As the House stumbles toward a consensus on managed-care reforms, doctors find themselves in the pivotal position of determining whether a Republican bill or a bipartisan measure wins the day.
With the GOP leadership acutely aware of its slim five-vote majority, three Republican members with medical backgrounds have had more influence than ever on the fate of patient protections.
Reps. Charlie Norwood (R-Ga.), a dentist; Greg Ganske (R-Iowa), a surgeon; and Tom Coburn (R-Okla.), a family physician, have worked with GOP leadership and Democrats as the trio pushes for a vote on some form of patient bill of rights.
When Congress adjourned for its annual August recess earlier this month, Norwood and Ganske had broken with Coburn and the House Republican leadership and had joined Rep. John Dingell (D-Mich.) in supporting a bipartisan bill. Coburn, meanwhile, continued to work with House Speaker J. Dennis Hastert (R-Ill.) to develop a leadership bill.
In a major concession before adjournment, Hastert acknowledged that the GOP had seen the handwriting on the wall and will now back patients' right to sue health plans when they are harmed by the denial of covered benefits.
That is a provision for which Norwood has pushed since his first managed-care bill, the Patient Access to Responsible Care Act of 1997.
"It's a victory that Hastert has come out and said, 'Yup, we're going to have to consider liability,' " said Norwood spokesman John Stone.
The situation in the House was unlike that in the Senate, where the Republican majority-forced to debate managed-care reform after being outflanked by Democrats-marched solidly toward a conservative-flavored bill that did not open the door to such lawsuits.
Sen. William Frist (R-Tenn.), a transplant surgeon and the Senate's only physician, was among Republican leaders arguing for the more-conservative approach.
Norwood was in a similar position last year when he eventually signed on with a House GOP bill that allowed a limited right to sue. But this year, Stone said, Norwood has taken a different role.
"He was not happy with the final GOP (bill)," Stone said. "This year, he was less willing to wait around for the Republican leadership."
Norwood decided to spurn GOP leadership in late July after talks related to drafting a bipartisan bill collapsed between the leadership and Dingell, Stone said.
"The slim (majority) is not nearly as important as the fact that you need a bunch of Democrats and a bunch of Republicans on the bill" for it to pass, Stone said.
Other sources said Norwood may feel less loyal to Hastert than he did to former Speaker Newt Gingrich, a fellow Georgia Republican. As a result, Norwood may feel more free to fight the leadership in pushing for more patient rights.
Ganske, meanwhile, has had a turbulent history with Republican leadership. He was one of the first sponsors of federal managed-care reforms-a 1996 bill that would have banned "gag clauses" that restrict physician communications with patients, and he resigned his seat on a national Medicare commission in 1998 after agreeing to support Democrats with their patient-protection legislation.
As Republicans with otherwise solid conservative credentials, Ganske and Norwood hold a lot of sway with other members who want to support managed-care legislation and don't want to be seen as either too liberal or too cozy with insurers, said some Capitol Hill aides and lobbyists.
"People know that (Norwood) generally has antipathy for government," said Ron Pollack, executive director of Families USA, a healthcare consumer group. "It makes for somebody who is rather formidable."
That has pushed GOP leadership to endorse greater regulation, said one Capitol Hill aide. "Their involvement and the people they bring along have moved (the legislation) to the left," said the aide, who requested anonymity. "The key now is where Coburn's going to come down. He's more conservative, but he's a doc," the aide said.
One veteran insurance lobbyist added that employers haven't made a convincing case that more regulation will increase costs and reduce employer-sponsored coverage. Also harming their case is the hot economy, which has caused labor shortages and pushed employers to expand benefit packages to attract skilled workers.
If Republicans fight managed-care reforms, they will appear to be mere apologists for managed-care plans, a position they don't want, the lobbyist said
"There are two things happening: The majority's slim, and a whole lot of Republicans are wondering why we're protecting insurance companies," said the lobbyist, who also requested anonymity.
Possibly out of fear about how managed-care reform could be used against them, more than a dozen Republicans signed onto the bill as sponsors the day it was introduced.
But insurance lobbyists aren't necessarily writing off all the Republicans who co-sponsored Norwood's bill.
"It's not a foregone conclusion that everyone who's a co-sponsor will vote for the bill," said Sharon Cohen, a lobbyist with the Health Insurance Association of America.