SUMMARY OF BILL PASSED BY THE SENATE ON JULY 15, 1999

PATIENTS NEED REAL PROTECTIONS, NOT PHONY SUBSTITUTES

July 16, 1999

S. 1344, the bill that passed the Senate on July 15, 1999, fails to provide the patient protections that America’s families need and deserve.

S. 1344 covers only a fraction of the people in this country with employment-based coverage and excludes more than 100 million Americans. Because most of its provisions apply only to the 48 million people in self-insured plans, this bill fails to provide basic protections to millions of Americans and exacerbates the ineffective patchwork system of protections already in place.

In addition to failing to protect millions of Americans, S. 1344 is deficient in other ways. For example, S. 1344:

• Does not ensure that treatment decisions such as how long a patient stays in the hospital are made by the patient’s doctor (except for certain breast cancer patients);
• Does not hold managed care plans accountable when their decisions to withhold or limit care injure patients;
• Does not provide for a genuinely independent appeals process—the plan selects the reviewing entity and can rig the outcome by defining the term "medically necessary" any way it chooses, no matter how inconsistent with best medical practice the definition may be;
• Does not ensure that patients undergoing a course of treatment (such as women undergoing chemotherapy for breast cancer) can continue to see the same health care professional when their provider leaves the plan or their employer switches plans;
• Does not ensure that women can obtain ob-gyn services from the participating health care professional of their choice;
• Does not require plans to allow parents to select health care professionals specializing in pediatrics as their child’s primary care provider;
• Does not require plans to have an adequate network of providers;
• Does not go far enough to ensure access to specialists (inside or outside the network);
• Does not prohibit plans from denying access to clinical trials (except for some cancer trials);
• Does not adequately protect people from having to pay out of pocket for emergency room care;
• Does not ensure that doctors and nurses can report quality problems without retaliation by HMOs, insurance companies, and hospitals; and
• Does not give consumers access to an independent consumer assistance program to help them choose plans and get the services they need.

Pat Gorman, Government Relations Associate, National Association of Social Workers, 750 First Street, NE, Suite 700, Washington, DC 20002-4241, Ph: 800-638-8799, ext. 336 or 202-336-8336, Fax: 202-336-8311, Email: pgorman@naswdc.org, Website: www.socialworkers.org