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Megan Flaherty With anti-HMO sentiment running high and a congressional election just around the corner, federal lawmakers are scrambling to pass legislation that would regulate the managed care industry. Democratic and Republican leaders in both houses of Congress have introduced several conflicting "patients’ rights" bills and are battling over the type and scope of managed care regulation. "We’re getting a rush [by lawmakers] to try to keep voters happy," said Ellen Severoni, RN, president of the nonprofit educational organization California Health Decisions, based in Orange. Constituents have appealed to elected officials to solve their managed care problems because they’re not finding mechanisms to help them within the healthcare system itself, she said. Rival plans Backers of the main congressional proposals—the Democrats’ "Patients’ Bill of Rights" and the Republicans’ House and Senate versions of "Patient Protection" bills—say the plans would ensure that HMO members get the health care they need. Last month, the House narrowly rejected the Democrats’ bill and passed the GOP bill instead; the Senate took an August recess without acting on either piece of legislation. Congress will take up the issue again this year. The Senate and House must agree on any bill before it goes to President Clinton. The president has said he would veto the GOP patient protection bill if it remains in its current form, claiming that it falls short of ensuring Americans the care they need and that it includes unnecessary provisions. Consensus, conflict The Democratic and Republican plans include some of the same consumer protections. Both parties would require health plans to pay for emergency care whenever a "prudent layperson" would consider it necessary. They would both guarantee women the right to see a gynecologist, obstetrician, or pediatrician without prior approval and prohibit gag clauses that restrict a provider from telling patients about all treatment options. But the Democrats’ and Republicans’ bills differ on many significant points. The Republicans’ bills would apply to fewer people than the Democrats’ bill (see "Who’d Be Covered") and expand the availability of tax-exempt medical savings accounts. Under the Republicans’ plan, certain disputes between consumers and health plans would be settled by outside medical experts. The Democrats’ plan would allow for out-of-court legal mediation, which would be overseen by the government. One of the most contentious points in the Democrats’ bill gives consumers the right to sue HMOs if they feel they are improperly denied care. Revving for reform Most managed care organizations have already voluntarily adopted many of the proposed patient protections, but no health plan has put them all in place, said Larry Levitt, director of the changing healthcare marketplace project for the Kaiser Family Foundation, a nonprofit, nonpartisan organization not affiliated with Kaiser Permanente. "There’s no way to guarantee patients’ rights without legislation," Levitt said. "These are reasonable, moderate reforms that most consumers expect are already practiced," said Bruce Livingston, executive director of Health Access, a San Francisco-based consumer health coalition. For example, most HMOs already provide their members with quick and easy access to an ob/gyn. However, "We need to watch out for the bad players, and government should be a protector of the population," Livingston said. "We need a baseline agreement on quality of care that can’t be violated by an HMO or any other form of insurance." Managed care has quickly taken over the insurance market, and people are now realizing what the system is all about—"taking in money on a regular basis and delivering as little care as possible," Livingston said. Resisting regulation Opponents of new federal regulations—including many health plans and businesses—say they’re overkill, since managed care plans are already subject to state laws. In addition, they say the premise that people are getting inferior care under HMOs is wrong. "Managed care has raised the overall quality of health care and has helped reduce healthcare cost inflation that was from two to three times the rate of general inflation prior to managed care," said Richard Coorsh, spokesperson for the Health Insurance Association of America. Federal mandates would hurt consumers more than help them, added Don White, spokesperson for the American Association of Health Plans. The increased costs will put affordable health care out of the reach of working families and small employers, increasing the number of uninsured, White said. "We believe the emphasis should be on providing high-quality, affordable health care to the largest group possible. A lot of discussions have missed that point entirely." Price of reform Government mandates will inevitably raise costs, Levitt agreed, but the real question is by how much. A recent study by the nonpartisan Congressional Budget Office of the most sweeping reform proposal, the Democrats’ Patients’ Bill of Rights, showed that the bill would raise premiums by 4 percent, or about $200 a year for an average family. Of that, employees would typically pay $60, and employers would foot the rest of the bill. "$60 per family is still within the range of what the American public would support," Levitt said. Coorsh thinks the Budget Office estimate is very low. "Nevertheless, assuming it was correct, it would result in a minimum of 800,000 people losing or not gaining private health insurance." Coorsh based his figures on a 1996 Budget Office analysis that showed that each 1 percent increase in premiums would result in approximately 200,000 people losing insurance because employers would stop offering it or employees would no longer be able to afford it. When added together, the minuscule costs of different mandates could get expensive, Severoni said. "We have to think about what to prioritize as most important, what will help most Americans, and what we could phase in later. I don’t think all the issues can be resolved in one legislative session. We need to be constantly involved in reforming the healthcare system." Room for compromise Because both political parties have included highly controversial provisions in their bills, lawmakers will have to negotiate heavily to get any legislation enacted this year, say analysts. Senators from both parties are working together to develop compromise legislation that excludes the most disputed aspects of each bill, including the Democrats’ provision giving patients the right to sue HMOs and the Republicans’ expansion of medical savings accounts. Meanwhile, some consumer groups and nonprofit HMOs are also working together for managed care reform. HIP Health Plans, the Group Health Cooperative of Puget Sound, and Kaiser Permanente joined forces last year with Families USA and the American Association of Retired Persons to identify consumer protection principles they’d like to see enacted nationally, including requiring health plans to pay for emergency care and prohibiting gag clauses, said John Mills, a lobbyist for New York-based HIP Health Plans. Whether any legislation will be passed this year is still up in the air, experts say. "There should be room for compromise," Levitt said. The big question, he said, is whether Democrats and Republicans are serious about passing a bill or just trying win an election. |
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Who
is COVERED?
Congress is debating who will be covered by managed care bills as well as the content of the legislation. Democrats want their patients’ bill of rights to apply to 148 million Americans who are insured through their employers, plus a few million who buy coverage themselves. Senate and House Republicans are split over how far to extend protections. The Senate Republicans’ bill generally applies only to the 48 million employees who work for big companies that sponsor their own self-insured health plans, which are exempt from state laws. The House Republicans’ bill applies to that group, plus the 100 million consumers who belong to employer-sponsored plans regulated by state laws. Only the self-employed people covered by the Democrats’ plan would not be in this version. |
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