From The Post Senate Backs Republican Patient Plan (July 16) Senate Backs Modest Steps on Patients' Rights (July 15) Senate Defeats Two Patients' Rights Measures (July 14) Partisanship Opens Patients' Rights Debate (July 13) On Our Site Live Online: Sens. Durbin (D) and Santorum (R)

By Helen Dewar
Washington Post Staff Writer
Sunday, July 18, 1999; Page A16

The strategy worked flawlessly and resulted in passage of the GOP version of the bill Thursday after an almost textbook display of legislation by steamroller. As a result, Republicans escaped another humiliating defeat, reasserted their control over the Senate's agenda and at least partially blunted the Democrats' offensive on health issues.

"We set out to accomplish something, not just stop everything . . . and we did it," said Sen. Chuck Hagel (R-Neb.), who had been critical of the GOP leadership's handling of other legislation, including the gun bill.

Still, it is far less clear whether Republicans will look like winners by Election Day next year after the differences between the GOP bill that passed and the tougher measures promoted unsuccessfully by Democrats are exploited in debates, position papers and 30-second attack ads.

Democrats are already gearing up to make sure that the GOP's victory turns out to be Pyrrhic, a liability rather than asset as the parties square off over which can better address voters' health care concerns, which polls show to be a dominant early issue for the 2000 campaigns. They plan to try again with their own bill and to use the issue as a major theme next year.

"The story's not over because the issue will not ultimately be decided until the elections next year, and it's far from clear how that will play out," said Sen. Joseph I. Lieberman (D-Conn.), a moderate who helped draft a bipartisan compromise that was squeezed out of the action in the highly polarized debate over the two parties' bills.

Some Republicans signaled their own nervousness by voting for specific Democratic proposals, although never in numbers great enough to affect the outcome. And a few indicated privately they are worried about the political fallout, especially if President Clinton vetoes a Republican bill as a sham, as Vice President Gore has said he will. "So long as the Republican proposals never take effect, we'll never know if they work well or not . . . we'll just know what Clinton says about them," a GOP aide fretted.

Democrats are encouraged by a recent party poll indicating that they are trusted over Republicans by more than 2 to 1 to protect patients in managed-care plans, with even higher ratings for some of their specific proposals, including those most strongly opposed by the GOP, such as authority to sue health maintenance organizations for malpractice.

During early maneuvering on the issue, Democrats appeared to have the upper hand when, after a week of guerrilla warfare that brought the Senate to a standstill, they forced GOP leaders to agree to votes on key components of their plan. They figured that Republicans who wanted action on patient protections, especially those facing reelection next year, could be picked off on sensitive issues or forced to take risky votes that could be used against them.

But, one after another, individual Democratic initiatives on issues ranging from emergency care to doctors' authority in determining treatment were torpedoed by Republicans, who then went on to offer more limited counterproposals. For instance, they killed a broad Democratic initiative on women's health and then approved one of its key elements -- letting physicians decide how long a woman should remain hospitalized after a mastectomy -- under sponsorship of Sen. Olympia J. Snowe (R-Maine), a moderate who is up for reelection next year.

This enabled Republicans to preserve the fragile unity of their caucus that had been shattered in the gun debate and inoculate themselves -- at least to some extent -- against future attacks from the Democrats.

During the week, the GOP also was aided by an expensive media blitz by its business allies to stir up public opposition to the Democrats' bill, just as they did with a similar advertising campaign that helped kill Clinton's health care plan in 1994. But targeted senators said the campaign had little, if any, impact.

"Frankly, the ads were confusing to people," said Sen. Mike DeWine (R-Ohio), who supported the GOP bill, without any pressure from the outside, after he won some changes he wanted. "People said, 'I know I'm supposed to be against [Sen. Edward M.] Kennedy's bill, but what is it? I don't understand,' " DeWine said Friday. As a result, neither DeWine nor other senators targeted by the ad campaign received many phone calls or letters on the issue.

