The Senate's emotional weeklong debate on managed health care ended late Thursday with the approval of a Republican measure that would take modest steps to broaden the rights of some patients.
Republicans said the bill, which passed 53-47, largely along party lines, makes important strides to protect patients without risking an increase in the price of health care or leaving insurance companies and employers vulnerable to frivolous lawsuits from patients.
But Democrats blasted the measure, saying it leaves out more than 100 million Americans, including many people in HMOs, and offers only weak protections to those it purports to help.
President Clinton also strongly criticized the Republican bill, threatening a veto if it comes to his desk.
"It has zero chance of going through his desk because it's a fraud," Vice President Al Gore said at a Capitol Hill news conference. Gore and the Democrats pledged to keep bringing the issue back until a version they can support becomes law.
The House has not yet considered managed care legislation this year but plans to take up the issue later this month.
Most of the patients' rights in the Senate-approved bill would somewhat broaden access to emergency care, obstetrician-gynecologists and clinical trials for the 48 million people who work for companies that self-insure their employees--in other words, where the employer, rather than an outside insurer, assumes the risk. Many states, including California, have similar laws, but they do not apply to companies that self-insure. There are about 2 million Californians in self-insured plans.
Under the measure, both the self-insured and an additional 75 million people whose employers purchase health insurance plans would gain access to an independent appeal process if they want to dispute a denial of coverage by their managed health-care plans.
To win over wavering Republican members, a $13.4-billion package of tax breaks over five years was added to the bill, including a deduction for the purchase of long-term care insurance, giving the self-employed a 100% tax deduction for their health insurance premiums and expanding the availability of medical savings accounts.
Also added to the legislation, at the behest of Sen. Olympia J. Snowe (R-Maine), was a provision to ensure that a woman and her doctor--not her insurance plan--decide how long she can stay in the hospital after a mastectomy.
Two Republicans voted against the bill: Sens. John H. Chafee of Rhode Island and Peter G. Fitzgerald of Illinois.
The Republican legislation "will strengthen the rights of patients and change the way HMOs work without wrecking the health care system," said Senate Majority Leader Trent Lott of Mississippi.
Democrats sharply disagreed, saying the bill would do nothing to improve the quality of health care. "You can put lipstick on a pig and it's still a pig," said Sen. Edward M. Kennedy (D-Mass.). "That is what the Republican proposal is all about."
The debate allowed both parties to win political points.
Republicans were able to say that they passed a bill protecting patients' rights--a boast that could prove especially useful for senators who are facing reelection in 2000. And Democrats can point out that Republicans rejected broader patients' rights.
Overall, however, Republicans carried the day, blunting many of the Democratic charges by offering their own versions of most provisions.
A Democratic version of the measure was supported by many doctors, nurses and consumer groups. Fighting the Democratic measure was the health insurance industry, HMOs and employer groups, who spent millions of dollars on a lobbying and advertising campaign to defeat it.
"I am disgusted and frustrated by the fact that a very strong special interest can have such a grip on our Congress," said Jack Lewin, executive director of the California Medical Assn.
"The result, in my view, actually strengthens the hand of the investor-owned HMOs over patients . . . . It's disheartening and frustrating. This should be a bipartisan issue," Lewin said.
Lott hailed the Senate action. "It is the right thing to do, and this is the right time to do it."
"This is a victory for patients, with improved access to health care for Americans," declared Sen. Bill Frist (R-Tenn.), the Senate's only physician, who helped put together the GOP plan. "It achieves a balance [for] doctors and patients . . . with a cost that does not hurt access to care."
The Republicans received tacit support from the business community and insurers, who were on hand throughout the debate in a marble-floored room a few feet from the Senate chamber to help review amendments and buttonhole lawmakers.
"We have thought for some time that the concept of independent review of health plan decisions is an essential building block for public trust," said Karen Ignagni, president of the American Assn. of Health Plans, which represents most managed care plans and backed the Republican version of an independent review of health plan decisions. She added that her plans were uncomfortable, however, with even the Republican bill's specific requirements to guarantee coverage of emergency and specialist care, among others.
