Republicans and Democrats struggled to upstage each other with rhetoric, pathos and parliamentary maneuvers yesterday as the Senate opened a politically charged debate over the rights of patients in managed-care health plans.

The initial hours of the four-day debate showcased the two parties' competing approaches to one of the hottest issues before Congress: How far the government should go in regulating health plans that have become the major source of Americans' medical care.

The partisan sparring, scheduled to culminate in a vote Thursday night, marks the first full-fledged debate in Congress on patients' protections -- an issue that is of intensely personal interest to the public and could figure prominently in the 2000 campaigns.

"This is an historic day," said Minority Leader Thomas A. Daschle (D-S.D). "People all across this country have made it clear what is happening today with health insurance cannot be allowed to continue."

For politicians of both parties, the rallying cry for "patients' rights" has become a favorite theme among the current generation of attempts at health reform. Neither of the approaches the Senate is considering would substantially overhaul the health care system -- they would not, for instance, extend insurance to all 43 million Americans without coverage. But they would tip the balance of power among doctors, patients and the insurance industry -- a balance that has shifted markedly toward health plans in the era of managed care.

The Senate is taking up the issue just a year after the House hastily approved a GOP version with barely any debate. The legislation before the Senate is similar to bills that were advanced last year but died in a partisan standoff before formally reaching the floor. GOP leaders say the House will consider the issue again later this year.

While the outcome in the Senate this time remains uncertain, Republicans expressed confidence yesterday their bill would prevail. If that happens, the White House said, senior advisors to President Clinton would recommend that he veto the bill.

The behind-the-scenes maneuvering during yesterday's debate also underscored the extraordinary parliamentary tactics that both parties are prepared to employ in hopes of winning some advantage.

Republicans tried to gain an edge last week by making the Democrats' bill the vehicle for debate, hoping to make it more awkward for the Democrats to offer their own amendments. But yesterday, the Democrats counterattacked, offering the Republican bill as an alternative to their own. For the moment at least, this means that each party can amend the other's bills, and the Senate can chose between the two at the debate's end.

During yesterday's arguments, Democrats accused Republicans of pandering to the insurance industry without providing adequate protection to patients, while Republicans charged that Democrats would go too far in strengthening government control, increasing medical costs and thus causing more Americans to become uninsured.

Each side armed itself with maze-like charts, grisly photographs and superheated language to promote its own plan and demonize the alternative.

"The Democrat plan means more government, more lawyers, more rules, more uninsured and more government control, but the only thing it does not mean, the one thing it does not provide, is more freedom," said Sen. Phil Gramm (R-Tex.), describing "freedom" as the hallmark of the GOP bill.

Across the aisle, Daschle accused Republicans of offering a "placebo, not a plan." A "profit-protection plan for the insurance industry," said Sen. Edward M. Kennedy (D-Mass.), who is co-sponsoring the Democratic proposal with Daschle.

The pep rallies were drenched in alarmist rhetoric and featured ordinary Americans imported to Capitol Hill to help the politicians make their case.

Standing against a blue backdrop printed with the words, "Patients First," Republicans contended that allowing Americans to sue their HMOs, as Democrats want, would drive up medical costs so much that people no longer would be able to afford coverage, ultimately causing 1.8 million Americans to lose insurance over the next five years.

To illustrate their point, the GOP introduced Richard Gallo, who traveled with his wife and three children from Indiana, Pa., where he opened an office supply store three years ago. Calling the opportunity to own his own business "an American dream," Gallo said that he nevertheless had been unable so far to afford health insurance for his family or his seven employees. And while he hopes to be able to purchase some soon, he said, "if Congress continues to enact bills that will keep driving up the cost, that will be impossible to us."

For their part, Democrats were flanked by D.C. General Hospital employees who wore white lab coats, symbolizing the party's contention it is defending health care professionals and regular Americans.

Daschle introduced Ray Cerniglia, who said that his son, Matthew -- a 12-year-old who liked skateboarding and had started to get calls from girls -- died of cancer in February after the family failed to persuade their HMO to pay for high-dose chemotherapy and a "stem cell rescue."

"It is crazy that while we are caring for and fighting for Matthew's life, we had to, at the same time, fight our HMO for coverage of a life-saving treatment," Cerniglia said. He said he agreed with Democrats that Congress needs to give doctors more control over medical decisions and that patients should be able to sue their HMOs.

The large, well-funded lobbies with a stake in health care were also out in full force. Speakers at the Democratic rally yesterday included John Sweeney, president of the AFL-CIO, and representatives of a dozen consumer and medical advocacy groups who held up placards with their organization's name. Meanwhile, a coalition of business and insurance interests, affiliated with the GOP but eager to block any bill from passing, is running a major advertising campaign this week.

Patients' Rights

Republicans and Democrats each have put forward a "Patients' Bill of Rights," but the proposals are not at all the same. Here are some of the main differences.


Democrats: Want to weaken the power of health plans by forbidding them to overrule doctors' decisions about what kind of treatment a patient needs.

Republicans: Oppose this idea.


Democrats: Want to begin allowing patients to sue an HMO or an employer for malpractice in state courts.

Republicans: Oppose this idea.


Democrats: Want to require HMOs to have an inside grievance system in which patients who have been denied care could appeal to an internal review board made up of doctors or other health care professionals not involved in the original decision.

Republicans: Want to require a similar internal grievance system for patients in certain kinds of HMOs.


Democrats: Want to allow women to visit obstetrician-gynecologists and children to visit pediatricians without getting permission from their HMO. Would permit patients to see specialists repeatedly for ongoing treatment of certain medical problems.

Republicans: Would allow only patients in certain HMOs such direct access to ob-gyns and pediatricians.


Democrats: Want to require all HMOs to pay for hospital emergency room treatment whenever patients believe they have a medical emergency.

Republicans: Want to create a similar requirement that HMOs pay for true emergencies, but oppose coverage of treatment in emergency rooms for non-emergencies.


Democrats: Oppose this idea.

Republicans: Want to make it easier for Americans to create "medical savings accounts," which allow tax deductions for money people set aside for medical expenses.


Democrats: All Americans who belong to HMOs, currently about 160 million people.

Republicans: Some protections would apply to all Americans in HMOs, but many would be available only to patients in certain kinds of HMOs -- from about 123 million people to 48 million people, depending on the provision.

SOURCE: Staff reports