House Republicans yesterday pushed through a controversial series of tax breaks intended to make it easier for Americans to buy health insurance, while mounting a late but intense campaign to defeat broad new patient protections that will come to a vote today.

On a largely party-line vote, the House adopted legislation giving all Americans the freedom to defect from traditional insurance plans and create tax-free savings accounts to cover their medical bills. The idea--already being tried on a small scale--has been promoted by conservatives but is anathema to many Democrats.

The measure also offers tax relief to people who buy insurance on their own, shoulder most of the cost of their employers' health benefits or purchase insurance policies to cover nursing home bills. Other parts of the bill are designed to allow small companies to band together in new ways to buy less expensive coverage.

"It's going to mean a whole lot of people who are uninsured right now . . . won't have to face the risk of illness without the shield of insurance," said Rep. James M. Talent (R-Mo.), the bill's chief sponsor.

Democrats, on the other hand, call the changes counterproductive, saying they would give the most help to people who are affluent and healthy and, in some cases, would circumvent states' insurance protections. The White House cited a new congressional analysis estimating that the GOP tax breaks would help less than 1 percent of those now without health coverage.

The GOP-sponsored bill was approved 227 to 205. Among area lawmakers, Rep. Constance A. Morella (R-Md.) broke with her party to oppose the measure, while Virginia Democrats Virgil H. Goode Jr. and James P. Moran Jr. backed the Republican plan.

The acrimonious debate yesterday was the warm-up act to the main show that will play out today when the House considers rival bills that would, to varying degrees, guarantee new rights to patients in health maintenance organizations and other forms of managed care. The core of the disagreement hinges on how much of a right patients should have to sue their health plans for malpractice if they believe they suffered medical harm because they couldn't get the care they wanted.

On Tuesday, House Speaker J. Dennis Hastert (R-Ill.) and other party leaders veered away from their long-standing opposition to allowing such lawsuits, throwing their support, instead, behind a bill that would permit consumer litigation in certain limited circumstances.

After months of relatively lax attempts to unify Republicans on the divisive issue of "patients' rights," Hastert and other GOP leaders yesterday began in earnest to try to sway wavering votes. The party, which holds a five-vote majority, has been internally polarized, with nearly two dozen GOP lawmakers announcing that they would support the broadest patient protection bill, which would grant patients substantial freedom to sue HMOs.

Republicans who favor that broad bill, sponsored by Reps. Charles Whitlow Norwood Jr. (R-Ga.) and John D. Dingell (D-Mich.), said they were approached yesterday by Hastert and other key party members who support the more limited approach. Yesterday morning, the speaker "put his arm around me in a bear hug and said, 'Let's talk health care,' " said Rep. Mark Foley (R-Fla.), who noted that he is likely to still vote for the Norwood-Dingell bill but that he is reevaluating his decision.

Meanwhile, congressional sources said leadership aides have begun to ask business and health insurance lobbyists--who have ardently opposed the effort to expand patients' right to sue--whether they would be willing to remain neutral on the more limited proposal to allow lawsuits, sponsored by Reps. Tom Coburn (R-Okla.) and John Shadegg (R-Ariz.).

Those last-minute pleas for neutrality showed no evidence of success, as business and insurance interests undertook a last-minute lobbying blitz. The National Association of Manufacturers dispatched a memo Tuesday to about 200 lawmakers, primarily centrist Democrats and moderate Republicans, warning that, if they support the Norwood-Dingell measure, manufacturers that experience increases in insurance premiums would stuff a note in workers' pay envelopes urging them to protest to their congressional representative.

The party was able to maintain greater discipline in passing the bill to promote access to insurance. Republicans have made the cause of the uninsured a rallying cry this year, but Democrats accuse them of trying to weaken support for patient rights by tying them to the controversial tax measure.

The access bill approved yesterday echoes portions of patients' rights legislation that the House approved last year and includes some measures that have already been approved by the Senate.

The tax provisions in the new House bill would cost nearly $49 billion by 2009, according to the Ways and Means Committee. And the issue's bitter partisan flavor was plain even before the two-day debate began, as House Democrats--joined by President Clinton--accused Republicans of unfairly structuring the debate in a way that did not allow any attempt to include a way to cover that cost.

The most contentious part of the bill, expanding access to so-called medical savings accounts (MSAs), builds on an innovation that Congress approved on a limited basis three years ago. The accounts allow people to set aside money for medical care tax-free, while purchasing special insurance policies with high deductibles that cover only expensive, catastrophic illnesses.

The 1996 law created a four-year experiment allowing no more than 750,000 MSAs across the country, but only a fraction of that number have been sold so far, and many have been purchased by people who already have other kinds of health insurance.

Republicans argue that MSAs are a creative new form of insurance. But Democrats contend that such accounts amount to a kind of tax shelter for wealthy people who need relatively little medical care and, thus, would have limited impact on the ranks of the 44 million uninsured Americans. MSAs and other tax provisions do "virtually nothing for those [who] have nothing," Rep. Robert E. Andrews (D-N.J.) said during yesterday's debate.

A Guide to the Patients' Rights Bills

The House will consider three bills that would give more clout to people with private insurance, particularly managed-care plans.

Key Differences

Lawsuits against HMOs

Independent grievance system

Access to specialists

Experimental treatment

Norwood/Dingell

Lets patients sue in state court if an HMO denies or delays giving them a service even if it is not part of their benefit package. Patients may sue without first going through an independent appeals system.

If patients are dissatisfied with the care their HMO allows them, they can complain to an outside review panel, whose findings are binding on the health plan.

Guarantees that patients may visit a medical specialist when they need one.Allows patients to take part in clinical trials of new therapies.

Health plans do not have to pay more for such therapies than they would for standard treatment.

Coburn/Shadegg

Allows patients who have been injured to sue their HMOs in federal court for limited damages but only if they first bring their complaint to an appeals panel, and it concludes that the HMO had wrongly denied care.

Creates a similar review system, but allows patients to protest only when HMOs deny services that are part of their benefit package.

Same.

Requires health plans to pay for eligible patients to take part in clinical trials of new cancer therapies.

Boehner

Does not expand patients' ability to sue.

System resembling Coburn/Shadegg's, but with potentially higher fines if the plan flouts the panel's orders.

Does not address specialists.Similar to Coburn/Shadegg.

Similarities

Information disclosure. Patients are guaranteed more information about their health plans' rules and the services covered.

"Gag rules." HMOs may not forbid doctors to discuss expensive treatment alternatives with their patients.

Emergency care. Health plans must pay bills for all emergency room visits, as long as the patient believed immediate care was necessary.

Women and children. Women may visit obstetrician-gynecologists and children may visit pediatricians without permission from a "primary care" doctor.