External
Affairs
Where will the Health Reform Debate Lead? | to
pdf >>
By Donald
W. Parsons, MD
The "Patient Bill of Rights,"--the "Patients' Bill of
Rights"--the "Promoting Responsible Managed Care Act"--the
"Patient Access to Responsible Care Act"--the "Patient
Protection Act"--who can keep them straight? This summer, we are
caught in a deluge of lengthy proposals to reform--and perhaps to weaken
or destroy--managed care. In the few legislative days left this year,
the 105th Congress is determined to milk the anti-HMO sentiment in the
country for all its potential political worth. Proposals for health
care reform are proliferating, and harsh rhetoric from the President,
both parties, and both houses of Congress suggests to some that irreconcilable
differences will block passage of any legislative bill again this year.
Other informed opinion knows that this issue has major political traction
going into the fall campaigns and that to do nothing may risk many incumbents'
jobs. Will any of these proposals pass?
Some Proposals: Déjà Vu?
The various bills have common elements that mimic the protections
applied to Medicare last year in the Balanced Budget Act. For example,
the bills generally agree that all insured persons should have access
to emergency care and that provision of this care should apply the prudent
layperson standard. Other requirements that everyone seems comfortable
with would provide more information to beneficiaries and ban gag rules--contractual
limitations to what physicians may tell their patients. (This implicit
indictment of the managed care industry belies a recent General Accounting
Office study indicating that no health plan contractual clauses limit
patient/clinician communication.) Women's access to obstetricians/gynecologists
and children's access to pediatricians for routine services and primary
care are common features of most proposals. All sponsors want internal
and external mechanisms for appealing disputed coverage determinations
when health plans deny services. Other provisions within these complex
bills, however, are very controversial.
Objections to Provisions
We often hear the phrase "poison pill" used to
describe provisions that are highly objectionable to various special
interest groups. For example, in H.R. 4250, officially titled the "Patient
Protection Act of 1998" and passed by a slim majority in the House,
Republican members of Congress have included provisions that would allow
aggregate purchasing by small businesses through association health
plans and through Healthmarts, a mechanism that would afford small businesses
their choice of health plan options. However, because these new programs
would all come under ERISA protections, they would not be required to
meet the state-regulated standards that Kaiser Permanente (KP) and other
health plans are required to obey. Moreover, large businesses, insurance
interests, and state regulatory agencies object to these provisions
as anticompetitive. We also are opposed to these provisions because
they could allow manipulation of insurance pools, resulting in much
higher premiums for sicker people, who might drop their traditional
and managed care coverage. Similarly, the bill's provision for the widespread
expansion of Medical Savings Accounts--touted by conservative Republicans
as critical to fulfilling the promise of expanding choice in the marketplace--could
divert the healthiest and wealthiest people into low-cost, high-deductible
insurance programs, leaving the sick and the poor in very expensive
comprehensive care programs. In addition, medical malpractice reform
provisions included in H.R. 4250 are anathema to President Clinton and
Congressional Democrats who are supported heavily by contributions from
trial attorneys.
The Democratic health reform proposal, S. 1890, also contains a "poison
pill" provision: health plan liability, or the right to sue any
health plan for perceived bad outcome. Self-insured large and small
businesses alike have warned that if this legislation passes, many businesses
will simply drop their voluntarily offered insurance programs because
no business wants to risk its treasury on the outcome of a malpractice
suit over which it had little control. This is not an idle threat. The
President has promised to veto any legislation that lacks this provision.
KP and other health plans and insurers regard this provision as the
single most objectionable proposed piece of legislation. Potential health
plan financial losses for delay or denial of care could undermine utilization
programs and vitiate care management.
Other Movements for Reform
In addition to the partisan bills offered by the two political
parties, Senators John Chafee (R-RI), Robert Graham (D-FL), and Joseph
Lieberman (D-CT) have established the nucleus of a mainstream bipartisan
coalition in the Senate by introducing S. 2416, the "Promoting
Responsible Managed Care Act of 1998." Their hope is that when
the Senate Republicans fail to garner the required 60 votes to stop
a Democratic filibuster and when Senators Kennedy and Daschle and the
President concede that the Democrats' "Patient Bill of Rights"
cannot prevail over opposition from the Republican majority, enough
right-minded Senators will support a middle-of-the-road proposal.
This strategy has failed twice in recent years, beginning with the Clinton
health care reform initiative. We wonder: Is there time for accomplishing
anything other than acrimonious accusations that have dominated the
Congressional debate so far? Only four weeks remain on the legislative
calendar, and distractions have surfaced.
KP Involvement
Where is KP in the debate? One channel for our influence
is the process of drafting original bills. Because this influence is
indirect, however, it can be difficult to track. For example, three
years ago, we spent almost a year collaborating with the American College
of Emergency Physicians to draft the Cardin/Graham "Prudent Layperson
Access to Emergency Medical Services Act" (S. 356/H.R. 815). Although
this bill per se has not been passed, its fundamental concepts and much
of its language have surfaced in subsequent proposals. Many 1998 proposals
on emergency access can trace their lineage back to the Cardin bill.
More directly, KP has participated in drafting parts of the Dingell/Kennedy
bill as well as the Chafee proposal. We will also add our voice to future
debates. If a bill passes this year, we hope it will be compatible with
our Principles of Consumer Protection, a statement that has influenced
the President's Commission on Consumer Protection and Quality in the
Health Care Industry in writing its report on the Patients' Bill of
Rights (and succeeding iterations and proposals). We won't get everything
we want, but any legislation that passes will be likely to hold our
competitors to standards that we have defined in Permanente Practice
and that are fundamental to the workings of the Kaiser Foundation Health
Plan.
Current Forecast: Turbulence Ahead
Will we or won't we have health reform this year? The debate
is turning into a political free-for-all. Harsh campaign rhetoric has
resulted in hardening of partisan positions in Congress and veto threats
from the President. Special-interest advocates are weighing in with
specific objections to key elements of all proposals. And distractions
on both domestic and international fronts are sapping energy and attention.
We hear threats of stalling the 12 remaining appropriations bills, which
could lead to another government shutdown at year-end. This strategy
worked to discredit the majority party three years ago--why not try
it again? We expect the last month of the 105th Congress to be consumed
with bitter exchange over several political issues, leaving the health
care bills for a new Congress convening in January.
