Behind this week's highly charged fight over a so-called patients' bill of rights on Capitol Hill looms a fundamental question: How much control do Americans have over their health care?
The answer, it turns out, is less than they did just a few years ago.
And as the Senate finishes up another major attempt at health-care reform, the result is not likely to give consumers a lot more choice over who administers their care or how much they receive.
Instead, the mainly Republican-backed legislation picks more around the edges of the issue, giving about 30 percent of Americans in federally regulated plans more recourse to appeal if their managed-care company denies treatment. They would also be able to receive more access to emergency-room care and certain medical specialists.
But some liberal and conservative analysts alike say such steps do little to address fundamental flaws in the health-care system, including the issue of the uninsured and giving those with insurance more choice.
"Congress is missing the most important question, which is how to enable people to choose plans that are right for their own needs," says Gail Wilensky, who was President Bush's top health-policy adviser.
While the need to improve health-care access was a catch phrase in this week's debate on both sides of the aisle, some experts say that proposals approved in the Senate will make minor adjustments to a system still in need of overhaul. That's if President Clinton doesn't veto the bill, as threatened. He contends the Republican-backed plan offers "toothless and halfhearted protections" to consumers.
Let the states decide
But Republicans, backed by the insurance and managed-care industries, counter that it's up to the states to make decisions about the types of coverage consumers should be offered, not the federal government. And while they support reforms that would require insurance companies to allow patients to appeal denials and require women be given access to certain types of gynecological care, those reforms would cover only the 48 million Americans covered by large self-insured companies. They are currently exempt from state regulations.
The Democrats' proposals would have covered all 161 million Americans with private health insurance. They had tried to ensure that all insured Americans had the right to see to certain specialists.
They wanted to give doctors instead of insurance companies the right to determine what is "medically necessary," and to give consumers the right to sue their managed-care company, if denied service. Republicans contend that would increase the overall cost of health insurance.
The Democrats, backed by the American Medical Association and patients'-rights groups, say the cost increase would be minimal, estimated by the Congressional Budget Office at about $2 a month on the average premium.
Democrats also say that leaving such decisions to the states has created a patchwork of protections that has left millions of Americans at the mercy of profit-minded insurance companies. Between 1994 and 1998, 39 states approved some form of "patient protection act," according to the National Conference of State Legislatures. But a NCSL survey of state lawmakers active on the issue also found that dealing with the problems associated with managed care remains a top priority in all 50 states.
The problem is that public doesn't "feel very good about having insurance coverage that doesn't give them health care when they need it most," says Ron Pollack, head of the Families USA Foundation, a heath-care advocacy group in Washington.
The insurance industry contends the vast majority of the Americans that have health-care insurance do get the service they need and are satisfied with their current plan. Richard Coorsh of the Health Insurance Association of America, a Washington-based trade group, also says that Americans still have plenty of choices.
Sure, there's choice
He notes that while only 13 percent of Americans are in a traditional fee-for-service plan where they can go to any doctor or hospital, another 58 percent are in managed-care programs that allow them to choose from a list of approved physicians or pay more to go outside the network. Some 30 percent are in more restrictive Health Maintenance Organizations.
"Consumers made it clear they wanted choice and flexibility, and the industry has responded," says Mr. Coorsh.
But patients'-rights groups and many health-care analysts argue that managed-care plans too often put the bottom line first. In an effort to save money, they're also criticized for refusing to pay for expensive procedures when most needed.
"What scares Americans most right now is that when they're terribly sick, the treatment they get will be restricted in managed care in ways that they never imagined before," says Robert Blendon, a health expert at Harvard University in Cambridge, Mass. "That's what's driving this whole debate."
Because many businesses now offer only one health plan to employees, free market competition doesn't do much to remedy consumer concerns. "If people don't have a choice of plan, it means the market can't really function perfectly," says Larry Levitt of the Kaiser Family Foundation, a health-care think tank in Menlo Park, Calif. "If there's a plan that's being overly restrictive or the perceived quality is poor, consumers can't vote with their feet because there's nowhere to walk."
(c) Copyright 1999. The Christian Science Publishing Society