After extensive arm-twisting by Democrats, Senate leaders last week agreed, beginning today, to consider and vote on the Patients’ Bill of Rights legislation that has managed-care companies so unhappy. The upcoming vote prompted these companies to begin an advertising blitz in selected states reminiscent of the Harry and Louise ads of ’93. But this time, instead of blaming Team Clinton for their troubles, managed care ought to be blaming itself.

It won’t, of course. It will claim to be a victim of congressional overzealousness. It will enlist the support of business groups to assert that any increased cost in health care inevitably must be passed on to consumers. And it will say that higher costs will increase the number of people without insurance, as if the current managed-care system is doing anything to decrease the number of uninsured.

The current shortcomings in managed care are not caused so much by what these companies do, however, as by what they are. An opening sentence from a business story this spring captures the problem neatly: Aetna Inc., the nation’s biggest health insurer, said today that its first-quarter earnings rose 15 percent, more than expected, as it raised premiums on employer health plans and shed unprofitable Medicare business.

The patient-insurer battles over access to treatment, over choice of physician and, between doctor and insurer, over who is in control of treatment options is often about that sentence. Managed-care executives hold the fate of people’s lives in one hand and the duty to reward shareholders in the other, and those two responsibilities are perpetually in conflict. Higher prices and reduced coverage rewards the owners of these companies, even as they threaten the health of their subscribers.

If managed-care companies sold clothespins or ping-pong balls none of this would matter because consumers could either find an affordable alternative or do without. But those options does not exist in the health-care insurance business, and the alternative for the 44 million Americans without coverage is to access the system through the most expensive way possible, to get care at a hospital emergency room when an illness reaches an advanced stage. That costs everyone.

The bills before Congress will not solve this problem, but properly constructed, could provide expert panels to expedite decisions on disputed requests for treatment and, through another provision, establish state-level agencies to help people through managed-care regulations. These could improve access by taking away some of the mystery of the decisions made by managed-care companies.

Ultimately, however, the nation will revisit the debate that brought Harry and Louise into everyone’s livingroom. Fiddling, as Congress intends to do this week, leaves for another day the underlying contradiction in health-care coverage that rewards most the companies that provide least.