Rep. Tom Coburn (R-Okla.) was telling an HMO horror story, one of those infuriating tales about greed-driven care that have dominated the patients' rights debate in Congress.
Just last Monday, Coburn said, a pregnant woman visited her obstetrician in Muskogee after she was exposed to the chicken pox virus. The doctor prescribed a routine $700 injection of antiserum. But her insurance company refused to pay, even though she had obstetric coverage.
"This was a no-brainer," Coburn said the next day. "She needed that injection to protect her baby. I know that what they did was wrong."
If that medical opinion sounds a bit presumptuous for a member of Congress, well, Coburn was also the obstetrician on the case. In fact, there are nine doctors in the House, as well as four dentists. And a few of the Republican doctors are taking a lead role in pushing new protections for managed-care patients, giving their House leaders migraines in the process.
Coburn, usually one of the most conservative members of the House, Rep. Charles Whitlow Norwood Jr. (R-Ga.), a dentist, and Rep. Greg Ganske (R-Iowa), a plastic surgeon, have denounced the narrower Republican HMO bill that recently passed the Senate as bad medicine, and they have stymied their leaders' efforts to write a similar prescription in the House.
With most House Democrats united behind a sweeping "patients' bill of rights," and with House Republicans holding a mere five-vote majority, the GOP doctors are the latest nightmare for House Speaker J. Dennis Hastert (R-Ill.), who had to beg his caucus to unite behind a $792 billion tax cut last week. And with polls pointing to managed care as a potent political issue for 2000, the stalemate could become a nightmare for the entire Republican Party.
"The doctors obviously play an important role. And they obviously have strong opinions on this issue," said John Feehery, a spokesman for Hastert. "It's not an easy situation."
On July 15, the GOP-controlled Senate agreed in a largely party-line vote to provide limited protections for about 48 million Americans, assuring them easier access to emergency rooms and specialists, while expanding their ability to appeal payment decisions by HMOs. The Senate rejected the Democratic alternative, which would extend much stronger protections to all 161 million Americans with private health insurance, including a right to sue their HMOs and a guarantee that only their physicians can decide what care is "medically necessary."
In general, Republicans have argued that tight restrictions on HMOs will fatten the wallets of trial lawyers, drive up health insurance costs for all Americans and increase the growing ranks of the uninsured. Democrats have responded that when HMOs are allowed to consider profits before patients, health insurance is almost meaningless. The GOP doctors are the wild card in the debate, fired up by their personal experiences, taking on some of their supporters in the business community as well as their own House leaders.
"I know I'm fighting my friends on this one," Norwood said. "But they understand that I'm not backing down. If I'm driving them nuts, well, that's the way it goes."
In the past, the physicians have tried to work with their leadership on managed care, to no avail. On a flight home to Atlanta, Norwood once asked then-Speaker Newt Gingrich what it would take to get an HMO bill to the floor. Gingrich grinned and told him to find 200 co-sponsors. Norwood signed up 238, but the bill went nowhere. Similarly, Ganske rounded up 285 co-sponsors for a bill to end "gag rules" that prevent doctors from telling their patients about expensive options, more than enough to pass it. Nothing happened.
Hastert favors limited HMO reforms along the lines of the Senate bill, and he had hoped to pass something quickly to defuse the issue. But the doctors are no longer playing nice. The day the Senate bill passed, Coburn, Norwood, Ganske and Rep. John Cooksey (R-La.), an eye surgeon, appeared at an American Medical Association news conference to blast it as an "HMO Bill of Rights." Coburn and Norwood have drafted legislation in the Commerce Committee with many elements of the Democrats' patients' bill of rights. Ganske tried to work with them, but he broke off to write his own bill, which is even closer to the Democratic alternative.
"Our leadership has delayed and delayed and delayed," Ganske said. "They've been twisting people's arms off, and so have the business lobbyists. But this issue isn't going away."
For now, it doesn't seem to be going anywhere. In May, after Commerce Chairman Thomas J. Bliley Jr. (R-Va.) suggested he liked the Coburn-Norwood bill, Hastert abruptly decided to shift the focus of the managed care issue to the Education and Workforce Committee. But Norwood is on that committee, too, and when a subcommittee chairman, John A. Boehner (R-Ohio), tried to bring up a leadership-approved package of limited patient protections, Norwood rounded up enough GOP moderates to freeze the process. Hastert is still trying to sort out the whole situation.
