In taking on HMOs, the Senate produced lots of drama. TIME sorts
out what makes sense and what doesn't
By Matthew Miller
July 19, 1999
Web posted at: 11:05 a.m. EDT (1505 GMT)
Anyone who watched Senate Democrats wax hysterical over managed
care's evils while Republicans passed their milder version of
HMO reform last week can be forgiven for not knowing two
essential facts. First, 97% of treatment decisions by doctors
are okayed by managed-care plans, one study shows. So those
grisly stories repeated from the Senate floor--the woman who
didn't get the catheterization and died--are true exceptions.
Next, about 40 states already give patients some of the
protections Democrats sought in their broader "bill of rights."
The disingenuousness was bipartisan, of course. The Republicans,
who had gleefully foiled President Clinton's first-term plan to
cover uninsured Americans, were suddenly fretting that costly
regulations proposed by the Democrats would boost the ranks of
those left behind.
At the end of the week, the Senate had managed to do only what
it seems to do best these days--tee up rhetoric for the
presidential race. The Democratic front runner, Al Gore, called
the vote "a fraud," and Clinton threatened to veto the bill. But
the vote was useful in the way it teed up something else: a
preview of what could be a real debate. Four of last week's
fights prove that when our leaders do get serious about health
reform, they will have to move beyond tearful anecdotes and
start making hard choices. The cases in point:
The number of uninsured Americans
The portion of the GDP that the U.S. spends on health care. It
is slightly less than five years ago because of managed care,
but far higher than the rate in other industrialized countries
The number of plans most Americans have access to through their
To judge from the rush to outlaw "drive-by"
mastectomies, you'd think we faced a crisis. But outpatient
mastectomies (as they're known off the Senate floor) aren't
really a serious national problem. Roughly 15% of mastectomies
are done on an outpatient basis today, up from 2% in 1991.
Naturally there are some abuses. But as with everything from
cataracts to cartilage, technical leaps often make outpatient
surgery the safer, cheaper option. Johns Hopkins University, for
example, one of the nation's top breast-surgery centers, does
mostly outpatient work and reports fewer infections and happier
patients. As it turns out, women are as likely to have drive-by
mastectomies in fee-for-service plans as in HMOs. Moreover, HMOs
tend to give women more mammograms and clinical breast exams;
such early-detection methods can help avoid the need for surgery
altogether. The upshot: new safeguards that both political
parties seek won't change much in the real world. But that
doesn't mean such body-part legislation is harmless. "Once
Congress starts mandating benefit by benefit," laments Fran
Visco, president of the National Breast Cancer Coalition, "they
won't have time to do anything else."
When Democrats say your doctor, not some
faceless HMO bureaucrat, should decide what's medically
necessary, it seems unassailable--but only until you recall that
giving doctors unfettered discretion is what drove health costs
to 13.5% of America's total GDP in the first place. A
presidential commission found that excessive tests and
procedures account for up to 30% of the nation's health bill.
Experts say there are huge and inexplicable regional variations
in the frequency of bypass operations, back surgeries and
countless other treatments. Whatever its ills, managed care
represents an overdue attempt to understand best medical
practices in ways that boost quality while freeing up wasted
resources for better uses. Robert Reischauer of the Brookings
Institution puts it more bluntly than politicians can: "Are we
really trying to undo the ability of health plans to make
rational rationing decisions?"
SUE OR REVIEW
By opening courts more broadly to patients who
have been denied care, would we be providing a cost-raising sop
to the trial lawyers or a good way to hold HMOs accountable?
Democrats rightly fume that under today's patchwork laws, health
plans often can be sued only for the cost of the treatment they
withheld, not the greater damage done to the patient.
Reimbursing Mom for the price of that wrongly denied test is a
cruel mockery after an undetected cancer has spread and she's
dying. The broader question is whether having juries
second-guess HMOs after the fact is likely to improve treatment
when it matters. The better first resort, embodied in the Senate
G.O.P. bill and endorsed by many in both parties, calls for
binding, independent and expert external reviews when care is
withheld. This system, already automatic in Medicare and
launched in numerous states, seems to be working. The key is a
process that guarantees immediate action in urgent cases.
Democrats say their broader rules would raise monthly
premiums by about the cost of a Big Mac. Republicans say the
cost would be enough to buy all the McDonald's franchises in the
country. The truth is, nobody knows. The nonpartisan
Congressional Budget Office guesses that broader Democratic
rules would raise premiums 4.8%.
Deciding whether that's a good deal turns in part on how you
view the trade-off between cost and access in a nation where 43
million people have no health coverage. A bill of rights that
gives more to health care's haves while ignoring its have-nots
raises moral dilemmas that will only get dicier as a new
generation of pricey medical breakthroughs comes along.
Paradoxically, it was Republicans who last week seemed to carry
the flag for those left behind, though it wasn't their chief
aim. They did so by putting fears of big new costs, and the
obstacles they could represent to expanding coverage, ahead of
fresh goodies for those who are now in the tent. Democrats,
meanwhile, counted on the debate to lift middle-class trust in
their party on health issues, essential to their bid to win back
Congress in 2000. But there was little in the debate on either
side to inspire faith that the really tough decisions on health
care will be made anytime soon in Washington.
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Cover Date: July 26, 1999