House OKs HMO Bill Boosting Patient Rights

A far-reaching package of patient protections overwhelmingly passed the House on Thursday over the objections of Republican leaders, who urged members to vote for a more modest measure.

The bill, one of four competing measures considered by the House, passed by a vote of 275 to 151--a far wider margin than had been expected, underscoring the grass-roots momentum of the issue and the desire of House members to be on record in favor of restraining health maintenance organizations before next year’s election.

For Democrats and the White House, the vote was a triumph on a signature issue for the party and one that they had pushed for the last three years. This time, they fought efforts by the Republican leadership to weaken the provision that would allow patients who are injured to recover damages from their health plans in court.

The vote represented “a major victory for every family in every health plan,” President Clinton told reporters in New York. He praised the bipartisan coalition that pushed through the bill.

The House measure, which was co-sponsored by Rep. Charlie Norwood (R-Ga.), a dentist, and Rep. John D. Dingell (D-Mich.), the most senior member of the House, was passed after three other, more limited alternatives were defeated.

In all, 206 Democrats voted for the bill, along with 68 Republicans and one Independent. Just two Democrats, both from Kentucky, opposed the measure.

The bipartisan bill offers patients a long list of protections, including guaranteed payment for emergency care, the right to see specialists, the right to independent medical review of health plan denials and the right to sue a health plan in state court. Lawsuits brought under state laws would be subject to whatever caps on damages the state had in place.

If the bill becomes law, California’s recently enacted liability law would remain undisturbed, because the House bill would provide that patients may sue in state court under state rules. However, Californians could get more rights under the legislation than they now have in several areas, including access to clinical trials and access to care by medical specialists, experts said.

“It is time we asked the insurance industry to be responsible for its actions,” said Norwood, who has pushed for the legislation for years in defiance of his party’s leadership.

Groups representing health plans sharply criticized the House vote, pointing out that even without broader rights in court, more lawsuits are being filed against the industry--including two filed this week against Aetna/US Healthcare that claim the company failed to live up to its obligations to members. Both suits seek class-action status.

“[House] members may have cast a vote against health plans today, but the people who are going to pay the bill are working families,” said Karen Ignagni, president of the American Assn. of Health Plans. “We’ve seen two suits filed [this week] . . . and even though we think we are going to win, working families are going to absorb the cost of defending them.”

Republican leaders warned that, if the bipartisan bill should become law, trial lawyers would be major beneficiaries. They said that the cost of health care would increase and that quality of care would be little improved.

While many Republicans said that they could support new, strict rules to help ensure that patients get the health care they need from their managed-care plans, they called the House bill’s approach extreme.

“Trying to keep a balance is the task before this House,” said Speaker J. Dennis Hastert (R-Ill.). The difference between the bills is in how far they go to “give license to the trial lawyers. . . . No one has any idea what the cost will be when you go too far.”

Despite the lopsided vote in the House, the bill’s prospects of becoming law are dim at best. The Senate version of the patient protection measure--with which the House bill must be reconciled--would cover far fewer people and is weaker on almost every provision, making compromise particularly difficult.

“You don’t see too many cross-breeds between Chihuahuas and great Danes walking around,” said Rep. William M. Thomas (R-Bakersfield).

Employers, health insurers and HMO executives, who have spent several million dollars battling every patients’ rights bill over the last couple of years, said they were committed to trying to kill the liability provisions--if not the entire bill--in the House-Senate conference.

“To see nothing come out of conference is my hope,” said Bruce Josten, executive vice president for government affairs for the United States Chamber of Commerce. “The best outcome is no outcome.”

Senate Majority Leader Trent Lott (R-Miss.) said that House-Senate conferences on other legislation have a higher priority and that resolving the differences on this bill “would take some time.”

Asked if he could envision the Senate’s embracing any expansion in health plans’ liability, Lott said: “I can’t think of any circumstance where I’d like more lawsuits.”

Dingell, who is viewed as one of the masters of the legislative game, said that he had no plans to celebrate before a Rose Garden ceremony where the bill would be signed into law. “The time for rejoicing is really not here. We have to go back to work,” he said.

Doctors, who lobbied hard for the legislation, flying in physicians from members’ districts for personal meetings and walking the halls of Congress as recently as a week ago, were jubilant at their surprise victory but resolved to continue their effort with the conference committee.

The American Medical Assn. “has fought for five years to see this kind of legislation passed,” said Thomas R. Reardon, president of the group.

“Today we are one giant step closer to a law that allows physicians to make medical decisions, that allows patients to appeal if their care is delayed or denied. . . . Let’s finish the job.”

Passage of the strong bill by the House reflects a combination of factors--several of them unique to the managed health care debate. Perhaps most striking was the populist power of the issue itself, which appears to have caught the GOP leadership by surprise.

The insurance industry complained loudly and with some justification that horror stories told by advocates of patients’ protections failed to represent the broad satisfaction of most patients with their health plans.

However, because of lawsuits and media accounts of patients deprived of care by HMOs, even those who personally have had good experiences with their health plans were made nervous about what would happen if they needed costly care. Both Republicans and Democrats spoke in debate about constituents who had been denied care by their health plans--with catastrophic results.

“Some of these horror stories . . . have resonated with members,” said Rep. Ray LaHood (R-Ill.), noting that the patients’ rights issue is likely to have significant impact in some districts in next year’s election.

“There was an underestimation of how deep the backlash was against managed care,” said Mark Peterson, a political scientist at UCLA’s School of Policy Studies. “It turns out there’s a pervasive fear among the middle class about what their prospects would be if they got sick.”

For Republicans, the issue presented a political minefield, and even when their leaders decided to back a bill with narrow liability provisions, they did so only halfheartedly.

Rank-and-file Republicans were all over the map on the issue, making it difficult for Hastert to marshal them around one plan. The staunchest conservatives objected to even the narrowest liability provisions and their ‘no’ votes helped doom the alternative bill backed by the leadership.

Further complicating matters were divisions among the business groups and health insurers, from whom the leadership sought signals on how far to go in regulating the managed-care industry.

The insurers were staunchly opposed to supporting any measure that increased their vulnerability to lawsuits. The Chamber of Commerce opposed the bill backed by the leadership.

“Mostly the insurance industry was not willing to concede that this stringent liability could ever pass, and thus would never look for the middle ground,” said a senior business lobbyist.

The result was that, when the leadership finally endorsed one of the bills, there was just 48 hours until the floor debate--too little time to round up votes to pass the plan.

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Times staff writers Janet Hook in Washington and James Gerstenzang in New York contributed to this story.

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

WHO’S COVERED?

* House: All Americans with private health insurance.

* Senate: Many provisions apply to 48 million people in a specific health plan--known as self-insured health plans--regulated only by federal law. These plans are often set up and run by large companies.

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CAN PATIENTS SUE?

* House: Lifts federal ban on lawsuits for Americans in health plans that fall under federal regulation.

* Senate: No new rights to sue.

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WHAT PATIENTS RECEIVE

* House: Prompt access to medical specialists. No prior approval on emergency-room care.

* Senate: Prompt access to medical specialists. No prior approval on emergency care. But both provisions apply only for the 48 million in self-insured plans.