Managed care takes key role in election

Rep. John Ensign, R-Nev., and Sen. Harry Reid, D-Nev., both rank high in campaign contributions from the managed health care industry even though they sharply disagree on patients' rights.

Ensign, who hopes to unseat Reid in November's general election, led all 435 House members with $31,750 from the industry between Jan. 1, 1997, and July 1 of this year. Reid ranked third among the 100 senators with $32,000 in contributions for the current six-year Senate election cycle through July 1.

With both men expecting to raise about $3 million for their campaigns, the contributions from the managed care industry are a relatively small percentage of the total, but many of the other leading contributors also have an interest in patients' rights.

Through July 1, Reid's largest contributors were miscellaneous businesses ($537,001), lawyers and lobbyists ($350,377), financial, insurance and real estate interests ($291,169) and members of the health care industry ($171,907).

Ensign received his largest contributions from miscellaneous businesses ($272,695), financial, insurance and real estate interests ($190,923) and the health care community ($170,174).

But the managed care industry has become the focus of one of the most contentious issues as Democrats and Republicans head into the fall elections. One of the hottest topics in Congress today is the debate over the way health maintenance organizations and insurance companies should treat consumers.

The outcome will determine whether Nevadans receive better health care, including greater access to prescription drugs, specialists and emergency rooms, and more freedom to get their grievances resolved for denied care.

While Ensign and Reid disagree on the way to accomplish those goals, both men have received the largest share of their managed care largess from the same source, Sierra Health Services of Las Vegas.

The state's leading health maintenance organization and its executives have donated $30,750 to Reid since 1993, more than any other company. Sierra and its employees also are second on Ensign's list since last year with $12,500 in contributions, trailing only Circus Circus Enterprises.

The statistics were compiled by the Center for Responsive Politics, a nonpartisan congressional watchdog group in Washington, D.C., that tracks campaign contributions. Rep. Jim Gibbons, R-Nev., tied for eighth place on the House side with $8,750 from managed care interests since last year, while Sen. Richard Bryan, D-Nev., ranked 44th among senators with $9,000 since 1993.

Ensign said he wasn't surprised by his top ranking. He sits on the House Ways and Means Health Subcommittee.

"We have a lot of managed care companies in Nevada compared to other states," Ensign said. "Nevada has a lot more people in managed care than do other states. We have aggressive marketing with a lot of companies signing up a lot of people."

Reid chairs the Senate Democratic Policy Committee, which has a hand in much of the major legislation sponsored by his party. He has sponsored numerous health care bills, including legislation that would require insurance companies to pay for female contraceptives and allow women to have more time to recover from mastectomies.

"People don't contribute money to my campaign so I'll vote the way they want to," Reid said. "They contribute to my campaign, I hope, because I do a good job."

Sierra Health Services spokeswoman Ria Marie Carlson, who has contributed to both Reid and Ensign, noted the irony of backing opposing candidates. On the issue of patients' rights, health maintenance organizations and insurance companies have sided mostly with Republicans. But Carlson said her company supports politicians from both major parties as a way of participating in the political process.

"We believe in a healthy debate and want to be part of it," Carlson said. "We're mature enough to understand there are differences of opinion on issues. We also believe it's a fact of life that politicians need donations to run their campaigns."

Gibbons, however, was perplexed by his high ranking since he doesn't sit on any committees that deal directly with health care legislation and hasn't been particularly outspoken on the issue. The congressman said his ranking is proof that there often is no correlation between a political donation and its recipient.

"This points out the fallacy of the argument that these contributions are given because of one's support for an issue," Gibbons said.

Ensign and Gibbons both voted for a House Republican-sponsored patients' rights bill that narrowly passed the lower chamber on July 24 but is thought to be headed for a veto if it reaches President Clinton's desk. The House legislation is an amalgamation of several GOP proposals, including a bill introduced by Ensign in early July.

Clinton and congressional Democrats, including Reid, are backing a separate measure they say covers more patients and gives them broader rights. The bill was crafted by Reid's Democratic Policy Committee. Senate Republicans also have a bill that is narrower than the House GOP version. The Senate is expected to address the issue in September.

A major difference between the proposals is the grievance procedure for patients who are denied health care by the provider. House Republicans advocate creation of a panel of medical professionals who would serve independently of the health maintenance organization to review grievances.

After a review, the patient would be allowed to collect up to $250,000 but couldn't seek punitive damages. Some doctors favor this provision because they believe it would curb malpractice insurance costs.

Democrats would allow the patient to go directly to court and sue for an unlimited amount, including punitive damages. Trial lawyers support this concept. Up to now, managed care providers have been exempted from most such lawsuits, and patients usually recover only the cost of the denied care.

Ensign believes a patient could get a grievance resolved sooner under the GOP plan. The congressman said that if a patient goes to court, the case could be tied up for two years "and you could be dead."

"Why do you think the trial lawyers are the biggest supporters of the Democratic bill?" Ensign said. "It would make them a ton of money.

"If you want access to health care in time, then support the Republican bill. Where Clinton has a problem is he wants you to sue for unlimited amounts. That will lead to higher malpractice premiums, and when the doctor takes on higher premiums, he's going to pass the cost on to his patients."