"We are concerned about the amount of micromanagement that has been added to the bill," Ignagni said.
The debate over patients' rights has mushroomed in recent years along with the growth of managed health-care plans, which now provide health care for more than 80% of Americans who buy their insurance through their employer. Typically, such plans limit access to treatments and services to hold down costs.
In doing so they have often taken on the role of making medical decisions once made by doctors.
The regulation of health insurance plans and HMOs is especially complicated because of a confusing patchwork of state and federal legislation that covers some people and not others and leaves about 125 million people with little ability to appeal denials of care by their health plans. It also does not allow taking a health plan to court to recover significant damages if a plan's decision to deny treatment results in death or disability.
At the heart of the differences between Republicans and Democrats is a fight over who will control health care decisions, whether a health plan can be held liable for its mistakes and how many people should be covered by a federal patient protection law rather than by state laws.
The Republican measure left much of the control in the hands of managed care plans and health insurers. They said their measure would raise the cost of health care by less than 1% over five years.
The Democratic version largely would have given control back to doctors, nurses and their patients. It also would have given patients broad rights to sue plans for negligence in state court if a plan's health care decisions hurt the patient.
The result would have been a bigger increase in cost: The nonpartisan Congressional Budget Office estimated a 5% increase in health insurance premiums. Democrats said they thought the cost increase would be worth it to safeguard patients' health.
"This is a regulation bill and it costs money, but I believe the benefits exceed the costs," said Sen Bob Kerrey (D-Neb.).
On the issue of how many people should be covered by the measure, Republican senators chose to wrap themselves in the mantle of states' rights and limit most of their guarantees of service, such as access to specialists, to those 48 million Americans whose health plans are completely unregulated. However, their approach fell apart when some senators demanded that certain provisions, such as the prohibition on one-day mastectomies, cover everyone with health insurance.
The result is a bill that is a hodgepodge, applying different patient protections to different numbers of people.
The political gamesmanship of the entire debate was underscored by a Republican decision to block a bipartisan effort at a compromise bill. Democrats did not block the effort but were hardly enthusiastic about the middle-ground measure.
"Most Republicans and most Democrats would rather have an issue than a solution," said Sen. Max Baucus (D-Mont.). The debate was "one of the most partisan and the most vacuous, the most devoid of effort to try to reach a solution that I've heard in a long time."
Times staff writers Sharon Bernstein in Los Angeles and Stephen Fuzesi in Washington contributed to this story.
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Here are some key elements of the managed care bill passed Thursday by the Senate on a party-line vote.
These provisions cover 48 million people whose employers operate self-insured plans:
* Emergency care--Requires coverage for emergency care that is necessary to maintain the stability of a patient. In the case of an out-of-network provider, health plans must coordinate transfer, discharge and make other arrangements within one hour of being contacted. Emergency ambulance services would also be covered.
* OB-GYN--Grants direct access for all obstetrical care. Women also would have direct access to routine gynecological care, but more extensive care and referrals could be subject to some plan limits.
* Continuity--Extends until the end of life the transition period for a terminally ill patient whose provider has left a plan's network.
These provisions cover 140 million people, including those in self-insured plans, those in group health plans and people with individual policies:
* Mastectomies--Requires in-patient coverage for breast cancer surgery for as long as a doctor and patient deem necessary. Plans also must cover a second opinion following a breast cancer diagnosis.
* Genetic information--Health plans cannot deny coverage or adjust premiums and rates based upon the results of genetic testing or a family medical history.
This provision covers 125 million people in self-insured and group health plans:
* External appeals--Allows patients to appeal a denial of care by their health plan to an independent panel of doctors but limits which health plan decisions can be contested. The decision is binding, and the plan could be fined $10,000 a day for failing to comply with the timetable for completing a review.
Source: Senate leadership