care hospitals that closed, 256
were urban. Friedman, supra note 127, at 310. Hospital closures
left many communities stripped of any available resource. For
instance, the 'entire north side of St. Louis, parts of
Philadelphia, and even sections of New York City are virtually
devoid of hospital care.' Id. at 313. Although surviving
hospitals often maintain that patients may find 'a safe harbor
there,' the reality is that disabled individuals and individuals
'with linguistic, cultural, geographic, or finanical access
problems are less able to find substitute care.' Id. (quoting
Alan Sager, Associate Professor at the Boston University School
of Public Health).
The inadequate infrastructure also has to do with the lack of
physicians practicing in the inner city. This lack of
infrastructure is due both to physicians who have moved their
practices from inner city communities and to the shortage of
physicians trained in primary medicine. See generally Watson,
supra note 126, at 1649-50. In 1961, 50% of U.S. doctors were
primary care providers; by 1990 that figure had dropped to 33%.
Marc L. Rivo & David Satcher, Improving Access to Health Care
Through Physician Workforce Reform, 270 JAMA 1074-78 (1993). In a
study performed by the Council on Graduate Medical Education,
projections indicate that the number of primary care providers
will continue to decline. John M. Eisenberg, Economics, 270 JAMA
198-200 (1993). The lack of providers and facilities from which
to obtain health care is equally as devastating as economic
barriers, and providing universal coverage will not, by itself,
remove all infrastructure barriers.
129. FN129. See infra notes 137-51 and
130. FN130. Basically, each health plan
must enter into a provider participation agreement with essential
community providers. HSA s 1431(a). The agreement provides that
the plan shall make payment to the provider. Id. s 1431(c). The
participation agreement between the health plan and an essential
community provider shall provide that the health plan agrees to
treat the provider at least as favorably as other providers. Id.
s 1431(b). In particular, the agreement must be similar with
respect to the scope of services for which payment is made by the
plan to the provider, the rate of payment for covered care and
services, the availability of financial incentives, limitations
on financial risk provided, assignment of enrollees, and access
by the provider's patients to providers in medical specialties or
sub-specialties participating in the plan. Id. Essential
community providers are not merely any providers serving in
underserved areas but those that have been certified by HHS. The
Act provides that any of the following health care providers or
organizations can be certified as an essential community
provider: a migrant health center; a community health center; a
homeless program provider; a public housing provider; a family
planning clinic; an Indian health program; an AIDS provider under
the Ryan White Act, 42 U.S.C. s 300ee-3 to -12 (1991); a maternal
and child health provider; a federally qualified health center; a
rural health clinic; a provider of school health service; or, a
community practice network. Id. s 1582(a)(1)-(11). Other
categories of health care providers and organizations may also be
certified as essential community providers. Id. s 1583(a). An
essential community provider who is aggrieved by the failure of a
health plan to fulfill a duty imposed by the HSA may commence a
civil action against the plan. Id. s 5240(a). If the court finds
that the health plan has failed to fulfill its duty, the
essential community provider may recover compensatory damages,
other appropriate relief, and reasonable attorney's fees,
including expert fees. Id. s 5240(b), (c).
131. FN131. Specifically, it applies
during the five-year period beginning with the first year in
which any health plan is offered by an alliance. Id. s 1432(a).
132. FN132. The Act authorizes the
preparation of recommendations regarding essential community
providers, including studies that assess the definition of
essential community providers, the sufficiency of the funding
levels for providers, the effects of contracting requirements
relating to such providers, the effects of contracting
requirements on such providers, health plans, and enrollees, the
impact of the payment rules for such providers, and the impact of
national health reform on such providers. Id. s 1432(b). Congress
will decide whether and to what extent to continue requiring the
health care plan to contract with essential community providers.
Id. s 1432(c).
133. FN133. The HSA provides for regional
alliances to encourage the development of plans to serve areas
that have inadequate health services. In particular, a regional
alliance may encourage the establishment of new health plans in
an area that has inadequate health services. Id. s 1329(b).
