HMO REFORM: N.Y. Times says Congress Should Follow State’s Lead
Arguing that recent health care reforms in California show that "state leaders are well ahead of Congress in addressing the need for managed care regulation," a New York Times editorial suggests that the "sweep of California legislation ... along with similarly broad legislation in Texas, sets an important standard by which to judge national reform." Pointing to the California reforms that expand the right to sue, guarantee patients the right to an independent review of benefits denials and provide coverage for contraception and severe mental illnesses, the editorial notes that other "states may follow California's lead if they see that such reforms can improve health care without significantly increasing costs." However, the editorial asserts that the state initiatives "do not replace the need for federal legislation." Under the 1974 Employee Retirement Income Security Act (ERISA), people enrolled in private employer-sponsored plans cannot sue for damages, but the editorial indicates that the California legislation "tries to get around the legal hurdle by framing the new state-granted right to sue as based on the right to obtain quality care rather than the right to particular benefits." According to the editors, this approach may not survive in the courts "unless Congress closes the loophole in federal law that now shields health plans from meaningful liability." Since the new state reforms will benefit "[m]ore than 20 million Californians," the editorial urges Congress to use the legislation as a guideline in their upcoming debate over patients' rights. The editors conclude that "Americans elsewhere need Congress to enact basic protections to insure that patients get the care they need" (10/1).
On the Other Hand ...
Yesterday's Sacramento Bee, however, reported that the "two key bills" signed into law in California this week -- the right to sue and the right to seek an independent review -- "may not dramatically change how most HMO enrollees resolve their disputes." The piece notes that "[s]everal large plans already allow their members to ask an independent panel to review an HMO's treatment denial or delay." And as for the right to sue, "many HMO members will be banned from seeking a jury trial" if they've already signed an arbitration agreement with their HMOs. Jamie Court of Citizens for Quality Care said, "We would like legislation clarifying that just because you sign up for an HMO doesn't mean you give up the right to go to court." But state business secretary Maria Contreras-Sweet, who chaired Davis' task force on HMO reform, said patients who are concerned about arbitration agreements can "look for health plans that don't require them." Contreras-Sweet said, "If it needs further remedy, we will take it up. But at this point, we think we have added a consumer right and amplified choice" (Griffith, 9/30).