WASHINGTON — Senators were shouting. Senators were waving their arms.
Yet the casual listener to the floor debate on giving more leverage to patients in dealing with their managed health-care plans could get the impression that the two parties are extremely close. Lawmakers are due to finish work on the bill today.
On Wednesday, each side promised to protect women from being forced out of the hospital within a day of having a mastectomy. They both pledged more access to emergency rooms. Often it was hard to tell from the speeches which party a senator belonged to.
But there was good reason for the raucous debate.
Like health insurance policies themselves, the devil is in the details--and the details of the patients' rights bill reveal deep differences, even on some of the most seemingly similar provisions.
The Republicans typically have offered amendments with similar titles to those sponsored by the Democrats--but embodying more limited rights and applying to fewer people, in keeping with their philosophy of leaving most Americans' health care rights up to the states.
"This sort of neutralizes the issue," said Sen. Olympia J. Snowe, (R-Maine). "Our health care task force did identify the key issues that are serious problems, graphic problems where we would be politically vulnerable if we didn't address them in some way."
Democrats acknowledged that some expertise might be required to figure out the differences between the two bills.
"What they are trying to do is muddy the issue," said Sen. Bob Kerrey (D-Neb.). "But I think people who really follow this--the doctors, the nurses--are watching, and they know who is taking 'cover your rear-end' votes."
A close look at the competing provisions that allow access to obstetrician-gynecologists is a case in point. The issue is a major one for many women, 54% of whom consider their OB-GYN their primary care physician, according to a recent survey by the American College of Obstetricians and Gynecologists.
The GOP bill allows women "direct access" to obstetricians, while the Democrats give women the option of using OB-GYNs as their "primary care physician."
Sounds about the same, but look closer.
For starters, the Republican version applies only to the 48 million people in self-insured plans, in which the employer, rather than an outside agent, provides the coverage.
Sen. Susan Collins (R-Maine) said that the remaining 113 million people in health plans are subject to state insurance laws and that if the states wanted to mandate access to obstetrician-gynecologists, they were free to do so.
"In my home state of Maine, we require that a woman get one visit per year," Collins said. "The state Legislature rejected a proposal to open it up. If the state has made that decision, we should not overturn it."
But that's not the only difference between the parties' provisions on access to obstetrician-gynecologists.
Under the Republican bill, a gynecologist who gives a woman routine gynecological care can be required to send her back to her primary care physician if she needs to be referred for special treatment--unless the health plan permits the OB-GYN to make a direct referral.
What that means is that an OB-GYN who discovers that a woman has cervical cancer might not be able to refer the patient directly to an oncologist.
"This . . . is a sham proposal; it doesn't do anything for the women of this country," said Sen. Barbara Boxer (D-Calif.). Democrats noted that the American College of Obstetricians and Gynecologists had termed the Republican version "an empty promise."
But representatives of the managed health-care industry said they are only trying to keep some control over costs and that already many plans--81%, according to a study by the Kaiser Family Foundation--offer women the option of choosing their obstetrician-gynecologist.
"Consider the situation of a woman who needs a hysterectomy," said Karen Ignagni, president of the American Assn. of Health Plans. "Some plans may want it to be coordinated through the woman's primary care physician.
"We have real concerns [about] Congress getting into the role of writing health plan language; we've been concerned about that level of micromanagement," said Ignagni, whose organization represents more than 1,000 managed health-care plans nationwide.
The issue of emergency room care is similarly high-profile, since many people fear that they will go to the emergency room and then find they are stuck with thousands of dollars in charges they cannot afford to pay.
The fear is real. Blue Cross/Blue Shield sends its customers cheerful blue-and-white notices admonishing enrollees to call them before going to the emergency room "to avoid unnecessary out-of-pocket expenses."
In this case, both the Republican and Democratic provisions promise to guarantee that if a prudent layperson would think that a patient needed emergency care, the health plan must cover the cost of treating the patient at the nearest hospital.
Yet there are differences buried in the technical language.
The Democratic provision would cover all Americans with private health insurance. The Republicans would cover only the 48 million in self-insured health plans.
Another difference, according to the American College of Emergency Physicians, is that the GOP bill leaves open the possibility that a health plan could write a definition of emergency care that is different from that in the legislation and perhaps even make itself exempt from the bill's requirements.
One amendment that was approved Wednesday was a provision, authored by Snowe, that would guarantee that a woman and her doctor could decide how long she should stay in the hospital after breast cancer surgery, preventing so-called drive-by mastectomies.