Health alliances may encourage the development of community plans
by organizing health providers to create a plan, by providing
assistance with setting up and administering such a plan, and by
arranging favorable financing for such a plan. Id. Furthermore,
the Act authorizes the use of federal funds to improve the
infrastructure for urban and rural medically underserved
populations. Id. s 3411. In particular, the funding is to be used
to facilitate transition to a system in which medically
underserved populations have an adequate choice of
community-oriented providers and health plans; to promote the
development of community practice networks and community health
plans that integrate health professionals and health care
organizations supported through public funding with other
providers in medically underserved areas; to support linkages
between providers of health care for medically underserved
populations and regional and corporate alliance health plans; to
expand the capacity of community practice networks and community
health plans in underserved areas by increasing the number of
practice sites and by renovating and converting substandard
inpatient and outpatient facilities; to link providers in
underserved areas with each other and with regional health care
institutions and academic health centers through information
systems and telecommunications; and to support activities that
enable medically underserved populations to gain access to the
health care system and use it effectively. Id. Finally, the Act
allows HHS to make grants and to enter into contracts with
consortia of providers for the development of qualified community
health plans and qualified community practice networks. Id. s
134. FN134. See infra notes 144-50 and
135. FN135. HSA s 1351(a).
136. FN136. Minority 'set-aside' is a
term that refers to both public and private sector efforts to
reserve a predetermined percentage of benefits and opportunities
for racial minorities. Set-asides are most often associated with
public construction dollars, where a general contractor working
on a public building project must devote a certain percentage of
the bid price to minority sub-contractors. See Richmond v. J.A.
Croson Co., 488 U.S. 469 (1989) (minority set-asides for
municipal contractors); Fullilove v. Klutznick, 448 U.S. 448
(1980) (federal minority set-aside program in construction
industry); see also Wygant v. Jackson Bd. of Educ., 476 U.S. 267
(1986) (formula for preserving employment for minority teachers
during district-wide layoffs); Cliff Hocker, Richmond Enacts New
Set-Aside Law, Black Enter., Aug. 1993, at 24.
137. FN137. The health-related data
collection, surveillance and outcome monitoring function of
public health provides for regular collection and analysis of
information on key dimensions to ensure timely awareness,
decisions and interventions related to epidemics, emerging
patterns of disease and injury, prevalence of risks to health,
and outcomes of personal health services. HSA s 3312(b)(1).
138. FN138. The public health functions
related to enforcement focuses on air pollution, including indoor
air, exposure to high lead levels, water contamination, handling
and preparation of food, sewage and solid waste disposal,
radiation exposure, radon exposure, noise levels and abatement,
and consumer protection and safety. Id. s 3312(b)(2).
139. FN139. The public health functions
that focus on investigation and control of diseases and injuries
include improvements in emergency treatment preparedness,
cooperative activities to reduce violence levels in communities,
activities to control the outbreak of disease, exposure related
conditions and other threats to the health status of individuals.
Id. s 3312(b)(3).
140. FN140. The public information and
education function of public health focuses on mobilizing
communities and motivating individuals to reduce risks to health
such as tobacco use, abuse of alcohol and other drugs, sexual
activity that increases vulnerability to HIV infection and
sexually transmitted diseases, inadequate nutrition, physical
inactivity and childhood immunization. Id. s 3312(b)(4).
141. FN141. The accountability and
quality assurance focus of public health functions includes
monitoring the quality of personal health services furnished by
health plans and providers of medical and health services in a
manner consistent with the overall quality of care monitoring
activities undertaken under Title V of the Health Security Act
and monitoring communities' overall access to health services.
Id. s 3312(b)(5)
142. FN142. Laboratory services include
the provision of individual testing and pathology services
(including the system of state laboratories that screen for
metabolic diseases in newborns), providing toxicology assessments
of blood lead levels and other environmental toxins, diagnosing
sexually transmitted disease and tuberculosis requiring partner
notification, testing for cholera and other infections or
food-borne diseases, and monitoring the safety of water and food
supplies. HSA s 3312(b)(6).
143. FN143. The training and education
function of public health focuses on ensuring adequate training
with special emphasis on public health professionals such as
epidemiologist, biostatisticians, health educators, public health
administrators, sanitarians and laboratorians. Id. s 3312(b)(7).
144. FN144. Leadership, policy
development and administration activities focus on defining
health goals, standards and policies, and the development of
health coalitions. Id. s 3312(b)(8).
