A HEALTHY DEBATE?

July 12, 1999
		The Senate has begun to debate patients' rights legislation. Following a background report, Margaret Warner talks with two key senators and health care experts about Republican and Democratic proposals. The Health Unit is a partnership with the Henry J. Kaiser Family Foundation.

July 12, 1999: A background report on patients' rights. July 8, 1999: An Alzheimer's vaccine? Remaking Medicare June 24, 1999: Should doctors unionize? June 7, 1999: Mental Health Conference July 20, 1998: Three patients' rights bills. July 1998: Forum: Should the government manage care? July 9, 1998: Debating managed care The NewsHour's Health Spotlight. Browse the NewsHour's coverage of Health   Families USA American Association Of Health Plans The Democrats' 'Patients' Bill of Rights The Republican Patients' Bill of Rights Plus The Business Roundtable	MARGARET WARNER: For more on this, we're joined by Senators playing leading roles in this debate. Senator Edward Kennedy of Massachusetts is a lead sponsor of the Democratic legislation. Republican Bill Frist of Tennessee sits on the Senate Health, Education and Labor Committee; he's also a doctor. Also joining us: Karen Ignagni, president of the American Association of Health Plans, the largest national organization representing health care providers; and Ron Pollack, executive director of Families, U.S.A., a national organization for health care consumers. Senator Kennedy, what do Democrats want out of this? SENATOR TED KENNEDY: A very basic and fundamental principle and that is to have the doctors and the nurses and the patients be able to make the judgments about their health care and not have bureaucrats in insurance companies be making these medical judgments. That is at the heart of this particular proposal. And that is why 200 organizations representing the doctors, representing the nurses representing the women's organizations concerned about women's health, representing the disability groups, representing the children's groups all support our proposal. We believe that the opposition is basically a protection of the profits of the insurance industry and not putting the interest of the patients first. That's really what this debate is all about. MARGARET WARNER: Senator Frist, what do Republicans want to get out of this? SENATOR BILL FRIST : Well, our bill very clearly puts the patient at the heart of the discussions. Over the next week and to be the beneficiary of the bill that we end up passing at the end of the week. Basically three things: we want some very strong patient protections to make sure that patients are empowered when they come up head to head with managed care companies. Number two, we want to increase quality for that patient, that they know when they get health care, it will be than a good quality of health care. And third, access. We don't want anybody going to sleep tonight worried tomorrow whether they'll have access to our health care system. So again and again we'll come back to the fact that we don't want to do anything that unnecessarily raises costs and drives people to the ranks of the uninsured because that hurts people. MARGARET WARNER: Senator Kennedy, I hear you both saying what you really care about is quality of care for the patients. How profound is the major difference between the Republican and Democratic version?
	Differences in the two bills
	SENATOR TED KENNEDY: This shouldn't be a Republican or Democratic issue. I mean when a child gets ill or a child gets sick and they need that pediatric oncologist to deal with the cancer for that child, they ought to be able to receive it whether it's Democrat or Republican. And, we believe those kinds of medical judgments and decisions are best left with the medical profession. And with all respect to Dr. Frist, every single medical organization basically is supporting our proposal. It isn't because it's a Democratic proposal. It's because it is in the best interest of their patients. And we know that those who have been taking out those ads that you just showed before are funded by one industry: the insurance industry. Why? Basically when you look at legislation you want to know who benefits and who loses. On the one hand we have all of the health care groups that say that our proposal is the way to go. And you have on the other side, the insurance industry that's spending all this money to distort and misrepresent our legislation. And that's basically wrong. I think consumers and all over this country understand it. MARGARET WARNER: Senator Frist, what does it tell you that these major doctor organizations are supporting the Democratic version? SENATOR BILL FRIST: Well, I think you'll see over the course of the week, again and again we'll look at the overall system. That's why this access issue is critical. You will have certain special groups want more and more protection. But, what we're going to say is that yes, we need strong protections, gag clauses, prudent lay person, continuity of care, access to emergency rooms, access to specialists. But at the same time you don't want to go to the extreme throwing 20 billion dollars at trial lawyers because that raises premiums up. As premiums go up, it drives people to the ranks of the