President Clinton holds chart comparing patients' rights bills at Louisville event. (Reuters)

By Amy Goldstein and Terry M. Neal
Washington Post Staff Writers
Tuesday, August 11, 1998; Page A01

It was a step back onto fond, familiar terrain. At a campaign-style rally yesterday, President Clinton warned an audience of thousands that the nation's health care system is failing patients and warned Congress that he would accept no tepid Republican solutions to fix it.

"This is about a crying need for the American people, and it's time we did the right thing," Clinton told the crowd.

Yet as the president has moved once again into the treacherous realm of health reform -- in Louisville yesterday and in Washington all year -- his proposal to empower patients enrolled in managed-care plans borrows heavily from the painful lessons of his first term.

Although the White House seldom mentions it, political strategists say the ghost of his failed attempt at health reform four years ago hovers over the current "patients' rights" debate, guiding the strategies of both political parties and shaping what the issue's fate ultimately will be.

The first time Clinton set out to cure the nation's health care system, he delivered a nationally televised address, laced with passion and statistics and boldly promising every American "health care that can never be taken away." Exactly a year after that September 1993 declaration, his cherished Health Security Act was dead.

Now as Clinton seeks, once again, to control the future of American health care, he has adopted an indelible piece of political wisdom the last debate left behind: Even when Americans claim to be eager for aggressive health reforms, political and policy analysts say, they are in reality comfortable with government making only marginal turns of the screw. As a result, in championing a set of protections for patients with private insurance, the administration is pursuing a goal that is more closely in rhythm with the anxieties of the middle class and the will of congressional Democrats.

Yet the White House this time is sidestepping two deep flaws in the nation's health care system that Clinton tried, and failed, to mend before. No longer is the president promising access to care for the growing number of Americans -- now 41 million -- who are uninsured. Nor is he trying to place reins on medical costs, even though insurance premiums have started to rise more swiftly again after a few years of relative calm.

"The patients' bill of rights is a very powerful political issue, but for health policy wonks it's a very tiny change," said Robert J. Blendon, a health policy professor at the Harvard School of Public Health.

Republicans, who dominate on Capitol Hill, have shifted strategy, too. Four years ago, they resisted the Clinton health plan outright. This year, they have embraced patients' rights on their own terms, designing bills that would regulate health insurers, but to a lesser degree than Democratic versions.

With their narrower objectives and wider political support, the new generation of health reform proposals already have gained more momentum than their predecessor ever had. In 1994, no bill came to a vote in the House or Senate. It remains far from clear that a law will emerge this time either, but a Republican version of managed-care legislation was adopted by the House last month. In the Senate, the two parties have been arguing for weeks over how to handle rival bills, and debate has been postponed at least until September.

Yesterday, Clinton sharpened the issue's partisan contours, saying for the first time that he would veto both the House and Senate GOP plans if they reach his desk. Until now, White House aides had said he would reject the House plan but had not explicitly ruled out the Senate version.

Color chart in hand, Clinton recited eight ways in which he said the Democratic approach offered better protections. He said the Republican bills would, for example, provide too little confidentiality for medical records and would not guarantee that certain patients could keep their doctor for a few months if they were forced to switch health plans. "I have to tell you, we need a bill of rights, not a bill of goods," he said.

Despite the differences between the parties, the core policy goal of each is to try to make sure that people insured through private health maintenance organizations (HMOs) can get what their health plans promise. The House measure and three main Senate bills would, to varying degrees, give patients greater freedom to visit the doctors they want and create better avenues of appeal for patients who believe their insurer improperly denied care or refused to pay bills.

This rallying cry for patients' rights is not the first time since the demise of Clinton's first health plan that the federal government has waded into the issue. In 1996 and last year, Congress adopted laws to try to help two distinct groups -- uninsured children and working people who feared losing their coverage when they switched jobs or became ill. Although this year's bills would affect larger numbers of people, White House officials acknowledge that their new foray into health reform, once again, has limited objectives. Politically, they say, they have learned they have no choice.

"The best way to get something out of the Congress is to find something that is discrete, that isn't the answer to all the problems, but doesn't impose such overwhelming changes to the system," said Chris Jennings, Clinton's main health policy adviser. "The trick is to find those issues that are real to the public . . . without going overboard."

The administration's decision to latch onto the issue of patients' rights grew out of the very real shift during the last several years in the way most people get medical services. More than 72 million Americans now get health insurance through some form of HMO, compared with 41 million when Clinton was first elected in 1992.

