Defying a veto threat, the Democratic-controlled Senate passed sweeping patients' rights legislation Friday night, promising millions of Americans new health care protections and the ability to sue their HMOs.
The 59-36 vote sent the bill to the House, where the White House and Republican leaders were already laboring to rewrite it to restrict lawsuits.
"At long last, the Senate has acted to protect patients and doctors, and end abuses by HMOs and managed care plans," said Sen. Edward M. Kennedy, D-Mass., a leading supporter of the bill.
GOP critics saw it differently, and said so. Sen. Bill Frist, R-Tenn., a heart surgeon by training, said the measure was "more concerned about protecting the rights of trial lawyers than providing Americans with affordable high-quality health care."
But an alternative proposal that would have reduced the threat of lawsuits, supported mostly by Republicans, was swept aside, 59-36, moments before the final vote.
Designed to combat HMO horror stories, the legislation as originally drafted would give an estimated 190 million Americans new protections such as the right to emergency room care, access to specialists, minimum hospital stays for mastectomies and access to government-run clinical trials.
Patients could appeal any HMO's denial of care to an independent reviewer. The legislation also would permit patients to sue in state court if they lost their appeal, and to recover substantial damages if they win in court.
President Bush issued a veto threat against the bill last week, saying he agreed with the need to protect patients but was concerned the measure would prompt lawsuits, drive up the cost of insurance and cause businesses to cancel coverage as a result.
Republicans made the same point repeatedly during the debate, and Democrats agreed to a series of changes they said would alleviate the problem.
The vote was a victory for Democrats and Majority Leader Tom Daschle, D-S.D., who made their bill their first legislative priority after winning Senate control earlier in the month.
"I think we made a lot of improvements," Daschle told reporters. "And I think the president should reconsider" his veto threat.
Republican officials said that was unlikely, at least until Democrats agreed to further reduce the threat of lawsuits and the potential for enormous sums to be awarded in damages.
Years of politically-charged struggle over the issue has produced general agreement on the need for patient protections an issue that garners consistently high support in public opinion polls.
But over two weeks of debate, senators clashed often over the lawsuits that Democrats, aligned politically with the nation's trial lawyers, say are necessary to enforce those rights. Republicans, generally aligned with the health insurance industry, tried at several points to curtail the potential for suits.
One change, adopted on Thursday, would shield an estimated 94 percent of the nation's employers from lawsuits.
The bill's supporters agreed to others on Friday.
One would limit class action lawsuits. Another would require virtually all patients to complete an independent appeal of an HMO's denial of care before going to court.
Supporters raised objections to proposals to limit damages that patients could recover in successful lawsuits, and also objected to further restrictions on patients' abilities to bring suits.
Sen. Fred Thompson, R-Tenn., proposed the amendment to foreclose most suits while independent appeals were ongoing.
Passage, on a vote of 98-0, means denial of care decisions will ultimately be reviewed by "somebody who is objective, somebody who is an expert," he said, and will result in "doctors making decisions instead of lawyers."
Thompson's amendment would permit lawsuits in limited circumstances when appeals were in progress, principally when they consumed more than 31 days.
Sen. Mike DeWine, R-Ohio, authored the amendment to reduce the potential for class action suits, and it, too, cleared on a vote of 98-0.
But other changes advanced by critics were swiftly sidetracked by the bill's supporters.
Among them was one amendment by Sen. Wayne Allard, R-Colo., to ban all patients' rights lawsuits against employers with 15 employees or fewer. It was killed on a vote of 55-43.