Why HMO angst is a hard issue for Congress

[CShine]

WASHINGTON – A Supreme Court ruling this week highlights the increasingly difficult bind Americans face over how to curb healthcare costs while getting the care they want. The high court was unanimous: Employer-sponsored insurance plans are governed by federal law, so patients can't sue for big damages in state court when a health-maintenance organization refuses to pay for a doctor's recommended treatment. But the ruling is hardly without controversy, or consequences. To some observers, it shows the failure of Congress to enact legislation to deal with growing strains in the healthcare system. The reasons go beyond party politics. Questions of who can sue whom, for how much, go to the heart of important debates over how to ensure both high-quality care and reasonable costs.

"The decision moves the bar of who can get redress toward the HMOs and away from consumers," says Gary Claxton, vice president of the Kaiser Family Foundation in Menlo Park, Calif. "It looks like something that the Congress will now have to deal with."

If a health plan makes a bad decision on coverage and you are harmed by it, you now have very little redress if the decision is negligent, in bad faith, or even intentional. The ruling comes against a stark backdrop: Years in which Congress has considered, but failed to pass, patients' rights legislation, leaving states scrambling to pass such laws. Years of double-digit increases in healthcare costs. Malpractice-insurance premiums that are driving many doctors out of their practices. This week's news calls fresh attention to all those challenges, and could put pressure on Congress to reconsider moves such as the patients bill of rights, limits on damages in malpractice suits, or even more comprehensive health insurance.

"At a time when the Bush administration is pushing millions of seniors on Medicare into HMOs, it is more important than ever to put healthcare decisions back in the hands of patients and their doctors," says Sen. John Edwards (D) of North Carolina, who led the fight in the Senate in 2001 for patients' rights. The bill passed the Senate in 2001 by a vote of 59 to 36, but failed in the House, after President Bush threatened to veto the bill.

http://www.csmonitor.com/2004/0623/p03s02-usgn.html