Congress squeezed between business, patients of HMOs GOP forced to act rather than abandon issue to Democrats

'This has been a nightmare'

March 25, 1998|By Jonathan Weisman | Jonathan Weisman,SUN NATIONAL STAFF

WASHINGTON RTC — WASHINGTON -- Last May, Kerrie Jones awoke in her parents' Salisbury home in a panic. She had been celebrating her newly minted Johns Hopkins University master's degree the night before, but this was no hangover.

Pressure in her skull was so severe she could barely breathe. Pain in her ears was excruciating.

The 28-year-old Baltimorean sped off to the Peninsula Regional Medical Center emergency room and began a long, frustrating battle -- not with her health but with her managed care company.

The sudden onset of a vicious allergy cleared up quickly with a dose of Claritin, but Jones' health maintenance organization has not been so responsive. To this day, her insurer has refused to pay for her emergency care.

Jones' frustration is echoed in every corner of the nation, where 80 percent of workers are enrolled in some kind of managed care, up from 5 percent in 1980.

That anger is reverberating in Congress, squeezing Republicans between the public's demand for action and pressure from businesses and health insurers that want to curb costs and have long been supportive of Republicans in Congress.

"Everyone is feeling pressure from these long-standing Republican constituencies," said Paul R. Ginsburg, president of the Center for Studying Health System Change, a Washington research group.

"There's a lot of anti-managed-care sentiment among consumers and particularly among physicians. Those are pressures that are very difficult to resist."

For Jones, the political conflicts in Washington are matched by her own travails. According to Jones' insurer, an allergy attack -- no matter how severe -- was not worth a trip to an emergency room not covered by her HMO.

"This has been a nightmare," said Jones, a clinical chemistry researcher at Johns Hopkins.

"I don't care if they owe me 5 cents. It's the principle of the thing."

For many, her tale is symbolic of managed care companies with arcane rules designed to hold down costs.

"Every single day I deal with a horror story," said Carol Anderson of Gambrills, who has a dual perspective as a reimbursement specialist at George Washington University Medical Center and a breast cancer patient in an HMO.

"If they haven't gone through it themselves, they know somebody who has."

Members of Congress can hardly ignore a cause resonating with voters in an election year.

"This is an issue that is very important to our constituencies," said Rep. Benjamin L. Cardin, a Baltimore Democrat who has introduced one bill to broaden emergency care coverage and another to institute an outside review of coverage decisions.

"We're dealing with one of the most complicated and vital fields as far as consumers are concerned, and there's no federal regulation. The public is saying, 'Why aren't you doing something here?' "

On the other side, opposition to managed care legislation is being mounted by powerful forces: the insurance industry, big businesses as represented by the U.S. Chamber of Commerce and small businesses as represented by the influential National Federation of Independent Business.

These industries contend that many employers are able to offer health care coverage only because managed care has reined in costs.

"I have 11 office employees. I offer them insurance, but because of the costs, I can only pay for 40 percent," said Kent Swanson, a Republican small businessman in Towson who opposes managed care reform.

"If premiums keep going up, I'll have to look at even a lesser amount, if any at all."

Squeezed in the middle is a Republican leadership whose rank and file is nervous that Democrats will portray them this November as more attuned to the needs of big business than to the frustrations of their constituents.

"This is an issue you either deal with or you let the Democrats demagogue," said Rep. Charlie Norwood, a conservative Georgia Republican dentist whose managed care bill is both the most sweeping and most popular of the measures in Congress. "And [Republican leaders] know it."

The Norwood bill, sponsored in the Senate by New York Republican Alfonse M. D'Amato, has the support of a clear majority in the House: 226 members, 95 of them Republican.

The bill has united some of the most conservative Republicans with some of the most liberal Democrats. But GOP leaders have vowed never to bring it to a vote.

The legislation would establish minimum standards of coverage, such as emergency care. It would require access to specialists, extend coverage to doctors outside a prescribed list, ban "gag ++ orders" that restrict a doctor's right to tell patients of costly treatments, set up an expedited appeals process and let patients sue insurers for injury or wrongful death.

President Clinton has proposed a more limited "patients' bill of rights."

It would require health plans to cover emergency care more broadly, provide specialty care, supply information to patients on all treatment options, and permit enrollees to appeal decisions to an outside panel.

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