uninsured and we won't let a bill go through that hurts people by allowing them to go to the ranks of the uninsured. SENATOR TED KENNEDY: When you talk about costs though, that we ought to look at what is the authority on costs and the Congressional Budget Office and General Accounting Office say that the legislation that we have would increase the cost of one percent a year. One percent a year now. And we are facing at the present time the fact that the ten largest HMO's had a profit of 1.5 billion last year. CEO's salaries are going through the roof. They are planning to raise their costs eight or 10 percent. We want to make sure that the working families, middle-income families when they go in and buy a health insurance program that going to cover themselves and their family, will get what they pay for and not have the insurance gate keepers in the way looking out after the bottom line. That's what this is all about. MARGARET WARNER: Senators, let me get Karen Ignagni who represents the insurance gate keepers in on this. First of all, what is your reaction to the fact that both parties seem to be saying the industry needs some regulation? KAREN IGNAGNI: We have to step up in the industry and clearly talk about what's in the interests of patients versus what's in the interest of special interest protection. We've contributed to this dialogue. We've offered the issue of independent review as a way of beginning productive.... MARGARET WARNER: You're talking about reviewing coverage decisions... KAREN IGNAGNI: External review to have an objective third party determining whether or not an individual and his or her patient had the appropriate procedure, had the kinds of protections that should be afforded to them and whether or not everything worked out OK. From a patient point of view, let me give you an example of what I think is wrong with this debate. My physician, I present with breast cancer. My physician recommends because it is his or her style of practice that I have a radical mastectomy. What a health plan does is at that point, it performs an important evaluative service. We provide oversight. Yes, we do provide oversight. It's not green eye shades. It is an important quality activity so that the health plan looks to see whether that recommendation squares with scientific evidence and best practice. If I could have breast conserving surgery, as a patient I want that. The problem that bee have with this discussion thus far, we've gotten so much into the realm of politics, we really are quite . . . the policy is at risk. In fact, what we do in terms of contributing oversight activities, in the nature that I described, is very much on the line. It's definitely a step back. As a patient, I want that value added. And, that's not being talked about in this discussion. MARGARET WARNER: All right. You represent health care consumers. Where will they come out better, with which of these bills?
	The consumer's perspective
	RON POLLACK: I don't think there's much doubt. The Democratic bill really provides real patient protection. The Republican bill provides more HMO protection frankly. It's very limited in scope. Most of the provisions only cover less than one out of three people who have private insurance. Now we talk about this right of independent review. Under the Republican proposal, it isn't truly independent because who makes the decisions as to who will be the reviewer? It's the HMO's that make that decision. Now, to me, it's not independent if Karen's company decides who should be reviewing this. In addition to that, there are vast differences . . . MARGARET WARNER: Excuse me. Do you quarrel with the idea of oversight though as she described it? RON POLLACK: I quarrel with the type of oversight that's provided. I think it's good to have oversight. But what we have today is that the people who are making decisions about my health care and my family's health care are people who never see me, or who never see the family. And I've got a physician who I trust and who I respect. That's a very important relationship. And this has undermined that relationship because the physician may say this person needs this course of treatment and the patient may agree with that. And then somebody who is hundreds of miles away, who never, ever sees the patient, and who may not even have medical training, says "no." Now I think what this whole debate is about is trying to make sure that there's greater balance in the process. It's OK that there's some kind of oversight and that the HMO's provide some guidance. But when the HMO's are the final word in the process and when the person rendering that decision never sees me, I'm terribly worried. So I'm very happy that the Democratic bill does provide some empowerment to the physician and patient. MARGARET WARNER: Senator Frist, address that question. Who should ultimately decide what's medically necessary for a patient? SENATOR BILL FRIST: Well, I think one thing we cannot do is define what is medically necessary and appropriate in federal statute. Things move too quickly. If you try to define it in statute, we'll end up hurting people long-term. On the external review . . . and this is very important . . . in the Republican bill, we have an