Senate Republicans last week threw down the gauntlet on managed-care reform, passing stripped-down patient protections that drew criticism from Democrats and a veto threat from President Clinton.
The debate involved a series of procedural maneuvers to force Republicans to take hard votes on hot-button healthcare issues. Democrats pressed hard for Senate debate, and had tied up Senate action on some annual spending bills for at least a week in June.
But it had a virtually preordained conclusion. The bill that emerged was a weakened version of a Democratic-sponsored "patients' bill of rights." It satisfies some of the concerns of the health insurance industry and gives GOP senators a defense against Democratic attacks.
"What we're looking at is more of a political denouement than a political climax," said Mark Merritt, chief strategist for the American Association of Health Plans. "It's a poisonous political environment. This is not a reasoned discussion of how to improve the lives of patients."
Merritt described the Senate-approved bill as "not as horrendous as the Democratic bill, but it's not something we support. There's still too much government intervention. An increased number of regulations that add costs and don't do much to improve quality aren't really in anybody's interest."
Democrats, physicians and consumer groups complained bitterly that the bill was ineffectual and vowed to keep the pressure on.
"Insurance companies won. American families lost," said Sen. Charles Schumer (D-N.Y.).
Clinton was just as dissatisfied. "The Republican leadership's bill is a patients' bill of rights in name only," Clinton said. "If Congress insists on passing such an empty promise to the American people, I will not sign the bill. Passing a strong, enforceable patients' bill of rights should not be a partisan issue. This should be about protecting patients, not insurance companies."
The week started with Senate Republican Leader Trent Lott (R-Miss.) putting the Democrats' bill up for debate on the floor rather than a Republican alternative, as most observers anticipated.
This allowed Republicans to put Democrats on the defensive and offer amendments that would eliminate the most controversial provisions. Republicans won votes that allowed them to replace Democratic-sponsored language with less-burdensome proposals.
The GOP argued that the Democratic bill would push premiums up an average 4.8% and increase the number of uninsured.
A key vote came Thursday, a 53-47 decision to replace Democratic language that would have allowed patients to sue their health plans for injury or death resulting from denials of covered services.
"It drives up costs," said Sen. Judd Gregg (R-N.H.), who led the effort to strip that provision from the legislation.
Among the many changes to soften the Democratic bill, the Senate passed an amendment to invalidate the law if it raised health insurance premiums by more than 1% or increased the uninsured rolls by more than 100,000.
In a bow to some practitioners, the GOP legislation would prohibit health plans from excluding practitioners from their panels based on licensing or certification. That's been a big issue for nonphysician practitioners, who want to make sure they can still get managed-care business.
The final vote came Thursday night, after a bruising four days of partisan debate. A final "wraparound" amendment incorporated most of the Republican-sponsored patient protections and many of the amendments approved throughout the week (See bill summary, this page).
Reflecting the tenor of the debate, the vote was mostly along party lines. No Democrat voted for the final GOP bill, and two Republicans-freshman Sen. Peter Fitzgerald (R-Ill.) and Sen. John Chafee (R-R.I.)-voted against it.
A moderate on many healthcare issues, Chafee pushed at the 11th hour for a vote on a bipartisan compromise he sponsored with Sen. Bob Graham (D-Fla.).
In publicizing his efforts, Chafee said the GOP's actions last week sealed the fate of managed-care reforms.
"The Republican bill will pass, the president will veto it, the veto will be sustained, and the American public won't be any better off," Chafee said.
Sen. Joseph Lieberman (D-Conn.) added, "If this debate is to have any meaning, we should have three votes: one on the Republican bill of rights, one on the Democratic bill of rights, and one on the compromise bill."
In the end, the bipartisan group lured only Chafee and one other Republican, Sen. Arlen Specter (R-Pa.) on board, not enough to persuade the leadership to allow a vote on the group's proposal.
The House, meanwhile, is moving more slowly on managed care. Although a House Education and Workforce Committee panel has approved a reform bill, no further action on it has been scheduled.