145. FN145. Id. ss 3401, 3402.
146. FN146. Id. s 3411. The funding is
intended to provide a program of grants, contracts and loans and
will 'facilitate transition to a system in which medically-
underserved populations have an adequate choice of community-
oriented providers and health plans.' Id. It will do so by
promoting 'the development of community practice networks and
community health plans that integrate health professionals and
health care organizations supported through public funding with
other providers in medically underserved areas.' Id. It is also
intended 'to support linkages between providers of health care
for medically underserved populations and regional and corporate
alliance health plans. The funding will be used to expand the
capacity of community practice networks and community health
plans in underserved areas by increasing the number of practice
sites and by renovating and converting substandard inpatient and
outpatient facilities.' Id. It will also 'link providers in
underserved areas with each other and with regional health care
institutions and academic health centers through information
systems and telecommunications.' Id. Finally, it will be used 'to
support activities that enable medically underserved populations
to gain access to the health care system and use it effectively.'
147. FN147. Id. s 3421. The funding is
intended to remove barriers to health care and to assist
communities that include a substantial number of individuals who
have a limited ability to speak English to assure culturally
competent care. Id. s 3421(d), (e).
148. FN148. The Act attempts to ensure
health care for rural Americans by requiring alliance areas to
serve rural areas, by providing investment in rural
infrastructure, by creating incentives to expand rural
community-based networks and plans, by providing investments for
the development of the health workforce, and by providing for the
expansion of the rural public health system. The Act recognizes
rural health clinics as essential community providers. See supra
note 130. In addition, the HSA allows HHS to make grants to
establish rural information and referral systems, and it allows
HHS to make grants to carry out activities to provide rural
health care. Id. s 3132. The Act authorizes funding for projects
to train more primary care physicians and physician assistants,
including expanding the supply of physicians with special
training to serve in rural areas. Id. s 3062. Finally, The Act
amends the Social Security Act's Anti-Fraud and Abuse provisions
to allow more favorable provisions for rural providers. The HSA
amends s 1877(d)(2) of the Social Security Act, which limits
physician self-referrals, 42 U.S.C. s 1395nn(d)(2) (1988 &
Supp. V 1993), by allowing exceptions for rural physicians where
at least 85% of their services are furnished in rural areas,
rather than 'substantially all.' HSA s 4042(e). Section
1877(e)(4) (relating to physician recruitment) is amended to
limit the exception to entities located in rural areas, areas
with a shortage of health professionals, or an entity in which
85% of patients are members of medically underserved populations.
Id. s 4042(f)(4).
149. FN149. The Act provides
appropriation for the development of qualified community health
plans and practice groups, and community and migrant health
centers through fiscal year 2000. Id. ss 3412(a), 3401(b).
150. FN150. Byrd & Clayton, supra
note 69, at 22.
151. FN151. Byrd & Clayton, supra
note 69, at 24-26. As noted by one author:
Arranging care for those who are least well off is a matter of
how best to integrate them into a system of universal access. . .
. (S)pecial attention should be paid to the impact on the least
well off. Will the proposed system work for them? Will it
address, for example, the higher rates of disease and disability
among those of lower socioeconomic status? Does it recognize and
take into account flawed educational and transportational
infrastructures, cultural and linguistic barriers, the
stigmatization of certain diseases and lifestyles and so forth?
Reform in light of the intrinsic value of helping the least well
off means starting reconstruction, so to speak, from the bottom
up rather than from the top down.
Dougherty, supra note 73.
152. FN152. Friedman, supra note 127, at
5 (quoting Robert Van Hook, Executive Director of the National
Rural Health Association).
153. FN153. Regional and corporate health
alliances must ensure that health plans enter into sufficient
contracts with academic health centers to ensure that enrollees
receive the specialized treatment expertise of such centers. HSA
s 3131(a). More importantly, HHS has the authority to 'make
grants to (academic health) centers for the establishment and
operation of information and referral systems to provide the
services (to rural health plans).' Id. s 3132(a). Furthermore,
HHS may make grants to academic centers to carry out activities
which provide the services to residents of urban communities who
otherwise would not have adequate access to such services. Id. s
154. FN154. HSA s 3011. The HSA
designates the specific composition of the National Council.
Unfortunately, nothing in the Act requires the appointment of
ethnic Americans. Id. s 3001.