independent medical -- that is a doctor makes the final decision -- and the word is in there "independent medical specialist" makes the final decision. We put the doctors in charge, not the managed care plan, not the health maintenance organization. That's the whole purpose of the bill, to bring that pendulum back between the patient and the doctor and the managed care. It's gone too far, we believe towards managed care. But get it back to the middle, not throw it way over to where the doctor no matter what he or she says goes. It's that middle ground we've aimed for -- an independent medical specialist making the final decision, not the HMO, not the insurance plan but somebody totally independent using all the information available. MARGARET WARNER: Ron Pollack, time to jump in here. RON POLLACK: Margaret, the Senator is right that a physician makes these decisions under the Republican bill. But what Senator Frist is omitting from this discussion is that it's the HMO's decide who that physician should be. SENATOR BILL FRIST: You've said this... you've said it twice. Let me correct this because it's terribly important. MARGARET WARNER: Senator, one second and then I'll get back to you. RON POLLACK: I read this very carefully, comma by comma. Under the Republican bill, the decision as to who that reviewer is going to be is really the HMO so it's really not independent. MARGARET WARNER: Alright, Senator Frist briefly on that. SENATOR BILL FRIST: Yes, let me tell you because I ended up writing that part of the bill. Basically the health care plan has to appoint an entity that is certified either by the secretary, by the federal government or by the state government, an independent entity who makes the appointment of that independent, has to be independent and it's in there that way, Ron, exactly that way, a medical specialist who makes the final decision which is binding on the plan. No ifs ands or buts. SENATOR TED KENNEDY: The problem with this as Mr. Pollack pointed out, they will be selected by the HMO, paid for by the HMO and this is why the American Bar Association and the American Arbitration Association found that these kinds of protections outlined in the Republican bill just fail muster. You can't have the HMO paying for those individuals. We all know what happens in those kinds of circumstances. But let's get back to the underlying factor. Let's go ahead and try and pass legislation that is going to protect the doctors practicing the best in terms of health care. Under the existing Frist proposal, the HMO could decide what is going to be the medically necessary in there for the covering of their particular coverage, not what is the best medicine that we can have in our country. I think that is a major kind of loophole and mistake. MARGARET WARNER: Karen Ignagni has been dying to get back in. KAREN IGNAGNI: Two points. One is that not one of our health plans has any interest in choosing the reviewer and manipulating this process. We want it to be external. We want people to have truth and confidence in the system. No question about that, no argument about that. And I'm delighted actually we're spending so much time discussing this because I think it's a fruitful area for dialogue for bipartisan discussion. Point number two: 97 percent of what physicians recommend is approved by health plans. This legislation, the Kennedy-Daschle legislation, we are at risk of shutting down the type of accountability and oversight activities. We can describe that in caricature fashions -- green eye shades -- we've heard all of that. As a patient, I want to know that I'm getting the best scientific evidence and best practice and that is not the same as generally accepted physician practice. MARGARET WARNER: Senator Kennedy? SENATOR TED KENNEDY: Why is it then that all of the various professional groups don't agree with you? I mean if they are taking 97 percent of their recommendations why are they all up in arms? Why did we have 400 of them over today on the Senate steps? Why are the doctors themselves talking about getting into a union? Do you think that they are saying that this is the case? Look, the movie "As Good As It Gets" KAREN IGNAGNI: I'd be delighted to answer that. SENATOR TED KENNEDY: Alright, wait a minute, you'll have a chance . . . the movie "As Good As It Gets" when Helen Hunt said those words that we can't repeat on this and -- every movie theater in this country, they overwhelming response of people in those audiences, they understand, the American people understand. The HMO delivery of health care services is not as good as it gets and the principal reason is because the insurance companies and gate keepers are looking at that bottom line. That is the basic and fundamental point. MARGARET WARNER: Karen Ignagni wanted to answer that one point why most of the doctors are supporting the Kennedy bill. SENATOR KENNEDY: Daschle bill, Senator Daschle, I am glad to be a part of it KAREN IGNAGNI: I think the reason that many of the medical societies and organizations are supporting that is because we've had a revolution in health care. We have changed the way health care has been delivered. We have imposed accountability that never existed in the old system. You've given lots of