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HMO plan has backers in GOP

Joining with Democrats, the dissident Republicans say they have the support to bring their measure to a vote.

A group of dissident Republicans reached agreement with House Democrats on Thursday on a comprehensive bill to regulate the managed health care industry and predicted they would have enough support to force the Republican leadership to bring their measure to a vote.

The proposal, which would cover all 161-million Americans with private health insurance and give them expanded rights to sue insurance companies, was hastily made public by a bipartisan group of House members late Thursday afternoon, as they scrambled to introduce it and get the edge on the health issue before Congress left for its August recess.

Rep. Charlie Norwood, R-Ga., who negotiated the measure with Rep. John Dingell, D-Mich., said he did not think that the Republican leadership, which favors a more limited approach, was assembling a measure that could meet with President Clinton's approval and become law.

"We need a law on the books that will protect patients," said Norwood, who practiced dentistry for more than 20 years and is usually a staunch conservative. "Not a bill that protects politicians at the November ballot box. And this, in my opinion, is the only bill that can accomplish the goal."

Clinton, who had vowed to veto the Senate's version of managed care legislation, quickly endorsed the proposed measure and called on House Speaker Dennis Hastert to schedule a vote as soon as Congress returns in September.

"Today's action proves that patient protections need not and should not be a partisan issue," he said. "It is time to do what this bipartisan coalition has done: put the well-being of patients before politics and special interests."

Virtually all House Democrats were expected to coalesce around the bill. Their support, together with the nine Republicans listed as co-sponsors, would provide enough votes to ensure passage.

Hastert's spokesman, John Feehery, said the House would address the health care issue in the fall, but declined to specify what legislation would be brought to a vote.

Of the bipartisan legislation he said: "What about the uninsured? They don't address that issue at all." He said the speaker had been looking at an array of tax incentives to include in a Republican leadership measure to help the 43-million people without health insurance.

On Thursday afternoon after meeting with the speaker, several of his senior lieutenants on health issues met with business and industry officials opposed to the bipartisan approach. Rep. John Boehner, R-Ohio, who has been working with the speaker, said the lawmakers had urged business groups to tell employees that the bipartisan bill would "increase costs and end up with less affordability, which is going to create more uninsured."

Several industry groups immediately denounced the bipartisan legislation on just those grounds, saying that cost would rise because the measure would expand the right of patients to sue health care plans in state courts for their decisions.

"This legislation is built on the erroneous premise _ rejected this year alone in 24 states _ that trial lawyers are the sole guardians of good medical care," said Karen Ignagni, the president of the American Association of Health Plans.

House Republican leaders have been searching for an approach to regulating managed care since Senate Republicans last month approved a bill that would provide some protections for patients but complied with their party's desire for only limited regulation.

Many of the Senate bill's guarantees would apply only to the 48-million people whose employers provide the kind of self-insured health plans that are not regulated by the states. Such people are rarely in health maintenance organizations and do not often face the kind of "gatekeeper" arrangement that has led to many consumer complaints.

Although Republicans had been struggling for a broader bill that applied to all 161-million Americans with private health insurance, some dissident Republicans, led by Norwood and Rep. Greg Ganske of Iowa, who is a surgeon, accused their leaders of bowing to the insurance industry and began negotiating with Democrats.

The measure they agreed to Thursday would include an array of protections for Americans with private health insurance, guaranteeing that patients would be covered for emergency room care outside their health network, giving women direct access to obstetricians and gynecologists and giving children access to pediatricians. The bill would require that health plans have a process in place for guaranteeing that people have access to clinical trials, if that is the only treatment for their illnesses.

In cases in which a health plan has denied a patient a course of care, the legislation would give individuals the right to go to an external appeals panel made up of independent doctors to resolve disputes. They would make their judgment based on generally accepted medical practice, not on the insurance plan's definitions of what is medically necessary.

The bill also would give patients the right to sue a health plan in state courts. However, the measure provides that if a health plan complies with a decision of an external review panel, it can be sued for compensatory damages but not punitive damages.

Key provisions

+ Guaranteed access to specialists.

+ Permits patients to get referrals outside their networks if no in-network provider is available.

+ Gives women direct access to obstetricians and gynecologists.