GOP to Offer Prescription for Managed Care

After months of closed-door discussions about whether to rein in the managed care industry, Congress appears ready to get serious, beginning with today’s unveiling of a Senate Republican plan that includes both patient protections and a provision that the White House considers unacceptable.

At the same time, President Clinton plans to meet with the leaders of the American Medical Assn., which supports legislation drafted by congressional Democrats. White House officials said that Clinton will stand firm for a bill that would guarantee access to specialists and provide legal recourse for patients who are injured or killed as a result of a health plan’s decision.

Managed care legislation is probably the hottest political potato that Congress must juggle in the nine weeks before it adjourns for the Nov. 3 elections. And with a massive tobacco bill dead on the Senate floor, the issue also provides the last chance for Congress to enact major domestic legislation before facing the voters.

“This really has become the issue that fills the political vacuum of the times,” said Robert Blendon, a professor of health policy at Harvard University. “Everything else that Congress has been talking about for the past two years has died--campaign finance reform, tobacco. There’s no new crime bill on the horizon--but here is an issue that is very tangible that makes it look like Congress can do something to help middle class voters.”

To move legislation and to appease members in their own ranks, Senate Republicans decided on the plan they will unveil today. It is much like a House GOP bill, including at least one provision the White House and congressional Democrats said make it unacceptable. However, the Senate bill also contains sweeping patient-protection measures, including some measures backed by Democrats.

The “poison pill” in the GOP bill is a vast expansion in the availability of medical savings accounts, which substitute for employer-provided health insurance. Employers and employees can make tax-deductible contributions to the accounts, which can then be used to pay for unreimbursed medical expenses. Generally, consumers who have the accounts must also have high-deductible insurance plans.

Conservative backers said the savings accounts give consumers more health care choices. White House health policy experts, as well as others in the field, contended that expanding the availability of the accounts could lead more people to choose minimal insurance coverage and, as a result, get less preventive health care.

The GOP bill also includes provisions allowing women to use obstetrician-gynecologists as primary care physicians, allowing patients to appeal a plan’s decisions to an independent medical review board and allowing patients to continue seeing their doctors for a transition period when the doctors have been dropped by their health plans.

One key measure not included in the GOP bill is a patient’s right to recover damages if the health plan makes a medical decision that results in injury or death. Under the Democratic bill, patients would have the right to recover damages.

Under current law, most people in employer-provided health insurance plans are precluded from recovering significant monetary damages, even if their health plans wrongly deny them treatment and the decision results in injury or death.

Health maintenance organizations and other managed care plans, which limit access to tests, medical treatment and specialists to hold down costs, have become the predominant form of health insurance in America. As much as 75% of all private employer-provided health insurance is some form of managed care and, increasingly, public-sector health care programs such as Medicare and Medicaid also rely on managed care.

The immediate catalyst for this week’s activity was Senate Democrats’ move last week to block votes on any legislation unless Republicans allowed a vote on managed care legislation.

As lawmakers geared up to bring the bills to the floor, a number of groups representing insurers and health care plans scrambled to make the case that legislation is unnecessary because many of the patient protections in the proposals are being put in place voluntarily.

“There’s been a lot of discussion about whether our efforts would be rhetorical or real,” said Karen Ignagni, the president of the American Assn. of Health Plans, which represents more than half the managed care plans nationwide. To underscore the sincerity of its efforts, the group released a poll Tuesday showing that nearly all of its members are voluntarily adding at least some version of the patient protections in the legislation.

Large employers had much the same message but some said that they could live with the federal regulations as long as they are protected from patients’ lawsuits against company-provided health care plans.