speeches and staked your career on the old system that had too much of unnecessary procedures and things that why dangerous for patients. We've changed that. We've improved health care. RON POLLACK: It's really interesting to hear Karen talk about accountability because there truly isn't accountability under her scheme. What we've got are decisions being made more and more by HMO's taken out of the hands of doctors. And yet, doctors are the ones we can sue today. HMO's we can't sue today. It's really interesting. We're disempowering physicians. We're empowering HMO's but we can sue the doctors and we can't sue HMO's. There is something wrong with the system. MARGARET WARNER: Senator Frist. SENATOR BILL FRIST: Let me jump in. We've got to get back... get the rhetoric aside and come back to the patient. What we can do to improve the quality of health care of that particular patient to get the pendulum back where it should be and also don't forget the ranks of the uninsured. We've got to remember that there are 43 million people uninsured in this country today. The Kennedy bill will drive costs up, according to the CBO, premiums up 6 percent. Our bill 1 percent. For every 1percent, 300,000 people go to the ranks of the uninsured. MARGARET WARNER: Senator Frist, let me ask to you clear up something here. SENATOR BILL FRIST: That's two million people that we would throw to the ranks of the uninsured. We just can't do that. MARGARET WARNER: Senator Kennedy said earlier... SENATOR BILL FRIST: He said 1 percent a year. In five years that's 5 percent -- ours will go 1 percent a year. That's the whole point. It's about eight times more expensive.
	The Big Mac example
	SENATOR TED KENNEDY: The equivalent of a Big Mac per worker, three Big Macs for the employer. SENATOR BILL FRIST: One Big Mac is driving two million people to the ranks of the uninsured. SENATOR TED KENNEDY: I don't yield to Senator Frist in his interest in covering the uninsured on health insurance. Something that I've been interested in and had which we did extend in terms of children in the last Congress. I wish we had a lot of our Republican friends talking about this issue now, I wish we had them strong and supportive in terms as Senator Kassenbaum legislation. We are understanding that. We are sensitive. The fact of the matter is that the General Accounting Office has said with our kinds of protections they believe that there will be more that will be insured because people will want those protections. Why don't we bring that in. I'll put that in the record for you tomorrow Bill. SENATOR BILL FRIST: Our bill addresses access by having full deductibility of the uninsured. Why isn't that in your bill. Increase in medical savings account. One out of three people who have medical savings accounts didn't have insurance. MARGARET WARNER: I have two people here with something to say. Costs. Is there a danger that more people will lose insurance corning because of the cost? RON POLLACK: I think not really. I'm a little bit amused by this process. Those who have not been to the table in trying to expand coverage for people who are uninsured are now using the uninsured as a shield to protect against legislation that would protect all of us. I think that is a terrible thing. The insurance companies, the HMO's have been advertising we're going to see so many people uninsured. And in every single fight there has been about expanding coverage, they've been absent or been on the other side. The reality is that this is not going to cost significant amounts of money. Senator Kennedy's right. This is going to cost a person $2 per month. And I would suggest to you that the American people very much would want that so that they actually get the health care they thought they were purchasing. KAREN IGNAGNI: Here's what's wrong with this debate. The President of the United States last week made a compelling statement about what we need to do in Medicare. We need to adopt the techniques of the private sector to make the government program more quality performing and more efficient in terms of cost reducing. All of the activities that they would be required to incorporate into the traditional Medicare program are exactly the activities that we are being excoriated for on the floor of the Senate. You can't have it both ways. MARGARET WARNER: Alright, very briefly Senators. Senator Kennedy, are you going to have a deal or a bill this year? SENATOR TED KENNEDY: I hope we will. Senator Frist is committed to it. I think there are many on his side that are committed to it. I believe, I know President Clinton is committed to it and many on our side. We're interested in getting something that the President can sign but we are not there yet. It's better not to have a bill than to have a bad bill so it's really going to be what is going to happen on the floor of the United States Senate in the next few days. MARGARET WARNER: Senator Frist, prediction? SENATOR BILL FRIST: At the end of this week, with a lot of hard work and a lot of debate, we'll have a bill with strong patient protections that will increase quality and also increase access to health care in this country. MARGARET WARNER: Alright, Senators both, thank you, Ms. Ignagni and Mr. Pollack.