Clinton and AMA Team Up for Medical ‘Bill of Rights’


In an alliance that says as much about Washington as about health care, the White House on Wednesday joined hands with its sometime adversaries in the American Medical Assn. to promote a “patients’ bill of rights” that would strengthen doctors and patients in their dealings with cost-cutting insurers.

The teaming, on one of the Clinton administration’s top legislative goals, is expected to boost the chances that the measure will pass in some form, despite formidable Republican opposition that has derailed other White House proposals this year. Clinton even paid a visit Wednesday to the AMA’s wood-paneled Washington boardroom, where he joined a round-table with assorted patients and health care professionals on medical policy.

“In Washington you [even] do business with people who are trying to put you in jail,” explained a White House veteran who is familiar with the administration’s up-and-down relationship with the traditionally conservative doctors’ association. “It’s not helpful to the democracy to hold grudges. Never do you cut yourself off or set up a situation where you’re mortal enemies with somebody.”

The AMA--with 300,000 members the largest and best-known doctors’ organization--opposed Clinton’s ill-fated national health insurance plan five years ago. Since then, however, many physicians have become increasingly troubled by their loss of power to a burgeoning industry of managed-care firms that can dictate how much time doctors spend with patients and even have imposed incentives for reduced treatment.


The AMA’s blessing is no guarantee of success. Just weeks ago, the two sides also teamed up on an ill-fated tobacco bill, only to see it collapse on the Senate floor. But the cooperation certainly has drawn notice.

The “bill of rights” being promoted by Clinton and the AMA would establish certain new protections for patients and doctors, such as a process to appeal treatment decisions made by health plans, a right to recover substantial damages from a health plan that denied coverage resulting in injury or death and direct access to medical specialists.

But Republicans, pushing their own, more restrictive “bill of rights,” have resisted the idea of a proposed right to recover damages, arguing that it would escalate health care costs so much that some employers might not even offer the benefit. Such recovery is largely unavailable under current law.

In a setting far from the overtly political backdrop of the White House or the Capitol, the AMA offered the president an ideal opportunity to dramatize his case that managed care is sometimes inadequate. Clinton framed his argument for new protections by introducing victims of HMO decisions to reject coverage--a man whose sister died from cancer, another whose wife suffered a stroke and fungal infection that killed her in days.


A Kansas City woman at the round-table told how her husband dropped dead of a heart condition in their front yard after their HMO had put off approving surgery for him. “Medical care delayed might as well be denied,” Clinton said after hearing her tale. “Delayed medical care can be a death sentence.”

For their part, the doctors were delighted to host a president whose health care overhaul plan once sent shudders through the ranks of their profession. “We were, of course, extraordinarily honored to have the president here today,” said Nancy Dickey, a family physician from Texas who is president of the AMA. “We were pleased to create the setting for doctors, patients and nurses to talk with him. . . . It was a very useful and powerful interchange.”

The doctors’ welcome mat underscores fundamental changes in the increasingly bottom-line health care business, changes that have heightened physicians’ anxieties and in many cases altered their political calculus.

Initially in 1994, the AMA was prepared to support Clinton’s comprehensive health care reform plan, which, among other things, would have established universal insurance coverage for the public. But by early 1995, as the rank and file became familiar with emerging details of the plan, including proposed caps on medical premiums and the requirement that doctors cover their own clerical workers, the AMA announced its formal opposition.


A common complaint was that the Clinton plan would impose a powerful new federal bureaucracy on the medical profession.

“This is the administration that closed the door to the medical profession, when [it was] thinking about overhauling the entire health care system,” Dickey maintained in an interview Wednesday.

Since then, however, the forceful emergence of managed care companies--which have helped combat the chronic inflation in medical care but sometimes have done so in a heavy-handed manner--has raised other fears, as well.

“The AMA is reflecting the discontent--no, discontent is not strong enough a word--the anger and frustration of its members--at the intrusion of managed care into the doctor-patient relationship,” said Edward F. Howard, executive vice president of the Alliance for Health Reform, a nonpartisan organization that promotes understanding of the health care system.


