TOPICS > Health

Background: Bill of Health?

July 9, 1998 at 12:00 AM EDT

JIM LEHRER: Tonight we inaugurate a new venture for the NewsHour. It’s a partnership with the Henry J. Kaiser Family Foundation to expand our ongoing coverage of health care issues. Susan Dentzer, most recently with U.S. News & World Report and a frequent reporting guest on our program, will be the correspondent. She will do regular reports on the full range of issues that fall under the broad heading “health care.” Here’s her first on proposed managed care legislation.

SUSAN DENTZER: At least 160 million Americans are now in HMOs or some form of managed care, up from 92 million just six years ago. That means that a majority of Americans have now experienced some of the cost-saving techniques of these plans, such as restricting patients’ choice of physicians. A backlash to these measures is growing – and in an election season where there isn’t much else to talk about, politicians have noticed.

PRESIDENT CLINTON: Millions of Americans are looking to us for the right kind of action. They want us to pass a strong bipartisan Patients Bill of Rights, they want us to put progress over partisanship. They want us to leave our country stronger for the century just ahead.

REP. DENNIS HASTERT, (R) Illinois: Let’s face it when folks are sick, they should be able to see a doctor. Unfortunately, many are afraid that they will not receive the care they need, and I’m proud to say that our plan provides patients with the necessary protections to get them well without new taxes, without more bureaucracy, or the heavy hand of government.

SUSAN DENTZER: Even Hollywood has picked up on the public’s growing concern that managed care could translate into poor care–or no care–just when patients really need it.

[Scene from “As Good As it Gets”]

ACTOR: How about skin testing for allergies?


ACTOR: Standard scratch test, they poke ’em with a needle?

ACTRESS: No. I asked. They said my plan didn’t cover it and it wasn’t necessary anyways. Why? Should they have?

ACTOR: Well-

ACTRESS: (Expletive deleted) HMO (expletive deleted) pieces of (expletive deleted)–I’m sorry.

ACTOR: It’s OK. Actually, I think that’s their technical name.

BOB BLENDON: When they saw it on the movie, they could say this could happen to me and this is a phenomena going on in America. That’s what makes this such a powerful political issue.

SUSAN DENTZER: Robert Blendon is a public opinion expert at Harvard. He says people tell pollsters they are most concerned about these core issues.

BOB BLENDON: People absolutely feel in the emergency room if they have pains in the chest they don’t want to deal with an 800 number nor be second guessed later on. The second has to do with appealing if you are very very ill and you feel that you are being denied access to a medical specialist or an advanced drug, that you appeal to someone who has no financial stake and your decision is professionally responsible. That’s overwhelmingly popular. The issue about whether or not people–even if they pay more–should be able to go out of the plan and seek care from another specialist–even though they would pay more, that that is entitled in the plan-that’s unbelievably popular.

SUSAN DENTZER: Support for many of these protections cuts across party lines. Polls show that almost as many Republican voters want to see them enacted as Democrats. Roughly 40 states have already put some of these protections on the books. Now, in Congress, many Democrats and Republicans want to broaden these safeguards, and the parties are jockeying to take the lead on the issue. Senate Democrats tried in vain this week to force a vote on their Patients Bill of Rights Act, which would tackle many of these consumer concerns. Senate Minority Leader Tom Daschle says they’ll try again.

SEN. TOM DASCHLE: If our Republican colleagues won’t agree voluntarily to allow a full land fair debate on this issue, we will force them to address it.

SUSAN DENTZER: A House majority task force is preparing a Republican consumer protection bill, and Senate Republicans are developing their own plan to head off the Democratic alternative. A fight looms over parts of the bills that the managed care industry insists will only drive up health insurance costs and prompt employers to drop health coverage for their workers. A coalition of health insurers and employers is mounting a big-ticket ad campaign to make the point.

AD SPOKESMAN: Some politicians are bashing HMO’s and adding expensive new regulations. That scheme could increase costs even more and that hurts everyone.

SUSAN DENTZER: Congress has no more than 45 legislative days to act before it adjourns for the November election, resolving the bitter dispute and getting a bill out that the president would sign could be a tall order.

JIM LEHRER: And Susan Dentzer is here now. First, welcome to the NewsHour team, Susan.

SUSAN DENTZER: Thanks, Jim. It’s a delight to be here.

JIM LEHRER: Okay. Now, as you just said on the tape, both the Democrats and the Republicans want to do something about managed care, correct?

SUSAN DENTZER: Well, in principle. The Democrats almost certainly want to do something about it. They certainly want to have the issue to use in the elections against the Republicans, and there’s some debate within the party about whether it’s better to pass a bill, or whether it’s better to have a bill that goes down or doesn’t get passed because the Republicans vote against it, and then the party can say-the Democratic Party-

JIM LEHRER: Use it as a hammer.


JIM LEHRER: Use it as a hammer.

SUSAN DENTZER: Republicans, for their part, many of them are actually philosophically opposed to, as they were a few years ago in the Clinton health care reform debate, greater government intrusion into health care and into private health insurance. And many of them still have reservations about greater regulation of health plans. On the other hand, there are many Republicans who do recognize this is a very potent issue that needs to be dealt with.

JIM LEHRER: Well, let’s go through the differences. First of all, there are some common points. There are some things that both Republicans and the Democrats generally agree on, correct?

