The Senate ended
its week-long debate on managed care reform legislation last
night by voting
to pass a bill containing certain expanded patient protections.
These protections, however, hinge on the type of insurance
people are enrolled in. The Republican-backed proposal, one
of the many versions known as the "Patients Bill of
Rights" (S. 1344), passed largely along party lines
by a vote of 53 to 47. Two Republicans, Senator John Chafee
(R-RI) and Senator Peter Fitzgerald (R-IL) voted against
the bill. The White House announced its intention to veto
the bill if the measure reached the President in its present
form.
Bill Includes Some Access to
Specialty Care, Clinical Trials and Continuity of Care
- For those enrolled
in self-funded employers’ plans, the bill requires what it calls "timely" access
to medical specialists and primary care sub-specialists
if their conditions require one. This access is limited
to those who are already inside the health plan’s network.
- For cancer
patients in self-funded employers’ plans, the legislation covers the "routine
costs" associated with approved clinical trials. A
committee selected by the plan would determine the definition
of "routine costs."
- The legislation
gives terminally ill enrollees whose provider has left
the plan’s network
the opportunity to continue to see the same provider for
90 days.
Other General Aspects: Point
of Service and Emergency Care
- The bill would guarantee patients
the ability to use the point-of-service option to see non-network
providers regardless of how many different health plans
their employer offers. However, the employer must be self-insured
and have over 50 workers.
- The legislation seeks to provide
coverage of post-stabilization and to allow patients to
seek care in out-of-network hospitals without paying additional
costs.
Please find the enclosed article
from the Congressional Monitor detailing other interesting
aspects of the managed care reform debate.
Should you
have any questions or require additional information,
please do not hesitate to contact AST Public Policy Staff
at (202) 857-5322.
SENATE LEAVES NO ROOM FOR SURPRISES
ON MANAGED CARE
By Rebecca Adams, CQ Staff Writer
Jul. 15, 1999 - Republicans on
Thursday won their expected narrow passage of Senate managed
care legislation (S1344), after a weeklong battle that served
primarily to define party positions on the issue heading
into the 2000 election cycle.
At the end of four days of hard-nosed
deliberations, the chamber approved 53-47 GOP substitute
language that was inserted into the underlying Democratic
bill. President Clinton has targeted this final version for
a veto -- in the unlikely event it reaches his desk in its
present form.
The GOP substitute incorporated
many elements of the original Republican measure (S326),
altered slightly by a dozen amendments approved during the
week and by new provisions added by unanimous consent Thursday
night.
Only two Republicans voted against
their party's bill: Peter G. Fitzgerald, Ill., and John H.
Chafee, R.I.
A FOREGONE CONCLUSION:
As debate wound down Thursday and Senators prepared to cast
their long
anticipated final votes, Majority Leader Trent Lott, Miss.,
described the GOP bill's provisions as more modest than those
contained in the "dangerous" Democratic bill, and
said the GOP's protections for patients would prevent unnecessary
litigation while avoiding a sharp increase in the ranks of
the uninsured.
"All the consumer rights
in the world don't matter if you aren't able to get insurance," Lott
said.
Representatives of the insurance
industry immediately celebrated following the vote, though
some have criticized parts of the Republican bill as too
regulatory.
"We commend the Senate for
rejecting amendments that would have enriched trial lawyers
at the expense of affordable health care for working families," said
Karen Ignagni, president and CEO of the American Association
of Health Plans (AAHP).
The AAHP had argued that external
review processes, initiated when a patient questions a health
plan coverage decision, are a more appropriate means of aiding
patients whose coverage for a specific treatment has been
denied by their insurance carrier rather than the alternative:
allowing the patient to sue their plan.
Both bills contained external
review requirements, but they differed in the number of people
they protected and the guarantees they provided patients.
The Democratic bill would have allowed patients or their
survivors to sue in state courts when patients are harmed
by an insurer's refusal to pay for care.
Democrats criticized the GOP external
review provisions because they would allow managed care plans
to define which treatments are medically necessary, thus
limiting reviewers' authority.
Many of the approved bill's sections
would expand certain types of coverage to the 48 million
people in self-funded insurance plans, which are often used
by larger companies that are able to assume the underlying
financial risks of workers' medical costs.
The expanded coverage includes
emergency room care at out-of-network hospitals; access to
routine costs in clinical trials for cancer patients in government-sponsored
programs; direct access for women to obstetricians and gynecologists;
access to out-of-network doctors for people who are willing
to pay more and are employed by businesses with 50 or more
workers; and access to continued care for patients whose
provider has left a managed care plan.
Other provisions, such as an external
and internal review process for patients whose coverage has
been denied, would apply to 124 million people in both self-funded
and group plans. And provisions aimed at stopping so-called
drive-through mastectomies would affect the entire 161 million-person
universe of privately-insured people.
The GOP also added tax provisions
that were not in the original version of S326 reported out
of the Senate Health, Education, Labor and Pensions Committee
in March. Those would lift current limits on medical savings
accounts, which are coupled with high-deductible insurance
accounts for catastrophic costs. The bill would also allow
about 3.3 million self-employed people to deduct from their
taxes their full health insurance costs.
Republicans also expanded a provision
allowing continued care for patients whose providers leave
a network, so terminally ill patients could continue to see
the same doctor.
"We didn't say to states,
no matter what you did, we know better," Assistant Majority
Leader Don Nickles, Okla., said, explaining the bill's scope.
DEMOCRATS CRY FOUL: The defeated
Democratic bill would have extended a host of protections
to all 161 million privately-insured people.
Members of the minority argued
that the GOP bill contained more caveats than patient protections.
"They made it clear that
their strategy was focused on political cover instead of
meaningful reforms," said Minority Leader Tom Daschle,
S.D.
A bipartisan group of senators,
led by Chafee, attempted a last-minute effort to bring forth
a middle-ground bill. But in the end, the group was not granted
a vote on its proposal.
The House will next take up managed
care legislation. Some House Republicans said Thursday that
the leadership could move the Senate-passed bill to the floor
without a markup, although leadership aides say that they
will continue to try to work through the committee process.
Some moderate Republicans, led
by Charlie Norwood, Ga., are attempting to block the leadership
and force action on a more moderate bill with some additional
liability allowed for patients.
©1999 Congressional
Quarterly Inc. All Rights Reserved.
