Conferees Support Expanded Private Health Benefits

Embracing the first federal rules for private health insurance benefits, congressional negotiators agreed Thursday to support a major financial expansion of mental health coverage and a guarantee of 48-hour hospital stays for new mothers.

If the proposals are adopted by Congress and signed by President Clinton, as expected, they would represent an increase in coverage for millions of American workers and their families. They also would mark the first time that the federal government had set such detailed standards for health insurance benefits, which are now determined solely by private business.

The business community fought hard against the ideas, arguing that they amount to unwarranted government interference in benefits voluntarily provided to workers.

But the proposals were accepted by the negotiators after a bipartisan coalition of lawmakers spoke poignantly about family travails with mental illness and about new mothers being hustled out of hospitals.

Congress is taking a major step in “caring for those millions of Americans who suffer from these diseases of the brain,” Sen. Pete V. Domenici (R-N.M.) said of the mental health agreement after a bargaining session that finished at 1:30 a.m. Thursday.

House and Senate negotiators agreed on final versions of the amendments to attach to an appropriations bill. Final passage is expected next week, and Clinton seems certain to sign the bill. The new rules would take effect in January 1998.

Under the hospital provision, women with maternity insurance benefits would be guaranteed hospital coverage for at least 48 hours after a normal delivery and 96 hours after a caesarean section. The mother could go home sooner but could not be forced to do so by her insurance carrier or health plan.

Health insurance plans would be barred from offering money or rebates to encourage mothers to go home early. And they would be prohibited from pressuring doctors or giving them incentives to get the mothers and babies out of the hospital.

The provision could have a major impact in states such as California, where maternity stays are commonly 24 hours or less, according to Bill Bluhm, vice president of health practice at the American Academy of Actuaries. The California Legislature considered but rejected a bill this year to require a 48-hour minimum stay. The business community sees the provisions as the proverbial camel’s nose under the tent.

“We’ve started on the road to piece-by-piece federal mandates for health benefits,” said James Klein, president of the Assn. of Private Pension and Welfare Plans, which represents major firms with extensive health benefits.

“Down the road, there may be any number of other items that will seem like good ideas but they will burden the system,” eventually leading some employers to abandon health coverage.

Organizations representing doctors and hospitals welcomed the proposed legislation. “This is very positive--decisions will be in the hands of mothers and physicians rather than insurance companies,” said James Stacey, a spokesman for the American Medical Assn.

Both the maternity and mental health provisions “are very good steps for patients and their families,” said Rick Wade, senior vice president of the American Hospital Assn.

The mental health provision would provide much more generous spending benefits for persons suffering from serious mental illnesses, whose costs of treatment can mount rapidly. Health plans would be forbidden to have lower limits for mental health spending than for medical-surgical services.

A typical health insurance program today might have lifetime spending limits of $750,000 or $1 million for physical ailments and $50,000 or $75,000 for mental health. In addition, many plans have separate annual limits on mental health outlays.

The most likely response to the new law, congressional advocates say, is that companies would establish a single lifetime ceiling combining all spending, no matter what the cause of the illness.

However, companies would still be permitted to require workers to pay higher deductibles or co-payments for mental health services than for treatment of other ailments.

These changes were made because of business concerns about the prospect of additional costs. The agreement provides that, if an individual company’s health spending increases more than 1% because of mental health outlays, it could reimpose separate spending caps.

Companies with 50 or fewer workers would be exempted from the new rule, a change made in the all-night bargaining session. The original plan approved previously by the Senate set the exemption at firms with 25 or fewer workers.

Domenici estimated that employer health care costs would rise a minuscule 0.16%.

But if the expanded coverage leads to more hospitalization for mental ailments, the costs for employers could jump considerably more, Bluhm said.

Many individuals and families could be rescued from financial disaster under the new rule.

“I’ve got a huge membership of middle-class families, whose sons and daughters and brothers and sisters are on Medicaid [the federal health program for the poor] because they ran through their health insurance and spent their savings,” said Laurie Flynn, executive director of the National Alliance for the Mentally Ill, which represents 140,000 people with serious brain disorders and their families. People on Medicaid cannot work for fear that they will make too much money and lose their eligibility for benefits, she said.

Giving financial parity to mental health treatment “is the beginning of ending insurance discrimination,” Flynn said.

Opponents of the expansion of Washington’s role in health coverage were resigned to passage of the bill.

“We are very encouraged with the direction of the proposals in the final days of the session,” said Karen Ignagni, president of the American Assn. of Health Plans, which represents health maintenance organizations and preferred provider organizations.

Many lawmakers will find it politically tough to oppose the amendments in an election year. HMOs have been plagued by complaints that women have been sent home frail and ill after undergoing “drive-by deliveries.” And members of the Senate offered heart-rending tales of loved ones struggling with mental illness.

The amendments were “very difficult for people to oppose--members of Congress did not want to go back and run for reelection after casting a vote against this,” Klein said.

For employers and the organizers of health plans, however, the amendments are a disturbing precedent, the first federal intrusion into how they determine benefits.

“From the beginning, we were concerned about the role of government in medical decision-making and clinical practices,” Ignagni said.