In a dramatic shift, House Republican leaders Wednesday proposed legislation guaranteeing the rights of patients in health maintenance organizations and other managed-care plans, offering a sweeping set of initiatives that include many already endorsed by Democrats.
Republican leaders acted in response to pressure from their own rank and file, who feared that Democrats were stealing an election issue. With many GOP House members facing tough reelection campaigns, opinion polls show that voters strongly support patient protection proposals.
Like the Democratic plan introduced recently, the GOP proposal would require that managed-care plans cover emergency medical care, allow women to use their obstetrician-gynecologists as their primary care physicians and accelerate the timetable for dealing with patients' appeals of health plan decisions. Also, the Republican plan would allow such decisions to be appealed to independent boards of physicians.
However, the GOP leadership also threw in provisions previously dubbed "poison pills" by President Clinton. Among them: a cap on damages that doctors could be forced to pay in medical malpractice cases and an expansion in the types of health plans that would be exempt from state-based patient protection laws.
The GOP plan also leaves out several key measures that are part of the Democratic bill, most notably a provision that would give patients the right to sue their health plans when they suffer injury or death as the result of poor medical decisions. Under current law, most plans are exempt from medical malpractice lawsuits. Clinton has said that "a right without remedy is not a right."
Nationwide, roughly 175 million people are enrolled in managed-care plans, according to the American Assn. of Health Plans, which represents roughly 1,000 managed-care plans. Such plans limit access to specialists, sophisticated medical tests and treatments as a way of holding down costs.
The menu of GOP proposals suggests a sea change for the party, which had resisted efforts to regulate the managed-care industry steadfastly.
"I think that listening to our constituents collectively, we heard concerns," said Rep. J. Dennis Hastert (R-Ill.) to a standing-room-only crowd of insurance, health care and business industry lobbyists.
Hastert, who headed a Republican task force that studied the issue, added that his party was also forced to act by Rep. Charlie Norwood (R-Ga.), a dentist, who led an insurgent effort to force GOP leaders to take up his version of the patient bill, which had more than 220 co-sponsors.
Beyond election-year politics, lawmakers appear to be attempting to deal with the difficult problem of how to balance the interests of patients and those of a rapidly changing health-care marketplace in which, to many, the balance of power appears to have tipped away from patients.
"As managed care became the dominant form of health care, certain relationships have become distorted," acknowledged Rep. William M. Thomas (R-Bakersfield), a member of the task force.
"Given the degree of distortions, we have to deal with them. . . . You ought to have a right to know what is in your plan. You ought not to have to drive by an emergency room until you get to the one you're allowed to use. If you think your plan covers something and your plan says it doesn't, you ought to be able to appeal that decision," Thomas said.
The insurance industry and employer groups, whose opposition to such proposals in large measure was responsible for the reluctance of House GOP leaders to support patients' rights, said that they were disappointed by the party's new position. But they said it was a vast improvement over bills supported by Democrats, which they criticized especially for including a right to sue.
The Republican proposal "moves in a better direction than what has been discussed thus far in the Democratic bills but it still relies on mandates that have consequences for micro-managing the market," said Karen Ignagni, director of the American Assn. of Health Plans.
The organization is starting a television ad campaign in Washington this week to emphasize patient protection proposals that the industry says would mean increases in the cost of health insurance.
Democrats cited the industry's muted reaction as evidence that the GOP proposal represents little more than political cover. In making this argument, they criticized the Republicans for failing to include a right to sue and a right of access to specialists.
Democratic lawmakers want to allow patients--especially those with chronic conditions--to be able to see specialists without getting a referral each time from their primary-care physician.
"This gives the appearance of reform without the reality," said Sen. Edward M. Kennedy (D-Mass.), one of the leading proponents of patient protection bills in the Senate.
"If a child has a rare cancer and needs to see a cancer specialist, this does not guarantee access to a doctor outside the plan. If patients are killed or injured because a plan puts profits ahead of health, people have no recourse," Kennedy said.
But health care analysts and Clinton administration officials reacted more moderately, saying that the GOP proposal represented an opportunity for agreement on bipartisan legislation.
"Republicans have put serious consumer protections on the table," said Larry Levitt of the Kaiser Family Foundation, a nonprofit group that does health policy research and analysis. "They did leave out the liability issue, which some people feel is important. And obviously the devil is in the details but these appear to be real measures."
Chris Jennings, deputy director of domestic policy for the White House, said: "We welcome that the Republicans have finally entered this debate and we're particularly pleased that they recognize that federal legislation is needed."
Jennings and Secretary of Labor Alexis M. Herman said that Clinton is looking for improvements in three key areas.
The president wants:
* To ensure that patients--especially those with chronic health care problems--are guaranteed access to specialists without having to check back with their primary-care doctors before each visit to a specialist.
* To permit patients to continue with doctors who leave their plans, if necessary to ensure continuity of care.
* To give patients legal remedies should a plan's decision on medical treatment result in injury or death.