A sweeping patients' rights bill gained momentum Tuesday as Senate Democrats won critical votes over the measure's foes and neared compromise on key sticking points.
Amid these signs pointing toward Senate passage of the bill, President Bush stepped up his involvement in the debate. He followed up his recent threats to veto the measure with calls to at least three centrist lawmakers; White House aides said it was the start of a personal lobbying campaign to encourage efforts to produce a compromise that he can sign.
Democrats won a key test Tuesday when the Senate defeated, 57 to 43, an amendment by Sen. Phil Gramm (R-Texas) that would have given employers blanket protection from health care lawsuits by workers. The amendment's opponents argued that it was too broad, unfairly giving immunity even to employers who administer their own health plans and get directly involved in coverage decisions.
Both sides were careful to catalog remaining obstacles, including a still-elusive agreement on capping damages patients could collect in court when suing health maintenance organizations. But Democratic leaders expressed new optimism that they can pass the bill, or at least have broad agreement on its major components, by the end of the week.
"We're down to a few key issues," Senate Majority Leader Tom Daschle (D-S.D.) said. "We can say with greater optimism today that we will resolve these issues--perhaps even without a narrow vote."
The bill would create a host of new protections for the roughly 180 million Americans covered by health plans, giving them guaranteed access to specialists and emergency room care, and greatly expanding their ability to sue HMOs over denials of coverage.
All of the Senate's 50 Democrats voted against the Gramm amendment, including Sens. Barbara Boxer and Dianne Feinstein of California. They were joined by six Republicans and Sen. James M. Jeffords (I-Vt.).
"The clear momentum is with us," Sen. John Edwards (D-N.C.), one of the bill's sponsors, said after the vote. Tuesday's action was "an indication that our legislation is supported by a majority of the Senate."
After thwarting the Gramm amendment, the bill's sponsors moved toward a critical compromise on the issue of employer liability with four Senate moderates who have also been courted by the White House: Olympia J. Snowe (R-Maine), Mike DeWine (R-Ohio), Ben Nelson (D-Neb.) and Blanche Lambert Lincoln (D-Ark.).
The compromise would shield the vast majority of employers from lawsuits by allowing them to designate independent "decision makers" that administer their health plans and assume the legal risks. In most cases, the decision maker would be the company's HMO. Employers who are self-insured and administer their own health plans, however, could still be sued.
Moderates involved in the negotiations said the proposal would likely be presented today as an amendment.
If it passes, that would represent a setback to President Bush and Senate GOP leaders, who sought Tuesday to persuade Snowe and DeWine to combine their employer provision with other GOP measures in one package that could present a serious threat to the Democrats' bill.
Snowe all but ruled out that approach, saying she planned to stick to her commitment to Democrats "as long as they're willing to work out remaining issues" that she and other moderates have with the legislation. She said she secured that commitment from sponsors of the patients' bill: Edwards, Sen. Edward M. Kennedy (D-Mass.) and Sen. John McCain (R-Ariz.).
Republicans fear that once the employer liability issue is resolved, Democrats will have less incentive to negotiate on such remaining points as whether suits should be confined to federal courts--as Republicans insist--and how much patients ought to be able to collect in punitive and pain-and-suffering damages.
The Democrats' bill would allow unlimited pain-and-suffering damages and punitive awards up to $5 million. But President Bush, citing concerns that the Democrats' bill will drive up health care costs and add to the number of uninsured Americans, has threatened to veto the legislation unless it moves closer to a position staked out by Republicans to prohibit punitive damages and cap pain-and-suffering awards at $500,000.
Edwards acknowledged there has been little movement toward compromise on the issue, which now looms as the most serious potential impasse. But if Democrats continue to hold their coalition together, they may not need to give ground, and might actually welcome the opportunity to put Bush in the uncomfortable position of vetoing legislation that polls have found is extremely popular with the public.
Perhaps mindful of this possibility, Bush intensified his role in the negotiations, making calls Tuesday to Snowe, DeWine and Nelson. Bush also intends to begin hosting senators at the White House later this week to discuss the legislation, according to Ari Fleischer, the president's press secretary.
"The president is very concerned," Fleischer said, "because he wants to have a bill that he can sign into law that'll give patients those protections."
Referring to Bush's veto threat, Fleischer said that whether a patient protection bill becomes law was up to the Senate and the House, which will take up similar legislation later this summer.
"They can make it happen, and the best way to make it happen is to show some flexibility and be willing to work with the White House on the liability side of the ledger," Fleischer said.
In particular, the White House is working with Sens. John B. Breaux (D-La.) and Bill Frist (R-Tenn.), who have crafted a rival bill the president recently endorsed.
On Tuesday, Breaux tinkered with the bill in an effort to lure Democratic votes, abandoning the $500,000 cap and instead proposing that limits on damages be raised to $750,000 or an amount equal to three times any economic damages assessed in a given case.
Democrats said they were confident they could defeat such a measure and on Tuesday continued to display unflinching discipline in defeating, or defusing, a series of potential threats.
Besides the Gramm amendment, Democrats also defeated on a 61-39 vote a move by Sen. Charles E. Grassley (R-Iowa) to send their version of the bill back to committee. They also voted en masse to help pass another GOP amendment, offered by Sen. Christopher S. Bond (R-Mo.), that would repeal liability provisions of the legislation if more than 1 million Americans lose their health insurance during the first year the law is in effect.
Meanwhile, House Republicans unveiled their own patients' rights bill Tuesday, incorporating some of the compromise language from the Senate and saying they believe they have produced the only bill so far that Bush would sign into law.
Times staff writer Edwin Chen contributed to this story.