|Office of Management and Budget
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July 12, 1999
The President strongly supports enactment of S. 1344, which is identical to S. 6, the original Senate Democratic Patients' Bill of Rights. This bill is a strong and enforceable patients' bill of rights. It includes important patient protections, such as the right to emergency care wherever and whenever a medical emergency arises; the right to access the specialists a patient needs; the right to ensure care is not disrupted during treatment; the right to a fair, unbiased internal, and independent external appeals process that allows patients to address their concerns and grievances; and the right to hold health plans accountable when their decisions cause patients serious harm or death. The President is particularly pleased that this legislation includes every patient protection recommended by the Advisory Commission on Consumer Protection and Quality in the Health Care Industry.
Since November 1997, the President has been calling on the Congress to pass a strong, enforceable, and bipartisan patients' bill of rights. The outcome of the debate on S. 1344 will determine whether this Congress is serious about responding to the President's challenge. He is committed to working with members of both parties to pass a meaningful Patients' Bill of Rights this year; he is equally committed, however, to opposing legislation that is a Patients' Bill of Rights in name only.
Unfortunately, the Republican Leadership may seek to amend S. 1344 either by weakening key provisions of the bill or by substituting the provisions of S. 326, as reported by the Senate Committee on Health, Education, Labor and Pensions. S. 326 is seriously flawed. It covers too few people, it provides insufficient patient protections, and it contains inadequate enforcement provisions.
The shortcomings of the Republican leadership bill include:
It leaves tens of millions of Americans without adequate protections. By only providing all of its severely limited protections to self insured plans, it leaves over 110 million Americans unprotected. The President has repeatedly stated that all health plans should provide the protections in the Patients' Bill of Rights.
The Republican leadership bill either does not include or significantly waters down critical provisions that are necessary for high quality care. The following protections are either absent from this legislation or are insufficient:
External appeals and medical necessity. The weaknesses of the external appeals process are numerous and significant. For example, S. 326 would not ensure that arbitrary coverage denials by plans could be reversed by a fair appeals process because the plan's arbitrary definition of medical necessity would prevail. It also would not provide an independent appeals process, since the plan would be allowed to select the appeals entity. It would not ensure that appeals -- including emergency appeals -- are heard as swiftly as the patient's condition requires. Finally, S. 326 only would allow for external review for medical necessity provisions and not for other violations of the statute, such as failure to provide access to a specialist.
Emergency room services. The emergency room services provision of S. 326 is insufficient, as it does not: (1) prohibit plans from limiting access to an emergency room that is outside the plan's network; (2) prohibit plans from imposing higher cost-sharing requirements on patients who obtain emergency care without prior authorization; and (3) address coverage of post-stabilization care, which puts patients at risk for huge costs when a plan fails to timely respond to a request for post-emergency services.
Access to specialists. S. 326 does not ensure individuals with chronic, serious, and even life-threatening conditions direct access to specialists who are in the plan's participating physician network. In addition, if the plan has an insufficient number of specialists in their network, it has no provisions to ensure patients have access to specialists outside of the network. As such, patients would not be ensured access to needed specialists to treat conditions such as cancer or heart conditions.
Continuity of care protections. The bill does not have any continuity of care protections when an employer changes health plans. In cases when a doctor is dropped from a health plan these protections would apply only to individuals in institutions, women in their second trimester of pregnancy, and the terminally ill -- not to persons with chronic or ongoing illnesses who are in the middle of a course of treatment when their provider is dropped from the plan's network. For example, S. 326 would not protect a person with cancer from an abrupt disruption of their course of chemotherapy or radiation.
Its enforcement provision is inadequate to ensure that the patient protections are real. The limited rights outlined in S. 326 are not meaningful because patients who have died or been seriously harmed by wrongful actions by health plans would have no ability to seek compensation for their injuries.
For these reasons, the President agrees with virtually every major consumer organization, as well as almost every provider organization, such as the American Medical Association and the American Nurses Association, that S. 326 is insufficient and does not provide patients with the protections they need and deserve. As such, the Administration strongly opposes S. 326 as reported out of the Senate Committee on Health, Education, Labor and Pensions. If this legislation is passed and presented to the President, his senior advisers will recommend that he veto the bill.
Finally, the Administration would oppose the addition of irrelevant and unnecessary provisions that further undermine the chances for a bipartisan agreement on a Patients' Bill of Rights. It would be extremely unconstructive to amend this legislation with poorly designed options, such as an expansion of the Medical Savings Account Demonstration, that are not related to consumer protections, have received little or no serious and bipartisan review, and could undermine an already unstable insurance market.
While the Administration has serious concerns with S. 326, the President supports S. 1344 and remains committed to passing a strong, enforceable, and bipartisan Patients' Bill of Rights this year. His hope is that the Republican leadership will work with members of both parties who are committed to passing a meaningful Patients' Bill of Rights. Such legislation is long overdue. It is time to put progress ahead of partisanship and pass legislation that gives all Americans the health care protections they need and deserve.