Keep HMO Reform Alive

Last month, Senate Republicans passed a “patients’ rights” managed care bill whose dubious promise was underscored by a provision allowing HMOs themselves to define what constitutes medically necessary treatment.

Both political parties postured for the cameras with much storm and fury: Democrats denounced the measure as toothless. Republicans insisted they were only trying to keep health care costs down to prevent individuals and employers from being “priced out” of the insurance market. But something less high-minded was going on behind the scenes. Senate Majority Leader Trent Lott (R-Miss.) was refusing to schedule a floor vote on a reasonable managed care compromise by Sens. John H. Chafee (R-R.I.) and Bob Graham (D-Fla.). President Clinton had pledged his support for the gist of the bill.

This week, history is in danger of repeating itself.

Speaker J. Dennis Hastert is backing a GOP managed care bill in the House crafted last week at his request by Rep. William M. Thomas (R-Bakersfield). It extends protections to all 161 million Americans with private health insurance, not just to the 48 million in employer-sponsored health plans that the Senate GOP bill would have covered. But otherwise it reportedly retains most of the loopholes in the Senate bill.

Meanwhile, Hastert is refusing to get behind a more viable compromise bill by Rep. Charlie Norwood (R-Ga.). Norwood’s bill has broad support in the House, and last week allies of Norwood held talks with House Minority Leader Richard A. Gephardt (D-Mo.) to try to craft a compromise bill that would win the president’s support.

Many GOP leaders are now urging Hastert to bar House members from considering even parts of Norwood’s bill. They argue that only the passage of a bill that Hastert himself commissioned would represent a true GOP victory.

They are mistaken. By allowing consideration--and probably passage--of the most basic medical protections in the Norwood bill, Hastert could show voters that the House is capable of going beyond empty rhetoric to actually guarantee Americans some basic medical rights.

The key protection is a requirement that managed care plans allow patients to appeal treatment decisions to external reviewers truly independent of the health plan that denied them care. This reform would not drive up costs. Norwood accomplishes that by letting external reviewers evaluate HMO decisions based on “generally accepted principles of professional medical practice,” not, as the Senate bill does, on the HMO’s own “terms and conditions.”

Two weeks ago, an obstetrician demonstrated to Congress just how arbitrary and capricious those terms and conditions can be. He told how an insurance company refused to pay for a $700 treatment urgently needed to protect an unborn child. The mother-to-be had full obstetrical coverage and the medical need was “a no-brainer,” the physician said.

That obstetrician was conservative Rep. Tom A. Coburn (R-Okla.), the only member of Congress to maintain a private medical practice and a strong supporter of the Norwood bill.

If nothing else, Hastert should allow legislators to vote on Norwood’s external review language, which would at least elevate the role that medical science plays in managed care decisions.

Consumers have made it clear that they want help with their managed care problems. Congress has one last chance to come through.

To Take Action: House Speaker J. Dennis Hastert, phone (202) 225-2976, fax (202) 225-0697, e-mail dhastert@hr.house.gov