Patients’ Bill of Rights:
Will It Happen, and Will It Help?

J. Greene

Dinner’s cooking on the stove and you’re half watching the evening news where lots of serious-looking people in dark suits debate health-care reform, throwing around terms such as “medical necessity” and “utilization review.” Meanwhile, in the other room, your toddler wails in pain with yet another ear infection, prompting your own internal debate: Do you switch off the burner under the Hamburger Helper and take your sick kid to the emergency room, or wait to see the pediatrician tomorrow so you don’t get in trouble with the health maintenance organization?
       Believe it or not, the talking heads on TV are actually trying to make your medical decision easier. The patients' rights debate now raging in Congress is fueled by polls that say people like you are fed up with the way managed care treats patients. You want to be able to see the doctor when you need and know the health plan will pay.
      Of course, given the intense politicking around this issue, you may find it difficult to see your own life and problems reflected in all the partisan bickering. What do you care how members of Congress use their votes on this volatile issue in their campaign commercials? It doesn't make your baby feel any better.
      Still, when the dust settles, you may find legislators actually did something that affects you. The most likely provisions to make it through the political meat grinder are likely to be fairly innocuous — for instance, requiring an outside, independent review of disputes between HMOs and their members. Some HMOs have already begun offering third-party review voluntarily.
      As for anything more substantial, both sides have promised to nix their opponent's favorite provisions. For instance, business interests are in the midst of an ad campaign to defeat a proposal that grants patients the right to sue their health plans. Consumer advocates, complain that HMOs don't have to face the consequences of their decisions because of ERISA, a federal law that shields them from most lawsuits. But insurers argue that lawsuits would be counterproductive and would simply raise insurance costs for everybody. "We don't think trial lawyers are the sole guardians of quality of care in the health-care system," says John Murray, director of public affairs for the American Association of Health Plans. Instead, Murray's organization says external review of disputes by a third party should give patients all the recourse they need.
      At the same time, consumer advocates have found what they call "poison-pill" provisions, such as allowing "medical underwriting" — the practice of charging higher rates to people more likely to become sick — that prevent them from supporting the proposal.
      Judy Waxman, government affairs director of Families USA, believes enough Republicans in the House support a more consumer-friendly bill that it could pass, who have joined ranks with consumer groups against insurers and business lobbyists. The House has to pass something. The questions will be what will they pass and what happens in the Senate.
      To muddy the waters even further, some of the consumer rights proposed are limited to certain people. For instance, the legislation approved by the Senate applies in large part only to the 48 million Americans who get health coverage from larger companies that insure themselves, as opposed to employers that buy insurance from a health plan. And the vast majority of these people aren't even in HMOs, whose restrictive practices have prompted the calls for reform; instead, this group favors traditional fee-for-service plans, or PPOs.
      Few are willing to hazard a guess as to whether the House can pass meaningful legislation and then somehow make it match what the Senate has done. Larry Levitt, who researches the health-care system for the Kaiser Family Foundation, looks to the past when trying to predict the future. "The chances of ending up with something are slim," Levitt says.
      The bottom line: Don't get too excited about potential changes in how your HMO operates. Even if Congress acts on this issue, the results are likely to be so watered down that the new protections will affect you only in an unusual situation, and there's a decent chance you won't fall into one of the special categories of people who get protected. The best advice is to know your health plan's rules, know who to bother when you don't get what you need, and be vocal when care is denied. And about your kid's earache: Follow your instincts; dinner can wait.
 

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