"The doctors are bringing reality to the House," said AMA president Thomas Reardon. "They understand the issues. They understand what's happening to patients with managed care."
Of course, HMO lobbyists believe the opposite is true. They don't say so directly, but they imply that the doctors' personal experiences have given them skewed views of the industry. For example, Karen Ignagni, president of the American Association of Health Plans, said that while the HMO who refused to pay for the injection for Coburn's patient may seem heartless, the problem was probably created by an employer's decision not to purchase that benefit.
"It's very understandable that the doctors feel that way, being on the front lines, but we don't agree with them on the substance," Ignagni said. "Unfortunately, they're playing a very large role in this debate."
Coburn, Norwood and Ganske all arrived in Congress in the conservative Republican uprising of 1994, and none of them named health care as their top priority. But all of them say their experiences with managed care made them staunch advocates for reform, relating anecdotes about HMO bureaucrats who valued the bottom line over their own patients' care.
Coburn says he once sent a 26-year-old patient to the hospital because he feared she had bacteria in her blood; her HMO refused to pay, so she left against medical advice and ended up on a respirator. Norwood growls about clerks who told him to cap cavities instead of doing expensive root canals. And Ganske recalls an HMO official denying a breast cancer survivor's appeal for reconstructive surgery by asking: "What good is a woman's breast anyway?"
"It ain't like I made this stuff up or read it somewhere," Norwood drawled. "I keep hearing that we're overreacting to anecdotes, but this is real life. I've seen it."
A medical degree is no guarantee of rebelliousness on the issue. Sen. Bill Frist (R-Tenn.), a heart surgeon, helped lead the GOP fight for the more modest protections in the Senate, but managed-care critics (and some of the House doctors) point out that his brother runs the nation's largest for-profit hospital chain, Columbia-HCA, and that Frist himself owns at least $5 million in Columbia-HCA stock. Rep. Ernie Fletcher (R-Ky.), a family doctor from Lexington, is backing the GOP leadership on HMO reform as well.
Fletcher says his health care ideas were formed by his experience as a doctor, but also by his experience as a state legislator. In Kentucky, he said, a massive reform plan ended up increasing the cost of coverage and swelling the ranks of the uninsured by 25 percent.
"The lesson I took out of that is like the Hippocratic Oath: First, do no harm," said Fletcher, a freshman who sits on the Education and Workforce Committee. "I respect what the other doctors are trying to do. But I'm afraid their plans would just make things worse."
So like a patient in a waiting room, HMO reform is on hold for now. Ganske warns that if nothing happens once again, Democrats will run campaign ads in 2000 featuring victims like Jimmy Adams, an adorable Georgia infant who lost both hands and legs from gangrene after his HMO told his mother to drive him to an emergency room 42 miles away. The boy had a 104-degree fever and his heart stopped on the way to the hospital. In his latest newsletter, Ganske noted that Jimmy "will never play basketball or caress the cheek of the woman he loves with his hand."
That's right, GOP leaders grumble. The Democrats probably will run ads like that if Republicans fail to pass an HMO bill. So why won't the doctors help pass our HMO bill?
"The Democrats want nothing to happen for political reasons, and the doctors are playing into their desires for policy reasons," Boehner said. "It's a very unfortunate situation."
Medical Backgrounds on the Hill
Lois Capps (D-Calif.) Nurse
Tom Coburn (R-Okla.) Doctor
John Cooksey (R-La.) Doctor
Ernie Fletcher (R-Ky.) Doctor
Greg Ganske (R-Iowa) Doctor
Eddie Bernice Johnson (D-Tex.) Nurse
Sue W. Kelly (R-N.Y.) MA in health advocacy
John Linder (R-Ga.) Dentist
Carolyn McCarthy (D-N.Y.) Nurse
Jim McDermott (D-Wash.) Doctor
Charles W. Norwood Jr. (R-Ga.) Dentist
Ron Packard (R-Calif.) Dentist
Ron Paul (R-Tex.) Doctor
Mike Simpson (R-Idaho) Dentist
Louise M. Slaughter (D-N.Y.) MA in public health
Victor F. Snyder (D-Ark.) Doctor
David Weldon (R-Fla.) Doctor
Wayne Allard (R-Colo.) Veterinarian
Bill Frist (R-Tenn.) Surgeon