Nearly two years after the Senate’s last consideration of a patients’ bill of rights, this week the Senate began debate on a bill (S. 1052) to provide additional protections to individuals in managed care plans. Sponsored by Sens. John McCain (R-AZ), John Edwards (D-NC), and Edward Kennedy (D-MA), the bill is opposed by many Senate Republicans. The President issued a veto threat on June 21 over provisions in the bill pertaining to the right of patients to sue their health plans for denial of coverage.
Several of the access provisions of the bill would benefit women and children. S. 1052 would require a health plan to provide access to emergency care without prior authorization, as well as timely access to specialists when specialty care is covered by the plan. Additionally, the bill requires plans to provide direct access for “obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology.” S. 1052 also would require plans to allow enrollees to designate a pediatrician as a child’s primary care provider.
In the event that a provider terminates participation in a health plan, S. 1052 would require that plan to continue coverage for a transitional period of time if the enrollee is undergoing a course of treatment for a serious and complex condition, is scheduled to undergo non-elective surgery, is pregnant or undergoing treatment for the pregnancy, or is terminally ill.
S. 1052 also would require health plans to provide coverage for routine patient costs associated with individuals participating in a federally approved clinical trial. Tests conducted primarily for the clinical trial would be excluded from coverage, and plans would not be required to pay for items and services that “are reasonably expected” to be covered by the sponsors of the clinical trial.
Health plans also would be required to provide coverage for inpatient hospital stays resulting from a mastectomy, lumpectomy, or lymph node dissection. Under the bill, coverage would be provided “for a period of time as is determined by the attending physician, in consultation with the patient, to be medically necessary and appropriate.”
Finally, health plans would be prohibited from restricting health care professionals from advising enrollees about medical care or treatment that is not necessarily covered by the plan.
After Republicans stalled debate on the bill for several days while trying to reach an agreement for its consideration, the Senate on June 20 unanimously voted, 98-0, to proceed with debate on the bill.
The same day, the Senate rejected an amendment by Sen. Tim Hutchinson (R-AR) that would have allowed the self-employed to immediately deduct 100 percent of their health insurance premiums. Under current law, the self-employed may deduct 60 percent of their premiums, with full deductibility phased in by 2003. The amendment was defeated when the Senate voted, 52-45, to sustain a point of order against the amendment because all tax-related bills must originate in the House.
Democrats argued against the amendment, saying that it was an attempt to defeat the bill. “On the Republican side, they are offering killer amendments in an effort to scuttle and stop this bill. They know that if they can put a tax amendment on this bill, it is over,” argued Sen. Richard Durbin (D-IL).
Sen. Hutchinson countered, “I am sincere about this, and I resent it being portrayed as, I believe, a ‘cheap trick.’ It was called a ploy, an effort to derail. It is none of that. It is a sincere concern about those who are self-employed and who do not get equal treatment.”
On June 22, the Senate approved, 89-1, an amendment by Sen. McCain expressing the sense of the Senate that “men and women battling life-threatening, deadly diseases, including breast and ovarian cancer, should have the opportunity to participate in a federally approved or funded clinical trial recommended by their physician.” The amendment also expresses the sense of the Senate that children with life-threatening illnesses, including cancer, be permitted to participate in a federally approved or funded clinical trial recommended by their physician. Additionally, the amendment expresses the sense of the Senate that enrollees should be able to appeal a health plan’s decision that “an in-network physician without the necessary expertise can provide care for a seriously ill patient, including a woman battling cancer.”
Sen. McCain explained his reasoning for the amendment: “I happen to personally believe that clinical trials are important and should be part of health maintenance organization coverage, but that is up to the HMO. I happen to believe that treatment for breast cancer should be part of an HMO’s coverage, but I also believe that that is up to the health maintenance organization. What I am trying to do here is put the Senate on record of being in favor of trying to address these illnesses.”
The Senate will continue its consideration of the measure next week.