Ann Lewis, the White House communications director, said it is ironic to consider the differences in how doctors have lined up between 1994 and today. “Once they thought that the biggest danger maybe was government bureaucrats,” she said. “I would say the dangers posed by HMO bureaucrats is actual and in too many cases is a daily occurrence.”

Others pointed out that the AMA-Clinton alliance has been fueled by a sense that doctors, traditionally accustomed to great professional authority and respect, have endured a painful loss of autonomy in the last several years. Managed-care organizations have sharply curtailed doctors’ salaries and, in many cases, imposed constraints on their power to recommend treatment.

“The conventional wisdom is that, eight or 10 years ago, physicians controlled 70% to 80% of all medical decisions,” said Lynn Etheredge, a private health care analyst. “They decided whether you were admitted to a hospital and what procedures were done. Now they are subject to review by managed-care plans. That’s what a lot of this is about.”

David Durenberger, a health care lobbyist and former Republican senator from Minnesota, said the AMA is interested in “preserving and protecting the way medicine has been traditionally practiced. And that’s nothing new or different or unexpected.”


Yet, beyond all the reasons for the alliance, there remains the raw, political fact that the White House benefits from the support of an organization of medical doctors. Republicans, accustomed to a close working relationship with the AMA, were clearly displeased with Wednesday’s spectacle.

“The [AMA] leadership leaves something to be desired,” said Senate Majority Whip Don Nickles, (R-Okla.). The association officials, he added, “had allowed themselves to be used for political purposes and I’m not sure how cognizant of the fact they are.”

Declared Larry Levitt, a former White House health policy official who is now a senior health analyst at the Menlo Park-based Kaiser Family Foundation: “It makes a huge difference having the AMA on your side. Consumer groups alone obviously don’t have much in the way of financial resources or political clout. . . . Bringing the AMA on board makes a huge difference.”

Times staff writer Edwin Chen contributed to this story.



3 Cures for Managed Care

The chart compares the chief features of the proposal unveiled by the Senate Republican leadership Wednesday with those sponsored by Sen. Edward M. Kennedy (D-Mass.) and Rep. John D. Dingell (D-Mich.) and by the House Republican leadership.

Appeals process


DEMOCRATS: Requires an internal appeals process and a government-run external appeals process.

HOUSE REPUBLICANS: Requires internal appeals process and non-binding external review board.

SENATE REPUBLICANS: Requires internal appeals process and external appeals board selected by the health plan*



Access to specialists

DEMOCRATS: Allows the chronically ill to consult specialists to get adequate care. Allows women to choose an OB/GYN as primary care provider.

HOUSE REPUBLICANS: Allows children to choose a pediatrician and women to choose an OB/GYN as primary care provider.

SENATE REPUBLICANS: Allows women to choose an OB/GYN as primary care provider and children to see a pediatrician without a referral**



Health plan liability

DEMOCRATS: Allows plan members to sue under state malpractice laws.

HOUSE REPUBLICANS: Expands penalties for health plans for inferior care.




Continuity of care

DEMOCRATS: Requires up to 90 days of coverage after primary care doctor is dropped from plan or coverage is ended.



SENATE REPUBLICANS: Similar to Democrats’ plan**


Emergency room services


DEMOCRATS: Must be covered if a reasonable person would have concluded such care was needed.

HOUSE REPUBLICANS: Similar provision.

SENATE REPUBLICANS: Similar provision**.




DEMOCRATS: Allows 48-hour hospital stays.





Medical Savings Account

DEMOCRATS: No provision.

HOUSE REPUBLICANS: Some expansion of medical savings accounts.


SENATE REPUBLICANS: Allows tax-deductible contributions to medical savings accounts instead of comprehensive insurance.

* applies to 124 million Americans in employer-sponsored health plans

** applies to 48 million Americans whose employers operate self-insured plans

Sources: Health Insurance Assn. of America, Senate Republican leadership