The first signs that managed-care regulation could become an issue in November's congressional elections were on North Carolina airwaves this spring.
Shortly after the state's Democrats in May nominated malpractice attorney John Edwards to try to unseat Sen. Lauch Faircloth (R-N.C.), the Health Benefits Coalition, an organization of employers and insurers, aired radio spots in Raleigh and Charlotte criticizing the idea of allowing health-plan enrollees to sue their plans for malpractice.
Some of the leading patient-protection bills in Congress, including the Democratic bill that Edwards supports, would give enrollees that right.
Faircloth, however, agrees with the Health Benefits Coalition's argument-which it has repeatedly made in a national public relations campaign costing more than $1 million-that increased litigation will drive up costs and lead to increased numbers of uninsured workers.
"He is quite concerned about the increase of medical malpractice lawsuits increasing healthcare costs," said Faircloth spokesman Peter Hans.
As Republican leaders last week put the finishing touches on their own version of healthcare quality legislation, nobody was more sensitive to its potential electoral effect than hundreds of incumbents and challengers seeking House and Senate seats.
Although political consultants and pollsters don't expect managed care to become a nationwide issue, they said it could become a weapon in the arsenal of many candidates this fall.
In particular, it could be a wedge issue for the Democrats, who want to regain control of the House, which they lost in the watershed mid-term election of 1994. Likewise, Republicans have developed their legislation with an eye toward protecting that hard-won majority.
Political consultants said patient protection is most likely to arise in close races in which the issue cuts in favor of a specific candidate: districts where voters want more regulation or districts where voters oppose big government.
"The public cooker on this issue is already turning up," said Bob Castro, vice president of Luntz Research, the firm on which House Speaker Newt Gingrich (R-Ga.) relied in plotting the GOP 1994 takeover of Congress.
In that 1994 election, the Republicans succeeded in playing off President Clinton's failed Health Security Act as a big-government takeover of the healthcare system.
But today, Castro said, the political winds have shifted.
"This isn't about paying a little more or getting a little bit less to cover the uninsured," he said. "This is about the middle class wanting to get what they're paying for."
Indeed, some GOP consultants said Republicans philosophically opposed to government interference in the economy may be willing to make an exception in the case of patient protection.
Castro said his firm is advising its incumbent clients that voters have "expectations" about dealing with patient-protection issues.
"Even among those (voters) who are not inclined to have the government interfere in their lives, they are asking for something to be done," he said.
Rep. Greg Ganske (R-Iowa), one of the first sponsors of legislation banning "gag clauses" in contracts between physicians and plans, confirmed such sentiment among traditionally Republican voters such as members of the small-business group the National Federation of Independent Business, a leader in the Health Benefits Coalition.
"I gave a talk to women small-business owners, many of whom are NFIB members, and they said, `We think you need to fix this, and our national lobbyists are wrong,'*" Ganske said.
The Republicans' split personality on patient protection is best demonstrated by Sen. Alfonse D'Amato (R-N.Y.) and Rep. Charlie Norwood (R-Ga.). They are the sponsors of the controversial Patient Access to Responsible Care Act, or PARCA, one of the bills opening the door to malpractice lawsuits against managed-care plans. D'Amato also is sponsor of a bill mandating hospital stays for mastectomy patients.
The Republican healthcare quality bill, however, could go a long way toward inoculating GOP candidates from attacks by Democrats, Castro said.
"(Republican leaders) haven't been out front on this," he said. "It's all a matter of what they come up with. If they deliver, they might cut the legs right out from under the Democrats."
Ganske said Rep. John Linder (R-Ga.), the chief of the House Republicans' campaign committee, has warned GOP press secretaries that the issue might be one that voters will be most interested in during the election campaign.
But some Republicans might not need such proposals to defend themselves if they stick to Republican principles, added Jerry Klepner, director with the Washington lobbying firm Black, Kelly, Scruggs and Healey.
"Those who are opposed to the legislation are talking in context of the costs of the legislation and the notion of federal mandates," Klepner said.
Other consultants agree with Klepner, saying they doubt that there is strong public sentiment in favor of patient-protection legislation. They point to some polls that show slackening support for patient-protection measures once the price tag increases.
Studies have estimated consumer cost increases from the PARCA ranging from as little as 0.5% to as much as 39% (April 27, p. 3).
"I'm not sure there's as much of a backlash as some people suppose," said Gary Ferguson, senior vice president with American Viewpoint, a Republican firm. "I don't think it's a key that (Republicans) have some sweeping bill. I think it is important to show that they're taking steps to address this problem."
To make those points, the Health Benefits Coalition, which also aired the same anti-lawyer ad in Florida, Louisiana, Missouri and Ohio during Congress' Memorial Day break, expects to go back on the air in key districts when Congress recesses for Independence Day.
Indeed, Edwards' campaign isn't sure that it will be a winning issue as they take on Faircloth, a first-term senator who ousted an incumbent Democrat when he won his seat in 1992. "I don't know how strong it will be in the fall campaign," said spokesman Rob Black.