HMOs - The Battle Is Back

Say hello, again, to Harry and Louise - the famous TV couple from middle America whose anxiety-ridden kitchen table discussions helped scuttle health-care reform in 1994.

Since then, the national roar over health care has become a whisper. Congress has made some incremental changes, but they've had little effect.

The result: The once-touted crisis has gotten far worse. The number of uninsured has jumped from 33 million in 1993, at the peak of the Clinton reform effort, to 44 million today. After a brief lull, health-care cost is again soaring - some estimates put it at twice the rate of inflation. And health-care experts say that for millions of Americans the quality of medical care is deteriorating.

"There's no real health-care debate right now, but there sure is a crisis," says Alan Sager, a professor at Boston University's School of Public Health.

As a result, health-care reform is starting to reemerge on the political scene. Some experts even predict it will dominate the next presidential campaign. And Harry and Louise, who once complained about the lack of choice in the Clinton plan, may have different worries this time.

Polls show Americans are increasingly uneasy about their health-insurance coverage, whether they're in a health maintenance organization (HMO) or not. Their main concern: They may not get the kind of health care they believe they need, even if they are insured.

The National Coalition on Health Care, a consortium of businesses, unions, and nonprofit groups, analyzed 22 public-opinion surveys taken over the past year. It found a majority of Americans think the health-care system is seriously flawed.

Those who don't have insurance worry they won't be able to pay their bills if they become ill. Those who do, think that if they become seriously ill their insurance won't cover all the costs or provide the kind of care they need. They also fret about losing that coverage.

Dissatisfaction grows

"It touches middle-class anxiety," says Robert Blendon, a professor at Harvard University's School of Public Health in Boston. "There's this underlying belief that progress in America means that things get better for you, and people don't think their health care is getting better."

In fact, many think it's getting worse. The Picker Institute in Boston has found that public dissatisfaction with the health-care system has jumped significantly in 10 years, especially among people who are exposed to it. A nationwide survey of people leaving the hospital found dissatisfaction rates of 50 to 65 percent.

"Markets don't operate very long with a public dissatisfied like that," says Henry Simmons, president of the National Coalition on Health Care. "This issue is just boiling beneath the surface and it's going to blow."

Experts say several factors have masked the deterioration of the health-care system. First was the shift of millions of Americans from traditional fee-for-service insurance into managed-care plans, such as HMOs. Ten years ago, 1 in 10 Americans was in a managed care plan. Today, 9 out of 10 are in one. That shift brought about a one-time saving to the system that temporarily helped slow cost increases.

Next, is the media. Almost as soon as the Clinton plan failed in Congress, health care dropped off the front pages. Some analysts also contend that reporters misunderstood, and then misreported, the causes of the slowed rate of increase in health-care costs. As a result, the public incorrectly believed the system was self-correcting.

Then, there's the economy, now in its sixth year of growth. All the good economic news helped offset the country's growing frustration with health care.

"There's every evidence that if, and when, the economy declines, health care will become a surrogate measure to talk about economic recovery, just as it did in 1992," says Bill McInturff, a partner at Public Opinion Strategies, a Republican polling organization in suburban Washington.

Candidates on the stump in the 1998 midterm elections are already trumpeting the need to rein in renegade managed-care systems.

A flurry of health-care bills is again circulating around Congress, from the president's "patients bill of rights" to the Republicans' Patient Access to Responsible Care Act, known as PARCA. The Republican leadership is expected to come up with its own bill in the next few weeks.

"There's no question that patients' rights and HMO reform will be the key political issues this election," says Democratic pollster Mark Mellman.

The major Democratic and Republican bills now circulating hit on similar themes. They want to guarantee patients the right to choose a non-managed-care plan, and in some cases, their own doctor.

They also want to ensure timely access to services and eliminate the controversial "gag rules" by requiring doctors to tell patients all their treatment options.

They also require health plans to have clearly articulated grievance and appeals processes. The Republican plan would also give patients the right to sue if they are injured as a direct result of a decision made by the plan. The Democrats would leave that option up to the states.

The managed-care industry is not happy with either proposal. Its leaders contend that they're already responding to the public's fears and that the legislation is unnecessary. They also say such governmental interference will only result in higher prices and even more people losing their insurance.

Time for reform

"The bottom line is that they're trying to take us back to the old-style system that was too costly," says Karen Ignagni, president of the American Association of Health Plans, the industry's main lobbying group. "The people who are going to be penalized are the working families - the very people these politicians say they're out to protect."

Ironically, coping with the increasing number of uninsured and the spiraling costs is expected to take a back seat politically to HMO reform this year.

"There's still the residue of the [Clinton] Health Security Act failure that's left everyone feeling that to try to tackle the uninsured issue head on is to walk into a political quagmire," says Mark Schlesinger, a professor at the Yale School of Medicine.

That is frustrating to many health-care experts.

"Even some Republicans are coming to see that these incremental reforms aren't enough," says Dr. Simmons. "We've long contended that without universal coverage you really can't fix the problem."