SUSAN DENTZER: Yes, in principle, although, as with all these pieces of legislation, the devil is in the details and the details mean a great deal, but, in general terms, they both tend to agree that as Bob Blendon said at the top of our piece, greater access to specialists for individuals who think they need to be seen by medical specialists is important. That is to say if you’re in a plan that has a so-called primary care physician as a gatekeeper who has to refer you on to see, for example, a cardiologist or somebody else, that that referral should be pretty much automatic, and that’s a very important principle. In addition, there’s a desire to have access to physicians outside your plan if you want to pay extra for it, and in principle the legislation now being discussed on the Republican side, as well as the legislation proposed on the Democratic side, would allow people to purchase what’s known as point of service coverage that would allow you to do that.

JIM LEHRER: Now, this independent review of appeals, what does that mean?

SUSAN DENTZER: Well, in fact, most health plans have some kind of internal appeals process, as well as in theory an external appeals process so that if you feel you are denied care that is due you, you can appeal inside the plan to have that decision reversed. There is a lot of dispute about how independent this decision really is. Is it the five friends of the insurance company executive who are going to make that decision, or is it a legitimate outside provider without a financial stake in the outcome?

JIM LEHRER: And both sides want emergency room coverage, right? It’s automatic?

SUSAN DENTZER: Basically with varying degrees. In fact, the Republicans want to adopt a standard that many of the states have used called the prudent lay person standard. It means that if a prudent lay person in your position would have gone to an emergency room out of a concern that they might be having some serious medical episodes, then that coverage should be automatic. The Democrats want to go even a bit farther and say virtually anybody who walks into an emergency room without prior approval from the plan should have that care covered.

JIM LEHRER: Now the gag rule on doctors, what’s that about?

SUSAN DENTZER: This one is really kind of a throwaway, Jim. A couple of years ago there was a big dispute. Physicians were very worried that there were rules in the contract language that they had with insurance companies, that seemed to suggest that if the doctors talked about treatment options with patients, that the plans would not pay for, that they would somehow be kicked out of the plan, that they couldn’t talk about things that weren’t covered. In fact, the General Accounting Office-the auditing office of Congress looked into this, found really no instances where plans were really doing this. It seemed to be really a question of the confusion on the part of the doctors, so it’s an easy one now to pay your bill-

JIM LEHRER: Just sounds good-

SUSAN DENTZER: –because it doesn’t cost much.

JIM LEHRER: I got you. Sounds good. Now, confidential information. Everybody agrees, that should be safeguarded, right?

SUSAN DENTZER: Yes. Although, again, that’s an extremely contentious issue, and the devil was in the details, and as many people in Congress have made the point, you don’t want to safeguard information so much that you can’t use it first of all to improve the health care delivery system, or certainly also to improve medical care and medical research, so that’s a difficult one. It’s easy again to say it should be confidential. It’s hard to figure out precisely how to do it.

JIM LEHRER: All right. Now let’s go through the major differences now between the Democratic plan and the Republican plan. Quickly, the Democratic differences allow patients to use health plans and recover damages.

SUSAN DENTZER: This is really where the biggest battle is going to be fought if, in fact, these bills really do come to the floor. In fact, under a federal law that is elegantly known by the acronym ERISA, if you are in an employer-sponsored health plan, your ability to sue the plan, if you are injured because of care you receive or if you die, is very much constrained under state law, and, in fact, you cannot recover damages beyond the cost of your care. So let’s say if you had some care denied to you, you became disabled, the most you could get out of the plan was the cost of the care, not for example the compensatory damages that you might get in some other form of lawsuit. Democrats propose basically to get rid of this so-called ERISA pre-emption and basically allow you to go into state court, sue your planner, recover compensatory damages. This is extremely worrisome not only to health plans but also to employers, because they believe that they are the next step, they are the next ones who are going to be able to be sued.

JIM LEHRER: And the Republicans don’t support that. Now, moving ahead quickly to what the major Republican difference is-the cap on medical malpractice, right?

SUSAN DENTZER: Yes. In fact, the Democrats charge that what the Republicans have planned to do, and of course we don’t have Republican bills yet, we have a Republican press release in effect in the House, and we are soon to have, we think, a plan in the Senate, so we don’t quite know, but basically, what the Republicans in the House have said they want to do is attach some provisions that they’ve attached in prior years to their legislation, which would restrict the liability of doctors and medical malpractice suits. This has been popular in the past with groups like the American Medical Association. Interestingly enough, this year the AMA says they’re really not that interested in it, they really want to see the overall patient protection put in place, and they would forego this one, if they had to.

JIM LEHRER: Finally, Susan, is it too early to say that HMO regulation of some kind is the hot issue right now, I mean, replacing tobacco with campaign finance reform and all those other things that were going to get done but didn’t quite get done, is this one the new one?

SUSAN DENTZER: I think many politicians hope it will become a hot issue, and others of course fear that it will become the hot issue. It certainly is playing very actively in a lot of state races, a lot of gubernatorial races around the country. Governor-candidates for governor coming out and saying they’re in favor of these kinds of protections at the state level. Already, of course, some of these protections have been adopted at the federal level with respect to the Medicare and Medicaid programs. So I think that people want to fight the battle over it with these few legislative days left, to get this kind of conflict legislation through I think as we said would be a tall order, and maybe that we’ll be back fighting it again next year.

JIM LEHRER: We’ll we look forward to your many reports from the battlefield on this and other things in health care reform. And, again-on health care generally-and again welcome to the NewsHour.