Support Needed for Patients Bill of Rights

S. 6/H.R. 358 Have Most Protections of Managed Care Proposals

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April 7, 1999—Congress has once again begun to debate managed care reform, in hopes of passing legislation to meet consumers' need for patient protections in managed care plans. The major bills introduced (or reintroduced) in the new Congress are the Democrats' Patient's Bill of Rights (S.6, H.R. 358), Republican proposals in the House and Senate (S. 326, S. 300, H.R. 448), and compromise legislation (S. 374) introduced by Senator John Chafee (R-RI) (see the Bazelon Center's February 16 Alert).

The six proposals differ in their provisions on external grievance and appeals procedures, access to prescription medications, access to specialty care and, more importantly, the definition of medical necessity.

Another contentious issue is whether there should be a federal right to hold a health plan liable for treatment denials. Employer-based self insured plans that fall under ERISA are exempt from state law of the denied treatment.

Partisan Politics Block Patient-Centered Amendments

On March 18, 1999, the Senate Committee on Health, Education, Labor and Pensions passed a less-than-comprehensive bill (S.326) on a party line vote (10-8). This bill as reported out of committee provides insufficient protections for patients. First, the bill only covers the 48 million people in self-insured plans, such as plans of large employers, leaving more than 100 million Americans without proper protections. Furthermore, it does not provide adequate safeguards for some of the most vulnerable populations, such as women, children and individuals with special health care needs, mental disorders and other disabilities.

The committee defeated many key amendments, including a definition of medical necessity to prevent insurers from making arbitrary decisions based on cost rather than on good patient care. The committee also rejected the establishment of state ombudsman programs to help consumers properly navigate their health care plans, especially the appeals process. The bill provides limited protections for continuity of care, access to nonformulary drugs, and access to pediatric and OB/GYN specialists—but not to mental health specialists.

The Senate Finance Committee is scheduled to take this bill up next, with floor debate possible by May. In the House, prospects for a contentious debate are similar, especially on the key issues of medical necessity and health plan liability.

The Democrats' Patient's Bill of Rights (S. 6, H.R. 358) offers the best consumer protections, covers the most Americans and has legally enforceable remedies against health plans. Public pressure is now urgently needed to pass this comprehensive bill into law so that Americans receive "real" patient protections.

Action Needed Now

Call or write your Senator or Representative today—especially if your Senator is on the Finance Committee (see box at right)—to support strong managed care protections outlined in the "real" Patient's Bill of Rights (S. 6 and H.R. 358). You can stress that:

• All Americans enrolled in managed care plans deserve protection, not just those in self-insured plans.
• Managed care plans should be held accountable when their decision to withhold care injures a consumer.
• Physicians, not the insurer, should have the authority to decide what treatment is medically necessary.
• Consumers want independent assistance to help them get the services they need.
• Direct access to specialists, including mental health specialists, should be guaranteed.

If you have a personal story on how a managed care plan arbitrarily denied coverage or treatment, you are encouraged to share it.

The Honorable _____________________
United States House of Representatives
Washington, D.C. 20515

The Honorable _____________________
United States Senate
Washington, D.C. 20510

Phone or Fax: call the U.S. Capitol switchboard, 202-224-3121, and ask for your Representative's or Senator's office.

Visit: Take the opportunity, now through April 9, to visit with your Senator or Representative while he or she is in the district on spring recess.

Petition: You may also sign a petition demanding the "real" Patient's Bill of Rights on the Families USA website: http://www.familiesusa.org/pbr/.