Poll Taker All in all, do you think so-called managed care programs like HMOs treat most people fairly, or unfairly? Fairly Unfairly No Opinion Poll Taker compares your response to results from the July 9-12 Washington Post poll. • Complete Poll Data

By Helen Dewar
Washington Post Staff Writer
Friday, July 24, 1998; Page A04

It's not just about emergency rooms, medical specialists and lawsuits against health maintenance organizations. Driving the high-stakes debate over managed-care legislation – scheduled for an initial showdown today with an anticipated vote in the House – are attempts by both parties to manipulate what they see as one of the few compelling issues for this fall's campaign.

The bill could get manipulated to death in the process, according to some lawmakers and outside observers.

The politics of the issue has already pushed it to the top of Congress's midsummer agenda, spurring dueling news events complete with a daily stream of horror stories from both sides. Even more than the substance of rival bills, politics is likely to determine whether the 105th Congress produces a law or tosses the issue off to be resolved, or possibly further muddled, by the November elections.

Senate Minority Leader Thomas A. Daschle (D-S.D.) said recently chances are "no better than 50-50" for a bill that President Clinton could sign into law. Some outside observers believe the whole issue has become so entangled in the two parties' election-year strategies that Daschle's estimate may be too optimistic.

"I'm not sure anyone really wants a bill," said Stuart Rothenberg, publisher of the Rothenberg Political Report. "Democrats want to use the issue, saying Republicans are standing in the way of real reform. And Republicans are not really enthusiastic about the whole idea but know they have to do something."

"Right now the Democrats are on the offensive on this, Republicans are on the defensive, but both are viewing it more as an issue than a law," said Thomas E. Mann, director of governmental studies at the Brookings Institution. "Both sides have an incentive not to compromise."

Although the issue has been percolating for some time, Democrats began to push it hard after Clinton on Congress late last year to adopt a patients' "bill of rights." While many Republicans initially denounced the initiative as a piecemeal way of reviving Clinton's broader health care plan that died in 1994, they began to develop plans of their own as the issue gained in popularity.

It gradually replaced tobacco as the political passion of the moment, largely because health care touches more people more directly, according to many analysts.

By last week, each party in each chamber had a bill of its own, and Republicans were pushing for votes before the month-long summer recess begins early next month.

The House GOP measure, introduced only a week ago, will come up without benefit of committee hearings. There will be little debate and few if any amendments. In the Senate, Republicans want only take-it-or-leave-it votes on the two parties' plans, which they would surely win, while Democrats want as many as 20 amendments per side, forcing Republicans to vote time and again against the most popular features of their plan.

The Democrats' plan would impose the toughest regulations, covering everything from access to emergency room care and specialists to a patient's right to sue for malpractice damages. Republicans cover many of these areas but with a lighter regulatory touch and would keep a legal shield against litigation by most patients. The Senate GOP proposal applies its most specific protections to fewer patients than the other plans. Both Republican plans would also expand access to tax-exempt medical savings accounts, which are anathema to most Democrats.

Lawsuits, described by Democrats as the best enforcement tool, are the major flash point. Yesterday House Republicans, in attempt to show they are also tough on enforcement, agreed to increase fines – from $250 to $500 per day – that patients could collect from health plans that improperly deny care.

But the differences appear even larger in the "spin" that each party puts on the other party's plans.

Democrats describe the GOP plans as a "bill of goods" and "bill of wrongs" that borrows the bill-of-rights title from the Democrats but rejects provisions that would require real changes. Senate Republicans make a point of noting that "Dr. Bill Frist," a Tennessee senator and the only physician in the Senate, helped write their plan, while referring to the Democratic measure as "the Kennedy bill," evoking memories of more far-reaching health legislation backed by Sen. Edward M. Kennedy (D-Mass.), their favorite liberal target.

As they did in their successful Senate fight over tobacco, Republicans are portraying the Democratic plan as a "big government" power grab. Democrats respond that patients need the strongest possible protections against insurance companies and HMOs.

There is little disagreement that the managed-care issue has already left its mark on campaigns. Rep. John Linder (Ga.), chairman of the House Republicans' campaign committee, cites the case of a Democratic candidate in Georgia who gained in polls after running an ad that asked why you can't choose the doctor who delivers your baby if you can choose the mechanic who changes the oil in your car.

Linder believes GOP lawmakers will be sufficiently protected in the elections if the House and Senate pass bills, regardless of whether they get signed into law. "When we pass our patients bill, it will be less of an issue," he said. "Then we can talk about tax cuts and what to do with the [budget] surpluses," a better topic for the GOP.

Democrats believe they gain in either case: by passage of a bill that includes at least some of their key provisions or by passage of a limp Republican measure that gives them a good target for November. They insist they would rather have a law than an issue but believe they have the upper hand in either case. "It's clear the Republicans have been dragged reluctantly to the table on this and in many cases their heart isn't in it," said Democratic Congressional Campaign Committee Chairman Martin Frost (Tex.).

Outside observers agree the issue works best for Democrats but suggest that Republicans can largely neutralize it by pushing their alternatives.

The issue "enables Democrats to return to their health reform agenda" in a way that unifies the party rather than dividing it, Mann said.

It also gives them an opportunity to portray government in a favorable light, he said. "Instead of people being resentful of government bureaucrats interfering with their health care, now it's the private bureaucrats, and people see government as being in a position to do some genuine good for ordinary citizens." But, by using their own plans, Republicans can probably "do enough to neutralize the issue . . . in a year in which having a position to defend is sufficient."