HMO reform focus shifts to Augusta > Commitment of Snowe, Collins questioned

WASHINGTON — With the Senate vote last week to short-circuit debate on reforming managed care, Maine health care advocates say they are now planning to bypass Congress and pass similar legislation on the state level.

“We don’t need to wait for the federal government to act to protect our citizens,” said Joe Ditre, executive director of Consumers for Affordable Health Care, an Augusta-based coalition of advocacy groups.

Ditre’s call to health care arms came in the wake of an Oct. 9 Senate vote in which Maine’s senators, Republicans Olympia Snowe and Susan Collins, joined a GOP majority in defeating an attempt to debate the proposed “bill of rights” for patients.

With Congress set to adjourn for the rest of the year, the 50-47 vote against debating how managed health care companies conduct their business ensures there will be no action until at least next year.

Collins said the Democratic effort to force the debate was solely a partisan attempt to attack Republicans in advance of the Nov. 3 elections. If Democrats wanted to pass a bill, she said, they should have agreed to one of 10 Republican efforts to open debate on competing reform plans.

“They felt it would be a powerful issue at the ballot box if they could convince the public that Republicans were to blame,” Collins said.

But some consumer groups questioned the senators’ commitment to reining in the controversial industry, considering Democrats last week were willing to use the GOP plan as the focus of debate.

“It raises some doubt about their sincerity,” said Adrian Mitchem, legal counsel for Consumers Union, a liberal Washington-based group that publishes Consumer Reports.

But Snowe said the Senate should spend the precious days remaining in this session to pass the appropriations bills that will keep the government running and ensure that things like Social Security checks make it home in time. And she took a shot at the Democratic reform plan as a bureaucratic nightmare.

“[The Republican plan] proposes common-sense solutions to health care problems without creating government bureaucracy and red tape or raising premiums,” she said.

In Maine, growth in health maintenance organizations has skyrocketed. As of June 30, 270,155 Mainers received their insurance from an HMO, up 65 percent in just 18 months, according to the State Bureau of Insurance. Those figures do not include the hundreds of thousands of other consumers in Maine who receive insurance from some other form of managed care.

But doctors have warned about HMO bullying tactics over reimbursement for services, and patients have complained that vital procedures have been denied because of costs.

Regardless of the Beltway rhetoric, Ditre said his group’s efforts now would include introducing a bill next year in the Legislature that is based on the Democrats’ “Patients Bill of Rights.”

“As consumers we need to keep pressure on both [Washington and Augusta] to make sure something gets done,” he said.

The Democratic proposal requires all health care plans to pay for emergency room procedures and forbids insurance companies from applying a “gag rule” to restrict doctors from advising patients of costly procedures. It would also allow for an appeals process if an insurer denies paying for a medical procedure, and expands the rights of patients to sue insurers if that appeal is denied.

But Republicans allow only for an outside appeal process, without the added option to sue. “That way you avoid all the litigation that drives up cost,” Collins said. “And most important of all, you get the treatment up front rather than the punitive damages after the fact.”

The GOP plan, which Collins helped draft, includes many of the Democratic provisions: forbidding “gag rules,” guaranteeing ER care, and setting up an appeals process.

But it only covers a third of U.S. workers, those in large companies that craft their own in-house health plans regulated by Washington.

The other workers’ plans are regulated by their individual states, and Maine’s regulations currently are not tough enough, advocates say. Maine, for example, does not allow for an outside appeals process if a procedure is denied by an HMO.

The insurance industry, however, does not like either the Republican or Democratic plan, saying both will lead to increased premiums: And every 1 percent increase in premiums will lead to 200,000 workers nationwide losing health benefits because of the increased costs. The industry says more than 8,000 Mainers would lose benefits under the Democratic plan.

And neither of the plans does anything for the 150,000 Mainers and millions nationwide who do not have health care, Ditre said, adding, “This is a Band-Aid on a sick system.”

Collins said she plans to reintroduce the HMO reform plan in early 1999, a nonelection year, when partisan rhetoric tends to die down.

“People are then less concerned about getting credit,” she said, “and more concerned about passing legislation.”