Undaunted by their failure last year to win passage of a Patients' Bill of Rights, Democratic lawmakers are set to revive the legislation in 1999. But it's far from clear whether Democrats will have better luck this time around, outnumbered in both the House and Senate despite a surprisingly successful showing in midterm elections.
"It's hard to tell what's going to happen," says John Murray, spokesman for the American Association of Health Plans, a Washington-based trade group.
In addition to the Patients' Bill of Rights, lawmakers in the coming year are likely to tackle a variety of possible changes in Medicare, particularly finding ways to keep HMOs interested in serving seniors under the Medicare+Choice program.
Those predicting passage of some form of a Patients' Bill of Rights cite several factors. First, Democrats picked up five seats in the House, the same number by which the bill failed last year.
"I would hazard to guess that the odds are somewhat better than last year, principally because the Democratic gains may be enough to put (a bill) over the top," says Robert Doherty, senior vice president of governmental affairs and public policy at the American College of Physicians-American Society of Internal Medicine in Washington.
Second, the candidates who won--on both sides of the aisle--appear to be more moderate than their immediate predecessors, says Bill Pierce, director of public affairs at the Blue Cross and Blue Shield Association in Washington.
"That means you're moving away from the extreme parts of the bill," improving chances for passage, Pierce says.
Timing is also a favorable factor. Lawmakers realize there is little chance of a serious debate and legislation in 2000 given the presidential and congressional elections-a reason to push forward sooner rather than later.
Hill watchers, such as Doherty, also say lawmakers and the White House don't want to be viewed as doing nothing about healthcare with elections approaching in 2000.
Those less certain of passage argue little has changed as a result of the midterm elections. Republicans still solidly control the Senate and can tie up any bill indefinitely. In the House, Democrats need to be cohesive and find Republicans to support them. And while leadership among Republicans changed in the House, the party hasn't shown any more willingness to go along with last year's Democratic version of the bill.
"Ideologically, I don't think there's a big change from the old leadership," Doherty admits.
There is, however, a big change in style. House Speaker Bob Livingston (R-La.) likely will leave it to committee chairs to decide how to proceed on healthcare and other matters rather than concentrating power in task forces, as was the style of his predecessor, Rep. Newt Gingrich (R-Ga.), Pierce says.
"That could potentially slow (the process) down (but) . . . it brings a ray of sunshine and gives the players a chance to comment and for everybody to be involved," he says. Pierce predicts the outlines of the legislation will be clear by July.
Another factor weighing against passage is that healthcare does not appear to have been a major issue for voters during the midterm election. A poll conducted for the AAHP in November by Q.W. Ayers & Associates of Roswell, Ga., confirms this.
In response to an open-ended question asking the single most important factor in determining their vote, less than 1% of the thousand voters surveyed mentioned reform of managed care or health insurance issues.
"To suggest that there's some massive mandate would be a mistake," Murray says.
There is also the danger the sides may choose to use the Patients' Bill of Rights as a political tool to gain advantage over each other rather than seek compromise, Murray and others say.
The two flash points of the legislation will be language dealing with patient choice and the ability of patients to sue health plans, says Frederick Graefe, a partner at Washington law firm Baker & Hostetler.
"Members care more about seeing the physician they want to see as opposed to a wide menu of choice in plans," Graefe says. "The issue that is going to cause all the problems is ERISA (the federal Employee Retirement Income Security Act, which, among other things, precludes litigation against health plans). . . . The obvious solution is some form of arbitration and then let them go to court."
Graefe, who represents drug manufacturers, hospitals, doctors and others favoring malpractice reform, predicts the sides will reach compromise on choice but was far less optimistic on language dealing with ERISA.
In the end, Democrats and Republicans will pass a bill, but it will "be more like the Republican bill passed last year," says Robert Blendon, professor of health policy and political analysis at Harvard University. Blendon agrees with Graefe that the real sticking point will be the right to sue health plans, but he says Democrats believe healthcare is an important secondary issue and, as a result, will compromise.
The other major healthcare issue on Capitol Hill this year is Medicare. The Medicare+Choice program was created to give seniors more choice in health coverage by encouraging HMOs to cover them.
However, about 450,000 beneficiaries will be affected by plans pulling out of the market because they can't make money due to low reimbursement rates, Murray says.
"Congress and the administration are playing with fire if they think these seniors are going to get their health plans taken away from them," Murray says. "Congressmen are going to go home, and their constituents are going to be very likely to let them know they don't like it."
Blendon says Congress will be forced to allow the plans to "make more money." Congress and the administration "can't sit around and say there will be more choices and then have state after state where nothing is available," he says.
The Blues' Pierce predicts a large number of hearings to determine what went wrong with Medicare+Choice, creating an impetus for changes in the program.
At the same time, a committee of lawmakers and private citizens is meeting this year to examine ways to overhaul Medicare and will make recommendations to Congress. Blendon predicts the needed changes will be too politically controversial for lawmakers to pass legislation in 1999.
"At the moment, the polling shows that Americans recognize some problem and want something done but generally oppose most of the changes," Blendon says. "Congress has a very real problem, but there's not going to be a lot of public enthusiasm for any of the solutions."