GOVERNMENT & MEDICINE
"A big win for patients"
The patient protection issue moves into negotiations between the House and Senate, where differences in their approaches must be hammered out before a final vote.
Washington -- The resounding 275-151 victory of the bipartisan version of patient protection legislation in the House boosted chances that a "Patients' Bill of Rights" law might become a reality, the measure's supporters said.
"It's a big win for American patients," said AMA President Thomas R. Reardon, MD. "It's the first step to get a strong bill of rights through Congress, to the president and signed into law."
The wide margin -- the result of 68 Republicans breaking with their leadership and voting for the bill sponsored by Reps. Charles Norwood, DDS (R, Ga.) and John Dingell (D, Mich.) -- gives the bipartisan approach momentum as lawmakers enter into negotiations with the Senate.
The Senate in July passed a more limited patient protection package that differs greatly from the House bill in several key aspects. Those differences must be ironed out in a conference committee made of lawmakers from the House and Senate before legislation can be brought before both bodies for a final vote.
"We needed a large, bipartisan vote, and we've gotten that," said Dr. Norwood. "With that ammunition, we can go into conference and do what we started out to do -- not just get a bill, but get a law."
The House defeated three GOP-sponsored alternatives before passing the Norwood-Dingell measure.
Passage of the Norwood-Dingell bill may have prevented the issue from dying in Congress this session, said Rep. Greg Ganske, MD (R, Iowa), a co-sponsor of the measure and leader in the drive for patient protection legislation. About 300 consumer, provider and medical groups support the measure, he noted.
"By passing a good, strong bill, we'll be able to keep exposure on this legislation," he said. "If one of the substitutes had passed, there would be no push from those 300 groups."
But supporters of the Norwood-Dingell bill acknowledged that they have a tough road ahead.
"I'm happy, but we have a lot of battles to fight yet," Dr. Ganske said after the House vote.
The first hurdle is getting conference committee action.
The GOP leadership -- which fought the Norwood-Dingell approach -- will control the conference committee and its schedule. And Senate GOP power brokers, who defeated a tougher Democratic bill during that body's vote, aren't likely to view the House-passed bill any more favorably.
"You've got folks going to conference committee who aren't really supportive of the bill," said Mark Hamelburg, principal at William M. Mercer Inc., a national employer consulting firm.
House legislation supporters fear that GOP leaders could let the issue die a slow death in conference committee or produce out of the committee a bill stripped of the stronger House provisions.
Some advocates are calling for conference committee action before Congress adjourns for the year, probably in November. But others predicted that the committee won't act until next year because the issue will get pushed to the back burner as lawmakers struggle to pass the appropriations bills necessary to keep the government running.
The second major hurdle is reaching compromise on a handful of high-profile issues handled in widely different ways in the two bills.
The biggest area of disagreement is whether people with employer-based health coverage should be able to sue their health plan for malpractice if they think the plan has denied them a medically necessary benefit.
Norwood-Dingell advocates argue that liability is the only way to hold plans truly accountable to patients, while opponents argue it would drive up insurance costs and open employers' funding health plans to liability.
The House defeated bills that lacked a plan liability provision or would give patients limited abilities to sue in federal courts. The Norwood-Dingell approach passed in the House would let patients sue in state court. The Senate rejected plan liability.
According to Mercer's Hamelburg, the question is whether lawmakers can pass a final bill in the House without a strong liability provision or pass one in the Senate with it.
Norwood-Dingell advocates argue that the House vote's wide margin means the conference committee must include a liability provision in its package or risk opening the GOP to accusations of bad faith in a highly emotional, public forum.
"There will be a compromise on liability," Dr. Norwood predicted.
The compromise position could be to settle for a provision similar to the liability language in the failed House bills that would give patients limited rights to sue in federal court, said Robert Blendon, ScD, Harvard University professor of health policy and politics.
Insurance access stumbling block
Another potential roadblock to compromise is a set of GOP-favored provisions aimed at expanding Americans' access to insurance.
Both the Senate and House bills would lift limits on medical savings accounts and change the tax code to encourage the purchase of coverage. The House access provisions, passed separately and then added to the patient protection bill, also would allow the development of two insurance pooling mechanisms aimed at making coverage cheaper for individuals and small groups.
These proposals are opposed by Democrats and consumer groups, who argue that they would draw healthy people out of the small business and individual insurance markets, leaving the sick behind in a more expensive, less stable market. In a recent speech, President Clinton hinted that he would veto any bill with these provisions, which he referred to as "poison pills" that he "can't sign."
The access provisions have put some lawmakers and groups, such as the AMA, who have traditionally supported these concepts, in a tough spot.
"We're concerned about access, but we want that as a separate bill," Dr. Reardon said. "We're saying: 'Don't try to confuse the issue to defeat the Patients' Bill of Rights.' "
The major differences of opinion on the shape of the final legislation portend a bruising battle during conference committee, health policy analysts agreed.
"It's really going to be quite a wrestle," Dr. Blendon said.
Already, groups on both sides of the debate are gearing up for this next round.
The AMA has vowed to keep up its lobbying and grassroots campaign, credited by Norwood-Dingell sponsors and by outside analysts as a major contributor to the bill's success.
But business, insurance and HMO groups are keeping up the pressure against the House bill. They are focusing especially on the damage they think the liability provisions would do to employers' and individuals' ability to afford coverage.
For example, the American Assn. of Health Plans is running television ads of sharks swimming in a school of fish with a voice in the background warning that "America's richest trial lawyers are circling, and your health plan is the bait."
Despite the formidable obstacles to a compromise on patient protection legislation, some analysts predicted the conference committee could forge a bill able to pass both houses of Congress and garner Clinton's signature.
"I would not want to have this thing floating over my head in a campaign," Harvard's Dr. Blendon said, referring to next year's election. "If I were an incumbent in the majority party, I would want to take credit for something." Meanwhile, he said, Clinton might want to negotiate with the GOP to get a bill passed that he can be remembered by.
Patient protection showdown
The House and Senate: bills have some major differences that must be fought out in a conference committee if a final vote on the legislation is to occur.
Health plan liability