by Congressman Elijah E. Cummings
The life-sustaining care which medical science can offer in times of injury or sickness is miraculous, but people - not Providence - decide what medical treatment we will receive.
"Someone I don’t even know is controlling my life," a woman I will call Mrs. Smith complained to me recently. "First, he told me that I could not continue to be treated by my old doctor. Then, he said that the tests their new doctor prescribed were not warranted and the care she recommended would not be covered. We tried to challenge his decisions, but I don’t seem to have any recourse."
Mrs. Smith was not complaining about a government bureaucrat. Her private medical plan is part of her compensation at work. Now, when she is suffering from a painful and serious medical problem, the "insurance" which she believed would pay for her miracle is refusing to do so.
And my constituent is not alone. As a nation, we have learned that managing miracles is a complicated proposition. Confronted by rising costs, the employers and governmental bodies who pay for most group health plans have turned to "managed care."
The extent to which this transformation in our health care system has actually limited rising costs is a matter of some debate. What is clear, however, is that 160 million Americans who now depend upon managed care plans are concerned that their insurance will fail to fully protect them in times of need.
As a society, we have learned that privately managed costs do not automatically assure quality health care. This realization, in turn, is the source of efforts to protect patients from arbitrary, managed care decisions.
The health insurance industry and many employer groups oppose federal regulation, contending that the market is responding to patient concerns. It is fair to say, however, that Mrs. Smith, most Democrats and more than a few Republicans are not convinced.
Our national discussion about managed care is more than a debate about the specifics of health insurance coverage. The American people are seeking to regain a measure of control over their own medical destinies.
Leading this movement, President Clinton, House Democrats and over 40 consumer and medical organizations recently demanded that Congress quit stalling and enact a strong, enforceable Patients’ Bill of Rights this year.
I was honored to co-sponsor the proposed Democratic legislation (H.R. 358 / S.6), which addresses documented managed care problems far more effectively than weaker Republican reactions. Our initiative would guarantee to Mrs. Smith and all patients access to emergency room services and needed health care specialists, assure continued care if our doctors are dropped by our plans, prohibit our plan administrators from censoring the treatment options our doctors can discuss and - perhaps most important - provide us with an efficient, independent appeal process if we disagree with treatment determinations. Equally important, federal statutory rules which shield "self-insured" plans from legal responsibility for the harm they cause would be eliminated.
Our Patients’ Bill of Rights contains guarantees comparable to those which we, as Americans, consider essential to fundamental fairness in our legal system. Our health and survival deserve no less protection.
Medical decisions should be made by patients and their doctors. Medical costs should be allocated on the basis of clearly disclosed guidelines which we can understand. Adverse determinations should be subject to independent review.
We cannot protect the nation’s pocket book at the cost of our most basic principles. Medical insurance which does not assure quality care is unacceptable.
-The Honorable Elijah E. Cummings represents the 7th Congressional District of Maryland in the United States House of Representatives.