That growth spurt in HMOs is one of the central ironies in the recent politics of health care. During the last debate, the health insurance industry and other opponents of the Clinton plan fomented public anxiety by warning that the White House was trying to create a "forced march to managed care," recalled Alain C. Enthoven, a Stanford University health economist whose ideas influenced the president's proposal.

So when the Clinton plan was defeated, people frightened of HMOs were relieved. But as it turned out, employers, anxious to curb their health expenditures, were migrating swiftly toward managed care, with or without the government's hand.

The unfamiliar restrictions on how much and what kind of care insurers will provide, public opinion polls suggest, have heightened resentment toward managed care and created a greater desire for government to step in. Yet according to Andrew Kohut, director of the Pew Research Center for the People and the Press, Americans still do not want "a total revamping of health care. . . . It's a small-bore issue." On one hand, people mistrust HMOs, Kohut said. But they also mistrust "the long arm of Washington."

It is in the niche between these two clashing values that the White House has managed to fit the limited goal of patients' rights.

The White House's new attempt at health care reform contains certain similarities with its first plan. Both seek to educate consumers. Now as before, health plans would be required to disclose information about their benefits and rules in order to help patients select good insurance plans and avoid inferior ones. But while Clinton tried earlier to create controversial "regional alliances" to help consumers buy insurance from among an array of health plans at a reasonable price, the White House no longer would require employers to offer their workers a choice of plans. Defeated in its effort last time to tinker with the insurance market, the administration is now simply trying to tip the balance of power toward patients and away from HMOs.

This time, too, the White House has shown sensitivity to the political importance of simplicity and speed. In 1993, Clinton forced Democrats in Congress to wait for eight months in the face of mounting opposition, while a high-profile task force led by first lady Hillary Rodham Clinton labored to produce its recommendations.

Last year, Clinton created a less visible commission on health quality and assigned it to propose a set of patient protections as its first task. He moved far more swiftly once that group reached consensus. Late in November, on the day the commission handed in its advice, Clinton announced that he would adopt its recommendations in the government's insurance programs and called on Congress to extend them to people with private coverage.

And in contrast with the complicated vocabulary of the first White House health plan -- which featured "managed competition" and "health insurance purchasing cooperatives" -- the new plan had a clear, patriotic-sounding name: "Consumer Bill of Rights and Responsibilities."

"It looks like the minimum wage -- simple, easy to understand," said Harvard's Blendon. "This is very easy stuff to present to audiences emotionally."

That simplicity is useful to politicians on Capitol Hill and in the states where candidates have seized on it this year as a campaign issue. In Georgia, for example, Roy Barnes, a Democratic candidate for governor, is using this easy-to-grasp slogan: "You can choose a doctor for your pet, but you can't choose a doctor for your child."

The public's anger at HMOs and eagerness for government action has made the issue irresistible even to reluctant Republicans, who are accustomed to dismissing Democratic ideas for regulating private industry as "big government." Instead, House and Senate GOP leaders now are sparring with the Democrats over which party's approach to patients' rights is better -- and which deserves voters' credit.

It remains unclear whether this tug-of-war ultimately will end in a stalemate or a law.

Either way, according to GOP pollster Linda DiVall, the Republicans this year have carved out greater distance from insurance industry and employer groups, which once again are lobbying aggressively to defeat the bills on the grounds that they would make medical care more expensive. By advancing their own bills, DiVall said, the GOP is "not perceived . . . to be controlled by the special interests."

On the other hand, even if Congress eventually agrees to the more comprehensive safeguards that Democrats prefer, some believe they would not go far enough to solve the health care system's basic problems. "The [new patients' rights] just say, 'Can you get to a specialist?' " said health policy consultant Lynn Etheredge. "They don't say whether you're getting good quality medicine, whether you're getting the right treatment." Even Nancy Dickey, president of the American Medical Association, which opposed major parts of Clinton's first health plan but now is siding with the White House, said the patient protections would be a useful "interim step" while waiting for universal access to care.

Yet the White House's Jennings said Clinton has learned a hard lesson in pragmatism. "In the absence of the ability to do something comprehensive, you have two choices," he said. "You can do nothing and let the system get worse and worse, or you can work to address the problem in a targeted way."

Staff writer John F. Harris contributed to this report from Louisville.