WASHINGTON -- The battle over managed care reform began in earnest yesterday when House Republican leaders unveiled a far-reaching proposal to provide new rights for patients, ensure access to specialists and lower the cost of health care.
The proposal was driven by a popular outcry against managed care that threatens to make it the hottest issue of this congressional election year.
Pushed by their rank-and-file, GOP leaders reversed course from opposing any federal legislation to embracing a surprisingly broad proposal that could change the face of the U.S. health care industry. Their plan could come to a vote next month.
"This is a great day for patients, doctors and the American health care system," declared Illinois Rep. Dennis Hastert, chairman of the Republican task force appointed to draft managed care legislation.
"Let's face it, when folks are sick, they should see a doctor. Unfortunately, for too many Americans who have health care coverage, they find it difficult to get the care they need at the most vulnerable time." The GOP still must overcome opposition from all fronts.
Even before the proposal was unveiled, the health insurance industry condemned it as an unacceptable federal intrusion, claiming the cost of health care will rise. Medical groups blasted the proposal as a sham that wouldn't deliver on its promises.
And Democrats, who are not eager to resolve an issue they hope might propel them back into majority control of the House, decried the GOP plan as a toothless subterfuge.
"The Republican proposal is designed for show, not to become law," declared Rep. Richard A. Gephardt, the House Democratic leader. "Republicans are proposing an over-the-counter remedy for a prescription-sized problem."
Unfazed, Republicans insisted all the opposition only proved they had produced a balanced plan that did not favor any one interest.
Hastert said he will try to reach out to Democrats. "[But] we will not tolerate people trying to kill this bill, then saying this is a do-nothing Congress. We've played that game before," he said.
The GOP proposal -- five months in the making -- has yet to be translated into legislative language and lacks some key details. But its intentions are sweeping.
Under the proposal:
All insurance plans would have to allow patients to go to a doctor outside their particular medical network, and pay as much of that doctor's fee as they would have provided to a network physician.
Women would be allowed to designate their gynecologist as their primary care physician, eliminating the requirement for a referral from a general practitioner.
Similarly, parents could designate a pediatrician as the primary care physician for their children.
Coverage would have to be provided for any emergency room visit that a "prudent lay person" would deem necessary.
Patients would have new options to appeal denials of care or payment. Under the proposal, insurers would have to set up an internal review process that could take no longer than seven to 10 days to consider an appeal -- 72 hours in an emergency.
If care is still denied, the patient could turn to an external review panel of medical specialists -- though they would be specialists appointed by the insurer.
If the insurance company failed to follow the panel's advice, the patient could then go to court to receive a "significant" monetary penalty for every day access is denied.
The GOP leaders' plan would not include one of the key demands of Rep. Charlie Norwood, the Georgia Republican who almost single-handedly forced GOP leaders to address the managed care issue.
Could sue insurer
Norwood's bill would have allowed patients or their families to sue insurers for denial of care.
But Republican leaders refused to allow such suits, answering the demands of both insurance companies and business interests who had said the provision would be intolerable.
"There comes a time in any contest in which you need to stop fighting and declare victory," Norwood said, calling a truce in his own war with his party. "It is time now to pass this legislation because it is the right thing to do for patients of this country."
The GOP proposals actually go far beyond the issue of patient protection, straying into controversial areas of health-care access that could draw opposition.
'Association health plans'
For example, the package would create "association health plans" to allow small businesses, trade and professional groups, and church associations to band together and purchase their own health plans.
And so-called "health marts" would allow families and individuals to buy health insurance from large buying pools that would bring down costs through economies of scale.
Democrats quickly protested those provisions, complaining that buying pools would allow insurers to evade state regulations in favor of federal guidelines that in some cases may be less stringent.
Those consumers who remain in the state systems would likely be the sickest or most vulnerable populations, raising the cost of their health care.
That could be crippling for Maryland's health care system, charged Rep. Benjamin L. Cardin, the Baltimore Democrat who was wooed by Republicans seeking his support.
"They take 1 1/2 steps forward and 1 1/2 steps back," Cardin said of the GOP plan. "If they had made any progress, I'd be with them."
In another highly controversial provision, the package would limit damages from malpractice suits to $250,000.
Any bill with coverage pools and limits on malpractice awards "would be doomed from the start," predicted Labor Secretary Alexis Herman.
But unlike Democratic congressional leaders, Herman signaled the White House would be willing to work with the GOP.
Congressional Democrats may want an issue for the election, but with the collapse of the tobacco bill, President Clinton is desperate for a tangible accomplishment for his second term.
"I am pleased the Republican leadership has recognized the need for federal action," said Herman, who co-chairs the president's own commission on managed care reform. "We welcome the debate."
But with only a few months left in an election-shortened legislative season, White House cooperation may not be enough, especially when an industry that brought down Clinton's national health plan is united against any managed care legislation.
"It's very late in the year to get something done this big," said Bill Gradison, president of the Health Insurance Association of America, whose "Harry and Louise" advertisements helped sink Clinton's health plan. "I don't think it is preordained that there even will be action."
The House Republican proposal on managed care reform would:
Ensure that patients could see doctors outside managed care network.
Allow women to designate Ob/Gyn as primary care physician and pediatrician as children's primary care physician.
Establish expedited internal appeals process for denial of coverage.
Require coverage of emergency room care for conditions a "prudent lay person" would deem emergencies.
Bar insurers from keeping doctors from disclosing expensive care options.
Create associations to allow small businesses to pool coverage and reduce costs.
Expand availability of medical savings accounts.
Pub Date: 6/25/98