After defeating Democrats' efforts to grant major new rights to patients in managed-care plans, the Republican-controlled Senate came back yesterday with a series of more limited protections, including one to make it easier for women to stay in the hospital after breast cancer surgery.
On the third day of the Senate's health care debate, Republicans began to refine their approach to protecting patients' rights, proposing relatively modest steps to make it easier for patients to visit medical specialists, get emergency room care and take part in clinical trials of new therapies.
Democrats had sought to address all those issues in far broader ways, and the minority party complained that the GOP was only paying lip service to important problems in an effort to avoid appearing insensitive to patients. "This is going to be `Cover Yourself Day' on the part of Republicans," Minority Leader Thomas A. Daschle (D-S.D.) said as the Senate began debate yesterday.
But Republicans insisted they were striking a better balance between protecting patients and keeping costs down, and said the states are already doing a good job at regulating health plans. "We don't think the source of all wisdom when it comes to health care is in Washington, D.C.," said Assistant Majority Leader Don Nickles (R-Okla.).
The Senate is scheduled to wrap up work on the managed-care bill today, and despite Democratic complaints, the final version will almost certainly be shaped to Republicans' liking. A few issues have yet to be resolved, including a Democratic proposal to let patients sue their health maintenance organizations.
But after that, the bill's prospects are uncertain. House Republican leaders have said they will schedule a vote on their own managed-care bill, now being drafted in three committees, before Congress recesses Aug. 6 for a month. The White House has threatened a veto if Congress adopts a plan along lines favored by Senate Republicans.
Last night, a bipartisan group of moderates was trying to muster support for a compromise that contains many of the Democrats' goals but would not give patients as broad a right to sue. They claimed to have nearly enough support to prevail.
During the partisan skirmishing yesterday, Senate Republicans continued their unbroken series of victories on the managed-care bill, as the party remained unusually unified in supporting GOP proposals while squashing Democratic alternatives.
On a 53 to 47 vote, for instance, the Senate rejected a Democratic amendment to give patients easier access to medical specialists.
Democrats also tried unsuccessfully to resurrect a proposal to extend the bill's protections to all Americans with private health coverage, which the Senate rejected Tuesday in favor of a Republican approach that would apply to substantially fewer people. They failed again yesterday, 52 to 48.
The issue of how many people the federal law would protect is one of the main differences separating the parties on patients' rights. Democrats want their protections to apply to all 161 million Americans with any kind of private health insurance. Republicans argue that regulating HMOs is basically a state job and that the federal government should protect only patients in types of plans that lie beyond the reach of state regulation.
Under the GOP proposal, some regulations -- such as better coverage for emergency room treatment -- would apply only to 48 million people who get insurance through big businesses that insure themselves, rather than buying coverage through an insurance company.
Other parts of the GOP plan, such as measures to help patients lodge a grievance when their HMO denies them care, would apply to 123 million Americans who get insurance from private employers. But they would not apply to an additional 40 million people who are government employees or buy insurance on their own.
As they tinkered with their bill yesterday, Republicans chose to highlight an issue with especially broad symbolic appeal to female voters. On a party-line vote of 55 to 45, the Senate approved an amendment offered by Sen. Olympia J. Snowe (R-Maine) ensuring that doctors and patients can choose how long women stay in the hospital after mastectomies.
Only a day before, Republicans rejected a similar proposal as part of a broader Democratic initiative on women's health.
Democrats opposed the Snowe proposal because it supplanted their proposal to require insurers to allow patients with serious illnesses to participate in clinical trials. Republicans said they will have their own proposal on that issue today.
Despite the similarity, Republicans relied on a semantic distinction in arguing that their approach on mastectomies was superior because the GOP has included the words "medically appropriate," and thus would guarantee women up-to-date treatment. It was a distinction that Sen. Charles S. Robb (Va.), sponsor of the Democratic version, said distorted his proposal.
The GOP also omitted the Democrats' proposal to require health plans to allow women to choose an obstetrician-gynecologist as their primary doctor. On the other hand, the GOP trumpeted its inclusion of a protection not suggested by the Democrats: a promise that all men and women with a diagnosis of cancer could get a second opinion about their condition and the best kind of treatment.
Such a guarantee, Snowe said, "will reduce senseless deaths resulting from false diagnoses and empower individuals to seek the most appropriate treatment available."
But the Republicans' argument confounded parts of the health care industry. "I've never known it to be an issue," said Susan Pisano, a spokeswoman for the American Association of Health Plans. She said "it is definitely common practice to allow second opinions," although she said HMOs do not always pay for those by doctors outside their network of physicians -- as the GOP wants to require.
Thomas R. Reardon, president of the American Medical Association, which seldom is on the same side as the HMOs, agreed. "This is not something that has been high on the radar screen as an issue," he said.
Joseph Bailes, a Dallas cancer specialist who is president of the American Society of Clinical Oncologists, said HMOs sometimes are reluctant to pay for visits to major cancer centers or oncologists who perform highly specialized techniques. But in general, Bailes said, complaints about trouble getting second opinions are "much less prevalent" than they were a few years ago.
CAPTION: Sen. Edward M. Kennedy (D-Mass.) said his plan would increase monthly premiums for the average worker by less than the price of a Big Mac.