In the case of each medical specialty, the National Council
shall designate for each academic year the number of individuals
nationwide who are authorized to be enrolled in eligible medical
programs. Id. s 3012(a). Specifically, the Act requires that the
percentage of individuals enrolled in primary health care is not
less than 55%. Id. s 3012(b)(1). Furthermore, for each medical
specialty, the National Council is authorized to make annual
designations for periods of three academic years. Id. ss
3012(b)(1), 3013. In making the designation, the National Council
shall consider the incidence and prevalence of the diseases,
disorders or other health conditions with which the specialty is
concerned, the number of physicians who will be practicing in the
specialty in the academic year, and the number of physicians who
will be practicing in the specialty at the end of the five-year
period beginning on the first day of the academic year. Id. s
155. FN155. Significantly, the HSA
requires the National Council to consider the extent to which
each program trains members of racial or ethnic minority groups
when making allocations for eligible programs. Id. s
3013(c)(2)(A). 'With respect to a racial or ethnic group
represented among the training participants, the extent to which
the group is underrepresented in the field of medicine generally
and in the various medical specialties,' is considered. Id. s
3013(c)(2)(B). Furthermore, the Act provides funding for primary
care physician and physician assistant training. Id. s 3031(b).
This includes supporting projects to train additional primary
care providers and to increase the number of physicians capable
of serving medically underserved rural and inner city areas. Id.
The Act includes a provision for the training of ethnic
Americans. Id. The programs include: supporting projects to
increase the number of underrepresented minority and
disadvantaged persons in medicine, osteopathy, dentistry,
nursing, public health and other health professions; financial
assistance for underrepresented minority and disadvantaged
persons in health professions training programs; and funding for
recruitment and retention of underrepresented minority and
disadvantaged persons in the health professions. The funding can
be used to maintain efforts to foster interest in health careers
among such persons at the pre-professional level and to increase
the number ofminority health professionals in faculty positions.
Finally, it includes funds for training providers to supply
culturally sensitive care. Id.
156. FN156. For instance, by 1980,
three-fourths of all of Meharry's graduates had gone on to
practice in underserved rural and inner city communities. Marsha
F. Goldsmith & Charles Olson, Minority Physician Training:
Critical for Improving Overall Health of Nation, 261 JAMA 187
157. FN157. The HSA authorizes the
limitation on the number of individuals who can be enrolled in
medical programs. HSA s 3012(a). The Act also provides for the
allocation of training spots among medical specialties. Id. s
158. FN158. Eli Ginzberg & Miriam
Ostow, Beyond Universal Health Insurance to Effective Health
Care, 265 JAMA 2559 (1991).
New York City has operated a major health and hospital system
. . . committed to providing care to everyone, regardless of
ability to pay. Accordingly, New Yorkers may be said to have had
universal coverage for almost a century. . . . (The Health and
Hospitals Corporation of New York) is faced with severely
overcrowded conditions stemming from significant increases in
AIDS, psychiatric, and drug-abuse patients; a lack of available
discharge options for patients occupying acute care beds
unnecessarily; and bed closings due to shortages of key staff
such as nurses and social workers.
Ginzberg & Ostow, supra note 158, at 2559.
160. FN160. Ginzberg & Ostow, supra
note 158, at 2559. As reported in one newspaper:
With President Clinton trying to give all Americans health
insurance,places like the Washington Free Clinic might be
expected to be getting ready to go out of business. But the
Clinic volunteers who work out of a transformed church choir loft
are not planning to pack up anytime soon. Their patients are the
ones who often fall through the cracks of the existing health
care system. . . . And many of these people, even strong
supporters of the Clinton health plan admit, will still be out in
the cold after the plan.
Clinics for Poor Expect to Continue Being Needed, N.Y. Times,
Sept. 20, 1993, at B6.
161. FN161. HSA s 1005(a).
162. FN162. Id. s 1001(d).
163. FN163. Id. s 1001(e).
164. FN164. Eligible sponsors of
corporate alliances include large employer, multi- employer plan
sponsors, rural electric cooperatives and rural telephone
cooperative associations. A large employer is one that has more
than 5,000 full-time employees in the United States. Id. s
165. FN165. The Act allows military
personnel and families to elect the Uniformed Services Health
Plan rather than a plan through a regional alliance HSA s
166. FN166. Veterans and families may
elect a veterans health plan rather than a plan through a
regional alliance. Id. s 1004(b)(2).
167. FN167. The HSA permits eligible
individuals to elect the Indian Health Service rather than a plan
through a regional alliance. Id. s 1004(b)(3)
168. FN168. Byrd & Clayton, supra
note 47, at 5.
169. FN169. A health security card is
issued to each eligible individual by the alliance in which he or
she is enrolled. HSA ss 1001(b), 1324, 1383.