WASHINGTON -- President Clinton journeyed to Capitol Hill yesterday to deliver an impassioned appeal to Congress to overcome partisanship and pass far-reaching protections for managed-care patients this year.

With Republicans and Democrats still far apart on the details of such legislation, Clinton offered room for compromise even as he laid out two key demands: Any bill, the president said, must cover all Americans who have health coverage. And some provision must be included, he said, to enforce the protections.

"We need to do this for America," Clinton told members of a divided Congress. "We need to do everything we can to stop this from being a partisan political issue because it isn't, anywhere but Washington."

Both parties tout their own plans and remain at odds over the scope and reach of federal health care legislation, as well as over whether to create a right to sue health insurers for medical malpractice.

How the disputes are resolved could make a vast difference in how federal legislation will affect the lives of most Americans. In Maryland, for example, few managed-care patients would receive additional protections if the Senate Republican plan prevails unchanged, according to a study released yesterday by Families USA, a health care consumer group that is pushing the Democratic bill.

Senate Republicans proposed protections this week that would benefit mostly the 48 million Americans covered by health plans from their self-insured employers. Those plans, most of them at large corporations, are not covered by state regulators.

An additional 100 million Americans belong to health plans regulated by their states and would not benefit much from the Republican proposal. The Democratic plan, along with a House Republican plan, would expand patient rights to all insured Americans.

Maryland has adopted eight of the 13 main patient protections in the Democratic bill, according to the new study and insurance administration officials. The Senate Republican plan would extend federal protections to the 3 million Marylanders not covered by state protections.

The rest of Maryland's insured population already have significant protections, said Steven B. Larsen, the Maryland insurance commissioner.

"We've been fortunate to have a relatively visionary and progressive General Assembly and governors," Larsen said.

Maryland provides many key protections: access to emergency care if a "prudent lay person" would deem it necessary; access to doctors outside a network; the right of a woman to name her gynecologist as her primary care provider; access to an external review panel to appeal denials of coverage; the right of the

seriously ill or pregnant women to continue seeing doctors for 90 days if a health maintenance organization drops those physicians from its network; bans on financial incentives to entice physicians to deny or limit care; and access to clinical trials for managed-care patients.

But Maryland residents lack some protections that health care advocates are demanding and that the Democratic bill would provide. Those include: the right to sue a managed-care company for medical malpractice; the ability for the seriously ill or disabled to name a specialist as their primary care provider or maintain a standing referral to a specialist; and access, in some cases, to prescription drugs not on a health plan's list.

No state provides all 13 key protections.

Proponents of the more limited Senate Republican proposal say the federal government should not impose expensive regulatory requirements on state insurance agencies that better understand their residents' needs.

"Some of the other proposals, particularly the Democratic alternative, are well-intended, but the net result would be that it would greatly increase costs, reduce access, and frankly, it would increase the bureaucracy and the regulations by unbelievable leaps and bounds," said Sen. Don Nickles of Oklahoma, chairman of the Republican task force that drafted the Senate bill.

Clinton disagreed, demanding "all the protections for all the people. It's not true that we can leave this up to the states."

But Republicans could find allies in the states, even Democratic states. Larsen, who was appointed by Gov. Parris N. Glendening, a Democrat, expressed concern that federal legislation could undermine or pre-empt state regulations that benefit patients.

"As a state regulator," Larsen said, "I'm sympathetic to the argument that we have a system of state regulation because conditions vary from state to state. The difficulty on federal standards is always that there isn't enough attention paid to the [cost] involved."

Republicans and Democrats are also divided over whether to grant managed-care patients and their families the right to sue an insurer for damages. Democrats say such a right would force insurers to obey new patient protections. Republicans contend such costly suits would be a boon only to trial lawyers.

Clinton leaned toward the Democrats. "You can write all the guarantees you want into the law here in Washington, and if nobody can enforce them, the delay in the system will still cause people to die," he said.

But the president left open the possibility that some enforcement mechanism short of malpractice suits could suffice.

It was that issue, along with two others, that has begun dividing House Republicans. At a late-night meeting Wednesday, Reps. Bill Thomas of California and Charlie Norwood of Georgia, both Republicans, squared off over the issues of the right to sue insurers, access to specialists outside a provider network and the prospect of an external appeals process. Norwood, who is pushing for the broadest possible protections, prevailed, leaving the House Republican proposal much closer to the Democratic alternative than the Senate GOP version is.

Thomas, the chairman of a House subcommittee on health, declared yesterday that he could no longer support the House bill because it would interfere with health care markets and raise costs too steeply.

But, Thomas said, "The Democrats should take no joy from the fact that I am not co-sponsoring the Republican bill, because I am adamantly opposed to the Democrats' bill and will work to defeat it."

Pub Date: 7/17/98