Reid countered that the GOP grievance proposal is weak because there is no guarantee that the panel's recommendations can be enforced.

"You can't have a remedy if you have no way to enforce it," he said.

He also said it would be unfair to continue to exempt health maintenance organizations from litigation. Reid added that concerns about skyrocketing malpractice premiums are exaggerated.

"In America there are only two groups you cannot sue, HMOs and foreign diplomats," Reid said. "Our bill is a patients' bill of rights, and theirs is a patients' bill of wrongs. Ours is supported by the medical community, and theirs is supported by insurance companies, and insurance companies aren't interested in our health."

Assemblywoman Barbara Buckley, D-Las Vegas, author of a patients' rights bill that became state law last year, said the grievance system should include both an independent review panel of doctors and consumers and the right to sue for unlimited amounts.

In Nevada, patients who believe they've been given shoddy medical treatment must have their case reviewed by a medical-legal screening panel consisting of doctors and lawyers. If the panel doesn't think the patient has a legal case, the patient can still file a lawsuit. But if that patient loses in court, he must also pay all court costs.

Buckley, a legal-aid attorney, said that if an independent panel agreed with the patient, costly litigation could be avoided. But she also said that health maintenance organizations should be subject to unrestricted civil litigation like everyone else. Otherwise, she said, there would be no guarantee that a patient would be fairly compensated.

"We should have uniform protection for everyone insured by an HMO to make sure every plan is accountable to the public," Buckley said. "I don't know why HMOs should get a special break. It gives them the opportunity to make arrogant denials for health care."

Steve Burris, a Las Vegas attorney who is president of the Nevada Trial Lawyers Association, said many health maintenance organizations fail to deliver needed health care because they believe they are "bulletproof" from litigation.

"As a matter of consumer safety, it's a danger to put artificial caps (on malpractice judgments) in place," Burris said. "If health care providers know their liability is limited, they can make decisions based on economics rather than safety and health."

Republicans are encouraging use of medical savings accounts and would give businesses more flexibility to buy joint insurance, proposals opposed by Democrats. The Democrats, however, advocate greater access to medical specialists and prescription drugs. They also seek expanded opportunities for patients to continue to receive care when their physicians are no longer affiliated with the health maintenance organization.

Both versions include provisions for emergency-room care, direct access to obstetricians and gynecologists and increased sharing of information between doctor and patient.

Both plans also would cover an estimated 150 million people, the New York Times reported. But Reid said the Democratic plan, which is backed by the American Medical Association and consumer groups, would better protect 860,000 Nevadans with health plans underwritten by employers. Reid said those consumers need federal protection because their health plans fall under the Employee Retirement Income Security Act, which doesn't adhere to state-enacted protections such as Nevada's new patients' rights law.

The Times quoted the Congressional Budget Office as estimating that the GOP plan would save Medicare and Medicaid $1.5 billion over 10 years and wouldn't increase health care costs. But the Democratic plan would increase health insurance costs by 4 percent, the budget office told the newspaper.

Bryan has not yet decided to support the Democratic proposal because of lingering concerns, such as the provision that allows patients to seek punitive damages. But the senator called the Republican bills inadequate, particularly the Senate GOP version because it addresses only those individuals who are covered by employer-funded plans.

"There are 100 million people who wouldn't be included," Bryan said. "The Republican bills are also limited in terms of access to specialists. It's the HMO plan written by the HMO industry, and I don't think it's comprehensive enough. It's what I call a 'cover your base' plan."

Gibbons, however, argued that the House GOP bill is more comprehensive than Democrats believe.

"My main concern is protecting Nevadans, and the (GOP) Patient Protection Act accomplishes that," he said. "We want to give Nevadans who need health care the best health care when it's needed, not down the road when a court decides so."

Carlson said that given a choice, her company would support the House GOP plan but would do so grudgingly. Sierra's preference is that the federal government avoid placing mandates on managed care providers.

"The real issue is if Congress continues to mandate health care benefits, how is it going to affect costs consumers will have to pay, and how will it affect how many people become uninsured in this country?" Carlson said. "Mandates drive up costs and will add to the ranks of the uninsured."

Carlson said many provisions in the congressional bills are already practiced by Sierra. Her company, for instance, already gives women direct access to obstetricians and gynecologists. For that matter, Sierra patients can go to any doctor of their choice for what she termed a nominal additional cost.

Buckley's legislation also requires managed care providers to cover all reasonable emergency-room visits. A similar provision is in the congressional bills.

Ensign, in fact, said he incorporated elements of Buckley's Assembly Bill 156 in his legislation. But Buckley said the congressman omitted several critical elements, such as whistle-blower protection for nurses who wish to help patients get through the medical bureaucracy, and a requirement that only physicians be allowed to deny medical care. Before her bill became law, insurance-company clerks with no medical training had the power to reject requests for medical services.

Carlson said the debate over managed care has come to the forefront of this year's elections because other domestic issues have stabilized, and the United States isn't involved in a military conflict. With the economy running well and unemployment low, she said health care has become "a very easy target" for politicians.

"You can bring home issues that affect the American people with no (government) costs involved," Carlson said. "We need to do a better job of educating candidates on the impacts of their legislation if it comes to fruition."

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