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Outside in the Senate swamp (a patch of lawn under a big elm tree), pediatricians, ER doctors, student nurses and the like gathered with Kennedy at afternoon rallies. Justin Dart Jr., a polio-stricken Republican businessman, wheelchaired to a microphone in the 90-degree heat Thursday and likened managed care to a battle with death. "I've been sick for the past 18 months and I've had to fight for my rights as a consumer, for my right to live, every step of the way," he told 200 fired-up activists. "I'm willing to die for my country, but not for my insurance company."

The GOP, lacking organized patient support, faced more of a conundrum about how to handle its sound bites but decided to go with "hurtin' small-businessfolk who can't afford the higher premiums these tax-and-spend-liberals will give us." That's where Casey came in.

You had to admire the Republican moxie. The party that used universal health reform as a club to beat down the Clintons and then raked in HMO contributions while a million Americans each year -- mostly children -- lost their health insurance now claimed to be championing patient rights.

"Their bill is Step 1 toward government running the health care system, so when my mama needs to go see a doctor, she first has to talk to a government bureaucrat," said Senator Phil Gramm, R-Texas. "Our answer is, expand freedom and choice within the current system, empower families to decide."

The empowerment Gramm referred to was the expansion of medical savings accounts, tax-free funds that can be invested in health care or cashed in at the individual's discretion. Essentially they are a way for healthy people to opt out of insurance pools, which certainly improves that group's freedom but also increases the costs for everyone else.

Republican Senator John Chafee of Rhode Island, who voted with the Democrats throughout most of the debate, led a small bipartisan group that tried to post a compromise bill, but neither party would give him a slot to introduce it. Daschle was leery of the watered-down liability clause in the Chafee bill. Senator Trent Lott, R-Miss., gave no explanations, but imposed party discipline. "We've let the American people down," Chafee said sadly.

The bill that passed, 53-47, with Chafee and Republican Peter Fitzgerald of Illinois voting with the Democrats, was mostly the same one the GOP started with. It was not entirely bereft of substance. True, the highlighted abuses that it promised to end -- drive-through mastectomies, gag rules prohibiting doctors from discussing expensive options with patients, refused referrals for cancer patients -- are largely red herrings, since managed care has learned to shy from such viscerally unpopular measures already. But the bill promised patients the right to appeal refused services, contained a section prohibiting discrimination based on genetic diagnostics and offered better access to OB/Gyns for women and to emergency rooms for everyone. (Many plans routinely refuse payment for emergency room visits. In 1996, the state of Oregon fined a company called PacifiCare $20,000 after noting that in two years, the company initially denied nearly 5,000 claims based only on billing statements from the ERs.)

These are reasonable protections, but they are incremental. The Republicans shied from challenging the central power of managed care, which lies in the inherent structure of the new health-care marketplace. Even without gagging doctors, the large firms can force them to toe the line and avoid expensive treatments because doctors who disregard managed care guidelines risk being dropped from the firms' provider lists.

Daschle said, "Now we know what the Republicans mean by HMOs -- 'half measures only.'"

Whatever. Ramming home their bill, the Republicans knew it would be vetoed by Clinton. This had to be comforting to the insurance lobby since inaction was exactly what it wanted.

In his closing statement, Lott spoke about how wonderful the American health-care system was, with new drugs and therapies coming each month. Sure, some protections were necessary, he said, but "Congress should not imperil the continuing transformation of American medicine. It's not our job to interfere."

Even as he spoke, the invisible hand went on working its magic. There was the psychiatrist in Maryland, ordered by a mental health HMO to submit the transcript of her session with an obsessive-compulsive if she wanted reimbursement. There was the physician in Oregon who sought a blood-sugar test to see if a patient had diabetes, and was told the test could only be given to diabetics. An asthmatic in Washington, D.C., got to see a specialist after waiting for three years. And everywhere across the land, doctors with years of training and experience spent hours on the phone arguing with clerks about how to treat their patients.

Oddly, despite the relative absence of "government bureaucrats," private enterprise hasn't streamlined the U.S. health care system. In the United States, somewhere between 15 and 35 cents on the dollar of health care is spent on overhead. In Canada and Britain, with socialized care, the numbers are more like 5 to 10 cents. "The system is going to collapse of its own weight," predicts Judith Shindul-Rothschild, a Boston College nursing school professor who was an early critic of managed care. She compares the growing national alarm over HMOs to the 1960s panic about nursing homes that led to passage of Medicare. "I predict that we'll have a single-payer system in this country by 2010," she says.

Kennedy, meanwhile, promised to keep fighting for more meaningful reform. "I was here in 1964 when a Medicare proposition lost, and in 1965 when 18 senators who voted no the year before switched their votes," he told reporters. "I'm sure we'll be successful in the long run."
salon.com | July 16, 1999

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