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GOVERNMENT & MEDICINE
Clinton, GOP pledge action on uninsured, patient protection
Differences in Democrats' and Republicans' approaches on patient rights and insurance access still loom as major stumbling blocks to success.
Washington -- President Clinton set the legislative stage for action during his recent State of the Union address by calling on Congress to extend coverage to at least some of the 44 million Americans without health insurance and to pass a "real Patients' Bill of Rights."
For their part, Republican congressional leaders have acknowledged the need to expand health coverage to more people and have vowed to have patients' rights legislation on the president's desk by late April.
But huge differences in how those goals will be reached remain.
In delivering the GOP response to Clinton's address, Sen. Bill Frist, MD (R, Tenn.), faulted the president's plan to expand existing federal programs to sweep in more of the uninsured as one that will ensure a "bigger and more bloated" government.
And while the House and Senate passed managed care legislation last year, the measures remain greatly different as they head toward resolution in a conference committee.
In one sign of movement toward compromise, however, Dr. Frist echoed statements made by Republican party leaders that a final patients' rights bill would likely include at least a limited provision to allow people to sue their health plans.
Previously, many Republicans, including those in House and Senate leadership positions, had opposed a liability provision. They argued that lawsuits would drive up the cost of insurance and result in an even greater number of uninsured people as employers dropped health benefits.
The House bill, sponsored by Reps. Charles Norwood, DDS (R, Ga.) and John Dingell (D, Mich.), contains a liability provision that allows people with employer-based health coverage to sue their health plans for malpractice if they think the plan has denied them a medically necessary benefit.
Right to sue or window dressing?
The Norwood-Dingell bill, strongly supported by the AMA, passed the House last October by a resounding 275-151 vote after three GOP-sponsored alternatives were defeated. The defeated plans either lacked a liability provision or would have provided only limited ability to sue in federal court.
The Senate had, in July, rejected plan liability in its measure that passed by a largely partisan vote.
Advocates who favor the Norwood-Dingell bill argue that liability is the only way to hold plans truly accountable to patients. They view the Republicans' change of heart with caution, if not suspicion.
"The devil is in the details," said AMA President Thomas R. Reardon, MD. "It's too early to comment. Certainly our position is, if health plans are going to make decisions that result in harm to patients, then patients should have recourse to courts."
While encouraged that House and Senate leaders had shifted somewhat from their emphatic opposition to lawsuits, Adrienne Hahn, senior counsel for Consumers Union, noted that proposals defeated by the House had contained liability provisions that were rendered meaningless by various loopholes.
"We are concerned," she said. "We don't want [the Republican leadership] to be able to say, 'Sure we're for the right to sue,' but when the rubber meets the pavement, there is nothing there."
If the Republican leadership has made an about-face, said Ron Pollack, executive director of the consumer rights organization Families USA, it likely resulted because of an understanding of how strongly a patients' bill of rights is supported by the American people.
"They do not want to have the issue hanging around them like an albatross for the upcoming presidential election," he said.
Rhetoric vs. productivity
As for how much will actually be accomplished during this presidential election year, Rep. John Boehner (R, Ohio) was not optimistic.
"The rhetoric will rise and productivity will decline," he predicted.
Despite the timing, Boehner, who was appointed to the conference committee formed to resolve differences between the House and Senate managed care bills, said he expected a bill to emerge in this Congress, but only after a "bitter debate." The Democrats, he charged, would like to use the issue during the prime presidential campaign season.
And liability is not the only issue separating the House and Senate bills. Boehner said he sees a final bill that will include provisions designed to increase coverage for the uninsured.
Among the provisions in the House bill are such GOP-supported innovations as health marts and association health plans, which are designed to reduce the cost of health insurance for workers in small businesses.
Despite high hopes among Republican lawmakers that many of the uninsured would be covered under those new options, however, a recent Congressional Budget Office report said only 330,000 people now without health insurance would likely find coverage under such plans. Most firms purchasing insurance through an association health plan or a health mart would simply be switching from traditional insurance coverage, according to the report.
The House and Senate bills also differ in scope, with the House bill covering all 161 million workers with private insurance and most of the provisions in the Senate bill covering only the 48 million in self-financed health plans that are not regulated by the states.
The bills also differ substantially in designating who would determine the medical necessity of treatment -- physicians or health plans.
The state of health care
Excerpts from President Clinton's State of the Union address and the Republican response, given by Sen. Bill Frist, MD (R, Tenn.)
Patient protectionClinton: "I ask you to pass a real Patients' Bill of Rights."
Dr. Frist: "Congress will, for the first time, send the president a real Patients' Bill of Rights, with strong patient protections. ... Unlike the president, we see lawsuits as a last resort, not the first."
Insurance accessClinton: "Tonight I propose that we follow Vice President Gore's suggestion to make low-income parents eligible for the insurance that covers their children."
Dr. Frist: "[Clinton's plan] makes government even bigger and more bloated because each new proposal we hear about tonight -- and there were about 11 of them in health care alone -- comes with its own massive bureaucracy."
Medicare prescription drugsClinton: "In good conscience, we cannot let another year pass without extending to all our seniors this lifeline of affordable prescription drugs."
Dr. Frist: "The answer is not government-dictated price controls that stop life-saving research, or forcing the 65% of seniors who now have drug coverage to pay more or give up what they have."
Medicare solvencyClinton: "My budget ... dedicates nearly $400 billion of our budget surplus to keep Medicare solvent past 2025."
Dr. Frist: "To guarantee that seniors can rely on Medicare forever, we will add it to the Social Security lock box, which will lock away the surplus for both Social Security and Medicare."