WASHINGTON -- Senate Republicans -- spurred by increasingly strident Democratic demands and a steady diet of health care horror stories -- joined the drive to provide new protections for managed-care patients by offering their own proposal yesterday.

The Senate GOP plan, like the Democratic alternative and a House Republican proposal, would expand patient access to emergency care, specialists and doctors outside a managed-care company's prescribed network. It would also require new procedures to help patients appeal adverse coverage decisions, and it would greatly expand the availability of tax-favored savings accounts that encourage patients to pay for their own care.

"This is a great bill," declared Sen. Bill Frist, a Tennessee Republican and the Senate's only physician. "It's a bill about the rights of patients, a bill about [medical] research, a bill about quality of care."

Senate Majority Leader Trent Lott and House Speaker Newt Gingrich plan to hold votes on managed-care legislation this month. All sides agree on many of the goals of managed-care legislation, but the political parties are far apart on key provisions. Ultimately, passage of a bill may depend on whether Republicans and Democrats conclude that the American people will accept nothing less.

President Clinton indicated that he was willing to broker a compromise.

"It's not a political issue, and anybody who has experienced it feels the same way," he said as he listened to tragic stories of patients who died or were disabled as a result of managed-care decisions.

Democrats dismissed the Republican proposal out of hand, just as Republicans have criticized the Democratic alternative.

"I would describe this as too little too late," said Health and Human Services Secretary Donna E. Shalala.

Democrats are demanding that any managed-care legislation include the right to sue an insurer for damages if health care is unfairly denied, a proposal Republicans refuse to include.

Republicans have their own politically troublesome provisions, particularly a proposal to expand tax breaks for medical savings accounts that Democrats contend would allow the healthiest Americans to opt out of the health care system, raising costs for the sick and vulnerable.

The insurance industry is opposed to any further regulation of its business, saying it would drive up costs and increase the ranks of the uninsured.

"All these plans are in the same ballpark with variations in the details," said Charles N. Kahn III, the incoming president of the Health Insurance Association of America. "And both sides have their poison pills."

Striking turnaround

Still, the Senate Republican proposal marks a striking turnaround, especially for Sen. Don Nickles of Oklahoma, the assistant majority leader and chairman of the task force that produced the bill. Only months ago, Nickles said legislation reining in managed care may not be necessary, contending that managed-care companies had successfully tamed explosive health cost increases. The market, he said, would provide the protections patients needed.

But a political onslaught by Democrats seems to have changed Nickles' perspective. He even took the title of the Democrats' proposal: the Patients' Bill of Rights.

"The challenge for our task force was to correct some very real problems in our health care system," he said as he unveiled the GOP proposal.

Under the Republican proposal, many managed-care companies would have to cover any emergency room visit that would be deemed medically necessary by a "prudent layperson." Women would be able to see their gynecologists and children could visit their pediatricians without a referral from a general practitioner.

Employers who offer their workers only a single managed-care plan would have to allow their employees to go to a physician outside the insurer's network, but the worker would bear any additional cost. Small businesses would be exempt from that mandate.

Patients would also have the right to appeal decisions denying coverage to a panel of medical experts within the insurance company, who would have 30 days to overrule the initial decision, three days in an emergency. If that decision also comes back against the patient, another internal appeal would be possible, followed by an external appeal to an independent panel named by the insurance company.

That external appeal would be available, however, only if the care is considered to be medically necessary and would cost more than $1,000 or if the treatment was considered experimental and for a life-threatening ailment.

The bill also includes a broad section on research, screening and treatment for women's health issues, including a provision requiring the length of any hospital stay for breast cancer treatment to be determined only by a woman's physician.

Most of these patient protections, however, would apply to only the 48 million people covered by federally regulated health plans in which employers directly assume the financial risk for workers' medical care. Republicans said the other 114 million Americans with employer-provided health plans fall under state regulations.

Democrats contend that these protections should extend to all health plans, even those that are state-regulated.

'A desperate attempt'

Senate Democratic leader Tom Daschle of South Dakota labeled the GOP plan "a desperate attempt to dodge the American people's demands for real patient protections."

Sen. Edward M. Kennedy of Massachusetts, who co-wrote the Democratic bill with Daschle, said the GOP proposal "protects industry profits over protecting patients."

If Clinton steps in to negotiate a compromise, those differences could be overcome and some form of the legislation could pass, acknowledged Kahn, the insurance industry lobbyist.

Clinton would have to overrule many House Democrats who would rather keep managed care a political issue for the fall campaigns than achieve a legislative accomplishment.

Even so, "At the end of the day, if it comes down to Lott, Gingrich, and the president making the decision it still could happen," Kahn said.

But the longer the issue remains in play, the more time a coalition of insurance companies and employers will have to wear down support with advertising that paints any bill as a bureaucratic response to a nonexistent problem that will only raise health care costs and increase the ranks of the uninsured, said Bruce Josten, senior vice president of government affairs for the U.S. Chamber of Commerce.

"This has been nothing but a political debate, going back to Day 1, January," said Josten, a leading opponent of managed care legislation. "Four months ago, I think Republicans needed to say, 'I voted for [a managed care bill].' Today, I'm not so sure they even need that."

Pub Date: 7/16/98