STATE-LEVEL HEALTH REFORM: As Federal Measures Stall, States Step In
Despite "bitter conflict in Washington" stymieing efforts in Congress to pass patients' rights legislation, many states have enacted laws this year to protect patients and regulate HMOs. The New York Times reports that Republican and Democratic state legislators alike often perceive patient protection as a "constituent service" issue rather than "an occasion for ideological warfare." According to the National Conference of State Legislatures, 10 states this year joined the 17 states that last year passed comprehensive patient-protection laws: Alaska, Hawaii, Indiana, Kentucky, Nebraska, New Mexico, Pennsylvania, South Carolina, Tennessee and Wisconsin. Although the laws vary, they tend to ban so-called "gag clauses," establish procedures to facilitate patient appeals, guarantee access to medical specialists and expand emergency room coverage. While stalled federal patients' rights legislation prompted many states to enact their own protection laws, "no state has adopted all the requirements advocated by [President] Clinton and Democratic leaders of Congress," including allowing patients to sue their HMOs. Although legislation to allow this protection was proposed in 29 states, none passed it this year.
"We all recognize that health care is not a partisan issue," said Pennsylvania state Rep. Patrician Vance (R), co-sponsor of a state law regulating HMOs, citing a trend uniting legislators of both parties across the country. State Sen. Timothy Murphy (R), who co-authored the bill in Pennsylvania, said "skeptics" of HMO regulations were motivated by "horror story after horror story" from constituents complaining of denied care. Similarly, Tennessee state Rep. Steve McDaniel (R) joined state Sen. Jo Ann Graves (D) to sponsor their state's new patient protection law. "We wanted to make this a bipartisan issue," said McDaniel. Graves added, "That's how we were able to forge consensus. We put the patient first." South Carolina State Sen. Glenn McConnell (R), a self-described "Goldwater Republican," sponsored a law requiring health plans to provide easily understandable information on benefits although he said he normally opposes government regulation. "We were light-years ahead of Washington on this issue," he said, adding, "For the life of me, I don't understand how Congress can get hung up in partisan gridlock on legislation that would provide more information and more freedom of choice to consumers in the marketplace." And, the Times notes, while insurance companies and HMOs have "waged a fierce campaign against [f]ederal legislation to regulate managed care," they have "reluctantly" reached compromises "on the state level." Nebraska state Sen. David Landis (D) said, "We created a forum in which consumers, insurance companies and the director of the Insurance Department negotiated a bill they could all agree to."
The Times highlights the states' recent actions regarding HMO reform:
- All states "require HMOs to have grievance and appeal procedures," and 20 states require HMOs to establish independent appeals processes. Six states adopted laws this year mandating independent external appeals: Hawaii, Maryland, New York, Pennsylvania, Tennessee and Vermont.
- "Sixteen states require health plans to offer a 'point of service' option," allowing customers to see doctors outside their plan. Five states adopted laws securing this policy this year: Alaska, Indiana, South Carolina, Tennessee and Virginia.
- More than 20 states prohibit HMOs from using financial incentives to reward doctors, including four that adopted such laws this year: Alaska, Nebraska, New Mexico and Pennsylvania.
- Forty-six states ban so-called "gag clauses;" four states passed legislation this year: Alaska, Hawaii, Kentucky and South Carolina.
- Thirty-six states allow women to see OB/GYNs without a primary care referral, or to designate OB/GYNs as their primary care provider. Among those are seven states enacting such legislation this year: California, New Hampshire, Pennsylvania, South Carolina, Tennessee, Utah and West Virginia.
- Twenty-three states require HMOs to cover emergency room visits that would be deemed necessary by a "prudent layperson." Eight passed legislation this year: Hawaii, Indiana, Kentucky, New Mexico, Pennsylvania, South Carolina, West Virginia and Wisconsin.
- Seventeen states have "continuity of care" laws allowing pregnant women or patients with serious medical conditions 60 to 120 days with their current provider should the physicians be dropped from the HMO plan. Five states adopted such legislation this year: Indiana, Pennsylvania, South Carolina, Tennessee and Wisconsin (Pear, 9/14).
An Issue In Ohio
Following Anthem Blue Cross & Blue Shield's May decision to drop Medicare HMO service to 20,000 elderly members in Ohio, managed care has moved "to the forefront" in the state's upcoming elections. The Akron Beacon Journal reports that Ohio is among 25 states focused on patients rights legislation as election day nears. Efforts in the state are intensifying to pass a proposal to "force health plans to strengthen their quality assurance programs" -- including efforts to allow patients to designate a specialist as a primary care physician, establish procedures to provide patient appeals with a "prompt response" and increased coverage of emergency room care (Benton, 9/13).