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Copyright 2000 The Washington Post  
The Washington Post

March 19, 2000, Sunday, Final Edition


LENGTH: 1168 words

HEADLINE: Scope of Rival Health Care Bills Divides Hill Negotiators

BYLINE: Helen Dewar , Washington Post Staff Writer


After resolving many of the easy issues, congressional negotiators are closing in on what could be their most difficult dispute over legislation to protect patients in managed-care plans: who gets protected.

The Senate would cover fewer than one-third of the people that would be covered by the House, and this difference between the two chambers taps into age-old tensions involving states' rights and the federal responsibility to assure basic rights to all people.

"If we were able to agree on scope, we could probably settle most everything else," said Sen. Judd Gregg (R-N.H.), a member of the conference committee trying to bridge huge differences between rival versions of a "Patients' Bill of Rights" that were passed last year by each chamber. "It's almost the linchpin on which everything else depends."

Several other highly controversial issues have yet to be resolved, including whether patients can sue their health plans for malpractice, how much control the plans have over patients' treatment and whether to allow tax-free medical savings accounts on a nationwide basis.

But Republican leaders have signaled willingness to compromise on lawsuits, and key lawmakers have said the other issues can probably be resolved more easily than the question of how many Americans will be covered.

Few issues have prompted a greater sense of urgency in this preelection session of Congress than health care, which includes bills to cover prescription drug costs under Medicare and a variety of proposals to expand access to health care. But, at least so far, managed-care reform appears to have the highest profile, broadest impact and biggest political bite.

Polls indicate strong public support for managed-care protections, and Republican leaders are eager to pass a bill--preferably early and without undue rancor--to keep Democrats from exploiting the issue in this fall's campaigns. The problem is that the coverage issue has the potential to derail the whole deal.

A glimpse at the numbers helps explain why this may be difficult.

The House version of the legislation, passed last October by a bipartisan majority of 275 to 151, would cover virtually all Americans with private health insurance, which the Labor Department, using census and other figures, estimates at 191 million. This includes 169 million in employment-based plans and 22 million with individual coverage.

The Senate bill, approved in July by a largely Republican and far closer majority of 53 to 47, would concentrate on managed-care patients who are not already covered by state regulations.

Most of the Senate's specific protections, such as access to specialists, prescription drugs and clinical trials, cover only the 56 million people who are in federally regulated plans that are beyond the reach of the states. An additional 75 million people who are in job-related plans that are subject to state and federal regulation would be covered by provisions requiring greater disclosure of information about benefits and creating a process to appeal denial of treatment. Only two provisions, dealing with genetic discrimination and mastectomies, would apply to the rest of the privately insured market.

Those who favor the broadest possible coverage argue that specific protections, such as provisions in both bills that allow patients to use the closest hospital in emergencies, will not matter much if relatively few people are covered by the protections.

"We can pass the greatest bill in the world, but if we leave off more than 100 million people, we've really not done very well," said Rep. Charles Whitlow Norwood Jr. (R-Ga.), a dentist who co-sponsored the House bill with Rep. John D. Dingell (Mich.), one of the most influential Democrats on health care.

But many of Norwood's fellow Republican conservatives, especially senators, are just as adamant in insisting that the bill extend federal protections only to people who are not already protected by states.

Every state has regulations governing managed-care plans that are not covered by federal law and they are working, said Senate Assistant Majority Leader Don Nickles (R-Okla.), chairman of the House-Senate conference. "Do we really think the federal government should preempt state regulation of health care?" he asked. "Do we really want the federal government to regulate everyone's health care in this country?"

To some extent, these arguments underscore a major philosophical difference between the two parties. Democrats, who see an activist role for the federal government in expanding health care, argue that the bill should ensure that all Americans receive a minimum level of protections that states can exceed if they want.

Republican leaders, suspicious of federal intervention in most areas, counter that insurance regulation historically has been a prerogative of the states and should stay that way.

But the issue does not break down solely on party lines: More than 60 House Republicans supported the Norwood-Dingell bill, and the alternative favored by House GOP leaders also called for coverage of all managed-care patients. Some attribute the difference to the more sensitive political antennas of some House members, especially before an election in which control of their chamber is at stake.

Another issue in dispute is how adequately states already protect their managed-care patients. Republicans contend that most states have regulations dealing with all the key points in the Senate and House bills, while Democrats say the specific regulations vary widely, leaving many people with protections that fall far short of those proposed in the federal legislation.

Karen Pollitz, a health policy researcher at Georgetown University, has studied the state laws and found that they vary widely. "There are several thousand laws out there, but if you've seen one state, you've seen one state," she said. With different rules for plans regulated by state and federal law, there may be cases of neighbors--even members of the same family--who have different sets of protections.

Senate Republicans said that complexities will only grow if Washington sets a federal floor and lets states exceed it if they choose to do so, as the House bill would allow. "A regulatory nightmare," said a GOP aide.

"It's a nightmare the way it is now," said a Democrat, referring especially to the 75 million people who are covered to some degree by both state and federal regulations.

In meetings over the past several weeks, House and Senate negotiators have resolved relatively minor differences over emergency room treatment, pediatric coverage and licensing requirements. When the Senate returns from a week-long recess Monday, the negotiators may begin dealing with areas, such as the appeals process, that could lead into the tougher issues, including the bill's scope.

Nickles said earlier he wanted the conference to finish work by the end of March. Few now believe that target will be met.

LOAD-DATE: March 19, 2000

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