More significant, Republicans said, was the lesson they learned from the gun debate, when they split apart and left vulnerable colleagues open to charges that they were captives of the National Rifle Association. During the gun debate in late May, Republican GOP leaders sought to fend off a Democratic proposal for mandatory background checks for buyers at gun shows with a plan for voluntary checks, setting off a rebellion within their own ranks when it was interpreted as capitulation to the NRA. Eventually, the Democratic proposal was approved with a tie-breaking vote by Gore.

Many ascribed the more successful managed-care strategy both to Sen. Bill Frist (R-Tenn.), the Senate's only physician and an architect of the Republican plan, and to Assistant Majority Leader Don Nickles (R-Okla.), who led last week's fight. They said Nickles was more inclusive and savvy in the managed-care strategizing than Majority Leader Trent Lott (R-Miss.) and GOP policy committee chairman Larry E. Craig (Idaho), an NRA board member, had been in spearheading the gun fight.

Even though Lott and Nickles are not always on the best of terms, Lott credited both Nickles and Frist -- especially Frist -- for last week's success. "When we have Doctor Frist speaking against Ted Kennedy, it makes all the difference," he said.

Unlike the gun controversy, which burst on Congress after the Colorado high school massacre, Republicans had the advantage of two years of planning for the patients' rights fight, which they used to good advantage.

Even as the GOP plan was vetted through the normal committee process, Lott set up a task force under Nickles to plan strategy. Both the committee and task force reflected the wide philosophic spectrum of the party and, together, they gradually accommodated the views of nearly everyone.

As the vote approached, the task force was determined to avoid a repetition of the gun debacle, resulting in the strategy of challenging the Democrats, point by point, and what one senator called an "outreach program" to try to give Republicans what they needed to keep them from straying. Significantly, none of the 17 Republicans who are running for reelection next year bolted.

PATIENT PROTECTIONS

The Senate adopted these protections for patients in managed-care plans. They would apply to 48 million people who get health coverage from big companies that insure themselves and are not regulated by the states. The protections would not help 113 million people who get insurance from their employers or buy it on their own:

* Emergency room treatment. Health plans are required to cover treatment of medical emergencies, and prohibited from charging patients extra if they go to a hospital outside a plan's network. HMOs must also pay for additional care to keep a patient medically stable, as long as the doctor gets permission from the plan, but the plan could require the patient to be discharged or transferred to one of its own hospitals.

* Access to specialists. Health plans must guarantee that patients can visit medical specialists on a timely basis. But plans may require that specialty care first be approved by a patient's primary physician -- and may charge more if a patient goes outside the plan's physician network to find a specialist.

* Care for women and children. Patients may go to obstetrician-gynecologists and pediatricians for routine care without getting permission from their health plan. The bill does not require health plans to let women pick OB-GYNs as their primary doctors.

* Continuity of care. Patients who are pregnant or terminally ill may keep their physician for up to three months, even if the doctor is no longer part of their health plan.

* Gag clauses. HMOs may not forbid physicians to discuss with patients expensive kinds of treatment, even if those treatments are not covered.

* Clinical trials. Patients can take part in clinical trials of experimental therapies for cancer, but not for other serious illnesses.

The following would apply to 123 million Americans who get insurance through private employers, but not people who are self-employed or work for state or local governments:

* Grievance system. Patients may appeal to the health maintenance organization, and outside if necessary, when a plan won't pay for care that is part of its benefits package.

The following would apply to all Americans:

* Cancer patients. Insurers must cover hospital stays for breast cancer surgery for as long as women and their doctors think is necessary. Patients with any kind of cancer diagnosis can get a second opinion, including from physicians outside a health plan's network.

* Genetic discrimination. Health plans may not charge higher fees to patients who appear likely, based on genetic testing, to develop certain diseases.

* Consumer information. Health plans must disclose information about which services they cover, how much patients have to pay, whether patients may pick their own primary care physicians, and many other policies, including how the plan decides which treatment a patient needs.