Political Malpractice

By MATTHEW MILLER

Anyone who watched Senate Democrats wax hysterical over managed care's evils while Republicans passed their milder version of HMO reform last week can be forgiven for not knowing two essential facts. First, 97% of treatment decisions by doctors are okayed by managed-care plans, one study shows. So those grisly stories repeated from the Senate floor--the woman who didn't get the catheterization and died--are true exceptions. Next, about 40 states already give patients some of the protections Democrats sought in their broader "bill of rights." The disingenuousness was bipartisan, of course. The Republicans, who had gleefully foiled President Clinton's first-term plan to cover uninsured Americans, were suddenly fretting that costly regulations proposed by the Democrats would boost the ranks of those left behind.

At the end of the week, the Senate had managed to do only what it seems to do best these days--tee up rhetoric for the presidential race. The Democratic front runner, Al Gore, called the vote "a fraud," and Clinton threatened to veto the bill. But the vote was useful in the way it teed up something else: a preview of what could be a real debate. Four of last week's fights prove that when our leaders do get serious about health reform, they will have to move beyond tearful anecdotes and start making hard choices. The cases in point:

MASTECTOMIES To judge from the rush to outlaw "drive-by" mastectomies, you'd think we faced a crisis. But outpatient mastectomies (as they're known off the Senate floor) aren't really a serious national problem. Roughly 15% of mastectomies are done on an outpatient basis today, up from 2% in 1991. Naturally there are some abuses. But as with everything from cataracts to cartilage, technical leaps often make outpatient surgery the safer, cheaper option. Johns Hopkins University, for example, one of the nation's top breast-surgery centers, does mostly outpatient work and reports fewer infections and happier patients. As it turns out, women are as likely to have drive-by mastectomies in fee-for-service plans as in HMOs. Moreover, HMOs tend to give women more mammograms and clinical breast exams; such early-detection methods can help avoid the need for surgery altogether. The upshot: new safeguards that both political parties seek won't change much in the real world. But that doesn't mean such body-part legislation is harmless. "Once Congress starts mandating benefit by benefit," laments Fran Visco, president of the National Breast Cancer Coalition, "they won't have time to do anything else."

MEDICAL NECESSITY When Democrats say your doctor, not some faceless HMO bureaucrat, should decide what's medically necessary, it seems unassailable--but only until you recall that giving doctors unfettered discretion is what drove health costs to 13.5% of America's total GDP in the first place. A presidential commission found that excessive tests and procedures account for up to 30% of the nation's health bill. Experts say there are huge and inexplicable regional variations in the frequency of bypass operations, back surgeries and countless other treatments. Whatever its ills, managed care represents an overdue attempt to understand best medical practices in ways that boost quality while freeing up wasted resources for better uses. Robert Reischauer of the Brookings Institution puts it more bluntly than politicians can: "Are we really trying to undo the ability of health plans to make rational rationing decisions?"

SUE OR REVIEW By opening courts more broadly to patients who have been denied care, would we be providing a cost-raising sop to the trial lawyers or a good way to hold HMOs accountable? Democrats rightly fume that under today's patchwork laws, health plans often can be sued only for the cost of the treatment they withheld, not the greater damage done to the patient. Reimbursing Mom for the price of that wrongly denied test is a cruel mockery after an undetected cancer has spread and she's dying. The broader question is whether having juries second-guess HMOs after the fact is likely to improve treatment when it matters. The better first resort, embodied in the Senate G.O.P. bill and endorsed by many in both parties, calls for binding, independent and expert external reviews when care is withheld. This system, already automatic in Medicare and launched in numerous states, seems to be working. The key is a process that guarantees immediate action in urgent cases.

COST Democrats say their broader rules would raise monthly premiums by about the cost of a Big Mac. Republicans say the cost would be enough to buy all the McDonald's franchises in the country. The truth is, nobody knows. The nonpartisan Congressional Budget Office guesses that broader Democratic rules would raise premiums 4.8%.

Deciding whether that's a good deal turns in part on how you view the trade-off between cost and access in a nation where 43 million people have no health coverage. A bill of rights that gives more to health care's haves while ignoring its have-nots raises moral dilemmas that will only get dicier as a new generation of pricey medical breakthroughs comes along.

Paradoxically, it was Republicans who last week seemed to carry the flag for those left behind, though it wasn't their chief aim. They did so by putting fears of big new costs, and the obstacles they could represent to expanding coverage, ahead of fresh goodies for those who are now in the tent. Democrats, meanwhile, counted on the debate to lift middle-class trust in their party on health issues, essential to their bid to win back Congress in 2000. But there was little in the debate on either side to inspire faith that the really tough decisions on health care will be made anytime soon in Washington.