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The Supreme Court ruling that says patients cannot sue HMOs for denial of treatment leaves the responsibility of protecting patients under managed care to Congress.
State laws protecting patients under managed-care plans - so-called patients' bills of rights - aren't worth the paper they're written on after a unanimous U.S. Supreme Court decision this week. The court ruled against two Texas patients whose HMOs denied them care that had been prescribed by their doctors. The patients sued for damages, but the court rejected such suits, saying they aren't allowed under federal law.
We don't disagree with the court's decision. It correctly interpreted the federal law that prohibits patients from seeking damages from a managed-care provider for denial of a particular treatment. (Patients could still sue for reimbursement of the actual cost of treatment, but that is unlikely to motivate insurers to change.) Rather, the decision puts the responsibility to fix this intolerable situation where it belongs: on Congress.
Of course, Americans could be waiting a long time for Congress to act. But lawmakers should be reminded that the stakes are high: human suffering and shortened lives. The two patients behind the Supreme Court ruling are typical of the millions of Americans whose greatest barrier to good medical care is too often their own insurers.
Ruby Calad had a hysterectomy and abdominal surgery, but her insurance plan managed by Cigna allowed only a one-day hospital stay even though her surgeon wanted a longer recovery. Calad was sent home the next day but later had to be rushed to the emergency room with complications. The other patient, Juan Davila, had been prescribed the anti-inflammatory drug Vioxx for arthritis. His plan manager, Aetna, forced him to use Naprosyn instead, despite his doctor's concerns about its common side-effect of abdominal bleeding. Sure enough, Davila was within hours of dying when he was rushed to the hospital for blood transfusions.
It is of more than passing interest that both cases occurred in Texas, where then Gov. George Bush said (and repeated as a presidential candidate) that he supported a patient's right to sue an HMO for denied treatment. Yet it was his administration's attorneys who argued against the Texas law before the Supreme Court. The question remains: Who will lead the effort to protect patients under managed care?
The lack of an answer worries Justice Ruth Bader Ginsburg, who ruled with the majority but noted that "a regulatory vacuum exists" for addressing the problem. So far, Congress has not been up to the task.
Although both the Senate and House have passed different versions of a patient's bill of rights, there has been little progress on a final bill, and only the Senate would allow patients an adequate means to protect their rights. That bill - written by Sens. John McCain, R-Ariz.; John Edwards, D-N.C.; and Ted Kennedy, D-Mass. - would guarantee patients the right to have doctors make medical decisions and to prescribe specific drugs, and to hold the health plan accountable for harm done. The House bill would set a lower standard and pre-empt states from exceeding it.
The Supreme Court has left no doubt what needs to be done. Yet even the highest court in the land can't force Congress to step up to its responsibility, or the president to provide leadership, on this vital issue.